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Effective Ecological Effective Ecological InterventionsInterventions
Joshua Leblang,Ed.S. LecturerPublic Behavioral Health & Justice PolicyDepartment of Psychiatry
Oppositional Defiant Oppositional Defiant Disorder & Conduct DisorderDisorder & Conduct Disorder
Our youth now love luxury. They have bad manners, contempt for authority, they show disrespect for their elders … they contradict their parents …and tyrannize their teachers."
Socrates (c. 470-399 BC)
What is it?
Disruptive disorders, such as oppositional defiant disorder and conduct disorder, are characterized by antisocial behavior.
Oppositional Defiant Behavior as a DSM IV Diagnostic Category
Oppositional Defiant Disorder (ODD), is defined as "a recurrent pattern of negativistic, defiant, disobedient, and hostile behavior toward authority figures".
The disorder is reflected in behaviors such as frequent temper tantrums, arguing, defiance, non-compliance, externalizing blame, vindictiveness, and a range of other problem behaviors.
American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th
ed., text revision). Washington, DC: Author
Specific DSM IV ODD Criteria
For at least 6 months, shows defiant, hostile, negativistic behavior; (4 or more of the following):-Losing temper-Arguing with adults-Actively defying or refusing to carry out the rules or requests of adults-Deliberately doing things that annoy others-Blaming others for own mistakes or misbehavior-Being touchy or easily annoyed by others-Being angry and resentful-Being spiteful or vindictive
Conduct Disorder as a DSM IV Diagnostic Category
The essential features of Conduct Disorder (CD) involve "a repetitive and persistent pattern of behavior in which the basic rights of others or major age-appropriate societal norms or rules are violated“, resulting in a clinically significant impairment in functioning.
This includes aggressive behaviors, behaviors that result in property loss or damage, deceitfulness or theft, other serious rule violations (e.g., running away from
home, truancy).
DSM IV Conduct Disorder Criteria
For 12 months or more has repeatedly violated rules, age-appropriate societal norms or the rights of others.
Shown by 3 or more of the following, with at least one of the following occurring in the past 6 months:
Aggression against people or animals Frequent bullying or threatening Often starts fights Used a weapon that could cause serious injury Physical cruelty to people Physical cruelty to animals Theft with confrontation Forced sex upon someone
DSM IV Conduct Disorder Criteria Property destruction
-Deliberately set fires to cause serious damage-Deliberately destroyed the property of others (except fire-setting)
Lying or theft-Broke into building, car or house belonging to someone else-Frequently lied or broke promises for gain or to avoid obligations ("conning")-Stole valuables without confrontation (burglary, forgery, shoplifting)
DSM IV Conduct Disorder Criteria Serious rule violation
- Beginning by age twelve, frequently stayed out at night against parents' wishes
- Runaway from parents overnight twice or more (once if for an extended period)
- Frequent truancy before age 13
These symptoms cause clinically important job, school or social impairment.
If older than age 18, the patient does not meet criteria for Antisocial Personality Disorder.
CD/ODD presents as collection of behaviors rather than a coherent pattern of mental dysfunction. As such, there is no “magic bullet” to fix the problem.
How would you work with?
15 year old who refuses to go to school? 15 year old who refuses to go to school due to
bullying? 15 year old who refuses to go to school
because s/he was the babysitter for his/her baby brother
15 year old who refused to go to school because s/he was dealing drugs?
15 year old who refused to go to school because s/he wasn’t getting up in the morning --going to bed late at night playing video games --Parents having parties late at night?
Three treatments top the list for adolescents
ALL focus on family/ caregivers Functional Family Therapy Multidimensional Treatment
Foster Care Multisystemic Therapy
Blueprints for Violence Prevention
What usually happens to youth?
Youth gets in trouble
Sent to treatment Meets other anti-
social peers
No changes at home
CYCLE CONTINUES
Returns home
CommunitySchool
Peers
Family
An ecological approach
Work with the entire ecology. By addressing the multiple systems, it is possible to make longer lasting changes for families.
Youth
Bronfenbrenner, 1979
MULTISYSTEMIC THERAPY
Youths’ behaviors are influenced by their families, friends, and communities (and vice versa).
Families are the key to success, so all aspects of treatment are designed with full collaboration from the family.
Change can happen quickly, but it demands daily and weekly efforts from the youth and all the important people in his/her life.
Families can live successfully without involvement in social service agencies.
www.mstservices.com
How is MST Different?
Discipline: Offers a combination of “best practice” treatments within a disciplined structure
Accountability: At all levels, providers are held accountable for outcomes through MST’s rigorous quality assurance system
Ecological validity: Working in the youth’s natural environment with existing family supports, thereby ensuring cultural sensitivity
Focus on long-term outcomes: Empowerment of caregivers to manage future difficulties; focus on sustainability
How Does MST “Work?”
Intervention strategies: MST draws from research-based treatment techniques
Behavior therapy Parent management training Cognitive behavior therapy Pragmatic family therapies
— Structural Family Therapy— Strategic Family Therapy
Pharmacological interventions (e.g., for ADHD)
How is MST Implemented?
Single therapist working intensively with 4 to 6 families at a time
“Team” of 2 to 4 therapists plus a supervisor
24 hr/ 7 day/ week team availability 3 to 5 months is the typical treatment
time (4 months on average across cases)
Work is done in the community: home, school, neighborhood, etc.
How is MST Implemented? (continued)
MST staff deliver all treatment – typically no services are brokered/referred outside the MST team
Never-ending focus on engagement and alignment with the primary caregiver and other key stakeholder (e.g. probation, child welfare, etc.)
MST staff must be able to have a “lead” role in clinical decision making for each case
Highly structured weekly clinical supervision and Quality Assurance (QA) processes
Condensed Longitudinal Model of Youth Antisocial Behavior
Family
School
Antisocial Peers
Antisocial behavior
Prior antisocial behavior
Low MonitoringLow AffectionHigh Conflict
Low School InvolvementPoor Academic Performance
Explaining delinquency and drug use, by D.S. Elliott, D. Huizinga and S.S. Ageton. Beverly Hills, CA: Sage Publications, 1985, 176 pp
FAMILY
Poor monitoring
Ineffective discipline
Low warmth High conflict Parental drug
use/abuse
PEER
Association with drug-using peers,
Low association with prosocial peers
SCHOOL
Low achievement Truancy Low commitment to school
COMMUNITY FACTORS
•High crime
•Neighbors who use drugs
•Transience
Individual Factors
Antisocial behavior Mental health problems Low social conformity
MST Treatment Principles
Nine principles of MST intervention design and implementation
Treatment fidelity and adherence is measured with relation to these nine principles
Principles of MST
1. Finding the FitThe primary purpose of assessment is to understand the “fit” between the identified problems and their broader systemic context.
2. Positive & Strength FocusedTherapeutic contacts should emphasize the positive and should use systemic strengths as levers for change.
Principles of MST (continued)
3. Increasing ResponsibilityInterventions should be designed to promote responsibility and decrease irresponsible behavior among family members.
4. Present-focused, Action-oriented & Well-definedInterventions should be present-focused and action-oriented, targeting specific and well-defined problems.
Principles of MST (continued)
5. Targeting SequencesInterventions should target sequences of behavior within and between multiple systems that maintain identified problems.
6. Developmentally AppropriateInterventions should be developmentally appropriate and fit the developmental needs of the youth.
Principles of MST (continued)
7. Continuous EffortInterventions should be designed to require daily or weekly effort by family members.
8. Evaluation and AccountabilityIntervention efficacy is evaluated continuously from multiple perspectives, with providers assuming accountability for overcoming barriers to successful outcomes.
Principles of MST (continued)
9. GeneralizationInterventions should be designed to promote treatment generalization and long-term maintenance of therapeutic change by empowering care givers to address family members’ needs across multiple systemic contexts.
Environment of Alignment and Engagementof Family and Key Participants
Measure
Re-evaluate Prioritize
Do
IntermediaryGoals
IntermediaryGoals
InterventionDevelopment
InterventionDevelopment
MST Conceptualizationof “Fit”
MST Conceptualizationof “Fit”
Assessment ofAdvances & Barriers to
Intervention Effectiveness
Assessment ofAdvances & Barriers to
Intervention Effectiveness
InterventionImplementation
InterventionImplementation
MSTAnalyticalProcess
ReferralBehavior
ReferralBehavior
OverarchingGoals
OverarchingGoals
Desired Outcomesof Family and Other
Key Participants
Desired Outcomesof Family and Other
Key Participants
Where is MST Being Used? Over 30 states in the U.S. and in 10 countries Statewide infrastructure in Connecticut,
Georgia, Hawaii, New Mexico, Ohio and South Carolina
Nationwide program in Norway (25+ teams) Other international replications: Australia,
Canada, Denmark, Ireland, England, Sweden, Switzerland, the Netherlands, and New Zealand.
MST: 25+ Years of ScienceMST: 25+ Years of Science
14 Randomized Trials and 1 Quasi-Experimental Trial Published (>1300 families participating)
• 7 with serious juvenile offenders — 2 independent randomized trials by Ogden and
Timmons-Mitchell• 2 with substance abusing or dependent juvenile offenders• 2 with juvenile sexual offenders • 2 with youths presenting serious emotional disturbance• 1 with maltreating families• 1 with adolescents with poorly controlled diabetes
(independent: Ellis)
Other randomized trials are in progress
Long-term follow-up to the Missouri Delinquency Project: 14-year post-treatment outcomes Individuals who had been involved in MST as a
youth (average age at follow-up = 28.2 years): 54% fewer arrests 64% fewer drug-related arrests 57%fewer days in adult confinement 43% fewer days on adult probation
Long-term Outcomes
• 14-Year Follow Up 1357 days/ 3.72 years
582 days/ 1.59 years
MST Individual Therapy
Adult Days Confined
57% reduction
Supervisor TherapistYouth/Family
Consultant/ MST Expert
Manualized
Manualized Manualized
SupervisoryAdherenceMeasure
TherapistAdherenceMeasure
Organizational Context
Manualized
ConsultantAdherenceMeasure
MST Quality Assurance System
Why is MST Successful?
Treatment targets known causes of delinquency: family relations, peer relations, school performance, community factors
Treatment is family driven and occurs in the youths’ natural environment
Providers are accountable for outcomes Staff are well trained and supported Significant energies are devoted to
developing positive interagency relations
