Transcript Mental Health Status of School Children

Research to Practice:
Multisystemic Therapy (MST)
for Elementary School Students
with Behavior Disorders
Center for At-Risk Children’s Services
University of Nebraska-Lincoln
Jacquelyn A. Buckley, PhD & Michael H. Epstein, EdD
The Child Guidance Center
Tricia Monzon, MA
Mental Health Status of School Children
Three types of children in school settings
1-7%
Exhibit intense
problem behavior
5-15%
At risk for problem
behavior
80-90%
Not at risk
Three-Tiered Prevention Program
Tertiary Program: Multisystemic Therapy (MST)
Secondary Program: First Step to Success
Primary Program: Behavior and Academic Support
& Enhancement (BASE)
BASE
Primary Schoolwide Discipline Program
Ecological arrangements: traffic patterns, arrival and
dismissal, student supervision
Behavior: consistent expectations, continuum of
disciplinary responses, Think Time, behavior
intervention plans
Academic: focus on achieving outcomes, early
identification, evidence-based academic skill support
First Step to Success
Secondary Program (Grades K-1)
Contingencies for Learning Academic and Social Skills (CLASS)
Teaching and role-playing appropriate behavior
Continuous feedback with visual and verbal prompts
Whole class reinforcement for meeting goals
homeBase
Six weekly lessons: communication, cooperation, limit
setting, problem solving, making friends, developing
confidence
MST
Tertiary Program (Grades K-3)
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Family- and home-based treatment that strives to
change how youth function in their natural settings –
home, school, and neighborhood.
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Clinical trial of MST adapted for younger children
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Social-ecological framework
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Family preservation mode of service delivery
Who is eligible for MST?
School Referred (Principal as main contact)
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K-3rd grade student
BD label
Currently experiencing significant behavior problems
Additional ways to qualify:
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Lack of success in 1st Step Program
Fall screening of K-1 students
Exclusionary Criteria
Educational Labels
 MH, TBI, Autism, significant Visual/Hearing impairment, Dual
labels of BD and any excluded label (e.g., BD/MH)
Service History/Psychiatric Concerns
 Currently in psychiatric crisis (e.g., suicidal)
 More than 50% of the time over the past 2 years in out-of-home/
out-of-community placement or pattern of multiple placements
 Youth whose primary referral concern is internalizing behaviors
(e.g., depression)
 Youth with a Bipolar diagnosis
 Youth in foster care placements that are not potentially long-term
Why MST?
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Evidence-based intervention for antisocial and
delinquent adolescents
Effective in reducing criminal activity, antisocial
behavior, other behavior problems, and out-ofhome placements
Increases in family cohesion, adaptability, and
supportiveness (Henggeler et al, 1998)
Why MST?
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MST’s focus on families as the solution
U.S. Surgeon General: Report on Mental Health and
Report on Youth Violence
U.S. Department of Justice - OJJDP
NIDA, Center for Substance Treatment (CSAT) &
Center for Substance Abuse Prevention (CSAP)
National Association of State Mental Health
Program Directors (NASMHPD)
Washington State Institute of Public Policy
“Blueprints for Violence Prevention”
Adapted from MST Services (www.mstservices.com)
MST Assumptions & Beliefs
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Children’s behavior is influenced by their families,
friends, and community (and vice versa)
Families are the key to success
Families can live successfully without formal,
mandated services
Change can occur quickly
Therapists should be held accountable for achieving
outcomes
Research can provide guidance (i.e., empirically
supported treatments)
Adapted from MST Services (www.mstservices.com)
How MST works
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Treatment Site
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Provider
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Caseloads
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Home, school, neighborhood and
community
Single therapist (as part of, and
supported by a team)
4-6 families
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Length of Treatment
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4 to 6 months in most cases
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Typical MST “aftercare”
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No formal, mandated services in place
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Therapist Availability
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24 hr\7 day\wk team available
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Quality Assurance
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TAM,SAM, Phone consultation
Adapted from MST Services (www.mstservices.com)
MST Adaptations for K-3 Project
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Referrals from schools, not DJJ,DSS, CW
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Ages 5-9 with ED or DSM-IV label; MST typically
is implemented with youth ages 12-17
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Less emphasis on peers as a targeted area of
intervention
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K-3 youth not at imminent risk of placement; may
be a stronger focus on engagement of caregivers
Adapted from MST Services (www.mstservices.com)
MST Adaptations for K-3 Project
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Ensure supervisor has adequate knowledge base
regarding younger children and their families
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5-day initial training adapted to address evidence
base on early childhood risk and protective factors
& interventions
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Dr. Sonja Schoenwald of FSRC participates in
weekly telephone consultation in addition to the
MST consultant
Adapted from MST Services (www.mstservices.com)
MST Principles
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Nine principles of MST intervention design
and implementation
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Treatment fidelity and adherence is
measured with relation to these nine
principles
Adapted from MST Services (www.mstservices.com)
MST Treatment Principles
1. Finding the Fit
The primary purpose of assessment is to
understand the “fit” between the identified
problems and their broader systemic context.
2. Positive & Strength Focused
Therapeutic contacts should emphasize the positive
and should use systemic strengths as levers for
change.
MST Treatment Principles
3. Increasing Responsibility
Interventions should be designed to promote
responsibility and decrease irresponsible behavior
among family members.
4. Present-focused, Action-oriented & Welldefined
Interventions should be present-focused and
action-oriented, targeting specific and well-defined
problems.
MST Treatment Principles
5. Targeting Sequences
Interventions should target sequences of behavior
within and between multiple systems that maintain
identified problems.
6. Developmentally Appropriate
Interventions should be developmentally
appropriate and fit the developmental needs of the
youth.
MST Treatment Principles
7. Continuous Effort
Interventions should be designed to require daily or
weekly effort by family members.
8. Evaluation and Accountability
Interventions efficacy is evaluated continuously
from multiple perspectives, with providers assuming
accountability for overcoming barriers to successful
outcomes.
MST Treatment Principles
9. Generalization
Interventions 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.
Intervention Strategies
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Use of research-based treatment options
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Behavior Therapy including Parent Management Training
(PMT)
Cognitive behavior therapy
Pragmatic family therapies: Structural Family Therapy and
Strategic Family Therapy
Pharmacological interventions (e.g., for ADHD)
For K-3 project only:
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Components of Parent-Child Interaction Therapy (PCIT;
Eyeberg)
Components of The Incredible Years (Webster-Stratton)
Adapted from MST Services (www.mstservices.com)
Intervention Philosophy
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Services are comprehensive, individualized, and
address all identified drivers of the problem behaviors
Therapists are accountable for all outcomes
Families and communities are central and essential
partners in MST treatment
Barriers to services are removed (e.g., 24/7 availability
of team; scheduling meeting times that are convenient
to families)
Adapted from MST Services (www.mstservices.com)
Wait-List Control Group Design
Child Outcome Measures
Social
Child Behavior Checklist (CBCL); Behavioral and Emotional Rating Scale
(BERS); Social Skills Rating System (SSRS)
Academic
Woodcock-Johnson Tests of Academic Achievement, Third Edition (WJ-III);
Woodcock Reading Mastery Test – Revised (WRMT-R); Dynamic Indicators of
Basic Early Literacy Skills (DIBELS); Comprehensive Test of Phonological
Processing (CTOPP); Academic engaged time (AET)
Family Outcome Measures
Family Adaptability and Cohesion Scale – III (FACES-III); Parenting Stress
Index (PSI); Beck Depression Inventory (BDI-III)
Characteristics of Participating Schools
School
Total
Enrollment
% Free/Reduced
Lunch
% Minority
Status
% Student
Mobility
1
433
26.1
10.9
14.5
2
574
69.9
55.3
30.8
3
443
39.3
13.4
16.2
4
424
80.7
48.4
41.8
5
499
39.0
13.4
19.4
6
418
56.0
16.4
27.4
7
427
53.9
20.4
27.9
Child and Family Characteristics
1st Year Cohort
Data collected on 30 students referred for MST
 Data presented is intake data only
 12 month availability of program - outcome data still
being collected
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Child Demographics
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Gender
Males = 26 (87%)
Females = 4 (13%)
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Grade
Kindergarten = 4 (13%)
1st grade = 9 (30%)
2nd grade = 6 (20%)
3rd grade = 11 (36.7%)
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Ethnicity
Caucasian = 24 (80%)
African American = 4 (13%)
Hispanic/Latino = 1 (3%)
Native American = 1 (3%)
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School Services
Special Education = 24 (80%)
Title 1 = 3 (10%)
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Lunch Status
Regular = 12 (40%)
Free/Reduced = 18 (60%)
Child Developmental Risk Factors
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Prenatal
Maternal Medical Problems = 15 (50%)
Maternal Emotional Problems = 15 (50%)
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Natal
Child Medical Problems = 11 (37%)
Premature birth = 5 (17%)
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Family
Family History of Mental Illness = 12 (40%)
Family History of Criminal Activity = 15 (50%)
Family History of Substance Abuse = 11 (37%)
Family History of Domestic Violence = 16 (53%)
Adverse Family Composition = 24 (80%)
(e.g., divorce, separation)
Abuse
Physical = 7 (23%)
Sexual = 2 ( 7%)
Case Examples
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Examples of treatment principles and intervention
philosophy with case examples
Academic Achievement
(WJ-III & WJ Reading Mastery)
Mean Standard Score
110
105
100
100
96
96
95
90
85
Reading
Mathematics
Written Langauge
Social Adjustment (CBCL)
Mean Standard Score
75
70
70
68
65
60
60
55
50
Internalizing
Externalizing
Total Problems
Social Adjustment (SSRS)
140
122
Mean Standard Score
120
100
85
83
80
60
40
20
0
Social Skills
Problem Behaviors
Academic
Competence
Child Strengths (BERS)
10
Mean Standard Score
7.8
8
7.6
8.1
8.6
6.8
6
4
2
0
Interpersonal
Family Involvement
Intrapersonal
School Functioning
Affective
Percentile
Parental Stress (PSI)
110
100
90
80
70
60
50
40
30
20
10
0
85
90
88
Difficult Child
Total Score
65
Parent Distress Parent-Child
Dysfunction
Maternal Depression (BDI)
20
18
16
14
Mean Score
12
10.17
10
8
6
4
2
0
BDI Total Score
Family Functioning (FACES)
8
7
6
Mean Score
5
4.2
4
4
4.1
3
2
1
0
Cohesion
Adaptability
Type
Where are we now?
MST: 30 students in 2002-2003
40 students anticipated in 2003-2004
Contact Information
Jacquelyn A. Buckley, PhD, NCSP
Project Coordinator
[email protected]
Michael H. Epstein, EdD
Principal Investigator
[email protected]
Center for At-Risk Children's Services
University of Nebraska-Lincoln
Tricia Monzon, MA, LMHP, CPADAC
MST Supervisor
[email protected]
The Child Guidance Center
Lincoln, NE
For additional information about MST program
development, dissemination, and training, visit:
www.mstservices.com