1. 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

2. Mental Health Status of School Children Three types of children in school settings Exhibit intense problem behavior Not at risk At risk for problem behavior 1-7% 5-15% 80-90%

3. Three-Tiered Prevention Program Primary Program: Behavior and Academic Support & Enhancement (BASE) Secondary Program: First Step to Success Tertiary Program: Multisystemic Therapy (MST)

4. 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

5. 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

6. MST  Family- and home-based treatment that strives to change how youth function in their natural settings – home, school, and neighborhood.  Clinical trial of MST adapted for younger children  Social-ecological framework  Family preservation mode of service delivery Tertiary Program (Grades K-3)

7. Who is eligible for MST? School Referred (Principal as main contact)  K-3rd grade student  BD label  Currently experiencing significant behavior problems Additional ways to qualify:  Lack of success in 1st Step Program  Fall screening of K-1 students

8. 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 Exclusionary Criteria

9. Why MST? Evidence-based intervention for antisocial and delinquent adolescents Effective in reducing criminal activity, antisocial behavior, other behavior problems, and out-of- home placements Increases in family cohesion, adaptability, and supportiveness (Henggeler et al, 1998)

10. Why MST? 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)www.mstservices.com

11. MST Assumptions & Beliefs 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)www.mstservices.com

12. How MST works Treatment Site Provider Caseloads Length of Treatment Typical MST “aftercare” Therapist Availability Quality Assurance è Home, school, neighborhood and community è Single therapist (as part of, and supported by a team) è 4-6 families è 4 to 6 months in most cases è No formal, mandated services in place è 24 hr\7 day\wk team available è TAM,SAM, Phone consultation Adapted from MST Services (www.mstservices.com )www.mstservices.com

13. MST Adaptations for K-3 Project Referrals from schools, not DJJ,DSS, CW Ages 5-9 with ED or DSM-IV label; MST typically is implemented with youth ages 12-17 Less emphasis on peers as a targeted area of intervention 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)www.mstservices.com

14. MST Adaptations for K-3 Project Ensure supervisor has adequate knowledge base regarding younger children and their families 5-day initial training adapted to address evidence base on early childhood risk and protective factors & interventions Dr. Sonja Schoenwald of FSRC participates in weekly telephone consultation in addition to the MST consultant Adapted from MST Services (www.mstservices.com)www.mstservices.com

15. MST Principles Nine principles of MST intervention design and implementation Treatment fidelity and adherence is measured with relation to these nine principles Adapted from MST Services (www.mstservices.com)www.mstservices.com

16. 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.

17. 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 & Well- defined Interventions should be present-focused and action-oriented, targeting specific and well-defined problems.

18. 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.

19. 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.

20. 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.

21. Intervention Strategies Use of research-based treatment options  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:  Components of Parent-Child Interaction Therapy (PCIT; Eyeberg)  Components of The Incredible Years (Webster-Stratton) Adapted from MST Services (www.mstservices.com)www.mstservices.com

22. Intervention Philosophy 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)www.mstservices.com

23. 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)

24. Characteristics of Participating Schools

25. Child and Family Characteristics 1 st 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

26. Child Demographics Gender Males = 26 (87%) Females = 4 (13%) Grade Kindergarten = 4 (13%) 1 st grade = 9 (30%) 2 nd grade = 6 (20%) 3 rd grade = 11 (36.7%) Ethnicity Caucasian = 24 (80%) African American = 4 (13%) Hispanic/Latino = 1 (3%) Native American = 1 (3%) School Services Special Education = 24 (80%) Title 1 = 3 (10%) Lunch Status Regular = 12 (40%) Free/Reduced = 18 (60%)

27. Child Developmental Risk Factors Prenatal Maternal Medical Problems = 15 (50%) Maternal Emotional Problems = 15 (50%) Natal Child Medical Problems = 11 (37%) Premature birth = 5 (17%) 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%)

28. Case Examples Examples of treatment principles and intervention philosophy with case examples

29. Academic Achievement (WJ-III & WJ Reading Mastery) Mean Standard Score

30. Social Adjustment (CBCL) Mean Standard Score

31. Social Adjustment (SSRS) Mean Standard Score

32. Child Strengths (BERS) Mean Standard Score

33. Parental Stress (PSI) Percentile

34. Maternal Depression (BDI) Mean Score

35. Family Functioning (FACES) Mean Score

36. Where are we now? MST: 30 students in 2002-2003 40 students anticipated in 2003-2004

37. Contact Information Tricia Monzon, MA, LMHP, CPADAC MST Supervisor triciamonzon1@aol.com The Child Guidance Center Lincoln, NE Jacquelyn A. Buckley, PhD, NCSP Michael H. Epstein, EdD Project Coordinator Principal Investigator jbuckley2@unl.edujbuckley2@unl.edu mepstein1@unl.edumepstein1@unl.edu Center for At-Risk Children's Services University of Nebraska-Lincoln

38. For additional information about MST program development, dissemination, and training, visit: www.mstservices.com