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Following favorable psychosocial outcomes (e.g., decreased behavior problems, improved family relations) achieved in the first MST delinquency study (Henggeler et al., 1986), which used a quasi experimental design, three randomized trials of MST with violent and chronic juvenile offenders were conducted in the 1990s. In the Simpsonville, South Carolina Project, Henggeler, Melton, and Smith (1992) studied 84 juvenile offenders who were at imminent risk for out-of-home placement because of serious criminal activity. Youth and their families were randomly assigned to receive either MST or the usual services provided by the Department of Juvenile Justice (DJJ). At post treatment, youth who participated in MST reported less criminal activity than their counterparts in the usual services group; and at a 59-week follow-up, MST had reduced rearrests by 43%. In addition, usual services youth had an average of almost three times more weeks incarcerated (average = 16.2 weeks) than MST youth (average = 5.8 weeks). Moreover, treatment gains were maintained at long-term follow-up (Henggeler, Melton, Smith, Schoenwald, & Hanley, 1993). At 2.4 years post-referral, twice as many MST youth had not been rearrested (39%) as usual services youth (20%).

In the Missouri Delinquency Project (Borduin et al., 1995), participants were 176 chronic juvenile offenders and their families who were referred by the local DJJ. Families were randomly assigned to receive either MST or individual therapy (IT). Replicating results from the earlier studies, MST decreased youth behavior problems and improved family relations at post treatment. Four-year follow-up arrest data showed that youth that received MST were arrested less often and for less serious crimes than counterparts who received IT. Moreover, while youth who completed a full course of MST had the lowest rearrest rate (22.1%), those who received MST, but prematurely dropped out of treatment, had better rates of rearrest (46.6%) than IT completers (71.4%), IT dropouts (71.4%) or treatment refusers (87.5%). Moreover, an almost 14-year follow-up (Schaeffer & Borduin, 2005) showed that MST participants had 54% fewer arrests and spent 57% fewer days of confinement in adult detention facilities than did their IT counterparts. This differential in recidivism applied across violent, drug, and nonviolent offenses.

In the Multisite South Carolina Study, Henggeler, Melton et al. (1997) examined the role of treatment fidelity in the successful dissemination of MST. In contrast with previous clinical trials in which the developers of MST provided ongoing clinical supervision and consultation (i.e., quality assurance was high), MST experts were not significantly involved in treatment implementation and quality assurance was low. Participants were 155 chronic or violent juvenile offenders who were at risk of out-of home placement because of serious criminal involvement and their families. Youth and their families were randomly assigned to receive MST or the usual services offered by DJJ. Not surprisingly, MST treatment effect sizes were smaller than in previous studies that had greater quality assurance. Over a 1.7 year follow-up, MST reduced rearrests by 25%, which was lower than the 43% and 70% reductions in rearrest in the previous MST studies with serious juvenile offenders. Days incarcerated, however, were reduced by 47%. Importantly, high therapist adherence to the MST treatment protocols, as assessed by caregiver reports on the TAM, predicted fewer rearrests and incarcerations. Thus, the modest treatment effects for rearrest in this study might be attributed to considerable variance in therapists' adherence to MST principles.

The transport of MST programs to community settings began in the mid 1990s and provided an opportunity for independent evaluations of the effectiveness of MST in treating adolescent antisocial behavior, and two of these replications have been published. Ogden directed a 4-site randomized trial in which participants were 100 seriously antisocial adolescents in Norway (Norway does not have a juvenile justice system). The youths were randomized to MST versus usual Child Welfare Services conditions. Short-term outcomes at 6 months post recruitment showed that MST was significantly more effective at reducing youth internal and externalizing symptoms and out-of-home placements as well as increasing youth social competence and family satisfaction with treatment (Ogden & Halliday-Boykins, 2004). Importantly, analyses demonstrated differential site effects the one site with problematic adherence to the MST intervention protocols had the worst outcomes. In addition, a 2-year follow-up has shown that MST effects on out-of-home placements and youth internalizing and externalizing problems were maintained (Ogden & Hagen, in press). This study is important for demonstrating the effective transport of MST to distal community settings.

In the United States, Timmons-Mitchell and her colleagues (2006) have also provided an independent replication of MST effectiveness with juvenile offenders in community settings. Ninety-three juvenile offenders were randomized to MST versus treatment as usual (TAU) services. At 6 months post recruitment youths in the MST condition evidenced significantly improved functioning in several areas, and had a significantly fewer rearrests than TAU counterparts at 18-month follow-up. These results provide further support for the capacity of MST to achieve favorable outcomes when implemented in community practice settings.

In summary, across several trials with violent and chronic juvenile offenders, MST produced 25% to 70% decreases in long-term rates of rearrest, and 47% to 64% decreases in long-term rates of days in out-of-home placements. A recent meta-analysis that included most of these studies (Curtis, Ronan, & Borduin, 2004) indicated that the average MST effect size for both arrests and days incarcerated was .55, with efficacy studies having stronger effects than effectiveness studies.

Sheidow and Henggeler (in press) provide a comprehensive overview of MST substance-related research, which is a focus of much of the FRSC's current research portfolio. This work was prompted by the many similarities between the treatment needs of juvenile offenders and those of substance abusing adolescents (see Henggeler, 1993). 

Substance-related outcomes were examined in two of the early randomized trials of MST with violent and chronic juvenile offenders (Borduin et al., 1995; Henggeler et al., 1992), and these substance-related findings were published in a single report (Henggeler et al., 1991). Findings in the first study (Henggeler et al., 1992) showed MST treatment effects at post treatment for self-report alcohol and drug use. In the second study (Borduin et al., 1995), substance-related arrests at 4-year follow-up were 4% in the MST condition versus 16% in the comparison condition, a significant difference. Moreover, an almost 14-year follow-up of participants in this study showed that MST participants continued to have fewer drug related arrests than did their counterparts who received individual therapy (Schaeffer & Borduin, 2005). In a meta-analysis of family-based treatments of drug abuse(Stanton & Shadish, 1997), the MST effect sizes were among the highest of those reviewed.

Subsequent to the findings from these two trials, the effectiveness and transportability of MST was examined in a study with 118 juvenile offenders meeting DSM-III-R criteria for substance abuse (56%) or dependence (44%) and their families (Henggeler, Pickrel et al., 1999). Participants were randomly assigned to receive MST versus usual community services, which entailed probation services, outpatient substance abuse services (typically, weekly 12-step program meetings) or inpatient/residential treatment, and mental health services (public or private outpatient, school-based, family preservation, residential, and/or inpatient). Compared to the usual services condition, MST reduced self-reported alcohol and marijuana use at post treatment, decreased days incarcerated by 46% at the 6-month follow-up, decreased total days in out-of-home placement by 50% at 6-month follow-up (Schoenwald et al., 1996), and increased youth attendance in regular school settings (Brown, Henggeler, Schoenwald, Brondino, & Pickrel, 1999). Cost data from this study showed that the incremental cost of MST was offset by the reduced placement (i.e., incarceration, hospitalization, and residential treatment) of youths in the MST condition (Schoenwald et al., 1996). Moreover, a 4-year follow-up (Henggeler, Clingempeel et al., 2002). demonstrated significantly higher rates of marijuana abstinence, based on drug urine screens, for MST participants (55% abstinent) compared to participants who had received usual services (28% abstinent). The young adults who had participated in MST as youths 4 years earlier also engaged in significantly less criminal activity than did usual services participants, based on archival and self-report indices. For example, MST participants had an average of .15 convictions per year for violent crimesversus .57 convictions per year in the usual services group.

More recently, we have attempted to enhance MST substance-related outcomes by integrating contingency management (CM) interventions into MST treatment protocols. CM techniques (e.g., functional analysis of drug use, tracking and providing consequences for substance use) are theoretically and clinically compatible with MST, and CM has considerable empirical support (Petry, 2000; Roozen et al., 2004). Specifically, within the context of a randomized trial conducted in collaboration with juvenile drug court (Henggeler et al., in press), we evaluated (a) the effectiveness of juvenile drug court, per se; (b) the effects of integrating an evidence-based treatment (i.e., MST), as the community intervention component of the drug court process; and (c) whether the integration of CM techniques into the MST treatment protocol would improve substance use outcomes for MST. To conduct these comparisons, 161 juvenile offenders meeting diagnostic criteria for substanceabuse or dependence were randomized to one of four treatment conditions.

Family Court with Community Services: Youths appeared before a family court judge on average once or twice per year and received outpatient alcohol and drug abuse services from the local center of the state's substance abuse commission.

Drug Court with Community Services: Youths appeared before the drug court judge once a week for monitoring of drug use (urine screens) and participated in outpatient alcohol and drug abuse services from the local center of the state's substance abuse commission.

Drug Court with MST: Youths received an evidence-based treatment (MST) rather than community services in conjunction with drug court.

Drug Court with MST enhanced with Contingency Management: Youths received MST enhanced with key components of contingency management in conjunction with drug court.

Over a 1-year assessment period, measures of adolescent substance use, criminal behavior, mental health symptomatology, and days in out-of-home placement were assessed. In general, findings supported the view that drug court was more effective than family court services in decreasing rates of adolescent substance use and criminal behavior. Possibly due to the greatly increased surveillance of youths in drug court, however, these relative reductions in antisocial behavior did not translate to corresponding decreases in rearrest or incarceration. In addition, findings supported the view that the use of evidence-based treatments within the drug court context improved youth substance related outcomes. For example, during the first 4 months of drug court participation, 70% of the urine screens were positive for youths in the Drug Court with Community Services condition, in comparison with only 28% and 18% for counterparts in the Drug Court with MST and Drug Court with MST enhanced with Contingency Management conditions, respectively. These findings support the viability of juvenile drug courts and seem to show that CM can facilitate substance-related treatment gains when integrated into MST protocols. In addition, clinical- and cost-related outcomes are being examined in a 5-year follow-up. 

In summary, research findings have provided clear support for the effectiveness of MST in treating adolescent substance use problems. MST provides a comprehensive framework that can efficiently integrate specific interventions into a unified, methodical strategy. Based on this approach and experience from clinical trials, contingency management is a specific intervention that is consistent with the MST model and can be integrated readily into MST treatment for adolescent substance abuse.  

With the exception of higher rates of internalizing symptoms and deficient relations with same-age peers, research suggests that adolescent sexual offenders may have more in common with other delinquents than is generally assumed (Blaske, Borduin, Henggeler, & Mann, 1989; van Wijk et al., 2005). Such findings suggest that effective treatments for delinquency hold promise in treating juvenile sexual offenders. This proposition was first tested in a small randomized trial (N = 16) conducted by Borduin and his colleagues (Borduin, Henggeler, Blaske, & Stein, 1990). Juvenile sex offenders were randomized to MST versus individual counseling treatment conditions. At a 3-years follow-up, MST was significantly more effective at preventing recidivism for sexual offending (i.e., 12.5% for MST vs. 75% of individual counseling) and other criminal offending (25% for MST vs. 50% for individual counseling).  

These excellent results led to a larger study by Borduin and colleagues (preliminary findings reported in Borduin & Schaeffer, 2001) in which 48 juvenile sex offenders (50% had arrests for aggressive sexual offenses) and their families were randomized to MST versus usual sex offender treatment conditions. MST was significantly more effective than usual services at decreasing youth behavior problems and symptomatology, improving family relations, decreasing violence toward peers, and improving academic performance. Importantly, at a 9-year follow-up, MST was also significantly more effective at preventing sexual offending (12.5% recidivism for MST vs. 42% for usual services), other criminal offending (29% for MST vs. 63% for usual services), and incarceration (i.e., MST produced a 62% decrease in days incarcerated during adulthood). Finally, highly significant cost benefits were demonstrated for both aggressive and nonaggressive sex offenders treated with MST.

The promising results from these two efficacy trials (i.e., doctoral students as therapists, Borduin as the clinical supervisor) formed the foundation for a larger (N = 160) effectiveness trial (i.e., using community-based practitioners) that is currently in progress, with Henggeler, Letourneau, Borduin, and Schewe as the investigators. In this trial, the MST adaptations for juvenile sex offenders (MST- Problem Sexual Behavior [MST-PSB]) have been clearly specified and include clear family safety plans for community protection, interventions to address the offender's grooming strategies for victims, and interventions to reduce family denial and minimization of the offense. This larger trial is comparing MST-PSB with a traditional cognitive behavioral group sex offender treatment delivered by juvenile probation. Youths adjudicated for hands-on sex crimes are being recruited for participation, and outcomes are being followed for 24 months post recruitment. Outcomes analyses are anticipated for 2008. If this effectiveness study proves as successful as the two efficacy studies, MST will be conceptualized as a treatment for youth with delinquent behaviors, including aggressive and nonaggressive sexual offenses. 

In light of the favorable decreases in psychiatric symptoms in three MST studies with juvenile offenders (Borduin et al., 1995; Henggeler et al., 1997; Henggeler et al., 1986) and the lack of evidence for the effectiveness of inpatient psychiatric hospitalization, a randomized clinical trial was conducted to examine the viability of MST as an alternative to the inpatient treatment of youths presenting psychiatric emergencies (e.g.., suicidal, homicidal, psychotic). As described in the corresponding treatment manual (Henggeler, Schoenwald et al., 2002), several clinical adaptations were made to the basic MST model to better address the needs of youths presenting psychiatric emergencies and their families (MST- Psychiatry). The MST- Psychiatry team received increased resources (e.g., decreased caseloads, additional training in evidence-based practices for adult psychopathology and substance abuse, increased clinical supervision, a crisis caseworker, and a continuum of placement options such as shelters and the hospital inpatient unit) to address the mental health and substance use needs of the youths and their caregivers; and child psychiatry (i.e., evidence-based pharmacotherapy) was fully integrated into the intervention model. 

Participants included 156 youths presenting psychiatric crises and approved for emergency hospitalization by an independent physician. These participants were recruited in local emergency rooms and the admissions office of the child psychiatric hospital. Following recruitment, youths and their families were randomized to MST- Psychiatry or admission to the inpatient unit. For youths randomized to MST- Psychiatry, the treatment team attempted to stabilize the psychiatric emergency outside the hospital if at all possible with youth safety the overriding priority. Clinical and service outcomes at 4-months post study entry strongly favored MST- Psychiatry (Henggeler et al., 1999). In comparison with psychiatric hospitalization followed by usual community services, MST- Psychiatry was significantly more effective at decreasing youth symptomatology, improving family relations, and increasing school attendance. Moreover, MST- Psychiatry resulted in a 72% reduction in days hospitalized and a 50% reduction in other out of home placements (Schoenwald, Ward, Henggeler, & Rowland, 2000). At an approximately 16 month follow-up, MST- Psychiatry was significantly more effective at decreasing rates of attempted suicide (Huey et al., 2004), but the favorable short-term clinical, school, and placement results dissipated (Henggeler et al., 2003). Similarly, economic analyses (Sheidow et al., 2004) showed that MST- Psychiatry produced better outcomes at a lower cost during the initial 4 months post recruitment, but equivalent costs and outcomes during the follow-up period.  

The favorable short-term findings in the alternative to hospitalization study have been replicated recently by Rowland et al. (2005). In a study with Hawaii's Felix Class Youths, 31 youths with serious emotional disturbance at imminent risk of out-of-home placement were randomized to MST- Psychiatry versus the intensive Hawaii Continuum of Care. At 6 months after intake and in comparison with counterparts receiving the Continuum of Care services, youths in the MST- Psychiatry condition reported significantly greater reductions in externalizing symptoms, internalizing symptoms, and minor criminal activity; and archival records showed that MST- Psychiatry youths experienced 68% fewer days in out-of-home placements. Together, these studies provide strong support for the capacity of MST- Psychiatry to produce favorable short-term clinical and service outcomes for youths presenting serious psychiatric problems. However, in contrast with the favorable long-term outcomes that MST has achieved for criminal activity (Schaeffer & Borduin, 2005) and drug use (Henggeler, Clingempeel et al., 2002), these favorable short-term outcomes have not been sustained for this challenging psychiatric population.

Addressing the psychosocial, mental health, and substance abuse needs of maltreating families child abuse and neglect has become one of the leading areas of treatment development and research among FSRC investigators. The foundation of this research was based on the first randomized trial of MST that was conducted almost 20 years ago (Brunk, Henggeler, & Whelan, 1987) with 33 maltreating families. Families were randomized to MST versus behavioral parent training conditions, and post-treatment outcomes showed that family interactions for families in the MST condition changed in ways that reflected the use of more favorable parenting strategies. More recently, Swenson and her colleagues (Saldana, Henggeler, Faldowski, Ward) have completed a randomized trial with 86 families in which the adolescent has been physically abused. In this study, MST adapted for maltreatment (MST-Child Abuse and Neglect; MST-CAN) is being compared with an evidence-based behavioral parent training condition, and clinical (e.g., symptoms, parenting, maltreatment) and service (e.g., placement and cost) level outcomes are being examined through 16 months post recruitment. MST-CAN includes several important clinical adaptations to the basic MST model, including interventions for post-traumatic stress disorder and rigorous guidelines for assuring child safety. This work has led to additional projects that have recently begun that integrate MST-CAN with Reinforcement Based Therapy (Jones, Wong, Tuten, & Stitzer, 2005) in the treatment of families in which the caregiver has a significant substance abuse problem that is contributing to the identified maltreatment.

Researchers at Wayne State University have taken the lead in adapting and evaluating the use of MST for improving the health outcomes of youths with challenging and costly health care problems (MST-Health Care [MST-HC). MST was selected as the platform for this work because of its capacity to overcome barriers to service access and to address the multidetermined nature of difficulties in following complex medical adherence regimens. Encouraged by results from a successful pilot study (Ellis, Naar-King, Frey, Rowland, & Greger, 2003), Ellis, Naar-King and their colleagues evaluated the capacity of MST-HC to improve the health status of adolescents with type 1 diabetes who had chronically poor metabolic control (Ellis, Frey et al., 2005; Ellis, Frey et al., in press). In a randomized design, 127 inner-city adolescents with chronically poor metabolic control were randomized to receive either MST-HC with standard medical care or standard medical care. At 7 months post referral, significant findings favoring the MST-HC condition emerged for several key outcomes. Youths in the MST-HC condition, in comparison with counterparts receiving standard care alone, had improved metabolic control, engaged in blood testing more frequently, reported less diabetes-related stress, and had fewer diabetes-related inpatient hospitalizations, which led to significantly lower medical charges and direct care costs (Ellis, Naar-King et al., 2005). Moreover, mediational analyses showed that MST-HC improved metabolic control through increased regimen adherence. The investigators are currently examining the long-term stability of these favorable outcomes. 

In light of the promising outcomes for youths with poorly controlled diabetes, this research group is testing adaptations of the MST model for other challenging health problems. For example and again bolstered by successful pilot research (Cunningham, Naar-King, Ellis, Pejuan, & Secord, in press), Ellis, Naar-King and colleagues (Ellis, Naar-King, Cunningham, & Secord, in press) conducted an uncontrolled study to examine the capacity of MST-HC to reduce viral loads in 19 children with perinatally acquired HIV who exhibited high viral loads in the absence of viral resistance. By focusing interventions on addressing identified barriers to medication compliance, the average viral loads for these youths decreased from 37,972 to 1,848 during the 6 months of MST-HC, and these reductions were stable during a 3-month follow-up. The investigators plan to conduct a more rigorous (i.e., randomized) evaluation of MST-HC with HIV+ youths who have high viral loads. In addition, Naar-King, Ellis and colleagues have recently been funded to adapt and pilot test MST-HC to improve food choices and weight loss in obese African American youth. This research team is clearly forging new ground in the extension and adaptation of MST for challenging and costly health care problems, and their commitment to rigorous research is exemplary.

One of the long-term goals of the MST quality assurance system is to develop strategies that enable continuous tracking of therapist adherence and youth outcomes. Such a system, however, requires the demonstration of empirical linkages between key components of quality assurance. This section describes the empirical status of the linkages shown in Figure 1.

Five published studies have demonstrated significant associations between therapist fidelity and youth outcomes. Analyses of data collected in two randomized trials showed that caregiver reports of high adherence on the MST therapist adherence measure (TAM) during treatment were associated with low rates of rearrest and incarceration of chronic juvenile offenders at a 1.7 year follow-up (Henggeler et al., 1997) and with decreased criminal activity and out-of-home placement in substance abusing juvenile offenders approximately 12 months post-referral (Henggeler, Pickrel, & Brondino, 1999). Using data from these two randomized trials, findings from Huey, Henggeler, Brondino, and Pickrel (2000) and Schoenwald et al. (2000) supported the view that therapist adherence to MST principles influences those processes (e.g., family relations, association with deviant peers) that sustain adolescent antisocial behavior. In addition, the 45-site MST transportability study (Schoenwald, Sheidow, Letourneau, & Liao, 2003) discussed subsequently, also demonstrated a significant association between therapist adherence and youth outcomes. Thus, the connection between therapist fidelity to MST treatment principles and improved youth outcomes (see Figure 1) is relatively well established. 

Two large scale studies have examined additional linkages in the MST quality assurance system depicted in Figure 1 (above). A 9-site study with 74 MST therapists, 12 MST supervisors, and 285 families of youths presenting serious clinical problems examined the link between MST supervisory practices and therapist fidelity in community-based MST programs. Findings showed that supervisor expertise in MST and empirically supported treatments was associated positively with therapist fidelity to MST treatment protocols (Henggeler, Schoenwald, Liao, Letourneau, & Edwards, 2002). In contrast with expectations, however, supervisory focus on MST treatment principles and the development of therapist competence were associated with low therapist adherence. To explain these latter findings, therapist adherence difficulties were hypothesized as the driver of these appropriate supervisor behaviors.

In what might be the most extensive study of the functioning of an evidence-based practice in community settings that has been conducted to date, Schoenwald and her colleagues have conducted a 45-site transportability study that included 405 MST therapists and 1,711 families that these therapists treated (Schoenwald, Letourneau, & Halliday-Boykins, 2005; Schoenwald, Sheidow, & Letourneau, 2004; Schoenwald et al., 2003). One set of findings (Schoenwald et al., 2004) from this project showed that the competence of MST consultants (see Figure 1, above) was associated with increased therapist adherence and improved youth outcomes. On the other hand, when consultants focused on maintaining a supportive alliance with therapists, especially in the absence of consultant competence, therapist adherence and youth outcomes were attenuated. These findings demonstrate the important role that "experts" can play in the effective transport of evidence-based practice to community settings, but caution that not all consultative emphases are useful in achieving program goals. Other findings (Schoenwald et al., 2003) have depicted complex relations by which the organizational climate and structure of provider agencies can either enhance or mitigate therapist adherence and corresponding youth outcomes. In addition, consistent with findings from the 9-site transportability study (Schoenwald, Halliday-Boykins, & Henggeler, 2003), therapist-caregiver similarity on ethnicity and gender have emerged as important predictors of therapist adherence and youth outcomes (Halliday-Boykins, Schoenwald, & Letourneau, 2005; Schoenwald et al., 2005).

In sum, research on the MST quality assurance system is finding anticipated and unanticipated associations among the various linkages depicted in Figure 1 (above). Importantly, this work will continue to inform efforts to transport MST to community based providers effectively in ways that support the work of therapists, supervisors, and other stakeholders to achieve the same types of favorable outcomes that have been obtained in MST randomized trials for youths presenting serious clinical problems.

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Ellis, D. A., Naar-King, S., Frey, M. A., Templin, T., Rowland, M., & Cakan, N. (2005). Multisystemic treatment of poorly controlled type 1 diabetes: Effects on medical resource utilization. Journal of Pediatric Psychology, 30, 656-666.

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Henggeler, S. W., Halliday-Boykins, C. A., Cunningham, P. B., Randall, J., Shapiro, S. B., & Chapman, J. E. (in press). Juvenile drug court: Enhancing outcomes by integrating evidence-based treatments. Journal of Consulting and Clinical Psychology.

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