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Young people at risk of developing anti-social personality disorder: the use of multisystemic therapy as an early intervention with the family
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Young people at risk of developing anti-social personality disorder: the use of multisystemic therapy as an early intervention with the family

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Speakers: Dr Simone Fox and Juliette Wait. First National Personality Disorder Congress, Birmingham, 19-20th November 2009.

Speakers: Dr Simone Fox and Juliette Wait. First National Personality Disorder Congress, Birmingham, 19-20th November 2009.

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  • 1. Young People at risk of developing ASPD: the use of multi-systemic therapy as an early intervention within the family Dr Simone Fox Chartered Clinical & Forensic Psychologist MST Supervisor Merton & Kingston Dr Juliette Wait Chartered Clinical Psychologist MST Supervisor Reading PD Congress 19 th November 2009
  • 2. Aims of Presentation
    • To think about Personality Disorder from an adolescent perspective
    • To develop an understanding of the risk factors in the development of antisocial PD
    • An overview of MST and how it addresses these risk factors
  • 3. Group Exercise
    • In pairs identify one risk and one protective factors for the onset of behavioural problems in adolescence;
      • Individual
      • Family
      • School
      • Peer group
      • Community
    • Feedback on flipchart
  • 4. Risk & Protective Factors
    • Ongoing involvement in community activities
    • Strong indigenous support network
    • High mobility
    • Low community support
    • High disorganisation
    • Criminal subculture
    Community
    • Commitment to schooling
    • Good school-home links
    • Good relationship with teacher(s)
    • Low achievement
    • Dropout
    • Low commitment to education
    • Aspects of school – e.g. weak structure & chaotic environment
    School
    • Bonding with pro-social peers
    • Association with deviant peers
    • Poor relationship skills
    • Low association with pro-social peers
    Peer
    • Attachment to parents
    • Supportive family environment
    • Marital harmony
    • Lack of monitoring
    • Ineffective discipline
    • Harsh and inconsistent discipline
    • Low warmth
    • High conflict
    • Parental difficulties e.g. drug abuse, psychiatric conditions, criminality
    Family
    • Intelligence
    • Being first born
    • Easy temperament
    • Conventional attitudes
    • Problem-solving skills
    • Low verbal skills
    • Favourable attitudes towards ASB
    • Psychiatric symptomatology
    • Cognitive bias to attribute hostile intentions to others
    Individual Protective Factors Risk Factors Context
  • 5.
    • Common findings of 50+ years of research: delinquency and drug use are determined by multiple risk factors:
      • Family (low monitoring, high conflict, etc.)
      • Peer group (law-breaking peers, etc.)
      • School (dropout, low achievement, etc.)
      • Community (  supports,  transiency, etc.)
      • Individual (low verbal and social skills, etc.)
    Delinquency is a Complex Behaviour
  • 6. Causal Models of Delinquency and Drug Use Condensed Longitudinal Model Family School Delinquent Peers Delinquent Behavior Prior Delinquent Behavior Low Parental Monitoring Low Affection High Conflict Low School Involvement Poor Academic Performance Elliott, Huizinga & Ageton (1985)
  • 7. Theoretical Assumptions
    • Children and adolescents live in a social ecology of interconnected systems that impact their behaviors in direct and indirect ways
    • These influences act in both directions (they are reciprocal and bi-directional)
    Based on Bronfenbrenner, Haley and Minuchin
  • 8. Ecological Model Child Family Peers School Neighborhood Community/Culture
  • 9. Implications for Effective Intervention
    • The research on delinquency and substance use suggests that, to be most effective , services should be:
    • Comprehensive and have the capacity to address all of the relevant risk factors present for each youth and family
    • Individualised to the strengths and needs of each youth and family
    • Delivered in the naturally occurring systems and be implemented in “ecologically valid” ways
  • 10. What is MST?
    • Intensive, goal oriented and time limited intervention
    • Community-based, family-driven
    • Targets the multiple causes of anti-social and criminal behaviour in young people
    • Highly structured clinical supervision and quality assurance processes
    • Strong track record of client engagement, retention and satisfaction
  • 11. Who is the target population for MST?
    • Family and key participants in the environment of young people
    • MST “client” is the entire ecology of the young person - family, peers, school, community
    • Age range 11-17 years
    • High risk of out-of-home placement eg. care, custody, residential school
    • Placement risk due to their behaviour at home / school / in the community
    • May be involved with the criminal justice system
  • 12. What is MST?
    • Focus is on families as the solution
    • Focus on empowering the caregivers / parents to solve current and future problems
    • Parents are full collaborators in planning and delivering interventions
    • Assumption - Children’s behaviour is strongly influenced by their families, friends and communities (and vice versa)
    • Works in partnership with a combination of systems (parents, family, peers, school and community) to address risk factors
  • 13. How does MST work?
    • Assessing and understanding the factors contributing to identified problems
    • Having clear goals to work towards
    • Prioritising key factors and interventions
    • Interventions based on techniques that have strong evidence base:
    • Behaviour therapy
    • Parent management training
    • Cognitive behavior therapy
    • Pragmatic family therapies
    • Pharmacological interventions (e.g., for ADHD)
    • Supporting the parent/carer in devising strategies to target factors contributing to the young person’s behaviour
  • 14. How is MST implemented?
    • Single therapist works intensively with 4 families at a time
    • Meetings at least 2-3 times a week
    • Community and home based
    • Out-of-hours service run by the team which is available to families 24 hours a day, 7 days a week
    • Team has 3-4 therapists and clinical supervisor
    • Involvement typically ranges from 3 to 5 months
  • 15. How is MST implemented?
    • Team provides the family with a single point of contact
    • MST team deliver all treatment
    • Typically no services are referred outside the MST team
    • Never ending focus on engagement and alignment with the primary caregiver and other key stakeholders – addressing barriers
    • MST team must be able to have a lead role in clinical decision making for each case
  • 16. MST Quality Assurance System
    • Team comprised of range of professionals – multi-disciplinary/multi-agency
    • Structured training – orientation and regular boosters
    • Frequent professional development planning
    • Weekly clinical supervision and case review
    • Weekly consultation with consultant in USA
    • Research validated adherence process – for therapists and supervisor
  • 17. What’s different?
    • Traditional models
    • Individual (family)
    • Clinic-based
    • Fixed times
    • High caseloads – less intensive
    • Open-ended
    • Supervision
    • MST
    • Ecological
    • Home-based
    • Flexible/24 hour
    • Low caseloads – 3x weekly +
    • Fixed goal-driven
    • Quality assurance
    NB Not better, just different approach to address a different need
  • 18. Why does it need to be different?
    • Multi-determined nature of serious antisocial behaviour
    • Risk factors span the ecology in which the child is embedded
    • Families with complex problems struggle to access traditional services
    • High costs of antisocial behaviour – incarceration, placement, victimisation
    • Therapist adherence predicts outcome
  • 19. Video
  • 20. References
    • Kazdin A. E., & Weisz, J. R. (1998). Identifying and developing empirically supported child and adolescent treatments. Journal of Consulting and Clinical Psychology , 66, 19-36.
    • Henggeler, S. W., Schoenwald, S. K., Borduin, C. M., Rowland, M. D., & Cunningham, P. B. (2009). Multisystemic treatment of antisocial behaviour in children and adolescents – 2 nd edition. New York: Guildford Press.
    • www.mstservices.com