Multisystemic Therapy for Disruptive Behavior Problems in Youths With Autism Spectrum Disorders: A Progress Report

Youths with autism spectrum disorders (ASD) often engage in serious disruptive behaviors that interfere with their ability to successfully manage day‐to‐day responsibilities and contribute to relationship problems with caregivers, peers, and teachers. Effective treatments are needed to address the factors linked with disruptive behavior problems in this population of youths. Multisystemic therapy (MST) is a comprehensive family‐ and community‐based treatment approach that has been effective with other difficult‐to‐treat populations of youths and holds promise for youths with ASD. In this article, we review the broad range of factors associated with disruptive behaviors among youths with ASD and discuss how MST interventions can be adapted to address those factors. We also present a framework for our adaptation of the MST model for youths with ASD. This framework includes a recently completed pilot study as well as an ongoing efficacy trial that together have served to identify key interventions for our adaptation of the MST model.     

An Evaluation of Mechanisms of Change in Multisystemic Therapy for Juvenile Justice‐Involved Youths A Decade Following Treatment

Although researchers have identified the more immediate mechanisms of change in family‐based treatments for juvenile justice‐involved youths, it is not known whether these same mechanisms continue to prevent criminal offending into adulthood. The present study evaluated whether caregiver‐directed improvements in family relations, youth prosocial peer relations, and youth academic performance during multisystemic therapy (MST) for serious and violent juvenile offenders had an impact on young adult involvement in criminal activity and sentencing 10.2 years following treatment. The results showed that improvements in family relations were associated with reduced odds of criminal outcomes a decade later for former MST participants. Furthermore, improvements in youth prosocial peer relations and academic performance were also related to lower odds of long‐term criminal activity. These results are consistent with the underlying theory of change in family‐based treatments and demonstrate that caregivers are critical to achieving and sustaining decreased antisocial behavior for youths with serious and violent criminal histories.     

School enrolment following multisystemic treatment: A register-based examination among youth with severe behavioural problems

This article addresses the ongoing debate about the effectiveness of multisystemic treatment (MST) by examining school enrolment at age 18 among youths who have received MST. The analyses are restricted to youths who engage in antisocial behaviour and/or substance abuse. We used propensity score matching to compare school enrolment between youths who had received MST and a control group who had not received MST. The analyses of population data showed a somewhat lower school enrolment in the MST group compared with youths receiving treatment as usual.     

Multisystemic Treatment of Juvenile Sexual Offenders

Abstract

Multisystemic therapy (MST)is an ecologically-based treatment model that has proven effective with violent and chronic juvenile offenders and that holds promise with juvenile sexual offenders. This article describes the empirical underpinnings, theoretical foundation, and clinical features of MST and provides a brief review of MST outcome studies with juvenile sexual offenders. The theoretical foundation and clinical features of MST draw upon empirical findings regarding the multidetermined nature of serious antisocial behavior as well as upon social-ecological models of behavior in which the youth and family's school, work, peers, and neighborhood are viewed as interconnected systems with dynamic and reciprocal influences on the behavior of family members. In two randomized trials with juvenile sexual offenders, MST has had positive effects on key social-ecological factors (e.g., family affective relations, peer relations, school performance) associated with sexual offending and has demonstrated long-term reductions in criminal activity and incarceration. The success of MST can be attributed primarily to (a) the match between MST intervention foci and empirically identified correlates/causes of sexual offending in youths and (b) the flexible use of well-validated intervention strategies in the natural environment.     

Harnessing the Power of Play in Emotionally Focused Family Therapy With Preschool Children

Emotionally focused family therapy (EFFT) is an attachment‐based therapy model that has been used with older children and adolescents. More recently, it has been suggested for use with young children. EFFT holds promise as a clinical treatment for young children coping with attachment problems, but more detailed guidelines are needed for implementing the model with this age‐group. Whereas preschool and kindergarten age children are less able to participate in talk therapy than older children, accommodations need to be made to this approach when the identified patient is a young child. This article offers a variety of play therapy activities that may be incorporated within an EFFT framework to strengthen the emotional bonds in families with children ages four to six.     

Punks,Goths, and Other Eye‐Catching Peer Crowds: Do They Fulfill a Function for Shy Youths?

Adolescent peer crowds such as Punks and Goths are mainly identified by their strikingly unusual or even shocking appearances. Although many studies find these crowds, few have tried to explain why some youths take on these startling or shocking appearances. We hypothesized that an off‐putting appearance is a way to cope with behavioral inhibition by limiting social contacts. Using data from 1,200 7th–11th graders, we compared peer crowds characterized by their startling appearance (“Radical” crowds) with three theoretically relevant comparison groups. Results showed that youths affiliating with Radical crowds were more inhibited than other youths, including those in crowds previously shown to be shy or socially anxious. Inhibited Radicals, however, had poorer emotional adjustment than inhibited youths in other crowds. If Radical styles are a way for inhibited youths to cope by limiting social contacts, the strategy does not seem to be beneficial for emotional adjustment.     

Relationships of sexual, physical, and emotional abuse to emotional and behavioral problems among incarcerated adolescents

This study examined the relationships of sexual, physical and emotional abuse to emotional (internalizing) and behavioral (externalizing) problems among incarcerated girls and boys. Participants were youth who were remanded to the correctional facilities within a statewide juvenile correctional system in a southern state in the United States of America. Each participant completed a structured interview regarding abuse history, emotional and behavioral difficulties, and demographic characteristics. Multiple regression analyses indicated that girls were more likely than boys to internalize their problems. The only abuse variable that was positively and significantly associated with emotional problems was emotional abuse. Greater behavioral problems were significantly related to youths being younger in age, white ethnicity, history of sexual abuse, and history of physical abuse. There were overall gender differences for internalizing problems, but not for externalizing problems among incarcerated adolescents. Furthermore, physical and sexual abuses were related to externalizing problems but not to internalizing problems. Thus, different types of abuse appear to have different effects on adolescent behavior. Implications for future research and practice are discussed.     

Relationships of Sexual,Physical, and Emotional Abuse to Emotional and Behavioral Problems Among Incarcerated Adolescents

ABSTRACT

This study examined the relationships of sexual, physical and emotional abuse to emotional (internalizing) and behavioral (externalizing) problems among incarcerated girls and boys. Participants were youth who were remanded to the correctional facilities within a statewide juvenile correctional system in a southern state in the United States of America. Each participant completed a structured interview regarding abuse history, emotional and behavioral difficulties, and demographic characteristics. Multiple regression analyses indicated that girls were more likely than boys to internalize their problems. The only abuse variable that was positively and significantly associated with emotional problems was emotional abuse. Greater behavioral problems were significantly related to youths being younger in age, white ethnicity, history of sexual abuse, and history of physical abuse. There were overall gender differences for internalizing problems, but not for externalizing problems among incarcerated adolescents. Furthermore, physical and sexual abuses were related to externalizing problems but not to internalizing problems. Thus, different types of abuse appear to have different effects on adolescent behavior. Implications for future research and practice are discussed.     

Associations Between Social Support Network Characteristics and Receipt of Emotional and Material Support Among a Sample of Male Sexual Minority Youths

Few studies have examined how social support network characteristics are related to perceived receipt of social support among male sexual minority youths. Using egocentric network data collected from a study of male sexual minority youths (N = 592), multivariable logistic regression analyses examined distinct associations between individual and social network characteristics with receipt of (1) emotional and (2) material support. In multivariable models, frequent communication and having friends in one's network yielded a twofold increase in the likelihood of receiving emotional support whereas frequent communication was associated with an almost threefold higher likelihood of perceived material support. Finally, greater internalized homophobia and personal experiences of gay-related stigma were inversely associated with perceived receipt of emotional and material support, respectively. Understanding the evolving social context and social interactions of this new generation of male sexual minority youths is warranted in order to understand the broader, contextual factors associated with their overall health and well-being.     

Bad Boys or Poor Parents: Relations to Female Juvenile Delinquency

This study examined the interrelations between parental relationships, romantic relationships, and antisocial behavior among female and male juvenile delinquents. Participants from a diverse sample of 1,354 adolescents (14–17 years) adjudicated of a serious (i.e. felony) offense were matched based on age, race, and committing offense, yielding a sample of 184 girls matched with 170 boys. Results indicate that while female offenders are more likely to date boys 2 years their senior, age difference alone is not directly related to self‐reported offending. Instead, findings suggest that girls who engage in self‐reported delinquent behavior are more likely to experience a high degree of antisocial encouragement exerted on them by their current romantic partner. Interestingly, this relation varies with the quality (warmth) of parental relationships and the romantic partner's level of antisocial encouragement, with the association between partner encouragement and self‐reported offending being strongest among youths reporting warm relationships with their opposite‐sex parent.     

The relationship of trauma exposure to sex offending behavior among male juvenile offenders

The most common type of adult and juvenile sex offender treatment utilizes a Relapse Prevention (RP) model. In RP clients learn about their offense cycle with an emphasis on recognizing high-risk situations and negative emotional states that can be precursors or triggers to offending behavior. This study identifies ways that traumatic experiences and trauma-associated feelings can be offense triggers for juvenile sex offenders. Researchers interviewed the treating clinicians of 40 male juvenile sex offenders who received at least six months of RP sex offender treatment. Results showed that 95% of the youths had experienced a Post Traumatic Stress Disorder (PTSD) Criterion A traumatic event and that 65% met criteria for PTSD based on clinician judgments. Overall, clinicians identified prior trauma exposure as being related to the offense triggers in 85% of offenders. Specifically, the following trauma-related feelings were identified as offense triggers: intense fear in 37.5% of sex offenders, helplessness in 55%, and horror in 20%. Implications for sex offender treatment programs are discussed.     

Multidimensional Family Therapy: A Science‐Based Treatment System

MDFT is a family‐based intervention for adolescent substance abuse and associated mental health and behavioural problems (Liddle, 2010). Integrative in several ways, MDFT uses an ecological or contextual conceptual framework to understand the developmental tasks of teens and their families. Research‐derived knowledge about risk and protective factors, and proximal causes, correlates and contributors to adolescent drug and related problems inform clinical thinking and interventions with every case. A multisystems approach, MDFT assesses and intervenes in four areas: (1) the adolescent as an individual and a member of a family and peer network; (2) the parent(s), both as individual adults and in his or her role as mother; father or caregiver; (3) the family environment and family relationships, as manifested in day‐to‐day family transactional patterns; and (4) extrafamilial sources of influence such as peers, school and juvenile justice. Interventions are made within and coordinated across domains. Progress in one area or with one person has implications for and use in others. Individual meetings with parent(s) and teen set the stage for family sessions, and family meetings may offer content and new outcomes that need to be brought to extrafamily meetings with juvenile justice or school personnel. MDFT was developed and tested as a treatment system rather than a one‐size‐fits‐all approach. A treatment system offers different versions of a clinical model that vary according to factors such as clinical sample characteristics (older versus younger adolescents, juvenile justice involved versus no involvement in juvenile justice systems), and treatment parameters (type of clinical setting and treatment dose).     

Sexual modes questionnaire: Measure to assess the interaction among cognitions,emotions, and sexual response

The goal of the present article is to present a new measure developed to assess cognitive and emotional factors of sexual function. This instrument was developed especially to test some hypotheses derived from Beck's new theoretical conceptualization (the modes theory; A. T. Beck, 1996). This model, characterized by its systemic and integrated approach, constitutes a remarkable development from a linear to a network perspective of the cognitive‐emotional‐behavioral processes. The new concept of mode, as a composite of schemas (cognitive, emotional, and behavioral) interacting together, is theoretically sound and supported by recent research findings from clinical and experimental sets (see A. T. Beck, 1996, for a revision). Our aim is to develop a new measure specifically created to assess these integrated and interdependent processes in the field of sexuality. The Sexual Modes Questionnaire (SMQ; male and female versions) is a combined measure constituted by three interdependent subscales: automatic thoughts, emotions, and sexual response presented during sexual activity. Psychometric studies showed good reliability and validity results in both versions, and high correlations between several dimensions of the three subscales support the concept of mode and its interactional character. Moreover, the capacity showed by the SMQ to discriminate between sexually functional and dysfunctional subjects and its high correlations with measures of sexual functioning emphasize the role of cognitive‐emotional processes on sexual problems, supporting the clinical value of the measure.     

Treatment outcomes among adolescents with substance abuse problems: the relationship between comorbidities and post-treatment substance involvement

This study examines comorbid mental disorders in relation to post-treatment outcomes (12 months post-intake) among adolescents (N=419) who entered three residential drug treatment programs. When contrasted with youths who had no comorbid mental disorders or youths with a single comorbid condition, those with combined internalizing and externalizing disorders (mixed comorbidity) had higher levels of substance-related problems and poly-drug use at entry to treatment, and poorer outcomes, e.g. relapse, particularly evident for drugs other than alcohol or marijuana. A significantly higher proportion of those with mixed comorbidity were admitted to short term residential treatment, as compared to long term residential care. However, the effects of comorbidity were independent of both planned and actual length of stay, suggesting that comorbidities can negatively impact treatment outcome in multiple ways, apart from length of stay. Since co-occurring problems appear to profoundly limit treatment effectiveness, treatment strategies that address comorbidity are needed to improve outcomes.     

Family Support Groups for Family Members of Mentally Ill Offenders: Therapeutic Factors

This study investigates therapeutic factors of a Family Support Group (FSG) intervention for family members of mentally ill offenders. Seventeen family members completed the ‘Group Therapeutic Factors‐Client Questionnaire’ (GTF‐CQ‐28) during four sessions of two FSGs. Results indicate that family members experienced the following therapeutic factors over the course of treatment: the relational climate, interactional confirmation, expressing and experiencing mutual positive feelings, forgetting own problems, hope from seeing progress in others, guidance from therapists, and getting interpersonal feedback treatment. The therapeutic factors, including learning by observation, support from the group, and universality of problems, correlated with a decrease in self‐blame, improved emotional well‐being, and experiencing less loss of control over one's life, respectively. Further, family members were satisfied with what the FSG has provided for them personally and for the relation with their relative. Finally, clinical implications of the FSG are discussed. The study sheds light on valuable therapeutic factors within an FSG and the important role of therapists.     

Youth service caseworkers: Social and legal factors affecting their recommendation to place youths in secure care facilities

This study examines the effects of social and legal variables on youth service caseworkers' recommendation to place youths in a secure care setting. While the findings of this study indicate that caseworkers' recommendation to place youths in such a facility is primarily influenced by their juvenile delinquency or legal background characteristics, the social variable “family composition” has a significant impact on the recommendation. This suggests that caseworkers view single-parent families as less capable than two-parent families of managing youths' serious delinquency problems and, therefore, are more likely to recommend youths from single-parent families for secure care placement consideration. The fact that legal variables are the strongest predictors of secure care decision outcomes indicates that objective criteria are being used to determine which youths to consider for secure care placement. Also, it is found that the more offenses that are committed the more likely that one will be a violent offense. This finding implies that the issue of serious juvenile delinquency should be examined and dealt with from a broad juvenile justice perspective directed at prevention as opposed to a limited focus on only the secure care process.     

Parents and Peers in Relation to Early Adolescent Problem Behavior

Concurrent and prospective associations between parent‐youth dyadic hostility and adolescent externalizing and internalizing problem behavior were examined in a sample of 416 families. Parenting control, parents’ well‐being, and youths’ affiliation with deviant peers were included as integral covariates. Information from multiple sources was analyzed using structural equation modeling. Concurrently, youth externalizing problems were associated with dyadic hostility, deviant peers, inadequate parenting control, and fathers’ well‐being (inversely). Internalizing problems were associated with inadequate parenting control and lower levels of fathers’ well‐being. Prospectively, some of these relations continued over 2 years, with a few new associations emerging. A process model is proposed in which parent‐youth dyadic hostility during early adolescence influences parenting, peer relations, and parents’ well‐being over time.     

Collaborative Treatment for Sexual Behavior Problems in an Adolescent Residential Center

Abstract

Many residential treatment and sex offender programs for adolescents historically have used coercion-based interventions. Treatment programs employing coercive techniques often replicate the same destructive and intrusive behaviors they seek to eliminate. Tension between departments coupled with poor communication and discomfort around sexual behavior issues within the staff of residential treatment centers are more likely to inhibit the progress of the youths they serve.

Collaboration among residential, educational, and clinical components enables staff to work in a direct, genuine, and respectful fashion with students who have histories of sexually abusive behavior. It further assists in maintaining a safe and predictable environment for these students. Finally, it helps students eliminate destructive behaviors by directly and consistently addressing four key areas: sexually abusive behavior, antisocial attitudes, social/emotional functioning, and overall self-care. It is not the author's intention to hold Bennington School, Inc.up as a model residential treatment program or to criticize other residential facilities. Rather, it is hoped that what is working in Bennington may be helpful to others.

Many who have worked on the front lines of residential treatment with sexually abusive adolescents have received training in elements specific to sexually abusive behavior. The origins of treatment for youth who have sexually abused were noteworthy for their lack of offense-specific interventions (National Adolescent Perpetration Network, 1993). However, a wealth of literature soon emerged addressing the need for assessment and treatment techniques specific to this population (Perry & Orchard, 1992; Barbaree, Marshall & Hudson, 1993). Much of this literature made assumptions regarding high levels of chronicity (Perry & Orchard,1992) while other contributions stressed the role of denial and minimization (Barbaree & Cortoni, 1993). As a result, while many issue-specific forms of assessment and treatment were developed, they often did not take into account other developmental needs and issues in the lives of sexually abusive youths (Lane, 1997).

Concurrent with this emerging research was a substantial increase in the number of treatment programs for juvenile sex offenders (National Adolescent Perpetration Network, 1993). In this context, it is not surprising that many treatment programs relied heavily on treatment targeting denial, minimization, and perceived sexual deviance without taking into account other treatment needs of youths. Although a recent literature review of adolescent residential programs (Curwen, 2000) notes a trend away from shame-based approaches, there appears to be less clarity on specific criteria on which to base residential treatment of adolescents who have sexually abused (Curwen, 2000).

Finally, recent research shows that among adult populations, accepting responsibility for abusive behavior in treatment is more likely to result from a warm, genuine, and empathic treatment style (Marshall, Fernandez, & Anderson, 1999). Group therapy participation, similarly, results from encouragement, open questions, and nonconfrontational challenge. The emerging themes of recent trends and research should inspire those at the front lines of residential treatment to reconsider not just basic treatment approaches, but the most minute elements of their interactions with youths.     

Attachment‐Based Family Therapy With a 13‐Year‐Old Girl Presenting With High Risk for Suicide

This article describes the application of Attachment‐Based Family Therapy (ABFT) to the treatment of a 13‐year‐old female adolescent presenting with high risk of suicide, complicated by a history of depression and sexual trauma. The article begins with an overview of ABFT, including (a) how attachment theory guides treatment; (b) the structure of the clinical model; and (c) the data that provide empirical support. A case example is then presented that exemplifies the primary clinical procedures used to reach therapeutic goals in ABFT, including attachment repair and autonomy/competence promotion. Weekly changes in suicide ideation and depression scores are presented. The article concludes with a discussion about implications for family‐based treatment of suicidal youth.