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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
19th November 2009
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
• An overview of MST and how it addresses
these risk factors
Group Exercise
• In pairs identify one risk and one
protective factors for the onset of
behavioural problems in adolescence;
o Individual
o Family
o School
o Peer group
o Community
• Feedback on flipchart
Context Risk
Risk Factors & Protective Factors
Protective Factors
Individual • Low verbal skills • Intelligence
• Favourable attitudes towards ASB • Being first born
• Psychiatric symptomatology • Easy temperament
• Cognitive bias to attribute hostile intentions to others • Conventional attitudes
• Problem-solving skills

Family • Lack of monitoring • Attachment to parents

• Ineffective discipline • Supportive family environment
• Harsh and inconsistent discipline • Marital harmony
• Low warmth
• High conflict
• Parental difficulties e.g. drug abuse, psychiatric
conditions, criminality

Peer • Association with deviant peers • Bonding with pro-social peers

• Poor relationship skills
• Low association with pro-social peers

School • Low achievement • Commitment to schooling

• Dropout • Good school-home links
• Low commitment to education • Good relationship with teacher(s)
• Aspects of school – e.g. weak structure & chaotic

Community • High mobility • Ongoing involvement in community activities

• Low community support • Strong indigenous support network
• High disorganisation
• Criminal subculture
Delinquency is a Complex Behaviour

• Common findings of 50+ years of

research: delinquency and drug use are
determined by multiple risk factors:
o Family (low monitoring, high conflict, etc.)
o Peer group (law-breaking peers, etc.)
o School (dropout, low achievement, etc.)
o Community ( supports,  transiency, etc.)
o Individual (low verbal and social skills, etc.)
Causal Models of Delinquency and
Drug Use
Condensed Longitudinal
Model Prior Delinquent
Family Behavior
Low Parental Monitoring
Low Affection
High Conflict Delinquent Delinquent
Peers Behavior


Low School Involvement

Poor Academic Performance Elliott, Huizinga & Ageton
Theoretical Assumptions
Based on Bronfenbrenner, Haley and Minuchin
• 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)
Ecological Model
Implications for Effective
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
What is MST?
• Intensive, goal oriented and time limited
• 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
Who is the target population for MST?
• Family and key participants in the environment of young
• 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
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
• Assumption - Children’s behaviour is strongly influenced
by their families, friends and communities (and vice
• Works in partnership with a combination of systems
(parents, family, peers, school and community) to
address risk factors
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
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
• Team has 3-4 therapists and clinical supervisor
• Involvement typically ranges from 3 to 5 months
How is MST implemented?
• Team provides the family with a single point of
• 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
MST Quality Assurance System
• Team comprised of range of professionals
– multi-disciplinary/multi-agency
• Structured training – orientation and regular
• Frequent professional development planning
• Weekly clinical supervision and case review
• Weekly consultation with consultant in USA
• Research validated adherence process – for
therapists and supervisor
What’s different?

Traditional models MST

• Individual (family) • Ecological
• Clinic-based • Home-based
• Fixed times • Flexible/24 hour
• High caseloads – • Low caseloads –
less intensive 3x weekly +
• Open-ended • Fixed goal-driven
• Supervision • Quality assurance

NB Not better, just different approach to address a different need

Why does it need to be different?

• Multi-determined nature of serious antisocial

• 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
• 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 – 2nd
edition. New York: Guildford Press.