Author: Bret Orton

Parent Management Training is a 14-week parent-training intervention that is designed to improve oppositional/defiant behaviors in children and adolescents. The program is delivered to parents and children in 12 consecutive weekly sessions lasting 75 minutes, with the 13th session occurring 2 weeks later. Parents learn to be more consistent and contingent in their behavior management practices, including use of clear and direct commands, differential attention, contingent reinforcement, response cost, and time-out from reinforcement. The parent-child joint sessions allow parents to practice new strategies in the clinical setting.

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Return to Blueprints Bulletin Issue 3. July 2017.

Communities That Care (CTC) is a prevention system, grounded in science that gives communities the tools to address their adolescent health and behavior problems through a focus on empirically identified risk and protective factors. CTC provides a structure for engaging community stakeholders, a process for establishing a shared community vision, tools for assessing levels of risk and protection in communities, and processes for prioritizing risk and protective factors and setting specific, measurable, community goals. CTC guides the coalition to create a strategic community prevention plan designed to address the community’s profile of risk and protection with tested, effective programs and to implement the chosen programs with fidelity. CTC instructs the coalition to monitor program implementation and to periodically reevaluate community levels of risk and protection and outcomes, and to make adjustments in prevention programming if indicated by the data. Implementation of CTC is organized into five stages, each with its own series of “benchmarks” and “milestones” to help guide and monitor implementation progress. CTC is installed in communities through a series of six training events delivered over the course of 6 to 12 months by certified CTC trainers.

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Return to Blueprints Bulletin Issue 5. January 2018.

Multisystemic Therapy® (MST®) is an intensive family- and home-based treatment that strives to create healthier families and reduce recidivism among chronic, violent, or substance-abusing male and female juvenile offenders at risk of out-of-home placement. MST seeks to improve the real-world functioning of youth by changing their natural settings – home, school, and neighborhood – in ways that promote prosocial behavior while decreasing antisocial behavior. Therapists work with youth and their families to address the known causes of delinquency on an individualized, yet comprehensive basis. By using the strengths in each system (family, peers, school, and neighborhood) to facilitate change, MST addresses the multiple factors known to be related to delinquency across the key systems within which youth are embedded. The extent of treatment varies by family according to clinical need. 

Master-level therapists maintain small caseloads of 4 to 6 families, providing most mental health services and coordinating access to other important services (e.g., medical, educational, and recreational). While the therapist is available to the family 24 hours a day, 7 days a week, the direct contact hours per family varies according to clinical need. Generally, the therapist spends more time with the family in the initial weeks of the program (daily if needed) and gradually tapers off (as infrequently as once a week) during a 3- to 5-month course of treatment.

MST has over 60 published studies, with most of the findings from randomized studies providing evidence that MST can produce short- and long-term reductions in criminal behavior and out-of-home placements for serious juvenile offenders. For example, in the Columbia, Missouri study, immediately after treatment, MST resulted in decreased behavior problems in MST youth, relative to controls. Additionally, MST families reported more cohesion, adaptability, and supportiveness, and less conflict-hostility than control families. At the four-year follow-up, 26.1% of the MST treatment group had been arrested at least once, compared to 71.4% of those in individual therapy. At 13.7 years and 21.9 years post-treatment, MST participants compared to control counterparts were less likely to be arrested, had fewer arrests and fewer days in confinement. At 25 years post-treatment, an evaluation of siblings of the original subjects found that siblings in the control group were significantly more likely to have been arrested at least once as compared to siblings in the treatment group.

An independent replication in Norway showed that MST, in comparison with usual services, decreased youth externalizing and internalizing symptoms and out-of-home placements, and that some effects were sustained for at least two years.

MST returns $1.62 for every dollar invested.

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Return to Blueprints Bulletin Issue 7. July 2018.

Rochester Forensic Assertive Community Treatment (R-FACT) is an outpatient treatment program to reduce recidivism and promote recovery among justice-involved adults with a serious mental illness. The program is an adaptation of assertive community treatment (ACT), developed to prevent psychiatric hospitalization and promote housing stability. However, ACT alone has not been shown to reduce recidivism. R-FACT adapts the ACT model by targeting criminogenic risk factors, utilizing legal authority to promote engagement, and emphasizing mental health and criminal justice collaboration to promote effective problem solving. These elements distinguish R-FACT from ACT and from other FACT-type interventions. By targeting the drivers of crime and emphasizing shared problem solving, R-FACT represents a criminiologically-informed hybrid that combines practices from the fields of mental health and community corrections.

R-FACT consists of four components, including 1) high-fidelity assertive community treatment provided by a team of criminal justice–savvy staff, 2) identification and targeting of criminogenic risk factors, 3) use of legal authority to promote engagement in necessary interventions (i.e., legal leverage), and 4) mental health/criminal justice collaboration to promote effective problem solving. In the R-FACT model, legal leverage can be provided by a judge, a probation officer, or a parole officer, depending on the collaborating criminal justice agency. 

Lamberti et al. (2017) conducted a randomized control trial in which 70 offenders with a diagnosis of severe mental illness who were recruited and participated in the study between February 10, 2011, and May 14, 2014 were randomly assigned to R-FACT or enhanced treatment as usual. A single judge provided judicial oversight, which for the treatment group included weekly meetings between R-FACT clinicians, the judge and representatives from the public defender and district attorney offices to discuss problems and agree upon intervention strategies prior to any court appearances. Weekly court appearances were initially required, and the frequency of subsequent meetings was determined by the judge in collaboration with a clinical team liaison and attorneys. Evaluation data were collected at baseline and after a one-year intervention period. All participants (treatment and control) entered the study under a conditional discharge status, whereby their pre-enrollment sentences were suspended pending successful compliance with legal stipulations that included accepting mental health treatment and avoiding further criminal activity.

Findings showed that compared to control, at posttest offenders in the treatment group had significantly fewer convictions for new crimes and spent significantly fewer days in jail. In terms of risk and protective factors, offenders in R-FACT treatment were also engaged in outpatient treatment for significantly longer periods of time, and they spent significantly fewer days in the hospital, on average.

Citation:
Lamberti, J. S. (2017). Understanding and preventing criminal recidivism among adults with psychotic disorders. Psychiatric Services, 58, 773-781.

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Return to Blueprints Bulletin Issue 8. December 2018.

Child FIRST (Family Interagency, Resource, Support, and Training) is a home-based program that aims to alleviate the effects of trauma and stress in order to prevent or reduce emotional disturbance, developmental and learning problems, and abuse and neglect in prenatal to 5-year-old children. 

The intervention simultaneously focuses psychotherapy on the parent-child relationship and develops a comprehensive “system of care” that connects families to desired community services. Thus, the approach is tailored to individual families and driven by their unique circumstances and characteristics.

Due to the highly individualized nature of the program, treatment implementation can vary across families. Though, typically, each family is assigned one Child FIRST team, which is comprised of one Master’s level mental health professional and one Bachelor’s level care coordinator. The team visits the family in the home for 60 to 90 minute sessions.  Visits generally occur twice per week during the initial assessment phase and taper to once or twice per week. These services usually span six to twelve months.

The qualifying study was conducted in Bridgeport, Connecticut from 2003 to 2005 with 157 low-income families. Participant selection criteria required either social, emotional, or behavioral problems in the child or increased psychosocial risk of the parent. Families of a variety of ethnicities with children between 6 and 36 months old were randomly assigned to the Child FIRST treatment or Usual Care condition.

Child FIRST treatment lasted 22 weeks and included an average of 12 in-home sessions with a standard Child FIRST team, with each session ranging between 45 and 90 minutes. Therapy was provided for all family members who were involved in the care of the child and focused on helping adults to better understand the motives and behavior of the child as well as their own emotions. Therapists strived to train healthier response patterns in parents and foster enjoyable relationships between parents and children.  Additionally, the care coordinator assisted the family in connecting with desired community services.

A battery of assessments was given post-treatment and in a six-month follow-up to assess outcomes in child language, child social-emotional adjustment, maternal mental health symptoms, utilization of community services, and Child Protective Services (CPS) involvement. Compared to the Usual Care group, Child FIRST families had greater access to community services post-treatment and in follow-up. 

Furthermore, results demonstrated a significant reduction in parenting stress post-treatment and an improvement in child language post-treatment and in six-month follow-up. Reduced externalizing behaviors in children and lower levels of psychological distress in parents were also evident at the six-month follow-up. Moreover, families that received Child FIRST were less likely to be involved in CPS after three years.

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Return to Blueprints Bulletin Issue 2. May 2017.

The Body Project is a body acceptance intervention that was designed to help high school and college age women resist sociocultural pressures to conform to the thin ideal and reduce their pursuit of thinness. 

This group-based intervention targets females who are between 15 and 22 years old with body dissatisfaction, a known risk factor for eating disorders such as anorexia nervosa, bulimia and binge eating. The program is based in cognitive dissonance theory, proposing that reductions in the internalization of the thin ideal will result in a decreased desire to conform, consequently decreasing eating disorder risk factors and symptoms among participants. 

The Body Project is not intended as a stand-alone treatment for individuals meeting criteria for an eating disorder, so attempts should be made to exclude such individuals.

Body Project participants receive four one-hour group sessions that provide them with social support, opportunities for self-affirmation and the skills needed to resist social pressure. The weekly sessions, which accommodate five to ten participants, include verbal, written and behavioral exercises that attempt to create dissonance in participants by engaging them in a critique of the thin ideal. 

It is recommended that group facilitators be individuals with Master’s-level training in a mental health discipline or peer educators under supervision of a mental health professional. All program materials, including training and fidelity monitoring resources, are available online. The developer also offers in-person trainings, technical assistance and fidelity consulting. 

The Body Project was named a Blueprints Model Program after several randomized control trials reported consistent evidence of effectiveness among the target population. All five studies used similar recruitment methods at universities and high schools, enrolling females who were between 14 and 22 years old with body image concerns. 

Throughout the studies, Body Project participants reported more desirable outcomes compared to control groups and other conditions, including healthy weight intervention participants and expressive-writing intervention participants. At posttest, Body Project participants often had significantly greater reductions in thin-ideal internalization, body dissatisfaction, dieting, negative affect and eating disorder symptoms. All of these outcomes were maintained at one-, two- and/or three-year follow-up in at least one of the studies that collected follow-up data.

At the time of its Blueprints application, the Body Project was being implemented at more than 110 universities in the United States and the Dove Corporation was disseminating a variant of the program to younger female adolescents in 70 countries.

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Return to Blueprints Bulletin Issue 2. May 2017.

Teaching Kids to Cope (TKC) is a 10-session group intervention designed to reduce depression and stress by enhancing the coping skills among high school adolescents and young adults displaying depression symptoms. Each session lasts 45 minutes. Participants are guided through a process to discover their distorted thinking patterns and to test their thinking against reality using suggested approaches. They also explore and practice problem identification, alternate ways of viewing a situation, and alternate ways of reacting. 

The TKC program focuses on behavioral techniques but also incorporates cognitive components. The behavioral techniques aim to improve coping skills, which include activity planning, social skills training, assertiveness training, bibliotherapy, role-playing, conflict resolution, and relaxation training. 

The TKC incorporates experiential exercises such as trust-fall, buddy assignments, and role-playing situations from school and home. Art is incorporated into the sessions through drawing exercises. The cognitive components employ techniques such as externalization of negative voices, reframing, and cognitive rehearsal.

To improve access to the treatment for high school students seeking help, this intervention is offered during regular school days. Eligible students should score in the mid-range (at least 60) on the Reynolds Adolescent Depression Scale (RADS). The intervention is implemented by a psychiatric nurse in collaboration with the school nurse or guidance counselor.

Studies were conducted in high schools, and a Jordanian study was conducted of college young adults. The outcomes for the evaluation of TKC demonstrated the following significant program effects, comparing the intervention to the control group: a short-term decrease in depressive symptoms and stress levels and a decrease in depressive symptoms for female intervention participants. 

The significant risk and protective factors included an increase in the use of beneficial coping strategies, seeking social support, planful problem-solving, positive reappraisal and a decrease in avoidance coping behavior. 

TKC received the Blueprints Promising Program designation in September 2015.

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Return to Blueprints Bulletin Issue 4. November 2017.

Positive Action is a comprehensive, school-based program for kindergarten through 8th grade students, which promotes learning through enhancement of self-concept.  Positive Action operates on the philosophy that thoughts lead to actions, actions lead to feelings, and feelings lead to thoughts.  When this cycle is positive, it is maintained intrinsically because self-efficacy is a robust motivator.

Positive Action consists of 140 scripted, age-appropriate lessons lasting approximately 15 minutes.  Lessons are delivered by a school teacher, external instructor, or in an alternative setting two to four times per week.  The program aligns with existing academic standards and affords the flexibility of customization for chosen outcomes. The curriculum is comprised of six units, encompassing the conceptual foundation of the program, developing habits for healthy mind and body, personal management and self-control skills, building beneficial relationships, understanding responsibility and self-awareness, and goal-setting and achieving.  In addition to classroom coursework, Positive Action consists of additional kits for school administration and counselors in order to coordinate efforts and affect the school climate overall.

The Blueprints Model Program qualifying studies included two randomized trials.  The first trial, beginning in 2001 in Hawaii, followed first and second grade students to fifth and sixth grade in 2006.  In the second trial, students in Chicago, IL were monitored from third grade in 2004 to eighth grade in 2010. Research methodology and program implementation were similar in both trials.  Schools were matched on several variables, including demographics, school size, disciplinary referrals, and standardized achievement scores. Then, matched pairs were randomly assigned to either the program implementation condition or control condition.

Results revealed significant positive effects on antisocial behavior, academic self-efficacy, and skills for social interaction in schools that implemented Positive Action compared to those in the control condition.  In Hawaii, schools observed significant reductions in suspensions and absenteeism as well as improvements in academic proficiency and school supportiveness among their students. These effects were maintained through the one-year post implementation follow-up.  Additionally, in Chicago, students displayed greater academic motivation and schools demonstrated lower normative support for aggression. Moreover, both trials exhibited improved social interaction skills among students who received the program.

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Return to Blueprints Bulletin Issue 4. November 2017.

A short-term (approximately 30 hours) family therapy intervention and juvenile diversion program helping at-risk children and delinquent youth, ages 11-18, to overcome adolescent behavior problems, conduct disorder, substance abuse and delinquency. Therapists work with families to assess family behaviors that maintain delinquent behavior, modify dysfunctional family communication, train family members to negotiate effectively, set clear rules about privileges and responsibilities, and generalize changes to community contexts and relationships.

FFT should be implemented with a team of 3-8 master’s level therapists, with caseloads of 10-12 families, for 3–5 months, with oversight by a licensed clinical therapist. FFT is a phased program with steps which build upon each other. These phases consist of:

• Engagement, designed to emphasize within youth and family factors that protect youth and families from early program dropout;
• Motivation, designed to change maladaptive emotional reactions and beliefs, and increase alliance, trust, hope, and motivation for lasting change;
• Assessment, designed to clarify individual, family system, and larger system relationships, especially the interpersonal functions of behavior and how they relate to change techniques;
• Behavior Change, which consists of communication training, specific tasks and technical aids, parenting skills, contracting and response-cost techniques, and youth compliance and skill building;
• Generalization, during which family case management is guided by individualized family functional needs, their interface with environmental constraints and resources, and the alliance with the FFT Therapist/Family Case Manager.

FFT has been evaluated in multiple studies in samples across the United States and Sweden. Study design has ranged from random assignment, to quasi-experimental designs that involved matched but not randomly assigned comparison groups, to comparisons with base rates for that population. Overall, FFT has produced statistically significant reductions in recidivism and improved family interaction problems.

In a Utah study, FFT families, 6-18 months following treatment, showed significant improvement compared to no treatment and alternative treatment groups in rates of reoffense (26% versus 47%-73%). A follow-up study with the siblings of the targeted youth found that at 2.5 to 3.5 years after intervention, significantly fewer siblings had juvenile court records (20%) compared to families receiving no or other interventions (40% to 63%).

A meta-analysis of effect size for eight evaluations of FFT reported a mean unadjusted effect size of -.59 and an adjusted mean effect size of -.32, demonstrating that FFT is a cost effective approach for reducing juvenile crime.

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Return to Blueprints Bulletin Issue 5. January 2018.

Guiding Good Choices (GGC) is a family competency training program for parents of children in middle school that gives parents the skills needed to reduce their children’s risk for using alcohol and other drugs. The program contains five-sessions, with an average session length of 2 hours each week. Children are required to attend one session that teaches peer resistance skills. The other four sessions are solely for parents and include instruction on: (a) identification of risk factors for adolescent substance abuse and a strategy to enhance protective family processes; (b) development of effective parenting practices, particularly regarding substance use issues; (c) family conflict management; and (d) use of family meetings as a vehicle for improving family management and positive child involvement.

Specifically, Session 1 creates opportunities for involvement and interaction in the family and rewarding children’s participation in the family. Session 2 establishes clear family rules about substance use, monitoring the behavior of children, and disciplining children. Session 3 teaches children skills needed to resist peer influences to use drugs. Session 4 focuses on reducing and managing anger and family conflict. Session 5 focuses on expressing positive feelings and developing family bonds and involvement.

The certifying study, which used a randomized design with schools blocked on school size and proportion of students residing in lower income households, included families of sixth graders enrolled in 33 rural schools in 19 contiguous counties in a Midwestern state. After completion of the 5-week intervention, families were assessed approximately 6, 18, 30, 48, and 72 months following the pretest (when students were in the sixth, seventh, eighth, tenth, and twelfth grades, respectively). An additional follow-up was conducted with the target children when they had entered young adulthood, at the approximate age of 21.

Across five waves of data (through grade 10), GGC was significantly associated with a slower rate of increase in polysubstance use (alcohol, tobacco, and marijuana) and general delinquency (e.g., theft, vandalism, violence) over time, compared with controls. At this four-year follow-up, GGC also reduced the rates of initiation for alcohol and marijuana. From 6th through 12th grade, GGC reduced the rate of increase in depressive symptoms, compared with controls, and showed slower overall growth in tobacco use.

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Return to Blueprints Bulletin Issue 6. April 2018.