Multisystemic Therapy – Problem Sexual Behavior (MST-PSB)

A juvenile sex offender treatment program designed to reduce criminal and antisocial behavior, especially problem sexual behavior, by providing intensive family therapy services in the youth's natural environment over a 5-7 month period.

Program Outcomes

Academic Performance
Adult Crime
Alcohol
Delinquency and Criminal Behavior
Marijuana/Cannabis
Mental Health - Other
Prosocial with Peers
Sexual Risk Behaviors
Sexual Violence

Program Type

Family Therapy
Juvenile Justice - Other

Program Setting

Home
Correctional Facility
Mental Health/Treatment Center

Continuum of Intervention

Indicated Prevention

Age

Late Adolescence (15-18) - High School
Early Adolescence (12-14) - Middle School

Gender

Both

Race/Ethnicity

Endorsements

Blueprints: Model
Crime Solutions: Promising
OJJDP Model Programs: Promising
SAMHSA : 3.6-3.9

Program Information Contact

Dr. Russell Borduin
Email: rborduin@mstpsb.com
Website: www.mstpsb.com

Program Developer/Owner

Charles M. Borduin
University of Missouri

Brief Description of the Program

Multisystemic Therapy (MST) is an intensive family- and community-based treatment that addresses the multiple causes of serious antisocial behavior across key systems within which youth are embedded (family, peers, school, and neighborhood). MST for sexual offenders (MST-PSB) focuses on aspects of a youth's ecology that are functionally related to the problem sexual behavior and includes reduction of parent and youth denial about the sexual offenses and their consequences; promotion of the development of friendships and age-appropriate sexual experiences; and modification of the individual's social perspective-taking skills, belief system, or attitudes that contributed to sexual offending. The intervention is individualized for each family; families are provided family therapy, youth are provided individual therapy and services are delivered over a period of 5-7 months. Therapists have 3-5 families on their caseloads, and rotating members of the team are available to respond to crises 24 hours a day, 7 days a week.

See: Full Description

Multisystemic Therapy (MST) is an intensive family- and community-based treatment that addresses the multiple causes of serious antisocial behavior across key systems within which youth are embedded (family, peers, school, and neighborhood). A clinical volume (Henggeler & Borduin, 1990) and treatment manual (Henggeler, Schoenwald, et al., 2009) specify MST interventions for youth antisocial behavior and delineate the processes by which youth and family problems are prioritized and targeted for change. The MST-PSB model is described in a supplemental treatment manual (Borduin, Letourneau, Henggeler, & Swenson, 2009). The approach is guided by the same principles and uses many of the same evidence-based techniques as in MST for nonsexual offenders but focuses on aspects of the youth's ecology that are functionally related to the problem sexual behavior. At the family level, MST interventions often aim to (a) reduce caregiver and youth denial about the sexual offenses and their sequelae, (b) remove barriers to effective parenting, (c) enhance parenting knowledge, and (d) promote affection and communication among family members. Moreover, conjoint work with family members and other appropriate persons in the youth's social ecology (e.g., teachers, extended family) is essential in the development of plans for risk reduction, relapse prevention, and victim safety. At the peer level, interventions often target youth social skill and problem-solving deficits to promote the development of friendships and age appropriate sexual experiences. Peer relations interventions are conducted by the youth's caregivers, with the guidance of the therapist, and often consist of active support and encouragement of relationship skills and associations with non-problem peers, as well as substantive discouragement of associations with deviant peers (e.g., applying significant sanctions). Likewise, under the guidance of the therapist, the caregivers often develop strategies to monitor and promote the youth's school performance; interventions in this domain typically focus on establishing improved communication between caregivers and teachers and on restructuring after-school hours to promote academic efforts.

Usually, problem sexual behaviors diminish in frequency and intensity when systemic interventions are implemented in MST-PSB. Some youths, however, continue to display serious aggressive or impulsive behavior in one or more contexts (e.g., with certain peers) after systemic interventions have been consistently implemented by caregivers, teachers, and other key persons in the youth's natural ecology. In such instances, adolescent cognitive distortions and cognitive deficiencies are assessed as possible contributing factors to the aggressive or impulsive behavior and, when relevant, are targeted using individual interventions. The therapist makes every effort to implement individual interventions in the presence of caregivers to ensure that the cognitive and behavioral changes initiated during these interventions can be reinforced and modeled by caregivers and sustained in the home and other settings (e.g., school, neighborhood). The main objectives of the therapist's individual interventions with the adolescent are to help him or her think through and behaviorally practice solutions to the specific interpersonal problems targeted for change. Cognitive-behavioral interventions to accomplish these aims generally draw on strategies such as modeling, role-play and perspective-taking exercises, behavioral contingencies, self-monitoring, and self-instruction.

There are also some circumstances in which MST therapists engage in short-term individual treatment with a caregiver of a youth with problem sexual behavior. Decisions to pursue individual treatment with a caregiver most often pertain to problems that interfere with caregiver functioning, such as depression, anxiety disorders, substance abuse, and recent or past victimization. The therapist should have evidence that the individual problem, as opposed to other factors (e.g., marital problems, practical needs, skill deficits, a history of adversarial relations with school officials), is a powerful predictor of the youth's antisocial behavior. In such cases, cognitive-behavioral interventions are often a first choice for individual treatment of a caregiver in the context of MST. Other interventions are also used in some cases (e.g., psychopharmacological treatment for a serious psychiatric disturbance, multicomponent behavior therapy for substance abuse).

MST-PSB is individualized for each family; families are provided family therapy, youth are provided individual therapy and services are delivered over a period of 5-7 months. Therapists have 3-5 families on their caseloads, and rotating members of the team are available to respond to crises 24 hours a day, 7 days a week.

Outcomes

Primary Evidence Base for Certification

Study 1

Borduin et al. (1990) found that, relative to the control group, the MST group had significantly fewer:

rearrests for sexual crimes (12.5% vs. 75%)

Study 2

Borduin et al. (2009, 2021) demonstrated that, relative to the control group, the following outcomes were significantly improved in the MST condition:

mother, father and youth psychiatric symptoms
youth behavior problems
family functioning
peer relationships
school grades
person and property crimes

Additionally, over the 8.9- and 24.9-year follow-up periods, compared to the control condition, MST participants had significantly fewer:

arrests for any crimes, sexual crimes, and non-sexual crimes
days in detention facilities, incarceration, and on probation
family civil suits relating to family instability

Study 3

Henggeler et al. (2009) and Letourneau et al. (2009, 2013) found that the MST treatment group improved significantly more than the control group at the 12-month posttest on measures of:

deviant sexual interests and risk
delinquency at 18 and 24 months
substance use
youth-reported externalizing
out-of-home placement

Brief Evaluation Methodology

Primary Evidence Base for Certification

Of the three studies Blueprints has reviewed, all meet Blueprints evidentiary standards (specificity, evaluation quality, impact, dissemination readiness). Studies 1, 2 and 3 were conducted by the developer.

Study 1

In a small pilot study conducted in Columbia, Missouri (Borduin et al., 1990), 16 adolescents arrested for sexual offenses were randomized to either MST or individual therapy conditions. Recidivism data were collected at an approximately 3-year follow-up.

Study 2

A second study (Borduin et al., 2009, 2021) also conducted in Columbia, Missouri, used a randomized controlled design to examine 48 youths and their families who were randomly assigned to MST (n = 24) or a usual services control group (n = 24). Self-report data were gathered at baseline and posttest, and two follow-up assessments using police and court records were conducted an average of 8.9 and 24.9 years after treatment.

Study 3

A third study conducted in Chicago, Illinois (Henggeler et al., 2009; Letourneau et al., 2009, 2013) examined 127 participants referred by the Cook County State's Attorney's Office after having been charged with a sexual offense. They were randomized into the treatment group (n = 67) or control group (n = 60) and assessed at baseline, 6 months, 12 months, 18 months, and 24 months.

Blueprints Certified Studies

Study 1

Borduin, C. M., Henggeler, S. W., Blaske, D. M., & Stein, R. J. (1990). Multisystemic treatment of adolescent sexual offenders. International Journal of Offender Therapy and Comparative Criminology, 35, 105-114.

Study 2

Borduin, C. M., Schaeffer, C. M., & Heiblum, N. (2009). A randomized clinical trial of Multisystemic Therapy with juvenile sexual offenders: Effects on youth social ecology and criminal activity. Journal of Consulting and Clinical Psychology, 77, 26-37.

Study 3

Letourneau, E. J., Henggeler, S. W., Borduin, C. M., Schewe, P. A., McCart, M. R., Chapman, J. E., & Saldana, L. (2009). Multisystemic Therapy for juvenile sexual offenders: 1-year results from a randomized effectiveness trial. Journal of Family Psychology, 23, 89-102.

Risk and Protective Factors

Risk Factors

Individual: Antisocial/aggressive behavior*, Early initiation of antisocial behavior, Early initiation of drug use, Favorable attitudes towards antisocial behavior, Favorable attitudes towards drug use, Physical violence*, Rebelliousness, Substance use*

Peer: Interaction with antisocial peers*, Peer substance use, Romantic partner violence

Family: Family conflict/violence, Family history of problem behavior, Household adults involved in antisocial behavior, Neglectful parenting, Parental attitudes favorable to antisocial behavior, Parental attitudes favorable to drug use, Parent history of mental health difficulties*, Parent stress, Poor family management, Psychological aggression/discipline, Violent discipline

School: Low school commitment and attachment, Poor academic performance*

Protective Factors

Individual: Clear standards for behavior, Problem solving skills, Prosocial behavior, Prosocial involvement, Rewards for prosocial involvement, Skills for social interaction*

Peer: Interaction with prosocial peers*

Family: Attachment to parents*, Nonviolent Discipline, Opportunities for prosocial involvement with parents, Parental involvement in education, Parent social support

School: Opportunities for prosocial involvement in education, Rewards for prosocial involvement in school

Neighborhood/Community: Opportunities for prosocial involvement, Rewards for prosocial involvement

* Risk/Protective Factor was significantly impacted by the program

Subgroup Analysis Details

Sample demographics including race, ethnicity, and gender for Blueprints-certified studies:

In all three studies, the vast majority of participants were boys with a mean age of 14 years.

The sample for Study 1 (Borduin et al., 1990) was 100% male, 62.5% White and 37.5% Black.
The sample for Study 2 (Borduin et al., 2009) was 95.8% male, 72.9% White and 27.1% Black; among all youths 2.1% indicated Hispanic ethnicity.
The sample for Study 3 (Letourneau et al., 2009) was 97.6% male, 54% Black and 46% White, and 31% of youth indicated Hispanic ethnicity.

Training and Technical Assistance

Orientation training in the MST-PSB model lasts for 2 days and follows training in the standard MST model (5 days). MST-PSB orientation training relies on various formats, including slide presentations, video presentations, role plays, and small group exercises. The content covers a range of topics, including:

an introduction to the MST-PSB model (i.e., costs and correlates of youth problem sexual behaviors, a review of the effectiveness of usual treatments for these behaviors, and a description of the empirical evidence supporting MST-PSB as a family-based alternative to usual treatments);
safety considerations in the treatment of youth with problem sexual behaviors (including risk reduction, safety planning, and a family clarification process in which responsibility for the offense is accepted and understood);
strategies for recognizing and handling caregiver and youth denial of problem sexual behaviors;
a review of what is known about normative sexual behavior, the role of family sexuality in the development of inappropriate sexual behaviors, and prior sexual victimization as a risk factor for sexual offending;
procedures for reporting sexual abuse; (f) strategic and structural family therapy interventions for youth with problem sexual behaviors;
assessment and intervention strategies targeting peer relations of problem sexual behavior youth; and
strategies for assessing and treating behavioral and psychological sequelae of sexual victimization in children and adolescents.

Following the 2-day orientation, training continues through weekly telephone MST-PSB consultation for each team of MST-PSB clinicians aimed at monitoring treatment fidelity and adherence to the MST-PSB treatment model, and through quarterly on-site booster trainings (2 days each). Fully trained MST-PSB Experts teach the on-site MST-PSB supervisor to implement a manualized MST supervisory protocol and collaborate with the supervisor to promote the ongoing clinical development of all team members. The MST-PSB Expert also assists at the organizational level.

The ongoing MST-PSB clinical support is provided to replicate the characteristics of training, clinical supervision, consultation, and monitoring provided in the successful clinical research trials of MST-PSB. This program implementation protocol has been refined through extensive experience with communities and providers in MST-PSB sites in the United States and internationally.

Benefits and Costs

Program Benefits (per individual): $22,991
Program Costs (per individual): $14,794
Net Present Value (Benefits minus Costs, per individual): $8,197
Measured Risk (odds of a positive Net Present Value): 59%

Source: Washington State Institute for Public Policy
All benefit-cost ratios are the most recent estimates published by The Washington State Institute for Public Policy for Blueprint programs implemented in Washington State. These ratios are based on a) meta-analysis estimates of effect size and b) monetized benefits and calculated costs for programs as delivered in the State of Washington. Caution is recommended in applying these estimates of the benefit-cost ratio to any other state or local area. They are provided as an illustration of the benefit-cost ratio found in one specific state. When feasible, local costs and monetized benefits should be used to calculate expected local benefit-cost ratios. The formula for this calculation can be found on the WSIPP website.

Start-Up Costs

Initial Training and Technical Assistance

The program development & start-up fee for one MST-PSB team is $11,000 and $8,000 for any subsequent teams. This fee includes assessment of provider readiness, establishment of program parameters, review of local legislation pertinent to the target population, identification and engagement of community stakeholders, workforce development support, presentation of the MST-PSB model in a community forum, and a 2-day MST-PSB clinical orientation training for treatment team members and program administrators.

Implementing sites are also responsible for paying for travel costs for MST-PSB trainers to attend the orientation at the agency site and a community orientation. These costs are estimated at $4,000.

Team members who are new to the MST model must also attend a 5-day, standard MST orientation training (provided by MST Services in Charleston, SC) to acquire the basic foundations of the MST model; the cost of this training is $850 per staff member, plus travel and lodging costs.

Curriculum and Materials

Costs for curriculum are subsumed within the initial training costs described above.

Licensing

Annual license fees of $4,000 per organization (Agency license) and an additional $2,500 per team (Team license) are required.

Other Start-Up Costs

Costs above are calculated for one MST-PSB team, trained together with their supervisor. Increasing the number of teams trained at one time can produce economies of scale.

Intervention Implementation Costs

Ongoing Curriculum and Materials

None.

Staffing

Ratios: Each MST-PSB therapist serves an average of 4 families at a time.

Qualifications: Supervisors must be licensed Master's mental health professionals. Therapists should be Master's Level, but license is not required.

Time to Deliver Intervention: Each family is served for an average of six months with at least one weekly visit to the home.

Other Implementation Costs

Costs that will vary by locality include administrative support, space, travel, supplies, and communications. Implementation costs vary significantly across the country.

Implementation Support and Fidelity Monitoring Costs

Ongoing Training and Technical Assistance

Ongoing training, fidelity monitoring, and technical assistance costs are bundled into one annual consultation fee of $41,000 (provider organization with a single team) or $33,500 (per team when the provider organization has multiple teams).

Fidelity Monitoring and Evaluation

Fidelity Monitoring included in T/A cost above. Additionally, a provider organization may choose to either (a) have the Therapist Adherence Measure-Revised (TAM-R; Henggeler et al. 2006) administered to each family by an approved MST call center at a cost of $25 per family per month or (b) use a designated staff member (estimated at .20 FTE to administer the TAM-R to each family.

Ongoing License Fees

Annual license fees of $4,000 per organization (Agency license) and an additional $2,500 per team (Team license) are required.

Other Implementation Support and Fidelity Monitoring Costs

No information is available

Other Cost Considerations

MST Services, Inc. recommends that, when estimating costs, one should consider the implementation of the "highest quality program" in order to assure accountability for the best possible client outcomes. Economies of scale can be achieved when multiple teams can be supported at one time.

Year One Cost Example

In this example, an organization is setting up two MST-PSB teams, each with a .5 FTE supervisor and four therapists to serve approximately 64 families over the course of a year. This example assumes the agency does not have MST trained therapists on staff and staff and supervisors have to attend the MST training at MST Services Inc. If an agency was already implementing MST, and had trained MST staff available, they would not have to incur training costs. First year costs would include:

Program Development Start-Up Fee (11,000 + 8,000)	$19,000.00
Travel for MST Services Consultants	$4,000.00
Training for new staff at MST Services Inc (850 * 9)	$7,650.00
Travel and lodging for 5 day training ($2,000 * 9)	$18,000.00
Licenses-1 organizational and 2 team	$9,000.00
Support fee for two teams charged by purveyor	$67,000.00
Salary for one supervisor @ $60,000	$60,000.00
Salaries for eight therapists @ $50,000	$400,000.00
Administrative staff to collect TAM-R (.20TFE Admin)	$6,000.00
Fringe @ 30%	$139,800.00
Overhead @ 25% of staff cost	$151,450.00
Total One Year Cost	$881,900.00

With 8 therapists with an average caseload of four families for six months of service, a total of 64 families annually could be served at a cost of $13,780 per family for the first year. The per-family cost would be significantly lower after the first year, when the program no longer incurs program development and initial training fees.

Funding Overview

The strong track record of MST in helping state and localities achieve savings on costly out-of-home placements has led to the leverage of significant state and local funds for MST-PSB, most typically in the budgets of juvenile justice and child welfare agencies. Medicaid is also an important source of support for MST, and many states have included MST in their Medicaid State Plans as a mental health therapy. Foundation support and public-private partnerships can play an important role in helping states and localities get MST programs up and running so that they can begin to divert youth from costly placements and reinvest the savings on those placements in the continued operation and expansion of the program.

Funding Strategies

Improving the Use of Existing Public Funds

Redirection: Many states and communities have redirected state and local funding from detention and residential placements to MST. The reasons for redirecting funds include: an interest in keeping youth with their families and in their communities; poor results with current strategies and the strong track record of results for MST and; the potential for cost savings by implementing MST and keeping young people out of costly out-of-home placements.

Reinvestment: Reinvestment is a strategy that can help to bring MST to scale by seeking a commitment from public agencies that they will reinvest the savings generated by implementing MST and reducing the use of out-of-home placements into sustaining and replicating the program. It may be helpful to pair this strategy with a public-private partnership in which a private funder helps to facilitate and support the development of commitments from public agencies to reinvest savings. See the Opportunity Compact example below.

Allocating State or Local General Funds

Many states have chosen to fund MST with general funds as part of a commitment to evidence based practices and in an effort to achieve better outcomes for youth. Some counties and cities have made additional contributions to funding the program.

Maximizing Federal Funds

Entitlements: Medicaid is an option for funding MST as a family therapy. This approach requires the state to provide state matching funds, with the state share percentage set by the federal government. This option is limited to the Medicaid eligible portion of the population to be served. Medicaid will not typically cover the full cost of program implementation with fidelity and must be used in combination with other funding strategies to fully fund the program.

Formula Funds:

Juvenile Accountability Block Grant (JABG) Funds are focused on reducing juvenile offending through efforts that promote accountability, including providing effective early intervention through mental health screening and treatment.
Office of Juvenile Justice and Delinquency Prevention (OJJDP) Formula Funds support a variety of improvements to delinquency prevention programs and juvenile justice programs in states. Evidence-based programs are an explicit priority for these funds, which are typically administered on a competitive basis from the state administering agency to community-based programs.
The Mental Health Services Block Grant (MHSBG) can fund a variety of mental health promotion and intervention activities and is a potential source of support for functional family therapy programs.
Title IV-B, Parts 1 & 2 provides fairly flexible funding to state child welfare agencies for child welfare services including prevention and family preservation activities.

Discretionary Federal Grants: Such grants have mostly been used for start-up expenses. Federal agencies including SAMSHA and OJJDP administer relevant discretionary grant programs.

Foundation Grants and Public-Private Partnerships

A number of states have used foundation grants to provide start-up funding for MST programs. Foundations are not as good a source of ongoing implementation funding. An Opportunity Compact is an example of a relevant public/private partnership, where private funding initiates an intervention such as MST with the potential of saving money from the avoidance of a costly alternative. Savings are then used to sustain the intervention.

Debt Financing

Program related investment, social investment bonds or government bonds can all be used for start-up and initial implementation funding for programs such as MST which target cost avoidance for youth who would otherwise need an expensive alternative such as out-of-home placement. Savings from avoided costs would repay the investment as well as sustain the intervention. A social impact bond that is supporting MST is being piloted in Essex County, England. For more information see http://www.socialfinance.org.uk/work/sibs/vulnerable-children.

Generating New Revenue

While presenting a challenge in securing needed public support, new revenue should be considered in the form of taxpayer referenda, new taxes and fees or dedicated revenue streams such as tax form check-offs.

Data Sources

All information except unit cost comes from the responses to a questionnaire submitted by the purveyor, MST Services, Inc., to the Annie E. Casey Foundation. The unit cost is from Drake, Elizabeth K., et.al., "Evidence-Based Public Policy Options to Reduce Crime and Criminal Justice Costs: Implications in Washington State", Victims and Offenders, 4:170-196, 2009

Program Developer/Owner

Charles M. BorduinDepartment of Psychological SciencesUniversity of MissouriColumbia, MO 65211-2500USAborduinc@missouri.edu www.mstpsb.com

Program Outcomes

Academic Performance
Adult Crime
Alcohol
Delinquency and Criminal Behavior
Marijuana/Cannabis
Mental Health - Other
Prosocial with Peers
Sexual Risk Behaviors
Sexual Violence

Program Specifics

Program Type

Family Therapy
Juvenile Justice - Other

Program Setting

Home
Correctional Facility
Mental Health/Treatment Center

Continuum of Intervention

Indicated Prevention

Program Goals

Population Demographics

Juvenile sex offenders between the ages of 11 and 17 years, inclusive.

Target Population

Age

Late Adolescence (15-18) - High School
Early Adolescence (12-14) - Middle School

Gender

Both

Race/Ethnicity

Subgroup Analysis Details

Sample demographics including race, ethnicity, and gender for Blueprints-certified studies:

In all three studies, the vast majority of participants were boys with a mean age of 14 years.

The sample for Study 1 (Borduin et al., 1990) was 100% male, 62.5% White and 37.5% Black.
The sample for Study 2 (Borduin et al., 2009) was 95.8% male, 72.9% White and 27.1% Black; among all youths 2.1% indicated Hispanic ethnicity.
The sample for Study 3 (Letourneau et al., 2009) was 97.6% male, 54% Black and 46% White, and 31% of youth indicated Hispanic ethnicity.

Risk/Protective Factor Domain

Individual
School
Peer
Family

Risk/Protective Factors

Risk Factors

Peer: Interaction with antisocial peers*, Peer substance use, Romantic partner violence

School: Low school commitment and attachment, Poor academic performance*

Protective Factors

Individual: Clear standards for behavior, Problem solving skills, Prosocial behavior, Prosocial involvement, Rewards for prosocial involvement, Skills for social interaction*

Peer: Interaction with prosocial peers*

Family: Attachment to parents*, Nonviolent Discipline, Opportunities for prosocial involvement with parents, Parental involvement in education, Parent social support

School: Opportunities for prosocial involvement in education, Rewards for prosocial involvement in school

Neighborhood/Community: Opportunities for prosocial involvement, Rewards for prosocial involvement

*Risk/Protective Factor was significantly impacted by the program

Brief Description of the Program

Multisystemic Therapy (MST) is an intensive family- and community-based treatment that addresses the multiple causes of serious antisocial behavior across key systems within which youth are embedded (family, peers, school, and neighborhood). MST for sexual offenders (MST-PSB) focuses on aspects of a youth's ecology that are functionally related to the problem sexual behavior and includes reduction of parent and youth denial about the sexual offenses and their consequences; promotion of the development of friendships and age-appropriate sexual experiences; and modification of the individual's social perspective-taking skills, belief system, or attitudes that contributed to sexual offending. The intervention is individualized for each family; families are provided family therapy, youth are provided individual therapy and services are delivered over a period of 5-7 months. Therapists have 3-5 families on their caseloads, and rotating members of the team are available to respond to crises 24 hours a day, 7 days a week.

Description of the Program

Multisystemic Therapy (MST) is an intensive family- and community-based treatment that addresses the multiple causes of serious antisocial behavior across key systems within which youth are embedded (family, peers, school, and neighborhood). A clinical volume (Henggeler & Borduin, 1990) and treatment manual (Henggeler, Schoenwald, et al., 2009) specify MST interventions for youth antisocial behavior and delineate the processes by which youth and family problems are prioritized and targeted for change. The MST-PSB model is described in a supplemental treatment manual (Borduin, Letourneau, Henggeler, & Swenson, 2009). The approach is guided by the same principles and uses many of the same evidence-based techniques as in MST for nonsexual offenders but focuses on aspects of the youth's ecology that are functionally related to the problem sexual behavior. At the family level, MST interventions often aim to (a) reduce caregiver and youth denial about the sexual offenses and their sequelae, (b) remove barriers to effective parenting, (c) enhance parenting knowledge, and (d) promote affection and communication among family members. Moreover, conjoint work with family members and other appropriate persons in the youth's social ecology (e.g., teachers, extended family) is essential in the development of plans for risk reduction, relapse prevention, and victim safety. At the peer level, interventions often target youth social skill and problem-solving deficits to promote the development of friendships and age appropriate sexual experiences. Peer relations interventions are conducted by the youth's caregivers, with the guidance of the therapist, and often consist of active support and encouragement of relationship skills and associations with non-problem peers, as well as substantive discouragement of associations with deviant peers (e.g., applying significant sanctions). Likewise, under the guidance of the therapist, the caregivers often develop strategies to monitor and promote the youth's school performance; interventions in this domain typically focus on establishing improved communication between caregivers and teachers and on restructuring after-school hours to promote academic efforts.

Theoretical Rationale

MST-PSB is based upon family systems theory (Bateson, 1972; Hoffman, 1981; Minuchin, 1985) and the theory of social ecology (Bronfenbrenner, 1979), both of which fit closely with research findings on the correlates and causes of serious antisocial behavior (including sexual offending) in youths and serve as a basis for case conceptualization and treatment planning in MST-PSB. Family systems theory views the family as a rule-governed system and an organized whole that transcends the sum of its separate parts. From this perspective, it is assumed that problematic individual behaviors and symptoms are intimately related to patterns of interaction between family members and must always be understood within the context of those interaction patterns. The theory of social ecology (Bronfenbrenner, 1979) shares some of the basic tenets of family systems theory but encompasses broader and more numerous contextual influences within a youth's life. The youth is viewed as being nested within a complex of interconnected systems that include the individual youth, the youth's family, and various extrafamilial (peer, school, neighborhood, community) contexts. The youth's behavior is seen as the product of the reciprocal interplay between the youth and these systems and of the relations of the systems with each other. Thus, although the interactions between the youth and family or peers are seen as important, the connections between the systems are viewed as equally important. Based on this theoretical rationale, MST-PSB interventions are tailored to address the specific risk and protective factors that are salient to the social environments of the individual and family receiving the treatment.

Theoretical Orientation

Person - Environment

Brief Evaluation Methodology

Primary Evidence Base for Certification

Study 1

Study 2

Study 3

Outcomes (Brief, over all studies)

Primary Evidence Base for Certification

Study 1

Borduin et al. (1990) found that MST participants relative to control participants were less likely to have been rearrested for sexual crimes and had a lower frequency of arrests for sexual crimes.

Study 2

Significant outcomes were found for MST participants, relative to control participants, on 17 of the 18 outcome measures in Borduin et al. (2009), including improved caregiver and youth psychiatric symptoms; family functioning; and youth behavioral problems, peer relations, grades in school, criminal behavior, and sexual reoffending. Borduin et al. (2021) found significant intervention effects at the 24.9-year follow-up on arrests, sentencing, and family civil suits relating to family instability.

Study 3

Henggeler et al. (2009) and Letourneau et al. (2009) found that the MST treatment group improved significantly more than the control group on 8 of 11 outcomes tested: youth-reported deviant sexual interest, youth-reported sexual risk, caregiver-reported deviant sexual interest, caregiver-reported sexual risk, delinquency, substance abuse, youth-reported externalizing, and out-of-home placement. The 18- and 24-month follow-ups (Letourneau et al., 2013) showed significant program benefits for one of nine outcomes tested, self-reported delinquency.

Outcomes

Primary Evidence Base for Certification

Study 1

Borduin et al. (1990) found that, relative to the control group, the MST group had significantly fewer:

rearrests for sexual crimes (12.5% vs. 75%)

Study 2

Borduin et al. (2009, 2021) demonstrated that, relative to the control group, the following outcomes were significantly improved in the MST condition:

mother, father and youth psychiatric symptoms
youth behavior problems
family functioning
peer relationships
school grades
person and property crimes

Additionally, over the 8.9- and 24.9-year follow-up periods, compared to the control condition, MST participants had significantly fewer:

arrests for any crimes, sexual crimes, and non-sexual crimes
days in detention facilities, incarceration, and on probation
family civil suits relating to family instability

Study 3

Henggeler et al. (2009) and Letourneau et al. (2009, 2013) found that the MST treatment group improved significantly more than the control group at the 12-month posttest on measures of:

deviant sexual interests and risk
delinquency at 18 and 24 months
substance use
youth-reported externalizing
out-of-home placement

Mediating Effects

In Study 2, Borduin et al. (2021) found that improvements in prosocial peers mediated the program effect on sexual offenses, reductions in deviant peers mediated the program effect on both incarceration and probation sentencing, and improvements in both adaptability and cohesion in family relations mediated the program effect on family civil suits.

In Study 3, in a mediation analysis of the sexual offender outcomes achieved at 12 months post-recruitment in Letourneau et al. (2009), Henggeler et al. (2009) demonstrated that caregiver follow-through on discipline practices and decreased disapproval with youth's friends mediated program benefits on sexual deviance, risk taking, and antisocial behavior.

Effect Size

In Study 2, Borduin et al. (2009) reported effect sizes as eta-squared, which ranged from small to moderate for all outcomes, while Borduin et al. (2021) reported odds ratios, which were uniformly large. In Study 3, Letourneau et al. (2013) included odds ratios. For the significant outcome of delinquency at 18 and 24 months, the odds ratio of .41 indicated a medium effect size.

Generalizability

All three studies meet Blueprints standards for high quality methods with strong evidence of program impact (i.e., "certified" by Blueprints): Study 1 (Borduin et al, 1990), Study 2 (Borduin et al., 2009, 2021), and Study 3 (Henggeler et al., 2009; Letourneau et al., 2009, 2013). The samples for all studies were composed of youths who had been arrested for sex offenses, and nearly all participants were males.

Study 1 (Borduin et al., 1990) took place in Columbia, Missouri and compared the treatment group with an individual therapy control group.
Study 2 (Borduin et al., 2009, 2021) took place in Columbia, Missouri and compared the treatment group to a control group receiving usual community services which included cognitive behavioral therapy.
Study 3 (Henggeler et al., 2009; Letourneau et al., 2009, 2013) took place in Chicago, Illinois and compared the treatment group to a control group receiving typical services provided to juvenile sexual offenders.

Notes

As an upstream preventive intervention, this program targets and reduces problem behaviors that are associated with increased risk of developing substance use disorder or opioid use disorder later in life.

In Study 2, using arrest data from the Borduin et al. (2009) randomized trial with 48 juvenile sexual offenders, who averaged 22.9 years of age at the 8.9-year follow-up, costs and benefits of MST-PSB versus usual community services was calculated. Based on criminal justice system expenditures, the value to taxpayers over an average follow-up period of 8.9 years, was a savings of $14.41 for every $1 spent. When adding in tangible benefits to crime victims (i.e., fewer property and medical expenses, greater productivity), the benefit-cost ratio was $12.84, for a total of $27.26 per dollar spent. Intangible benefits to crime victims, such as pain and suffering, resulted in a benefit-cost ratio of $21.55. Taking these three together resulted in a total benefit-cost ratio of $48.81 per dollar spent.

Endorsements

Blueprints: Model
Crime Solutions: Promising
OJJDP Model Programs: Promising
SAMHSA : 3.6-3.9

Peer Implementation Sites

Southwest Family Guidance Center
2221 Rio Grande Blvd NW
Albuquerque, NM 87104

Primary Contact:
Renee Martinez
Lead Supervisor-Special Programs
reneemartinez.counseling@gmail.com
505-917-4479

Secondary Contact:
Craig Pierce, CEO
cpierce.swfgc@gmail.com
505-604-4589

Wheeler Clinic
91 Northwest Drive
Plainville, CT 06062

Contact:
Deb Batsie-Hernandez, LMFT
Director of Community Based Services
Dbatsie-hernandez@wheelerclinic.org
860-559-7367

Family Psychology Mutual
Cambridgeshire MST Services
Scott House, 5 George Street, Huntingdon PE29 3AD.
England

Contacts:

Tom Jefford , CEO, tom.jefford@cambridgeshire.gov.uk

Brigitte Squire, CEO, Brigitte.squire@cambridgeshire.gov.uk

Judith Hill, Business Support Manager, Judith.hill@cambridgeshire.gov.uk

Sarah Reeves, MST-PSB Manager, sarah.reeves@cambridgeshire.gov.uk

Program Information Contact

Dr. Russell Borduin
Email: rborduin@mstpsb.com
Website: www.mstpsb.com

References

Study 1

Certified Borduin, C. M., Henggeler, S. W., Blaske, D. M., & Stein, R. J. (1990). Multisystemic treatment of adolescent sexual offenders. International Journal of Offender Therapy and Comparative Criminology, 35, 105-114.

Study 2

Certified Borduin, C. M., Schaeffer, C. M., & Heiblum, N. (2009). A randomized clinical trial of Multisystemic Therapy with juvenile sexual offenders: Effects on youth social ecology and criminal activity. Journal of Consulting and Clinical Psychology, 77, 26-37.

Borduin, C. M., Quetsch, L. B., Johnides, B. D., & Dopp, A. R. (2021). Long-term effects of multisystemic therapy for problem sexual behaviors: A 24.9-year follow-up to a randomized clinical trial. Journal of Consulting and Clinical Psychology. Advance online publication. http://dx.doi.org/10.1037/ccp0000646

Study 3

Henggeler, S. W., Letourneau, E. J., Chapman, J. E., Borduin, C. M., Schewe, P. A., & McCart, M. R. (2009). Mediators of change for Multisystemic Therapy with juvenile sexual offenders. Journal of Consulting and Clinical Psychology, 77, 451-462.

Certified Letourneau, E. J., Henggeler, S. W., Borduin, C. M., Schewe, P. A., McCart, M. R., Chapman, J. E., & Saldana, L. (2009). Multisystemic Therapy for juvenile sexual offenders: 1-year results from a randomized effectiveness trial. Journal of Family Psychology, 23, 89-102.

Letourneau, E. J., Henggeler, S. W., McCart, M. R., Borduin, C. M., Schewe, P. A., & Armstrong, K. S. (2013). Two-year follow-up of a randomized effectiveness trial evaluating MST for juveniles who sexually offend. Journal of Family Psychology, 27, 978-985.

Study 1

Summary

Borduin et al. (1990) found that, relative to the control group, the MST group had significantly fewer:

rearrests for sexual crimes (12.5% vs. 75%)

Pilot Study of MST Treatment of Adolescent Sexual Offenders - Missouri

This was a small study of 16 adolescents arrested for sexual offenses randomized to either MST or individual therapy (IT) conditions. Youth in MST received an average of 37 hours of treatment, and IT youth received an average of 45 hours of treatment. Recidivism data were collected at an approximately 3-year follow-up. Results showed that fewer subjects in the MST condition had been rearrested for sexual crimes (12.5% vs. 75%), as well as nonsexual crimes (25% vs. 50%). The frequency of sexual rearrests was significantly lower in the MST condition than in the IT condition (0.12 vs. 1.62). The number of rearrests was also lower in the MST group than the IT group for nonsexual offenses (0.62 vs. 2.25).

Study 2

Summary

Borduin et al. (2009, 2021) conducted in Columbia, Missouri, used a randomized controlled design to examine 48 youths and their families who were randomly assigned to MST (n = 24) or a usual services control group (n = 24). Self-report data were gathered at baseline and posttest, and two follow-up assessments using police and court records were conducted an average of 8.9 and 24.9 years after treatment.

Borduin et al. (2009, 2021) demonstrated that, relative to the control group, the following outcomes were significantly improved in the MST condition:

mother, father and youth psychiatric symptoms
youth behavior problems
family functioning
peer relationships
school grades
person and property crimes

Evaluation Methodology

Design: Using a randomized controlled design, researchers compared the efficacy of MST versus usual community services (UCS). UCS included cognitive-behavioral individual therapy for 60-90 minutes once a week and cognitive-behavioral groups for 90 minutes twice a week provided through the juvenile justice court. A total of 51 families were referred to the study by the juvenile court system; 3 refused participation in the study, resulting in 48 (94%) youth and their families being randomly assigned to MST (n = 24) and UCS (n = 24). The mean length of treatment/services was 30.8 weeks for the MST participants and 30.1 weeks for the UCS participants.

In Borduin et al. (2009), data were gathered at baseline and posttest, and assessments using police and court records of juvenile and adult criminal activity were conducted an average of 8.9 years after treatment had been completed so that adult arrest data on every youth could be collected. Attrition from the study was 4% (2 lost from control, 0 from intervention), however, arrest data were located on all participants.

Borduin et al. (2021) examined outcomes over a period through an average of 24.9 years after treatment (at age 39.4 on average). With the use of administrative records, the follow-up had no attrition.

Sample: The youths averaged 4.33 previous arrests for sexual and nonsexual felonies. The mean age of the youths was 14 years; 95.8% were boys; 72.9% were White and 27.1% were Black, and among all youths 2.1% indicated Hispanic ethnicity; and 31.3% lived with only one parental figure (always a biological parent). The primary caretaker of the youth included biological mothers (91.7%), biological fathers (6.3%), or stepmothers (2.1%). Families averaged 3.3 children, and 54.8% of the families were of lower socioeconomic status.

Measures: Borduin et al. (2009) included a diverse set of outcome measures. A multi-agent assessment battery was used to obtain outcome measures related to the instrumental and ultimate goals of MST. Instrumental goals, which are theory driven, included improved individual adjustment (psychiatric symptoms and behavior problems), improved family relations, improved relations between the youth and his/her peers, and improved grades in school for the youth. Ultimate goals, common to all treatments of juvenile sex offenders, included decreases in rates of criminal activity, arrests and incarceration.

Instrumental goals (13 total measures)

Psychiatric symptoms in mothers, fathers and youths were assessed by the 53 self-report items of the Global Severity Index (GSI) of the Brief Symptom Inventory (BSI), resulting in three outcome measures.
Behavior problems in youth were assessed through mother and father reports (total score) on the 89-item Revised Behavior Problem Checklist (RBPC), resulting in one outcome measure.
Mother, father and youth perceptions of family relations were evaluated with the 30-item Family Adaptability and Cohesion Evaluation Scales-II (FACES-II), which assesses the constructs of cohesion and adaptability, resulting in two outcome measures.
Parent, youth, and teacher perceptions of the youth's peer relations were evaluated with the 13-item Missouri Peer Relations Inventory, which measures three factor-analytically derived dimensions of peer relations: emotional bonding, aggression and social maturity, resulting in three outcome measures for the mean of parents and teacher reports and three outcome measures for youth self-report.
Parent and teacher reports of youth grades were obtained across 5 content areas (English, math, social studies, science, and other) and the mean resulted in one outcome measure.

Ultimate goals (5 total measures):

Youth reports on the Self-Report Delinquency Scale (SRD; 40 items) were used to assess criminal activity during the previous 3 months for person and property, resulting in two outcome measures.
Criminal arrest data for the youth were obtained yearly from juvenile office records by research assistants who were uninformed as to each participant's treatment condition. Adult criminal arrest data were obtained from a computerized database by a state employee (also uninformed about treatment condition) who conducted a search by participant name. Each arrest was classified as either a sexual or a nonsexual offense, resulting in two outcome measures.
Juvenile incarceration was measured as the number of days that a youth was placed by the Department of Youth Services in a residential facility. Adult incarceration was measured as the number of days that a participant was sentenced to serve in an adult correctional facility. This was summed to provide one outcome measure.

Borduin et al. (2021) used data from administrative records of the state of Missouri. The specific behavioral outcomes included arrests for felony offenses that resulted in convictions, sentencing in the form of both incarceration and probation, and family civil suits against the participant relating to domestic or adult abuse, child protection or endangerment, and paternity.

The authors checked and determined that all participants resided in Missouri during the follow-up period, although they could not confirm that the participants were continuously present for all 24.9 years. Research assistants coding the measures from criminal and court records were uninformed as to each participant's treatment condition. The researchers also took steps to reduce the possibility of false positives for those participants whose names appeared in court records by using detailed matching information. For one measure, family civil suits, checks showed high interrater reliability (kappa = 1.0).

Analysis: Borduin et al. (2009) used analyses of variance to examine group-by-time interactions to see if the effects of the intervention over time were significantly different between groups. Survival analysis was also conducted to compare risk of rearrest and incarceration between intervention and control participants.

Borduin et al. (2021) used odds ratios for dichotomous outcomes (e.g., any arrest), survival analyses for the length of time to the first instance of outcomes (e.g., time of arrest), and negative binomial regression analyses for continuous outcomes (e.g., number of rearrests. The models did not include baseline outcomes, which were not meaningful at young ages, or any other covariates.

Outcomes

Implementation Fidelity: Therapists delivering the intervention received training in the MST model and ongoing quality assurance through 3-hour weekly group supervision sessions and individual supervision as needed. The therapists in the UCS condition had been certified as juvenile sexual offender counselors through a university-based training program. However, the study presented no quantitative information on implementation fidelity.

Baseline Equivalence: Analyses of variance and chi-square tests in Borduin et al. (2009) showed no differences in pretreatment criminal histories or demographic characteristics of MST and UCS participants. However, averaged caregiver reports indicated that MST youths had more behavior problems than did UCS youths; no other between-groups differences were observed for other outcome measures at the pretreatment assessment.

Differential Attrition: Borduin et al. (2009) provided no information on differential attrition, but 100% of the intervention families and 91.7% of the control families (n = 2 dropouts) completed assessments at both pretest and posttest, and all subjects were used in the long-term follow-up. Borduin et al. (2021) had no attrition.

Posttest and Long-term (Borduin et al., 2009):

Instrumental Outcomes: Significant Group x Time interaction effects were found for 12 of the 13 instrumental outcomes (youth self-report of aggression in peer relations was the only exception) at posttest. Mother, father, and youth psychiatric symptoms were significantly decreased in the MST condition versus the UCS condition at posttest (p s <.05). Parents in the MST group reported a decrease in youth behavior problems from pre- to posttreatment, whereas parents of UCS youths reported an increase in behavior problems (p = .05). Significant interaction effects were observed for both measures of perceived family functioning, with families receiving MST reporting increases in cohesion and adaptability at posttreatment and parents of UCS youth reporting a decrease in the same areas (p < .001). Parents, teachers and youths reported increases in emotional bonding and social maturity from pre- to posttreatment for youths in the MST condition, whereas peer bonding and social maturity decreased over time for UCS youths (p s < .008). Finally, parents and teachers of youths in the MST condition reported increases in youths' grades at posttreatment, whereas parents and teachers of UCS youths reported decreases in grades (p < .001).

Ultimate Outcomes: Significant effects were found for all five of the ultimate outcomes. MST youths reported decreases in person and property crimes from pre- to posttreatment, whereas youths receiving UCS reported increases (p s < .001). Additionally, MST participants had 83% fewer arrests for sexual crimes and 70% fewer arrests for other crimes than did their UCS counterparts. MST participants also spent 80% fewer days in detention facilities than did UCS participants. Youths in the MST condition were also at lower risk of rearrest during the follow-up than were UCS participants. By the end of 8.9 years, 75% of participants in the UCS group had been arrested at least once, compared with 29.2% of MST participants. MST participants were at lower risk for sexual offenses and nonsexual offenses during follow-up. By the end of the 8.9-year follow-up, 45.8% of UCS participants had been arrested at least once for a sexual crime and 58.3% had been arrested for a nonsexual crime, compared with 8.3% and 29.2%, respectively, of MST participants.

Long-term (Borduin et al., 2021)

First, for the four measures of any adverse outcome (Table 2), the intervention group, relative to the control group, had by the end of the follow-up period significantly fewer criminal arrests for any offense, any sexual offense, and any non-sexual offense and had significantly fewer family civil suits. All tests showed large odds ratios, ranging from 3.4 to 8.3, that favored the intervention group.

Second, for the four measures of time to an adverse event, the intervention group, relative to the control group, had a significantly slower time to arrest for any offense, any sexual offense, and any nonsexual offense, and significantly slower time to a civil suit related to family instability.

Third, for the six count measures, the intervention group had significantly fewer offenses, sexual offenses, nonsexual offenses, days incarcerated, and days on probation than the control group (Table 3).

Mediation analyses with four mediators at posttest and five outcomes at long-term follow-up produced 20 tests (Table 4). Five of the tests showed significant mediation. Borduin et al. (2021) found that improvements in prosocial peers mediated the program effect on sexual offenses, reductions in deviant peers mediated the program effect on both incarceration and probation sentencing, and improvements in both adaptability and cohesion in family relations mediated the program effect on family civil suits.

Study 3

Summary

Henggeler et al. (2009) and Letourneau et al. (2009, 2013) conducted a study in Chicago, Illinois in which they examined 127 participants referred by the Cook County State's Attorney's Office after having been charged with a sexual offense. They were randomized into the treatment group (n = 67) or control group (n = 60) and assessed at baseline, 6 months, 12 months, 18 months, and 24 months.

Henggeler et al. (2009) and Letourneau et al. (2009, 2013) found that the MST treatment group improved significantly more than the control group at the 12-month posttest on measures of:

deviant sexual interests and risk
delinquency at 18 and 24 months
substance use
youth-reported externalizing
out-of-home placement

Evaluation Methodology

Design: A treatment (MST vs. Treatment as Usual for Juvenile Sexual Offenders [TAU-JSO]) by time (pretreatment, 6 months, 12 months, 18 months, 24 months) factorial design with random assignment of youth to treatment conditions was used.

One hundred and seventy-eight eligible youth were referred to the study and 131 consented to participate. Two families immediately withdrew (both in TAU-JSO) upon learning they were not randomized into their desired intervention, and two others (one in MST, one in TAU-JSO) were subsequently excluded because of degenerative brain disorders in the youth, leaving a final sample of 127 participants. The participants were referred by the Cook County State's Attorney after having been charged with a sexual offense. Inclusion criteria were (1) judicial order for outpatient sexual offender treatment either as part of postadjudication probation or pre-adjudication diversion, (2) presence of a local caregiver with whom the youth resided, (3) youth age between 11 and 17 years inclusive, (4) fluency in either English or Spanish, and (5) absence of current psychotic symptoms or serious mental retardation.

Randomization of the 127 subjects into the treatment group (n = 67) and control group (n = 60) came before the baseline assessment. The assessments with each youth and caregiver occurred at five points in time: within 72 hours of recruitment into the study, 6 months postrecruitment, 12 months postrecruitment, 18 months postrecruitment, and 24 months postrecruitment.

On average, the program lasted 7.1 months and treatment as usual lasted 12.48 months. For many subjects, the 6-month assessment came before program completion, and the 12-month assessment serves as a posttest. Again based on the average treatment duration, the 18-month assessment occurred 6 months after program completion and the 24-month assessment occurred 1 year after program assessment. However, the maximum length of treatment was not reported, making it difficult to precisely determine the timing of the posttest and assessments for all subjects.

All youth in the TAU-JSO condition were referred for sexual offender-specific treatment, and the vast majority received services provided by the juvenile sexual offender unit at the juvenile probation department, including supervision by probation officers and weekly meeting in sexual offender treatment groups. The control group did not receive the family and ecological emphasis of MST.

Overall, 127 assessments were completed at baseline, 124 (98%) at 6 months, and 120 (94%) at 12 months in Letourneau et al. (2009), and 123 (97%) at T2 (6 months) and 116 (91%) at T3 (12 months) in Henggeler et al. (2009). Based upon the original 131 randomized, the completion rates at 12 months would be 92% or 89%. For the 18-month and 24-month assessments, Letourneau et al. (2013) reported 93% and 92% completion rates but dropped the three girls in the sample to focus on boys.

Sample: The mean age of youth at pretreatment was 14.6 years. Only 3 (2.4%) participants were female; the majority of youth were Black (54%) or White (44%), and 31% of youth indicated Hispanic ethnicity. Thirty-five percent of youth had non-sexual offenses in addition to sexual offenses, ranging from ordinance violations to serious person-related offenses. In the three months before baseline, 11% of the youth had received mental health services and 4% had received substance abuse services. Youths' primary caregivers were mothers (64%), fathers (15%), other female relatives (19%), foster parents (2%) and a male relative (1%). Family economic status varied, with 33% of families earning less than $10,000/year, 38% earning $10,000 to $30,000/year and 28.5% earning $30,000 or more.

Measures: During the assessment interview, caregivers and youth jointly completed individual assessment protocols separately, usually at their homes. Research assistants administering the assessments were not always blind to the condition.

Outcome Measures: As only one instance of sexual offense reoffending occurred during the initial 12-month study period, the outcome measures focused on related components of sexual offending.

Inappropriate adolescent sexual behavior was assessed using two subscales of the Adolescent Sexual Behavior Inventory (ASBI) from both youth and caregiver perspectives. The 5-item (youth) and 9-item (parent) deviant sexual interests subscale taps youth behaviors such as owning pornography, use of sex lines and voyeurism. The 10-item (youth) and 8-item (parent) sexual risk/misuse subscale assesses overt sexual behaviors such as having unprotected sex, being sexually used by others, and pushing others into having sex.
Youth delinquency was measured with self-reports of delinquent activities in the past 90 days. The General Delinquency subscale was used, which includes a wide variety of criminal and delinquent behaviors.
Youth substance use was assessed with a subscale of the Personal Experience Inventory (PEI), which combines two items assessing the frequency of adolescent alcohol and marijuana use for the previous 90 days. Some analyses used a combined measure, while others used alcohol and marijuana separately.
Youth mental health symptoms were assessed with the Externalizing and Internalizing scales of the parent-reported Child Behavior Checklist (CBCL) and the corresponding Youth Self Report (YSR).
The caregivers reported monthly on youth out-of-home placement.
New arrests were identified at 2-years post-recruitment from juvenile and adult records from city, state, and federal criminal justice sources; statutory offenses, traffic violations, probation violations, and sex offender registry violations were excluded.

Mediating Measures:

Parenting. Scales from the Pittsburgh Youth Study were used to evaluate Lax Discipline (seven items for both caregiver and youth scales), Caregiver Supervision (five items for caregiver scale and four items for youth scale), and Communication (four items for caregiver scale and five items for youth scale). The items that comprise these parenting scales are rated using a Likert response format. The internal consistencies (Cronbach's alphas) for the parenting scales (youth and caregiver reports) ranged from .64 to .84 across the three times of assessment.
Peer relations. Caregiver disapproval of the youth's friends and youth association with deviant versus conventional peers were assessed with three validated scales from the PYS. These scales assessed Bad Friends (combining four items from youth reports with four items from caregiver reports), Peer Delinquency (11 items, youth report), and Peer Conventional Activities (eight items, youth report). The internal consistencies (Cronbach's alphas) for the peer relations scales ranged from .67 to .89 across the three times of assessment.

In addition to the outcome and mediating measures, criminal records from city, state and national sources were accessed to determine index sexual offenses and prior sexual and nonsexual offense charges. Police investigative reports were reviewed for descriptive information on index sexual offenses pertaining to victim gender, age at offense, and relationship to offender as well as whether an offense included penetration, multiple victims, multiple offenders, or excessive force.

Analysis: Two-level Mixed-Effects Regression Models in HLM used restricted maximum likelihood estimation for continuous outcomes and used a logit link function and Laplace approximation of maximum likelihood function for dichotomous outcomes. All outcomes for the 18-month and 24-month assessments were dichotomized for the analysis. The models controlled for baseline outcomes, as either covariates or condition-by-time interactions.

Results for the 6-month and 12-month assessments in Letourneau et al. (2009) were reported separately. However, results for assessments at 18 months (6 months post program) and 24 month (1 year post program) were combined in Letourneau et al. (2013), which means the long-term sustainability was not separated from the shorter-term follow-up.

Because earlier studies had demonstrated program effects in the expected direction, the tables reported in Letourneau et al. (2013) listed one-tailed significance levels for all but one of the outcomes.

The analyses used intent-to-treat samples by including all available subjects. Letourneau et al. (2009) and Henggeler et al. (2009) dropped only the four subjects who did not complete the baseline assessment. Letourneau et al. (2013) dropped, in addition, the three girls in the sample to generalize the results to boys (but noted that results including the three girls were not substantively different than the results for boys alone).

Outcomes

Implementation fidelity: The MST Therapist Adherence Measure showed mean adherence scores of 3.99, below those of MST therapists in another study but well above those of community-based therapists who were not delivering MST. The 91% treatment completion rate met or exceeded MST program standards; few youth failed to complete MST (n = 6) or TAU-JSO (n = 6).

Baseline equivalence: The study stated that in no case did a statistically significant between-groups difference emerge for baseline index offenses, prior nonsexual offenses, or demographic variables (Letourneau et al., 2009, p. 96).

Differential attrition: The study reported no formal tests for differential attrition.

Posttest: Letourneau et al. (2009) found a significant condition-by-time interaction for 8 of 11 outcomes tested. Treatment effects did not vary by the nature of the juvenile's offense.

Relative to the treatment-as-usual condition, MST youth evidenced significantly greater reductions over time on four measures of problem sexual behavior, delinquent behavior, and substance use. For example, the percentage of MST youth who reported delinquent behavior decreased by about 60% from T1 to T3, whereas the corresponding decrease for youth in the TAU-JSO condition was 18%. Similarly, the percentage of MST youth who reported substance use decreased by about 50% from T1 to T3, whereas the percentage of substance using youth in the TAU-JSO condition increased by 65% during this same time.

Also, MST youth relative to the treatment-as-usual condition evidenced significantly greater reduction in self-reported externalizing symptoms over time. However, there were no differences across conditions on three other mental health measures: parent-reported externalizing, youth-reported internalizing, and parent-reported internalizing

Finally, the probability that an MST youth was in an out-of-home placement during the past 30 days remained approximately 7% through the 12 months post-recruitment. For youth in the TAU-JSO condition, the probability of being placed increased from 8% to 17% during the course of the follow-up. The change differed significantly across the conditions.

Henggeler et al. (2009) affirmed the previous findings by reporting that the intervention significantly affected five of six outcomes examined: externalizing (youth self-report), delinquency, substance use, youth-reported sexual deviance and risk taking, and caregiver-reported sexual deviance and risk taking.

Mediation: The mediation analysis in Henggeler et al. (2009) examined nine mediators with five outcomes. The intervention significantly affected two of the nine mediators, bad friends and lax discipline. Additional tests then showed that bad friends significantly mediated effects on delinquency, substance use, and youth-reported sexual deviance and risk taking, while lax discipline significantly mediated delinquency, youth-reported sexual deviance and risk taking, and caregiver-reported sexual deviance and risk taking.

Long-term: The results in Letourneau et al. (2013) only partially meet the criteria for long-term sustainability. They combined the outcomes at the 24-month or 1-year postprogram assessment with the outcomes for the 18-month or 6-month postprogram assessment. The long-term follow-up thus cannot be separated from shorter-term follow-up.

Using a one-tailed test of significance, the authors reported significant results for five outcomes. Although the tables listed significance for one-tailed tests, the 95% confidence intervals in Table 3 identified condition effects that were significant for a two-tailed test (i.e., when the confidence interval for the odds ratios did not include 1). According to the more stringent standard, only one of nine tests, that for self-reported delinquency, showed significantly better outcomes for the treatment than the control group.