Abstract
Background
Multisystemic Therapy® (MST®) is an intensive, home-based intervention for families of youth with social, emotional, and behavioural problems. MST therapists engage family members in identifying and changing individual, family, and environmental factors thought to contribute to problem behaviour. Intervention may include efforts to improve communication, parenting skills, peer relations, school performance, and social networks. MST is widely considered to be a well-established, evidence-based programme.
Objectives
We assessed (1) impacts of MST on out-of-home placements, crime and delinquency, and other behavioural and psychosocial outcomes for youth and families; (2) consistency of effects across studies; and (3) potential moderators of effects including study location, evaluator independence, and risks of bias.
Search Methods
Searches were performed in 2003, 2010, and March to April 2020. We searched PsycINFO, MEDLINE, ERIC, NCJRS Abstracts, ProQuest and WorldCAT dissertations and theses, and 10 other databases, along with government and professional websites. Reference lists of included articles and research reviews were examined. Between April and August 2020 we contacted 22 experts in search of missing data on 16 MST trials.
Selection Criteria
Eligible studies included youth (ages 10 to 17) with social, emotional, and/or behavioural problems who were randomly assigned to licensed MST programmes or other conditions. There were no restrictions on publication status, language, or geographic location.
Data Collection and Analysis
Two reviewers independently screened 1802 titles and abstracts, read all available study reports, assessed study eligibility, and extracted data onto structured electronic forms. We assessed risks of bias (ROB) using modified versions of the Cochrane ROB tool and What Works Clearinghouse standards. Where possible, we used random effects models with inverse variance weights to pool results across studies. We used odds ratios for dichotomous outcomes and standardised mean differences for continuous outcomes. We used Hedges g to adjust for small sample sizes. We assessed the heterogeneity of effects with χ2 and I 2. Pairwise meta-analyses are displayed in forest plots, with studies arranged in subgroups by location (USA or other country) and investigator independence. We provide separate forest plots for conceptually distinct outcomes and endpoints. We assessed differences between subgroups of studies with χ 2 tests. We generated robust variance estimates, using correlated effects (CE) models with small sample corrections to synthesise all available outcome measures within each of nine outcome domains. Exploratory CE analyses assessed potential moderators of effects within these domains. We used GRADE guidelines to assess the certainty of evidence on seven primary outcomes at one year after referral.
Main Results
Twenty-three studies met our eligibility criteria; these studies included a total of 3987 participating families. Between 1983 and 2020, 13 trials were conducted in the USA by MST program developers and 10 studies were conducted by independent teams (three in the USA, three in the UK, and one each in Canada, the Netherlands, Norway, and Sweden). These studies examined outcomes of MST for juvenile offenders, sex offenders, offenders with substance abuse problems, youth with conduct or behaviour problems, those with serious mental health problems, autism spectrum disorder, and cases of child maltreatment. We synthesised data from all eligible trials to test the claim that MST is effective across clinical problems and populations. Most trials compared MST to treatment as usual (TAU). In the USA, TAU consisted of relatively little contact and few services for youth and families, compared with more robust public health and social services available to youth in other high-income countries. One USA study provided “enhanced TAU” to families in the control group, and two USA studies compared MST to individual therapy for youth. The quality of available evidence for M T is mixed. We identified high risks of bias due to: inadequate randomisation procedures (in 9% of studies); lack of comparability between groups at baseline (65%); systematic omission of cases (43%); attrition (39%); confounding factors (e.g., between-group differences in race, gender, and attention; 43%); selective reporting of outcomes (52%); and conflicts of interest (61%). Most trials (96%) have high risks of bias on at least one indicator. GRADE ratings of the quality of evidence are low or moderate for seven primary outcomes, with high-quality evidence from non-USA studies on out-of-home placement. Effects of MST are not consistent across studies, outcomes, or endpoints. At one year post randomisation, available evidence shows that MST reduced out-of-home placements in the USA (OR 0.52, 95% confidence interval [CI] 0.32 to 0.84; P < .01), but not in other countries (OR 1.14, CI 0.84 to 1.55; P = .40). There is no overall evidence of effects on other primary outcomes at one year. When we included all available outcomes in CE models, we found that MST reduced placements and arrests in the USA, but not in other countries. At 2.5 years, MST increased arrest rates in non-USA countries (OR 1.27, CI 1.01 to 1.60; P = .04) and increased substance use by youth in the UK and Sweden (SMD 0.13, CI −0.00 to 0.27; P = .05). CE models show that MST reducesd self-reported delinquency and improved parent and family outcomes, but there is no overall evidence of effects on youth symptoms, substance abuse, peer relations, or school outcomes. Prediction intervals indicate that future studies are likely to find positive or negative effects of MST on all outcomes. Potential moderators are confounded: USA studies led by MST developers had higher risks of bias, and USA control groups received fewer services and had worse outcomes than those in independent trials conducted in other high-income countries. The USA/non-USA contrast appears to be more closely related to effect sizes than than investigator independence or risks of bias.
Authors' Conclusions
The quality of evidence for MST is mixed and effects are inconsistent across studies. Reductions in out-of-home placements and arrest/conviction were observed in the USA, but not in other high-income countries. Studies that compared MST to more active treatments showed fewer benefits, and there is evidence that MST may have had some negative effects on youth outside of the USA. Based on moderate to low quality evidence, MST may reduce self-reported delinquency and improve parent and family outcomes, but there is no overall evidence of effects on youth symptoms, substance abuse, peer relations, or school outcomes.
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