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Multisystemic Therapy - Problem Sexual Behavior (MST-PSB)

Blueprints Program Rating: Model

A juvenile sex offender treatment program 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.

  • Academic Performance
  • Adult Crime
  • Delinquency and Criminal Behavior
  • Illicit Drug Use
  • Mental Health - Other
  • Prosocial with Peers
  • Sexual Risk Behaviors
  • Sexual Violence

    Program Type

    • Family Therapy
    • Juvenile Justice, Other

    Program Setting

    • Correctional Facility
    • Home
    • Mental Health/Treatment Center

    Continuum of Intervention

    • Indicated Prevention (Early Symptoms of Problem)

    A juvenile sex offender treatment program 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.

      Population Demographics

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

      Age

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

      Gender

      • Male and Female

      Race/Ethnicity

      • All Race/Ethnicity

      Race/Ethnicity/Gender Details

      While no subgroup analysis was conducted, most of the subjects were boys in the three clinical trials (i.e., 100% in Borduin et al., 1990; 95.8% in Borduin et al., 2009; and 97.6% in Letourneau et al., 2009). In two of the clinical trials (i.e., Borduin et al., 1990; Borduin et al., 2009), about two thirds of the subjects were White (63.5% and 72.9%, respectively) and the remainder were Black; in contrast, more than half (54%) of the subjects in Letourneau et al., (2009) were Black and the remainder were White. Among all subjects, 2.1% in Bourduin et al., (2009) and 31% in Letourneau et al. (2009) indicated Hispanic ethnicity.

      • Family
      • School
      • Peer
      • Individual
      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, Parent history of mental health difficulties*, Parent stress, Parental attitudes favorable to antisocial behavior, Parental attitudes favorable to drug use, Poor family management, Psychological aggression/discipline, Violent discipline
      • School: Low school commitment and attachment, Poor academic performance*
      • Neighborhood/Community: Community disorganization, Laws and norms favorable to drug use/crime, Low neighborhood attachment
      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*, Non-violent discipline, Opportunities for prosocial involvement with parents, Parent social support, Parental involvement in education
      • 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.

      See also: Multisystemic Therapy - Problem Sexual Behavior (MST-PSB) Logic Model (PDF)

      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.

      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.

      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.

      • Person - Environment

      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 (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.

      A second study also conducted in Columbia, Missouri (Borduin et al., 2009) used a randomized controlled design to compare the efficacy of MST versus usual community services (UCS), the latter consisting of cognitive-behavioral group and individual treatment. 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 for the UCS participants. 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.

      In a third study conducted in Chicago, Illinois (Henggeler, 2009; Letourneau et al., 2009, 2013), 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 with a sample of 127 participants. The participants were referred by the Cook County State's Attorney's Office after having been charged with a sexual offense. 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.

      Results from Borduin et al. (1990) 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 IT group for nonsexual offenses (0.62 vs. 2.25).

      Significant outcomes were found for 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.

      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.

      Borduin et al. (1990) demonstrated that the following outcomes were significantly lower in the MST condition:

      • rearrests for sexual crimes (12.5% vs. 75%)
      • rearrests for nonsexual crimes (25% vs. 50%)

      Borduin et al. (2009) demonstrated that 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-year follow-up period, compared to the control condition, MST participants had

      • 83% fewer arrests for sexual crimes
      • 70% fewer arrests for other crimes
      • 80% fewer days in detention facilities

      Letourneau et al. (2009) 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 (also at 18 and 24 months in Letourneau et al., 2013)
      • substance use
      • youth-reported externalizing
      • out-of-home placement

      In a mediation analysis of the sexual offender outcomes achieved at 12 months postrecruitment 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.

      In study 2, Borduin et al. (2009) reported effect sizes as eta-squared, which ranged from small to moderate for all outcomes. 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.

      Results are limited to juvenile sex offenders and males (since very few participants across all studies were female).

      All studies suffered from the following limitations:

      • Over 95% of the samples were male, so generalizability to females is limited.
      • Although attrition was minimal in all studies, no information was provided on whether attrition differed significantly between conditions or by demographic or outcome measures; however, intent-to-treat analyses were used in all analyses (i.e., no participants were excluded for reasons of treatment dropout, low treatment compliance, etc.).

      Study 2 suffered from these additional limitations:

      • One baseline measure differed across groups.
      • Therapists were not randomly assigned to conditions, so it is possible that therapist characteristics such as motivation, commitment, social facility and flexibility were confounded in the study.
      • Researchers were unable to confirm that youths maintained continuous residence in Missouri throughout the entire 8.9 year follow-up period, therefore the possibility that a portion of the youths may have committed crimes in other states cannot be ruled out.
      • Resources were not available to track treatment utilization by participants during the follow-up period, so it is unknown how other treatment services may have contributed to the between-groups differences that were observed in ultimate outcomes.

      Study 3 suffered from these additional limitations:

      • A small portion (5%) of otherwise eligible youth was excluded from the study because they were initially sent to restrictive placements; the findings do not necessarily generalize to the most serious juvenile sexual offenders.
      • Research assistants were often not blind to treatment conditions.
      • Due to the relatively short follow-up period, researchers were unable to include sexual reoffending as a key outcome variable.
      • The 18- and 24-month follow-ups revealed few benefits compared to the earlier assessments (unless one-tailed significance tests were used).

      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.

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

      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

      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.

      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.

      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.

      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.

      Dr. Richard Munschy
      Phone: 860-348-1938
      Fax: 860-225-4776
      Email: munschy@mstpsb.com
      Website: www.mstpsb.com

      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

      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.

      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.

      Pilot Study of MST Treatment of Adolescent Sexual Offenders - Missouri (Borduin et al., 1990)

      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).

      Sexual Offender Study - Missouri (Borduin et al., 2009)

      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.

      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.

      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: 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.

      Analysis: Analyses of variance were used to examine group x 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.

      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 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: No information on differential attrition was provided, however 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.

      Posttest and Long-term Follow-up:

      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.

      Sexual Offender Study - Illinois (Henggeler et al., 2009; Letourneau et al., 2009, 2013)

      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.