1 Evidence-based treatment for justice-involved youth Eric Trupin The past ten years have seen a rapid increase in the development of evidence-based interventions for youth; however, many challenges remain. These factors include the challenges associated with service delivery, the importance of initial engage ment, and the complex nature of the problem (Wasserman et al., 2000). On the other hand, treatment research in this area (and the more global child and adolescent treatment research) has moved considerably toward recognizing the need for empirically supported treatment. In 1995, the American Psychological Association Division 12 Task Force on Promotion and Dissemination of Psychological Procedures was charged with the task of identifying treatment approaches with demonstrated efficacy. Efficacy refers to the ability to bring about the desired change under ideal conditions, and an efficacious program is one with scientific evidence demonstrating positive changes among those who receive the treatment. This term is contrasted with the word effective, which refers to the likelihood that a person will comply with a given treatment. An effective program has the ability to produce positive change in the general population. In a compre hensive review of the literature, the APA s Task Force (Levant, 1995) established the validity of numerous treatment approaches. They applied the terms empiri cally validated or empirically supported and probably efficacious to represent therapeutic approaches with varying degrees of scientific evidence. The list of therapies deemed valid or well-established and probably efficacious was updated in 1998 (Chambless et al., 1998) and again in 2001 (Chambless & Ollendick, 2001). O Donohue, Buchanan and Fisher (2000) provided a synthesis of the characteristics associated with empirically supported treatment. They agreed empirically supported treatments should have: (a) a skill development focus; (b) a problem-focus; (c) continuous assessment of progress; (d) some type of homework/out-of-session work; and (e) a recognition of the importance of the therapeutic relationship. The Mental Health Needs of Young Offenders: Forging Paths toward Reintegration and Rehabilitation, eds. Carol L Kessler and Louis J. Kraus. Published by Cambridge University Press. Cambridge University Press 2007.
2 341 Evidence-based treatment Most empirically-supported treatments focus on specific risk factors for delin quency, as well as systemic and behavioral targets of the youth and family. The identification of risk factors for youth involved in the juvenile justice system requires both a life-span and an ecological perspective. In a comprehensive review of risk factors for youth violence, Hawkins et al. (2000) identified risk factors from a developmental perspective, as well as from an ecological or systems point ofview. Risk factor identification begins with the recognition that prenatal exposure to teratogens (e.g., tobacco, alcohol, and illicit drugs) is a risk factor for poor fetal growth and neurodevelopmental impairment. Complications during pregnancy have been found to be associated with violent offenders (Kandel & Mednick, 1991). Significant stressors in the home and in particular the synergistic effects of multiple stressors (e.g., unemployment, housing conditions, and family/marital discord) are associated with poor parenting practices. Parents ability to monitor and provide structure for their children presents as a significant risk factor begin ning in early childhood. These stressors are also associated with poor maternal life outcomes with the end result of multiple successive births to families with limited financial and social supports. A meta-analysis of treatment outcome studies for children and adolescents provided additional support for behaviorally- and parent-focused intervention for children and adolescents (Weisz et al., 1995). Research on empirically supported treatments (EST5) has resulted in positive changes in the psychotherapy field, including the integration of curricula on ESTs in training programs (Chambless & Ollendick, 2001). However, this research has also been instrumental in suggesting a framework for evaluating programs. For example, a well-established program must have at least two randomized controlled trials (RCTs) demonstrating that it will result in the desired outcomes compared with a control condition (placebo or wait-list control). In some cases, a large series of rigorous single-case studies are accepted as meeting the minimum criteria. To receive this classification, a program must use a treatment manual or well-specified protocol, specify the characteristics of the sample, and result in the desired outcomes by at least two different research teams (Chambless & Ollendick, 2001). Treatments placed in a validated, but less well-established category ( probably efficacious ) must have at least one RCT demonstrating superiority of the treatment over a control condition or a small series of single case studies. Programs deemed promising have some evidence (e.g., a case series) indicating improvements attributable to the treatment approach. Although this framework has been criticized on a number of dimensions (e.g., heavy emphasis on quantitative data; Chambless & Ollendick, 2001), few can argue against the value of contrasting treatment approaches to distill the components necessary for desired change.
3 342 Eric Tru pin Treatment can and should occur at different stages. In this chapter we will pinpoint the conceptual foundations and treatment strategies for early interven tion, and community-based treatment programs, and will provide case examples illustrating the unique features of each approach. In addition, we will present two promising transition programs with implications for treatment of youth in secure programs prior to their participation in community-based aftercare treatments. Early intervention and community-based treatment programs are intended to provide alternatives to secure facilities for juveniles involved in criminal activity. These approaches are analogous to strategies used in public health to prevent, control, and reduce the impact of illness on quality of life, morbidity, and mortality. Program classifications Early intervention Early intervention programs primarily seek to identify and counter negative influences in youths lives that are likely to lead to escalated antisocial behavior and are typically applied to youth prior to incarceration in secure facilities. Two examples of early intervention programs include diversion programs and mentor ing programs. Diversion programs Diversion programs are designed to minimize the negative impacts of incarcer ation, such as stigmatization and negative peer relationships, by diverting youth involved in first-time or misdemeanor crimes from entering secure facilities (Shelden, 1999). The tenets of this early intervention approach are based on labeling research (Schur, 1971). This research suggests that labeling behaviors as deviant creates a class of individuals who are deemed outsiders as a result of engaging in behaviors that are outside the norm of appropriate behavior (Schur, 1971). Outsiders are more likely to continue engaging in antisocial behaviors as a result of how others react or label their behaviors. Research also shows that association with a negative peer group, as is the case in incarceration settings, plays a key role in the escalation of an existing delinquency problem (Elliot, Huizinga, & Ageton, 1985). Key intervention strategies and targets for change Diversion programs target youth with minor offenses (e.g., truancy, shoplifting) and aim to stop future recidivism by targeting specific risk factors for recidivism such as parent child relations, youth self-esteem, and youth decision-making.
4 343 Evidence-based treatment Parents, teachers, and correctional staff refer youth to diversion programs if the youth appears to be at risk for continued criminal behavior. Referrals can occur either before or during the adjudication process. Once referred, the youth and family become involved in a number of different activities. Common elements in diversion programs include a diagnostic assessment, counseling, tutoring, job training, community service restitution, and substance abuse treatment. Youth participate in psychoeducational treatment groups to learn anger management, conflict resolution, decision-making, substance abuse, peer pressure, and selfesteem. Parents can also receive training in parenting styles and decision-making. The family receives training as a relational unit in communication. The length of treatment can vary from four weeks to six months (Davidson et al., 1985). Many programs are associated with the 4-H organization (Cummings & Clark, 1993). If the youth successfully completes the diversion program, his/her criminal charges are suspended. Evaluation There is conflicting evidence on the efficacy of diversion programs. Early diversion programs were found to actually increase recidivism and perceived labeling (Polk, 1995). However, later programs have shown more success. The Washington State Institute for Public Policy (WSIPP) found a Washington-based diversion program to have significant effects in reducing recidivism. This program features commun ity members, family members, a youth counselor, and the youth developing the youth s treatment plan, which can include community service, restitution, and/ or counseling. Research by WSIPP for this program suggested a significant (5.1 percent) drop in recidivism at six months post-program completion for participants compared to their recidivism rates established prior to completing the program, as well as substantial cost-savings to taxpayers in the amount of $2,775 per participant (Barnoski, 1997). In a study examining the effectiveness of Back-on-Track, an after-school diver sion program that uses a multimodal approach for the treatment of early-career juvenile offenders, Myers et al. (2000) found program completers were signifi cantly less likely than matched controls to have committed subsequent criminal offenses at 12 months. In addition, they have significantly fewer subsequent criminal charges at 9- and 12-month follow-up intervals than the control group. However, generalizabiity remains an issue as dropout rates continue to be high (27 percent) after enrollment. Predictors and correlates of success Diversion programs continue to be popular alternatives to incarceration for many reasons, including active involvement from community members and families in
5 344 Eric Trupin solving problems of delinquency and the emphasis on restorative justice. However, there are a number of limitations to diversion programs. Before entering a diversion program, youth must admit guilt to the crime and agree to the terms of the diversion program. Youth who are unwilling or unable to complete the requirements of the diversion programs or who reoffend must return to court for sentencing and detention. Little formal emphasis is placed upon motivation or commitment strategies to encourage youth and families to remain in the programs when difficulties arise. In addition, family involvement is essential and often mandatory in most diversion programs, so when parents or family members refuse to engage or are unable to support their child in the program, the youth is often unable to complete the program as well. Mentoring programs Mentoring programs endeavor to provide youth with adult role models to serve both a supportive and an advocacy function. This approach is based loosely on the modeling component of social cognitive theory (Bandura, 1985), although it originated in the late 19th century as an extension of the friendly visitor model (Grossman & Garry, 1997). Adult role models establish relationships with youth to model and reinforce positive development in all domains of life (school, sports, career, art, and family). The Big Brothers Big Sisters of America (BBBS) programs are among the most widely known examples of mentoring programs, and include perhaps the clearest understanding of program parameters which include: complete orientation for all volunteers volunteer screening including written applications, background checks, exten sive interviewing, and a home assessment youth assessment, including written applications, child and parent interviews, and a home assessment matching protocols that consider the need of the youth, abilities of volunteers, preferences of the parent, and capacity of program staff supervision of the volunteers via contacts with parer~ts, volunteers, and youth at regular intervals during the program. Key intervention strategies and targets for change Younger adolescents (c.12 years) are referred to mentoring programs when they have begun to exhibit delinquent behavior and are deemed at risk for continued delinquency. In a large evaluation of the JUMP initiative, Novotney and colleagues (2000) reported that the most prominent risk factors across 7399 youth included school problems (69 percent; e.g., poor grades, school behavior), social/family problems (54 percent), and delinquency (13 percent; fighting). Alcohol, nicotine, and drug use were not prevalent in this population (2.35 percent, 2.1 percent and
6 345 Evidence-based treatment 3 percent respectively). Teen pregnancy was also very low (1.5 percent among females); the latter factors reflecting the early intervention nature of mentoring programs. Services are delivered by volunteers who interact regularly and build relation ships with a single youth. Typically, the mentoring relationship lasts approxi mately one year. Evaluation The BBBS program has assessed the outcomes of youth who have participated in their programs compared to their non-participating peers. After 18 months, participating youth showed significant decreases in drug use and assaultive beha vior and increases in successful academic behavior, attitudes, and relationships with parents and peers (McGill, Mihalic & Grotpeter, 1998). In addition, prelimi nary reports indicate other mentoring programs can reduce recidivism (Barnoski, 2002a). Future reports may indicate significant cost-savings for these types of programs. Predictors and correlates of success Limitations of mentoring programs include the unavailability of adult mentors for the vast numbers of youth seeking this type of supportive relationship (Novotney eta!., 2000). This is particularly true for male mentors. To counter this limitation, programs are beginning to partner with businesses and encourage employers to grant leave time to their employees to participate in mentoring programs (Davidson et al., 1990). Another limitation is the lack of specificity of treatment targets. Mentoring programs recruit and train mentors yet most programs do not specify how treatment should be delivered or the content of the mentoring sessions. Programs may vary widely and process evaluation measures, besides matching and satisfaction, are left unspecified. The success of mentoring programs is contingent on the strength of the mentor mentee relationship. This requires matching youth and adults on characteristics that are deemed important for effective mentoring. Among the characteristics found most important are matching by gender and ethnicity, and the length of commitment on the part of the mentor (Novotney et a!., 2000). In their evaluation of several mentoring programs associated with the JUMP initiative, Novotney and colleagues found equivalent satisfaction levels without gender matching, but same-sex matching resulted in improvements in gang and drug avoidance. The success of these programs at this time seems heavily dependent on demon strated quality recruitment methods from churches and other pro-social envi ronments, as well as the early intervention to low-risk clients to affect behavior change prior to the development of long-term or entrenched behavior patterns.
7 346 Eric Trupin Community-based treatment programs Community-based treatment programs provide rehabilitative services to youth and families in the home and community, primarily as an alternative to incarcer ation in secure settings. This type of service delivery represents a shift from previous responses to juvenile crime including punitive approaches or indivi dualized treatment in an office or institutional setting. This shift is accompanied by a change in attitude toward families, from that of a dysfunctional cause of the child s psychopathology to an effective partner with professionals (Duchnowski et a!., 2000). Two types of community-based programs include multisystemic therapy (MST) and functional family therapy (FFT). Multisystemic therapy Multisystemic therapy is based on systems theory and the theory of social ecology. Multisystemic therapy services are individualized to the characteristics and beha viors of each individual and his/her particular social ecology with assessment and intervention occurring in the natural ecology. Services are delivered in the home, school, and community (Schoenwald & Rowland, 2002). Key intervention strategies and targets for change MST targets youth engaged in serious antisocial behavior and their families. Ongoing research is examining the effects of MST on youth with a variety of serious emotional disorders and emotional problems (Schoenwald & Rowland, 2002). Multisystemic therapy employs several different types of interventions integrated from structural and strategic family therapies, parent management techniques, cognitive behavior therapy, and problem-focused interventions at the system level. It targets and incorporates multiple systems including the family, school, commu nity, church, and peer groups, relying heavily on initial and continued commitment strategies to engage and motivate stakeholders in the youth s treatment. Multisystemic therapy services are provided for three five months per family depending on the seriousness of the problems and the success of the interventions. Therapists, typically master s-level or highly skified bachelor s-level individuals, are available to their clients 24 hours a day, 7 days a week, and each therapist works with only four five families at a time. Frequency, duration, and intensity of the treatment varies in accordance with the needs of each family (Schoenwald & Rowland, 2002). Individual therapy for adolescent substance use or mental illness are provided if ecological change does not result in a reduction of substance use and psychiatric symptoms, or if improvements in the ecology are impeded by the youth s substance use or psychiatric symptoms. Treatment goals are developed in collaboration with the family, and family strengths are built upon and used as primary change agents. The overarching goals
8 347 Evidence-based treatment of MST are to reduce the rates of antisocial behavior in the youth, reduce out-ofhome placements, and empower families to resolve future difficulties. Evaluation Since the completion of early studies indicating favorable effects of MST (Henggeler et a!., 1986, Brunk et a!., 1987), there have been larger, more recent randomized clinical trials documenting the clinical effectiveness and costeffectiveness of MST with youth who engage in serious antisocial behavior. In a randomized study comparing MST with individual therapy, Borduin et a!. (1995) found that youth who received MST were significantly less likely to be rearrested than those who received individual counseling. For those who did recidivate, MST youths were less likely to be arrested for violent crimes and drug offenses. Results from a randomized study by Henggeler eta!. (1992) showed that MST was effective at reducing rates of criminal activity and institutionalization. In addition, families that received MST reported increased family cohesion and decreased adolescent aggression with peers in comparison with the comparison group. Results from various studies also indicate that MST may be more costeffective than traditional services (Schoenwald eta!., 1996; Washington Institute for Public Policy, 1998). Predictors and correlates of success A large factor in MST s success is the emphasis on quality assurance and account ability of therapists for outcomes. Significant resources are devoted to ongoing therapist training and clinical consultation to maintain treatment integrity and fidelity. Multisystemic therapy therapists are clinically supervised on a routine basis, and are held responsible for achieving outcomes within families by contin uous engagement and the removal of barriers to success. A major goal of clinical supervision is to continually assess the effects of therapist interventions on the family in order to make adjustments in the treatment plan to fit the needs of the family (Henggler & Borduin, 1995). Functional family therapy Although commonly used as an intervention program, Functional family therapy (FFT) is considered by some as a prevention approach to reduce the likelihood of violent and serious offending (Wasserman et al, 2000). Functional family therapy is a family behavioral intervention that employs well-established techniques from applied behavior analysis (Sulzer-Azaroff & Mayer, 1977) to increase family communication and improve problem-solving abilities. Functional family therapy has been implemented in a variety of treatment settings with demonstrated efficacy.
9 348 Eric Trupin Key intervention strategies and targets for change Target populations range from at-risk pre-adolescents to youth with very serious problems such as conduct disorder, violent acting-out, and substance abuse. While FFT targets youth aged 11 18, younger siblings of referred adolescents often become part of the intervention process. A major goal of FFT is to use specific skills such as reframing to improve family communication while decreasing negativity and blaming between family mem bers. The family is treated as a whole, so that both strengths and problems within the family are attributed as relational issues, instead of sole issues of particular individuals. Specific techniques used in FFT include contingency management and contracting, token economy, and social reinforcement. Parents are taught how to establish and communicate clear rules and consequences for their child s behavior by creating contracts that link prosocial child behavior with specific rewards. A token economy (a point system used to monitor prosocial behavior in exchange for additional privileges) is often used to provide a link between behaviors and consequences. The FFT intervention is typically spread over a three-month period and the intensity of services varies depending on the needs of the family. On average, eight twelve sessions are provided for mild cases and up to 30 hours of direct service (e.g., clinical sessions, telephone calls, and meetings) are provided for more difficult cases (Sexton & Alexander, 2000). Functional family therapy therapists pay particular interest in building balanced alliances with all family members to avoid the appearance of siding with one family member or another. Goals for treatment are based upon the goals of the family, and the therapist assists the family in achieving small obtainable changes in order to introduce successes into the family (Alexander & Parsons, 1982). The FFT program is divided into four distinct phases: (1) Introduction or impression (2) Motivation (3) Behavior change (4) Generalization. Treatment goals are developed for each family and must be matched to the family culturally and contextually, taking into consideration the values and norms of the family, as well as the phase of treatment in which the family is participating (Alexander & Parsons, 1982). Evaluation Results from both randomized trials and non-randomized comparison group studies indicate that FFT significantly reduces recidivism for various juvenile offense patterns (Alexander et a!., 2000). In a summary of outcome findings
10 349 Evidence-based treatment from FFT studies conducted over the last 30 years, Sexton and Alexander (2000) report that FFT can reduce adolescent rearrest rates by percent when compared with no treatment, other family therapy interventions, and traditional juvenile court services. Predictors and correlates of success As with MST, FFT places a high priority on quality assurance measures and outcome evaluation. A significant factor in FFT s success is the emphasis on adherence, fidelity, and clinical consultation for therapists. This includes adher ence measures for in-session characteristics as well as family interaction processes, leading the FFT program to produce therapists who can demonstrate sensitivity as well as the ability to focus and structure family contacts in order to produce the best outcomes. Multidimensional treatment foster care Multidimensional treatment foster care (MTFC) is a model that has demonstrated effectiveness with severely emotionally disturbed, antisocial children and adoles cents who would otherwise be treated in group care (Chamberlain & Reid, 1998). The philosophy behind MTFC is that the most effective treatment for youth who exhibit antisocial behavior is likely to take place in a family environment in which systematic control is exercised over the contingencies governing the youth s behavior. Multidimensional treatment foster care parents are the primary treatment agents for youth in the program, and the youth s own biological! step!adoptive!relative families participate in the treatment in preparation for reunification with their child at the program s end (Fisher & Chamberlain, 2000). Key intervention strategies and targets for change The objectives of the MTFC program are to provide youth with close supervision, fair and consistent limits, predictable consequences for rule breaking, a supportive relationship with at least one mentoring adult, and limited exposure and access to delinquent peers (Fisher & Chamberlain, 2000). There are three primary mecha nisms within the model that contribute to positive outcomes: (1) proactive approach to reducing problem behaviors; (2) implementation of an individualized behavior management system within the foster home; and (3) separation and stratification of members of the treatment team including behavior support specialists, youth therapists, consulting psychiatrists, case managers, and clinical supervisors (Fisher & Chamberlain, 2000).
11 350 Eric Trupin In addition, the unification plan to ultimately unite the youth with the biological family occurs through the provision of family therapy to the biological family and by teaching the interventions used in MTFC to the biological parents. Closely supervised home visits are conducted throughout the youth s MFTC placement, and the biological parents are encouraged to have frequent contact with the program regarding their child s progress (Chamberlain & Mihalic, 1998). Evaluation Evaluations of MTFC youth compared with non-participating control youth indicate a reduction in incarceration days, arrest rates, runaway behaviors, hard drug use, and quicker community placement rates from secure settings (Chamberlain & Mihalic, 1998). Other evaluations on therapeutic foster care (TFC) programs indicate TFCs to be cost-effective as a result of the abovementioned outcomes. Research also shows some TFC programs to increase the treatment program completion rates (Chamberlain, 1998). Promising programs In addition to the empirically supported program examples mentioned (diversion, mentoring, multisystemic therapy, functional family therapy, and multidimen sional treatment foster care), we would like to introduce two promising programs for juveniles that have some evidence indicating improvements attributable to the treatment approach: family integrated therapy (FIT) and dialectical behavior therapy (DBT). Family integrated therapy This treatment project is currently being piloted in Washington State, and is designed to transition high-risk, high-need juvenile offenders with co-occurring disorders of mental illness and chemical dependency from secure facilities back into their home communities. The program is based upon multisystemic therapy (MST), providing ecological interventions to the youth and family, but incorpor ates components from motivational enhancement therapy (MET) and dialectical behavior therapy (DBT). Youth receive intensive family- and community-based treatment targeted at the multiple determinants of serious antisocial behavior by individual providers who are available 24 hours per day, 7 days per week. The program strives to promote behavior change in the youth s home environment, emphasizing the systemic strengths of family, peers, school, and neighborhoods to facilitate change. This intervention stresses the transition process and begins during the youth s final two months in the secure residential setting, and continues for four six months while the youth is under parole supervision.
12 351 Evidence-based treatment Predictors and correlates of success Like MST and FFT programs, family integrated therapy also places a high empha sis on therapist and program adherence and fidelity, and is currently piloting a therapist-adherence measure. This tool objectively measures therapist effective ness from the perspective of the family. The first results show the therapists assessed are adhering to MST principles at a level consistent with achieving positive outcomes. Families report FIT therapists are conducting productive sessions, are engaging families in problem-solving, and are improving the ways families interact with each other. Perhaps one of the finest aspects of this program is the emphasis placed on motivation and engagement of families. This program specifically targets juveniles who represent the most high risk for recidivism and the most complex treatment needs: co-occurring mental illness and chemical dependency. For many reasons, the families of these youth are very difficult to engage in treatment and community intervention. This has prompted FIT therapists to become very persistent, persua sive, and creative in creating hope and motivating families to engage in the treat ment process. A continual assessment method is used to first assess what factors motivate the family in order for therapists to get a foot in the door, and then joint assessment with the family and in clinical consultation is used to determine treatment planning. Preliminary reports regarding engagement indicate the FIT program is demon strating success in engaging families to at least participate in the program, which is very promising for this population. Future studies will indicate whether or not decreases in criminal behavior, substance use, mental health symptomotology; increases in school and work participation; relationship improvements; and gen eral quality of life improvements; will be present. Dialectical behavior therapy Dialectical behavior therapy (DBT) is empirically supported for treatment of borderline personality disorder in the adult female population (Koons et at., 2001; Evans et at., 1999; Linehan et at., 1999; Linehan et at., 1991); however, for many reasons, DBT is being tested and implemented in an off-the-shelf fashion for a variety of different populations. One population for which the use of DBT has produced promising data is in the treatment of mentally ill juvenile offenders in secure settings. The symptoms for borderline personality disorder which DBT is highly effective in treating include parasuicidal and suicidal behavior, and emotional dysregula tion, or high emotional vulnerability plus an inability to regulate emotions (Linehan, 1993). Individuals suffering from emotional dysregulation have the following traits: