Multisystemic Therapy With Juvenile Sexual Offenders: Clinical and Cost Effectiveness

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1 Multisystemic Therapy With Juvenile Sexual Offenders: Clinical and Cost Effectiveness Charles M. Borduin Missouri Delinquency Project Department of Psychological Sciences University of Missouri-Columbia

2 Juvenile Sexual Offender Treatment: How Much Do We Really Know? Most treatment focuses on individual youths Is such treatment clinically effective? Is such treatment cost effective? Is it time for a change?

3 Juvenile Sexual Offender Treatment: Focus on the Individual Youth Most treatment approaches focus exclusively on altering youths individual characteristics and are patterned after existing interventions with adult sexual offenders Treatment programs are based on theories about deviant sexual arousal, relapse prevention, and abuse cycles Treatments last 12 to 24 months, include sex-offenderspecific modules (i.e., deviant arousal reduction, cognitive restructuring, victim empathy training, relapse prevention), and often involve group therapy

4 Juvenile Sexual Offender Treatment: Is it Clinically Effective? Studies (n = 3) examining sex-offender-specific cognitivebehavioral treatment for juveniles have failed to use randomized designs Even so, results from these studies are not encouraging & show only small between-groups differences in sexual recidivism & even worse outcomes for general recidivism (Hanson et al., 2002) To date, individually oriented treatment approaches for juvenile sexual offenders have little empirical support

5 Juvenile Sexual Offender Treatment: Is it Cost Effective? Considerable financial resources are being devoted to individually oriented treatments (which have little evidence of clinical effectiveness) in both residential and outpatient settings For example, South Carolina Medicaid reimburses from $91,250 (at $250 per day per youth, minimum length of stay approximately 12 months) to $219,000 (24 months at $300 per day per youth) for residential treatment of juvenile sexual offenders

6 Juvenile Sexual Offender Treatment: Is it Time for a Change? It is not surprising that individually oriented, sexoffender-specific treatment fails to substantially improve recidivism rates in juvenile sexual offenders It is also not surprising that such treatment is expensive Why?

7 Are Juvenile Sexual Offenders Different from Other Juvenile Offenders?

8 Correlates of Juvenile Sexual Offending Most studies have serious methodological limitations, but findings suggest that multiple risk factors are linked with sexual offending in juveniles: Individual factors (e.g., internalizing problems) Family factors (e.g., low warmth, high conflict, low monitoring) Parental problems (e.g., spousal violence, substance abuse) Peer relations (e.g., social isolation, immaturity) School performance (e.g., low achievement, behavior problems, school suspension, learning disabilities)

9 Correlates of Juvenile Sexual Offending Ronis and Borduin (2003) recently provided a more rigorous evaluation of juvenile sexual offenders and their social systems : 115 youths, divided into 5 demographically matched groups: aggressive sexual offenders (i.e., sexual assault, rape) nonaggressive sexual offenders (i.e., molesting younger children) aggressive nonsexual offenders (i.e., aggravated assault) nonaggressive nonsexual offenders (i.e., burglary, auto theft) nondelinquent youths (i.e., no history of arrests) Offenders averaged 8.6 arrests; mean age was 14.0 years; 68% were White and 32% African American; 51% were lower SES A multiagent, multimethod assessment battery assessed: youth and parent individual adjustment (i.e., symptoms, behavior problems) self-reported and observed family relations youth, parent, and teacher reports of youth peer relations academic performance (i.e., grades in school)

10 Correlates of Juvenile Sexual Offending Results of between-groups comparisons: Neither aggressive sexual offenders nor nonaggressive sexual offenders evidenced unique problems in their individual adjustment, family relations, peer relations, or academic performance Aggressive and nonaggressive sexual offenders shared many common problems with both groups of nonsexual offenders (across all domains of functioning) relative to nondelinquent youths The results suggest that sexual offending and nonsexual offending are linked with multiple common risk factors

11 Implications of Research Findings for the Design of Effective Interventions Because the determinants of juvenile sexual offending and those of other forms of juvenile offending may be more similar than dissimilar, effective treatments for delinquency (e.g., MST) hold promise in treating juvenile sexual offenders Prevailing treatment models (i.e., cognitive-behavioral approaches) address few of the determinants of juvenile sexual offending and do little to promote youths competencies in real world settings

12 Findings from Randomized MST Efficacy Studies with Juvenile Sexual Offenders (Missouri Delinquency Project)

13 Study 1: Borduin, Henggeler, Blaske, & Stein (1990) Sample 16 male adolescents and their families participated Most of the offenders had at least 2 arrests for sexual offenses (69% rape or sexual assault, 31% molestation) and all had been previously incarcerated Offenders averaged 4.1 arrests for sexual and other criminal offenses combined Mean age of youths was 14.2 years; 62.5% were White and 37.5% were African American; 69% lived with one parent Design Random assignment to: Individual Counseling or Multisystemic Therapy Average treatment length: Multisystemic Therapy = 37 hours Individual Counseling = 45 hours

14 Study 1 (continued) Results of 3-Year Follow Up MST was significantly more effective at: Preventing sexual offending (recidivism was 12.5% for MST vs. 75.0% for Individual Counseling) Preventing other criminal offending (25.0% vs. 50.0%) Incarceration at time of follow up: 0 of 8 youths who received Multisystemic Therapy 3 of 8 (37.5%) youths who received Individual Counseling

15 Study 2: Borduin, Schaeffer, & Heiblum (2003) Sample Characteristics: 48 sexual offenders and their families participated 24 had one or more arrests for sexual offenses involving aggression (i.e., sexual assault, rape) 24 had one or more arrests for nonaggressive sexual offenses (i.e., molestation of younger children) Youths averaged 4.3 arrests (all offenses) Mean age of youths was 14.0 years; 66.7% were White and 33.3% were African American; 70.8% lived with one parent

16 Method Design: Pretest--posttest control group design Eligible youths were referred in yoked pairs and randomly assigned to MST or usual services Average length of MST = 30.8 weeks Follow up into early adulthood (M age = 23.4 years) Multiagent, multimethod battery used to assess: Instrumental outcomes (youth, family, peer, school) Ultimate outcomes (criminal activity, incarceration)

17 Instrumental Outcomes at Posttreatment MST was significantly more effective at: Decreasing behavior problems in youth Decreasing youth criminal offending (self-reported) Decreasing parent and youth symptomatology Increasing family cohesion and adaptability Decreasing youth association with deviant peers Decreasing violence toward peers by aggressive offenders Improving youth grades in school

18 Time In Out-of-Home Placements One Year After Referral Weeks MST Usual Srv Aggress Nonagr All

19 Short-Term Costs: Out-of-Home Placements One Year After Referral Based on the Missouri Division of Youth Services (DYS) Secure-Care Program Program cost per day is $ Multisystemic Therapy $ 3, Usual Services $ 14, Placement Cost (Per Youth)

20 Ultimate Outcomes at 9-Year Follow-Up MST was significantly more effective at: Preventing sexual offending (recidivism was 12.5% for MST vs. 41.7% for usual services) Preventing other criminal offending (29.2% vs. 62.5%) Decreasing days incarcerated during adulthood (by 62%)

21 Recidivism Rates for Aggressive Sex Offenders at 9-Year Follow-Up Percent Rearrest MST Usual Srv Sex crime Other crime Any crime

22 Recidivism Rates for Nonaggressive Sex Offenders at 9-Year Follow-Up Percent Rearrest Sex crime Other crime 10 0 MST Usual Srv Any crime

23 Long-Term Cost-Benefits to Taxpayers and Crime Victims at 9-Year Follow Up Based on the Washington State Institute for Public Policy (2001) Cost-Benefit Model This model was developed to identify ways to lower crime and lower total costs to taxpayers and crime victims Our estimates reflect Missouri costs (whenever available) to taxpayers and average national costs to crime victims

24 Estimating the Cost of One Criminal Offense Taxpayer Costs: Police and sheriffs offices Superior courts and county prosecutors Local adult jails and community supervision Local juvenile detention and supervision State juvenile rehabilitation administration State Department of Corrections Crime Victim Costs: Monetary Quality of Life

25 Estimating the Cost of Treatment Programs Personnel Therapists salaries Supervisor s salary Support staff salaries Operating expenses Rent Utilities Phone Supplies Therapist travel to homes, schools, etc. Converted to base year 2003 dollars using the U.S. Gross Domestic Product Deflator (2001)

26 Average Costs Per Juvenile Sexual Offender at 9-Year Follow Up MST Usual Services Taxpayer Costs Crime Victim Costs Total Costs $33,278 $13,783 $47,062 $153,027 $76,824 $229,852

27 MST Cost-Benefits Per Juvenile Sexual Offender at 9-Year Follow Up Nonaggressive Sex Offender Aggressive Sex Offender Total Sample Taxpayer $67,615 $171,882 $119,748 Crime Victim $35,692 $90,389 $63,040 Total Cost- Benefit (MST) $103,307 $262,271 $182,789

28 More Research is Needed Both of the MST clinical trials with juvenile sex offenders had small sample sizes (Ns = 16 and 48), so the results should be considered promising but not conclusive We need to assess the effectiveness of MST with a larger sample of juvenile sex offenders and using practicing clinicians from community mental health provider agencies

29 MST Effectiveness Study with Adolescent Sex Offenders A Chicago-based study that began in September 2003 is examining 160 adolescent sex offenders This study represents a collaboration between Cook County State s Attorney s Office, Cook County Probation, Central Baptist Treatment Providers, and the study investigators Youth are being randomly assigned to MST or Usual Services

30 MST Effectiveness Study (continued) Usual Services involve sex-offender-specific outpatient group treatment provided by the Probation Department. Youth returning from detention and from residential treatment are also eligible. MST involves standard MST with additional training on adaptations specific to adolescent sexual offenders and their families.

31 Clinical Adaptations of MST for Treating Juvenile Sexual Offenders Reduce family denial and minimization of offense Help family develop plan to ensure community safety and prevent offender relapse Evaluate and address offender s grooming strategies Assess within-family victimization issues and determine related treatment needs Interventions targeting peer relations are often needed

32 Conclusion If the effectiveness study proves as successful as the two smaller efficacy studies, MST will be conceptualized as a treatment for youth with delinquent behaviors, including aggressive and nonaggressive sexual offenses

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