Shared learning database

The Brandon Centre
Published date:
February 2011

In partnership with Haringey and Camden Youth Offending Teams, Research Department of Clinical, Educational and Health Psychology University College London and the Centre for the Economics of Mental Health Kings College London, the Brandon Centre initiated and ran the first UK randomised controlled trial of Multisystemic therapy (MST) in order to test whether MST plus management as usual is more effective than management as usual in preventing re-offending by young people aged 13 to 17. The trial was run from 2004 to 2010, 108 families participated in the study, preliminary findings two years post treatment show a significant decline in the probability of re-offending and in the number of offending behaviours in favour of MST. The trial and NICE clinical guideline 77 supported the development of MST as a commissioned service.

Guidance the shared learning relates to:
Does the example relate to a general implementation of all NICE guidance?
Does the example relate to a specific implementation of a specific piece of NICE guidance?


Aims and objectives

The overall aim of the initiative was to evaluate whether MST could be successfully carried out in the UK and could be as effective in preventing and reducing re-offending and save costs compared with usual services as the developers of MST have demonstrated in the USA. A further aim, supported by the publication of NICE clinical guideline 77, was to offer MST as a commissioned service for young people with severe conduct problems as part of a menu of NICE evidence-based interventions for young people at risk of or who have conduct problems including parent training, which we already offered, and brief strategic family therapy which we hoped to offer. MST was a new way of tackling antisocial behaviour in young people. MST builds on family strengths by helping parent or carers improve their skills for managing their teenager's antisocial behaviour. Several studies in the USA found that MST can help the young person and her/his parent or carer and can reduce how often young people get in trouble with the law. Outside the USA the results have been more equivocal. However, the question of whether MST would help young people in the UK had not been studied. The help from Youth Offending Services in the UK is very different from that provided to young offenders in the USA and the cultures within which the young people live are different between the two countries. MST is a promising form of help for young people in trouble with the law. It is fast becoming the "gold standard" or "treatment of choice". It is a therapy that requires a lot of time and effort on behalf of families and therapists, and is relatively expensive for organisations delivering MST. An evaluation of MST in the UK was therefore needed to determine whether the treatment was helpful for the young offender and her/his parent or carer, could be carried out in a successful manner in the "real UK world", and could reduce costs compared with usual services. The overall objective of the study was to find out whether MST would reduce the chances of young people breaking the law more than the help available for them from the Youth Offending Service. The study also aimed to find out whether for young people who continued to break the law MST would help the young person be re-convicted less often than if the young person receives help only from the Youth Offending Service and whether MST would help the young person 'stay out of trouble' for a longer period of time than if the young person received help only from the Youth Offending Service. There were a number of secondary aims in areas that MST is meant to be effective: whether MST would help the young person think more positively about obeying the law and following rules at home, at school, and in the wider community; whether MST would improve relationships between the young person and her/his parent; whether MST would improve the ability of the parent or carer to put rules into effect that would help the young person stay out of trouble. We were also interested to learn whether specific characteristics of the young personality including ADHD, psychopathy and poor cognitive skills would make MST less effective. We also wanted to learn whether MST was more effective than usual youth offending team services in reducing the time young people spent in custody and whether MST made cost savings. A final goal of the study was to learn about the views of young people and their parent or carer regarding what it is like to undergo MST, what their experiences and opinions were and what they found helpful and unhelpful about MST. Objectives, associated with the publication of NICE clinical guideline 77, were to establish PCT and local authority commissioning for MST to replace Department of Health funding with a view to becoming self sufficient, to establish referral pathways and to demonstrate the effectiveness of MST as a commissioned service.

Reasons for implementing your project

There were three influences that led to initiating the first UK trial of MST by the Brandon Centre. Firstly outcome data from the Centre's psychotherapy service showed that 12 to 21 year-olds with conduct problems were not doing well in psychotherapy. Treatment outcome data using the Achenbach System of Empirically Based Assessment showed that the outcomes for young people with externalising problems were poor and that a diagnosis of conduct disorder predicted early drop out from treatment by 12 to 18 year olds. A second influence was what we learned from adapting and testing with young offenders a manualised treatment programme that taught social problem solving skills, anger management and social perspective taking skills in 20 sessions. Although outcome and attendance data demonstrated improvements that were superior to those achieved by our psychotherapy service it became clear that external factors including parental monitoring, family relationships and rules, the young person's engagement and performance in education, and peer group relationships were not being addressed and were critical in whether the young person continued to engage in antisocial behaviour. A third influence was what we learned from examining evidence-based practice. We were led to Multisytemic therapy for reasons stated in previous answers. We decided to evaluate MST as a randomised controlled trial because by 2002, UK youth offending teams were providing comprehensive multidisciplinary services for young offenders so it could not be assumed that MST would be more effective. Also trials outside USA had not emulated those obtained from trials run by the developers of MST. Regarding the commissioning of MST, local CAMHS commissioners were seeking alternatives to costly Tier 4 medium stay admissions and following the publication of NICE guideline 77, Camden PCT was therefore interested when we proposed a pilot of three cases to receive MST instead of admission to a medium stay hospital.

How did you implement the project

In order to introduce MST we needed to obtain quite substantial amounts of funding. When we were planning the project in 2002 the cost of a MST team including a co-ordinator, a supervisor and three MST therapists was £250,000 per annum. We therefore needed to find charitable foundations that might be interested in funding the project since at this time Department of Health and Youth Justice Board were not interested in providing funding. A UK charitable trust, the Tudor Trust, and an American foundation, the Atlantic Philanthropies agreed to fund the project, initially for three years and subsequently for a fourth year. The Department of Health then funded the last two years of the project. We needed to establish whether MST Services would agree to support and license the project and whether Haringey Youth Offending Team and subsequently Camden Youth Offending Team would be partners for the project so that we could recruit families of convicted young people on a community order. Having decided to run the evaluation as a randomised controlled trial, we engaged the Research Department of Clinical, Educational and Health Psychology University College London for the evaluation of the clinical outcomes and later the Centre for the Economics of Mental Health Kings College London to conduct a cost offset analysis. The Brandon Centre already had a relationship with the funders who had provided funding for other Centre mental health projects although not on the scale for this trial. Also the Brandon Centre's programme of mental health outcome monitoring was receiving statistical support from Research Department of Clinical, Educational and Health Psychology University College London and the director was an honorary senior lecturer. Prior to submitting and obtaining research ethics committee approval, approval for the trial was sought and obtained from the Youth Justice Board.

Key findings

We ran a RCT in partnership with Haringey and Camden Youth Offending Services recruiting young offenders on a referral order or a supervision order. The parent and young person completed a battery of measures before and after treatment. Data about the young person's offending history were recorded from Youth Offending Service and police databases over a period of three years. Data collection is ongoing. A qualitative study obtained data on parent and young person's experience of MST. At two years follow-up there is a statistically significant greater decline in the probability in offending in the MST group and in the number of offending behaviours, mainly non-violent. Also there is significantly greater improvement in parenting skills for the MST group. A cost offset analysis shows MST making a net saving of £2,223.00 per participant over three years. In the qualitative study parents praised MST for parental skills being reinforced and family relationships being promoted. Outcomes for young people included hopes for a more positive future and understanding how their behaviour impacts on their parent. MST was successful in preventing three CAMHS referred cases of young people with significant mental health problems and severe conduct problems from Tier 4 medium stay hospital admission. This led to local authority commissioning from social services, special educational needs and youth offending service. In Camden, we established referral pathways, assessment procedures, feedback and outcome reporting systems via a Tier 4 monitoring group. This model was set up in Enfield when it commissioned MST for 2010/11. By 2010/11 75% of the budget for the MST team was supported by local commissioning, which has survived for 2011/12 despite financial constraints.

Key learning points

1. Assessing and demonstrating impact: Often providers view outcome monitoring using standardised and reliable measures as a 'tick box' activity rather than an opportunity to learn about the impact of a service or intervention and make changes in the light of findings. We would urge another organisation to view such monitoring as a learning opportunity and not to be afraid to make changes in services. 2. Drawing on the evidence base: We would also urge drawing on the evidence base as we did in identifying MST. We also think it is not enough to draw on research from else where, direct evidence of impact is required. We happened to run a RCT, the gold standard of outcomes research, but there are other ways of measuring impact. NICE's recommendation of MST was crucial in encouraging local commissioning of the intervention. 3. The importance of partnership: In measuring the impact of MST we worked in partnership with local youth offending teams and academic departments without which the project would not have been possible. The local commissioning of MST also depended on working in close partnership with a number of different commissioners and providers of CAMHS. 4. User involvement: The qualitative study we ran was incredibly illuminating and thought provoking. We learned such a lot about MST from parents and young people that was not shown by the findings from the quantitative study that has fed into how we now deliver MST as a commissioned service. Also some parents and young people involved in the study have subsequently become important advocates for MST.

Contact details

Geoffrey Baruch
The Brandon Centre

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