Research Review: The effectiveness of multidimensional family therapy in treating adolescents with multiple behavior problems - a meta-analysis

BACKGROUND

Multidimensional family therapy (MDFT) is a well-established treatment for adolescents showing both substance abuse and/or antisocial behavior.

METHOD

The effectiveness of MDFT in reducing adolescents' substance abuse, delinquency, externalizing and internalizing psychopathology, and family malfunctioning was examined by means of a (three-level) meta-analysis, summarizing 61 effect sizes from 19 manuscripts (N = 1,488 participants).

RESULTS

Compared with other therapies, the overall effect size of MDFT was significant, albeit small in magnitude (d = 0.24, p < .001), and similar across intervention outcome categories. Moderator analysis revealed that adolescents with high severity problems, including severe substance abuse and disruptive behavior disorder, benefited more from MDFT than adolescents with less severe conditions.

CONCLUSIONS

It can be concluded that MDFT is effective for adolescents with substance abuse, delinquency, and comorbid behavior problems. Subsequently, it is important to match specific characteristics of the adolescents, such as extent of impairment, with MDFT.

Common elements of evidence-based systemic treatments for adolescents with disruptive behaviour problems

A growing number of evidence-based systemic treatments for adolescents with disruptive behaviour problems exist. However, it is not clear to what extent these treatments have unique and common elements. Identification of common elements in the different treatments would be beneficial for the further understanding and development of family-based interventions, training of therapists, and research. Therefore, the aim of this Review was to identify common elements of evidence-based systemic treatments for adolescents with disruptive behaviour. Several common elements of systemic treatments were identified, showing a strong overlap between the interventions. Investigation of these common mechanisms and techniques could potentially build strong universal systemic treatment and training modules for a broad spectrum of adolescents with problem behaviours.

Common elements of evidence-based trauma therapy for children and adolescents

Background: Numerous evidence-based trauma therapies for children and adolescents have been developed over several decades to minimize the negative outcomes of post-traumatic stress disorder (PTSD). However, PTSD remains a complex construct and is associated with pervasive problems and high comorbidity. To gain more insight, much could be learnt from the similarities in trauma therapies. Objective: The purpose of this study is to derive common elements from evidence-based trauma therapies for children and adolescents. Method: Therapies were selected from a literature search. Five evidence-based trauma therapies were included in this study. A common element list was created through an existing and modified Delphi method, with a diverse group of Dutch trauma therapists. An element was deemed common when it appeared in three or more of the therapies. The final list was presented to international experts on the included trauma therapies. Results: A substantial commonality of techniques and mechanisms was found across the five evidence-based trauma therapies for children and adolescents, showing a strong overlap between therapies. Conclusion: The identified elements create a basis for research and clinical practice, with regard to targeted trauma therapies tailored to each individual child and his or her support system. This promotes therapy modules that are more flexible and accessible for both therapists and clients, in every environment, from specialized psychiatric units to sites with meagre resources. With current integrated knowledge, we can enhance the effectiveness of child psychiatry and refine trauma therapies.

HIGHLIGHTS

Using a modified Delphi method, a substantial commonality of techniques and mechanisms is found in evidence-based trauma therapies for children and adolescents.Understanding the techniques and mechanisms of trauma therapy could be of help in refining upcoming therapies, and creates a basis for future research.Commonalities promote therapy modules that are more flexible and accessible for both therapists and clients, in environments ranging from specialized psychiatric units to sites with meagre resources.

Multidimensional Family Therapy Reduces Self-Reported Criminality Among Adolescents With a Cannabis Use Disorder

Multidimensional family therapy (MDFT) is an established treatment program for youth displaying multiproblem behavior. We examined whether MDFT decreased criminal offending among cannabis abusing adolescents, as compared with individual psychotherapy (IP). In a Western European randomized controlled trial comparing MDFT with IP, a sample of 169 adolescents with a cannabis disorder completed self-reports on criminal offending. Half indicated they had committed one or more criminal offenses in the 90 days before the baseline assessment. Follow-up assessments were at 6 and 12 months after randomization. The proportion of adolescents reporting nondelinquency increased during the study period, most so in the MDFT condition. In addition, MDFT lowered the number of violent offenses more than IP. This difference was not seen for property crimes. In cannabis abusing adolescents, MDFT is an effective treatment to prevent and reduce criminal offending. MDFT outperforms IP for violent crimes.

Neurobiological Responses towards Stimuli Depicting Aggressive Interactions in Delinquent Young Adults and Controls: No Relation to Reactive and Proactive Aggression

Neurobiological measures underlying aggressive behavior have gained attention due to their potential to inform risk assessment and treatment interventions. Aberrations in responsivity of the autonomic nervous system and electrophysiological responses to arousal-inducing stimuli have been related to emotional dysregulation and aggressive behavior. However, studies have often been performed in community samples, using tasks that induce arousal but not specifically depict aggression. In this study, we examined differences in psychophysiological (i.e., heart rate, respiratory sinus arrhythmia, skin conductance level) and electrophysiological responses (i.e., P3, late positive potential, mu suppression) to aggressive versus neutral scenes in a sample of 118 delinquent young adults and 25 controls (all male, aged 18–27). With respect to group differences, we only found significant higher SCL reactivity during the task in the delinquent group compared to controls, but this was irrespective of condition (aggressive and neutral interactions). Within the delinquent group, we also examined associations between the neurobiological measures and reactive and proactive aggression. No significant associations were found. Therefore, although we found some indication of emotional dysregulation in these delinquent young adults, future studies should further elucidate the neurobiological mechanisms underlying emotional dysregulation in relation to different types of aggression.

Patients' and volunteer coaches' experiences with an informal social network intervention in forensic psychiatric care: a qualitative analysis

BACKGROUND

Improving supportive social networks in forensic psychiatric patients is deemed important due to the protective effects of such networks on both mental health problems and criminal recidivism. Informal interventions targeted at social network enhancement by community volunteers showed positive effects in various patient and offender populations. However, these interventions have not specifically been studied in forensic psychiatric populations. Therefore, forensic psychiatric outpatients' and volunteer coaches' experiences with an informal social network intervention were explored in this study.

METHODS

This qualitative study was based on semi-structured interviews conducted alongside an RCT. Forensic outpatients allocated to the additive informal social network intervention, and volunteer coaches, were interviewed 12 months after baseline assessment. Interviews were audio-recorded and transcribed verbatim. Reflexive thematic analysis was used to identify and report patterns in the data.

RESULTS

We included 22 patients and 14 coaches in the study. The analysis of interviews revealed five main themes reflecting patients' and coaches' experiences: (1) dealing with patient receptivity, (2) developing social bonds, (3) receiving social support, (4) achieving meaningful change, and (5) using a personalized approach. Patient receptivity, including willingness, attitudes, and timing, was a common reported barrier affecting patients' engagement in the intervention. Both patients' and coaches' experiences confirmed that the intervention can be meaningful in developing new social bonds between them, in which patients received social support. Despite, experiences of meaningful and sustainable changes in patients' social situations were not clearly demonstrated. Coaches' experiences revealed broadened worldviews and an enhanced sense of fulfillment and purpose. Finally, a personalized, relationship-oriented rather than goal-oriented approach was feasible and preferable.

CONCLUSION

This qualitative study showed positive experiences of both forensic psychiatric outpatients and volunteer coaches with an informal social network intervention in addition to forensic psychiatric care. Notwithstanding the limitations, the study suggests that these additive interventions provide an opportunity for forensic outpatients to experience new positive social interactions with individuals in the community, which can initiate personal development. Barriers and facilitators to engagement are discussed to improve further development and implementation of the intervention.

TRIAL REGISTRATION

This study is registered at the Netherlands Trial Register (NTR7163, registration date: 16/04/2018).

Exploring the effects of a wearable biocueing app (Sense-IT) as an addition to aggression regulation therapy in forensic psychiatric outpatients

Objective

Preventing and reducing violence is of high importance for both individuals and society. However, the overall efficacy of current treatment interventions aimed at reducing aggressive behavior is limited. New technological-based interventions may enhance treatment outcomes, for instance by facilitating out-of-session practice and providing just-in-time support. Therefore, the aim of this study was to assess the effects of the Sense-IT biocueing app as an addition to aggression regulation therapy (ART) on interoceptive awareness, emotion regulation, and aggressive behavior among forensic outpatients.

Methods

A combination of methods was used. Quantitatively, a pretest-posttest design was applied to explore group changes in aggression, emotion regulation, and anger bodily sensations associated with the combination of biocueing intervention and ART. Measures were assessed at pretest, after 4 weeks posttest, and after one-month follow-up. During the 4 weeks, a single-case experimental ABA design was applied for each participant. Biocueing was added in the intervention phase. During all phases anger, aggressive thoughts, aggressive behavior, behavioral control, and physical tension were assessed twice a day, and heart rate was measured continuously. Qualitative information regarding interoceptive awareness, coping, and aggression was collected at posttest. 25 forensic outpatients participated.

Results

A significant decrease in self-reported aggression was found between pre- and posttest. Furthermore, three-quarters of participants reported increased interoceptive awareness associated with the biocueing intervention. However, the repeated ambulatory measurements of the single-case experimental designs (SCEDs) did not indicate a clear effect favoring the addition of biocueing. On group level, no significant effects were found. On the individual level, effects favoring the intervention were only found for two participants. Overall, effect sizes were small.

Conclusion

Biocueing seems a helpful addition to increase interoceptive awareness among forensic outpatients. However, not all patients benefit from the current intervention and, more specifically, from its behavioral support component aimed at enhancing emotion regulation. Future studies should therefore focus on increasing usability, tailoring the intervention to individual needs, and on integration into therapy. Individual characteristics associated with effective support by a biocueing intervention should be further investigated, as the use of personalized and technological-based treatment interventions is expected to increase in the coming years.

The effectiveness of an additive informal social network intervention for forensic psychiatric outpatients: results of a randomized controlled trial

Objectives

A supportive social network is associated with better mental health and wellbeing, and less criminal behavior. Therefore, this study examined the effectiveness of an additive informal social network intervention to treatment as usual (TAU) among forensic psychiatric outpatients.

Materials and methods

An randomized controlled trial (RCT) was conducted in forensic psychiatric care, allocating eligible outpatients (N = 102) to TAU with an additive informal social network intervention or TAU alone. Participants receiving the additive intervention were matched to a trained community volunteer over 12 months. TAU consisted of forensic care (e.g., cognitive behavioral therapy and/or forensic flexible assertive community treatment). Follow-up assessments were conducted at 3, 6, 9, 12, and 18 months after baseline. The primary outcome was the between-group effect on mental wellbeing at 12 months. Between-group effects on secondary outcomes (e.g., general psychiatric functioning, hospitalization, criminal behavior) were explored.

Results

Intention-to-treat analyses showed non-significant between-group effects on mental wellbeing on average over time and at 12 months. However, significant between-group effects were found on hospitalization duration and criminal behavior. Specifically, TAU participants were hospitalized 2.1 times more days within 12 months and 4.1 more days within 18 months than participants in the additive intervention. Furthermore, TAU participants reported 2.9 times more criminal behaviors on average over time. There were no significant effects on other outcomes. Exploratory analyses revealed that sex, comorbidity, and substance use disorders moderated effects.

Conclusion

This is the first RCT examining the effectiveness of an additive informal social network intervention in forensic psychiatric outpatients. Although no improvements were found on mental wellbeing, the additive intervention was effective in reducing hospitalization and criminal behavior. The findings suggest that forensic outpatient treatment can be optimized by collaborating with informal care initiatives aimed at improving social networks within the community. Future research is warranted to determine which specific patients might benefit from the intervention and if effects can be improved by extending the intervention duration and enhancing patient compliance.Clinical Trial Registration: [https://trialsearch.who.int/Trial2.aspx?TrialID=NTR7163], identifier [NTR7163].

Forensic Psychiatric Outpatients' and Therapists' Perspectives on a Wearable Biocueing App (Sense-IT) as an Addition to Aggression Regulation Therapy: Qualitative Focus Group and Interview Study

BACKGROUND

Given the increased use of smart devices and the advantages of individual behavioral monitoring and assessment over time, wearable sensor-based mobile health apps are expected to become an important part of future (forensic) mental health care. For successful implementation in clinical practice, consideration of barriers and facilitators is of utmost importance.

OBJECTIVE

The aim of this study was to provide insight into the perspectives of both psychiatric outpatients and therapists in a forensic setting on the use and implementation of the Sense-IT biocueing app in aggression regulation therapy.

METHODS

A combination of qualitative methods was used. First, we assessed the perspectives of forensic outpatients on the use of the Sense-IT biocueing app using semistructured interviews. Next, 2 focus groups with forensic therapists were conducted to gain a more in-depth understanding of their perspectives on facilitators of and barriers to implementation.

RESULTS

Forensic outpatients (n=21) and therapists (n=15) showed a primarily positive attitude toward the addition of the biocueing intervention to therapy, with increased interoceptive and emotional awareness as the most frequently mentioned advantage in both groups. In the semistructured interviews, patients mainly reported barriers related to technical or innovation problems (ie, connection and notification issues, perceived inaccuracy of the feedback, and limitations in the ability to personalize settings). In the focus groups with therapists, 92 facilitator and barrier codes were identified and categorized into technical or innovation level (n=13, 14%), individual therapist level (n=28, 30%), individual patient level (n=33, 36%), and environmental and organizational level (n=18, 20%). The predominant barriers were limitations in usability of the app, patients' motivation, and both therapists' and patients' knowledge and skills. Integration into treatment, expertise within the therapists' team, and provision of time and materials were identified as facilitators.

CONCLUSIONS

The chances of successful implementation and continued use of sensor-based mobile health interventions such as the Sense-IT biocueing app can be increased by considering the barriers and facilitators from patients' and therapists' perspectives. Technical or innovation-related barriers such as usability issues should be addressed first. At the therapist level, increasing integration into daily routines and enhancing affinity with the intervention are highly recommended for successful implementation. Future research is expected to be focused on further development and personalization of biocueing interventions considering what works for whom at what time in line with the trend toward personalizing treatment interventions in mental health care.