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Multisystematic therapy, management as usual produce similar results in teen antisocial behavior
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Research findings do not support multisystemic therapy over management as usual for adolescents with moderate-to-severe antisocial behavior, with no significant difference observed in the proportion of participants in out-of-home placement between treatment groups.
“High-quality, quantitative systematic reviews of 22 randomized controlled trials showed that multisystemic therapy is a promising intervention for improving the prognosis of antisocial and offending behavior in adolescence,” Peter Fonagy, PhD, from University College London, and colleagues wrote in The Lancet Psychiatry. “However, outside the USA, the replicability of these findings has been mixed, with some studies showing that multisystemic therapy does not reduce antisocial behavior more than usual interventions.”
Researchers examined the effectiveness and cost-effectiveness of multisystemic therapy compared with usual management for the treatment of adolescent antisocial behavior in a multisite, randomized controlled trial in England.
They randomly assigned families of participants aged 11 to 17 years with moderate-to-severe antisocial behavior to receive management or 3 to 5 months of multisystemic therapy followed by management as usual to determine out-of-home placement at 18 months. For multisystemic therapy intervention, therapists worked with caregivers to improve parenting skills, family relationships, support from social networks, skills, communication problems, school attendance and achievement, and reduce the teen’s association with delinquents. Management as usual was based on the top local services available to youths and designed to be in line with current community practice informed by treatment guidelines.
In total, 342 families received multisystemic therapy followed by management as usual and 342 received usual management. Researchers observed no long-term benefits in behavior, mental health, social care, education or cost-effectiveness for multisystemic therapy compared with usual management. In fact, multisystemic therapy seemed to worsen some of these outcomes for some teenagers, according to Fonagy and colleagues. The number of participants in out-of-home placement was not significantly different between the groups at 18 months (13% vs. 11%; OR = 1.25 [95% CI 0.77–2.05]); however, out-of-home placement was cut by 20% in both groups. Notably, parents may have benefited more from multisystemic therapy than children, but this remains uncertain and will be examined in ongoing follow-up study of this population, according to the researchers.
“Multisystemic therapy was not superior to management as usual in reducing out-of-home placements and bringing about long-term advantages in other outcomes,” Fonagy and colleagues wrote. “The findings also reflect the effectiveness of mental health, youth offending, and social care services in England — which were active in both groups of the trial — in reducing the risk of crime and protecting young people and society, at least when under the scrutiny of a randomized controlled trial.”
In a related commentary, Barbara Maughan, PhD, from the department of social genetic and developmental psychiatry at King’s College London, and Frances Gardner, DPhil, from the department of social policy and intervention at University of Oxford, wrote that these findings raise questions about the nonsuperiority of one treatment over the other, specifically about why the results of multisystemic therapy differ between the U.S., where it was developed, and the U.K.
“It is tempting to view this study alongside other European trials that have been unable to replicate findings for well-known U.S. interventions,” Maughan and Gardner wrote. “We cannot be certain why this failure to replicate findings has occurred; variations in treatment fidelity and quality of standard services, as well as a trend towards increased rigor and transparency in trial conduct and reporting, might all have had a part. Fonagy and colleagues promise further publications on the management-as-usual services in their trial, which might cast light on some of these issues.” – by Savannah Demko
Disclosures: Fonagy and all other authors report grants from the Department for Children, Schools and Families and the Department of Health, and non-financial support from Youth Justice Board and the National Institute for Health Research (NIHR) Clinical Research Network. Maughan and Gardner report no relevant financial disclosures.