Do We Know the Best Treatment for Antisocial Behaviour?
Part 4 of the Brain & Mind Series
Antisocial behaviour (ASB) is a costly problem for society. ASB involves a range of behaviours that violate rules and the rights of others, such as stealing or being violent, and it usually emerges during adolescence. It has been estimated that if a ten-year-old shows persistent ASB, they will cost society approximately ten times more than peers who do not by the time they reach 27 years of age (Independent Commission on Youth Crime and Antisocial Behaviour, 2010). Because of the costliness of untreated ASB, it is important that we can offer the best available (i.e. gold standard) therapy to reduce ASB. Multisystemic therapy is often considered the “gold standard” treatment for ASB in adolescents. However, this paper argues that this is an oversimplification. It is argued that despite research showing it to be the best treatment for ASB in adolescents, and despite it being perhaps the most heavily tested intervention of its kind, research has not always been able to demonstrate that it is the best available treatment for ASB.
Furthermore, weaknesses have been found in the evidence used to show multisystemic therapy to be the best treatment compared to alternatives. These include the influence of a developer effect whereby the superiority of multisystemic therapy compared to other treatments is better demonstrated, or only demonstrated, when the developers of multisystemic therapy test it. There are also important outstanding questions that need answering to better understand under what circumstances (e.g. which countries) multisystemic therapy might be the best treatment available.
Here’s my informed opinion – what’s yours?
Multisystemic therapy has been heralded as the gold standard treatment of antisocial behaviour in adolescence, and yet the evidence for this doesn’t quite stack up. While multisystemic therapy had strong evidence behind it early-on, recent research that is more rigorous has not been able to consistently demonstrate multisystemic therapy to be the best available treatment. However, currently we do not quite understand why this is. I think it is likely to be due to a range of factors that are yet to be fully understood, rather than merely because current research is more rigorous. Until this is confirmed, it seems that multisystemic therapy is not always the best available treatment. This is important because we need effective treatments for antisocial behaviour as it is a costly problem on a societal level.
Multisystemic therapy is often referred to as the “gold standard” treatment for antisocial behaviour. Discuss why this statement may be an oversimplification, with reference to the strengths and limitations of the MST evidence-base.
It is estimated that if a ten-year-old’s persistent antisocial behaviour (ASB) remains untreated, by the time they reach 27 years of age they will cost society approximately ten times more than peers not exhibiting persistent ASB (Independent Commission on Youth Crime and Antisocial Behaviour, 2010). ASB is characterised by repetitive and ongoing behaviour that violates major societal norms or rules and the rights of others (Connor & Fraleigh, 2010), and is mostly likely to manifest during adolescence (Sampson & Laub, 2003). Multisystemic therapy (MST) is often referred to as the ‘gold standard’ treatment for ASB in adolescents. This paper discusses why this may be an oversimplification with reference to the strengths and weaknesses of the MST evidence-base. Defining ‘gold standard’ as the best tool currently available (see Claassen, 2005), it is argued that MST can be considered gold standard in that, relative to alternative treatments for ASB, MST is the best multicomponent treatment, the most extensively tested, and the most empirically supported. However, it is then argued that MST’s evidence-base is impaired by a number of weaknesses, including a developer effect, conflicting findings concerning MST’s transportability, and important research gaps, which put MST’s gold standard status under scrutiny.
An Overview of MST
MST is an intensive family- and home-based intervention designed to reduce serious ASB in adolescents and prevent future delinquency (Henggeler, Schoenwald, Borduin, Rowland & Cunningham, 2009). It involves directly addressing the known risk factors for delinquency, whilst simultaneously building protective factors (Greenberg & Lippold, 2013) mainly by facilitating positive family interactions, reducing exposure to deviant peers, and improving academic engagement (National Implementation Service, n.d.). Multisystemic therapists generate an individualised treatment plan for each family that can incorporate multiple evidence-based therapeutic approaches, including cognitive behavioural therapy, behavioural parent training, and strategic and structural family therapy (Borduin, 1999).
Strengths of MST’s Evidence-Base
A critical assumption within MST’s theoretical framework is that to be effective interventions for ASB should address multiple risk factors individually (Henggeler et al., 2009). There is a body of evidence confirming that ASB in adolescents is indeed determined by the multiple risk factors addressed by MST (see reviews by Liberman, 2008; Loeber, Burke & Pardini, 2009). Moreover, despite such evidence showing ASB to be multidetermined, there are few multicomponent interventions (Shader, 2002), and MST is considered the best known of these (Henggeler & Schaeffer, 2016).
MST is also perhaps the most extensively tested intervention for ASB in adolescents (Markham, 2018). Importantly, this has involved numerous randomised control trials (RCTs). RCTs are a gold standard method for gauging the relative effectiveness of treatments (Barton, 2000). Fifteen MST RCTs were systematically reviewed by van der Stouwe, Asscher, Stams, Deković and van der Laan (2014), and it was concluded that MST had beneficial effects compared to control treatments. Moreover, upon assessing the quality of MST’s evidence-base, McCart and Sheidow (2016) classed MST as well-established for the treatment of ASB in justice-involved youth. This means MST has the most desirable level of empirical support possible for this target group according to the criteria used from the Journal of Clinical Child and Adolescent Psychology. This classification was based on a systematic review of 86 empirical papers, published over a 48-year period, which examined the relative effectiveness of evidence-based psychosocial therapies for adolescents with disruptive behaviour. While MST wasn’t the only treatment for ASB to be classed as well-established for justice-involved youth, the only other treatment that was (Treatment Foster Care Oregon; TFCO) is unsuitable for youth not justice-involved whereas MST was classed as probably efficacious for this population (McCart & Sheidow, 2016). Furthermore, all other evidence-based ASB treatments suitable for youth not justice-involved received a lower classification than MST for this population (McCart & Sheidow, 2016). This would indicate that for youth exhibiting ASB in general, MST can be considered the best treatment available based on the relative quality and extensiveness of its evidence-base.
Weaknesses of MST’s Evidence-base
However, while MST may have the highest level of empirical support for youth exhibiting ASB in general, it was highlighted in McCart and Sheidow’s (2016) aforementioned review that positive outcomes weren’t obtained when treatment adherence was low. In other words, the successfulness of the treatment was contingent upon the extent to which therapists carried out what they were supposed to do according to the MST manual. Notably, this was not a prominent issue for the majority of other evidence-based treatments for ASB (McCart & Sheidow, 2016).
It must also be highlighted that purely parental interventions have been deemed effective for treating ASB in children up to 10 years of age, without the need for multimodal interventions such as MST (National Collaborating Centre for Mental Health, 2013). Furthermore, the aforementioned studies that showed favourable outcomes, reviewed by van der Stouwe et al. (2014), and assessed by McCart and Sheidow (2016), have major weaknesses to be discussed subsequently. These weaknesses further highlight that it would be an oversimplification to consider MST as the best available treatment for ASB.
A Developer Effect
One of the major weaknesses of MST’s evidence-base discussed thus-far is that most of the trials that demonstrated positive effects were run by the developers of MST, and weaker or non-significant effects were found by trials run by investigators that had no affiliation to MST developers (i.e. independent trials), thus indicating a ‘developer effect’ (Curtis, Ronan & Borduin, 2004; van der Stouwe et al., 2014). This is important because the developers of MST cannot always be involved in monitoring its delivery.
Nonetheless, independent trials have demonstrated favourable effects, all be them smaller in magnitude. The independent trials assessed by McCart and Sheidow (2016) that showed favourable disruptive behaviour outcomes for MST included those by Asscher, Deković, Manders, van der Laan and Prins (2013), Butler, Baruch, Hickey and Fonagy (2011), Ogden and Halliday-Boykins (2004), and Timmons-Mitchell, Bender, Kishna and Mitchell (2006). Furthermore, Asscher et al.’s (2013) and Butler et al.’s (2011) studies were assessed as being strong in a systematic review by Markham (2018) who used a set of techniques developed by the National Institute of Clinical Evidence (2012) to gauge the reliability and validity of RCTs.
Conflicting Findings Challenging MST’s Transportability
Findings from these independent trials additionally indicate that MST is internationally transportable. This is because Asscher et al.’s (2013), Butler et al.’s (2011), and Ogden and Halliday-Boykins’ (2004) trials were carried out in the Netherlands, UK, and Norway respectively, and replicated that found in the USA (e.g. Timmons-Mitchell et al., 2009; Painter, 2009) in that they found MST led to significant decreases in disruptive behaviour.
However, trials in Canada and Sweden have not replicated these effects (Cunningham, 2002; Leschied & Cunningham, 2002; Löfholm, Olsson, Sundell & Hansson, 2009; Sundell et al., 2008). Overall, there have been larger effects found for MST studies conducted in the USA, where MST was originally developed, suggesting MST’s effectiveness may vary geographically (Butler, Anokhina, Kaminska, Watmuff & Fonagy, 2017; van der Stouwe et al., 2014), and thus that it would be an oversimplification to consider MST as the gold standard treatment for adolescents with ASB on an international level.
Additionally, there are weaknesses of the studies that have shown MST to be internationally transportable. For instance, Asscher et al. (2013) did not report the average length of treatment, adequately conceal treatment allocation, nor provide a good description of methodology (Markham, 2018). Moreover, in a follow-up study by Asscher et al. (2014) it was found that there were no differences in recidivism between MST and management-as-usual. Butler et al. (2011) used a relatively small sample size, thus suggesting findings may not be generalizable. Indeed, a more recent RCT by Fonagy et al. (2018), also conducted in the UK, used a much larger sample size and found that MST was not superior to management-as-usual for adolescents with moderate-to-severe ASB.
Furthermore, Fonagy et al.’s (2018) RCT is perhaps the most rigorous examination of MST to-date. Its strengths included using an active comparator, controlling for site effects and numerous individual differences (e.g. sex, age, age of ASB onset), using centres that had long-term experience running MST, measuring programme fidelity, and providing supervision from experts in MST. These methods are highly desired features of RCTs for therapeutic interventions (see Chambless & Hollon, 1998; Sexton, Fisher, Graham & Elnahrawy, 2015). Results from this high-quality RCT further suggest the consensus that MST is the gold standard treatment for ASB is an oversimplification, and perhaps even unfounded.
This leads us onto the question of why studies outside of the USA have not been able to consistently demonstrate MST to be transportable. Fonagy et al. (2018) suggested that they were not able to replicate findings from the USA concerning the superiority of MST because management-as-usual in the UK is more effective. Maughan and Gardner (2018) highlight that the reason Fonagy et al. (2018) and other European studies have not replicated USA findings may be due to a whole host of factors alongside the quality of management-as-usual including variability in treatment fidelity, and/or because more recent trials have been more rigorous and transparent compared to earlier USA trials. However, until further details are provided concerning management-as-usual in Fonagy et al.’s (2018) study, and future studies disentangle these effects, it is only possible to conclude that MST may not always be the best treatment available, especially outside the USA.
While MST’s evidence-base for the treatment of ASB in adolescents may be the most extensive and of the highest quality, it has a number of key weaknesses which suggest that MST tends to only be superior to alternative treatments under certain conditions. These include when treatment adherence is high, when children are over ten, when the developers are involved in its delivery, and when delivered in the USA. Fundamentally, as trials have become more rigorous, MST’s superiority to alternative treatments has become less pronounced or cannot be demonstrated. For these reasons, it is an oversimplification to refer to MST as the ‘gold standard’ treatment for ASB.
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