The Influence of Risk Level and Program Fidelity On Completing Multisystemic Therapy Among Juvenile Offenders

Purpose: This study examined whether adherence (i.e. fidelity) to the Multisystemic Therapy (MST) program model impacts the relationship between pre-treatment risk factors and completing MST treatment, among youth involved with Maryland’s Department of Juvenile Services (DJS).  MST completion has been associated with improved outcomes – including reduced rates of delinquency – in youth presenting with antisocial behavior (Curtis, Ronan, & Borduin, 2004).  Moreover, delivering MST with fidelity to the treatment model further reduces the likelihood of youth engaging in delinquent behavior (Schoenwald, Hengeller, Brondino, & Rowland, 2000).  The present study explored whether certain risk factors for delinquency are predictive of the completion of MST treatment, with a focus on how therapist fidelity to the MST treatment model mediates this relationship. These questions were addressed within the RE-AIM framework of service implementation, specifically considering the Implementation component of RE-AIM, which emphasizes the consistency of program delivery (National Cancer Institute, 2012).  It was hypothesized that youth with higher risk levels would be less likely to complete MST, and that MST model adherence would dissipate this relationship between risk level and program completion.

Method: The present study was a secondary analysis of data originally collected as part of a statewide initiative to evaluate the implementation of Evidence-based Practices throughout Maryland.  The data used in this study were collected between October 2009 and December 2011 from the DJS administrative database, the Multisystemic Therapy Institute (MSTI) national database, and local agencies providing DJS-funded MST services in Maryland.  Logistic regression analysis was used to determine if (1) DJS-assessed risk level for delinquency was predictive of completing the MST program, and (2) whether receiving services delivered with a Therapist Adherence Measure (TAM) above the target adherence score altered the relationship between risk factors and MST program completion, among DJS-referred youth who discharged from MST with the opportunity for full course of treatment (n = 208).

Results: Chi-squared tests indicated that lower risk levels were significantly associated (χ² =14.94, p=.001, OR=2.027, CI=.974-4.219) and TAM adherence scores above the target threshold were marginally significantly associated (χ² =3.66, p=.056, OR=2.027, CI=.974-4.219) with completing treatment.  Contrary to the hypothesis, the logistic regression model found that TAM adherence scores did not mediate the relationship between risk level and completing treatment.  Though mediation was not found, TAM adherence score (OR = 2.31, p = .032, CI=1.076-4.963) was a significant predictor of completion when controlling for prior risk level.

Implications: These findings demonstrate that both risk level for delinquency and model adherence are considerable factors in the completion of MST treatment.  The finding that controlling for risk level increases the predictive power of program fidelity on completing treatment might imply that it is more challenging for therapists to deliver MST with fidelity to higher-risk youth.  Thus, when working with higher-risk youth and families, MST providers should consider affording additional resources on implementing MST with fidelity to achieve the well-documented outcomes found for MST (Curtis, Ronan, & Borduin, 2004).