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Vol. LIX, No. 5
March 9, 2007

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From Bench to Frontline
Innovative Care Keeps Kids Out of Trouble, Says Schoenwald
Dr. Sonja Schoenwald
Dr. Sonja Schoenwald, resourceful NIH grantee

For over a century, youthful criminal offenders have been managed differently from adults; they receive rehabilitation instead of punishment.Incarcerated youths have high rates of mental disorders and the Department of Justice (DOJ) has recommended improved mental health services. Yet children in the juvenile system do not, in general, have an enforceable right to treatment and can receive only those services available in their jurisdictions. Without the necessary care, delinquent youths likely face further incarceration.

In a recent visit to NIH, the Medical University of South Carolina's Dr. Sonja Schoenwald discussed psychosocial services for the highest-risk youth. Her talk, "Innovations in the Effectiveness of Care: Getting What We Know How to Do to Those Who Need to Do It," was part of the NIMH Director's Innovation Speaker Series.

Schoenwald focused on transporting multisystemic therapy (MST) from research to usual care settings. "Transport," she explained, "is a way to export a technology that you've tested in an efficacy or effectiveness trial and get it out into end-user contexts, so that you can see how the thing lives and breathes there."

MST is an intensive, short-term, family- and community-based treatment for youths with serious antisocial behavior. It is one of the few successful alternatives to the incarceration of violent, chronic juvenile offenders and appears to prevent re-arrest.

"If you can get them past 19," said Schoenwald, "the odds of their committing repeat crimes goes way down."

The stakes are huge. In 2005, drug abuse violations by juveniles approached 200,000, according to DOJ estimates. Violent crimes by juveniles topped 1.2 million, with 5,000 of these committed by children under 12.

MST is delivered in a home-based model, with therapists available 24-7. MST does not arrange or coordinate multiple services; rather, it addresses the known risk factors for delinquency, providing family, marital, youth, peer and school interventions.

MST was developed in the late 1970s, with studies multiplying in the mid 1980s. "The targets a group of kids that was getting locked up" in juvenile prisons, residential treatment facilities and boot camps, Schoenwald said. The study outcomes showed that MST decreased crime 2.4-4 years post-treatment; decreased behavior problems and symptoms in the youths and their families; and produced cost savings. Lock-up costs were $45,000 to $100,000 per youth per year, compared to MST at $8,000 per treatment episode.

The study trials were done by model developers or clinicians trained by them. Schoenwald wanted to see if community settings could get good outcomes. In 1993, she took the lead in developing training protocols and support systems for therapists and staff in frontline settings. After several years, it was time to evaluate.

"What did we know about transportability then? Very little," she said. "The term had not yet made it into the major journals." Her requests for funding for transport studies were nixed by universities and foundations, so she and her colleagues used personal funds. "It was a little dicey," she said. "I could have lost my shirt."

Funding from the DOJ's Office of Juvenile Justice and Delinquency Prevention, among other sources, eventually came through. Now her group could develop manuals, measures and web-based infrastructure to monitor adherence and outcomes. As she began to collaborate with 9 different provider organizations, she found that most had no computers.

"It isn't proven that we can do this out in the world," she told them, "so we just have to agree that we're experimenting together, then collect the data and see how it works."

She and her team developed treatment and supervision manuals and training/clinical procedures for therapists, supervisors and consultants. Eventually, her colleagues established a university-licensed tech-transfer entity, MST Services, as well as an institute through which adherence and outcomes could be shared. Now, if a county justice system requested an program, Schoenwalds team could offer a systematic approach.

In 1999, NIMH funding came through, allowing Schoenwald to test outcomes and adherence in 45 community sites. At one year post-treatment, she saw significant reductions in youth behavior problems that mirrored results in the randomized trials. There were also reductions in criminal charges through 4 years post-treatment.

A NIDA follow-up grant is supporting further studies testing the magnitude of the change in criminal drug use outcomes against those seen in prior randomized trials. Schoenwald is also investigating questions of staff turnover, expansion strategies, data analysis and how to train organizations to be their own experts.

What have they learned so far? She advised, "Before embarking on any large-scale dissemination, test, measure and evaluate." Involve end-users, so collaborators understand the benefits to them, not just researchers. Seeking funding? Get creative. Learn about tech-transfer protocols and venture out of your own world.

"If we had not gone outside our own academic discipline, we would've gone nowhere," said Schoenwald, who read widely in search of models, including business, education and the military. She quipped, "Now I know why pilots use flight simulators before they fly."

There are now more than 300 MST teams in the U.S. and internationally. "Even in community- based implementation," said Schoenwald, "I think we're going to be able to deliver...on the promise found in the trials: keeping kids out of trouble."

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