Abstract
BackgroundThere is an urgent need for clinically effective and cost-effective methods to manage antisocial and criminal behaviour in adolescents. Youth conduct disorder is increasingly prevalent in the UK and is associated with a range of negative outcomes. Quantitative systematic reviews carried out for the National Institute for Health and Clinical Excellence have identified multisystemic therapy, an intensive, multimodal, home-based, family intervention for youth with serious antisocial behaviour, as one of the most promising interventions for reducing antisocial or offending behaviour and improving individual and family functioning. Previous international trials of multisystemic therapy have yielded mixed outcomes, and it is questionable to what extent positive US findings can be generalised to a wider UK mental health and juvenile justice context. This paper describes the protocol for the Systemic Therapy for At Risk Teens (START) trial, a multicentre UK-wide randomised controlled trial of multisystemic therapy in antisocial adolescents at high risk of out-of-home placement.Methods/DesignThe trial is being conducted at 10 sites across the UK. Seven hundred participants and their families will be recruited and randomised on a 1:1 basis to multisystemic therapy or management as usual. Treatments are offered over a period of 3 to 5 months, with follow-up to 18 months post-randomisation. The primary outcome is out-of-home placement at 18 months. Secondary outcomes include offending rates, total service and criminal justice sector costs, and participant well-being and educational outcomes. Data will be gathered from police computer records, the National Pupil Database, and interview and self-report measures administered to adolescents, parents and teachers. Outcomes will be analysed on an intention-to-treat basis, using a logistic regression with random effects for the primary outcome and Cox regressions and linear mixed-effects models for secondary outcomes depending on whether the outcome is time-to-event or continuous.DiscussionThe START trial is a pragmatic national trial of sufficient size to evaluate multisystemic therapy, to inform policymakers, service commissioners, professionals, service users and their families about its potential in the UK. It will also provide data on the clinical and cost-effectiveness of usual services provided to youth with serious antisocial behaviour problems.Trial registrationISRCTN77132214
Highlights
There is an urgent need for clinically effective and cost-effective methods to manage antisocial and criminal behaviour in adolescents
This paper describes the protocol for the Systemic Therapy for At Risk Teens (START) trial, a UK evaluation of multisystemic therapy (MST) [1], an intensive familyand home-based intervention for young people with serious antisocial behaviour
For MST to be considered valuable, its superiority should be demonstrated outside the US in care systems meeting the following three conditions: the evidence base for treatment as usual (TAU) is stronger than for TAU in earlier clinical trials initiated by the developers of MST; the motivation of the therapists delivering MST to demonstrate favourable outcomes associated with the therapy is lower than that of those who were involved in the development of MST; and sentencing policy within the justice system does not result in a comparison with alternatives, such as custodial sentences
Summary
A number of high-quality efficacy studies have demonstrated the success of MST in reducing antisocial behaviour and out-of-home placements in high-risk youth, the replicability of the original findings from the US when MST has been transported internationally has been mixed, especially when field trials have not involved the developers of the programme. With appropriate caveats, this study will permit starting the process of identifying the specific subgroups of youth who uniquely benefit from MST as opposed to MAU. This will have obvious practical benefits to services which have to treat a large, heterogeneous group of youth showing antisocial behaviour. Building on an initial qualitative study of MST in the Brandon Centre trial [44], young people and their carers will be interviewed to elicit their views on receiving this intensive, ecologically valid intervention and, to learn what factors they identify as having facilitated or inhibited treatment change. All authors participated in the review and revision of the manuscript and approved the final manuscript
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