‘The efficacy of Forensic Ambulant Systemic Therapy’
A multiple
case study about a family intervention for juveniles with severe
behavioral and externalizing problems
Masterthesis Forensische Orthopedagogie Graduate School of Child Development and Education University of Amsterdam Student: G.P.M. Bout, 10868100 Mentor UvA: E. Kornelis Second mentor UvA: G. J. J. M. Stams Mentor De Waag: E. Schippers Amsterdam, August 28th, 2017
Abstract
Forensic Ambulant Systemic Therapy (FAST) is a family-based treatment for families with children between the ages of 12 and 18 with severe behavioral and externalizing problems and moderate to high risk for recidivism. To obtain preliminary evidence of the efficacy of FAST a multiple case study (N = 2) was conducted. First, the program integrity during treatment was measured for both families by using the “FAST Checklist”. The program integrity was found to be good. Secondly, changes in motivation, emotion regulation and communication of the two families were measured by the “FAST Goal List” at three times: before treatment and two assessments during treatment. It was expected that FAST, when provided with sufficient program integrity, would be effective for both families. Against expectations, reliable change analyses showed only one overall significant change. Neither the other parent, nor the
therapists or the juveniles reported a significant change. Also, the difference between the results of the juveniles and the parents was notable. Even though most of the changes were not significant, they did show a trend towards positive change. This means that the results of this study are promising, but additional research is recommended, which should focus on validating the instruments and examining post treatments effects, including possible moderation and mediation by motivation and self-awareness of the juveniles.
KEYWORDS: behavioral problems, externalizing problems, motivation, communication,
Introduction
Research of Statistics Netherlands [CBS] (2017) showed that a probation measure was imposed on more than 6800 juveniles in the Netherlands in 2016. Among them were
considerable more boys (80%) than girls (20%), and most of them were between the ages of 15 and 17 (53%). Of all those juveniles, 40% received some kind of youth care like
supervision, counselling or treatment (CBS, 2017).
A decrease of juvenile criminality has been one of the Dutch government’s aims during the past few years (Openbaar Ministerie [OM], 2016). In adolescents and young adults, psychosocial development is still ongoing. Therefore, there should be an approach that
contributes to the perpetrator’s development and his or her role in our society. This approach should also reduce the risk of recidivism (OM, 2016). For juveniles with severe antisocial and delinquent behavior a new therapy, named Forensic Ambulant Systemic Therapy (FAST), was developed. The efficacy of this therapy has not been tested yet. Previously, a process evaluation of FAST was conducted (Hoogsteder, 2016), which showed promising results. In the present study the efficacy and program integrity of FAST is investigated.
The history of FAST
Centre for forensic outpatient treatment De Waag offers FAST, and other treatments, to juveniles and adults at several locations in The Netherlands. De Waag also develops forensic ambulant treatment programs. The researchers take into account two main starting points when developing a treatment: the RNR-principles and the social-ecological model of human psychological development (Andrews & Bonta, 2010; Van der Ploeg, Scholte, & Nijkerk, 1990). The risk principle states that intensive treatment should be directed to the higher risk offenders and that treatment of low risk offenders should be minimized. The need principle states that criminogenic needs should be a target in treatment. The responsivity principle states that treatment should be provided in a way that goes together with the
offender’s abilities and way of learning (Andrews & Bonta, 2010). When these principles are followed, the risk for recidivism will most likely decrease (Andrews & Bonta, 2010). The social-ecological development model assumes that both individual risk factors and
environmental risk factors contribute to the development of antisocial behavior (Van der Ploeg et al., 1990). It is therefore is important to keep in mind the interaction between the changes in the child and its surroundings. This interaction takes place in several frameworks of socialization. Treatment can unveil this process and operate by using a systemic approach. On top of that, theory about cognitive and behavioral deficits in executive functionings and social information processing is used in developing treatments (Hoogsteder et al., 2016a).
Out of this theory, treatments are being developed that combine a systemic approach with the cognitive behavioral therapeutic model. The use of a systemic approach was researched and found to be effective (Cottrell & Boston, 2002). Cottrell and Boston (2002) state that especially juveniles with cross-border behavior and their families could benefit from systemic therapy (Cottrell, & Boston, 2002). The reason why systemic therapy is so effective is that it not only utilizes input of the client, but also input of the client’s parents. Research shows that the input of parents in treatment of juveniles is of great value for several reasons (Loeber, Slot, & Stouthamer-Loeber, 2006; McEwen & Sapolsky, 1995; Miller & Rollnick, 2002; Racz & McMahon, 2011; Stoltz, Van Londen, & Dekovic, 2015). First of all, systemic therapy is especially important, because parents can contribute to treatment more efficiently when they are included (Racz & McMahon, 2011). Racz and McMahon (2011) point out the importance of parental monitoring in treatment, defined as “actively structuring the child’s environment” and “actively tracking the child’s whereabouts”. Juveniles can find it hard to stay motivated sometimes when they have to commit to something they do not really like (Miller & Rollnick, 2002). Parents then can provide support and guidance and make sure the structure of the treatment is being followed (Racz & McMahon, 2011).
Second, Loeber and colleagues (2006) point out the influence of risk factors on juveniles and the way it changes over time. Children are the most susceptible for influence of their parents (Loeber et al., 2006). This susceptibility remains up to the age of 15, when social bonds with peers gain importance (Loeber et al., 2006). Thus, parents have to set a good example, so children can learn by watching them and the parents’ influence is not a risk factor and contributes to a good development.
Third, research shows that not only juveniles, but also their parents can benefit a lot from systemic treatment (Stoltz et al., 2015). Systemic treatment can unveil and improve patterns of communication between parents and their children (Stoltz et al.,2015). Finally, systemic therapy can reduce the level of stress in a family. A high level of stress can be obstructive, because too much stress can make people incapable of learning, coping and changing (McEwen & Sapolsky, 1995). The way social information is processed (part of the cognitive behavioral model) can be used to train clients (Hoogsteder, 2015). Learning to recognize signals, interpret signals, clarify goals, prepare to react, make decisions and to execute the reaction helps prevent behavioral problems (Crick & Dodge, 1994). Responding to several risk factors matches the Need-principle of the RNR-model.
Because of the social-ecological view and the systemic approach, previously Multisystem Therapy (MST) was used at De Waag (Hoogsteder et al., 2016a). MST is an intensive treatment for juveniles with serious antisocial behavior and their families. Risk factors are addressed and the strength of the family is the starting point of the treatment (Henggeler, Schoenwald, Borduin, Rowland, & Cunningham, 1998). According to the meta-analyses of Van der Stouwe and colleagues (2014), MST is moderately effective when treating severe behavioral problems, recidivism, family problems, out of home placement, substance abuse and hanging out with the wrong peers. Also, MST makes parents feel more competent and helps them to improve their education skills (Dekovic et al., 2012).
The origination of FAST
However, in practice MST appeared insufficient in treating the juveniles at De Waag (Hoogsteder, 2016). Because of that, Hoogsteder (2016) developed a new therapy that
combines the main features of MST with elements of the interventions Nonviolent Resistance Therapy (NVRT) and Responsive Aggression Regulation Therapy (Re-ART) (Hoogsteder et al., 2016a). These three particular therapies were combined, because they showed positive results in research and because they are suitable for juveniles in the forensic practice
(Dekovic, Asscher, Manders, Prins, & Van Der Laan, 2012; Hoogsteder, Hendriks, Van Horn, & Wissink, 2012; Van der Stouwe, Asscher, Stams, Dekovic, & Van der Laan, 2014;
Weinblatt & Omer, 2008). Also, research was conducted by Hoogsteder (2016) about the risk factors that the treatments should address (for example: family problems, intellectual and social capacities, social network) for juveniles in the forensic practice to benefit from
treatment the most. Re-ART and NVRT were found to be the best complement to MST in that area, taking into account the Risk-principle of the RNR-model (Hoogsteder, 2016). On top of that, the Responsivity-principle is addressed, because MST, Re-ART and NVRT are therapies that can shaped by client (Hoogsteder, 2016).
Re-ART is used for the treatment of children with severe aggression problems that get them in trouble. The main goal of this intervention is to minimize the risk for recidivism of violent behavior by reinforcing the self-regulation skills of the juveniles (Blake & Hamrin, 2007) and by addressing behavior and cognition on a structural basis (Hoogsteder et al., 2012). An evaluation study in a juvenile prison showed Re-ART contributed to lowering the risk of recidivism and to lowering the amount of aggressive behavior, coping skills,
responsivity and irrational thoughts (Hoogsteder et al., 2012).
The main goal of NVRT is for parents to end the violent or destructive behavior of their child without having to deal with escalations at home, by being present and being there
for their children (Omer & Wiebenga, 2015). Research of Weinblatt and Omer (2008) showed a decrease in parental helplessness and escalatory behaviors and an increase in the amount of social support they perceived after receiving training in NVRT. Also, their children’s negative behaviors decreased (Weinblatt & Omer, 2008).
Implementation of FAST
After combining these three treatments, FAST was developed: a therapy for juveniles between the ages of 12 and 18 and their parents (Hoogsteder et al., 2016a; Hoogsteder et al., 2016b). Out of this fusion, three key elements for FAST arose: motivation, communication and emotion regulation. Research of Ward, Vess, Collie and Gannon (2006) showed the importance of those three elements when the risk for recidivism is addressed. First, FAST spends a lot of time on motivating the clients and their families. A meta-analysis of Norcross, Krebs and Prochanska (2011) showed that the result of treatment is strongly connected with the treatment motivation. Also, treatment adherence goes hand in hand with better
relationships inside the family and less antisocial behavior (Huey, Henggeler, Brondino, & Pickrel, 2000). A second important element of FAST is the communication between the juveniles and parents and between the therapist and clients, because it can guide to treatment success or failure (Hermans, Eelen, & Orlemans, 2007). Thirdly, being able to regulate emotions is of high importance for FAST, because relationships within a family can deteriorate when family members cannot regulate vehement emotions (Fosha, Siegel, & Solomon, 2009). Therefore, it is relevant to keep on motivating the clients and to monitor their communication and emotion regulation skills, the way FAST therapists are trained to do.
By taking into account the key elements, FAST strives to reach two main goals. The first one is to reduce the risk for recidivism of both antisocial behavior and criminal behavior. The second one is to prevent the juvenile of being placed somewhere outside his parental home (Hoogsteder, 2015). FAST can help juveniles to manage their behavioral problems by
paying attention to their individual risk factors and their family’s risk factors. The treatment starts intensively and de-intensifies later on. It mostly takes three to nine months, aftercare not included (Hoogsteder, 2015).
Instruments for monitoring
To monitor the progress of treatment FAST uses certain instruments. The FAST Goal List helps the therapists with monitoring motivation, communication within the family and emotion regulation skills. Because juveniles, parents and therapists can have different opinions and different perspectives on how well the therapy works, there are three different Goal Lists: one for the juvenile, one for the parents and one for the therapist. The execution of FAST is monitored by filling in evaluation checklists. These checklists are designed to check whether a treatment is carried out properly (Hoogsteder et al., 2016b).
Also, the juvenile’s level of irrational thoughts is monitored. According to Youngstrom, Findling and Calabrese (2003) having irrational thoughts is common for juveniles with a forensic background. Out of irrational thoughts, risk factors for motivation, communication and emotion regulation can occur (Youngstrom et al., 2003). Youngstrom and colleagues also state it is important to know what kind of irrational thoughts contribute to the juvenile’s antisocial behavior, because a lot of juveniles with those problems have
internalizing problems too. Also, Orobio de Castro (2007) showed that irrational thoughts correlate with the amount of distrust a juvenile has. Therewith, the amount of distrust is related to the motivation of this juvenile and the therapeutic relationship with the therapist. When the juvenile is not motivated enough or does not have a good relationship with the therapist, treatment can come into question (Orobio de Castro, 2007). On top of that, the treatment can be planned more efficiently when it is known which irrational thoughts are related to the antisocial behavior (Sudak, 2006).
Previous research FAST
So far, one process evaluation of FAST has taken place (NJI, 2016). Evaluation lists were used to measure the program integrity and it turned out to be sufficient. The program integrity had to be met for at least 70% (NJI, 2016) and it turned out to be 74,5% during the treatment and 77,7% after the treatment was done. Also, the conditions of the treatment were looked at and they were met (for example: all the therapists were licensed to use this
treatment and no children were under the age of twelve). According to Hoogsteder (2016) the average rate that parents gave the effectiveness of FAST was a 7.6 (on a scale from 1 to 10) and the average rate that the juveniles gave was a 7.9. The parents and juveniles said they had more grip on their problems after the FAST trial (3.1 versus 7.2 for the juveniles, 2.7 versus 6.8 for the parents) and they all found role-playing and aggression regulation modules the most helpful (Hoogsteder, 2016). The therapists were positive about the effectiveness of FAST too (NJI, 2016).
This study
The aim of this pilot study is to investigate the efficacy of FAST. It will be
investigated whether the clients and their families have benefited from the FAST-treatment. It will also be investigated if the clients and their families were able to reach their treatment goals. To be as sure as possible that the effects are most likely due to the treatment, the program integrity of the treatment of the client and its family will be investigated first. It is expected that the scores on the FAST Goal Lists will improve during the intervention for the juveniles, the parents and the therapists.
Method
Sample
The data were collected at the centre for forensic outpatient treatment De Waag in the Netherlands. Of all the families that were indicated for FAST (N = 53), there were two (N = 2) of which data of three measurement moments were available at the end of data collection (January-June 2017). At the start of treatment the families gave permission to use their files and questionnaires for research.
The first participating family consists of a 12 year old girl with two younger brothers and her mother and stepfather. One brother is biological and the other one is a half-brother. Her biological parents divorced when she was a little girl and since then she has not had contact with her father. She was physically abused by her biological father, just like her mother was. Five years ago, her mother met her stepfather and they started living together and had a son. Again, her home turned into an unsafe place. There were a lot of fights, arguments and irritations between her mother and stepfather and between the girl and the mother and stepfather (also physical). At the moment, the mother and the biological brother are staying with grandmother (mother’s side), the half-brother is at home with the stepfather and the girl is staying with her aunt. The mother and stepfather are not sure anymore if they want to stay together. The girl shows a lot of aggressive behavior at home. The parents say she is not able to follow the rules and she does not listen. It often leads to verbal aggression and regularly to physical aggression. The girl’s grades at primary school are good and her IQ is estimated above average, but her behavior in school is getting worse too. She already had a few
arguments, one of them leading to a physical fight. She was diagnosed with Opposite Defiant Disorder (ODD) and Post Traumatic Stress Disorder (PTSD). Her parents already get
relationship therapy, because of their many severe fights, but that is not sufficient. Her family is seen as a poorly functioning one by the therapists of De Waag and that is why FAST was
indicated. Background information is shown in table 1.
The second participating family consists of a 14-year-old boy, his older sister and his parents. His mother and father are together and his sister still lives at home. The family seems close and they still do a lot of things together. The boy has special education because he has an estimated below average intelligence and because he had trouble keeping up at school because of his behavior. He was diagnosed with a behavioral disorder that originated in his early childhood. He is also diagnosed with ADHD and he has trouble concentrating. He is also very impulsive and he shows a lot of aggressive behavior. He is always very bustling and he often gets tantrums. During a tantrum, he says he cannot control himself. When the boy has a tantrum and he does not get what he wants, he often threatens with suicidal remarks. The parents do not succeed in limiting the boy and his behavior and they take his suicidal threats very seriously. They also worry about his friends at school, because they think they are criminal. The boy has not been convicted for any crime so far, but he admits he is guilty of vandalism and fighting. He uses alcohol and cannabis, because it makes him calm. The therapists of De Waag consider the family to be functioning well, but the parents need help in dealing with their son. Therefore, the family is indicated for FAST. Background information is shown in table 1. Note that FAST-treatment of both participants is still ongoing.
Table 1
Background information participants
Participant one Participant two
Sex Female Male
Age 12 14
Risk recidivism “family”¹ High Moderate
Risk recidivism “domestic violence”²
High n/a
Risk recidivism “aggression”³
Moderate-High Moderate-High
Convictions None None
Intelligence Above average Below average (estimated*)
Diagnoses ODD, PTSS ADHD, Behavioral disorder
NOS
Externalizing behavior Yes Yes
Type of dysfunctional behavior
Aggression Aggression
Intensity treatment 2 times per week 2 times per week
Optional modules trauma substance abuse
Status treatment ongoing ongoing
Note. N/a = not applicable
¹functioning of the client’s family members and the quality of the relationship of the client and the family members (according to the risk taxation instrument RAF GGZ Youth)
²violence done by someone in the direct surroundings of the client (according to the risk taxation instrument RAF GGZ Youth)
³harming someone, trying to harm someone or threatening to harm someone physically (according to the risk taxation instrument RAF GGZ Youth)
To measure whether the participants had irrational thoughts and if so, what kind of thoughts, they filled in the Brief Irrational Thoughts Inventory (BITI). More information about the BITI can be found in appendix 1. The test showed both participants have irrational thoughts on all scales (table 2). Although it seems that both participants mostly have irrational thoughts of the type Aggressive Behavior, they relatively have about the same amount of other types of irrational thoughts as well. The Aggressive Behavior scale just has more items than the other scales, which explains the higher scores. When looking at the percentage scores on the scales we see an equal distribution over the scales. Ergo, both participants have equally distributed levels of irrational thoughts on all scales, with participant one scoring overall higher than participant two.
Table 2
Scores on the subscales of the BITI of participant one and two
Participant one
Score (% score on scale)
Participant two
Score (% score on scale) Aggressive behavior (externalizing) 30 (55%) 18 (33%) Sub-assertive behavior (internalizing) 18 (60%) 12 (40%) Distrusting 14 (58%) 8 (33%) Total 62 (57%) 38 (35%)
Note. The maximum scores of the subscales are 54 for Aggressive Behavior, 30 for Sub-assertive
Behavior and 24 for distrust.
Inclusion criteria FAST
when they meet several criteria (Hoogsteder, 2016). First of all, the juvenile has to have an IQ-score of 80 or higher. Secondly, the juvenile’s risk of recidivism has to be moderate or high, measured by therapist with the RAF GGZ Youth. Also, the juvenile and his or her family should score a moderate to high risk for the domain Family of the RAF GGZ Youth. Thirdly, the externalizing problem behavior of the juvenile has to affect at least two living domains, like school, work or home. Four, the juvenile should have been diagnosed with (or at least have severe traits of) ODD or CD, whether or not combined with ADHD, substance abuse, an anxiety disorder, a mood disorder or a deficit in executive functions. Finally, the family should not be motivated to get treatment at De Waag on location, so outreaching therapy is needed (Hoogsteder, 2016). There are no inclusion criteria that parents have to meet.
FAST, the intervention
FAST is a systemic therapy. MST was the predecessor of FAST, thereby FAST uses some of the basic principles of MST and added a few new principles. In total there are 10 FAST principles every treatment has to be led by (Hoogsteder et al., 2016a). For example, one of the principles states it is important to see behavioral problems in their systemic context. To analyze behavioral problems like that, a technique named “analysis circle” is used, in which a problem gets sifted in a clear way (appendix 3). Another example is that therapists have to use the strengths of the client and his family and reachable goals have to be set, to keep the client and the family motivated. One last example is that interventions have to be responsive. Interventions need to match the needs of the client and his family and their learning
possibilities, as mentioned before with the responsivity principle (Hoogsteder et al., 2016a). Before there can be decided how the treatment will be executed (for example: which modules will be used?) there will be a family session. In this session, the family’s goals will be
discussed. The risk taxation that gets done for every juvenile that is indicated for FAST, can function as a guide for setting goals (Hoogsteder et al., 2016a). After all, risk taxation shows
which factors should be tackled. The factors with the highest risk will be addressed first and so on (Hoogsteder et al., 2016a). The treatment is considered done, once the goals are reached. This has to be confirmed by making a plan for the future that is focused on
prevention of relapse (Hoogsteder et al., 2016a). When a juvenile shows a lot of aggressive and deviant behavior, the elements of Nonviolent Resistance Therapy (NVRT) are used. These elements help parents improve the communication with their child and realize new forms of authority by giving them specific skills (Hoogsteder et al., 2016a). The skills the parents learn are avoiding power battles and provocations, breaking the habit of meeting their child’s demands, validating and limiting their child’s aggressive behavior and increasing the amount of attention and involvement for their child (Hoogsteder et al., 2016a). The most important elements of Re-ART that are used in FAST are recognizing irrational thoughts, learning to create helping thoughts and working on skills to fix problems in an efficient way (Blake & Hamrin, 2007; Hoogsteder et al., 2016a). When needed it is also possible to add therapy sessions for traumas and problematic substance abuse problems (Hoogsteder et al., 2016a).
Procedure
This is a multiple case study about a new treatment. Data collection consisted of data from the Brief Irrational Thoughts Inventory (BITI), three types of FAST Goal Lists and three types of FAST Checklists. Before the start of the study, the FAST Goal Lists and the FAST Checklists were altered and improved to a newer version in a feedback round with Waag-therapists. The FAST Checklists for the juvenile, parents and therapist were not filled in at the beginning of treatment, but after two months and after four months (figure 1). The FAST Goal Lists were filled in by the juvenile, the parents and the therapist at the beginning of the
therapy and after that every two months (figure 1). The BITI was filled in at the beginning of the therapy by the juvenile and was supposed to be filled in after four months, but due to
varying circumstances the second measurement did not come true (figure 1). That is why the BITI’s first measurement was merely used as background information about client one and two. Therapists mostly worked with families at their homes, but sometimes at De Waag on location too. Therefore, the lists were filled in on several locations. The data was filled in the SPSS data file and was completed with background information (age, location of treatment, diagnosis, IQ etc.) from the Electronic Patient Record System (EPRZ) of De Waag.
Figure 1. Procedure research program integrity (FAST-checklists), FAST Goal Lists, BITI
Instruments
FAST checklist
To investigate the program integrity first of all a list with indication criteria was used to make sure the conditions of FAST were met. This checklist contains ten conditions, for example “There has to be a FAST program manager at every De Waag-location”. All the conditions had to be met. Second, the degree of program integrity was tested with the FAST Checklists that the juvenile, the parents and the therapist had to fill in every two months. Each checklist contains 12 items. An example of an item of the juvenile’s checklist is “Do you feel comfortable with your therapist?”. An example of an item of the parent’s checklist is “Do you believe the treatment has worked so far?”. An example of an item of the therapist’s checklist
T0
• FAST Goal Lists
• Brief Irrational Thoughts Inventory Treat
ment
T1 • FAST Goal Lists • FAST Checklists Treat
ment
is “Were you able to provide enough outreaching therapy?”. The questions can be answered with a score from 1 to 10, wherein a score of 1 means “very bad/definitely not/never” and a score of 10 “excellent/definitely/always”. Higher scores indicate a better program integrity and lower scores indicate a worse program integrity.
FAST Goal List
The FAST Goal Lists for juveniles, for parents and for therapists were used to measure a change of problems overtime. With these lists the problems of the client and his or her system were displayed. The juvenile, parents and therapist filled in the list in the beginning of the therapy and then after every two months. The lists contain 15 items with goals about the functioning of the juveniles and the parents. The goals can be given scores from 1 to 10, wherein a score of 1 means “totally not true” and a score of 10 “totally true”. An example of an item of the therapist’s FAST Goal List is “The juvenile does not show aggressive
behavior”. An example of an item of the juvenile’s FAST Goal List is “I am motivated to participate in this treatment”. An example of an item of the parent’s FAST Goal List is “I (almost) never argue with my child”. The highest possible score on all of the Goal Lists is 130 points. The lower the score, the more antisocial behavior and the higher the score, the less antisocial behavior. A score of 130 would mean there is no antisocial behavior in the family at all and the family functions perfectly.
The standard deviations and alphas for the RCI were calculated with the data of all the received lists (27) from all clients in treatment between January and June, as shown in table 3.
Table 3
Standard deviation and Cronbach’s alpha of the FAST Goal Lists
Mean Standard Deviation Cronbach’s Alpha
Goal List Juvenile 94.377 31.09 .943
Goal List Parent 116.949 33.475 .911
Goal List Therapist 112.789 37,432 .780
Note. The analyses were done with the collected FAST Goal Lists of the 27 families that contributed
data.
Analyses
To judge whether the conditions for program integrity are met, the following calculation will be used: (number of conditions met/number of conditions) * 100. If the outcome reaches a percentage of 70 or higher (≥ 70%), we may assume the PI is sufficient. (Hoogsteder et al., 2016b).
To monitor the progress of the client’s goals, the Reliable Change Index (RCI) will be used. RCI is a statistic that we can use to find out if the change of a person’s scores is
significant or not. It is often used to measure change before and after an intervention. The RCI can be calculated by dividing the difference score, between the individual’s score before and after the intervention, by the standard error of the difference of this test. If the RCI turns out to be between -1.96 and 1.96, the change is not significant (equated to the 95% confidence interval). If the RCI turns out to be 1.96 or higher or lower than -1.96, the change is significant. The RCI is presumed to be normally distributed, with an average of 0 and a standard deviation of 1 (Hafkenscheid, Kuipers & Marinkelle, 1998: Jacobson & Truax, 1991).
Results
Program integrity
Table 4 shows the program integrity of participant one. All the indication criteria were met. This client is not living at home at the moment, but according to the indication criteria that is no problem when it is intended to move back home within two months. For the first and the second measurement the juvenile and the therapist scored the same percentage of program integrity. It is notable that the parent reported a lower percentage of program integrity during the second measurement. In all cases, at all the measurement moments the program integrity was sufficient.
Table 4
Program integrity client one and two
T1 T2 T1 T2
Juvenile one 87.5%¹ 87.5%¹ Juvenile two 100%¹ 100%¹
Parent one 100%¹ 93.75%¹ Parent two 100%¹ 100%¹
Therapist one 100%¹ 100%¹ Therapist two 87,5%¹ 100%¹ Indication
criteria
Were met Indication
criteria
Were not met²
Note. A score of 70% or higher is considered sufficient.
¹Sufficient
²Even though there were doubts about this client’s intelligence, the therapist judged the client to be suitable for FAST.
Table 4 also shows the program integrity of participant two. The indication criteria were not fully met, because there were doubts about the intelligence of this client. One of the criteria states a client has to have an IQ-score higher than 80. In intelligence test was never done, but the therapist estimated this client to be mentally challenged. However, the therapist
also estimated the client to be suitable for this treatment. On both measurement moments, the parent and juvenile reported a full score on program integrity. The therapist even showed a higher score during the second measurement. Overall, program integrity was good.
Effectiveness
Table 5
Reliable Change Index of the FAST Goal List of client one and two: T0, T1, T2
T0 T1 T2 RCI T0-T2 RCI T0-T1 RCI T1-T2 Juvenile one 91.43 77.15 88 .14 1.36 -1.03 Parent one 98 103.158² 128.421² -2.15¹ -.37 -1.14 Therapist one 94.32 79.03 109.2² -.22 .62 -.83 Juvenile two 116.69 102 109 0.73 1.4 -.67 Parent two 105.71 127 131 -1.79 -1.51 -.28 Therapist two 92.3 124 137 -1.8 -1.28 -.52 ¹Significant change
²There was one missing value that was compensated by calculating the list’s mean and replacing the missing value with the mean.
The results of the first client showed one statistically significant change: the parent’s score increased from T0 to T2 (table 5; figure 2). The increase meant the parent believes their family’s goals are being reached more and more. Notable was the difference between the large increase of the parents and the decrease of the juvenile and the therapist between the first and the second measurement. Both juvenile, and therapist reported a decrease of achieved goals, while the parent reported an increase. This means they have another opinion and they think the family has drifted further away from reaching the goals. After the second
list was higher than the second measurement, but still lower than the first one. The therapist’s final measurement was considerably higher than the second measurement, but just slightly higher than the first one. The therapist apparently believed the family was a little closer to reaching their goals at T2, compared to the first measurement. The juvenile believed her family was further from the goals than during the first measurement.
Figure 2
FAST Goal List client one T0, T1, T2
0 20 40 60 80 100 120 140 T0 T1 T2
Figure 3
FAST Goal List client two T0, T1, T2
The results of the second client did not show any statistically significant changes (table 5; figure 3). Notable is that the parent’s score and the therapist’s score both increased between all the measurements. However, the juvenile’s score decreased after the first
measurement and only slightly increased after the second one. This means the parents and the therapist think the family got closer to reaching their goals over time, but the juvenile did not feel the same.
Table 6
Scores on key elements emotion regulation, communication and motivation of family one and two, on T0, T1, T2 and the change from T0-T2
T0 (item¹) T1 (item¹) T2 (item¹) T0-T2 Participant 1 Emotion regulation (J*) 41.44 (4.6) 32.43 (3.6) 32 (3.56) -9.44 (-1.04) Communication (J) 22.85 (5.74) 20.57 (5.14) 24 (6) +1.15 (+.26) Motivation (J) 27.14 (6.7) 24.15 (6.04) 32 (8) +4.86 (+1.3) Emotion regulation 33 30.16 35.42 +2.42 0 20 40 60 80 100 120 140 T0 T1 T2
(P*) (3.67) (3.35) (3.94) (+.27) Communication (P) 33 (5.5) 32 (5.33) 40 (6.67) +7 (+1.17) Motivation (P) 32 (6.4) 41 (8.2) 53 (10.6) +21 (+4.2) Emotion regulation (T*) 28.6 (3.18) 21.88 (2.43) 39 (4.33) +10.4 (+1.15) Communication (T) 21.44 (3.57) 17.16 (2.86) 25 (4.17) +3.56 (+0.6) Motivation (T) 44.28 (7.38) 39.99 (6.67) 45.2 (7.53) +.92 (+0.15) Participant 2 Emotion regulation (J) 65.7 (7.3) 41 (4.56) 50 (5.56) -15.7 (-1.74) Communication (J) 25.28 (6.35) 33 (8.25) 33 (8.25) +7.72 (+1.9) Motivation (J) 25.71 (6.43) 28 (7) 26 (6.5) +.29 (+.07) Emotion regulation (P) 38.58 (4.29) 53 (5.89) 58 (6.44) +19.42 (+2.15) Communication (P) 45.7 (7.62) 49 (8.17) 40 (6.67) -5.7 (-.95) Motivation (P) 21.43 (4.29) 25 (5) 33 (6.6) +11.57 (+2.31) Emotion regulation (T) 29.44 (3.27) 46 (5.11) 54 (6) +24.56 (+2.73) Communication (T) 24.29 (4.05) 37 (6.17) 41 (6.83) +16.71 (+2.78) Motivation (T) 38.57 (6.43) 41 (6.83) 42 (7) +4.43 (+.57)
*J=juvenile, P=parent, T=therapist
¹total score per element divided by number of items per element
To get more insight on the scores of the FAST Goal Lists, the items of this list were subdivided among the three key elements (appendix 2). In table 6 are the scores of the juveniles, parents and therapists on these elements. The key elements that changed the most over time in the first family were emotion regulation and motivation (table 6). The juvenile reported a decrease in emotion regulation skills of herself and her parent, with a drop of 9.44 points (-1.04 per item). However, looking at the items of the FAST Goal List, the juvenile reported the lowest scores on the questions about her own emotion regulation skills, not about the skills of her parent. The therapist reported an increase of 10.4 points (+1.15 per item) on
emotion regulation for both juvenile and parent. The parent reported a mild increase of her emotion regulation skills and her daughter’s. This means that the juvenile thinks the emotion regulation skills of especially herself decreased, while the parent and the therapist think her skills and her parent’s skills increased. Key element motivation increased the most according to the parent. The parent reported an increase of 21 points (+4.2 per item) of her own
motivation and of the motivating of her daughter, while the juvenile and the therapist reported a milder increase. This means that the juvenile, the parent and the therapist all felt like the parent and juvenile became more motivated over time, but the parent felt like it the most. Key element communication slightly increased according to the juvenile and the therapist. The parent reported the biggest increase, to wit seven points (+1.17 per item). This means the parent feels like the communication at home changed, more than the juvenile and the therapist do.
The keys elements that changed the most in the second family were emotion
regulation and communication. The juvenile reported a decrease of emotion regulation of 15.7 points (-1.74 per item), the parent an increase of 19.42 points (+2.15 per item) and the
therapist an increase of 24.56 points (+2.73 per item). However, looking at the items of the FAST Goal List, this juvenile reported the lowest scores on the questions about his own emotion regulation skills too and not of the skills of his parent. This means that the juvenile thinks the emotion regulation skills of especially himself decreased, while the parent and the therapist think his skills and his parent’s skills increased. The therapist reported the biggest change on communication of parent and juvenile, to wit an increase of 16.71 points (+2.78 per item), while juvenile reported a smaller increase (+1.9 per item). The parent even reported a mild decrease. This means that the parent did not think that the communication increased and that the juvenile and therapist think the communication did increase in the family, but the therapist feels like that the most. The parent reported the biggest change on motivation of
herself and her son, namely an increase of 11.57 points (+2.31 per item), while the juvenile and the therapist merely reported small changes. This means that the juvenile, the parent and the therapist all felt like the parent and juvenile became more motivated over time, but the parent felt like it the most.
Notable is that only one significant change was found: the overall score of the first parent on the FAST Goal List. The decrease of the total score both clients show from T0 to T1 was striking too. Also, it is notable that the juveniles and parents have such varied results. Looking at the subdivided items led to the finding that both client one and two reported an overall decrease in their own emotion regulation skills, while the parents and the therapists reported an increase.
Discussion
The aim of this study was to investigate the efficacy of FAST. It was expected that FAST, when provided with sufficient program integrity, would be effective for both families. The program integrity was found to be sufficient, which led us to focusing on the efficacy of FAST. As opposed to the expectations, this research did not find a lot of significant changes. Only the first parent’s change of score from T0 to T2 was significant, which means the parent felt like the family goals were achieved significantly more after four months of FAST. None of the other changes were significant. However, except for the juveniles, there was a trend towards positive change.
Explanations of the results
The first remarkable finding of this study is that there was not a lot of significant change towards reaching the treatment goals. This could be explained by the fact that, for both participants, the treatment is still ongoing. This means their family goals were not reached yet. When treatment is not completed and finished, the overall efficacy is not clear yet.
2016a; Hoogsteder et al., 2016b). The last phase of treatment and the aftercare are as equally important as the other phases, because they all contribute to a positive outcome of FAST (Hoogsteder et al., 2016a; Hoogsteder et al., 2016b). When a treatment is halfway done, it cannot be expected that the goals already are (partially) reached. This hypothesis is supported in the research of Minnaert, Spelberg and Amsing (2009). They point out the importance of a thorough and complete treatment for a good outcome. Another explanation can be the
instrument that was used. The FAST Goal List was filled in to monitor the progress of treatment. However, this instrument was just recently developed and had never been researched yet. Because of that, these lists are not validated yet and because they are not validated, it is unknown if they are measuring what they are meant for to measure (Billiet & Waege, 2003). Therefore, the results measured with these lists, should be interpreted
carefully. One more explanation can be the motivational stage that the participants were in. To make change happen, motivation to change is needed (Miller & Rollnick, 2002). The amount and phase of motivation differs from person to person. Also, the speed on which a person can switch to a phase where the level of motivation is higher, differs per person (Miller & Rollnick, 2002). Therefore, it may be possible that the participants in this study were
incapable of changing this quickly. The scores on the motivation of the juveniles slightly increased on the FAST Goals List, which may seem contradictory. However, this score measured motivation in another way, like the motivation to go to school or to stop using drugs. There was one item that measured the overall motivation for treatment, but except for this item, the rest did not measure the motivation to change their emotion regulation skills or the way they communicate at home.
The second remarkable finding was the fact that only parent one reported a significant change, while parent two and therapist one and two did not. According to Conger, Patterson and Ge (1995), stressed people are sometimes not able to see what happens in front of them
and they often have trouble disciplining their children (Gershoff, 2002). Also, research of Starcke and Brand (2016) shows that stress can lead to reward seeking. Therefore, parent one might not acknowledge her family’s problems like her daughter and the therapist do. The reason that she might not acknowledge the problems, could be that she is not able to see the problems in her family. This hypothesis can be supported by the information in the file of participant one. It states that family one functioned poorly. It says the level of stress in this family was very high, because of the fights and abuse that led to unsafety. Unlike family one, the information in the file of the second family said that they functioned well and they were a warm and loving family. Their main stress factor was the behavior of their son, but the relations between the family members were good, which made them feel supported. This could explain why parent one may have had a blind spot, while parent two did not.
The third remarkable finding was the overall difference between the scores of the parents and the juveniles. This means the parents experienced FAST as more effective than the juveniles. The results of the juveniles showed that the decrease between T0 and T1 was mostly due to the decrease in emotion regulation skills. This could be explained by the development of self-awareness. Research showed that self-focused attention, like done during treatment, can lead to the development of self-awareness (Gibbons et al., 1985; Plant & Ryan, 1985). According to Gibbons and his colleagues (1985), people reported feeling worse when self-aware. Also, they were more capable of reporting about themselves (Gibbons et al., 1985). The information in de files of the participants supports this hypothesis. Both
participants experienced problems with regulating their emotions and therefore showed a lot of behavioral problems. Their deficit of emotion regulation skills caused the decrease. It is possible they just noticed their problems with regulating emotions more, because of the self-awareness they gained.
Limitations
The present study had some limitations . First of all, this multiple case study examined only two families. It is therefore not possible to generalize the findings about FAST.
Secondly, this research was done within a short period of time. In this period both participants had treatment and it is still ongoing. Because of that, there were no measurements done at the end of treatment, which led to a lack of information about the progress of treatment. Third, because FAST is such a new therapy, little is known about the validity of the instruments (Goal Lists, Checklists). Like mentioned before, not validating the FAST Goals Lists means it is not sure if the efficacy was really measured by using those lists. Using the not validated the FAST Checklist means it is not sure whether or not the program integrity was validly and reliably measured. Because of the lack of research, all results have to be interpreted
cautiously. Fourth, the treatment of both participants was still ongoing. Because of that, the effect of a finished treatment is still unclear. Also, one of the participants did not meet all the indicated inclusion criteria. There were doubts about his intelligence, because one of the criteria states the IQ has to be over 80, and the estimated IQ of this juvenile was 75 to 80. A more thorough assessment of his intelligence would have provided more information to support the decision of referral to FAST.
Implications for practice and research
This study pointed out some important implications for research and practice. First of all, future research should focus on validating the FAST Goal Lists and the FAST Checklists, so that the measuring the efficacy of FAST can be done properly. Second of all, future
research should be done for a longer amount of time, so the full progress of the treatment can be investigated. When the whole treatment can be followed, the overall change can be
clients, so it becomes clear if change was influenced by motivation or it should research motivation too, to gain more insight of the change of motivation during treatment. For the same reason, future research should control for, or co-investigate, self-awareness.
In practice, guidance for the juveniles when coping with their emotion regulation skills may be needed more. It is unclear how much guidance the juveniles in this study received, but they reported a decrease in emotion regulation. Especially in the beginning of treatment they reported the biggest drop, which may indicate that they may have needed it the most then. Also, more awareness about the stage of motivation clients and their families are in might be convenient. When therapists know in which stages clients are, they can use different skills to motivate them. Miller and Rollnick (2002) describe various skills that can be used to motivate people in different stages of change. Two examples are giving compliments and giving
emotional reflections during conversations (Miller & Rollnick, 2002). It is unclear what was done by the therapists to motivate the clients in this study, and this subject could be further investigated.
Another important point is that in practice at De Waag waiting lists for FAST grow quickly. The dataset used for this study showed a lot of clients who initially did not meet up to the inclusion criteria. However, after multidisciplinary consultation it was decided that
FAAST was indicated for these families. A more thorough investigation of the fulfilment of inclusion criteria might elucidate why clients are included when they do not strictly meet the criteria. This might eventually lead to reconsideration or adjustment of the criteria, which might in turn affect the FAST-waiting lists.
Right now, one of the inclusion criteria for juveniles is that they have to have an IQ-score above 80. However, research of Collot d’Escury (2007) shows there are a lot of people with a lower IQ-score among the people with convictions. Juveniles with forensic behavior
cannot be compared with the regular population, because research showed that 35% has an IQ under 85 (Spaans, 2005). There might even be a relation between low intelligence and
criminal behavior (Taylor & Lindsay, 2010). Knowing this, FAST could include an extra substantial part of the forensic population by developing an extra version of the treatment: one for juveniles with a low IQ.
The fact that there still is a lot of criminality among juveniles shows that therapies like FAST are of high importance. FAST is well substantiated with theory, but there is still a lot of work to do in practice and research. To start measuring the efficacy of FAST, the instruments should be validated first. After that, studies with larger sample sizes and longer periods of time should be done. While doing research, it should be examined whether motivational stage and self-awareness are mediators and/or moderators of significant changes in outcomes. Another possibility is to co-investigate these subjects. The results of this explorative pilot showed that there is a trend towards positive change and that FAST can be a promising intervention.
References
Andrews, D. A., & Bonta, J. (2010). Rehabilitating criminal justice policy and practice.
Psychology Public Policy and Law, 16(1), 39-55. doi:10.1037/a0018362
Billiet, J., & Waege, H. (2003). Een samenleving onderzocht: Methoden van
sociaal-wetenschappelijk onderzoek. Antwerpen: De Boeck
Blake, C. S., & Hamrin, V. (2007). Current approaches to the assessment and management of anger and aggression in youth: A review. Journal of Child and Adolescent Psychiatric
Nursing, 20(4), 209-221.
Centraal Bureau voor de Statistiek (2017). Jeugdbescherming en jeugdreclassering 2016. Den Haag: CBS
Collot d’Escury, A. (2007). Lopen jongeren met een lichte verstandelijke beperking meer kans om in aanraking te komen met justitie? Kind en adolescent, 28, 128-137. doi:10.1007/BF03061031
Conger, R. D., Patterson, G. R., & Ge, X. (1995). It takes two to replicate: A mediational model for the impact of parents' stress on adolescent adjustment. Child Development,
66(1), 80-97. doi:10.1111/j.1467-8624.1995.tb00857.x
Cottrell, D., & Boston, P. (2002). Practitioner review: The effectiveness of systemic family therapy for children and adolescents. Journal of Child Psychology and Psychiatry and
Allied Disciplines, 43(5), 573-586. doi:10.1111/1469-7610.00047
Cracco, E., Goossens, L., & Braet, C. (2017). Emotion regulation across childhood and adolescence: Evidence for a maladaptive shift in adolescence. European Child &
Adolescent Psychiatry, 26(8), 909-921. doi:10.1007/s00787-017-0952-8
Dekovic, M., Asscher, J. J., Manders, W. A., Prins, P. J. M., & Van der Laan, P. H. (2012). Within-intervention change: Mediators of intervention effects during multisystemic therapy. Journal of Consulting and Clinical Psychology, 80(4), 574-587.
doi:10.1037a0028482
Gershoff, E. T. (2002). Corporal punishment by parents and associated child behaviors and experiences: A meta-analytic and theoretical review. Psychological Bulletin, 128(4), 539-579. doi:10.1037//0033-2909.128.4.539
Gibbons, F. X., Smith, T. W., Ingram, R. E., Pearce, K., Brehm, S. S., & Schroeder, D. J. (1985). Self-awareness and self-confrontation: Effects of self-focused attention on members of a clinical population. Journal of Personality and Social Psychology,
48(3), 662-675. doi:10.1037/0022-3514.48.3.662
Hafkenscheid, A., Kuipers, A., & Marinkelle, A. (1998). De vragenlijst als effectmaat bij ‘n=1’: Hoe bruikbaar zijn statistische definities van ‘klinische significantie’ en betrouwbare verandering? Gedragstherapie, 31, 221-239.
Henggeler, S. W., Schoenwald, S. K., Borduin, C. M., Rowland, M. D., & Cunningham, P. B. (1998). Multisystemic treatment of antisocial behavior in youth. New York: Guilford. Hermans, D., Eelen, P., & Orlemans, H. (2007). Inleiding tot de gedragstherapie. Houten:
Bon Stafleu van Loghum
Hoogsteder, L. (2015). Forensische Ambulante Systeem Therapie (FAST): Werkblad
beschrijving interventie. Utrecht: De Waag
Hoogsteder, L. (2016). Procesevaluatie Forensische Ambulante Systeem Therapie (FAST). Utrecht: De Waag
Hoogsteder, L., Hendriks, J., Van Horn, J., & Wissink, I. (2012). Agressie Regulatie op Maat: Een evaluatiestudie in een justitiële jeugdinrichting. Orthopedagogiek: Onderzoek en
Praktijk, 51, 481-493.
Hoogsteder, L., Schippers, E., Zwarter E., Naarden, M., Jacobse, P., Van der Duijne, A., & Verkuil, J. (2016). Algemene programmahandleiding: Therapeut FAST. Utrecht: De Waag
Hoogsteder, L., Wissink, I. B., Stams, G. J. J. M., Van Horn, J. E., & Hendriks, J. (2014). A validation study of the brief irrational thoughts inventory. Journal of Rational-Emotive
& Cognitive-Behavior Therapy, 32(3), 216-232. doi:10.1007/s10942-014-0190-7
Hoogsteder, L., Zwarter, E., Jacobse, P., Naarden, M., Van Duijne, A., & Verkuil, J. (2016).
Managementhandleiding FAST. Utrecht: De Waag
Huey, S. J., Henggeler, S. W., Brondino, M. J., & Pickrel, S. G. (2000). Mechanisms of change in multisystemic therapy: Reducing delinquent behavior through therapist adherence and improved family and peer functioning. Journal of Consulting and
Clinical Psychology, 68(3), 451-467.doi:10.1037//0022-006X.68.3.451
Jacobsen, N. S., Truax, P. (1991). Clinical significance: A statistical approach to defining meaningful change in psychotherapy research. Journal of Consulting and Clinical
Psychology, 59, 12-19.
Fosha, D., Siegel, D. J., & Solomon, M. (2009). The Healing Power of Emotion: Affective
Neuroscience, Development & Clinical Practice. New York: W. W. Norton &
Company
Koopmans, P. C., Sanderman, R., Timmerman, I., & Emmelkamp, P. M. G. (1993). The
Irrational Beliefs Inventory: Development and psychometric evaluation. Groningen:
RU, NCG
Loeber, R., Slot, N. W., & Stouthamer-Loeber, M. (2006). A three-dimensional cumulative
developmental model of serious delinquency. Cambridge: Cambridge University
McEwen, B. S., & Sapolsky, R. M. (1995). Stress and cognitive function. Current Opinion in
Neurobiology, 5(2), 205-216.
Miller, W. R., & Rollnick, S. (2002). Motivational interviewing: Preparing people for
change. New York: The Guilford Press
Stafleu Van Loghum
Nas, C. N., Brugman, D., & Koops, W. (2008). Measuring self-serving cognitive distortions with the ‘‘How I Think’’ Questionnaire. European Journal of psychological
Assessment, 24, 181–189.
Norcross, J. C., Krebs, P. M., & Prochaska, J. O. (2011). Stages of change. Journal of clinical
psychology, 67(2), 143-154.
Omer, H., & Wiebenga, E. (2015). Geweldloos verzet in gezinnen: Een nieuwe benadering
van gewelddadig en zelfdestructief gedrag van kinderen en adolescenten. Utrecht:
Springer Media
Openbaar Ministerie (2016). Richtlijn en kader voor strafvordering jeugd en adolescenten:
Inclusief strafmaten HALT. Den Haag: OM
Orobio de Castro, B. (2007). Agressieregulatietrainingen tegen reactieve en proactieve
agressie door jeugdigen in Justitiële Jeugdinrichtingen: Een vergelijking tussen gedragsinterventies. Den Haag: Ministerie van Justitie (DJI).
Plant, R. W., & Ryan, R. M. (1985). Intrinsic motivation and the effects of self-consciousness, self-awareness, and ego-involvement: An investigation of internally controlling styles.
Journal of Personality, 53(3), 435–449. doi:10.1111/j.1467-6494.1985.tb00375.x
Racz, S. J., & McMahon, R. J. (2011). The relationship between knowledge and monitoring and child and adolescent conduct problems: A 10-year update. Clinical Child and
Family Psychology, 14(4), 377-398. doi:10.1007/s10567-011-0099-y
Spaans, E. (2005). Een IQ-puntje meer of minder…? Prevalentie-onderzoek licht verstandelijk
gehandicapten in de justitiële jeugdinrichtingen. DJI, intern rapport. Gedownload op 5
juli 2017 van
https://www.rijksoverheid.nl/onderwerpen/jeugdcriminaliteit/documenten
Meta-Analysis. Psychological Bulletin, 142(9), 909-933. doi:10.1037/bul0000060
Stoltz, S., Van Londen, M., & Dekovic, M. (2015). Effects of parent and child characteristics on participation and outcome of an individualized booster parent intervention for children with externalizing behavior. European Journal of Developmental Psychology,
12(4), 395-411. doi:10.1080/17405629.2015.1018172
Sudak, D. (2006). Cognitive behavioral therapy for clinicians. Hagerstown: Lippincott Williams & Wilkins
Taylor, J.L., & Lindsay, W.R. (2010). Understanding and treating offenders with learning disabilities: A review of recent developments. Journal of Learning Disabilities and
Offending Behaviour, 1, 5-16. doi:abs/10.5042/jldob.2010.0173
Timmerman, I., Sanderman, R., Koopmans, P. C., & Emmelkamp, P. M. G. (1993). Het
meten van irrationele cognities met de Irrational Beliefs Inventory, IBI. Handleiding.
Groningen: RU, NCG
Van der Ploeg, J. D., Scholte, E. M., & Nijkerk, J. H. (1990). Probleemgedrag en tijdstip van
interventie: Het sociaal-ecologisch model. Leiden: Universiteit van Leiden
Van der Put, C. E., Dekovic, M., Stams, G. J. J. M., Hoeve, M., & Van der Laan, P. H. (2012). The importance of early intervention in juvenile delinquency: Research on the links between risk factors and recidivism at different ages. Child and Adolescent, 33, 2–20.
Van der Stouwe, T., Asscher, J. J., Stams, G. J., Dekovic, M., & Van der Laan, P. H. (2014). The effectiveness of Multisystemic Therapy (MST): A meta-analysis. Clinical
Psychological Review, 34(6), 468-481. doi:10.1016/j.cpr.2014.06.006
Wallinius, M., Johansson, P., Larden, M., & Dernevik, M. (2011). Self-serving cognitive distortions and antisocial behaviour among adults and adolescents. Criminal Justice
Ward, T., Vess, J., Collie, R. M., & Gannon, T. A. (2006). Risk management or goods promotion: The relationship between approach and avoidance goals in treatment for sex offenders. Aggression and Violent Behavior, 11(4), 378-393. doi:
10.1016/j.avb.2006.01.001
Youngstrom, E. A., Findling, R. L., & Calabrese J. R. (2003). Who are the comorbid adolescents? Agreement between psychiatric diagnosis, parent, teacher, and youth report. Journal of Abnormal Child Psychology, 31, 231–245.
Appendix 1: BITI
The BITI was used to measure the juvenile’s irrational thoughts. The BITI contains 18 items that can be answered by the juvenile with a score from 1 to 7. A score of one stands for “I do not agree at all” and a score of seven for “I totally agree”. The items of the BITI are divided into three subscales: Aggression and Justification (AJ), Sub-assertiveness (S) and Distrust (D). The AJ-scale contains statements of externalizing nature and the S-scale contains statements of internalizing nature. An example of a question of the AJ-scale is “When
somebody looks at me in a threatening way, the only thing I can do is hit him/her”. An example of a question of the S-scale is “I find it hard to give my opinion”. An example of a question of the D-scale is “Nobody can be trusted”. The juvenile had to fill in the BITI every three months. The highest score possible on the total BITI is 108. The highest scores for the subscales are 54 for AJ, 30 for S and 24 for D. A score of 108 would mean the client has a lot of irrational thoughts and was not able to rationalize any of the statements on the list. The higher the score on the BITI, the more irrational thoughts. Research of Hoogsteder and
colleagues (2014) on a sample (N = 256) of justice-involved youths between the age of 13 and 22 states that the BITI has ecological validity, because the instrument was developed in practice. This research also showed the construct validity was sufficient and the instrument does not easily get affected by gender, age, intelligence or ethnicity. Furthermore, the internal consistency and the convergent validity were average to good. Only the concurrent validity was insufficient (Hoogsteder et al., 2014). The BITI was also researched by COTAN and the reliability was found to be good. The criterion validity was insufficient and the construct validity was sufficient (Koopmans, Sanderman, Timmerman, & Emmelkamp, 1998;
Timmerman, Sanderman, Koopmans, & Emmelkamp, 1998). Because the criterion validity showed insufficient, the results of the BITI should be interpreted carefully.
Appendix 2: subdivision scales FAST Goal List Juveniles M = Motivation 1 M C = Communication 2 C E = Emotion Regulation 3A C 3B C 4 C 5 M 6 M 7A E 7B E 8A E 8B E 9 E 10B E 10A E 11 E 12 E 13 M Parents 1A M 1B M 2A C 2B C 3A C 3B C 4A C 4B C 5 M 6 M 7A E 7B E 8A E 8B E 9 E 10A E 10B E 11 E 12 E 13 M
Therapists 1A M 1B M 1C M 2A C 2B C 3A C 3B C 4A C 4B C 5 M 6 M 7A E 7B E 8A E 8B E 9 E 10A E 10B E 11 E 12 E 13 M
