多系统治疗与常规管理治疗青少年反社会行为的比较（START）：一项实用、随机对照的优效性试验。
Multisystemic therapy versus management as usual in the treatment of adolescent antisocial behaviour (START): a pragmatic, randomised controlled, superiority trial.
作者信息
Fonagy Peter, Butler Stephen, Cottrell David, Scott Stephen, Pilling Stephen, Eisler Ivan, Fuggle Peter, Kraam Abdullah, Byford Sarah, Wason James, Ellison Rachel, Simes Elizabeth, Ganguli Poushali, Allison Elizabeth, Goodyer Ian M
机构信息
Research Department of Clinical, Educational and Health Psychology, University College London, London, UK.
Research Department of Clinical, Educational and Health Psychology, University College London, London, UK.
出版信息
Lancet Psychiatry. 2018 Feb;5(2):119-133. doi: 10.1016/S2215-0366(18)30001-4. Epub 2018 Jan 5.
BACKGROUND
Adolescent antisocial behaviour is a major health and social problem. Studies in the USA have shown that multisystemic therapy reduces such behaviour and the number of criminal offences committed by this group. However, findings outside the USA are equivocal. We aimed to assess the effectiveness and cost-effectiveness of multisystemic therapy versus management as usual in the treatment of adolescent antisocial behaviour.
METHODS
We did an 18 month, multisite, pragmatic, randomised controlled, superiority trial in England. Eligible participants aged 11-17 years with moderate-to-severe antisocial behaviour had at least three severity criteria indicating past difficulties across several settings and one of five general inclusion criteria for antisocial behaviour. We randomly assigned families (1:1) using stochastic minimisation, stratifying for treatment centre, sex, age at enrolment to study, and age at onset of antisocial behaviour, to receive either management as usual or 3-5 months of multisystemic therapy followed by management as usual. Research assistants and investigators were masked to treatment allocation; the participants could not be masked. The primary outcome was out-of-home placement at 18 months. The primary analysis included all randomised participants for whom data were available. This trial is registered, number ISRCTN77132214. Follow-up of the trial is still ongoing.
FINDINGS
Between Feb 4, 2010, and Sept 1, 2012, 1076 families were referred to nine multi-agency panels, 684 of whom were assigned to management as usual (n=342) or multisystemic therapy followed by management as usual (n=342). At 18 months, the proportion of participants in out-of-home placement was not significantly different between the groups (13% [43/340] in the multisystemic therapy group vs 11% [36/335] in the management-as-usual group; odds ratio 1·25, 95% CI 0·77-2·05; p=0·37).
INTERPRETATION
The findings do not support that multisystemic therapy should be used over management as usual as the intervention of choice for adolescents with moderate-to-severe antisocial behaviour.
FUNDING
Department for Children, Schools and Families, Department of Health.
背景
青少年反社会行为是一个重大的健康和社会问题。美国的研究表明，多系统疗法可减少此类行为以及该群体所犯罪行的数量。然而，美国以外地区的研究结果并不明确。我们旨在评估多系统疗法与常规管理相比，在治疗青少年反社会行为方面的有效性和成本效益。
方法
我们在英国进行了一项为期18个月的多中心、实用、随机对照优势试验。符合条件的年龄在11至17岁、有中度至重度反社会行为的参与者，至少有三个严重程度标准表明其在多个环境中过去存在困难，以及反社会行为的五个一般纳入标准之一。我们使用随机最小化方法将家庭以1:1的比例随机分配，按治疗中心、性别、入组研究时的年龄以及反社会行为开始时的年龄进行分层，分别接受常规管理或3至5个月的多系统疗法，之后再进行常规管理。研究助理和研究人员对治疗分配情况不知情；参与者无法被设盲。主要结局是18个月时的家庭外安置情况。主要分析包括所有有可用数据的随机分组参与者。该试验已注册，注册号为ISRCTN77132214。试验的随访仍在进行中。
结果
在2010年2月4日至2012年9月1日期间，1076个家庭被转介至9个多机构小组，其中684个家庭被分配接受常规管理（n = 342）或先接受多系统疗法再接受常规管理（n = 342）。在18个月时，两组中处于家庭外安置的参与者比例无显著差异（多系统疗法组为13% [43/340]，常规管理组为11% [36/335]；优势比1.25，95%置信区间0.77 - 2.05；p = 0.37）。
解读
研究结果不支持将多系统疗法作为中度至重度反社会行为青少年的首选干预措施，而应优先选择常规管理。
资金来源
儿童、学校和家庭部、卫生部。
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