Multisystemic Therapy (MST) is an intensive intervention for families with a young person aged 11 to 17, who are at risk of going into care due to serious antisocial and/or offending behaviour.
An MST-trained social worker or psychologist provides home-based therapeutic support to the young person and their parents for a four-to-six-month period with the aim of doing ‘whatever it takes’ to improve the family’s functioning and the young person’s behaviour.
The information above is as offered/supported by the intervention provider.
11 to 17 years old
Individual
Child outcomes:
UK available
UK tested
Multisystemic Therapy (MST) is a ‘wrap-around’ family and community-based intervention for children and young people aged 11 to 17, where young people are at risk of an out-of-home placement in either care or custody due to their involvement in crime or severe antisocial behaviour.
The MST model assumes that youth offending behaviours are multi-determined by issues existing at the level of the child, family, school, and community. A master’s qualified social worker or psychologist works intensively with the child and family to do ‘whatever it takes’ to address these multiple risks, so that the young person can remain safely with their family, in school and out of trouble.
MST support is typically provided over a period of three to five months, with the MST therapist being on call to families 24 hours a day, seven days a week. The frequency and nature of the sessions vary, depending on the needs of the family and the stage of the treatment, typically ranging from three days a week to daily support.
At the beginning of the treatment, MST therapists discuss with each family member the potential root causes for the young person’s behaviour and agree goals for treatment. The therapist will consult with the adolescent’s school and other individuals from the community (for example, police and youth justice workers) involved in their case.
The therapist will then discuss with their MST supervisor various options to determine the best treatment ‘fit’ for the family. The therapist shares these ideas with the family and uses shared decision-making methods to help family members agree a treatment plan. The therapist and family members then review this plan on an ongoing basis to determine the extent to which it is meeting the family’s needs.
A primary aim of the plan is to help family members identify strengths within their immediate family, extended family, and community. These strengths are then used to overcome weaknesses within the family system which may be contributing to the child’s problematic behaviour.
The MST model assumes that the parents are the primary agents of change, so it is typical for plans to include intensive work with the parents to help them improve the quality of their relationship with their child. Typical examples of the kind of work MST therapists do include:
11 to 17 years
Families with a young person aged 11 to 17, who are at risk of going into care or custody due to serious antisocial and/or offending behaviour.
Disclaimer: The information in this section is as offered/supported by the intervention provider.
Science-based assumption
Criminal and violent behaviour during adolescence increases the risk of criminal behaviour in adulthood and can significantly reduce a young person’s future life chances.
Science-based assumption
Criminal and violent youth behaviour is multi-determined by risks associated with the child, family, school, and community.
Science-based assumption
Children at risk of out-of-home placement due to youth offending or violent behaviour are referred to the treatment.
Intervention
The family receives ‘wrap around’ care that includes individual therapeutic support for the young person and parents
The therapist also advocates for the young person at school and the community.
Short-term
Improved parenting behaviours
Improved young person’s behaviour
Improved family communication.
Medium-term
Improved adolescent wellbeing
Improved social skills
Increased attendance at school or training.
Long-term
Reduced risk of youth offending
Reduced risk of substance misuse
Reduced risk of criminal behaviour in adulthood.
Families with a young person aged 11 to 17, who are at risk of going into care or custody due to serious antisocial and/or offending behaviour.
MST is delivered by a therapist to young people and families on an individual basis in their homes or other community settings. Therapists are available to the family 24/7 and carry a caseload of four to six families at a time.
Therapy sessions typically last between 50 minutes and two hours.
The frequency of the sessions may vary depending on the needs of the family and the stage of the treatment, typically ranging from three days a week to daily.
The MST model considers the parents as the primary agents of change. Each family’s treatment plan therefore includes a variety of strategies to improve the parents’ effectiveness and the quality of their relationship with their child. It is essential that these strategies ‘fit’ with each family’s unique set of strengths and weaknesses.
A key aim of the therapy is to identify strategies that work for each individual young person and family. Work is also undertaken with the network of formal and informal supports around the young person and family to improve family relationships with agencies such as schools but also to develop sustainable positive supports in the community.
A second aim of the intervention is to help families assume greater responsibility for their behaviours and generate solutions and skills for solving their family problems now and in the future. A variety of evidence-based intervention strategies are used with individuals, families, and caregivers, including family sessions, role-plays, structural and strategic family therapy, parent training, including use of behaviour plans, safety planning, and cognitive behavioural therapy. There may also be specific targeted interventions for substance abuse in young people.
The strategies follow a set of MST principles and the MST analytical process, so that problems are resolved in a strategic way with the families. All of these interventions are related to the aims of (1) reducing antisocial/offending and high-risk behaviours in young people, (2) keeping young people safely at home, improving family relationships and reducing out-of-home placement, and (3) helping support young people to be successful in school, work, and other community activities.
The practitioner who delivers this intervention is an MST therapist/practitioner with a master’s qualification or higher in a helping profession.
Practitioners receive 40 hours of intervention training (a five-day MST orientation). Booster training of practitioners is required.
It is required that practitioners are supervised by one host-agency supervisor, with 40 hours of MST practitioner training plus 16 hours of MST supervisor training.
It is required that practitioners are supervised by one intervention developer supervisor.
Intervention fidelity is maintained through the following processes:
Contact person: Cathy James
Organisation: MST
Email address: cathy.james@kcl.ac.uk
Website/s: https://www.mstukandireland.org/
*Please note that this information may not be up to date. In this case, please visit the listed intervention website for up to date contact details.
MST is underpinned by a substantial number of rigorously conducted randomised controlled trials, observing mixed findings, which include studies showing long-term reductions in youth offending behaviour and out-of-home placements, as well as studies showing no effect in improving these important outcomes. The rating of 4+ is based on MST’s five most robust studies (including two conducted in the UK) with evidence consistent with Foundations’ Level 3 evidence strength threshold. Two of these studies have evidence of the benefits lasting longer than 12 months, providing evidence that is consistent with Foundations’ Level 4+ evidence strength threshold.
MST can be described as evidence-based: it has evidence from at least one rigorously conducted RCT or QED demonstrating a statistically significant positive impact on at least one child outcome, as well as at least one more RCT or QED. MST’s evidence base includes mixed findings. It includes rigorously conducted studies suggesting positive impact alongside studies, which on balance, indicate no effect or negative impact.
Further information about MST’s evidence base, including less positive findings, is provided in the more detailed summaries of the individual evaluations contributing to MST’s rating. This evidence includes two recent studies conducted in Sweden and the UK observing no improvements in care placements and criminal offences in comparison to those observed in young people receiving usual care. It is worth noting, however, that the benefits and costs of MST are comparable to usual care in both of these studies, suggesting that MST remains an effective alternative to usual care.
Reduced internalising behaviour problems
Long-term: 18 months later
Improvement index
Interpretation
Study
Reduced out-of-home placement
Immediately after intervention
Improvement index
Interpretation
Study
Reduced out-of-home placement
Long-term: 18 months later
Improvement index
Interpretation
Study
Reduced youth offending
Long-term: 18 months later
Improvement index
Interpretation
Study
Reduced aggression
6 months later
Improvement index
Interpretation
Study
Reduced delinquency
6 months later
Improvement index
Interpretation
Study
Reduced delinquency – six months later
Improvement index
Interpretation
Study
Reduced delinquency
Long-term: 18 months later
Improvement index
Interpretation
Study
Reduced family-related civil court cases
Long-term: 21.9-year after the intervention
Improvement index
Interpretation
Study
Reduced psychopathic traits
Immediately after the intervention
Improvement index
Interpretation
Study
Reduced reoffending (ever arrested)
Long-term: 4 years after the intervention
Improvement index
Interpretation
Study
Reduced reoffending (ever arrested)
Long-term: 13.7 after the intervention
Improvement index
Interpretation
Study
Reduced reoffending (ever arrested)
Long-term: 21.9-year after the intervention
Improvement index
Interpretation
Study
Reduced anti-social behaviour
Immediately after the intervention
Improvement index
Interpretation
Study
Reduced reoffending (number of times rearrested)
Long-term: 13.7 years later
Improvement index
Interpretation
Study
Reduced reoffending (number of times rearrested)
Long-term: 21.9-year later
Improvement index
Interpretation
Study
Reduced child behavioural problems
Long-term: 18 months later
Improvement index
Interpretation
Study
| Identified in search | 35 |
| Studies reviewed | 5 |
| Meeting the L2 threshold | 0 |
| Meeting the L3 threshold | 5 |
| Contributing to the L4 threshold | 4 |
| Ineligible | 30 |
| Study design | RCT |
| Country | United Kingdom |
| Sample characteristics | 108 families with children aged 13 to 17 on a court order for treatment, a supervision order of at least three months duration, or, following imprisonment, on licence in the community for at least six months. 82% of the participants were male. |
| Race, ethnicities, and nationalities |
|
| Population risk factors | Child participants had an average of more than two offences at intake (range 0–6). Over half the convictions included violent offences and 41% had only non-violent convictions. Less than 30% of the participants lived with both parents; over two-thirds lived with their mothers but not their fathers, and less than 10% with their fathers but not their mothers. Only one-third was in mainstream education. 31% of the parents had left school with no academic qualifications; 40% had no vocational qualifications; and 54% were without income. In sum, almost all subjects lived in socioeconomically disadvantaged families. |
| Timing |
|
| Child outcomes | Post-intervention
12-month follow-up
18-month follow-up
|
| Other outcomes | Improved positive parenting (Parent report). |
| Study rating | 3 |
| Citations | Butler, S., Baruch, G., Hickey, N. & Fonagy, P. (2011) A randomized controlled trial of Multisystemic Therapy and a statutory therapeutic intervention for young offenders. Journal of the American Academy of Child and Adolescent Psychiatry. 50 (12), 1220–1235. |
| Study design | RCT |
| Country | United States |
| Sample characteristics | 176 youths aged 12 to 17 with a least two criminal arrests. 67.5% of the sample were male. |
| Race, ethnicities, and nationalities |
|
| Population risk factors |
|
| Timing |
|
| Child outcomes | Post-intervention
4-year follow-up
13.7-year follow-up
21.9-year follow-up
|
| Other outcomes | Post-intervention (Study 2a)
|
| Study rating | 3 |
| Citations | Study 2a: Borduin, C. M., Mann, B. J., Cone, L. T., Henggeler, S. W., Fucci, B. R., Blaske, D. M. & Williams, R. A. (1995) Multisystemic treatment of serious juvenile offenders: Long-term prevention of criminality and violence. Journal of Consulting and Clinical Psychology. 63, 569–578. Study 2b: Schaeffer, C. M. & Borduin, C. M. (2005) Long-term follow-up to a randomized clinical trial of Multisystemic Therapy with serious and violent juvenile offenders. Journal of Consulting and Clinical Psychology. 73, 445–453. Study 2c: Sawyer, A. M. & Borduin, C. M. (2011) Effects of Multisystemic Therapy through midlife: A 21.9-year follow-up to a randomized clinical trial with serious and violent juvenile offenders. Journal of Consulting and Clinical Psychology. 79, 643–652. |
| Study design | RCT |
| Country | Norway |
| Sample characteristics | 100 youths and their families referred to treatment for serious antisocial behaviour. |
| Race, ethnicities, and nationalities | 95% Norwegian |
| Population risk factors |
|
| Timing |
|
| Child outcomes | Post-intervention
Two-year follow-up
|
| Other outcomes | None |
| Study rating | 3 |
| Citations | Study 3a: Ogden, T. & Halliday-Boykins, C. A. (2004) Multisystemic treatment of antisocial adolescents in Norway: Replication of clinical outcomes outside of the US. Child and Adolescent Mental Health. 9 (2), 77–83. Study 3b: Ogden, T. & Hagen, K.A. (2006) Multisystemic Therapy of serious behaviour problems in youth: Sustainability of therapy effectiveness two years after intake. Journal of Child and Adolescent Mental Health. 11, 142–149. |
| Study design | RCT |
| Country | Sweden |
| Sample characteristics | 156 youths aged 12 to 17 who fulfilled the criteria for a clinical diagnosis of conduct disorder. |
| Race, ethnicities, and nationalities |
|
| Population risk factors |
|
| Timing |
|
| Child outcomes | None |
| Other outcomes | None |
| Study rating | NE |
| Citations | Sundell, K., Hansson, K., Löfholm, C.A., Olsson, T., Gustle, L. & Kadesjo, C. (2008) The transportability of Multisystemic therapy to Sweden: Short-term results from a randomized trial of conduct-disordered youths. Journal of Family Psychology. 22 (4), 550–560. |
| Study design | RCT |
| Country | United Kingdom |
| Sample characteristics | 684 young people aged 11 to 17, with moderate-to-severe antisocial behaviour problems. 63% of the sample were male. |
| Race, ethnicities, and nationalities |
|
| Population risk factors |
|
| Timing |
|
| Child outcomes |
|
| Other outcomes |
|
| Study rating | NE |
| Citations | Fonagy, P., Butler, S., Cottrell, D., Scott, S., Pilling, S., Eisler, I. … & Ellison, R. (2018) Multisystemic therapy versus management as usual in the treatment of adolescent antisocial behaviour (START): A pragmatic, randomised controlled, superiority trial. The Lancet Psychiatry. 5 (2), 119–133. |
The following studies were identified for this intervention but did not count towards the intervention’s overall evidence rating. An intervention receives the same rating as its most robust study or studies.
Asscher, J. J., Deković, M., Manders, W. A., van der Laan, P. H., Prins, P. J. M. & the Dutch MST Cost-Effectiveness Study Group 4. (2013) A randomized controlled trial of the effectiveness of Multisystemic Therapy in the Netherlands: Post-treatment changes and moderator effects. Journal of Experimental Criminology. 9, 169–187.
Asscher, J. J., Deković, M., Manders, W. A., van der Laan, P. H., Prins, P. J. M., van Arum, S. & the Dutch MST Cost-Effectiveness Study Group 4. (2014) Sustainability of the effects of multisystem therapy for juvenile delinquents in the Netherlands: Effects on delinquency and recidivism. Journal of Experimental Criminology. 10, 227–243.
Baglivio, M. T., Jackowski, K., Greenwald, M. A. & Wolff, K. T. (2014) Comparison of multisystemic therapy and functional family therapy effectiveness: A multiyear statewide propensity score matching analysis of juvenile offenders. Criminal Justice and Behaviour. 41, 1033–1056.
Barth, R. P., Greeson, J. K. P., Guo, S., Green, R. L., Hurley, S. & Sisson, J. (2007) Outcomes for youth receiving intensive in-home therapy or residential care: A comparison using propensity scores. American Journal of Orthopsychiatry. 77, 497–505.
Brown, T. L., Henggeler, S. W., Schoenwald, S. K., Brondino, M. J. & Pickrel, S. G. (1999) Multisystemic treatment of substance abusing and dependent juvenile delinquents: Effects on school attendance at posttreatment and 6-month follow-up. Children’s Services: Social Policy, Research, & Practice. 2 (2), 81–93.
Ellis, D., Naar-King, S., Templin, T., Frey, M., Cunningham, P., Sheidow, A., Cakan, N. & Idalski, A. (2008) Multisystemic Therapy for adolescents with poorly controlled type 1 diabetes: Reduced diabetic ketoacidosis admissions and related costs over 24 months. Diabetes Care. 31 (9), 1746–1747.
Ellis, D. A., Frey, M. A., Naar-King, S., Templin, T., Cunningham, P. & Cakan, N. (2005) Use of Multisystemic Therapy to improve regimen adherence among adolescents with type 1 diabetes in chronic poor metabolic control: A randomized controlled trial. Diabetes Care. 28 (7), 1604–1610.
Ellis, D. A., Naar-King, S., Cunningham, P. B. & Secord, E. (2006) Use of Multisystemic Therapy to improve antiretroviral adherence and health outcomes in HIV-infected pediatric patients: Evaluation of a pilot program. AIDS Patient Care and STDs. 20 (2), 112–121.
Fain, T., Greathouse, S. M., Turner, S. F. & Weinberg, H. D. (2014) Effectiveness of Multisystemic Therapy for minority youth: Outcomes over 8 years in Los Angeles County. Journal of Juvenile Justice. 3 (2), 24–37.
Glisson, C., Schoenwald, S. K., Hemmelgarn, A., Green, P., Dukes, D., Armstrong, K. S. & Chapman, J. E. (2010). Randomized trial of MST and ARC in a two-level Evidence-Based treatment implementation strategy. Journal of Consulting and Clinical Psychology. 78 (4), 537–550.
Henggeler, S. W., Borduin, C. M., Melton, G. B., Mann, B. J., Smith, L. A., Hall, J. A., Cone, L. & Fucci, B. R. (1991) Effects of multisystemic therapy on drug use and abuse in serious juvenile offenders: A progress report from two outcome studies. Family Dynamics of Addiction Quarterly. 1 (3), 40–51.
Henggeler, S. W., Clingempeel, W. G., Brondino, M. J. & Pickrel, S. G. (2002) Four-year follow-up of Multisystemic Therapy with substance-abusing and substance-dependent juvenile offenders. Journal of the American Academy of Child and Adolescent Psychiatry. 41 (7), 868–874.
Henggeler, S. W., Melton, G. B. & Smith, L. A. (1992) Family preservation using multisystemic therapy: An effective alternative to incarcerating serious juvenile offenders. Journal of Consulting and Clinical Psychology. 6, 953–961.
Henggeler, S. W., Melton, G. B., Brondino, M. J., Scherer, D. G. & Hanley, J. H. (1997) Multisystemic Therapy with violent and chronic juvenile offenders and their families: The role of treatment fidelity in successful dissemination. Journal of Consulting and Clinical Psychology. 65, 821–833.
Henggeler, S. W., Melton, G. B., Smith, L. A., Schoenwald, S. K. & Hanley, J. H. (1993) Family preservation using multisystemic treatment: Long-term followup to a clinical trial with serious juvenile offenders. Journal of Child and Family Studies. 2, 283–293.
Henggeler, S. W., Pickrel, S. G. & Brondino, M. J. (1999) Multisystemic treatment of substance-abusing and dependent delinquents: Outcomes, treatment fidelity, and transportability. Mental Health Services Research. 1 (3), 171–184.
Henggeler, S. W., Rodick, J. D., Borduin, C. M., Hanson, C. L., Watson, S. M. & Urey, J. R. (1986) Multisystemic treatment of juvenile offenders: Effects on adolescent behavior and family interaction. Developmental Psychology. 22, 132–141.
Henggeler, S. W., Halliday-Boykins, C. A., Cunningham, P. B., Randall, J., Shapiro, S. B. & Chapman, J. E. (2006) Juvenile drug court: Enhancing outcomes by integrating evidence-based treatments. Journal of Consulting and Clinical Psychology. 74 (1), 42–54.
Henggeler, S. W., Rowland, M. D., Randall, J., Ward, D. M., Pickrel, S. G., Cunningham, P. B., Miller, S. L., Edwards, Zealburg J. J., Hand, L. D. & Santos, A. B. (1999) Home based Multisystemic Therapy as an alternative to the hospitalization of youths in psychiatric crisis: Clinical outcomes. Journal of the American Academy of Child & Adolescent Psychiatry. 38, 1331–1339.
Huey, S. J., Henggeler, S. W., Rowland, M. D., Halliday-Boykins, C. A., Cunningham, P. B., Pickrel, S. G. & Edwards, J. (2004) Multisystemic therapy effects on attempted suicide by youths presenting psychiatric emergencies. Journal of the American Academy of Child & Adolescent Psychiatry. 43 (2), 183–190.
Leschied, A. & Cunningham, A. (2002) Seeking effective interventions for serious young offenders: Interim results of a four-year randomized study of Multisystemic Therapy in Ontario, Canada. Centre for Children and Families in the Justice System.
Naar-King, S., Ellis, D., Kolmodin, K., Cunningham, P., Jen, C., Saelens, B. & Brogan, K. (2009) A randomized pilot study of Multisystemic Therapy targeting obesity in African-American adolescents. Journal of Adolescent Health. 45 (4), 417–419.
Painter, K. (2009) ‘Multisystemic therapy as community-based treatment for youth with severe emotional disturbance. Research on Social Work Practice. 19, 314–324.
Rowland, M. D., Halliday-Boykins, C. A., Henggeler, S. W., Cunningham, P. B., Lee, T. G., Kruesi, M. J. & Shapiro, S. B. (2005) A randomized trial of Multisystemic Therapy with Hawaii’s Felix Class youths. Journal of Emotional and Behavioral Disorders. 13 (1), 13–23.
Schaeffer, C. M., Saldana, L., Rowland, M. D., Henggeler, S. W. & Swenson, C. C. (2008) New initiatives in improving youth and family outcomes by importing evidence-based practices. Journal of Child and Adolescent Substance Abuse. 17 (3), 27–45.
Schoenwald, S. K., Ward, D. M., Henggeler, S. W. & Rowland, M. D. (2000) MST vs. hospitalization for crisis stabilization of youth: Placement outcomes 4 months post-referral. Mental Health Services Research. 2 (1), 3–12.
Stambaugh, L. F., Mustillo, S. A., Burns, B. J., Stephens, R. L., Baxter, B., Edwards, D. & Dekraai, M. (2007) Outcomes from wraparound and Multisystemic Therapy in a center for mental health services system-of-care demonstration site. Journal of Emotional and Behavioral Disorders. 15 (3), 143–155.
Timmons-Mitchell, J., Bender, M., Kishna, M.A. & Mitchell, C. (2006) An independent effectiveness trial of Multisystemic Therapy with juvenile justice youth. Journal of Clinical Child and Adolescent Psychology. 35 (2), 227–236.
Trupin, E. J., Kerns, S. E. U., Walker, S. C., DeRobertis, M. T. & Stewart, D. G. (2011) Family integrated transitions: A promising program for juvenile offender with co-occurring disorders. Journal of Child & Adolescent Substance Abuse. 20, 421–436.
Weiss, B., Han, S., Harris, V., Catron, T., Ngo, V. K., Caron, A., Gallop, R. & Guth, C. (2013) An independent randomized clinical trial of Multisystemic Therapy with non-court-referred adolescents with serious conduct problems. Journal of Consulting and Clinical Psychology. 81 (6), 1027–1039.
Note on provider involvement: This provider has agreed to Foundations’ terms of reference (or the Early Intervention Foundation's terms of reference), and the assessment has been conducted and published with the full cooperation of the intervention provider.
Rated 1: Set up and delivery is low cost, equivalent to an estimated unit cost of less than £100.
Rated 2: Set up and delivery is medium-low cost, equivalent to an estimated unit cost of £100–£499.
Rated 3: Set up and delivery is medium cost, equivalent to an estimated unit cost of £500–£999.
Rated 4: Set up and delivery is medium-high cost, equivalent to an estimated unit cost of £1,000–£2,000.
Rating 5: Set up and delivery is high cost. Equivalent to an estimated unit cost of more than £2,000.
Set up and delivery cost is not applicable, not available, or has not been calculated.
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Supporting children’s mental health and wellbeing: Lorem ipsum dolor sit amet, consectetuer adipiscing elit. Aenean commodo ligula eget dolor. Aenean massa. Cum sociis natoque penatibus et magnis dis parturient.
Preventing child maltreatment: Lorem ipsum dolor sit amet, consectetuer adipiscing elit. Aenean commodo ligula eget dolor. Aenean massa. Cum sociis natoque penatibus et magnis dis parturient.
Enhancing school achievement & employment: Lorem ipsum dolor sit amet, consectetuer adipiscing elit. Aenean commodo ligula eget dolor. Aenean massa. Cum sociis natoque penatibus et magnis dis parturient.
Preventing crime, violence and antisocial behaviour: Lorem ipsum dolor sit amet, consectetuer adipiscing elit. Aenean commodo ligula eget dolor. Aenean massa. Cum sociis natoque penatibus et magnis dis parturient.
Preventing substance abuse: Lorem ipsum dolor sit amet, consectetuer adipiscing elit. Aenean commodo ligula eget dolor. Aenean massa. Cum sociis natoque penatibus et magnis dis parturient.
Preventing risky sexual behaviour & teen pregnancy: Lorem ipsum dolor sit amet, consectetuer adipiscing elit. Aenean commodo ligula eget dolor. Aenean massa. Cum sociis natoque penatibus et magnis dis parturient.
Preventing obesity and promoting healthy physical development: Lorem ipsum dolor sit amet, consectetuer adipiscing elit. Aenean commodo ligula eget dolor. Aenean massa. Cum sociis natoque penatibus et magnis dis parturient.
Rated 2: Has preliminary evidence of improving a child outcome from a quantitative impact study, but there is not yet evidence of causal impact.
Rated 2+: Meets the level 2 rating and the best available evidence is based on a study which is more rigorous than a level 2 standard but does not meet the level 3 standard.
Rated 3: Has evidence of a short-term positive impact from at least one rigorous study.
Rated 3+: Meets the level 3 rating and has evidence from other studies with a comparison group at level 2 or higher.
Rated 4: Has evidence of a long-term positive impact through at least two rigorous studies.
Rated 4+: Meets the level 4 rating and has at least a third study contributing to the Level 4 rating, with at least one of the studies conducted independently of the intervention provider.
Rating has a *: The evidence base includes mixed findings i.e., studies suggesting positive impact alongside studies, which on balance, indicate no effect or negative impact.
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