school based mental health workshop: assessing and treating violent youth
TRANSCRIPT
How much School Violence is in the US?
o USo 33 school shootings in the 1990’s (10 years)o 40 school shootings from 2000-2010 (10 years)o 44 school shootings from 2011-2013 (3 years)
RISK FACTORS FOR YOUTH VIOLENCE
The more chronic and severe the risk factors the higher the risk for future violence.
TWO TYPES
o Chronically violent and delinquent (generally from violent homes with criminal substance abusing parents)
o Psychotic (or autistic), narcissistic, with insufficient supports, and endure event that severely injures ego (generally from pro-social homes, but youth are Neurologically impaired and not in treatment).
Historical Risk Factors for Youth Violenceo Past behavior problemso Past Assaults
o Chronicityo Severity
o Escape from custodyo Fire settingo Harmed Animalso Early behavior problemso Enuresiso Delinquency
Recent mental health and behavioral health issues
o Anger managemento Runawayo Lacks remorseo Poor problem solvingo Belief in the legitimacy of aggressiono Social skill deficitso Bullying behavioro Deviant peer groupo Limited association with pro-social peerso Paranoiao IQ below 80
Recent mental health and behavioral health issues II
o School problemso Risk for placemento Impulsiveo Emotions poorly regulatedo Psychosis or autistic (usually high IQ)o Self-harm
Historical Factors IIo Attachment
problemso Abuse and neglecto Family violence,
abuse, neglect, or criminality
o Parental insufficientcy
o Parental absenseo Bullying
Historical Substance Abuse & Neurological Problems
o Substance abuseo Neurologicalo Mental health
Resiliency factorso Average or better IQo Positive experiences with caregiverso Positive school experienceo Lack of untreated psychiatric or
substance abuse problems in caregiverso Positive future goalso Positive activitieso Effective treatmento Pro-social peerso Modulates emotions wello Takes medication as prescribed
Child Development
Corrective developmental experiences and healthy relationships can change the brain.
The balance between healthy and unhealthy biology (including genes), environment and experiences will determine the health of development.
Healthy skill development is necessary to function effectively in the world of people.
Child development
What Developmental areas are affected by trauma
o Problem solvingo Self managemento Moral reasoningo Logico Affect regulationo Interpersonal relatednesso Task behavioro Concentrationo Impulsivityo Effective Communication
Stage I – Ages 0-2. Immediate Gratification
Stage II – Ages 2 -7. Reciprocity begins to develop
Stage III – Ages 8 – 11. Empathy Develops. More organized , less impulsive.
Stage IV (12-18) Learning the importance of group membership and the “Golden Rule”
Can be blocked by Trauma
Can be blocked by Trauma
Can be blocked by Trauma
Trauma Negatively Affects Moral Development, Kohlberg, 1969 (Expanded from Piaget)
Targets of Assessment
Types of AssessmentAssessments inform treatment
Assessment
Assessment Targets
o Symptoms (Health)o Development of skills (Health)o Family dynamics (Home)o School or job functioning (Community)o Career Goals, Relationships, Spirituality (Meaning)o Danger to self and others
Assessment
When problems are severe, chronic, acute, dangerous, immediate specialty assessments are needed to determine immediacy of danger, as well as type, and intensity of treatment needed.
1. Get 3rd party information when possible2. Psychological Testing may be needed3. Interventions that meet the needs of the client and his or her family4. Safety must be the number 1 priority. You cannot help children if
they are not safe.1. Dangerousness2. Suicidality3. Domestic violence
Suicide Risk vs. Self Harm
Assessment of Danger to self
Assesso Assess Risk factors, especially those that can be
changedo Assess resiliency factors especially those that
can be increasedo Conduct suicide inquiryo Determine risk level and interventiono Document
Each client is assessed for risk of dangerousness at regular intervals, or as needs change
• Clients at risk of dangerousness are identified and charted
• Immediate safety needs of others are addressed• Treatment and monitoring strategies to ensure
procedures for safety of others are implemented• Treatment and monitoring strategies are
individualized and documented in the client’s health record
• Outcomes of strategies are charted
Assessment of Danger to Others
Basic Principles of Assessment of Very Complex, High Risk Caseso Assess for dangerousness: Domestic Violence, Abuse, risk of
violence, risk of sexual offending, and suicidality and o Take appropriate safety measures. Agencies that actively employed
standardized risk and need assessments had a greater impact on recidivism than agencies that did not (correlations with effect sizes of .33 and .16, respectively (CRIME & DELINQUENCY, Vol. 52 No. 1, January 2006 7-27; DOI: 10.1177/0011128705281756)
o Assess developmental level of parents and child in a variety of skill areas. Behavior Objective Sequence (Braatan). Skills must be taught in developmentally appropriate sequence.
o Assess systems for cooperation, communication, and mutual supporto Determine types and levels of treatment needed (dosage)
Instrument Risk of Violence
Ages Case Management
Can be Administered
Unaided Clinical Judgement
r =.12; AUC =.51(Chance)
Any No NA Many studies
SAVRY (Handbook of Violence Risk Assessment By Randy K Otto)
R = .56-.67; AUC = .77-.80 (good)
12-18 No Hand Structured Professional Judgment;
CARE2 (The Handbook of Forensic Psychology edited by Irving B. Weiner, Allen K. Hess)
r = .62; AUC = .87 (Very Good)
6-18 Yes Hand or online Risk and Needs; 1,026 males and females, ages 6-18 in the US
LS-CMI (Int J Offender Ther Comp Criminol. 2012 Feb;56(1):113-33. Epub 2011 Feb 13)
r = .39; AUC = .75 (good)
16+ Yes Hand or computer
Risk and Needs; 250,000 youth and adult offenders in US and Canada
PCL-YV (Int J Law Psychiatry. 2008 Jun-Jul;31(3):287-96.)
AUC = .73 males (acceptable).50 females(Chance)
12-18 No Hand Measure of Psychopathic traits (Kosson, et. al. Psychol Assess. 2002 Mar;14(1):97-109.)
SAVRYhttp://savry.fmhi.usf.edu/ (ranks as most
accurate by Singh JP, Grann M, Fazel S, 2011) The SAVRY is composed of 25 items (Historical, Clinical, and Contextual) drawn from existing research and professional literature in adolescent development and on violence and aggression in youth. An additional five Protective Factors are also provided. (Bartel, Borum, & Forth, 1999; Borum, Bartel, & Forth, 2000). Ages 12-18 years.
LS-CMI – Treatment Planning for Delinquency1. LS-CMI
http://www.mhs.com/product.aspx?gr=saf&prod=ls-cmi&id=overview The Level of Service/Case Management Inventory (LS/CMI) is an assessment that measures the risk and need factors of late adolescent and adult offenders. The LS/CMI is also a fully functioning case management tool. This single application provides all the essential tools needed to aid professionals in the treatment planning and management of offenders in justice, forensic, correctional, prevention and related agencies. (16 years +). Male and female norms.
PCL-YVhttp://www.mhs.com/product.aspx?gr=edu&prod=pclyv&id=overview
(Ranks as least accurate by Singh JP, Grann M, Fazel S, 2011 meta-analysis) Correlations with female violence is NS. The Hare Psychopathy Checklist: Youth Version (PCL:YV) is a 20- item rating scale for the assessment of psychopathic traits in male and female offenders aged 12 to 18. The PCL:YV uses an expert-rater format that emphasizes the need for multidomain and multisource information. Using a semistructured interview and collateral information, the PCL:YV measures interpersonal, affective, and behavioral features related to a widely understood, traditional concept of psychopathy. Ages 12-18
CARE2http://care2systems.com The CARE-2 (Child &
Adolescent Risk Evaluation) Assessment by Dr. Kathy Seifert works to identify youth who are at risk for violence and determines specific interventions needed to prevent any future risk of aggressive behavior. Updated and enhanced, this invaluable tool examines every factor that may be affecting the youth's development, and puts a plan in place for the youth to mature into a positively pro-social functioning member of society. (ages 6-19)
Developmental Assessment
6 Core Concepts of Child Developmento Children are always learning and
development has a sequence that must be followed and age is not a determinate of developmental level (roll over, sit up, crawl, stand up, walk)
o Skill building usually follows developmental sequences and be taught within the context of a healthy, nurturing, dependable relationship.
o Attachment experiences (good, bad, or ugly) and trauma change the brain.
Trauma can interrupt the sequences of development
Assess where a child is on a developmental scaleo Many are at immediate gratification and seeking a safe
base.o Immediate gratification and needs of the self are primaryo Must learn perspective taking and reciprocity before empathyo If the youth is still seeking a safe base, that must be
established before exploration of the world and information gathering
o A safe environment is essential for healthy developmento You need some type of developmental guide for use in your
treatment plan
Assessment of High Risk Childreno 8 Symptom Categorieso Traumatized Braino 3 or 4 Attachment Patternso Holistic Assessment and
Treatment Practiceso Assessing Development Using the
BOS
Behavior – Lack of eye contact, enuresis, violence, out of control behavior, hoarding food, lies, steals, oppositional and defiant, breaks the rules, impulsive, destructive, hyperactive, self-destructive, harms animals, irresponsible
Emotions – intense anger & temper, sad, depressed, hopeless, moody, fearful, anxious, irritable, inappropriate emotional reactions, emotions not well regulated
Level 3. 8 Symptom Categories of DTD/CPTSD/RAD – past & present; frequency, duration, and severity. What other disorders have these symptoms?
symptoms – 2.
thoughts – negative beliefs about others and relationships, lacks cause and effect thinking, attention & learning problems
negative beliefs about self
Symptoms 3. Relationships – lacks trust, controlling (bossy) with children and adults, is not genuinely affectionate with family, indiscriminately affectionate with strangers, unstable peer relationships, blames others for misdeeds, victimizes others and is victimized.
Symptoms - 4
o Physical - failure to thrive, poor hygiene, tactilely defensive, enuresis & encopresis, accident prone, high pain tolerance,
o Moral/Spiritual – lack compassion, remorse, pro-social values, identification with evil or the “dark side”
o Development - delayed developmento Core Beliefs/Internal Working Model of
self, others, and world is Negative
The Behavior Objective Sequence
o By Sheldon Braatano A developmentally sequenced
group of skills in 6 Domains.o Age is not the determiner of skill
levelo Youth must learn skills in
appropriate developmental sequence.
o Find out at what level they have mastered skills (can do it 90% of the time without prompting)
Adaptive: Responds appropriately toroutine and new expectationsrespond independently to materials for amusementappear alert and able to focus attentionbring no weapons to schooluse amusement materials appropriatelywait for turn without physical interventionuse and return equipment without abuseaccept positive physical contacttouch others in appropriate waysrefrain from stealingrespond when angry without hittingrecognize and show regard for possessionsaccept verbal cue for removal from a situationrespond when angry without abuse of propertyrespond appropriately to substituterespond when angry without threatswalk to timeout without being moved by an adultwork or play without disrupting othersrefrain from inappropriate behavior when otherslose controlrespond to provocation with self-controlrespond when angry with self-removal
Self-Management Skills
Responds appropriately to challenging experiences with self-control in order to achieve success
o (E) Appear alert and able to focus attention on activitieso Wait or take turns when directed without physical intervention –
verbal prompts may be useo Respond when angry without verbal threats or intent to harmo (M) Seek adult help in personal and/or group crisiso Maintain personal control and routinely comply with established
procedures in group situations without reminders.o (H) Maintain self-control when faced with disappointment,
frustration, or failure without adult intervention.o Obey new or temporary authority figure, without presence of
other permanent staff
Communication
o Ability to share with and receive information from other people to meet a need or affect another person in a positive way.o Speak using a volume appropriate to the situationo Wait until a speaker is finished before respondingo Express feelings about self or others to an adult appropriatelyo Spontaneously participate in group discussionso Maintain appropriate social distance when speaking to anothero Speak courteously to others, using appropriate references, with no
cues.o Describe personal strengths that will enable success
Interacting with others in social and task situations in ways that meet personal and interdependence needs and
contribute to a sense of belonging
• Respond to an adult when his or her name is called• Accept help from an adult when offered• Sit quietly for 15 minutes or more in a group listening
activity• Develop positive relationships with more than 1 adult• Share materials and equipment with peers with minimal
reminders from adults• Physically or verbally come to the support of another
student by offering assistance in a difficult situation• Spontaneously resist negative peer pressure
Interpersonal Behaviors
Task Behaviorso Student engages in task or activity with or without assistance
o Accept assistance from an adult on academic taskso Refrain from inappropriate behavior when asked by an adult to correct
errorso Complete daily assignmentso Choose and actively participate in elective classeso Ignore distractions of others while workingo Self-chart progress in reading or matho Participate in structured role-playing activitieso Complete and turn in assigned homework when due
Personal Behaviors
o Student engages in a counseling dialogue with a helping person, permitting adult to help resolve issues or solve problems or build self esteem.o Express negative feelings to an adulto Follow through with specific directions from an adult to modify
behavior in a given situationo Participate in determining a short term plan for dealing with an
immediate situationo Attend to a peer when a peer is speakingo Express feelings about self to peerso Seek counseling t avoid conflicto Contribute to group rule making and consequenceso Verbally demonstrate knowledge of alternative coping
strategies for managing stress
Assessing parents
Parents
o Attachment/trauma historyo Awareness of Emotional & Environment Triggerso Parenting Attitudes and Competencies
o The child needs a loving home with nurturing, affection, routine, structure and boundaries.
o There are skills to learn about anger management, reframing the meaning of behaviors, teaching, rather than punishing
o Parent Mental Health, Substance Abuse, Offending Behavior, Dangerousness & Stabilityo Parents must take care of their mental health to do this job
effectivelyo Safety of the home
Assessment of Family System
o Family backgroundso Families of origino Marital relationshipo Relationships among siblings and
between children and parentso Structure – Family Systems Worko Ongoing Patterns (“family dance”)o Support Systemso Stressors and Stress Managemento Rules, Roles, and Boundaries
PREVENTION
PROVEN EFFECTIVE PREVENTION
o Head Start with Family Involvement
o Healthy Familieso Early detection and treatmento Ending child abuse, neglect and
domestic violence
Interventions
EBP
• Case management• Multi-system integration• Family Therapy• Developmental approaches with skill building• CBT• Role playing• Dosage is important• Holistic approaches• Neuro-feedback & CES• Wrap-around
Evidence based treatment for complex cases
Developmental Interventions with BOS
PROMISING PRACTICE
Questions and Answers