Intensive Support and Supervision Program. Dr. Laurel Johnson, Ph.D., C. Psych. Dr. Catherine Krasnik, MD,PhD, FRCP(C)

Transcription

1 Intensive Support and Supervision Program Dr. Laurel Johnson, Ph.D., C. Psych. Dr. Catherine Krasnik, MD,PhD, FRCP(C)

2 The Beginning In 2003: Introduction of the Youth Criminal Justice Act in Canada An increased emphasis community dispositions and on effective rehabilitation Since 2003, approximately 90% of youth currently in the Canadian correctional service system are under community supervision Youth Correctional statistics in Canada, 2010/2011

3 Mental Health in Youth Justice Many youth straddle youth justice and mental health services 2010/11 admissions to open/secure custody/residential indicates that 18.2% of youth admitted into the system have an identified mental health need 24% of 430 youth sentenced to secure custody have an identified mental health need Ontario Children s Mental Health Association, 2012

4 The Scope of the Problem US data suggests as many as 66% of males and 75% of females meet criteria for one or more psychiatric disorders in juvenile justice samples (Teplin et al., 2002) In fact, the general consensus across studies is that the vast majority of incarcerated youth meet formal criteria for at least one DSM-IV disorder (estimates typically range from %) Comparatively, the prevalence rate of any disorder among normative populations in the US is estimated to be approximately 37% (Costello, et al., 2003) Courtesy of Tracey Skilling, Ph.D., C.Psych., CAMH

5 Scope of the Problem-Canada Toronto and BC studies of youth in custody Youth in Custody 18-31% current Depression 30% any Anxiety disorder 25-50% PTSD 20-33% estimated to have ADHD 30-70% Conduct Disorder % met criteria for drug or alcohol abuse Recent study (BC) reports 6% identified with Schizophrenia Youth in General Population 4-8% Depression 4% Anxiety disorder Less than 1% PTSD 5-10% estimated to have ADHD 4-8% Conduct Disorder 2-7% drug/alcohol abuse Likely less than 1% of youth (population estimates for adults about 1% for schizophrenia) Courtesy of Tracey Skilling, Ph.D., C.Psych., CAMH

6 Concurrent Disorders Armstrong and Costello (2002) comprehensive review: 60% of youth with a SUD have a comorbid psychiatric diagnosis Most commonly conduct disorder, oppositional defiant disorder, depression, anxiety In the CAMH Youth Addictions program - research suggested upward of 90% --name change to Youth Concurrent Disorders Clinic as a result Highly relevant in youth justice from a mental health perspective and also from a criminal justice perspective especially in light of poor prognosis and challenges in treatment Courtesy of Tracey Skilling, Ph.D., C.Psych., CAMH

7 Cognitive and Academic Issues Studies from several countries (Canada, USA, UK, and Australia) show problems related to cognitive and academic functioning are higher among youth in serious trouble with the law than youth in the general population. Courtesy of Tracey Skilling, Ph.D., C.Psych., CAMH

8 Scope of the Problem (UK, Canada, US, Australia) Youth in Custody 7-20% IQ<70 (below 2nd%ile) 31-40% IQ =70-79 (Borderline) 7-75% Learning Problems (actual learning disability diagnosis estimates lie between 25-30% as most solid estimate) Problems in math, spelling and reading commonly noted Communication Youth in General Population 2% 9% 5-10% Courtesy of Tracey Skilling, Ph.D., C.Psych., CAMH

9 Report to British Parliament (2010) A court faced with a sullen, uncommunicative and defensive 17 year old tends to view the behaviour differently once aware that he has been assessed as having communication difficulties, cannot understand a lot of the language being used and is functioning at the level of a child 10 years younger. Courtesy of Tracey Skilling, Ph.D., C.Psych., CAMH

10 Key Messages and Implications for Treatment Trauma Trauma-informed care Concurrent Disorders/Comorbid issues Need treatment for both concurrently Cognitive issues common Treatment must take into account abilities Not just diagnoses that are important Sub-diagnostic symptoms important predictors of poor outcome later, too Courtesy of Tracey Skilling, Ph.D., C.Psych., CAMH

11 Why is Treating Mental Health Needs Important in the Context of Juvenile Justice? Mental health needs may be directly related to risk for continued involvement with the justice system and rehabilitation (Criminogenic Needs) Examples of mental health issues directly related to risk for continued problems: substance use disorders, attention issues and impulsivity, pedophilia, educational issues Courtesy of Tracey Skilling, Ph.D., C.Psych., CAMH

12 Also Mental health needs may be indirectly related to successful rehabilitation efforts. Responsivity factors = characteristics of an adolescent that may have some impact on responsiveness to criminogenic needs treatment. Cognitive factors, mood/anxiety, substance use Courtesy of Tracey Skilling, Ph.D., C.Psych., CAMH

13 Ministry Response In 2005, MCYS introduced the Intensive Support and Supervision Program (ISSP) as one element of its Alternatives to Custody and Community Intervention Strategy A COMMUNITY-BASED, ALTERNATIVE-TO- CUSTODY PROGRAM FOR YOUTH WHO PRESENT WITH SIGNIFICANT MENTAL HEALTH NEEDS Provides a response for youth and the court system that is different from other community support programs in terms of the level, type, and intensity of the service

14 Full Community Programming Partial Least restrictive community-based orders May be supervised by MCYS More restrictive & custody orders Supervised by MCYS

15 9 ISSP Pilots in Ontario Kinark Youthdale Lutherwood Agency Durham Family Court Clinic Hands the Family Help Network/Algonquin Child and Family Services Child and Family Centre of Sudbury Eastern Ontario Youth Justice Agency St. Lawrence Youth Association Region(s) York, Halton, Peel, Dufferin, Simcoe Toronto Kitchener/Waterloo Durham North Bay/Algonquin Sudbury Ottawa Peterborough Also Intensive Support and Supervision Programs located in: Quebec Alberta British Columbia

16 Initial ISSP Model All models of ISSP differ At Kinark, ISSP initially implemented an MST model An intensive family- and community-based treatment program that focuses on addressing all environmental systems that impact chronic and violent juvenile offenders Exclusionary criteria Those with suicidal, homicidal, or demonstrating psychotic behavior requiring acute mental health inpatient treatment; Those who do not have a family support system; Those who present with more than light to moderate substance abuse. MST outcome studies focus on youth with disruptive behavioural disorders who are chronic and violent offenders, but not specifically identified as having mental health diagnoses

17 ISSP Model Evolved MST discontinued, but elements were retained Principles, tools (i.e., fit circles) CBT, Solution-Focussed added No structured model, however

18 ISSP Redevelopment at Kinark In the fall of 2011, Kinark identified the need to examine the state of the program with an independent audit Changes to the program necessary in order to further develop and evolve the ISSP forward, ensuring it is providing the right service to the right population of youth that will achieve the best outcomes in a safe and sustainable manner

19 Family Constellation of Clients NULL 17 (31%) ( ) Biological Mother and Partner 4 (7%) Biological Parents 5 (9%) CAS Care 1 (2%) Foster Care 1 (2%) Grandparents 5 (9%) Group Home/Other Agency 1 (2%) Single Mother Biological 4 (7%) In Detention 2 (4%) Single Father Biological 3 (5%) Other Relative/Friend 3 (5%) Intact Family 2 (4%) Independently 7 (13%)

20 Admissions to ISSP by Age at Admission ( ) (34%) (18%) 11 (20%) (9%) 5 (9%) 2 1 (2%) 1 (2%) 2 (4%) 1 (2%)

21 Diagnoses (by number of occurrences) for youth in program ( )(n=55) Bipolar Disorder Depression Depression/Dysthymia Dysthymia Schizophrenia Drug-induced psychosis Psychosis Anxiety Disorder (including GAD) PTSD Adjustment Disorder Attachment Disorder Learning Disability Intellectual Disability Asperger Syndrome FASD ADHD Disruptive Behavioural Disorder Conduct Disorder Personality Disorder Oppositional Defiant Disorder Substance Use Disorder Gender Identity Disorder Pyromania Tourettes

22 Number and Proportion of Youth with Substance Use Disorders 2007/ / / /11 TOTAL # of clients % of total clients admitted to fiscal year 42.9% 54.5% 53.8% 40.0% 47.8%

23 Redevelopment 1. Eligibility Criteria To ensure the right youth are being served and are amenable to the treatment offered 2. Staffing Model More efficient and effective staffing model with clear role definitions 3. Service Model Robust and clearly defined clinical, interdisciplinary process 4. Treatment Appropriate application of EBPs to achieve desired outcomes 5. Safety Protocols To ensure effective safety management for both clients and staff 6. Evaluation Framework Measurement of desired outcomes and program efficacy

24 Eligibility Criteria (MCYS) Youth, male or female, years old at the time of the offence Youth has a diagnosed mental health need (mood/anxiety disorder, trauma-related disorder, selfharm or suicidal ideation, psychotic-spectrum disorder, substance-use disorder, developmental delay) demonstrated within a recent court-ordered Section 34 assessment The diagnosed mental health need is not solely ADHD, CD, and/or ODD Youth voluntarily consents to actively participate in the program

25 Eligibility Criteria (MCYS) Based on the nature or seriousness of the offence, the youth would likely receive a custody disposition Youth resides in our service area in a permanent, or semi-permanent, living situation The youth has one or more responsible adults who will support him/her while in treatment The youth can be safely supervised in the community There are current and/or historical indicators of the youth s capacity to function in the community There are current and/or historical indicators of the youth s responsiveness to therapeutic intervention

26 YORK HALTON/ DUFFERIN/PEEL SIMCOE Staffing Model Therapist (4 Youth) Therapist (4 Youth) Therapeutic Support Worker Therapeutic Support Worker Therapist (4 Youth) Therapist (4 Youth) Supervisor Admin Psychology Psychiatry

27 Service Model Referral Suitability Intake Formulation Treatment Discharge Aftercare Communication with probation Review of collaterals (S34 Assm t, PSR, RNA) Consents Clinical interview URICA (readiness for change) Multidisciplinary team review Assessments (CAFAS, CANS, Risk, Psychological, Psychiatric, Community Support) Safety plan Treatment plan Community support needs Engagement/Commitment EBP Connections with community supports/treatment providers Community reintegration efforts Mental health continuity of care Youth autonomy Individualized as required.

28 Referral Inquiry Probation may make an inquiry as to client eligibility and/or program capacity and/or requirements. Referral Received Probation submits completed Referral Package including S34 Assessment Report and other relevant documents (RNA, PSR). Decision of Eligibility Communication to Probation. Consent forms obtained.

29 Suitability Clinical Interview Therapist and TSW interview client and caregivers assessing motivation and commitment. Standardized Assessments Measures include Readiness for Change (URICA) and Symptomatology (SCL-90) inventories. Interdisciplinary Team Review Team reviews information to determine suitability. Decision of Suitability If suitable, communication to PO. PO to secure ISSP Order.

30 Intake Psychiatric Evaluation Psychiatrist confirms diagnoses and symptom presentation. Reviews medication needs. Psychological Evaluation Psychologist confirms diagnosis and symptom presentation. Conducts standardized Risk Assessment (SAVRY). Standardized Assessments Therapist evaluates overall functioning (CAFAS) and needs and strengths (CANS). TSW evaluates community support needs.

31 Formulation Therapist TSW Psychiatrist Psychologist URICA SCL-90 SAVRY CANS CAFAS CSNA TREATMENT PLAN SAFETY PLAN COMMUNITY SUPPORT PLAN

32 Treatment Plans Standardized and focussed Treatment Plan Treatment Plan Review

33 Treatment Motivation and Engagement Motivational Interviewing DBT Commitment Strategies Therapist meets with client minimum of 2 hours per week for therapeutic intervention Change Process CBT Anxiety Depression Trauma DBT Emotion Regulation Distress Tolerance Interpersonal Effectiveness Mindfulness Behaviourism/ Contingency Mgmt Individual and/or Family

34 Motivational Interviewing A collaborative, person-centered form of guiding to elicit and strengthen motivation for change. Supported by over 200 randomized clinical control trials across a range of target populations and behaviors including substance abuse, health-promotion behaviors, medical adherence, and mental health issues.

35 Dialectical Behaviour Therapy A comprehensive treatment approach for multidiagnostic, difficult-to-treat, high-risk individuals who engage in high-risk behaviours Emotion disregulation at the core DBT clients are taught more skillful ways to Regulate their emotions Deal with distressing situations in their lives Improve relationships with the people around them

36 Discharge Client s treatment goals have been met. Client s probation order is about to expire. Client is no longer voluntary. Discharge Communication with PO. Discharge Plan. More appropriate MH services are identified and secured.

37 Safety Protocol Comprehensive safety protocols Risk Assessments At intake and quarterly throughout service Strong, unique safety plans that are directly related to the risk assessment information and tailored specifically to the individual UMAB Assigned agency office space to be used as the basis for client contact Protocol for in-home client visits for exceptional cases

38 Evaluation Implementation evaluation To assess the extent to which the program is running as it was intended Outcome evaluation To assess the degree to which the program is achieving its intended outcomes for youth and the community at large

39 Implementation Evaluation Objectives To what extent has ISSP been implemented as it was intended (from August 1, 2012 to present) To what extent is ISSP serving its target population (what is the profile of the youth who are being served by ISSP to date) Gather this information from the MCYS guidelines, KIDS4 data, Client files, and interviews with ISSP staff and Probation Officers

40 Outcome Evaluation Objectives To what extent is the program achieving its intended outcomes with youth To what extent do ISSP participants show a reduction in criminogenic behaviour How satisfied are youth and community stakeholders with the program Outcome data will include a number of screening, pre, 9-month & post measures, as well as recidivism rates This data will also be collected on a similar comparison group (youth referred to ISSP but who do not participate i.e. are not voluntary)

41 Intended Outcomes Increased awareness of need for change Increased motivation for change Decreased high risk/maladaptive behaviours Decreased symptomatology Improved emotion regulation Increased problem-solving skills Reduced substance use Increased autonomy Secured community support and resources Improved overall functioning Increased/maintained family functioning Improved prosocial behaviours Reduced YJ severity/involvement High satisfaction with service

42 Outcome Evaluation Measures Measure: Areas of focus: Admin. by: When: BECK Youth Inventories Emotion Regulation TSW (score by Psychologist) Symptom Checklist 90-R (SCL-90-R) MH Symptomatology TSW (score by Psychologist) The Difficulties in Emotion Regulation Scale (DERS) Criminal Sentiment Scale (CSS) Questionnaire Paulhus Deception Scale (BIDR) Social Desirability TSW (distorted responses) University of Rhode Island Change Assessment (URICA) Screening, 9 Months & Post Screening, 9 Months & Post Emotion Regulation TSW Screening, 9 Months & Post Criminogenic Attitudes TSW Screening, 9 Months & Post Pre Identified Strengths, Self Efficacy, Motivation TSW Pre, 9 Months & Post

43 Outcome Evaluation Measures Measure: Areas of focus: Admin. by: When: Physical & Daily TSW Needs, Community Supports report) Ontario Common Assessment of Need (OCAN) ISSP Revised Version Child and Adolescent Needs and Strengths - Mental Health (CANS-MH) Child and Adolescent Functional Assessment Scale (CAFAS) Structured Assessment of Violence and Risk in Youth (SAVRY) Youth Level of Service / Case Management Inventory (YLS/CMI) 2.0 Pre, 9 Months & Post (self Needs & Strengths of Therapist Pre, 9 Months & Youth and Caregiver with TSW Post Overall Functioning Therapist Pre, 9 Months & Post Relationships & Risk Behaviours Education, Relationships, Substance Use, Risk Client Satisfaction Questionnaire Experience / Satisfaction Psychologist Psychologist Self Pre, 9 Months & Post Pre, 9 Months & Post Post

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