BEHAVIOR REST OF THE STORY

Transcription

1 Children Who Have Been Traumatized One Court s Response Judge Michael L. Howard Kim Genis Chuck Schuster

2 The Court s Perspective Children appear before the Court because they are charged with committing an unruly or delinquent act They do not present as a trauma case, but rather as one who has misbehaved We are to correct the behavior and protect the community Traditionally accomplished with consequences for actions

3 Case History Josh, age 15, charged with School Truancy Anthony, 16, charged with misuse of credit cards

4 Case History Briana, 17, charged with domestic violence What if we had missed the trauma?

5 BEHAVIOR REST OF THE STORY

6 A traumatic experience is an event that threatens someone s s life, safety, or well- being.

7 Types of Trauma Acute Trauma: : A single traumatic event limited in time. Chronic Trauma: : A series or pattern of traumatic events occurring with no protection, no support, no opportunity to heal. The effects are cumulative.

8 Types of Trauma Complex Trauma: Usually refers to trauma, often consistent and ongoing, experienced at the hands of an adult responsible for well-being of child. Youth hi involved di in the juvenile justice system with a history of trauma typically have experienced complex trauma

9 This can be experienced as a violation of our social contract with children

10 Abused v. Normal Brain Normal Child Abused/Neglected Child (As cited by Felitti & Anda, 2003; Source CDC)

11 Examples of Potentially Traumatic Events Physical, emotional, or sexual abuse Community violence and victimization Abandonment and neglect Domestic violence Traumatic loss Serious accident Medical trauma, illness/injury Natural disaster Terrorism/war Prostitution

12 Trauma... Renders the youth helpless Self-portrait of 5th grader: His mother had cancer and he was afraid she would die and leave him alone with his alcoholic father. (Herman, 1992)

13 Child Traumatic Stress can lead to Post Traumatic Stress Disorder (PTSD).

14 Variables Associated with Development of PTSD 1. Characteristics of the EVENT: Type and intensity Proximity, pattern, and duration Experience of direct harm or witnessing harm of others Reaction by others

15 Digging Deeper But why do some children develop PTSD and some children do not develop PTSD when they have nearly identical exposure to traumatic events?

16 Variables Associated with Development of PTSD 2. Characteristics of the CHILD: Prior history of exposure to trauma Subjective experience Prior psychiatric py history Coping style Strengths (across domains) Culture Gender and Age

17 PTSD Avoidance Re-experiencing Hyperarousal Avoiding traumatic reminders Nightmares and/or intrusive memories Abnormally increased arousal, responsiveness to stimuli, and scanning for threats

18 Hyperarousal Can Look Like Misbehavior or Bad Temper

19 Traumatic Reminders When faced with people, situations, places, or things that remind them of traumatic events, ents children may experience intense and disturbing feelings tied to the original trauma. Adapted from the NCTSN Child Welfare Toolkit

20 Traumatic Reminders These trauma reminders can lead to behaviors that seem out of place, but were appropriate and and perhaps even helpful at the time of the original traumatic event.

21 Traumatic Reminders Children who have experienced trauma may face so many trauma reminders in the course of an ordinary day that the whole world seems dangerous and no adult seems deserving of trust.

22 PTSD Biased Perceptions People can experience PTSD biased perceptions, seeing themselves to be in perpetual danger, always watching for the next bomb to drop, for the next person to harm them. They can lose the ability to feel safe, re-experience experience joys in life, and to engage in meaningful positive relationships with others. (Bessel van der Kolk)

23 Implications for Juvenile Justice Thus, there are some situations where using a forceful or intimidating or authoritative manner might evoke stronger violence or increase resistance.

24 Implications for Juvenile Justice Those who have experienced child traumatic stress: Often distrust people in authority and see them as threats because of being abused or harmed by adults that are supposed to protect them. Police, teachers, principals, bosses, etc can be perceived as threats.

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26 KEY POINT: The world is a safe place and rights of others matter VERSUS The world is not a safe place and rights of others don t matter Which orientation do you see in the youth with whom you work?

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29 How trauma leads to delinquency? Victimization Survival Coping Victim Coping Loss of personal integrity and control Dysregulation of emotions and information processing Rigid, distrustful, callous on the outside Damaged, hopeless, empty on the inside Taking any means necessary to avoid perceived revictimization Aggressive, oppositional, defiant, violating laws Foreshortened sense of future (Ford, Chapman, Mack, & Pearson, 2006; Kerig & Becker, 2010)

30 Behavioral Control Poor modulation of impulses Self-destructive behavior Risk-taking behavior Aggression toward others Little appreciation of cause-and- effect consequences of their behavior Self-mutilation, sleep and eating disorders, oppositional or antisocial behaviors Difficulty with rule compliance

31 Prevalence of Trauma and PTSD One study found that 92% of youth incarcerated had experienced one or more traumas (Teplin et al., 2002). Wood et al., (2002) found that t 92% of incarcerated adolescents knew someone who had been killed; 57% saw someone being killed; 72% report being shot or shot at; and 29% report having been sexually assaulted.

32 Prevalence of Trauma and PTSD In a study of youth in California Youth Authority facilities, Steiner and colleagues (1997) found: 32% of boys met full criteria for diagnosis of PTSD 49% of girls met full criteria for diagnosis of PTSD

33 Trauma Influences Behavior in Ways that Impact Your Work In a study of youth in the CYA, researchers found those with higher levels of traumatization: Had higher levels of institutional misconduct; Had 3x the suicidal activity; Had 3.5x the sexual misconduct; and Upon intake, had greater scores for depression, anxiety, suicidal ideation, substance abuse, and anger compared to their offender counterparts with low or no trauma history. *DeLisi, Drury, Kosloski, Caudill, Conis, Anderson, Vaughn, & Beaver, 2010

34 Being abused or neglected increased the likelihood of arrest as a juvenile by 59% and as an adult by 28% and for a violent crime by 30%

35 Abused and neglected children were younger at first arrest than others, committed nearly twice as many offenses and were arrested more frequently.

36 Identifying Trauma From the Bench Interviews by Court Staff Court Staff using recognized Trauma Screening tools

37 Screening vs. Assessment Screening Anyone can do it Used to identify those in need of more detailed assessment or services Should be used at initial point of contact Assessment Done by a trained clinician Informs diagnosis and treatment Detailed Can be used to assess improvement

38 Youth Have Multiple l Traumas When we screen Court-involved Youth, we find: One trauma triggers another and another Where do we start? attitude from professionals Numbing is disguised as indifference or attitude 38

39 Youth in Juvenile Justice: Their behavior DEFINITELY gets the attention of the system We want youth to stop certain behaviors -- learn from punishment Trauma as a reason looks like an excuse for the behavior to some people p 39

40 Youth Reacting to Trauma Youth can t connect traumatic events to changes in themselves We expect them to have more capacity to look inside Those that can look inside may not want to -- it hurts/ it s too hard 40

41 Attitudes Owning the negative belief system Looking for validation of belief system and finding it Revenge justified perception 41

42 Family and Community High emphasis on stop these behaviors from parents, schools, court Family is struggling g with the youth 42

43 Screening for Trauma Some youth and custodians are non- readers Best combination: Structured inventory questions that t are followed by an interview i Interview gathers details, permits greater understanding 43

44 UCLA Scale: Not the Football Team Public domain instrument Parent and youth versions Asks the essential questions Quick to score 44

45 UCLA PTSD Scale Provides immediate feedback: Presence of trauma symptoms Level of interference with functioning Frequency of interference 45

46 What Do I Do Next? Educate Trauma affects people they don t get over it so easily. It changes them. There are special ways to get help for it. People are afraid to bring it up. 46

47 Education: Your reactions made sense at the time because you were trying to survive but later on, they didn t fit - you got in trouble. If you don t like to talk about it there are ways to feel better without talking about it. 47

48 Juvenile Judge as Community Convener Trauma Awareness Training Identified those who wanted to know more and do more Stark County Traumatized Child Task Force

49 Task Force Participants Court Mental Health and Recovery Board and Service Providers Domestic Violence Project Sh Schools, Assistant it tc County Superintendent it t Local Foundations Department of Job and Family Services and CPS United Way After School Programs Private Foster Care Agencies Child Psychiatrist and Local Medical Foundation

50 Trauma-Informed System ATrauma Trauma-Informed System of Care acknowledges and responds to the role of trauma in the development of emotional, behavioral, educational, and physical difficulties in the lives of children and adults. The System recognizes and avoids inflicting secondary trauma.

51 Secondary Trauma Secondary Trauma occurs when child serving systems re-traumatize a child through policies and procedures. Example: Use of restraints to correct misbehavior.

52 Task Force Goals Develop a Comprehensive, Trauma- Informed System of Care. Assess, Develop, Support Trauma-Focused Resources. Promote Positive Early Childhood d Experiences to Build Resiliency.

53 Community participation Large Scale Event to Promote Community Awareness Bruce Perry Planned for 200 attendees, got 500 Awareness raised, referrals start, capacity lacking

54 Community planning Inventory of current treatment resources Who is providing treatment? Is it really evidence based trauma treatment? The Case of the Dropped Book

55 Questions for Mental Health Provider Does the individual or agency conduct a comprehensive trauma assessment. What specific standardized measure is given? What did the assessment show? What were some of the major areas of concern?

56 Questions for Mental Health Provider Is the individual or agency familiar with evidenced based treatment models? Have clinicians had specific training in the evidenced based models? (how much, when, where, by whom?) Does the individual or agency provide ongoing clinical supervision and consultation to staff, focusing on measuring and maintaining fd fidelity to the model?

57 Questions for Mental Health Provider What approach or approaches does the agency use to engage the child and family? How are parent support, conjoint therapy, parent training and/or psychoeducation offered?

58 Evidence Based Trauma Focused Treatments Key components include: Randomized d controlled studies supporting their effectiveness Manualized treatment, specialized training, and supervision

59 Evidence Based Trauma Focused Treatments t Treatment components that include: Strong therapeutic relationship Education Relaxation Increasing emotional awareness and managing emotions Increasing cognitive awareness and generating helpful and accurate cognitions Enhancing sense of safety and social skills

60 Examples of Evidence Based Models Trauma-Focused Cognitive Behavioral Therapy (Cohen, Mannarino, & Deblinger) TARGET-A A (Ford) Child Parent Psychotherapy (Lieberman & Van Horn) For more information: and explore their list of Treatments that Work

61 Treatment Improvements Children & Adolescents in the Clinical Range: Baseline & Last Follow up Behavioral Problems * (n=8880) CBCL >63 Briggs-King, E., (June 29 th, 2011) *p.0001 CDS September 2010

62 Contact Information Ernestine Briggs-King, PhD Data & Evaluation Program, Director

63 Community planning, con t Build treatment capacity, economically Training for therapists who were interested Kris Buffington Keeping the tools sharp The Learning Collaborative

64 Current Task Force Activities Ongoing assessment of Trauma Treatment Resources. Institutionalize referral, treatment and follow up protocols. Coordinate school based educational support for trauma victims using Care Teams.

65 Traumatic exposure, school failure, and delinquency are related.

66 Exposure to Chronic Trauma and Stress Emergency centers of the brain can become overused and overdeveloped d Fight or flight mode becomes very well-developed Cognitive center underdeveloped (synaptic pruning)

67 Impact on Education Very effective survival techniques come at a cost to the executive functions of our brain, such as focus and self control that enhance learning and contribute te substantially to school success.

68 Impact: Disengagement from School At least half of all maltreated children will experience serious school problems, especially conduct issues. (Putnam) Maltreated children have 3x the drop out rate of the general population. p (Focal Point, 2007)

69 Children with emotional and behavioral disorders who are also in special education classes have the highest school drop out rate of any disability group (50%).

70 Current Task Force Activities Work with Child Welfare System to make them Trauma informed

71 The Relationship of Adverse Childhood Experiences to Adult Health Status A collaborative effort of Kaiser Permanente and The Centers for Disease Control Vincent J. Felitti, M.D. Robert F. Anda, M.D.

72 Categories of Adverse Childhood Experiences Category Prevalence (%) Abuse, by Category Psychological (by parents) 11% Physical (by parents) 11% Sexual (anyone) 22% Household Dysfunction, by Category Substance Abuse 26% Mental Illness 19% Mother Treated Violently 13% Imprisoned Household Member 3%

73 Adverse Childhood Experiences vs. Current Smoking or more ACE Score Vincent J. Felitti, M.D. Robert F. Anda, M.D.

74 ACE Score vs. Smoking and COPD ACE Score: Percent Wi ith Problem or more 2 0 Regular smoking by age 14 COPD Vincent J. Felitti, M.D. Robert F. Anda, M.D.

75 Childhood Experiences vs. Adult Alcoholism % Alc coholic ACE Score Vincent J. Felitti, M.D. Robert F. Anda, M.D.

76 ACE Score vs. Intravenous Drug Use % Have In jected Drugs or more ACE Score Vincent J. Felitti, M.D. Robert F. Anda, M.D.

77 ACE Score and Hallucinations 12 Ever Hal llucinat ted* (% %) >=7 ACE Score *Adjusted for age, sex, race, and education. Abused Alcohol or Drugs No Yes

78 Childhood Experiences Underlie Chronic Depression istory of % With a Lifetime Hi Depression >=4 ACE Score Women Men Vincent J. Felitti, M.D. Robert F. Anda, M.D.

79 Childhood Experiences Underlie Suicide % Attempt ting Suicide ACE Score Vincent J. Felitti, M.D. Robert F. Anda, M.D.

80 Estimates of the Population Attributable Risk* of ACEs for Selected Outcomes in Women Mental Health PAR Current depression 54% Chronic depression 41% Suicide attempt 58% *That portion of a condition attributable to specific risk factors

81 Adverse Childhood Experiences vs. Likelihood of > 50 Sexual Partners 4 o Odds Rati Adjusted or more ACE Score Vincent J. Felitti, M.D. Robert F. Anda, M.D.

82 Adverse Childhood Experiences vs. History of STD 3 A djusted O dds Ratio or more ACE Score Vincent J. Felitti, M.D. Robert F. Anda, M.D.

83 ACE Score vs.unintended Pregnancy or Elective Abortion % hav ve Uninten nded PG, o r AB Unintended Pregnancy Elective Abortion or more ACE Score

84 Evidence from ACE Study Suggests: Adverse Childhood Experiences determine the likelihood of the ten most common causes of death in the United States. Top 10 Risk Factors: smoking, severe obesity, physical inactivity, depression, suicide attempt, alcoholism, illicit drug use, injected drug use, 50+ sexual partners, h/o STD. Vincent J. Felitti, M.D. Robert F. Anda, M.D.

85 With an ACE Score of 0, the majority of adults have few, if any, risk factors for these diseases.

86 However, with an ACE Score of 4 or more, the majority of adults have multiple risk factors for these diseases or the diseases themselves.

87 The risk factors underlying these adult diseases are effective coping devices.

88 Death Early Death Disease, Disability Adoption of Health-risk Behaviors Social, Emotional, & Cognitive Impairment Adverse Childhood d Experiences i Birth The Influence of Adverse Childhood Experiences Throughout Life

89 Evidence from ACE Study Suggests: Adverse childhood experiences are the most basic cause of health risk behaviors, morbidity, disability, mortality, and healthcare costs. Web site: Vincent J. Felitti, M.D. Robert F. Anda, M.D.

90 Childhood Trauma is: Single greatest preventable cause of mental illness Single greatest preventable cause of drug and alcohol abuse in women Single greatest preventable cause of HIV high-risk behavior (IV drugs, promiscuity) Significant contributor to leading causes of death (heart disease, cancer, stroke, diabetes, suicide) OhioCanDo4Kids.Org

91 The Message to Juvenile Justice Screening tools exist that enable us to find out if trauma is negatively affecting a child s behavior If it is a factor, evidence based treatment is available On an out-patient basis At a reasonable cost Limited to only 12 to 16 weeks Produces positive results

92 Treatment Improvements Children & Adolescents in the Clinical Range: Baseline & Last Follow up Behavioral Problems * (n=8880) CBCL >63 Briggs-King, E., (June 29 th, 2011) *p.0001 CDS September 2010

93 Resources About Trauma and Trauma Treatment National Child Traumatic Stress Network ( National Center for Trauma Informed Care ( Child Trauma Academy ( CARES Institute Child Abuse Research Education Service (

94 Resources About Trauma and Trauma Treatment Center for Traumatic Stress in Children and Adolescents Allegheny General Hospital ( hild National Institute for Trauma and Loss in Children ( Advanced Trauma solutions ( net) International Society for Traumatic Stress Studies (