Ct assessing and treating violent youth
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Ct assessing and treating violent youth

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Assessing and managing risk for violence among juveniles is an important forensic task. Clinical judgement is never sufficient for this important job. This presentation outlines methods of......

Assessing and managing risk for violence among juveniles is an important forensic task. Clinical judgement is never sufficient for this important job. This presentation outlines methods of assessing and managing risk of violence among young people.

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  • 1. Assessment Of Highly Complex Cases Dr. Kathy Seifert k.seifert@espsmd.com
  • 2. ASSESSMENT Targets of Assessment Types of Assessment Assessments inform treatment
  • 3. OBJECTIVES 1. Participants will be able to state the purposes of the three levels of assessment. 2. Participants will be able to name 2 assessments for risk of dangerousness to others 3. Participants will be able to name 5 risk factors for violence 4. Participants will be able to explain how assessments can inform treatment
  • 4. THREE LEVELS OF ASSESSMENT – LEVEL 1 1) Initial screening with a psycho-social interview and review of records using an Integrated Health Model 1) Be logical and systematic about your assessment 2) Define Types of problems across domains - physical, mental, family, school, substance abuse, environment, stressors 3) Look at information from a variety of psychological paradigms 4) Assess level of severity and acuteness 5) List strengths of youth and family 6) Be culturally sensitive 7) Assess for smoking, weight, exercise, physical symptoms, family history of chronic disease and refer to MD when needed. 8) Determine need for further assessment and treatment needs
  • 5. ASSESSMENT LEVEL 2 If there are problems, a more in depth assessment is needed in that area. Areas might include Behavioral health, substance abuse, physical health, cognitive health, safety 1. Get information from other systems, such as schools, when you can 2. Assessment may be done by a specialist in that area 3. Be methodical and organized 4. Assessment should determine types and intensity of treatment 5. A variety of tools are available
  • 6. ASSESSMENT LEVEL 3 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 possible 2. Psychological Testing may be needed 3. Interventions that meet the needs of the client and his or her family 4. Safety must be the number 1 priority. You cannot help children if they are not safe. 1. Dangerousness 2. Suicidality 3. Domestic violence
  • 7. DANGER TO SELF Suicide Risk vs. Self Harm
  • 8. DANGER TO SELF  Assessment of suicidal risk is complex  “the assessment of suicidal risk should be made and documented with frequency during ongoing treatment, especially at times of impending transition, heightened stress, or changes in environmental supports.”  Berman, Alan L. Jobes, David A. Silverman, Morton M. , (2006). Adolescent suicide: Assessment and intervention (2nd ed.)., (pp. 119-167). Washington, DC, US: American Psychological Association, ix, 456 pp. doi: 10.1037/11285-009
  • 9. TREATMENT  "one-size treatment" does not fit all – Berman, et al.  using more treatment options in a synthesized manner is superior to rigidly adhering to only one or two approaches – Berman, et al.
  • 10. SAFE-T  http://store.samhsa.gov/product/Suicide-Assessment-Five-Step- Evaluation-and-Triage-SAFE-T-/SMA09-4432  Assess Risk factors, especially those that can be changed  Assess resiliency factors especially those that can be increased  Conduct suicide inquiry  Determine risk level and intervention  Document
  • 11. ONTARIO HOSPITAL ASSOCIATION GUIDEBOOK  http://www.oha.com/KnowledgeCentre/Documents/Final%20%20Sui cide%20Risk%20Assessment%20Guidebook.pdf  Each client is assessed for risk of suicide at regular intervals, or as needs change  Clients at risk of suicide are identified  Client’s immediate safety needs are addressed  Treatment and monitoring strategies to ensure client safety are implemented  Treatment and monitoring strategies are documented in the client’s health record
  • 12. SELF-INJURY  Attempt to Cope with internal or external stressors  Generating endorphins  Managing emotions  Eliciting response from environment  Trigger dissociative state  Treatment issue based on the function of the behavior
  • 13. DANGER TO OTHERS  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
  • 14. BASIC PRINCIPLES OF ASSESSMENT LEVEL 3 (VERY COMPLEX CASES)  Assess for dangerousness: Domestic Violence, Abuse, risk of violence, risk of sexual offending, and suicidality and 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)  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.  Assess systems for cooperation, communication, and mutual support  Determine types and levels of treatment needed
  • 15. Instrument Risk of Violence Ages Case Manag ement Can be Administe red Unaided Clinical Judgement r =.12; AUC =.51 Any No NA Many studies SAVRY (Handbook of Violence Risk Assessment By Randy K Otto) R = .56- .67; AUC = .77-.80 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 6-18 Yes Hand or online Risk and Needs; 1,026 males and females, ages 6-18 LS-CMI (Int J Offender Ther Comp Criminol. 2012 Feb;56(1):113-33. Epub 2011 Feb 13) r = .39; AUC = .75 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 .50 females 12- 18 No Hand Measure of Psychopathic traits (Kosson, et. al. Psychol Assess. 2002 Mar;14(1):97- 109.)
  • 16. SAVRY http://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.
  • 17. LS-CMI – TREATMENT PLANNING FOR DELINQUENCY 1. 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.
  • 18. CARE2 http://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)
  • 20. CARE2 4 NORMS  Male/female  Pre-teen/Teen  Mark all that apply  Items with scores are added and resiliency scores subtracted  risk scale are statistically derived on a sample of 1000+ youth and studies of subsets  Evidence based intervention plans
  • 21. HISTORICAL FACTORS  Past behavior problems  Past Assaults  Chronicity  Severity  Escape from custody  Firesetting  Harmed  Animals  Early behavior problems  Enuresis  Delinquency
  • 22. RECENT MENTAL HEALTH AND BEHAVIORAL HEALTH ISSUES  Anger management  Runaway  Lacks remorse  Poor problem solving  Belief in the legitimacy of aggression  Social skill deficits  Bullying behavior  Deviant peer group  Limited association with pro-social peers  Paranoia  IQ below 80
  • 23. RECENT MENTAL HEALTH AND BEHAVIORAL HEALTH ISSUES II  School problems  Risk for placement  Impulsive  Emotions poorly regulated  Psychosis  Self-harm
  • 24. RESILIENCY FACTORS  Average or better IQ  Positive experiences with caregivers  Positive school experience  Lack of untreated psychiatric or substance abuse problems in caregivers  Positive future goals  Positive activities  Effective treatment  Pro-social peers  Modulates emotions well  Takes medication as prescribed
  • 25. HISTORICAL FACTORS II  Attachment problems  Abuse and neglect  Family violence, abuse, neglect, or criminality  Parental insufficientcy  Parental absense  Bullying
  • 26. HISTORICAL SUBSTANCE ABUSE & NEUROLOGICAL PROBLEMS  Substance abuse  Neurological  Mental health
  • 27. PCL-YV http://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
  • 28. SAVRY – BORUM, BARTEL, FORTH  The SAVRY is composed of 24 items in three risk domains (Historical Risk Factors, Social/Contextual Risk Factors, and Individual/Clinical Factors), drawn from existing research and the professional literature on adolescent development as well as on violence and aggression in youth. Not designed to be a formal test or scale, there are no assigned numerical values nor are there any specified cutoff scores. Based on the structured professional judgment (SPJ) model, the SAVRY helps you structure an assessment so that important factors will be emphasized when you formulate a final professional judgment about a youth’s level of risk.  http://www4.parinc.com/Products/Product.aspx?ProductID=SAVRY  Ages 12 – 18
  • 29. SAVRY ITEMS SIMILAR ON 4 SCALES Risk Item/Factors Items/Factors included in the SAVRY Historical Risk Factors - History of Violence - History of Nonviolent Offending - Early initiation of Violence - Past Supervision/Intervention Failures - History of Self-Harm or Suicide Attempts - Exposure to Violence in the Home - Childhood History of Maltreatment - Parental/Caregiver Criminality - Early Caregiver Disruption - Poor School Achievement
  • 30. SAVRY ITEMS 2 Social and Contextual Risk Factors - Delinquency - Peer Rejection - Stress and Poor Coping - Poor Parental Management - Lack of Personal/Social Support - Community Disorganization Individual/Clinical Risk Factors - Negative Attitudes - Risk Taking/Impulsivity - Substance-Use Difficulties - Anger Management Problems - Low Empathy/Remorse - Attention Deficit/Hyperactivity Difficulties - Poor Compliance - Low Interest/Commitment to School
  • 31. SAVRY ITEMS – PROTECTIVE FACTORS Protective Factors - Prosocial Involvement - Strong Social Support - Strong Attachments and Bonds - Positive Attitude Toward Intervention and Authority - Strong Commitment to School - Resilient Personality Traits
  • 33. 6 CORE CONCEPTS OF CHILD DEVELOPMENT  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)  Skill building usually follows developmental sequences and be taught within the context of a healthy, nurturing, dependable relationship.  Attachment experiences (good, bad, or ugly) and trauma change the brain.
  • 34. CHILD DEVELOPMENT - 2  Corrective developmental experiences and healthy relationships can also 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.
  • 35. WHAT DEVELOPMENTAL AREAS ARE AFFECTED BY TRAUMA  Problem solving  Self management  Moral reasoning  Logic  Affect regulation  Interpersonal relatedness  Task behavior  Concentration  Impulsivity  Effective Communication
  • 37. Trauma Negatively Affects Moral Development, Kohlberg, 1969 (Expanded from Piaget) Can be blocked by Trauma Can be blocked by Trauma Can be blocked by Trauma
  • 38. ERIKSON’S STAGES • 1 Hopes: Trust vs. Mistrust (Oral-sensory, Birth-2 years) (Safe Base) • 1.2 Will: Autonomy vs. Shame & Doubt (Muscular- Anal, 2-4 years) (Exploration from Safe Base) • 1.3 Purpose: Initiative vs. Guilt (Locomotor-Genital, Preschool, 4-5 years) (I can do things on my own) • 1.4 Competence: Industry vs. Inferiority (Latency, 5- 12 years) (I am Competent) • 1.5 Fidelity: Identity vs. Role Confusion (Adolescence, 13-19 years) (Who am I?) • 1.6 Love: Intimacy vs. Isolation (Young adulthood, 20-24) (Establishing a family/ career)
  • 40. ASSESS WHERE A CHILD IS ON A DEVELOPMENTAL SCALE  Many are at immediate gratification and seeking a safe base.  Immediate gratification and needs of the self are primary  Must learn perspective taking and reciprocity before empathy  If the youth is still seeking a safe base, that must be established before exploration of the world and information gathering  A safe environment is essential for healthy development  You need some type of developmental guide for use in your treatment plan
  • 41. ASSESSMENT OF CHILDREN – LEVEL 3 Level 3 is for children and teens with severe behavioral disturbances.  8 Symptom Categories  Traumatized Brain  3 or 4 Attachment Patterns  Holistic Assessment and Treatment Practices  Assessing Development Using the BOS
  • 42. LEVEL 3. 8 SYMPTOM CATEGORIES OF DTD/CPTSD/RAD – PAST & PRESENT; FREQUENCY, DURATION, AND SEVERITY. WHAT OTHER DISORDERS HAVE THESE SYMPTOMS?  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
  • 44. 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.
  • 45. SYMPTOMS - 4  Physical - failure to thrive, poor hygiene, tactilely defensive, enuresis & encopresis, accident prone, high pain tolerance,  Moral/Spiritual – lack faith, compassion, remorse, pro- social values, identification with evil or the “dark side”  Development - delayed development  Core Beliefs/Internal Working Model of self, others, and world is Negative
  • 46. HOLISTIC ASSESSMENT PRACTICES  Measure all areas of strengths, stressors, and symptoms for youth and family  Anything you change within the system will affect other subsystems, but try to affect as many areas as possible
  • 47. THE BEHAVIOR OBJECTIVE SEQUENCE  By Sheldon Braatan  A developmentally sequenced group of skills in 6 Domains.  Age is not the determiner of skill level  Youth must learn skills in appropriate developmental sequence.  Find out at what level they have mastered skills (can do it 90% of the time without prompting)
  • 48. ADAPTIVE SKILLS Responds in a developmentally appropriate manner to rules and expectations AND Changes those responses as the circumstances change Example I expect a __ year old to walk into the counseling office and be able hold a conversation with the counselor AND when the format is changed to group therapy, the youth is able to adapt to the different format and relate to peers in the group, not just counselor.
  • 49. Adaptive: Responds appropriately to routine and new expectations respond independently to materials for amusement appear alert and able to focus attention bring no weapons to school use amusement materials appropriately wait for turn without physical intervention use and return equipment without abuse accept positive physical contact touch others in appropriate ways refrain from stealing respond when angry without hitting recognize and show regard for possessions accept verbal cue for removal from a situation respond when angry without abuse of property respond appropriately to substitute respond when angry without threats walk to timeout without being moved by an adult work or play without disrupting others refrain from inappropriate behavior when others lose control respond to provocation with self-control respond when angry with self-removal
  • 50. SELF-MANAGEMENT SKILLS Responds appropriately to challenging experiences with self-control in order to achieve success  (E) Appear alert and able to focus attention on activities  Wait or take turns when directed without physical intervention – verbal prompts may be use  Respond when angry without verbal threats or intent to harm  (M) Seek adult help in personal and/or group crisis  Maintain personal control and routinely comply with established procedures in group situations without reminders.  (H) Maintain self-control when faced with disappointment, frustration, or failure without adult intervention.  Obey new or temporary authority figure, without presence of other permanent staff
  • 51. COMMUNICATION  Ability to share with and receive information from other people to meet a need or affect another person in a positive way.  Speak using a volume appropriate to the situation  Wait until a speaker is finished before responding  Express feelings about self or others to an adult appropriately  Spontaneously participate in group discussions  Maintain appropriate social distance when speaking to another  Speak courteously to others, using appropriate references, with no cues.  Describe personal strengths that will enable success
  • 52. INTERPERSONAL BEHAVIORS  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
  • 53. TASK BEHAVIORS  Student engages in task or activity with or without assistance  Accept assistance from an adult on academic tasks  Refrain from inappropriate behavior when asked by an adult to correct errors  Complete daily assignments  Choose and actively participate in elective classes  Ignore distractions of others while working  Self-chart progress in reading or math  Participate in structured role-playing activities  Complete and turn in assigned homework when due
  • 54. PERSONAL BEHAVIORS  Student engages in a counseling dialogue with a helping person, permitting adult to help resolve issues or solve problems or build self esteem.  Express negative feelings to an adult  Follow through with specific directions from an adult to modify behavior in a given situation  Participate in determining a short term plan for dealing with an immediate situation  Attend to a peer when a peer is speaking  Express feelings about self to peers  Seek counseling t avoid conflict  Contribute to group rule making and consequences  Verbally demonstrate knowledge of alternative coping strategies for managing stress
  • 56. PARENTS  Attachment/trauma history  Awareness of Emotional & Environment Triggers  Parenting Attitudes and Competencies  The child needs a loving home with nurturing, affection, routine, structure and boundaries.  There are skills to learn about anger management, reframing the meaning of behaviors, teaching, rather than punishing  Parent Mental Health, Substance Abuse, Offending Behavior, Dangerousness & Stability  Parents must take care of their mental health to do this job effectively  Safety  Parenting knowledge and style  Parents need to learn about attachment and trauma and skills to help their children
  • 58. ASSESSMENT OF FAMILY SYSTEM  Family backgrounds  Families of origin  Marital relationship  Relationships among siblings and between children and parents  Structure – Family Systems Work  Ongoing Patterns (“family dance”)  Support Systems  Stressors and Stress Management  Rules, Roles, and Boundaries
  • 60. EVIDENCE BASED TREATMENT FOR COMPLEX CASES  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
  • 61. PROMISING PRACTICES  Trauma and attachment work  Routine and structure  Healthy, safe environments  Narrative Therapy
  • 63. BOS - Level 3 (skills typically mastered during preschool years): Focus: Self; Significance; Success Issues: Trust; Pleasure; Security; Support Interventions: Routines; Repetitions; Modeling; Concrete Rewards; Limit Setting; Consistent and Planned Consequences; Continuous Supervision Adult Role: “Benevolent Dictator”
  • 64. Level 2 (skills typically mastered during elementary years): Focus: Group membership; Competence; Sensitivity to Others; Awareness of Values; Communication Skills Issues: Applying Skills in Groups; Balancing Personal and Group Needs; Responding to New Settings and People; Managing Movement Interventions: Routines; Repetitions; Verbal Rewards; Limit Setting with Expanded Choices; Consistency with Group Consequences; Natural and Logical Consequences Adult Role: “Group Leader”
  • 65. Level 1 (skills typically mastered during adolescence and early adulthood): Focus: Belonging; Cooperation; Personal “Power,” Individualtion Issues: Applying Skills in New Situations; Expanding and Reinforcing Competencies; Transitions to New Environments Interventions: “Normal” Expectations; Social Rewards; Expanded Choices; Group Problem Solving; Self Selected Goals Adult Role: “Guide/Facilitator”
  • 66. SUMMARY  3 levels of assessment  Initial screening  Specialty assessment, ie. Addictions, trauma  Assessment for dangerousness and types and intensity of treatment  Assessment for dangerousness at Level 3  SAVRY & CARE2
  • 67. OTHER ASPECTS OF ASSESSMENT  Assessment of youth, family, family system  Developmental Assessment with BOS  Neurological Assessment  Medical Assessment  Educational Assessment  Assessment for intensity, longevity, and types of treatment – EBP and Promising Practice