Interventions for highly complex cases of Youth at Risk for Violence

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The interventions for youth at risk for violence is different than those for youth with minor to moderate problems. The services must include family and be more varied and intensive than traditional …

The interventions for youth at risk for violence is different than those for youth with minor to moderate problems. The services must include family and be more varied and intensive than traditional mental health services. The teaching of developmental skills is also important.

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  • 1. EBP for Highly Complex Cases Dr. Kathy Seifert k.seifert@espsmd.com http://care2systems.com
  • 2. Targets of Interventions Types of Interventions Intensity of Interventions
  • 3. objectives 1. Participants will be able to name 5 risk factors for violence 2. Participants will be able to name 2 EBP for Highly Complex Cases
  • 4. Suicide Risk vs. Self Harm Danger to self
  • 5. "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. Treatment
  • 6. 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
  • 7. 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 Danger to Others
  • 8. Interventions must provide 1.Healthy, safe environment 2.Healthy developmental experiences Trauma Interferes with Child Development
  • 9. 6 Core Concepts of Child Development o 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 best within the context of a healthy, nurturing, dependable relationship. o Attachment experiences (good, bad, or ugly) and trauma change the brain.
  • 10. 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. Child development - 2
  • 11. What Developmental areas may need intervention o Problem solving o Self management o Moral reasoning o Logic o Affect regulation o Interpersonal relatedness o Task behavior o Concentration o Impulsivity o Effective Communication
  • 12. 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)
  • 13. Erikson’s Stages o 1 Hopes: Trust vs. Mistrust (Oral-sensory, Birth-2 years) (Safe Base) o 1.2 Will: Autonomy vs. Shame & Doubt (Muscular-Anal, 2-4 years) (Exploration from Safe Base) o 1.3 Purpose: Initiative vs. Guilt (Locomotor-Genital, Preschool, 4-5 years) (I can do things on my own) o 1.4 Competence: Industry vs. Inferiority (Latency, 5-12 years) (I am Competent) o 1.5 Fidelity: Identity vs. Role Confusion (Adolescence, 13-19 years) (Who am I?) o 1.6 Love: Intimacy vs. Isolation (Young adulthood, 20-24) (Establishing a family/ career)
  • 14. Trauma can interrupt the sequences of development
  • 15. Promising Practices o Trauma and attachment work o Routine and structure o Healthy, safe environments o Narrative Therapy o Change to an Empowerment Ending to the Story
  • 16. Provide interventions that match the child’s developmental level. o Many severely traumatized children are at the immediate gratification stage of development and are seeking a safe base. o Immediate gratification and needs of the self are primary o Must learn perspective taking and reciprocity before empathy o 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 development o You need some type of developmental guide for use in your treatment plan
  • 17. The Behavior Objective Sequence o By Sheldon Braatan o A developmentally sequenced group of skills in 6 Domains. o Age is not the determiner of skill level o Provide interventions on the child’s level of development o 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)
  • 18. 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.
  • 19. 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
  • 20. 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 activities o Wait or take turns when directed without physical intervention – verbal prompts may be use o Respond when angry without verbal threats or intent to harm o (M) Seek adult help in personal and/or group crisis o 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
  • 21. 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 situation o Wait until a speaker is finished before responding o Express feelings about self or others to an adult appropriately o Spontaneously participate in group discussions o Maintain appropriate social distance when speaking to another o Speak courteously to others, using appropriate references, with no cues. o Describe personal strengths that will enable success
  • 22. 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
  • 23. Task Behaviors o Student engages in task or activity with or without assistance o Accept assistance from an adult on academic tasks o Refrain from inappropriate behavior when asked by an adult to correct errors o Complete daily assignments o Choose and actively participate in elective classes o Ignore distractions of others while working o Self-chart progress in reading or math o Participate in structured role-playing activities o Complete and turn in assigned homework when due
  • 24. 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 adult o Follow through with specific directions from an adult to modify behavior in a given situation o Participate in determining a short term plan for dealing with an immediate situation o Attend to a peer when a peer is speaking o Express feelings about self to peers o Seek counseling t avoid conflict o Contribute to group rule making and consequences o Verbally demonstrate knowledge of alternative coping strategies for managing stress
  • 25. 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”
  • 26. 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”
  • 27. 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”