School based mental health workshop: assessing and treating violent youth

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School based mental health workshop: assessing and treating violent youth

  1. 1. Assessment, Prevention, and Treatment of Youth Violence Dr. Kathy Seifert k.seifert@espsmd.com
  2. 2. How much School Violence is in the US? o US o 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)
  3. 3. RISK FACTORS FOR YOUTH VIOLENCE The more chronic and severe the risk factors the higher the risk for future violence.
  4. 4. 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).
  5. 5. Historical Risk Factors for Youth Violence o Past behavior problems o Past Assaults o Chronicity o Severity o Escape from custody o Fire setting o Harmed Animals o Early behavior problems o Enuresis o Delinquency
  6. 6. Recent mental health and behavioral health issues o Anger management o Runaway o Lacks remorse o Poor problem solving o Belief in the legitimacy of aggression o Social skill deficits o Bullying behavior o Deviant peer group o Limited association with pro-social peers o Paranoia o IQ below 80
  7. 7. Recent mental health and behavioral health issues II o School problems o Risk for placement o Impulsive o Emotions poorly regulated o Psychosis or autistic (usually high IQ) o Self-harm
  8. 8. Historical Factors II o Attachment problems o Abuse and neglect o Family violence, abuse, neglect, or criminality o Parental insufficientcy o Parental absense o Bullying
  9. 9. Historical Substance Abuse & Neurological Problems o Substance abuse o Neurological o Mental health
  10. 10. Resiliency factors o Average or better IQ o Positive experiences with caregivers o Positive school experience o Lack of untreated psychiatric or substance abuse problems in caregivers o Positive future goals o Positive activities o Effective treatment o Pro-social peers o Modulates emotions well o Takes medication as prescribed
  11. 11. Child Development
  12. 12. 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
  13. 13. What Developmental areas are affected by trauma 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
  14. 14. 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)
  15. 15. Targets of Assessment Types of Assessment Assessments inform treatment Assessment
  16. 16. 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
  17. 17. 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 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
  18. 18. Suicide Risk vs. Self Harm Assessment of Danger to self
  19. 19. Assess o Assess Risk factors, especially those that can be changed o Assess resiliency factors especially those that can be increased o Conduct suicide inquiry o Determine risk level and intervention o Document
  20. 20. 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
  21. 21. Basic Principles of Assessment of Very Complex, High Risk Cases o 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 support o Determine types and levels of treatment needed (dosage)
  22. 22. Instrument Risk of Violence Age s Case Manag ement Can be Administ ered 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.)
  23. 23. 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.
  24. 24. LS-CMI – Treatment Planning for Delinquency 1. LS-CMI http://www.mhs.com/product.aspx?gr=saf&pr od=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.
  25. 25. PCL-YV http://www.mhs.com/product.aspx?gr=edu&prod=pclyv&id=overvi ew (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
  26. 26. 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)
  27. 27. Developmental Assessment
  28. 28. 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 within the context of a healthy, nurturing, dependable relationship. o Attachment experiences (good, bad, or ugly) and trauma change the brain.
  29. 29. Trauma can interrupt the sequences of development
  30. 30. Assess where a child is on a developmental scale o Many are at immediate gratification and 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
  31. 31. Assessment of High Risk Children o 8 Symptom Categories o Traumatized Brain o 3 or 4 Attachment Patterns o Holistic Assessment and Treatment Practices o Assessing Development Using the BOS
  32. 32. 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?
  33. 33. symptoms – 2. thoughts – negative beliefs about others and relationships, lacks cause and effect thinking, attention & learning problems negative beliefs about self
  34. 34. 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.
  35. 35. 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 development o Core Beliefs/Internal Working Model of self, others, and world is Negative
  36. 36. 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 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)
  37. 37. 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
  38. 38. 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
  39. 39. 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
  40. 40. 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
  41. 41. 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
  42. 42. 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
  43. 43. Assessing parents
  44. 44. Parents o Attachment/trauma history o Awareness of Emotional & Environment Triggers o 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 & Stability o Parents must take care of their mental health to do this job effectively o Safety of the home
  45. 45. Assessment of Family System o Family backgrounds o Families of origin o Marital relationship o Relationships among siblings and between children and parents o Structure – Family Systems Work o Ongoing Patterns (“family dance”) o Support Systems o Stressors and Stress Management o Rules, Roles, and Boundaries
  46. 46. PREVENTION
  47. 47. PROVEN EFFECTIVE PREVENTION o Head Start with Family Involvement o Healthy Families o Early detection and treatment o Ending child abuse, neglect and domestic violence
  48. 48. Interventions
  49. 49. 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
  50. 50. Developmental Interventions with BOS PROMISING PRACTICE
  51. 51. Questions and Answers

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