Breaking the Cycle of Violence

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Presentation by Daniel Flannery, Ph.D. given at the 2010 RWJF LFP Annual Meeting in St. Paul, MN

This presentation will present recent research on the links between brain development and neurochemistry, mental health and violence. We will compare traditional treatment programs that focus separately on perpetrators, victims and witnesses with examples of specific, innovative, multi-systemic treatment models that providers have employed in an attempt to break the cycle of violence. Our discussion will revolve around several video vignettes and principles of Trauma-Informed care.

Participants will address the challenges of pilot-tested, “evidence-based practice” versus the “practice-based evidence” of community programs. Treatment challenges related to co-morbid functioning of high-risk individuals will be discussed including substance use, offending, mental health, family functioning and academic achievement. Examples of specific innovative treatment models and local and national data on multi-system involved youth and intervention outcomes will be provided. We will also consider the difficulties and benefits of working in collaborative, community-based coalitions to effect change and how this movement has been affected by policy, resources, and increased demands for accountability.

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  • A high percentage (over half) of all SCY youth scored above clinical on General Mental Distress, Depressive Symptoms, Behavior Complexity, and Conduct Disorder indices…A significantly higher proportion of females than males scored above clinical on the Internal Mental Distress, General Mental Distress, Somatic Symptoms, Depressive Symptoms, Homicidal-Suicidal Thought, Anxiety Symptoms, Traumatic Stress, and Hyperactivity Disorder indices.
  • N=186; Males=153, Females=33
  • For the period November 2008 through May 2010, 159 youth were enrolled in the YFCP program 142 youth and their caregivers (89.3%) consented to participate in the research study On average, there were 7.5 enrollments per month
  • Grouped by ORC
  • Data obtained from Plans of Care in Synthesis via Care Coordination Data only available for 121 youth; of these, 115 had an Axis I diagnosis
  • Scores of 3 or more on any subscale indicate a probable disorder in that area
  • Breaking the Cycle of Violence

    1. 1. Breaking the intergenerational cycle of violence Daniel J. Flannery, PhD Professor of Social and Behavioral Sciences College of Public Health Kent State University Robert Wood Johnson Foundation October, 2010
    2. 2. Workshop overview <ul><li>What is the cycle of violence? </li></ul><ul><li>Violence and the brain </li></ul><ul><li>Violence and mental health </li></ul><ul><li>Research on the intergenerational cycle of violence </li></ul><ul><li>Interventions to break the cycle </li></ul><ul><ul><li>Trauma Informed Care </li></ul></ul><ul><ul><li>Other evidence-based treatments </li></ul></ul><ul><li>Policy and practice </li></ul><ul><li>Discussion </li></ul>
    3. 3. Defining the cycle <ul><li>Is childhood exposure related to increased risk for adult perpetration of violence? </li></ul><ul><ul><li>Violence as learned social behavior </li></ul></ul><ul><ul><li>Exposure as witness or victim </li></ul></ul><ul><ul><li>Mental health consequences and trauma </li></ul></ul><ul><ul><li>Impact of violence on the brain </li></ul></ul><ul><ul><li>Co-morbid difficulties related to long-term outcomes </li></ul></ul>
    4. 4. HOW ARE WE SOCIALIZED? <ul><li>DESIRE FOR… affection </li></ul><ul><li>acceptance </li></ul><ul><li>recognition </li></ul><ul><li>positive regard </li></ul><ul><li>AVOID UNPLEASANT EFFECTS OF </li></ul><ul><li>IMITATE THE OF OTHERS </li></ul><ul><li>IDENTIFICATION: Be like people we </li></ul>REJECTION AND PUNISHMENT respect, admire, love.
    5. 5. 1. Punish inconsistently, but frequently and ineffectively. 2. Attend to and reward inappropriate child behavior. 3. Reinforce extremely coercive and aversive child behavior. PARENTS OF AGGRESSIVE KIDS 4. Fail to adequately reinforce prosocial behaviors.
    6. 6. Violence and the brain <ul><li>Hormones </li></ul><ul><li>Neurochemistry </li></ul><ul><li>Structure and function </li></ul><ul><li>Long-term impact </li></ul>
    7. 8. What makes the brain so important? <ul><li>Genes x environment </li></ul><ul><li>Use it or lose it – pruning away the connections </li></ul><ul><li>Critical periods are critical </li></ul><ul><li>The brain continues to grow through our 20s </li></ul><ul><li>Experience can change the structure of the brain </li></ul><ul><li>Chemicals and hormones </li></ul>
    8. 9. Important hormones in the brain <ul><li>Serotonin </li></ul><ul><ul><ul><li>5HTT </li></ul></ul></ul><ul><ul><ul><li>Mood and depression </li></ul></ul></ul><ul><li>Dopamine </li></ul><ul><ul><ul><li>Regulating emotions </li></ul></ul></ul><ul><ul><ul><li>Propensity for aggression and violence </li></ul></ul></ul><ul><li>Cortisol </li></ul><ul><ul><ul><li>Stress reactions </li></ul></ul></ul><ul><li>CRF (corticotrophin releasing factor) </li></ul>
    9. 11. Bodily Effects of “Stress Drugs”– fight or flight? <ul><li>Increased heart rate </li></ul><ul><li>Increased blood flow to the muscles and brain </li></ul><ul><li>Decreased blood flow to the skin and gut </li></ul><ul><li>Liver produces extra glucose to fuel defensive responses (adrenaline rush) </li></ul><ul><li>Vigilance, arousal and narrowing of attention in the brain </li></ul><ul><li>Formation of traumatic memories </li></ul>
    10. 12. Violence and mental health <ul><li>Risk and protective factors </li></ul><ul><li>Witness ► Victim ► Perpetrator </li></ul><ul><li>Mental health and trauma </li></ul><ul><li>Survey data </li></ul>
    11. 14. Birth Proposed Developmental Sequence of Violent Behavior Potential Points of Intervention Preschool Elementary School Adolescence Daniel J. Flannery (1997) School Violence: Risk, Preventive Intervention, And Policy ERIC Clearinghouse on Urban Education, Urban Diversity Series No. 109 Neurological Deficits Exposure to Violence Chronic Victimization Temperment Attachment Oppositional Behavior Aggressive Behavior Poor Impulse Control ADHD Perinatal Risk Low Birth Weight ___________ Parental Antisocial Family Management Cognitive Attributional Problems Peer Rejection Poor Social Skills Peer Problems Academic Problems Gang Activity Delinquent Behavior Violent Behavior
    12. 15. Policy Law Enforcement Systems Mental Health Labor/ Aftercare Child&Family Services Individual Family School Neighborhood Community Juvenile Justice Education
    13. 16. SAMPLE CHARACTERISTICS
    14. 17. VIOLENT BEHAVIOR ARIZONA ELEMENTARY OHIO ELEM./ MIDDLE OHIO/COLORADO HIGH SCHOOL * Within past year
    15. 18. PERCENTAGES OF STUDENTS WITNESSING VIOLENCE WITHIN THE PAST YEAR BY GENDER, GRADES 3-8
    16. 19. PERCENTAGES OF STUDENTS VICTIMIZED BY VIOLENCE WITHIN THE PAST YEAR BY GENDER
    17. 20. HIERARCHICAL REGRESSION ON VIOLENT BEHAVIOR, GRADES 3-8
    18. 21. PERCENT CLINICAL RANGE OF PTSD SYMPTOMS BY LEVEL OF SCHOOL VIOLENCE Source: Flannery, D. (1997). School Violence: Risk Preventive Intervention & Policy. Monograph for the Institute of Urban and Minority Education, Columbia University and the Eric Clearinghouse.
    19. 24. LOCATION: SMALL CITY (18.2%), SUBURBAN (2.7%), URBAN (79.1%) SAMPLE CHARACTERISTICS FAMILY STRUCTURE: SINGLE PARENT (49.2%), TWO PARENT (50.8%) AGE: 14-19 YEARS OLD DANGEROUSY VIOLENT MATCHED CONTROLS
    20. 27. PERCENTAGE OF ADOLESCENTS USING EACH COPING STRATEGY AT LEAST SOMETIMES
    21. 28. Research on the cycle <ul><li>Increased risk of violence perpetration as adolescents and as adults: </li></ul><ul><ul><li>Child abuse victimization </li></ul></ul><ul><ul><li>Exposure to interparental violence (IPV) </li></ul></ul><ul><ul><li>Genetic and personality factors (criminogenic) </li></ul></ul><ul><li>Link mediated by trauma symptoms, PTSD </li></ul><ul><li>Some gender differences but overall risk high </li></ul><ul><li>Not all children who grow up in abusive families become violent adults </li></ul>
    22. 29. Treatment issues <ul><li>Multi-systemic involvement and collaboration </li></ul><ul><li>Mental health issues/ trauma </li></ul><ul><li>Offending </li></ul><ul><li>Substance use/abuse </li></ul><ul><li>Academic failure </li></ul><ul><li>Family/ parenting/ coercive styles </li></ul><ul><li>Parent mental health and functioning </li></ul>
    23. 30. What constitutes evidence-based best practice? <ul><li>Scientific base (theory and research) </li></ul><ul><li>Behavior based outcomes </li></ul><ul><ul><li>Statistically significant </li></ul></ul><ul><ul><li>Effect sizes </li></ul></ul><ul><ul><li>Practical and clinical significance </li></ul></ul><ul><li>Implemented with fidelity </li></ul><ul><li>Taking to scale/ generalizability </li></ul><ul><li>Practice-based evidence </li></ul>
    24. 31. Interventions to break the cycle <ul><li>Trauma-informed care </li></ul><ul><li>TF-CBT </li></ul><ul><li>Hi fidelity wraparound services </li></ul><ul><li>System of Care models </li></ul><ul><li>Behavioral health/ juvenile justice </li></ul><ul><li>Youth and Family Community Partnerships </li></ul><ul><li>Children Who Witness Violence </li></ul>
    25. 32. Interventions for child trauma <ul><li>Has two criteria: </li></ul><ul><li>Well established : At least two-group design studies in which the intervention was either superior or equivalent to another intervention. </li></ul><ul><li>Probably efficacious :Two studies with superior results over no-treatment control, or two-group designs. </li></ul>
    26. 33. WELL-ESTABLISHED AND PROBABLY EFFICACIOUS INTERVENTIONS FOR CHILD TRAUMA Intervention Age Group Research Design Main Findings Adapted CBT(Cognitive Behavioral Therapy) models for physical and sexual abuse* 4-18 years 10 randomized trials 4 quasi experimental <ul><li>Improvement in child PTSD, depression, anxiety, behavior problems, and feelings of shame and mistrust </li></ul><ul><li>Decreased parental PTSD, depression and emotional distress about the child’s abuse </li></ul><ul><li>Decreased parent use of physical discipline and parent anger problems </li></ul><ul><li>Decreased family conflict </li></ul>Parent-Child Interaction Therapy (PCIT)* 4-12 years 1 randomized trial 4 quasi experimental <ul><li>Decreased parent physical abuse </li></ul><ul><li>Reduced negative parent-child interactions </li></ul><ul><li>Maintained effects at long term follow-up (3-6 years after treatment) </li></ul>Child-Parent Psychotherapy for Family Violence* Up to 5 years 4 randomized trials <ul><li>Decreased PTSD symptoms and behavior problems </li></ul><ul><li>Decreased maternal avoidance </li></ul>Cognitive Behavioral Intervention for Trauma in schools** 10-15 years 1 randomized trial 1 quasi experimental <ul><li>Improvement in PTSD and depressive symptoms </li></ul><ul><li>Maintained improvements at 6-month follow up </li></ul>Project 12-Ways/Safe Care for Child Neglect** Young Children 4 quasi experimental <ul><li>Improved skills in assertiveness and home management </li></ul><ul><li>Improved job skills </li></ul>
    27. 34. Trauma-informed care <ul><li>Treatment that incorporates: </li></ul><ul><li>An appreciation for the high prevalence of traumatic experiences in persons receiving services; and </li></ul><ul><li>a thorough understanding of the significant neurological, biological, psychological, and social effects of trauma and violence </li></ul>
    28. 35. Core components of trauma-informed care: assessment & treatment <ul><li>Safety </li></ul><ul><li>Self-regulation </li></ul><ul><li>Self-reflective information processing </li></ul><ul><li>Relational engagement </li></ul><ul><li>Positive affect enhancement </li></ul><ul><ul><li>A multi-system approach to interventions </li></ul></ul><ul><ul><li>A phase-based approach </li></ul></ul><ul><ul><li>Build strengths while reducing symptoms </li></ul></ul>
    29. 36. Creating a Trauma-informed child welfare system <ul><li>Maximize child’s sense of safety </li></ul><ul><li>Assess for trauma symptoms </li></ul><ul><li>Connect w/ providers to reduce emotions </li></ul><ul><li>Help child understand traumatic experience </li></ul><ul><li>Achieve control/ mastery of experiences </li></ul><ul><li>Address other behavioral/ MH problems </li></ul><ul><li>Support the family </li></ul><ul><li>Coordinate services among agencies </li></ul><ul><li>Workers manage own stress </li></ul>
    30. 37. Promising interventions in Ohio for high-risk youth <ul><li>CWWV </li></ul><ul><ul><li>Cuyahoga (Cleveland) and Summit (Akron) counties </li></ul></ul><ul><ul><li>Public housing </li></ul></ul><ul><li>Behavioral Health/ Juvenile Justice </li></ul><ul><li>Tapestry System of Care </li></ul><ul><li>Strengthening Community’s Youth (SCY) </li></ul><ul><li>Youth & Family Community Partnership (YFCP) </li></ul><ul><li>Integrated Co-occurring Treatment (ICT) </li></ul><ul><li>Trauma Informed Care </li></ul>
    31. 38. Justice Policy Institute <ul><li>Children are rarely screened for trauma, especially in the juvenile justice system </li></ul><ul><li>Children who experience trauma have disproportionate contact with the JJ system </li></ul><ul><li>The current justice system does not meet the needs of youth with trauma </li></ul><ul><li>Incarceration can be traumatic </li></ul><ul><li>Incarcerated youth do worse than those diverted to community-based treatment </li></ul>
    32. 39. Policy and practice in JJ <ul><li>Train workers to understand complex effects of trauma </li></ul><ul><li>Screen for and report trauma exposure </li></ul><ul><li>Thorough trauma assessment </li></ul><ul><li>Targeted prevention and early intervention </li></ul><ul><li>Specific evidence-based services for children who have experienced trauma </li></ul><ul><li>Avoid re-traumatizing youth </li></ul><ul><li>Consider trauma in sentencing and placement </li></ul>
    33. 40. Systems of Care <ul><li>Cuyahoga County, OH Tapestry </li></ul><ul><ul><li>High fidelity wrap around </li></ul></ul><ul><ul><li>MST </li></ul></ul><ul><ul><li>ICT </li></ul></ul><ul><ul><li>IHBT </li></ul></ul><ul><ul><li>SCY </li></ul></ul>
    34. 41. Mental Health Indices Notes: **A significantly higher proportion of females than males score in the “above clinical” range on scale, p<.01; *= p<.05 + Percentages calculated by total number of SCY youth (N=188) ^ Percentages calculated by total number of males (N=155) and total number of females (N=33) 1 One hundred eighty-six youth (154 males, 32 females) responded to questions on the Homicidal-Suicidal Thought, Attention Deficit- Hyperactivity Disorder, Inattentive Disorder, and Hyperactivity Disorder indices   Internal Mental Distress (IMD) General Mental Distress (IMD subscale) Somatic Symptoms (IMD subscale) Depressive Symptoms (IMD subscale) Homicidal-Suicidal Thought (IMD subscale) 1 Anxiety Symptoms (IMD subscale) Youth > Clinical+ 70 (37.2%) 105 (55.8%) 93 (49.5%) 120 (63.8%) 48 (25.8%) 78 (41.5%) Males > Clinical^ Females > Clinical^ 48 (31.0%) 22 (66.7%)** 80 (51.6%) 25 (75.7%)* 71 (45.8%) 22 (66.7%)* 92 (59.3%) 28 (84.8%)** 34 (22.2%) 14 (42.4%)* 58 (37.4%) 20 (60.6%)*   Traumatic Stress Behavior Complexity (BC) Attention Deficit Hyperactivity Disorder 1 (BC subscale) Inattentive Disorder 1 (BC subscale) Hyperactivity Disorder 1 (BC subscale) Conduct Disorder Youth > Clinical+ 63 (33.5%) 135 (71.8%) 100 (53.8%) 77 (41.4%) 30 (16.1%) 135 (71.8%) Males > Clinical^ Females > Clinical^ 45 (29.0%) 18 (54.5%)** 107 (69.0%) 28 (84.8%) 80 (51.9%) 20 (62.5%) 60 (38.9%) 17 (53.1%) 20 (13.0%) 10 (31.2%)* 108 (69.6%) 27 (81.8%)
    35. 42. Victimization <ul><li>Females scored significantly higher on the General Victimization Scale than males </li></ul><ul><li>A significantly higher proportion of youth scoring in the moderate-high victimization range (versus low range) were above clinical on all mental health indices ( p<.01) </li></ul>
    36. 43. The Behavioral Health/ Juvenile justice (BH/JJ) initiative in Ohio
    37. 44. <ul><li>The Behavioral Health/Juvenile Justice Initiative was developed by the Ohio Departments of Mental Health and Youth Services (ODMH & ODYS) to reduce the number of youth with mental health issues that were being sent to ODYS facilities. </li></ul><ul><ul><li>In lieu of detention, appropriate youth are referred to the BHJJ program for mental/behavioral health treatment. </li></ul></ul><ul><ul><li>Youth may be treated in the home, in outpatient settings, or in more intensive inpatient facilities. </li></ul></ul>What is BHJJ?
    38. 45. <ul><li>Participating counties must use an evidence-based treatment model, but are free to use the evidence-based treatment model that best suits the needs of the youth and families in the county. </li></ul><ul><ul><li>Types of EBP’s currently used: Multi-systemic Therapy (MST), Functional Family Therapy (FFT), Intensive Home-Based Therapy (IHBT), Integrated Co-Occurring Treatment (ICT), Hi-Fidelity Wraparound </li></ul></ul>What is BHJJ?
    39. 46. Youth and Family History (BHJJ) Females Males Has the child ever been physically abused? 23.2% 18.0% Has the child ever been sexually abused? 32.9% 5.7% Has the child ever lived in a household in which someone was convicted of a crime? 43.8% 37.7% Has the child ever run away? 54.7% 30.4% Has the child ever had a problem with substance abuse, including alcohol and/or drugs? 46.8% 39.4% Has the child ever talked about committing suicide? 51.5% 35.5% Has the child ever attempted suicide? 22.4% 8.3% Has the child ever been exposed to domestic violence or spousal abuse, of which the child was not the direct target? 48.9% 43.5% Has anyone in the child’s biological family ever been diagnosed with depression or shown signs of depression? 65.8% 58.9% Has anyone in the child’s biological family had a mental illness, other than depression? 43.2% 34.1% Has anyone in the child’s biological family had a drinking or drug problem? 69.4% 56.5%
    40. 47. Problems leading to BHJJ services Females Males Conduct/delinquency-related problems 92.7% 88.8% Substance use, abuse, dependence-related problems 41.8% 32.0% Depression-related problems 41.3% 19.7% School performance problems 44.7% 27.8% Hyperactive and attention-related problems 21.3% 20.2% Anxiety-related problems 18.7% 7.9% Adjustment-related problems 22.1% 5.9%
    41. 48. TSCC *All differences significant at the .05 level
    42. 49. Substance Use Over Time
    43. 50. <ul><li>BHJJ defines recidivism as a new charge (not a new adjudication) </li></ul><ul><ul><li>At 6 months after enrollment, 30% of the youth had a new charge </li></ul></ul><ul><ul><ul><li>18% misdemeanor and 5% felony (remainder were status/unruly) </li></ul></ul></ul><ul><ul><ul><li>Of the 30% with a new charge, only 18% were adjudicated delinquent </li></ul></ul></ul>BHJJ and Recidivism
    44. 51. <ul><ul><li>At 12 months after enrollment, 40% of the youth had a new charge </li></ul></ul><ul><ul><ul><li>26% misdemeanor and 5% felony (remainder were status/unruly) </li></ul></ul></ul><ul><ul><ul><li>Of the 40% with a new charge, only 27% were adjudicated delinquent </li></ul></ul></ul><ul><ul><li>Only 20 of 1033 youth enrolled in BHJJ were committed to a DYS institution (1.93%). </li></ul></ul>BHJJ and Recidivism
    45. 52. <ul><li>The State of Ohio has contributed $4.28 million to the BHJJ project over nearly four years. This amount does not include monies spent by the State through Medicaid reimbursement. During that time, over 1000 youth have been enrolled, for an average cost of around $4200 per youth. According to per diem and average length of stay data from ODYS, it costs nearly $82000 to house the average child in an ODYS facility. Using only the $4.28 million amount contributed by the State, each youth diverted from ODYS by the BHJJ project saves nearly $78000. </li></ul><ul><ul><li>If only 50% of the 1000 BHJJ youth would have been sent to ODYS if not for their inclusion in the BHJJ program, the savings associated with BHJJ is nearly $37 million. </li></ul></ul><ul><ul><ul><li>If only 10% would have been sent, the savings is still nearly $4 million </li></ul></ul></ul>Financial Benefit
    46. 53. YOUTH & FAMILY COMMUNITY PARTNERSHIP (YFCP) <ul><li>Preliminary Outcome Evaluation </li></ul>Presented by Kent State University September 8, 2010
    47. 54. Evaluation Overview <ul><li>Evaluation period is November 2008 through May 2010 </li></ul><ul><ul><li>142 youth and caregivers consented to participate in the research study </li></ul></ul><ul><li>Data sources </li></ul><ul><ul><li>KSU assessments </li></ul></ul><ul><ul><ul><li>Trauma Symptoms Checklist for Children (TSCC; Briere 1996) </li></ul></ul></ul><ul><ul><ul><li>Recent Exposure to Violence Scale (REVS) and Violent Behaviors (Singer et al. 1995) </li></ul></ul></ul><ul><ul><ul><li>Global Assessment of Individual Needs – Short Screen (GAIN-SS; Dennis et al. 2006) </li></ul></ul></ul><ul><ul><ul><li>Caregiver Information Questionnaire (CIQ; adapted from Tapestry program) </li></ul></ul></ul><ul><ul><li>Residential providers </li></ul></ul><ul><ul><ul><li>Ohio Scales </li></ul></ul></ul><ul><ul><li>Juvenile court </li></ul></ul><ul><ul><ul><li>Youth Level of Service Inventory (YLSI; Hoge & Andrews 2002) </li></ul></ul></ul><ul><ul><ul><li>ICASE </li></ul></ul></ul><ul><ul><ul><li>Placement unit tracking data </li></ul></ul></ul><ul><ul><li>Tapestry System of Care </li></ul></ul><ul><ul><ul><li>Synthesis </li></ul></ul></ul>
    48. 55. Charge at Referral (N=138) Charge at referral N % Domestic violence 31 22.5 Aggravated robbery, Robbery, Burglary, Breaking & entering 24 17.4 Theft, Unauthorized use of a vehicle, Receiving stolen property 24 17.4 Felonious assault, Assault, Menacing 22 15.9 Unruly 15 10.9 Disorderly conduct 5 3.6 Possession controlled substance 5 3.6 Obstructing official business 3 2.2 Gross sexual imposition, Sexual imposition 2 1.4 Arson, Criminal damaging 2 1.4 Carrying concealed weapon, Possession deadly weapon in school safety zone 2 1.4 Purchase/furnish alcohol to minor 2 1.4 Other/unknown 1 0.7
    49. 56. DSM-IV Axis I Diagnoses <ul><li>On average, youth have 1.72 Axis I diagnoses </li></ul><ul><ul><li>Range = 0 – 5 diagnoses </li></ul></ul><ul><li>Just over a third of YFCP youth have a mental health disorder (34.5%), and just under a third have a substance use disorder (27.5%) </li></ul><ul><li>There were a total of 218 diagnoses for 115 youth </li></ul><ul><ul><li>Externalizing disorders, including ADHD, Conduct, Oppositional Defiant, and Disruptive Behavior disorders comprise half of all diagnoses (n=109) </li></ul></ul><ul><ul><li>Substance Use Disorders account for just under a quarter of all diagnoses (n=48) </li></ul></ul>
    50. 57. Trauma Symptoms Checklist for Children at Intake (N=141) <ul><li>Assesses problems with anxiety, depression, anger, post-traumatic stress, dissociation, and sexual concerns due to exposure to traumatic events </li></ul><ul><li>One in five youth scored in the clinically significant range of at least one subscale at intake </li></ul><ul><li>15% of youth were scored as “under-reporters” </li></ul>
    51. 58. Recent Exposure to Violence at Intake (N=141) Violence Exposure  Witness Victim Violence in the neighborhood 72.3% 37.6% Violence at school 81.6% 47.5% Violence at home 28.4% 38.3%
    52. 59. Youth’s Violent Behaviors at Intake (N=141) Youth's Behavior % Told others he/she would hurt them 56.0% Slapped/hit/punched someone BEFORE being hit 63.1% Slapped/hit/punched someone AFTER being hit 86.5% Beaten someone up 30.8%
    53. 60. GAIN-SS Subscale Scores Over Time N=51) <ul><li>Youth’s subscale scores (proportion scoring 3 or more) decreased significantly over time </li></ul>
    54. 61. Children who witness violence <ul><li>The model </li></ul><ul><li>Film on police response via CWWV </li></ul><ul><li>Data on incidents and trauma </li></ul>
    55. 63. Pictures by children exposed to violence at home
    56. 64. Findings from CWWV (Cuyahoga County) n= 687 of 1518 exposed to DV, 1890 participants (avg age10.0) <ul><li>Greater behavior and mental health problems: </li></ul><ul><li>► Younger </li></ul><ul><li>► Girls (sexual concerns) </li></ul><ul><li>► Victimized vs. just saw/heard it happen </li></ul><ul><li>► Chronic vs. acute </li></ul><ul><li>► Thought greater control over situation </li></ul><ul><li>► Felt personally threatened </li></ul><ul><li>In adolescents, maladaptive coping predicted trauma symptoms (28%) and violent behavior (12%) </li></ul>
    57. 66. Tapestry System of Care in Cuyahoga County, Ohio
    58. 67. Family and Child History (Tapestry System of Care) Cleveland, OH Data Profile Report December 2009 Data are from the CMHS National Evaluation of the Comprehensive Community Mental Health Services for Children and Their Families Program. This report is based on data downloaded December 11, 2009. [a] Data reported were collected using the Caregiver Information Questionnaire–Intake (CIQ–I). <ul><li>69% of caregivers reported a family history of depression (n = 307). </li></ul><ul><li>46% of caregivers reported a family history of mental illness, other than depression (n = 308). </li></ul><ul><li>63% of caregivers reported a family history of substance abuse (n = 312). </li></ul>Has the child ever . . . Witnessed domestic violence? (n = 314) 41.1% Lived with someone who was depressed? (n = 311) 60.1% Lived with someone who had a mental illness, other than depression? (n = 313) 30.4% Lived with someone who was convicted of a crime? (n = 312) 32.1% Lived with someone who had a substance abuse problem? (n = 314) 42.4% Been physically abused? (n = 306) 12.7% Been sexually abused? (n = 302) 11.3% Run away? (n = 317) 26.2% Had substance abuse problems? (n = 316) 9.5% Attempted suicide? (n = 315) 16.5%
    59. 68. Demographic Characteristics of Children Served [a] Cleveland, OH Data Profile Report December 2009 Data are from the CMHS National Evaluation of the Comprehensive Community Mental Health Services for Children and Their Families Program. This report is based on data downloaded December 11, 2009. [a] Data reported were collected using the Enrollment and Demographic Information Form (EDIF). Demographics Gender (n = 851) Male 66.6% Female 33.4% Average Age at Intake (n = 851) Average Age 11.3 years Age Group (n = 851) Birth to 3 years 0.2% 4 to 6 years 10.9% 7 to 11 years 35.4% 12 to 14 years 33.0% 15 to 18 years 20.4% 19 to 21 years 0.0% Race/Ethnicity (n = 845) American Indian or Alaska Native 0.1% Asian 0.1% Black or African American 76.4% Native Hawaiian or Other Pacific Islander 0.2% White 13.8% Hispanic/Latino 7.6% Multi-Racial 1.7% Other 0.0%
    60. 69. Reliable Change Index [a] of Impairment, Anxiety, and Depression from Intake to 36 Months Cleveland, OH Data Profile Report December 2009 Data are from the CMHS National Evaluation of the Comprehensive Community Mental Health Serices for Children and Their Families Program. This report is based on data downloaded December 11, 2009. [a] The Reliable Change Index (RCI) is a relative measure that compares a child's or caregiver's scores at two different points in time and indicates whether a change in score shows significant improvement, worsening, or stability (i.e., no significant change). [b] Data reported were collected using Columbia Impairment Scale (CIS). This instrument collects data on the status of the child/family in the 6 months prior to the interview. The Revised Children’s Manifest Anxiety Scale (RCMAS), and Reynolds Adolescent Depression Scale–Second Edition (RADS–2) measure problems at the time of the interview.
    61. 70. Average Scores of Child Behavioral and Emotional Problems [a] for Children Ages 6 to 18 from Intake to 36 Months Cleveland, OH Data Profile Report December 2009 Data are from the CMHS National Evaluation of the Comprehensive Community Mental Health Services for Children and Their Families Program. This report is based on data downloaded December 11, 2009. n = 140 Eight Syndrome Scale Scores[b] [a] Data reported were collected using the Child Behavioral Checklist 6–18 (CBCL 6–18). This instrument collects data on the status of the child/family in the 6 months prior to the interview. [b] Internalizing and externalizing scores 64 or above are in the clinical range. Scores on the eight syndrome scales 70 or above are in the clinical range. Intake 6 Months 12 Months 18 Months 24 Months 30 Months 36 Months Withdrawn 68.4 66.3 64.8 64.5 63.9 63.9 63.6 Somatic Complaints 63.0 60.9 59.9 60.7 60.2 60.1 60.2 Anxious/ Depressed 66.8 64.1 62.5 61.6 61.6 60.9 60.9 Social Problems 70.4 67.7 66.0 65.7 65.3 65.4 65.1 Thought Problems 71.1 69.0 67.6 66.3 65.8 66.0 64.7 Attention Problems 73.2 68.9 66.7 66.5 66.3 65.6 65.6 Rule Break Behaviors 71.2 69.6 68.1 67.7 68.0 67.8 67.0 Aggressive Behavior 79.4 75.6 74.0 71.8 71.2 70.9 70.1
    62. 71. Reliable Change Index [a] of Child Behavioral and Emotional Problems in Children Ages 6 to 18 Years [b] from Intake to 36 Months Cleveland, OH Data Profile Report December 2009 Data are from the CMHS National Evaluation of the Comprehensive Community Mental Health Services for Children and Their Families Program. This report is based on data downloaded December 11, 2009. [a] The Reliable Change Index (RCI) is a relative measure that compares a child's or caregiver's scores at two different points in time and indicates whether a change in score shows significant improvement, worsening, or stability (i.e., no significant change). [b] Data reported were collected using the Child Behavioral Checklist 6–18 (CBCL 6–18). This instrument collects data on the status of the child/family in the 6 months prior to the interview.
    63. 75. Changes in policy and practice <ul><li>Limit exposure to violence across settings </li></ul><ul><li>Identify the problem early = > success </li></ul><ul><li>Prevention works </li></ul><ul><li>Co-morbid mental health issues and trauma </li></ul><ul><li>Braided funding </li></ul><ul><li>Child welfare vs. juvenile justice </li></ul><ul><li>Practice-based evidence vs. EBTs </li></ul>

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