This document summarizes a presentation on breaking the intergenerational cycle of violence. It discusses how childhood exposure to violence can increase the risk of adult perpetration, and the impact of violence on brain development and mental health. Interventions like trauma-informed care and cognitive behavioral therapy aim to treat trauma and break the cycle. Data is presented on programs in Ohio that serve at-risk youth using evidence-based models like multi-systemic therapy and wraparound services.

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

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.

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

15. Policy Law Enforcement Systems Mental Health Labor/ Aftercare Child&Family Services Individual Family School Neighborhood Community Juvenile Justice Education

16. SAMPLE CHARACTERISTICS

17. VIOLENT BEHAVIOR ARIZONA ELEMENTARY OHIO ELEM./ MIDDLE OHIO/COLORADO HIGH SCHOOL * Within past year

18. PERCENTAGES OF STUDENTS WITNESSING VIOLENCE WITHIN THE PAST YEAR BY GENDER, GRADES 3-8

19. PERCENTAGES OF STUDENTS VICTIMIZED BY VIOLENCE WITHIN THE PAST YEAR BY GENDER

20. HIERARCHICAL REGRESSION ON VIOLENT BEHAVIOR, GRADES 3-8

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.

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

27. PERCENTAGE OF ADOLESCENTS USING EACH COPING STRATEGY AT LEAST SOMETIMES

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%)

43. The Behavioral Health/ Juvenile justice (BH/JJ) initiative in Ohio

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%

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%

48. TSCC *All differences significant at the .05 level

49. Substance Use Over Time

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

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%

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%

63. Pictures by children exposed to violence at home

66. Tapestry System of Care in Cuyahoga County, Ohio

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%

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.

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

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.