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.

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”