Community Treatment Programs for Juveniles: A Best Evidence Synthesis

1. Community Treatment Programs for Juveniles: A Best Evidence Synthesis Birmingham Presents Lee A. Underwood, Psy.D., USA Consulting Group April 21, 2006

2. Introductory Thought I have come to a frightening conclusion. I am the decisive element in the treatment of juveniles. It is my personal approach that creates the climate. It is my daily mood that makes the weather. As a Provider, I possess tremendous power to make a youth’s life miserable or joyous. I can humiliate or humor, hurt or heal. In all situations, it is my response that decides whether a crisis will be escalated or de- escalated, and the youth humanized or de-humanized—Haim Ginnott, 1977

3. OVERVIEW • Prevalence, Awareness and Challenges • Delinquency & Mental Health • Trends in Community-Based Programs • Common Community Models • Cultural Competency & Bias

4. Prevalence, Awareness and Challenges

5. Prevalence Rates • U.S. Represents 2% of World’s Population • U.S. has 25% of World’s Prisoners • U.S. Population of Racial Minorities are 27-30% • U.S. Population of African-Americans is roughly14% of the 25% and 15% of the 25% are Hispanic speaking • Of the 2 Million Incarcerated, nearly 70% are African-Americans and Hispanic speaking

6. Prevalence Rates • One out of 5 African-Americans Males are in Prison Between the Ages of 18-24 • There are more African-American Males in Prison than in College • 9% of Hispanic-Americans compared to 3% of White-Americans are in secure settings

7. Prevalence Rates • According to the U.S. Census concerning data on divorce, child custody and child support, 50% of all white children and 75% of all black and brown children born in the last two decades are likely to live for some portion of their childhood with only their mothers.

8. Prevalence Rates • “Children growing up in homes with absent fathers are more likely to fail or drop out of school, engage in early sexual activity, develop drug and alcohol problems, and experience or perpetrate violence in greater numbers than children growing up in homes with fathers present.” Benson Cooke

9. Prevalence Rates • Each year more than one million children experience the divorce of their parents. In 1996, of 1,310 divorces in the District of Columbia, nearly half (46.4%) involved children. • Over 1/5 or (26%) of the absent fathers live in a different state than do their children. • Approximately 40% of the children who are fatherless have not seen their father in at least a year, and about 50% have never visited in their father’s house

10. Prevalence Rates Boys & Girls • Girls are 3-4 times more likely to be victims of sexual abuse than boys. • Girls are more likely to be victimized physically, and sexually by a family member. • Victimized girls are more likely to present serious mental health symptoms.

11. Prevalence Rates Cont’d Boys & Girls Cont’d • Girls have higher prevalence rates of depression, anxiety, PTSD, eating, sleeping, somatization and borderline personality disorders and features. • Girls have higher rates of co-occurring mental health and substance use rates. • Girls are more likely to run away from home to escape violence.

12. Prevalence Rates Cont’d Boys & Girls Cont’d • Boys and girls respond differently to abuse. Boys generally become aggressive. • Girls tend to internalize the injury, sometimes becoming aggressive and other times becoming depressed, or both at the same time. • Boys tend to minimize their negative emotions.

13. Prevalence Rates Cont’d Boys & Girls Cont’d • Boys tend to have disruptive relationships, overcompensate for control and severe their emotions. • Initial treatment for girls should focus on empowerment. • Initial treatment for boys should focus on relationships and on expanding their emotional repertoire.

14. Implications? • What are the Implications? • How does this data move you? • What do you do to perpetuate the data? • What do you do to eliminate the data? • How hopeful is change? • What does this say about staff awareness • How does personal and professional boundaries fit in?

15. Delinquency & Mental HealthRisk & Protective Factors

16. QUOTE “The criminally-minded adolescent is like a pirate who sails under his own flag without regard to ship or crew except that it serves his own good.” ANONYMOUS

17. Delinquency & Mental Health • Delinquency and mental health are intertwined and mutually stimulate each other. • Isolating delinquency risk factors from mental health risk factors is difficult. • Delinquency and mental health constructs tend to overlap. • Choosing the best treatment placement system is unreliable done. • Understanding predictors of delinquency and mental health can decrease recidivism in both areas.

18. QUOTE “Treatment rests on the basic strategy of making the client so clearly aware of his pattern of irresponsible thinking that he cannot continue them except by a full conscious and deliberate choice.” JOHN BUSH

19. Risk & Protective Factors • Risk Factors • Protective Factors • Strength-based Factors

20. Risk Factors Risk factors refer to the likelihood of a youth’s continued involvement in criminal behavior. Risk factors are related to the likelihood of recidivating back into child care systems. When one understands the key risk factors, there is a much improved accuracy and reliability in the treatment and aftercare planning process. A set of empirically supported variables (risk factors) have been identified and associated with delinquent and criminal behavior.

21. Individual (self-esteem, medical, personality) Peer (deviant associations, pro-social peers, gang affiliation, antisocial attitudes) Family (boundaries, structure, compliance, rules, connectedness, criminal role models) Neighborhood (poverty, antisocial, criminal role models, education) SubstanceAbuse (use patterns, associated behaviors, family substance use patterns) ChildhoodAbuse (I.e., sexual, physical, emotional)

22. Specific Risk Factors • Children with disabilities or mental retardation • For sexual abuse, risk increases with age • Females more likely to be sexually abused than males (but males DO get sexually abused) • Difficult/slow to warm up children

23. Specific Risk Factors Within Families • Substance abuse within family • Childhood history of abuse • Witnessing domestic violence • Lack of parenting skills • Neglect and abandonment • Coercive child-rearing • Lack of family warmth & boundaries

24. Specific Risk Factors Within Community • Poverty & impoverished environments • Dangerous/violent neighborhood • Poor school districts • Lack of access to medical care, etc. • Parental unemployment & homelessness • Deviant peer association • Personal & institutional racism

25. Protective Factors Protective factors refer to internal and external support systems that buffer the negative effects of trauma. Internal factors include resiliency, self-appraisal and explanatory styles. External factors include the protective role of caregiver supervision and monitoring.

26. Protective factors refer to internal and external support systems that buffer the negative effects of trauma Protective Factors Internal Factors External Factors • Resiliency • Self Appraisal • Explanatory styles • Protective role of caregiver • Supervision • Monitoring

27. General Protective Factors • Stable families • Emotional well-being of youth & family • Parental monitoring & supervision • Community participation • School attendance • Prosocial lifestyle

28. General Protective Factors (Additional) • Disrupted attachments • Family antisocial values • Harsh parental discipline • Lack of parental monitoring • Feeling of emotional distress that is impairing • Neurological impairments • Substance use • Poor parent-child relationships • Neglect • Coercive child-rearing • Lack of warmth and affection • Inconsistent parenting • Violence • Sexual Abuse

29. Specific Protective Factors Youth Personality • Easy tempo & approach • Positive Disposition • Active coping skills • Positive self-esteem • Good social skills • Internal locus of control • Balance between autonomy & help-seeking

30. Specific Protective Factors Families • Secure attachment • Supportive family environment • Household rules/structure • Parent monitoring • Extended family help and support • Parental model – good coping skills • High family expectations • High parental education

31. Specific Protective Factors Families • Positive relationships with family members • Opportunities for personal growth & development • Supportive and nurturing relationship with at least one parent • Cohesiveness and expressiveness • Consistent family discipline • Rules in planning and operating the home

32. Strength-based Factors A belief in the goodness of individuals-instead of viewing the youth who does not display skills as deficient; it is believed the youth has not had the experiences or opportunities to mastering essential skills. Given the skills, youth are able to transcend their current situation. A belief that youth are motivated by how others respond to them. When adults accentuate the positive areas in a youth’s life, this may result in heightened motivation.

33. Strengths-based Factors • A focus on the internal and external resources of individuals rather the solely the youth’s circumstances. • Explicitly seeking and building upon the individual strengths rather than the individual’s limitations. • Less focus on pathologies and deficits • A focus on past successes and ways in which the successes were achieved. • A focus on survivor skills rather than victim responses.

34. Strength-based Factors • A focus on personal accomplishments and the accompanying steps to achieve such • Recognition of interpersonal strength (i.e.-accepts and gives criticism) • Involves family involvement (a sense of belonging to the family) • A focus on intrapersonal strength (i.e.-demonstrates a sense of humor, provides criticism • A focus on affective strength (i.e.-asks for help, some insight into self-awareness)

35. Key Clinical Issues • The specific issues relevant to an individual’s offense and the individual’s mental health and substance abuse characteristics must be considered. • Multiple sources of information should be gathered. • Specialized psychometric instruments should be administered. • A series of screenings and assessment should be provided. • Differentiating personality disorders from mental health and substance abuse disorders is critical.

36. Key Clinical Issues - Cont. • When screening and assessing the juvenile’s appropriateness for community-based programming, it should include a review of his/her living arrangements, family warmth, boundaries, supervision and structure. • History of sexual psychological and physical victimization should be carefully gathered and interpreted. • Awareness of cultural differences is essential.

37. Trends in Evidence-based Community-based Treatment

38. What is Residential Treatment? • Provides specialized assistance to individuals requiring professional clinical support to assist with behavioral change and growth. • Residential services attempt to remove the youth from the home setting, and place them in a structured, supervised, therapeutic environment. • Depending on the need, residential placement may assist with youth struggling with specific issues including sexual aggression, firesetting, chemical dependency, emotional and behavioral issues, or severe as transitional programs for youth going back into the community with their families.

39. Treatment often includes individual, group, and family therapy; structured recreational activities; vocational training; skill development; and educational support. • Despite the wide use of residential treatment programs for adolescents the evidence-base is very weak. Most of the empirical evidence for residential treatment stems from two quasi-experimental studies, conducted over 20 years ago

40. What is Community Treatment? • Community programs may consist of system diversion, non-system diversion, and residential community corrections. • System diversion programs include those services that fully divert youth from the juvenile justice system. • Examples of these programs may include family counseling, crisis counseling, vocational training, and Big Brother Big Sister related organizations.

41. What is Community Treatment? • Conversely, non-system diversion programs include services that are formally part of the juvenile justice system. These services may include court ordered family counseling, skills training, and informal probation. Community corrections programs refer alternatives to incarceration, such as independent living, work programs, probation, parole, and other programs designed to manage adolescents in the community.

42. What is Community Treatment? • Effective community programs must simultaneously balance three major goals: (1) ensure public community safety, (2) hold youth accountable for their actions, and (3) provide an environment in which youth can develop into capable, productive, and responsible citizens

43. What Is Community Treatment? • Post-release treatment programs should rely on the following: • Utilization of clear cut and objective diagnostic indicators. • Utilization of family intervention services that is inclusive and culturally relevant. - Utilization of treatment interventions that are empowering for youth& their families.

44. What Is Community Treatment? • Implementation of ongoing reliability and validity studies. • Utilization of reliable and accurate treatment protocols that have sound empirical research with demonstrated effectiveness. • Use of multiple interventions that address a variety risk factors (family, school, peer, school, community, etc.).

45. What Is Community Treatment? • Utilization of mental health providers, not correctional staff as primary treatment providers. • Collaboration between juvenile justice, mental health, substance abuse and education systems.

46. Trends in Evidence-based treatment ·Recidivism rates of sample juveniles are lower than untreated groups. · Integrated treatment is most effective for co-occurring disordered youth. · Multisystemic therapy, Functional family therapy, Multi-dimensional therapeutic foster care have demonstrated empirical evidence. · Dialectical behavior therapy has undergone investigation and seems reliable

47. Trends in Evidence-based treatment Effective Programs Are: ·Reliable and valid. · Rigorously applied. · Systematically measured. • Focuses on ecology. • Reduces known risk factors. • Highly structured. • Closely supervised and monitored. • Curricula-based • Skill-based

48. Trends in Evidence-based treatment Effective Programs Are: ·Integrated service oriented. · Strengths based. · Individualized and targeted. • Undergone clinical trials. • Community-based. • Aware of protective factors. • Replicable.

49. Common Commuity ModelsTypes of Treatment

50. Types of Treatment ·Cognitive-behavioral. · Problem-solving. · Task centered. • Ecological. • Behavioral modification.