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Engagement for Success

Engagement for Success. Delivering Community-Based Child and Adolescent Mental Health Services to Youth in Wayne County’s Juvenile Justice System Presented by Shaun Cooper, Ph.D., LP Clinical Director, Juvenile Assessment Center Jennifer Fuller-Bohanon, M.A., LPC

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Engagement for Success

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  1. Engagement for Success Delivering Community-Based Child and Adolescent Mental Health Services to Youth in Wayne County’s Juvenile Justice System Presented by Shaun Cooper, Ph.D., LP Clinical Director, Juvenile Assessment Center Jennifer Fuller-Bohanon, M.A., LPC Director of CHOICES, Juvenile Assessment Center

  2. Demographics of the Wayne County Juvenile Justice Population • In 2012, the system was comprised of 1899 youth who were either formally adjudicated (N=1086, 57%) or deemed appropriate for diversion from formal adjudication (N=813, 43%). • Males outnumber females by a ratio of 3:1 among adjudicated youth; females comprise about 40% of the diversion population. • As is the case in jurisdictions throughout the United States, Wayne County JJ system is characterized by disproportionate minority contact (DMC). • Definition: The proportion of ethnic or racial minority youth enrolled in the JJ system exceeds their proportional representation in the U.S. population. • Racial/Ethnic composition of Wayne County JJ population: • African American – 71.8% • Caucasian – 21.7% • Arabic – 2.9% • Hispanic – 2.3%

  3. Distorted Attitudes • The popular image of the juvenile offender in Wayne County is of an African American or Hispanic male who is engaged in violent drug- and/or gang-related criminal activity. • Arabic youth (and those mistaken for Arabic youth) face discrimination related to fears associated with terrorism and ignorance regarding the principles of Islam. • The media and popular culture distort the image of the juvenile offender. In 2001, Dorfman and Schiraldi examined 77 studies on how the media report crime. This conclusion summarized their findings: • “Overall, the studies taken together indicate that depictions of crime in the media are not reflective of the rate of crime generally, the proportion of crime which is violent, the proportion of crime committed by people of color, or the proportion of crime committed by young people.”

  4. Profile of Adjudicated Youth • Approximately 2/3 of all juvenile offenses in Wayne County each year are either status offenses or misdemeanors. • Increasingly, youth who pose little safety risk to the community and are facing their first adjudication are being targeted for Diversion programming. • Increasingly, adjudicated youth in Wayne County are comprised of the 1/3 of all offenses are actually felonies; i.e. acts that pose significant damage to or loss of property or that pose a significant risk to community safety. • Only about 7% of juvenile offenses are so-called person crimes; those that entail immediate danger or harm to other individuals.

  5. Profile of Adjudicated Youth • Repeated status offenders or misdemeanants; i.e. those whose past cases had been repeatedly dismissed or had been previously routed into Diversion programming. • It has been determined that ongoing court supervision is necessary via the mechanism of periodic reporting by case managers. • It has been mandated via court order that the youth participate in specific treatment services to address their rehabilitative needs.

  6. Cultivation and Maintenance of Cultural Competence • Stereotypes are dehumanizing and do not promote the climate of trust, mutual respect, and connection necessary to advance a therapeutic agenda. • Developing and maintaining cultural competence is an ongoing process; complacency encourages either defaulting to old beliefs or accepting prevalent media messages uncritically.

  7. National Prevalence of Mental Illness among JJ Youth • Each year, more than 2 million children, youth, and young adults formally come into contact with the juvenile justice system, • Of those children, youth, and young adults, a large number (65–70 percent) have at least one diagnosable mental health need, and 20–25 percent have serious emotional issues (Shufelt & Cocozza, 2006; Teplin, Abram, McClelland, Dulcan, & Mericle, 2002; Wasserman, McReynolds, Lucas, Fisher, & Santos, 2002). • some 60 percent of youth who warranted a mental health diagnosis also met diagnostic criteria for a substance use disorder (Shufelt & Cocozza, 2006).

  8. Common Diagnoses Among Youth in the Juvenile Justice System • Anxiety disorders are diagnosed in approximately one quarter of males (26.4%) and just over half of females (56.0%) involved with the juvenile justice system. • Mood disorders are diagnosed in approximately 1 in 7 (14.3%) males and just less than 1 in 3 (29.2%) females. • Disruptive behavior disorders were diagnosed in approximately 45 percent of males and just over half (51.3%) of females involved with the juvenile justice system. Disruptive Behavior Disorders include Oppositional Defiant Disorder (ODD) and Conduct Disorder (CD). • Attention Deficit Hyperactivity Disorder (ADHD) affects about 3-5 percent of children and is diagnosed about twice as frequently among boys than girls.

  9. Co-occurring Disorders • Nationally, approximately 43 % of males and 55 % of females involved in the juvenile justice system had substance use disorders. Substance abuse disorders reflect use of alcohol or other controlled substance in a manner that clinically impairs one or more domain of functioning (e.g., academic, social, legal). • Nationally, 60 % of youth who warranted a mental health diagnosis also met diagnostic criteria for a substance use disorder (Shufelt & Cocozza, 2006). • At the Wayne County Juvenile Detention Facility (WCJDF), approximately 53% of youth test positive for illegal substances; the overwhelming majority of these positive urine drug screens were for marijuana. • 80% of youth screened at WCJDF admit to lifetime use of illegal substances.

  10. Co-occurring Disorders • Wayne County must continue to move toward an integrated system of care for addressing mental health and substance abuse issues. • Substance abuse reflects a critical form of maladaptive decision-making pertinent to coping with SED and trauma: • Social isolation due to sense of alienation from others • Poor peer selection • Self-medication • Anesthesia vs. stimulation • Escapism • Heightens sense of connection to others • Mitigates feelings of inadequacy

  11. Educational Needs • The JAC administers the WISC-IV (measure of intellectual skills) and the WRAT-4 (measure of academic achievement) to every adjudicated youth in Wayne County at the point of their enrollment in the system. • A Full Scale IQ of 70 indicates intellectual functioning at the 3rd percentile; i.e. the youth has scored better than only 3% of youth who comprised the representative standardization sample for the test. • Among Wayne County’s adjudicated youth: • 18.2% of Probation youth had a FSIQ < 70 • 28.7% of Committed youth had a FSIQ <70 • In the realm of academic achievement, Wayne County’s JJ youth demonstrated performance at the following levels: • 95% of 11-12 year-olds have reading and math skills below the 5th grade level • 95% of 17 year-olds have reading and math skills below the 11th grade level • 50% of the entire JJ youth cohort (ages 11-18) have reading and math skills below the 5th grade at the point of enrollment

  12. Educational Needs • In the realm of academic achievement, Wayne County’s JJ youth demonstrated performance at the following levels: • 95% of 11-12 year-olds have reading and math skills below the 5th grade level • 95% of 17 year-olds have reading and math skills below the 11thgrade level • 50% of the entire JJ youth cohort (ages 11-18) have reading and math skills below the 5th grade at the point of enrollment Considered together, these data reflecting intellectual and academic achievement deficits indicate poor school adjustment, which has profound implications for: • Development and formation of identity • Chronicity of psychological disturbance • Societal adjustment Delivery of MH services to JJ youth must entail utilization of case management services to interface with school officials.

  13. MH/JJ System Interface: Special Challenge • Important distinction between therapeutic and rehabilitative agendas (Kinscherff, 2012) • For example, one adolescent with a diagnosis of depression may manifest that depression by marked irritability that significantly contributes to his assaulting others. But as his depression is treated successfully, the likelihood of an assault also substantially lessens. Here, mental health treatment alone is sufficient to meet the goal of rehabilitation. • Another adolescent with a diagnosis of depression may manifest that depression primarily by withdrawal and social isolation, sleeping for many hours a day, and feeling a pronounced lack of physical energy. If this adolescent also has a prior history when not depressed of assaulting others to achieve intimidation or robbery, effective treatment of his depression may actually increase the likelihood of him returning to his baseline of assaulting others as he feels better and his physical energy returns. Here, effective treatment of his depression alone would be insufficient to meet the goal of rehabilitation.

  14. Assessment and Treatmentof Trauma • Trauma is the result of a highly stressful experience(s) that overwhelm an individual’s ability to cope. • Sometimes traumatized persons are able to recover, benefit from support, and move on without significant or persisting functional impairment. Other persons may be overwhelmed by intense single episode events (e.g., witnessing a parent being murdered, being sexually assaulted) or cumulatively by traumatic events (e.g., witnessing multiple episodes of community or domestic violence, being sexually abused over a period of time). • How trauma manifests is highly individual in terms of its immediate impact or efforts of the victim to adapt to the impact of the traumatic events.

  15. Assessment and Treatmentof Trauma Prevalence: • One study (Abram, Teplin, et al., 2004) found that 92.5 percent of youth in an urban juvenile detention center had experienced at least one traumatic event (mean: 14.6, median: 6) with 11.2 percent meeting criteria for PTSD in the previous year. • More broadly, a National Child Traumatic Stress Network study (NCTSN, 2008) determined that more than 50 percent of youth in the juvenile justice system have had trauma exposures and that over 50 percent of them had developed at least some trauma symptoms. • Of Wayne County’s JJ system cohort of Committed youth in 2012: • 24.8% featured a history DHS placement pursuant to a determination of abuse or neglect (33.1% females, 22.2% males). • 2.8% were classified as Dual Wards, meaning that they had been convicted of a juvenile offense while currently removed from biological family due to determination of abuse or neglect

  16. Assessment and Treatmentof Trauma • In children and adolescents, trauma-related symptoms or their efforts to adapt to the traumatic experience or persisting trauma-related symptoms can change their manifestation as the traumatized child continues to age and to develop. • Diagnostic conundrum: • Without careful consideration of a trauma history, the hypervigilance of a traumatized youth may be mistaken for the problems with attention and concentration of ADHD. • The emotional numbing that emerges as a defense against overwhelmingly painful trauma-related emotions may be confused with depression, and, particularly in delinquent youth with serious crimes against persons, may be misunderstood as a lack of capacity for empathy for others or lack of remorse for misconduct. • The intensely reactive emotional dysregulation that can result from trauma may be mistaken for the emotional instability of an emerging Bipolar Disorder

  17. Assessment and Treatmentof Trauma • It is now apparent that there are important clinical differences between children and adults who are exposed to a single traumatic episode and those exposed to chronic or multiple trauma exposures. • The diagnosis of PTSD has been modified for the DSM-5 to adequately describe persons with traumatic stress histories that were more extensive and/or began in childhood rather than adulthood. • Particularly when youth present with defiant, provocative, aggressive or illegal behaviors, failure to recognize the contributions of trauma exposures to those behaviors may result in an unsophisticated focus upon behavioral control that may actually make the concerning behaviors worse.

  18. Assessment and Treatmentof Trauma • Without recognizing the contribution of trauma exposures to the onset of symptoms and the emergence or maintenance of misconduct, interventions may fail to address critical developmental disruptions: • problems with attachment, • compromised ability for reciprocal relationships, • profound emotional dysregulation, • impaired empathy, • risk-taking and sensation-seeking, • aggression to self and/or others, • extreme mistrust, • demoralization, • sense of fundamental damage and persistent danger, • poor capacities for self-soothing, • somatic complaints

  19. Assessment and Treatmentof Trauma • Evidence that stress and trauma negatively impact brain development • Chronic or multiple traumatic exposure alters brain development in a way that leads youth towards misperceptions of threat, mistrust, emotional reactivity and dysregulation, extremely short-term perspectives, risk-taking, and efforts to block negative emotions by behaviors such as substance abuse or high-intensity behaviors. • Contribution of adverse childhood experiences (ACEs) to: • early and persisting adoption of risk behaviors (Anda, Felitti, et al, 2006), • the interaction among Conduct Disorder, high-risk behaviors, life-style factors, and PTSD (Karestan, Koenen, et al, 2005; Newman, 2002).

  20. What does this mean for the clinician?C.H.O.I.C.E.S. In FY 2012, • 63% Male, 36% Female • 8-18 years of age • Majority 16 years of age • 83% between 14 and 16 • 66% African American • 20% Caucasian • 9% Biracial/Multiracial, “Other” • 4% Latino/Latina • 1% Native American

  21. Intake • Understanding what brought the youth into the JJ system is necessary but not sufficient • Do not spend the entire session dissecting his/her offense • Be ‘mindful’ of the offense • Recognize it • Understand it • Move on • Begin to compile his/her story: Who is this person outside of his/her JJ involvement? What was his/her life like before? • Instill hope • Focus on strengths, resilience • Normalize • Communicate understanding, “I get it”, non-judgmental • Limits to confidentiality

  22. Courtesy of Western Michigan University Child Assessment Clinic

  23. Understanding Male Development Robertson & Shepard (2008) identify factors that comprise psychological development of boys as falling into one of 3 areas: • Object relations • Neurobiological • Gender role socialization

  24. Object relations • The separation-individuation ‘trauma’ of early childhood (Mahler, Pine & Bergman, 1975; Pollack, 1998) involves psychological stress that negatively impacts capacity for intimacy and increases vulnerability to depression. • Theorists offer that this is done sooner for boys so that they begin to take on gender role congruent identities. Females, on the other hand, are allowed to experience the closeness longer. Males experience this as abandonment (Pollack, 1998).

  25. Psychological consequences • Self-esteem begins to be centered on competition and more specifically, winning. Maintaining feelings of well-being and self-confidence becomes more difficult. Although boys desire attachment, they learn to avoid it. • Development of the “Boy Code” (Pollack, 1998).

  26. The mask of masculinity(Pollack, 1998) “Researchers have found that at birth, and for several months afterward, male infants are actually more expressive than female babies. But by the time boys reach elementary school much of their emotional expressiveness has been lost or has gone underground. Boys at five or six become less likely than girls to express hurt or distress, either to their teachers or to their own parents (p.10).”

  27. Getting behind the MaskStrategies for boys(Robertson & Shepard, 2008; Pollack, W.,1993) • Lecture less; listen more • Focus on strengths • Genuineness • Timing—establish trust • Normalizing • Understand the language of the mask • Use soft, kind language & tone so boys aren’t intimidated, afraid or ashamed to share their feelings • Accept a boy’s emotional schedule; timed silence syndrome • Use appropriate self-disclosure about emotional experiences • Connection through action; “Action talk”

  28. Understanding female offenders(Cauffman, 2008) • In 1980, boys were four times as likely as girls to be arrested; today they are only twice as likely to be arrested. • Although boys still dominate the juvenile caseloads, the prevalence of cases involving girls increased 92% between 1985 and 2002, while the caseload for boys increased only 29%. • The average duration of offending was 4.9 years for females and 7.4 years for males. • Pattern of offending: adolescent-limited vs. life-course-persistent.

  29. Understanding female development • Gender role socialization (Task Force, 2007; Johnson, Roberts & Worell (Eds), 2001) • Between the age of 8 & 11, girls tend to be androgynous. As they enter the adolescent phase, they begin to experience pressure toward more rigid conceptions of gender roles, how they are “supposed to behave” and with physical and sexual attractiveness. • Self-esteem decreases for both sexes after elementary school; however, the drop is more dramatic for girls. • Compared with boys the same age, adolescent girls are more anxious and stressed, experience diminished academic achievement, suffer from increased depression and lower self-esteem, experience more body dissatisfaction and distress over their looks, suffer from greater numbers of eating disorders and attempt suicide more frequently.

  30. Understanding female development More than 20% of women are physically assaulted by a partner and approximately 12% experience sexual assault at sometime in their lives. Child sexual abuse happens two to two-and-one-half times more often to girls than boys. Rates of childhood sexual abuse are similar for Black, White, Hispanic and Native American women (Pipher, 1994).

  31. Treatment interventions • Treatment for trauma – TF-CBT (Cohen, Mannarino& Deblinger, 2006). • Psychoeducation • Relaxation techniques • Affective regulation • Cognitive Coping • Trauma Narrative • In Vivo Exposure • Conjoint Session • Enhancing Safety • Strengths centered (Johnson, 2003) • Building support – reaching out to others • Building self-esteem • Focus on resilience • Identify multigenerational patterns (Boyd-Franklin & HaferBry, 2000)

  32. Working with African American Families: Cultural Considerations Boyd-Franklin (2003) • African legacy: collectivism & interdependence • Impact of Slavery: cultural, mental and spiritual; multigenerational • Impact of racism and discrimination • Strengths: • Strong kinship • Strong emphasis on work and ambition • Educational or achievement orientation • Spiritual and religious orientation

  33. Understanding and re-conceptualizing “resistance” • Healthy cultural suspicion • “Direct learned survival response” • Negative history with the welfare system & other social institutions & agencies • Loss of privacy • “Invisibility Syndrome” (Franklin & Boyd-Franklin, 2000)

  34. Treatment interventions • Address multiple systems • Individual • Home (Parent Education) • School (Advocacy, Collaboration) • Community (Identify resources) • Empowerment – teaching skills rather than doing things for the family; psychoeducation • Positive Identity development/Critical consciousness • Community based services • Helping family members feel visible

  35. Thank you!

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