Transcript Effectively Using Evidence of Trauma and Mental health

Effectively Using Evidence of
Trauma and Mental Health
Issues in Juvenile Court
Mari Radzik, Ph.D., Clinical Psychologist
Childrens Hospital Los Angeles
Division of Adolescent Medicine
Loyola Law School,
The Pacific Juvenile Defender Center
Sixth Annual Juvenile Delinquency Roundtable
November 20, 2009
1:30p.m. – 2:40p.m.
Objectives
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Dr. Radzik –
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will focus on how trauma affects adolescents
How does trauma histories impact behaviors
which may lead them to involvement with the
delinquency system
Ms. Patti –
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Will focus on the use of clinical evidence of
trauma and mental health issues in different
aspects of delinquency court
Outline of presentation
Trauma defined
 Adolescence defined
 Impact of trauma on adolescents
 Mental disorders
 Informed care/Interventions
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What is trauma?
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An extremely distressing experience that causes
severe emotional shock and may have long
lasting psychological effects
Hallmarks of traumatic events
 The event is unexpected
 The individual is unprepared for the event
 There wasn’t anything the person could do to
prevent the trauma
 The person experienced intense fear,
helplessness and horror
 Short term distress is almost universal
Types of trauma – your clients
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Acute Traumatic Event-occur at a particular
time and place and are usually short-lived
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Chronic Traumatic Situations-occurs
repeatedly over long periods of time
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Complex Trauma-simultaneous or sequential
occurrences of abuse, neglect, DV, community
violence, war, etc that disrupts a
adolescents/child’s security with primary
caregivers
Types of trauma - providers
 Secondary
Trauma or vicarious
traumatization
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the impact on the worker responding to
traumatic stress
We work with youth highly impacted by
trauma
Secondary traumatic stress can result from
continued contact with youth who have
experienced trauma
We need to take care of ourselves in order to
take care of others
The adolescent brain…a
work in progress
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95% of the brain has developed by the age of
6
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What youth engage in affects brain
development
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The next growth spurt is in adolescence and
continues to mature until about age 24
E.g. substance use, brain injury
Emotional information is interpreted differently
 Youth really do think differently
What is “Trauma Informed
Clinical Services”?
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Understanding that traumatic events affect all
factors of a person’s life:
 Physical
 Emotional
 Economic
 Spiritual
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Organizations/providers have started to
understand that vulnerabilities or triggers can
lead to re-victimization
What are traumatic events?
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For juveniles in the system,
Physical abuse
 Sexual abuse/assault
 Parental neglect
 Witness of crime
 Death of family members/friends/gang
member
 Multiple foster placement
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Common responses to
complex trauma
 Impulse
control issues
 Moodiness
 Attentional problems
 Self perception issues/Feeling damaged
 Relationship and Trust problems/revictimization by others
 Physical symptoms/chronic pain
 Hopelessness/aimlessness
The way youth respond to distress
often gets them in trouble…
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Gang involvement
Homelessness
Substance abuse/use
High risk sexual activity
Teen parenthood
Depression/suicidal ideation/withdrawal
Truancy/academic problems
Heightened vigilance to perceived threat
Low self esteem/helplessness/hopelessness
The impact of trauma on
juveniles in the system
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Mental health issues often hard to assess
– can be interpreted as negative
behaviors,
 Avoidance
 Oppositionality and resistance
 Manipulation
Without proper dx, often viewed as ‘bad’
rather than mentally ill
Mental Health Diagnoses
Commonly found
in the juvenile
justice system
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Behavioral disorders
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ODD-Oppositional Defiant Disorder
 Pattern of negative, defiant, hostile behavior
 Argues w/adults, defiant, short tempered
 Above and beyond – interferes with school/home life
Conduct Disorder
 Easily the most common diagnoses in the JJ system
 Recurrent/enduring pattern of the negative behaviors
 Violates the rights of others/society
 More aggressive, more persistent
 Usually have another diagnosis on deck
(From Boesky 2003)
Behavioral disorders
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ADHD – Attention Deficit/Hyperactivity
Disorder
 Continual pattern of…
• Inattention – distracted, disorganized,
forgetful, avoids task that require sustained
effort
• Hyperactivity – moves, fidgets, talks a lot,
can’t do quiet projects, full of energy
• Impulsivity – doesn’t follow directions,
makes careless mistakes
(From Boesky 2003)
Mood disorders
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Major Depression - MD
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Sx of at least two weeks and change in fx
• Depression; changes in sleep, eating activities, lack of interest,
hopelessness
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Important – depression looks like irritability in youth
• Agitation, anger, aggressive
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Dysthymic Disorder
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Less severe then then MD
Fatigue/low energy
Annoyed with everyone
Bipolar Disorder (“manic-depressive disorder”)
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Must assess/watch for suicidality
Serious fluctuations in mood
Manic and depressive mood states are severe and interfere
w/fx
(From Boesky 2003)
Learning issues
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Mental Retardation
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IQ of < 70 (100 is average)
Deficits in coping with life
Can’t take care of self well
Onset before age 18
Mild, moderate and severe rating • Mild – approx sixth grade functioning
• Moderate – approx 2nd grade functioning
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Learning Disorders
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(From
Can often be unassessed in clinical pops
Discrepancy in what they should be doing in school and
their actual performance
Boesky 2003)
Anxiety disorders
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PTSD – Post Traumatic Stress Disorder
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Exposure to traumatic event
• Response is fear, horror, hopelessness, disorganized state or
agitation
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Trauma is re-experienced
• Intrusive thoughts/images/recollections
• Flashbacks/dreams
• Physiologic arousal to cues/reminders
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Avoidance of triggers related to event
• Denial/avoidance
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Increased arousal
• Vigilance, alertness, sleep disorders, irritability/emotional lability
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Acute Stress Disorder
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Similar sx
Immediate response to trauma
(From Boesky 2003)
Psychotic disorders
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Key sx is a difficulty differentiating what is real
from what is not
Negative symptoms
 Hallucinations
 Delusions
 Disorganized speech and behaviors
Some other dx can also have psychotic sx
 Major depression
 PTSD
(From Boesky 2003)
Mental disorders, in sum
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Watch for co-morbidity
Refer these youth to appropriate
providers
Untreated mental disorders have poor
outcomes
Youth should still be held accountable for
their crimes/actions but should also
receive treatment to avoid recidivism
Interventions
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Review info with juvenile and family
repeatedly
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Gather all mental health background
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Have a professional interpret the data
If have a provider, contact them!
We want to help our client too!
Advocate vigorously at the fitness hearing
Gathering evidence
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Formal mental health assessments need
to be done to r/o dx
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To dx mental disorders • Standardized battery of tests
• Clinical interview
• Intellectual functioning, personality tools
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For trauma, assessment tools examples • UCLA PTSD reaction index
• TSCC – trauma symptom checklist for young
children
• Child Sexual Behavior Inventory
The “Holistic Representation
Model”
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JJ system may be the first
intervention/treatment offered to the
juvenile
Integrate the trauma-informed practice
Use the bio-psycho-social model
Work as a treatment team
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http://www.lls.edu/juvenilelaw/holistic.html
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Trauma Resources
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The National Child Traumatic Stress Network (NCTSN) www.nctsn.org  a collaboration of academic and community-based service centers
whose mission is to raise the standard of care and increase access to
services for traumatized children and their families across the United
States
 http://www.nctsnet.org/nctsn_assets/pdfs/JudgesFactSheet.pdf
http://tfcbt.musc.edu (the Medical University of Southern Carolina) –
web based distance learning education course to learn the TF-CBT model.
http://www.cachildwelfareclearinghouse.org/
 an online connection for child welfare professionals, staff of public
and private organizations, academic institutions, and others who are
committed to serving children and families
Cohen, JA, Mannarino, AP, and Deblinger, E (2006). Treating Trauma and
Traumatic Grief in Children and Adolescents. Guilford Press.
Trauma References
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Boesky, L.M. (2003). Mentally ill youths and the juvenile justice
system, a primer on mental health disorders. NCJFCL, winter, 17-22.
Curtis, N. M., Ronan, K. R., & Borduin, C. M. (2004). Multisystemic
treatment: A meta-analysis of outcome studies. Journal of Family
Psychology, 18, 411-419.
Danielson, C.,et al (2006). Identification of high-risk behaviors among
victimized adolescents and implications for empirically supported
psychosocial treatment. Journal of Psychiatric Practice, 12(6), 364383.
Foa, E.B., Keane, T.M., & Friedman, M.J. (Eds.). (2000). Effective
treatments for PTSD: Practice guidelines from the International
Society for Traumatic Stress Studies. New York: Guilford Press.
Hamblen, JL, Mueser, KT, Rosenberg, SD and Rosenberg, HJ. (2005).
Brief Cognitive Behavioral Treatment for PTSD, Therapist Manual.
Linehan, M. (1987). Dialectical Behavior Therapy for borderline
personality disorder: Theory and method. Bulletin of the Menninger
Clinic. 51(3): 261-276.
Schnier, A. (2009). Trauma – understanding the impact on youth
behavior. Presentation, Division of Adolescent Medicine, CHLA.
Thank you!
Mari Radzik, Ph.D.
[email protected]