Transcript Establishing Universal Mental Health Screening In A Youth

Managing Young People in Youth Detention who
suffer from Posttraumatic Stress and associated
Mental Health and Substance Misuse Problems
Assoc. Prof. Stephen Stathis
Consultant Psychiatrist
Ivan Doolan
Senior Social Worker – Forensic
On behalf of the Mental Health Alcohol Tobacco and
Other Drugs Service (MHATODS)
health • care • people
Children’s Health Services
“Sometimes it is more important to know what
sort of person has a disease, than what sort
of disease a person has.”
Sir William Osler, M.D
health • care • people
Children’s Health Services
Outline
• Brief description of Mental Health Tobacco and Other
Drugs Service (MHATODS)
• Prevalence of Mental Health Problems and Substance
Use for YP in detention
• Treatment of Traumatised YP in detention
– Specific issues in this population
– Management difficulties & dilemmas
– Relatively little on medication
health • care • people
Children’s Health Services
Imagine ……..
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Almost all your clients had conduct disorder
Almost all your clients had been abused
Up to 90% use drugs or alcohol
Over half were Indigenous
One third were:
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Depressed
Anxious
ADHD
Significant posttraumatic symptoms
Broad range of “other” mental health problems
health • care • people
Children’s Health Services
What is MHATODS?
• Mental Health Alcohol Tobacco and Other Drugs
Service
• First time in Qld. that mental health & drug and
alcohol treatment for young people has been
integrated
• Run in the Brisbane Youth Detention Centre
– Males in detention from Rockhampton to NSW border
– All females in Qld
health • care • people
Children’s Health Services
The MHATODS Team
• Half time Consultant Psychiatrist
• 4+ Allied Health Clinicians specialised in C&YMH and
substance misuse.
• Team Leader (½ time clinical load)
• Administration Officer
• Indigenous Health Worker/s
• +/- Psychology Masters students
• Psychiatric Registrar from January 2009
health • care • people
Children’s Health Services
Aim of MHATODS
• Provide YP in detention with the same services they
could expect if they were to attend a Community Mental
Health Clinic or Drug and Alcohol Service
• Some modification due to setting
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Limited History
Access to Family
Therapeutic Strategies
Rapid “churn-through”
health • care • people
Children’s Health Services
Case Discussion
ZZ; 15 yr. male with 9 yr. Hx of disruptive
behaviours. Seen in juvenile detention.
• Stealing
• Some fire setting & graffiti/destruction of public
property
• Fighting & suspensions
• Entered the JJS at age 13; property offences
• Lack of remorse.
health • care • people
Children’s Health Services
Case Discussion
Complicated by:
• Low-average IQ (V = 66; P = 78; FS = 71)
• Learning problems & school-based behavioural
problems
– Left school IX grade
• Never sit still in class/fidgety
• Poor attention & concentration
• Always disruptive
• “Weird”; unusual stereotypical behaviours
• Poor peer relationships
• Poor awareness of social cues
health • care • people
Children’s Health Services
Case Discussion
Well documented history of physical abuse and
neglect:
• DV - mother
• Repetition of M’s own childhood/ few friends, poor
parenting.
• Rarely sees father
• M’s current partner is physically abusive when
intoxicated
• Reported to DChS ++
health • care • people
Children’s Health Services
Case Discussion
Mums main concerns:
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He is always “hyper” …
He acts “crazy without thinking”
It is getting worse in high school.
He was diagnosed with ADD and the medicines helped
him
health • care • people
Children’s Health Services
Case Discussion
In talking with ZZ:
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Admits he gets frustrated and “blows up”
Constantly feels sad
Hx DSI ?? Suicide attempts (x3)
People laugh at him because he is “strange”; never can keep
friends
Difficulties sleeping: nightmares (trauma related) and some
flashbacks
Alcohol, occasional marijuana. ecstasy & speed:
– Likes the “rush”
– Attempt to get rid of “bad memories”
People call me a schizo & a retard”
Has heard that he can get “dex” from you
health • care • people
Children’s Health Services
Diagnosis ???
Lots of  Co-morbidities here:
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ADHD; Combined type
ODD / Childhood Onset Conduct Disorder
Depressive Disorder
PTSD
Polysubstance abuse
“Aspergers Disorder” / PDD-NOS
Learning Disorder
Borderline Mental Retardation/ V:P mismatch
health • care • people
Children’s Health Services
Multiple Paradoxes
• Rapid assessment required of complex cases vs. Short
assessment time frame
• Significant co-morbidity vs. Collateral Hx difficult to
obtain
• Medication Seeking vs. Lack of therapeutic relationship
• Remand vs. Sentence
health • care • people
Children’s Health Services
Multiple Paradoxes (cont)
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•
High levels of MH and D&A problems
– Precontemplative
– Difficult to engage
Marginalised group of YP where trust in authority
figures is rare
health • care • people
Children’s Health Services
Patterns of Substance Use at
BYDC
health • care • people
Children’s Health Services
Substance Use in Youth
Detention
• Lennings & Pritchard (1999) found 90% of young
people in detention had some degree of drug/alcohol
use.
• 33% of these believed they had a problem.
– Of those, 70% thought they should have treatment
• >50% young people in detention met criteria for a
substance use disorder (Teplin et al., 2002)
health • care • people
Children’s Health Services
Reported Substance Use
Prior to Admission to BYDC
• Chart audit of admissions in the period 1/1/06 –
31/3/06
• 209 admissions
• 174 individual young people
• 31 females; 143 males
• 78 Indigenous; 96 non-Indigenous
• Mean age 15.4 years (+/-1.3)
health • care • people
Children’s Health Services
Reported Substance Use
Prior to Admission to BYDC
Reported Drug/Alcohol Use Prior to Admission
85%
90.00%
83%
80.00%
72%
70.00%
61%
60.00%
52%
50.00%
40.00%
30.00%
19%
20.00%
10%
10.00%
4%
1%
0.5%
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health • care • people
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0.00%
Children’s Health Services
Reported Substance Use
Prior to Admission to BYDC
Males Reported Drug/Alcohol Use Prior to Admission
100.00%
86.08%
90.00%
83.54%
80.00%
72.15%
70.00%
62.03%
60.00%
54.43%
50.00%
40.00%
30.00%
17.09%
20.00%
9.49%
10.00%
1.27%
0.00%
3.16%
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0.00%
Children’s Health Services
Reported Substance Use
Prior to Admission to BYDC
Females Reported Drug/Alcohol Use Prior to Admission
90.00%
82.86%
82.86%
80.00%
68.57%
70.00%
60.00%
54.29%
50.00%
40.00%
40.00%
25.71%
30.00%
20.00%
14.29%
10.00%
2.86%
0.00%
5.71%
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Children’s Health Services
Audit Summary
• Males higher rates for marijuana, alcohol
• Females higher rates inhalants, amphetamines
• Non-Indigenous higher rates alcohol,
amphetamines
• Indigenous higher rates inhalants
health • care • people
Children’s Health Services
MHATODS Programs
• Four Session Individual Substance Use
Intervention Program
• Voluntary
• Individual one-on-one counselling for
anyone
• Aim is to understand substance use in
context of life and experience
• Can be referred by Caseworker, Nurse or
VMO
health • care • people
Children’s Health Services
MHATODS Programs
• Four Session Group Relapse Prevention
Program
• Voluntary
• Group counselling for anyone
• Aim is to maximise reducing or ceasing
substance use
• Can be referred by Caseworker, Nurse or
VMO
health • care • people
Children’s Health Services
Prevalence of Mental Health
Problems at BYDC
health • care • people
Children’s Health Services
MH Problems: YP in Detention
• 2/3 of males and 3/4 females in detention
centres will have one or more psychiatric
disorders (Teplin et al, 2002)
– Similar findings in Australia, Canada, UK &
Europe
– Comorbidity is the NORM rather than the
EXCEPTION
health • care • people
Children’s Health Services
PTSD in Youth Detention
(Abram et al. 2004)
• ~900 young people in juvenile detention
• Diagnostic Interview Schedule for Children,
version IV (DISC IV)
• 92.5% experienced 1 or more traumas (mean,
14.6 incidents; median, 6 incidents)
• Significantly more males (93.2%) than females
(84.0%) reported at least 1 traumatic experience
• 11.2% of the sample met criteria for PTSD in the
past year.
• > 50% with PTSD reported witnessing violence
as the precipitating trauma.
health • care • people
Children’s Health Services
Massachusetts Youth Screening
Instrument (MAYSI-2)
• Screens for 7 scales of mental health or
behavioural problems:
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Alcohol and Drug
Angry-Irritable
Depressed-Anxious
Somatic Complaints
Suicide Ideation
Thought Disturbance (males only)
Traumatic Experience (gender specific)
health • care • people
Children’s Health Services
RESULTS – Males vs
Females
90
Any Cut-Off
75
68
Alcohol/Drug Use
59
28
28
Angry-Irritable
Female
43
Depressed-Anxious
19
Male
45
Somatic Complaints
28
30
Suicide Ideation
13
Thought Disturbance (Male Only)
28
0
10
20
30
40
50
60
70
80
90
100
Percentage
Percentage of males (n=124) and females (n=40) scoring above screening cut-off
on each scale, excluding Traumatic Experiences.
health • care • people
Children’s Health Services
RESULTS
• 75% males and 90% of all females scored
above the clinical cut-off on at least one of the
scales (excluding Thought Dist. & Traumatic
Experiences).
• Females screened for significantly higher
mental health problems than males across
three scales:
– Depressed-Anxious (2 = 9.41; p < 0.01)
– Somatic Complaints (2 = 3.89: p < 0.05)
– Suicide Ideation (2 = 6.24; p < 0.05)
health • care • people
Children’s Health Services
What About Traumatic
Experiences?
health • care • people
Children’s Health Services
TE Subscale- 5 Questions
1.
2.
3.
4.
5.
Have you ever in your whole life had something bad or terrifying
happen to you?
Have you ever been badly hurt or in danger of getting badly hurt or
killed?
Have you had a lot of bad thoughts or dreams about a bad or
scary event that happened to you?
Have you ever seen someone severely injured or killed (in person
not just on TV)?
FEMALE: Have you ever been raped or in danger of being raped?
MALE: Have people talked about you a lot when you’re not there?
health • care • people
Children’s Health Services
RESULTS – TE Subscale
Disturbingly high rates of trauma
• 82% females reported at least 1 traumatic
event; Mean 3.4
• 67% of males reported at least 1 traumatic
event; Mean 2.2
health • care • people
Children’s Health Services
SUD Dx %
Correlation between TE and
SUD
100
90
80
70
60
50
40
30
20
10
0
90
73.1
79.9
70.6
56.1
1
2
3
4
5
TE Score
health • care • people
Children’s Health Services
Screening: Implications for
practice?
• DO NO HARM
• We know there is a high burden of D&A and MH problems
• We know there are heaps of traumatised young people in
detention
• We know that admission into detention precipitates
posttraumatic symptoms (PTS)
– Agitated young people historically poorly tolerated!!
• New environment including loss of (limited) supports
• Close living quarters
• Stress of court process
• ?Withdrawal symptoms
• Away from country (Indigenous)
• We don’t know evidence-based ways to treat these young
people
health • care • people
Children’s Health Services
Treatment for Trauma
Exposure/Fear Based Trauma
– Single episode trauma
– Characterised by Intrusive
Thoughts
– Few other MH issues
– Little SA
– Discrete trauma
– No Hx prior to index event
– Reasonable  health
health • care • people
Shame Based Trauma
– Prolonged abuse
• Torture/POW
• Childhood SA
• Interpersonal victimisation
– Trauma has effected the concept
of self
– “Complex PTSD”
• Associated MH Co-morbidity
– Sx linked to dependence, guilt &
humiliation
– Interventions
• Therapeutic Relationship*
• Need for medication
Children’s Health Services
Evidence Base - Adolescents
• Surprise, surprise.! Very little
• Usually associated with natural disasters or
single assaults (fear-based trauma)
• Soon after trauma
• Few with the types of traumatised YP we see in
detention
• Very few “brief” interventions
– 6, 8, 10, 18 weekly sessions
– 1-2 hour/session
health • care • people
Children’s Health Services
Evidence Base - Therapies
• Silverman (2008) reviewed 21 treatment studies
for children suffering from PTSD and PTSS
– Violence, Abuse, Disasters, MVA
• 8 studies using Traumatic-Focused CBT met
“Well Established Criteria” for efficacy
– Shared the following:
• Working with children individually
• Child exposure tasks via narratives, drawings or
imagination
• Most ~ 12 sessions; up to 20
• Most 45-90 minutes duration
health • care • people
Children’s Health Services
Dilemma: Highly Transient Population
<3
Days
3- 28 Days 1 – 6
Months
> 6 Months
Total
Ave. Daily
Pop. (ADP)
4
15
32
20
72
ADP %
6%
21%
45%
28%
100%
282
98
21
795
#Admissions/ 394
Year
health • care • people
Children’s Health Services
The Dilemma Continue
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Highly Transient Population in BYDC
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Environment of BYDC
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Short and frequent admission
Contain vs Exacerbate
Need for short term symptom control
Confounding bias
Co-morbidity is the norm
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Need to also treat MH and SU problems
health • care • people
Children’s Health Services
The Dilemma (continued)
• Psychologically minded
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Precontemplative
Stimulus to change in BYDC only?
External locus of control and medication … “Give me a pill, doc”
Cognitive Scores skewed to left
• Marginalised group of YP
– Lack of trust
• Community Toxicity
– Longstanding social disadvantage / Maslow’s Hierarchy
– Ongoing trauma after release
• Indigenous
– Narrative Approach best
health • care • people
Children’s Health Services
The Dilemma (yes, there is
more)
• Inappropriate dismantling of complex defenses
– “Professional Voyeurism”
• Ability to extract information from a patient which
does not assist in management
• What can you do with the history obtained?!
health • care • people
Children’s Health Services
Conclusion: Need to Develop Our
Own Program
• Brief (~ 4 sessions within a month)
• Narrative
• Focused on Acute symptoms reduction
– Solution Focused
• Psychoeducational
– Understanding the meaning behind the Sx
• Cognitive Restructuring
– Understanding the negative/intrusive thoughts
health • care • people
Children’s Health Services
Brief Intervention for Trauma
Symptoms (BITS)
• Narrative strength based approach
• Integrate trauma experience symptomatology
• Regain mastery of the parts of their lives
affected by their trauma related symptoms
health • care • people
Children’s Health Services
4 Sessions
1. Psychoeducation
2. Trauma Narrative
3. Cognitive Restructuring
4. Symptom Management
health • care • people
Children’s Health Services
Session 1: Psychoeducation
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Re-Experiencing Phenomena
Avoidance Symptoms
Arousal
Mood disturbances
Goal is to normalise the response
Normal/recognised experience to an abnormal
event
• “I would expect someone who has experienced
what you have to be having (flashbacks etc…)”
• Reassurance they are not going …. crazy,
womba etc
health • care • people
Children’s Health Services
Session 2: Trauma Narrative
• Attempt to get a young person to give you an
idea of what they have suffered
• Use of the TSCC
• A lot of young people have things happen to
them that are difficult to talk about. Has
something like that happened to you?
• eg. If sexual abuse evident
– “Sometimes adults touch children in a sex way, or make children touch
them in a sexual way. Has this happened to you?
– Sometimes children enjoy these things and then feel really guilty and
bad about it. Has that ever happened to you?
health • care • people
Children’s Health Services
Session 3: Cognitive
Re-Structuring
• Aim of this session is to enable the YP to move
from a position of self-blame and responsibility for
the trauma to a position of being able to place the
blame and responsibility with the perpetrator
• Many YP blame themselves for being unable to
stop the trauma
• Facilitate YP need to gain a realistic view of their
experience
health • care • people
Children’s Health Services
Realistic View
1. YP not to blame for what they have
experienced
2. They could not have stopped the trauma from
occurring
3. Responding to the trauma in a maladaptive
way is allowing the perpetrator to win / retain
control
health • care • people
Children’s Health Services
Addressing the Blame
• Question the YP in a manner that challenges
their thoughts
– “If you were talking to an X yr. old child who
experienced what you have, would you blame them?
– “What would you say to them?”
– “If you were an X yr. old child and the perpetrator was
an adult, who would be to blame?”
health • care • people
Children’s Health Services
Addressing the Blame (cont)
– “Children are brought up to obey adults. If an
adult tells you to do something, are you really
going to say no?”
• At what age does this change?
– “Children trust adults. Do you think a child is
going to question what an adult says or
does?”
• At what age does this change?
health • care • people
Children’s Health Services
Addressing the Maladaption
• Reframe the maladaptive coping mechanism
– “How have you coped with what has happened?”
• DSH
• Substance use
• Promiscuity etc
– “Is this helping or hurting you?”
– “What other ways might you cope?”
– “What would you suggest to other YP?”
health • care • people
Children’s Health Services
Session 4: Symptom Management
• Aim of this session is to identify strengths and
resilience YP possess that has allowed them to
survive the trauma
• YP often are unable to see any positives about
themselves
– Self-blame they have developed about the trauma.
– Toxic environment, few supports etc
• The goal in this session is assist the young
person to identify these positives.
health • care • people
Children’s Health Services
Focus on the Positive
• What do you do when you have ………….
(flashbacks, nightmares, intrusive thoughts, etc.)
• What have you found to help the most?
• What would you tell other young people to do?
• How have you been able to survive all of this
– What does that tell you about yourself?
– Did you ever think you possessed those strengths?
• I am amazed at how you have been able to
cope. What other coping methods have you
used?
health • care • people
Children’s Health Services
Medication
• Emerging evidence of some SSRIs and atypical
antipsychotics
• Quetiapine (low dose)
– Sedation
– Reduction in re-enactment phenomena
– Reduced affective lability
• Blinded trial of Quetiapine and Fluvoxamine
health • care • people
Children’s Health Services
Evaluation
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•
Pilot program
MAYSI as a screening tool
TSCC beginning and end
?Other instruments
• Watch this space!
health • care • people
Children’s Health Services
Future
• Medication vs. Therapy alone
• Individual vs. Group Therapy
– Group therapy is risky in detention
– Not a debrief
• Most of what passes as psychological debriefing
has essentially been debunked
health • care • people
Children’s Health Services
health • care • people
Children’s Health Services