Transcript Working with adolescent victims

TRAUMA-INFORMED PRACTICE WITH
YOUNG PEOPLE IN THE CRIMINAL
JUSTICE SYSTEM
Robert Leardi
Senior Clinician (Clinical Psychologist)
BBSc, PGDip Psych, MPsych (Clinical), MAPS
Nov 10, 2015
The menu for today:
1. How big is the issue?
2. Factors related to juvenile violent behaviour and delinquency
3. The ACE Study
4. What is trauma
– Trauma and the brain
– How youth respond to trauma
5. An individual trauma-informed intervention approach: P.A.C.E
6. Systemic trauma-informed approaches:
– The ITS
– The Sanctuary Model
7. Common issues and recommendations
Just how big is this issue…
Take your pick of the evidence (prevalence)…
■ 80% of incarcerated youths across Australia have experienced multiple traumatic
stressors (RACP, 2011).
■ Some studies have found at least 92% had one form of trauma (Abram et al. 2004).
■ Increase in the average number of young people incarcerated per day over the past
decade across Australia.
Overrepresentations everywhere…
■ 10-16yr olds account for <10% of the population, but account for ~25% of the
offender population (RACP, 2011)
■ Overrepresentation of Indigenous young people. In 2009, approximately 6% of young
people in the community identified as Indigenous, compared to 63.8% of young
people in detention. Similar (yet smaller) overrepresentation exists for Maori young
people.
Just how big is this issue…
Take your pick of the evidence (health and wellbeing)…
■ Even after controlling for conduct disorder, there is an overrepresentation of MH
disorders amongst incarcerated youths (up to 75%: Teplin et al., 2002)
■
Particularly Bipolar Disorder, Schizophrenia, MDD, PTSD, and SUDs
■ Suicidality (attempt, plan and ideation) and intentional self-harm are significantly
higher among young people in the youth justice system
■ Much higher AOD use; e.g., incarcerated youths have significantly higher rates of
drug use in one month compared to adolescents in the community in one year.
■ Higher rate of STIs (e.g. chlamydia infection)
Just how big is this issue…
Take your pick of the evidence (Child Protection and OOHC)…
■ Consistently strong correlations between childhood abuse or neglect and juvenile
justice involvement across multiple studies in multiple countries
– There’s a particularly strong correlation between criminal activity and
neglectful parenting
■ In a DHS study (Victorian sample).
 88% of young people sentenced to prison were subjected to an average of 4.6 CP
notifications.
 86% had been living in out-of-home-care
 More than half had been subjected to 5+ placements
Just how big is the issue…
Take your pick of the evidence (childhood trauma)…
■ Dierkhising et al. (2013)
– N = 658 adolescents (NCTSN dataset)
– To describe trauma histories, MH problems, and other risk factors for among
adolescents with recent involvement in the juvenile justice system.
“The results indicate that justice-involved youth report high rates of trauma exposure
and that this trauma typically begins early in life, is often in multiple contexts, and
persists over time. Findings provide support for establishing trauma-informed
juvenile justice systems that can respond to the needs of traumatised youth”
■ Consistent across the literature (e.g. Chamberlain & Moore, 2002; Ford et al., 2007;
Kerig & Becker, 2010)
■ More severe childhood trauma have been associated with more severe criminal
behaviour (Smith & Thornberry, 1995; Widom & Maxfield, 1996)
Predictors of adolescent violence:
VRS-YV (Lewis, Wong, & Gordon, 2004).
VRS-YV:
Canadian sample
Commonly used in Aus.
Predictive tool for
violence in young people
4 static factors
19 dynamic factors
Based off the adult
version
 Early onset serious  Poor education
antisocial
 Antisocial peers
behaviours
 Interpersonal
 Criminality
aggression
 Unstable family
 Poor emotional
upbringing
control
 Family antisocial
 Violence during
behaviour
institutionalisation
 Violent lifestyle
 Weapon use
 Callous and
 Low insight
unemotional
 Criminal attitudes  Mental disorder
 Substance abuse
 Impulsivity/
attention deficits
 Cognitive distortions
 Poor parent-child
Interaction
 Family stress
 Social isolation
 Community
disorganisation
 Poor compliance
Predictors of adolescent violence:
VRS-YV (Lewis, Wong, & Gordon, 2004).
VRS-YV:
Canadian sample
Commonly used in Aus.
Predictive tool for
violence in young people
4 static factors
19 dynamic factors
Based off the adult
version
 Early onset serious  Poor education
antisocial
 Antisocial peers
behaviours
 Interpersonal
 Criminality
aggression
 Unstable family
 Poor emotional
upbringing
control
 Family antisocial
 Violence during
behaviour
institutionalisation
 Violent lifestyle
 Weapon use
 Callous and
 Low insight
unemotional
 Criminal attitudes  Mental disorder
 Substance abuse
 Impulsivity/
attention deficits
TRAUMA
 Cognitive distortions
 Poor parent-child
Interaction
 Family stress
 Social isolation
 Community
disorganisation
 Poor compliance
Adverse Childhood Experience
(ACE) study
■ One of the most significant studies into the impact of adverse childhood experience
on growth and development
■ Adverse childhood experience includes
– Childhood abuse
– Neglect
– Exposure to other traumatic stressors
■ Developed the “ACE Score”, which is a total count of adverse childhood experiences
a person had
2
3
1
5
■ Almost of respondents and ACE Score of 1, more than had an ACE Score of 3.
ACE Study: Just a few of the results
What is Trauma?
The EXPERIENCE of a real or perceived threat
to a person’s life or bodily integrity
The life or bodily integrity of a loved one
It causes an OVERWHELMING sense of terror,
horror, helplessness, and fear
Trauma and the brain
■ How does trauma affect the
development of the brain?
■ Why is this important to
understanding youth
offending behaviours?
First, we must understand the
basics of brain development…
https://youtu.be/VNNsN9IJkws
Trauma and the brain
Fundamental principals or neurodevelopment: Perry (2006)
1. The brain is organised in a hierarchical fashion, with all incoming
sensory information entering the lower parts of the brain first
2. Neurons and neural systems are designed to change in a usedependent manner. In other words, the brain operates on a “use it or
lose it” principal.
3. The brain develops in a sequential fashion (starts from lowest regions
of brain and outwards).
4. The brain develops most rapidly in early life (including in-utero)
5. Some neural systems are easier to change than others
6. The human brain is designed for a different world
PREFRONTAL
CORTEX
CORTEX : - THINK 3-6 yrs
Executive Functions, Reasoning
Creativity, Respect, Language, Explicit
Memory
LIMBIC SYSTEM: - FEEL 1- 4 yrs
Play, Emotional Reactions
Relating, Attunement, Empathy, Implicit
memory
DIENCEPHALON & CEREBELLUM – ACT
6 mnths – 2 yrs
Sleep, Appetite, Balance, Gross and Fine
Motor Control,
CORPUS
CALLOSUM
BRAIN STEM : - LIVE 0 - 9 mths
Blood Circulation, Breathing
Heart rate, Sleep
Brain Plasticity (recall, principal 2)
The brain can reorganise itself by forming
new neural connections throughout life.
This process can allow the brain to
compensate for injury and disease and to
adjust in response to new situations.
In childhood, there is the greatest
vulnerability to harm but also the greatest
potential for healing
Children are less “resilient” than they are
ADAPTIVE
Resting Heart Rates:
Branch Davidian Children (Waco Siege, 1993) (21 children, CTA)
140
Assault
Fire
Parent
Visits
130
120
110
100
90
4/21/93
4/16/93
4/11/93
4/7/93
4/2/93
3/28/93
3/23/93
3/18/93
3/13/93
3/8/93
80
Trauma Impact - Memory
Implicit
Not consciously
recalled
Emotions
Sensations
Body Actions
Body Memories
Memory
Explicit
Consciously
recalled
Events, Facts
Auto-biological
Trauma and traumatic memories
■ Trauma may be remembered as isolated images, body sensations,
smells and sounds.
– Often, without “the story” to go with it.
■ Events or feelings in the present can trigger a memory of past trauma
– Young person acts as though the trauma is happening now
– They typically have little ability to distinguish between the past
and the present.
■ Triggers can be obvious (e.g. returning to a bedroom where trauma
took place) or subtle (a look, a song, a sound, a word, a smell, foods)
Chronic/toxic stress
■ Stress can be good for you! But not in large or chronic doses…
Chronic stress can lead to:
■ Damage to the hippocampus, underdevelopment of the PFC, loss of
dendritic branches
■ Amygdala is most reactive to facial expressions of anger and fear, and
sounds of anger and fear
https://youtu.be/rVwFkcOZHJw
How do youth respond to trauma?
1. Re-experiencing / Re-enacting
■ Intrusive memories (e.g. images,
memories of the event)
■ Nightmares
■ Flashbacks
■ Disturbed thoughts
■ Difficult behaviours in the units
How do youth respond to trauma?
2. Hyperarousal / Reactivity
■ Jumpiness
■ Nervousness
■ Quick to be startled
■ Always energetic
■ Fidgety
■ Hypervigilance
Hyperarousal is sometimes an
overgeneralised survival skill
How do youth respond to trauma?
3. Avoidance / Numbing
■ Feel numb
■ Shut down
■ Pull away from peers
■ Stop activities they used to enjoy
■ Avoid talking about trauma
– Try to avoid memories and
thoughts about trauma as well
How do youth respond to trauma?
4. Dissociation
■ One form of avoidance
■ Mentally separating the self from
the experience
■ Experiences the self as detached
from the body, somewhere else in
the room
■ Feeling like in a dream state
■ Lose sense/blocks of time
Think: “Psychologically fleeing”
The P.A.C.E Approach
Dr Daniel Hughes
PACE
■ The brain is designed to build and organise itself around attachments
■ We now know the human brain keeps developing rapidly past
adolescence
■ PACE promotes social engagement (and in turn, attachment) in a
trusting and nonthreatening manner
■ PACE stimulates the amygdala in a different (more positive) manner.
“Perhaps this situation does not require Fight/Flight/Freeze”
■ Helps young person delay their initial reaction. Initiates surprise.
PACE Approach
Dr Dan Hughes describes a therapeutic parenting approach in which
OOHC workers maintain an attitude of being:
Playful
Accepting
Curious
Empathy
Playfulness
■ Light hearted, relaxed & playful attitude can help child/young person,
sometimes unexpectedly, to experience fun.
– When you are laughing, you’re not experiencing shame
■ If they are usually resistant and do not see it coming they will find it
harder to avoid and disengage.
■ Playfulness can interrupt their sadness and heaviness.
■ Stimulates the prefrontal cortex
Accepting
■ Suspending judgment and accepting the child/young person as a
worthwhile human being.
■ No exceptions to accepting. Must accept all their ideas, feelings and
thoughts.
■ Accepts the behavioural choices young person is making and the
feelings behind these choices
– Acceptance behaviour is NOT the same as condoning behaviour
■ Feeling Accepted  less perceived judgement  less defensiveness
 greater chance for positive change talk
Curiosity
■ Wondering with the young person about the meaning behind the
behaviour and why they do the things they do.
■ Acceptance leads to curiosity
■ Curiosity is making best guesses about what is going on.
– The young person and worker figure it out together.
■ Curiosity helps young person feel heard and understood.
■ Being curious can help young person teach us
■ Needs to be done in a non-judgemental manner
Empathy
■ ‘Feeling with’ another person, feeling compassion for their struggles or
suffering.
■ Acceptance is showed through empathy.
■ Empathy eventually helps young person to acknowledge deeper
feelings of fear, sadness, hurt, anger, without fearing judgement.
■ Statements such as “I’m so sorry that happened” or “that must have
been really hard” show empathy.
■ Being mindful of not over empathising.
Trauma-informed practice
■ According to the Dierkhisinh et al. (2013) from National Child Trauma and Stress
Network, a trauma-informed system for Youth Justice is one in which programs,
agencies, and service providers:
1. Routinely screen for trauma exposure and related symptoms;
2. Use culturally appropriate evidence-based assessment and treatment for
traumatic stress and associated mental health symptoms
3. Make resources available to children, families, and providers on trauma
exposure, its impact, and treatment
4. Engage in efforts to strengthen the resilience and protective factors of
children and families impacted by and vulnerable to trauma
5. Address parent and caregiver trauma and its impact on the family system
6. Emphasize continuity of care and collaboration across child-service systems
7. Maintain an environment of care for staff that addresses, minimizes, and
treats secondary traumatic stress, and that increases staff resilience.
Dierkhising, C.B., Ko, S., and Halladay Goldman, J. (2013). Trauma-Informed Juvenile Justice Roundtable: Current
Issues and Directions in Creating Trauma Informed Juvenile Justice Systems. Los Angeles, CA & Durham, NC: National
Center for Child Traumatic Stress.
Systemic interventions:
The ITS model
■ Ombudsman Report 2010
– A recommendation to provide
a trauma-focused approach
in working with clients
■ VIC DHS tendered for a
service to provide traumainformed practice across
PYJP
■ Town Hall Meeting 2012
– Staff indicated a need for a
better understanding of
adolescent trauma
■ Take Two Berry Street
successful. Together they
developed the Intensive
Therapeutic Service (ITS)
UNDERSTANDING
YOUNG PERSON
Age, development,
gender and culture
Developmental
trauma and disrupted
attachment
Mental health
Current
circumstances:
custodial setting,
group dynamics
Family issues
RELATIONAL
Risk assessment
Individual capabilities
and capacities
BUILDING ON
STRENGTHS
SUPPORT
Respectful and
authentic engagement
with the young person
Where possible
enlisting family and
friends in supporting
young person
Maintain healthy
boundaries
Pro-social role
modelling
Limit setting
History
SELF-REGULATION
Co-regulation when
distressed or
hyperaroused
Understanding sensory
processing, selfregulation, relational
and cognitive domains
of each individual
Evidence informed
trauma focused
therapies
Practice self-regulation
approaches
Psycho-education
Understanding state
dependent functioning
Safety planning
Co-regulation
Recognising and
building
narratives of
success
Building on
positive identity
and connections
Re-shaping
identity
Building
resilience under
adverse
situations
Learning and
practicing new
skills
FOUNDATIONS OF THE INTENSIVE THERAPEUTIC UNIT AND OVERALL APPROACH
Safety for all: Physical, psychological, emotional
and cultural safety for young people and staff
promoted through consistency, routines and
predictability
A structured physical and programmatic
environment that allows for low stimulus areas that
support self-soothing and promote positive group
dynamics
Valuing Relationships
Integrated clinical, educational, recreational and
rehabilitation programs
Trauma, developmental, & strengths based
approaches underpin all practices
Action learning approach throughout framework
Organisational culture and social climate that
support and enable a therapeutic approach
Effective governance that ensures congruence across
the service (e.g. supervision, team meetings, reflective
practice, debriefing)
The ITS Model
Understanding the Young Person
■ Developing a shared understanding of the YP and their functioning
■ The YP’s history and experiences
– Impact on relationships
– Impact on feelings of safety/ways of feeling safe
■ Find ways of responding in a way that promotes healing/development
and reduces shame/fear
The ITS Model
Relational Support
■ Developing relationships
– Safety and firm boundaries
– Honesty
– Attuned
– Respect
– Sensitivity
■ Engaging the Young Person in
their treatment/changes
■ Therapeutic moments in day to
day interactions
■ Quality not just quantity of time
with young people
■ Joint activities
■ Inclusion of the family
The ITS Model
Self Regulation
■ Managing their behaviours and feelings
■ Monitoring themselves/their reactions
■ Environment/sensory experiences to regulate
■ Bottom-up process in changing brain
■ Co-regulating
■ Modelling, and in many instances, re-modelling appropriate emotion
coping
The ITS Model
Building on Strengths
■ Building on what they are good at,
■ Help them develop an alternative (positive) story about self
■ Support positive cultural connections
■ Catch them being ‘good’,
– Praise/feedback for their ‘catalogue’ of what they know about
themselves.
■ Even if it sounds silly, the experience of receiving positive feedback for
these young people is likely to be foreign, new, and different.
Systemic interventions:
The Sanctuary Model
Sanctuary is an organisational change
model, creating therapeutic communities
through integrating trauma theory and
promoting safety for all staff and clients.
■ Currently being implemented by
MacKillop Family Services and areas of
WA DHS
■ It is based on the following 4 pillars
1. Trauma Theory
Understanding the impact trauma has had on the
young person, e.g.
■ Development
■ Attachment
■ Social functioning
■ Mental health
■ Training staff around trauma
Understanding integrative concepts such as:
■ Parallel processing
■ Trauma re-enactment
2. The SELF Model
Safety
■ Cultural, physical, psychological social
Emotions
■ Helping to manage difficult emotions
Loss
■ Grieving, adjusting to change
Future
■ Focus on goals, instil hope
3. The Seven Commitments
i.
Nonviolence
ii.
Emotional intelligence
iii.
Democracy
iv.
Open communication
v.
Social responsibility
vi.
Social learning
vii. Growth and change
4. The Sanctuary Tools
■ Safety plans
■ Supervision
■ Community meetings ■ Core team
■ Red flag meetings
■ Psychoeducation
■ Self-care plans
■ Team meetings
■ Case and service
planning
■ Ongoing training
What else could we do?
■ Ideally, trauma-informed assessment and intervention should become
accessible through diversion programs (e.g. community based orders).
■ Assessment could be performed by guardians, CP workers, or other
diversion staff.
■ Ensure all case managers and foster carers are trained in being able
to recognise and respond to a young person’s trauma symptoms.
Common issues
Assessment:
■ Not all MH professionals are adequately trauma-informed. This is not as simple as it
sounds, with most MH professionals being proficient in identifying “classic” PTSD
and not “complex” PTSD or cumulative harm.
■ No gold-standard too for assessing complex PTSD. Rather, there are many individual
tools assessing individual symptoms (e.g. dissociative symptoms, mood
disturbances, cognitive assessments).
■ Often the issues of “intergenerational” trauma are missed in assessment; i.e., the
assessment is too child focused and not family focused enough.
■ Young person’s confidentiality and autonomy. If a young person does not believe
their information will be treated confidentially, the quality/accuracy of their
information will be affected and their assessment will be less informative.
Common issues
Treatment:
■ Not as much evidence for the effective treatment of female
incarcerated youths versus male incarcerated youths.
■ Many of whom have experienced specific kinds of trauma at much higher
rates than males (e.g. sexual exploitation) (Kerig, 2013).
■ An important ingredient for effective treatment is the positive
involvement from a young person’s parents in their intervention.
Unfortunately, by the time a young person has entered the Youth
Justice system, their families are often fragmented and unlikely to
participate in any treatment.
Common issues
Other:
■ Young people in OOHC are often held to a much higher degree of
accountability than their peers
■ “System abuse” and the impact of being assessed/treated by multiple
different services
■ Continuity of care, particularly when there are changes to the workers
involved in the young person’s care
What to do?
Just a few suggestions…
■ Implement minimum trauma-informed training
standards for staff involved in the direct care of
young people in youth justice
■ Ensure continuity of care
■ Challenge ‘old-school’ thinking
■ Advocate! Consider the reduced financial
burden on the health system if we are able to
improve the wellbeing of our most at-risk young
people
Resources
Berry Street Childhood Institute: www.childhoodinstitute.org.au
The Child Trauma Academy: www.childtraumaacademy.org
The National Child Trauma and Stress Network: www.nctsn.org
The ACE study: www.acestudy.org
The Centre for the Developing Child: http://developingchild.harvard.edu/
The Sanctuary Model: http://sanctuaryweb.com/
Contact details
Robert Leardi
[email protected]
(03)9421 9323
0448 917 188
[email protected] (private)