Culturally-Alert Clinical Interpretation of GAIN-Based Information with Adolescent Trauma Victims

1. Culturally-Alert Clinical Interpretation of GAIN-Based Information with Adolescent Trauma Victims Joint Meeting on Adolescent Effectiveness (JMATE) 2010

2. Objectives • Explore strategies to tease out clinically accurate data from substance-abusing trauma victims in a culturally-sensitive manner • Improve skills for assessment and treatment of culture-related trauma issues common to Hispanic/Latino youth • Develop culturally-alert diagnosis and treatment responses for GLB and rural adolescents with traumatic victimization that began at home

3. Panel Presenters • LaVerne Hanes Stevens, PhD • Maria Maldonado, BSBM • Matthew Orndorff, M.A. • Christopher Townsend, M.A.

4. The Global Appraisal of Individual Needs • The Global Appraisal of Individual Needs (GAIN) is a family of comprehensive bio-psychosocial assessment tools developed by Dr. Michael Dennis and a multi-disciplinary team of professionals at the research and training division of Chestnut Health Systems in Bloomington, Illinois. • The GAIN’s semi-structured administration protocol allows for flexibility in response to cultural factors by those who administer and those interpret the assessment.

5. Our Nation’s Increasing Diversity • Noting the work of Sue and Sue (2003), Garrett McAuliffe (2008) notes the following facts about culture and diversity in the United States: • Nearly half (45%) of students in America’s public schools are students of color. • At least 7% of the United States population is gay, lesbian or bisexual, and this population seeks out counseling services at high rates. • Latinos have become the largest ethnic minority group in the United States. • Seventy percent of the United States population reports religion as a central enterprise and 90% of the population have a belief in God. • Despite economic gains for African-Americans in the United States, this group continues to experience segregation and bias in housing and employment, and has a poverty rate that is double the poverty rate of European Americans. • Thirty percent of all new immigrants to the United States are Asian, making this America’s largest immigrant group.

6. Severity of Victimization by Race GVS = 15 items; E9 a-r Source: CSAT 2009 Summary Analytic Data Set (n=18,962)

7. Severity of Victimization by Sexual Orientation GVS = 15 items; E9 a-r Source: CSAT 2009 Summary Analytic Data Set (n=18,962)

8. Severity of Trauma by Race TSS = 13 items; M2a-M2p Source: CSAT 2009 Summary Analytic Data Set (n=18,962)

9. Severity of Victimization by Sexual Orientation TSS = 13 items; M2a-M2p Source: CSAT 2009 Summary Analytic Data Set (n=18,962)

10. Our Approach: DSM Axis IV, III, I, II, V • First, consider Axis IV (psychosocial / environmental issues) as well as religion or spiritual beliefs, acculturation, identity formation… • Next, weigh medical conditions (Axis III) that might contribute to, trigger, or be the source of distress. • Then consider clinical disorders (Axis I), with cultural expressions in mind (e.g. talking to spirits). • Finally, consider Axis II, personality disorders, with special care. Culture affects how personality is seen (e.g., what is narcissistic in an individualistic culture, what is dependent in a collectivist culture.) • Axis V ratings take into consideration all of the above.

11. Let’s look at some case studies

12. Culturally sensitive assessments for Hispanic/Latino youth using the GAIN Maria Maldonado, BSBM, The Center for Drug-Free Living

13. Case Study: Mario • Illegal immigrant from Mexico • 17-year old male (crossed the border at age 9) • Never met dad • Lives with single mom, a younger sister (14) and 2 younger brothers (ages 6 & 8) • Also lives with maternal grandmother, maternal uncle, aunt and one cousin (12) • His mother and most of his extended family do not speak English

14. Case Study: Mario Continued • Mario reports fear of immigration and being deported • Can not concentrate or focus • Bad grades and skips school • Has problems writing in English • Nightmares and lack of sleep • Mario feels alone and depressed • No healthcare coverage • Mario reports using alcohol until he gets drunk • Occasionally uses Xanax

15. GAIN Diagnostic Impressions Axis I • 305.0 Alcohol Abuse • Occasional use of prescription drugs: Xanax • 300.02 Generalized Anxiety Disorder • Rule out 309.81 Posttraumatic Stress Disorder, 308.30 Acute Stress Disorder or other disorder of extreme stress • 312.80 Conduct Disorder Axis II – Personality Disorders • Rule out 301.90 Personality Disorder NOS

16. Axis III - Medical Conditions GAIN Diagnostic Impressions • Lack of healthcare coverage • Lack of access to medical services • Has dental problems and is in pain • Home remedies

17. Axis IV- Psychosocial/Environmental Stressors GAIN Diagnostic Impressions • Fear of Immigration and deportation • High lifetime traumatic victimization • Nightmares, lack of sleep • Skipping school, bad grades • Weekly fighting at home • Weekly fighting with peers • Acculturation

18. The role of your clinical judgment:Do you agree with the diagnoses? Look at school, home and community environment • Mario is in constant fear of being deported • Fear can cause major stress and paranoia • Mario doesn’t feel safe at home due to fear for family • He doesn’t feel safe in school due to fear of being reported • He doesn’t feel safe in the community due to immigration raids • On a daily basis Mario experiences a great deal of “worry” not just for himself, but for fear of family separation • Mario’s younger brothers are U.S. Citizens

19. What role do you think Mario’s present circumstances and environmental stressors have? • Nightmares • He vividly remembers crossing the border and running for hours through the desert • At home is told never to say he is illegal • He reports lack of sleep due to anxiety • Runs away from home sometimes • Has rarely been to a doctor or dentist • He has to be the interpreter for family

20. Does Mario really have Conduct Disorder? • Looking again at Mario’s community, school and home environment. • He feels like an outsider like everyone is watching or talking about him • He is pressured at home for help but, told never say the truth, so he runs away or has angry outbursts • He doesn’t like school and he has always had trouble with writing in English • He skips school because he wants to avoid teasing and fights with peers for calling him names

21. Culturally sensitive assessment skills • Become familiar with the culture-related issues common to members of Hispanic/Latino groups. • Develop a list of any symptoms that a client has that might suggest the presence of a culture related syndrome and consider the presence of such syndromes before assuming the presence of psychopathology. • Consult with the client’s family, if appropriate, or other members of the culture to determine if the beliefs or behaviors are culturally supported.

22. Culturally sensitive assessment skills • Learn how members of the culture typically think about mental health and substance use disorders, as this may affect their self-report (e.g. under-reporting; over-reporting) • Determine the level and impact of client acculturation • Consider the perception and effect of racial discrimination and historical trauma

23. Culturally sensitive assessment skills • Assessment results and linkages to other services have to be done very carefully and sensitively, paying attention to lack of sophistication with agencies, clinical jargon and perceived stigma. Misinformation may not be deception but a result of embarrassment of what you may think of them. • If assessment is given in separate sessions and family does not show up for second interview, look at issues of transportation, time, childcare, fear of detection and stigma and continued developing rapport etc.). Client may be embarrassed to call you to cancel and may prefer not to show up.

24. Addressing Trauma on the Home Front: How to use the GAIN with victimized GLB or rural clients who turn to substances when they lack community supports. Matthew G. Orndorff, MA Chestnut Health Systems

25. Case Study: Carl • From rural farming community (population 300) • 16-year old white male who self identifies as gay • Came out to best friend and parents at age 15 • Parents did not accept him (labeled him as rebellious, no longer a good kid) • Disclosure to best friend went poorly • Faces constant harassment and bullying at school, home and in community • Bad grades • Skips school

26. Case Study: Carl Continued • Fear of harassment and bullying at home and school is consuming him • Can no longer concentrate or focus • History of running away • Carl feels completely outcast, alone and depressed • Carl regrets his decision to disclose his sexual orientation • Despite negative reactions is confident in his sexual identity • Has Alcohol Dependence • Occasionally “huffs” gasoline

27. GAIN Diagnostic Impressions • Axis I: Clinical Disorders/Focal Conditions • Alcohol Dependence • Past use of inhalants: Gasoline • 296.90 Major Depressive Disorder (MDD) • Rule out 309.81 Posttraumatic Stress Disorder, 308.30 Acute Stress Disorder or other disorder of extreme stress • 314.00 Attention Deficit Hyperactive Disorder-Inattentive Type • [(6+M3a1-9 & 1+ in M3d = 2)] • 312.80 Conduct Disorder • [3+ Sx in M3b1-15, M3b17-19 & 1 + days in M3c]

28. Items Endorsed: ADHD-Inattentive Type[(6+M3a1-9 & 1+ in M3c) or M3d=2)]

29. Items Endorsed: ADHD-Inattentive Type[(6+M3a1-9 & 1+ in M3c) or M3d=2)]

30. Does Carl Really Have ADHD-Inattentive Type? • Look at school environment and home environment • He is constantly tormented and harassed • Fear can be a major distraction and can effect anyone’s ability to focus or calm down • Client doesn’t feel safe probably spending a great deal of his time strategizing how to avoid the next un-kind word or physical torment • He probably is experiencing a great deal of “worry” as he doesn’t feel accepted at home, school or community, worry can also be a big distraction • Bottom line-I would be asking if these behaviors get worse when he is faced with situations in his environment that force him to constantly strategize ways to seek safety or avoid verbal attacks.

31. Items Endorsed: 312.80 Conduct Disorder [3+ Sx in M3b1-15, M3b17-19 & 1 + days in M3c]

32. Items Endorsed: 312.80 Conduct Disorder [3+ Sx in M3b1-15, M3b17-19 & 1 + days in M3c]

33. Does Carl Really Have Conduct Disorder? • Looking again at Carl’s community, school and home environment. • Carl feels like an outsider like everyone hates him • Carl is ridiculed at home, looking for escape (runs away) • Carl doesn’t want to go to school and is probably avoiding interaction with his father at home (lies and cons) • Carl skips school because he wants to avoid teasing and harassment • Bottom line-you must decide if the behaviors are maladaptive or just a mode of survival.

34. Environmental Factors

35. Environmental Factors

36. Environmental Factors

37. Environmental Factors

38. Environmental Factors

39. Environmental Factors

40. Other Items Endorsed

41. Using the GAIN with African American youth and youth with strong religious ties Christopher Townsend, MA Essential Concepts, Inc.

42. Case study: Bobby • 17 year old African American Male • Lives in an urban community with a drug dealer • Has a history of being in and out of foster care • Parents are substance abusers and have spent the majority of Bobby’s childhood in jail • Dropped out of school in the 10th grade • Currently on probation for possession with intent to sale illegal substances

43. Case Study: Bobby, continued • Frequently violated for non-compliance • He has been a “look out boy and transporter of substance” • Was homeless until the last 60 days • No family members in the state • Emancipated a year ago after graduating from life skills training from DSS

44. Case Study: Bobby, continued • Has experienced many episodes of being without food • Has been bullied most of life because of poverty • Joined gang a year ago for: • Food • Housing • Money • Protection

45. Case Study: Bobby, continued • Feels overwhelmed most of time • Fearful • Angry • Sad • Hears God speaking to him; telling him what to do. • Reports seeing visions of a different life

46. GAIN Diagnostic Impressions Axis IV: Psychosocial and Environmental • Weekly intoxication by others in living situation • Weekly substance use by others in living situations • Illegal activity in living situation • Weekly fighting in living situation • Illegal activity among peers • Weekly intoxication among peers • Weekly fighting among peers • Probation or parole violations in the past 90 days • High lifetime history of traumatic victimization • Death of a family member or close friend • Weekly illegal activity during the past 90 days • Financially support self from illegal activity

47. GAIN Diagnostic Impressions Axis III: General Medical Conditions • Lifetime history of allergies to: Pollen Axis I: Clinical Disorders/Focal Conditions • 304.30 Cannabis Dependence • 305.00 Alcohol Abuse • 304.20 Cocaine Abuse • Rule out 309.81 Posttraumatic Stress Disorder, 308.30 Acute Stress Disorder or other disorder of extreme stress • 312.80 Conduct Disorder • Psychotic Disorder NOS Axis II: Personality Disorders/Mental Retardation None reported Axis V: Average Clinical Functional Assessment Ratings • 12-month GAF: 55 90-Day GAF: 45

48. Is It Psychosis? • Bobby endorsed M1d_1, M1d_8, M1D_9, M5A_17, E13a-e • Feeling very anxious, nervous, tense, scared, panicked or like something bad was going to happen • Thoughts that someone was watching you, following you or out to get you • Seeing or hearing things that no one else could see or hear or feeling that someone else could read or control your thoughts • Prior diagnoses of Psychotic Disorder NOS

49. Is it Conduct Disorder? • Consider environmental factors and basic needs: • Are behaviors a disorder or a means to an end? • If the environment is changed and symptoms are not present; is it still a disorder? • Were the behaviors forced responses to preserve oneself? • What is the norm for the community?

50. Discussion