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Treating Girls with Trauma and Delinquency: An Integrated Approach

Treating Girls with Trauma and Delinquency: An Integrated Approach. Dana K. Smith, PhD Oregon Social Learning Center Eugene, OR. Background. Females with conduct problems have been under studied

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Treating Girls with Trauma and Delinquency: An Integrated Approach

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  1. Treating Girls with Trauma and Delinquency: An Integrated Approach Dana K. Smith, PhD Oregon Social Learning Center Eugene, OR

  2. Background • Females with conduct problems have been under studied • Proportion of girls in JJ system has risen nearly 50% in recent years & rates of violence have increased • Rates of co-occurring problems for girls in JJ are very high – esp. related to trauma, substance use, risky sexual behavior • Girls with conduct problems are at risk to be self-destructive, to associate with older, highly delinquent males, and to transmit problems to the next generation • Communities have fewer programs designed for girls & are challenged to develop evidence-based treatments for girls with conduct and other co-occurring problems

  3. Oregon Social Learning Center Girls Studies • In the early 1990’s, OSLC began testing a family-based treatment for girls with severe conduct problems: Multidimensional Treatment Foster Care (MTFC) • First randomized trial of MTFC for girls began in 1996 with a sample of 81 girls • A second study began in 2002 with another 85 girls

  4. The Oregon Juvenile Justice Girls Studies (Chamberlain, Leve, Smith, & Reid) Funded by: National Institute of Mental Health (MH 46690); National Institute on Drug Abuse (DA 15208); Oregon Youth Authority Sample: Rolling recruitment of juvenile justice girls 13 -17 referred by court judges in Lane County, OR between 1997 – 2006 for out-of-home placement due to chronic delinquency (n = 166).

  5. Services as Usual Group Care (GC): • Placement with 3–15 other youth and a shift staff model • Based on theory of “positive peer culture” • Most have in house schools • Group Therapy is the primary treatment mode • Most provide individual therapy • Some have family therapy • Treatment typically lasts 9-12 months

  6. Multidimensional Treatment Foster Care (MTFC) • Objective • Change the negative trajectory of antisocial behavior by improving social adjustment across settings • How is this achieved? • Simultaneous & well-coordinated treatments in multiple settings • Home • School • Community • Peer group

  7. The MTFC Model • Treatment is provided in a family setting • New skills are practiced & reinforced in-vivo • Treatment is facilitated by core program components for: • Youth • Families • MTFC Parents

  8. Daily structure & support via a Point & Level System Close supervision of whereabouts & associations Daily school card Daily mentoring by TFC parents Weekly individual therapy Weekly skill building & advocacy Psychiatric consultation Weekly contact with parents & frequent home visits Core Program Components: Youth

  9. Core Program Components: Families • Weekly family therapy focusing on increasing the effectiveness of parenting skills • Instruction in behavior management methods • Home visits with back-up • 24-hour, 7-day on-call support

  10. Provide structured behavior management (Point & Level System) Daily telephone contact for support & data collection (PDR) Weekly support & training meetings 24-hour, 7-day on-call support Emergency crisis intervention Respite 20 hours of pre-service training Core Components: MTFC Parents

  11. The MTFC Treatment Team • Program Supervisor • MTFC Parents • Family Therapist • Individual Therapist • Skills Trainer

  12. The MTFC Model Juvenile Parole/ Probation Foster Parents School Program Supervisor Natural Family Therapists Child Child Therapist Natural Family

  13. Research & Theory Behind the MTFC Model

  14. Program Development • Program development at OSLC is approached in two main ways: • Inside-Out (programs developed based on research) • Outside-In (programs developed to meet community needs) • Intervention & research programs continuously inform each other

  15. The Beginnings of MTFC • Developed in 1983 for adolescents referred from Juvenile Justice • Based on over two decades of longitudinal research • Coercive behavior • Follows a predictable developmental course • Tends to worsen over time

  16. Trajectory of Antisocial Behavior • The bad news is: • Once it starts, it is very easily sustained • Without intervention, it becomes: • More severe • More widespread • More difficult to treat • The good news is: • It grows in predictable ways • The “roots” are in family interactions that can be altered at any time

  17. Research on MTFC • Five randomized trials have been conducted on the efficacy of MTFC • Four more are currently underway • Implementation research on the model • Dissemination across US and Internationally

  18. MTFC Outcomes • Delinquency • Significantly fewer days in locked settings at 12- & 24-months • Significantly less delinquent behavior at 12- and 24-months • Significantly less deviant peer associations at 12-months • School engagement • Significantly higher rates of homework completion • Mediated treatment effects on time spent in locked settings • Pregnancy • Significantly lower rates of pregnancy at 24-months • Mental health • No significant reductions in mental health symptoms

  19. Mediators of Treatment Intervention

  20. Implications for Treatment • Changing the social environment can change the trajectory of criminal behavior • Necessary ingredients: • Close supervision • Consistent discipline • Separation from delinquent peers • Relationship with a positive, encouraging parent figure • Working with parents is needed to maintain positive changes

  21. Now the Girls….

  22. The Girls Rolling recruitment from juvenile department Ages 13 -17 Referred by court judges for out-of-home placement due to chronic delinquency Random assignment n = 166

  23. Behavioral, Health,& Mental Health Risks • 11.5 arrests (first at age 12 ½; 72% have at least 1 felony) • 57% clinical-level and 17% borderline-level internalizing scores (CBCL) • Over 3/4 of study girls meet criteria for 3+ DSM-IV Axis 1 diagnoses • 57% report an attempted suicide • 66% used hard drugs in last year (36% use weekly) • 26% had been pregnant

  24. Abuse Rates Physical Abuse 88% Sexual Abuse 69% Physical or Sexual 93% Both 63% Family Violence 79% At least one act of sexual abuse <13 76% Average sexual abuse acts <13 5

  25. Family History Ave. number of parental transitions 17 Ave. number of prior treatment placements 2.96 Mother convicted of crime 46% Father convicted of crime 63% At least 1 parent convicted 74%

  26. Gender Differences Risk Factors Boys Girls Age 1415** Arrests 14 11* % Mother convicted of crime 2146** % Father convicted of crime 3163** % At least 1 parent convicted 4174** % Physical abuse 6 88** % Sexual abuse 7 69** *p<.05 **p<.01

  27. Gender Differences Boys Girls # of prior treatment placements 1 3** % Sibs institutionalized 20 37** % Ran at least once 7492* % Attempted suicide 358** % Heavy drug/alcohol use 966** *p<.05 **p<.01

  28. Are there unique characteristics of girls that play a role in the development and treatment of delinquency?

  29. Trauma Experiences • Trauma measures: • Traumatic Stress Schedule (Norris, 1990) • Documented physical abuse • Documented sexual abuse • Childhood Sexual Experiences Questionnaire (Zaidi et al., 1991) • Domestic violence • Parental incarceration • Parental transitions • Number of previous out of home placements Alpha = .66 Smith, Leve, & Chamberlain, 2006

  30. Trauma and Juvenile Offending What Predicts Arrests? b Trauma composite .24* PTSD – Full criteria -.11 PTSD – Partial criteria .05 *p < .05

  31. Trauma and Substance Use What Predicts Substance Use? b CocaineMeth Trauma composite .21+ .27** PTSD – Full criteria .08 .04 PTSD – Partial criteria .11 .29** **p < .01

  32. Trauma and Health-Risking Sexual Behavior What Predicts HRSB? b Trauma composite .30** PTSD – Full criteria -.08 PTSD – Partial criteria .12 **p < .01

  33. The Relationship BetweenTrauma & Conduct Problems • The exact relationship has not been fully explained • Trauma exposure might exacerbate the development of coercive processes between youths & their caregivers (Snyder et al., 1997) • Trauma exposure might exacerbate the negative outcomes associated with delinquency (Smith et al., 2006) • Traumatic exposure alone might partially account for many of the features central to delinquent behavior – lack of empathy, impulsivity, anger, acting-out (Greenwald, 2002) • Their coexistence & negative outcomes are well documented

  34. Implications of Co-occurring Trauma & Delinquency • The link between trauma and delinquency is of particular concern once girls reach adolescence • Selection of antisocial partners • Early pregnancy • Intergenerational transmission of emotional & behavioral problems • Despite research on negative effects related to their co-occurrence, few interventions have addressed trauma & delinquency simultaneously

  35. K Award (NIMH)Treating Youths with PTSD and Conduct Problems • Girls ages 14-17 • N=45 • Random assignment • MTFC+T • SAU Control (Group Care) • Matched comparison • MTFC

  36. SAU (n = 17) 3-mo. in-placement assessment of mediating variables 6- & 12-mo. follow-up assessment of outcomes MTFC+T (n = 13) Randomization and Assessment Timeline • Baseline assessment • Enter randomized • placement Each girl had at least one criminal offense and at least one trauma experience Matched Comparison MTFC Standard (n = 15)

  37. Gaps in Treatment of Co-occurring Disorders in Girls Researchers and clinicians have suggested that the most effective method for treating co-occurring conditions is a simultaneous and integrated approach Evidence-based interventions exist for conduct problems and for trauma as separate conditions Treatment typically occurs in either sequential or parallel treatment No evidence-based models exist for the integrated treatment of trauma and delinquency

  38. Development of an Integrated Model Identification of evidence-based models Examination of compatibility Training in both models Initial integration with guidance from developers Pilot study Randomized trial

  39. Trauma-Focused CBT The Developers: • Esther Deblinger, PhD – University of Medicine and Dentistry of New Jersey • Judith Cohen, MD – Center for Traumatic Stress in Children and Adolescents, Allegheny General Hospital • Anthony Mannarino, PhD - Allegheny General Hospital Department of Psychiatry

  40. TF-CBT:Basics of the Model • Originally designed to treat youths who had experienced sexual abuse • Has since been modified for use with children and adolescents exposed to: • Violence • Traumatic loss • Natural disasters • Approx 12 sessions

  41. TF-CBT:Treatment Components PRACTICE: • Psychoeducation & Parenting Skills • Relaxation • Affective modulation • Cognitive coping & processing • Trauma narrative • In vivo mastery of trauma reminders • Conjoint child-parent sessions • Enhancing future safety & development

  42. Trauma-Focused CBTOutcomes - Child • Significantly fewer intrusive thoughts & avoidance behaviors • Significantly more adaptive coping • Significantly less depression, anxiety, disassociation, behavior problems, sexualized behavior, trauma-related shame • Improved interpersonal trust & social competence • Improved personal safety skills • Better prepared to cope with future trauma reminders Cohen et al., 2004

  43. Trauma-Focused CBTOutcomes - Parent • Significantly less depression & emotional distress associated with the child's trauma • Enhanced ability to support their children Deblinger et al., 2001 Cohen, Deblinger, et al., 2004

  44. Stages of Integration • Consultation with model developers • Hours and hours on the phone! • Training in both models • Proposal for integration • Individual therapy • Skills training • Parent reinforcement (point and level system) • Hours and hours on the phone!

  45. Integrating MTFC & TF-CBT • Phase I (3-4 months) • Stabilization (girl) • Delinquency treatment (girl & family) • Emotion-regulation training (girl) • Relaxation • Reframing • Coping • Self-care • Problem-solving • Phase II (10-12 weeks) • Trauma-focused CBT (weekly individual therapy sessions) • Modeling/coping skill building • Education/prevention skill building • Processing/exposure • Safety

  46. Integrating MTFC & TF-CBT(Phase I) • Stabilization (3 weeks) • Introduction to the point and level system • Establishing consistent, predictable routines • Sleep • Meals • School • Homework • No contact with old friends; one phone call home

  47. Integrating MTFC & TF-CBT(Phase I) • Delinquency treatment • Point and level system • Consistent routines • Compliance • Responsibility • Feedback • Individual therapy – individualized behavioral targets • Skills training – practicing new behaviors in the community • Family therapy – parent training for parents

  48. Integrating MTFC & TF-CBT(Phase I) • Emotion-regulation training (3-4 months) • Relaxation • Focused breathing • Muscle relaxation • Mindfulness • Meditation • Affective expression and modulation • Identifying affective states • Roles plays/activities to practice adaptive responses • Reframing • Identifying adaptive responses to traumatic experiences and stressful life circumstances • Self-care • Developing personal responsibility for emotional and physical states • Problem-solving • Teaching and practicing effective problem-solving and decision-making strategies

  49. Integrating MTFC & TF-CBT(Phase II) • Trauma-focused CBT (2-3 months) • Weekly individual therapy sessions • Education/prevention skill building • Normalizing response to traumatic experience • Reinforcing accurate cognitions • Cognitive coping • Exploring internal dialogue about the event • Recognizing the distinction and relationship between feelings, thoughts and behaviors • Identifying inaccurate and unhelpful thoughts • Generating alternative thoughts that are more accurate and helpful • Processing/exposure • Trauma narrative • Safety • Personal safety skill building

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