Treatment and Outcomes for Chronically Delinquent Adolescent Girls with CoOccurring Problems

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Treatment and Outcomes for Chronically Delinquent
Adolescent Girls with Co-Occurring Problems
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Acknowledgements

• Research Team Patricia Chamberlain,
  P.I. Leslie Leve, Co-Investigator John Reid,
  Co-Investigator Courtenay Padgett, Project
  Coordinator JP Davis, Intervention
  Coordinator Dana Smith, Interventionist Peter
  Sprengelmeyer, Interventionist
• Dr. Chamberlain is an owner of TFC Inc., which
  disseminates MFTC.

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RISK AND PROTECTIVE FACTORS
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Girls Research Program

• Female Delinquency
• Treatment Process

and Outcomes, NIMH, 19972002
Supplement 20022003
Women In Transition, Andrus Foundation, 20022006
New York City Girls Outcomes and Transport of
MTFC NIJ (Sprengel-meyer) 20042006
Preventing Problems for Girls in
Foster Care NIMH, 20032008
Treating Youths with PTSD CD K award NIMH,
(Smith) 20052010
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Girls Co-occurring Problems

• 12 average lifetime arrests (first arrest at age
  12 ½ 72 have at least 1 felony)
• 66 have used drugs in last year (36 use illicit
  drugs 1-7 times/week)
• High rates of STIs and early pregnancy
• 78 are academically below grade/age level
• Over 50 have had a suicide attempt

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Family History and Trauma Exposure among Girls

• 79 had at least one parent convicted of a crime
  
• 93 have a history of documented physical or
  sexual abuse (95 have been in the Child Welfare
  System)
• First sexual abuse (self-report) at age 8
• 79 have witnessed domestic violence
• 17 transitions in parent figures (6 before age
  13)
• 2.8 prior out-of-home placements

(Leve Chamberlain, 2004)
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Percent of Girls with Pregnancy Histories
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Percentage of Girls Who Engaged in HRSB in the
Prior 12 Months

• 89 Had sexual intercourse at least once
• 41 Had sex with someone known less than 24
  hours
• 32 Had sex with someone who injects drugs
• 45 Never or rarely used safe sex practices
  when having sex
• 51 Had sex with 3 or more partners in 12 mo.
• 27 Never/Almost never discussed safe sex with
  new partners

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Percent of Girls with an STI
Cumulative diagnosed with an STI
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Gender Comparison of Risk at BL

• Boys Girls
• Age at study entry 14.4 15.1
• Mother convicted of crime 21 46
• Father convicted of crime 31 63
• At least 1 parent convicted 41 70
• of prior treatment placements 1.3 2.9
• Sibs institutionalized 20 37
• plt.05. plt.01

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Gender and Risk Factors-continued

• Boys Girls
• Ran at least once 74 92
• Attempted suicide 3 57
• of Arrests 14 11.9
• plt.05. plt.01

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Crimes by Category

• M
• Offense type Boys Girls
• N all offenses/youth 13.5 11.9
• Property offenses 60 37
• Status offenses 17 32
• Person offenses 12 13
• Drug offenses 1 3
• Weapon offenses 1 1
• Other offenses 10 14

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What Predicts Girls Age of First Arrest?
b Girl
age .17 Menstrual onset .11 IQ .21 ADHD .00 Sever
e punishment .00 Sexual abuse -.05 Parental
transitions -.42 Biological parent
criminality -.28 R2 .52 F (8,
45) 5.98, p lt .0005. Leve Chamberlain
(2004), J of Child and Family Studies
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Why is Early Arrest Important?

• Girls who were first arrested before age 12
• Had significantly more participation in
  health-risking sexual behavior
• Had significantly more criminal offenses by age
  16, and more self-reported delinquent acts
• Had an increased likelihood of unplanned
  pregnancy and of becoming teen mothers
• (Did not have an increased risk of substance use
  or of depression in our study)

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MTFC Intervention Outcomes
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Overview (Comparing MTFC to GC)

• Boys (Chamberlain Reid, 1998 Eddy, Whaley,
  Chamberlain, 2004)
• More time in program/ fewer runaways
• Less time in locked incarceration in follow-up
• Fewer criminal offenses ( ½ the rate of GC boys)
• Less likely to commit violent crimes 2 years
  later
• Girls (Leve Chamberlain, 2004, 2007 Kerr 2008)
• More time in placement/fewer runaways
• Less time in locked incarceration (62 fewer
  days)
• 32 less symptom severity on mental health
  problems
• 42 fewer arrests
• Higher school attendance
• 50 fewer pregnancies during 24 month post
  baseline

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Mediators of Positive Outcomes (regardless of
intervention condition) for Boys

• Supervision
• Relationship with a mentoring adult
• Consistent non-harsh discipline
• Less association with delinquent peers

• Eddy Chamberlain, 2000
• Leve Chamberlain, in press

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Do MTFC Girls Associate with Fewer Delinquent
Peers During Treatment?
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Do MTFC Girls Receive More Supervision During
Treatment?
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Growth Model Delinquency Construct
(Chamberlain, Leve, DeGarmo, 2007)
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Deviant Peers as a Mediator
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Anxiety (BSI)
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Predictors of Drug Use and HRSB

• Peer Group
• 45 report hanging out with boys 5 years older
• 68 said that all or most of their friends
  could have been arrested in past year
• Partner (74 of sample)
• On average, partners were 2.7 years older
• 33 report that partner uses hard drugs

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Risks Factors

• As expected, girls tended to associate with
  older, highly delinquent males and partners
• The more drug-using and older these partners
  were, the greater the girls involvement in
  health-risking sexual behaviors
• Girls alcohol and marijuana use was affected by
  either high peer deviancy or high partner drug
  use.
• For marijuana use, slight protective effect of
  low partner drug use
• Older male peers (for marijuana use) and deviant
  peers (for hard drug use) resulted in more usage

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Core Elements of Multidimensional Treatment
Foster Care (MTFC)

• Family-based programming
• Multiple systems targeted
• Strength-based approach
• Developmentally-appropriate
• Safety Frame

Intervention
Theory
Research
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Clinical Dynamic

• Youth referred to MTFC
• Present with a high level of challenging
  behaviors typical parenting strategies are
  ineffective
• Draw adults to set harsh reactive limits, to be
  negative, to focus on discipline
• Support foster parents parents to re-establish
  the balance - reinforce normative positive and
  to set non-punitive, appropriate limits

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Core Components for Youth

• One youth is placed in each MTFC home
• Provided with daily structure and support by MTFC
  parents who use a behavior management level
  system
• Includes a daily school card
• Weekly individual therapy
• Weekly skill building advocacy

• Close supervision of whereabouts and associations
• Psychiatric consultation as needed
• Daily mentoring by MTFC parents
• Weekly contact w/ parents and frequent home visits

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Core Components for Foster Parents

• Conduct daily behavior management point and level
  system
• Receive daily telephone contact and data
  collection (M-F using PDR)
• Attend weekly support and training meetings

• Have 24-hour, 7-day
• on call access to their program supervisor
• Emergency crisis intervention
• Respite
• 20 hours of pre-service training

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Core Program Components for Families

• Weekly family therapy focused on Parent
  Management Training
• Instruction in behavior management methods
• Frequent home visits with crisis back-up
• 24-hour, 7-day on call access to their program
  supervisor
• Aftercare parent group

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Behavior Management System

• The behavior management system uses points and
  levels as a concrete way for parents to
• Teach appropriate skills
• Reinforce desired behaviors or attitudes
• Provide consequences for problem behavior

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Name Day/Date
Sample Behavior Management Chart
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General Principle

• Facilitate a balance encouragement and limit
  setting

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Benefits of the Point and Level System

• Regular opportunities to support and encourage
• Consequences are built into the program
• The program does the work
• Removes power struggles
• Deal with problems as they occur
• Everyone has the same expectations
• Can be individualized to fit specific needs
• Program supervisor is available to help

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Daily Report Telephone Check-in (PDR)

• 5-10 minute telephone call
• Behavior checklist format
• 0 behavior did not occur
• 1 behavior occurred, was not stressful
• 2 behavior occurred, was stressful
• Web-based, housed on OSLC server as WEBdr
• Data entry, management, and analysis all on-line
• Facilitates off-site consultation
• Tracks daily progress/problems
• Tracks foster parent stress
• Tracks program adherence

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Parent Daily Report Telephone repeated measure
of child behavior

• 5-10 minute telephone call
• Behavior checklist format
• 0 behavior did not occur
• 1 behavior occurred, was not stressful
• 2 behavior occurred, was stressful

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• Discipline Basics
• Discipline is not about revenge or winning.
• Discipline is about discouraging problem
  behavior.
• Use small consequences
• Be contingent
• Be consistent
• Respond dont react
• When its over, let it go

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Timing is Everything

• You are in control of when you choose to teach,
  discipline and reinforce
• Doing the right thing at the wrong time can end
  up making things worse
• As Program Supervisor one of your major tasks is
  to control the timing and flow of what happens
  when

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Teaching Opportunities
Child throws a tantrum
Parent yells, feels angry hopeless
Parent lectures more
Child feels remorseful or ashamed
Child whines argues
Parent nags
Parent forgives or gives in
Child doesnt mind
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Why this isnt always easy

• General challenges
• FP not doing PDR regularly
• FP not attending meetings
• FP not giving taking points effectively
• FP not calling the PS when problems are small

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Its Not Personal

• Easy to say, hard to do
• Recognition of the foster parents daily role
  living with the youth
• Importance of supporting the foster parents in
  not taking it personally
• How the foster parent group can help

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Common Traps

• Blaming FP/joining with the kid
• Directly teaching to FP in the midst of a report
  of a problem
• Asking why

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Staff Role Descriptions

• Treatment Foster Parents
• Program Supervisor (1.0 FTE)
• Family therapist (.50 FTE)
• Youth therapist (.50 FTE)
• Skill trainer (hourly)
• PDR caller/Foster parent recruiter (1.0 FTE)
• Consulting psychiatrist (hourly)
• Clinical supervisor/Program director

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Program Supervisor

• Coordinates all aspects of youths treatment
• Daily review of Parent Daily Report (PDR)
• Review of point sheets/school cards
• Conducts weekly foster parent meetings
• Facilitates weekly clinical meeting
• Supervises clinical staff
• Maintains a small case load (10-12 cases)
• Has authority over clinical, staffing,
  recruitment matching decisions

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Skills of the Program Supervisor

• Building and maintaining a relationship with the
  foster parents
• Coordination and supervision of the clinical team
• Executing the program with the youth (balancing
  encouragement and limit setting)
• Maintain an informative and encouraging
  relationship with aftercare resource
• Maintaining an effective relationship with the
  community (JJ, schools, Child Welfare, etc.)

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Facilitating Foster Parent Meeting

• Keep it fun!
• Encourage FP to FP support
• Provide support vs teaching
• Follow the meeting structure

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Foster Parent Meeting Structure

• Gather information on each youth
• Gather point sheets school cards from previous
  week
• Ask questions to clarify identify behaviors
• Reframe problem-solve
• How to use points
• Identify Strengths
• Anything else we can do for you?

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Coordination and supervisionof the clinical team

• Clinical meetings
• Establish structure
• Focus on behavior
• Use PDR points
• Develop interventions
• Plan for IT, FT, ST sessions for next week
• Supervision
• All clinical staff attend meetings weekly
• PS is availability to clinical team
• Team members check in before/after sessions
• 1-1 supervision as needed

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Structure of Clinical Meeting

• Review each youth individually
• PS presents summary of youths progress in foster
  home other settings
• Review PDR points
• Elicit behavioral and session information from
  IT, FT, ST
• Identify target behaviors
• Develop intervention strategies

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Translating Problems into Interventions
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Targeting Behaviors

• Step 1- Get good information
• Step 2- Identifying the pro-social opposite of
  negative behaviors
• Step 3- Make it point chart ready (label and
  include concrete examples)
• Step 4 Create interventions across roles

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Get Good Information

• What does it look like?
• Ask questions to get details about
• Context
• Frequency
• Intensity
• Duration
• Ask questions about the behavior in various
  settings

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Identify Pro-social Behaviors
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Develop Label Interventions
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Candace

• 16 years old, 60
• Referred for assault kidnapping
• Exhibiting rage behavior, breaking things,
  physical altercations, verbal outbursts towards
  family, cutting on herself, substance abuse
• Struggling in relationships with family peers
• Past sexual abuse by Grandfather
• Problems with self-image, depression, anxiety,
  irritability, impulsiveness, anger
• Expelled from High School enrolled in
  alternative school

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Candace Level 1 Interventions
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Candaces Level 2

• Target anxiety behaviors
• Individualizes her point sheet
• Adds Pacing yourself
• Adds Waiting for information
• Then adds Spreading rumors ???

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Candace Level 2 Interventions
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Candaces Level 3

• Target catty comments/talk
• Adds Being pleasant to point sheet

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Candace Level 3 Interventions
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Policy Implications

• Prevention! Stabilization permanancy in child
  welfare placements and educational supports
  during early/middle childhood
• Girls in the juvenile justice system are in great
  need of treatment programs that effectively
  treat their co-occurring drug use problems
• Consider the consequences of aggregate care (and
  gender differences)
• Consider extending JJ and CWS services beyond age
  18 (drug alcohol, mental health, sexual
  behavior, independent living)

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Future Direction A Prevention Approach

• Risk factors such parental criminality, family
  transitions, low IQ related to early onset arrest
• Most girls in the juvenile justice system have
  had a history of abuse
• New MTFC intervention with girls in the child
  welfare system prior to middle school entry
• Intervention components include
• 6 intensive sessions for foster parents
  (group-based)
• 6 intensive sessions for girls (group-based)
• Weekly skills-training for girls and foster
  parent meetings for foster parents throughout 6th
  grade

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