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Community Treatment Programs for Juveniles: A Best Evidence Synthesis


Community Treatment Programs for Juveniles: A Best Evidence Synthesis Birmingham Presents Lee A. Underwood, Psy.D., USA Consulting Group April 21, 2006 – PowerPoint PPT presentation

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Title: Community Treatment Programs for Juveniles: A Best Evidence Synthesis

Community Treatment Programs
for Juveniles A Best Evidence Synthesis
  • Birmingham Presents
  • Lee A. Underwood, Psy.D.,
  • USA Consulting Group
  • April 21, 2006

Introductory Thought
  • I have come to a frightening conclusion.
  • I am the decisive element in the treatment
  • of juveniles. It is my personal approach
  • that creates the climate. It is my daily
  • mood that makes the weather. As a
  • Provider, I possess tremendous power to
  • make a youths life miserable or joyous.
  • I can humiliate or humor, hurt or heal. In
  • all situations, it is my response that decides
  • whether a crisis will be escalated or de-
  • escalated, and the youth humanized or
  • de-humanizedHaim Ginnott, 1977

  • Prevalence, Awareness and Challenges
  • Delinquency Mental Health
  • Trends in Community-Based Programs
  • Common Community Models
  • Cultural Competency Bias

Prevalence, Awareness and Challenges
Prevalence Rates
  • U.S. Represents 2 of Worlds Population
  • U.S. has 25 of Worlds Prisoners
  • U.S. Population of Racial Minorities are 27-30
  • U.S. Population of African-Americans is
    roughly14 of the 25 and 15 of the 25 are
    Hispanic speaking
  • Of the 2 Million Incarcerated, nearly 70 are
    African-Americans and Hispanic speaking

Prevalence Rates
  • One out of 5 African-Americans Males are in
    Prison Between the Ages of 18-24
  • There are more African-American Males in Prison
    than in College
  • 9 of Hispanic-Americans compared to 3 of
    White-Americans are in secure settings

Prevalence Rates
  • According to the U.S. Census concerning data on
    divorce, child custody and child support, 50 of
    all white children and 75 of all black and brown
    children born in the last two decades are likely
    to live for some portion of their childhood with
    only their mothers.

Prevalence Rates
  • Children growing up in homes with absent fathers
    are more likely to fail or drop out of school,
    engage in early sexual activity, develop drug and
    alcohol problems, and experience or perpetrate
    violence in greater numbers than children growing
    up in homes with fathers present.
  • Benson Cooke

Prevalence Rates
  • Each year more than one million children
    experience the divorce of their parents. In 1996,
    of 1,310 divorces in the District of Columbia,
    nearly half (46.4) involved children.
  • Over 1/5 or (26) of the absent fathers live in a
    different state than do their children.
  • Approximately 40 of the children who are
    fatherless have not seen their father in at least
    a year, and about 50 have never visited in their
    fathers house

Prevalence Rates
  • Boys Girls
  • Girls are 3-4 times more likely to be victims of
    sexual abuse than boys.
  • Girls are more likely to be victimized
    physically, and sexually by a family member.
  • Victimized girls are more likely to present
    serious mental health symptoms.

Prevalence Rates Contd
  • Boys Girls Contd
  • Girls have higher prevalence rates of depression,
    anxiety, PTSD, eating, sleeping, somatization and
    borderline personality disorders and features.
  • Girls have higher rates of co-occurring mental
    health and substance use rates.
  • Girls are more likely to run away from home to
    escape violence.

Prevalence Rates Contd
  • Boys Girls Contd
  • Boys and girls respond differently to abuse.
    Boys generally become aggressive.
  • Girls tend to internalize the injury, sometimes
    becoming aggressive and other times becoming
    depressed, or both at the same time.
  • Boys tend to minimize their negative emotions.

Prevalence Rates Contd
  • Boys Girls Contd
  • Boys tend to have disruptive relationships,
    overcompensate for control and severe their
  • Initial treatment for girls should focus on
  • Initial treatment for boys should focus on
    relationships and on expanding their emotional

  • What are the Implications?
  • How does this data move you?
  • What do you do to perpetuate the data?
  • What do you do to eliminate the data?
  • How hopeful is change?
  • What does this say about staff awareness
  • How does personal and professional boundaries fit

Delinquency Mental Health Risk Protective
The criminally-minded adolescent is like a
pirate who sails under his own flag without
regard to ship or crew except that it serves his
own good. ANONYMOUS
Delinquency Mental Health
  • Delinquency and mental health are intertwined and
    mutually stimulate each other.
  • Isolating delinquency risk factors from mental
    health risk factors is difficult.
  • Delinquency and mental health constructs tend to
  • Choosing the best treatment placement system is
    unreliable done.
  • Understanding predictors of delinquency and
    mental health can decrease recidivism in both

  • Treatment rests on the basic strategy of making
    the client so clearly aware of his pattern of
    irresponsible thinking that he cannot continue
    them except by a full conscious and deliberate

Risk Protective Factors
  • Risk Factors
  • Protective Factors
  • Strength-based Factors

Risk Factors
  • Risk factors refer to the likelihood of a youths
    continued involvement in criminal behavior. Risk
    factors are related to the likelihood of
    recidivating back into child care systems. When
    one understands the key risk factors, there is a
    much improved accuracy and reliability in the
    treatment and aftercare planning process. A set
    of empirically supported variables (risk factors)
    have been identified and associated with
    delinquent and criminal behavior.

  • Individual (self-esteem, medical, personality)
  • Peer (deviant associations, pro-social peers,
    gang affiliation, antisocial attitudes)
  • Family (boundaries, structure, compliance, rules,
    connectedness, criminal role models)
  • Neighborhood (poverty, antisocial, criminal role
    models, education)
  • Substance Abuse (use patterns, associated
    behaviors, family substance use patterns)
  • Childhood Abuse (I.e., sexual, physical,

Specific Risk Factors
  • Children with disabilities or mental retardation
  • For sexual abuse, risk increases with age
  • Females more likely to be sexually abused than
    males (but males DO get sexually abused)
  • Difficult/slow to warm up children

Specific Risk Factors
Within Families
  • Substance abuse within family
  • Childhood history of abuse
  • Witnessing domestic violence
  • Lack of parenting skills
  • Neglect and abandonment
  • Coercive child-rearing
  • Lack of family warmth boundaries

Specific Risk Factors
Within Community
  • Poverty impoverished environments
  • Dangerous/violent neighborhood
  • Poor school districts
  • Lack of access to medical care, etc.
  • Parental unemployment homelessness
  • Deviant peer association
  • Personal institutional racism

Protective Factors
  • Protective factors refer to internal and external
    support systems that buffer the negative effects
    of trauma. Internal factors include resiliency,
    self-appraisal and explanatory styles. External
    factors include the protective role of caregiver
    supervision and monitoring.

Protective Factors
  • Protective factors refer to internal and external
    support systems that buffer the negative effects
    of trauma

Internal Factors
External Factors
  • Resiliency
  • Self Appraisal
  • Explanatory styles
  • Protective role of caregiver
  • Supervision
  • Monitoring

General Protective Factors
  • Stable families
  • Emotional well-being of youth family
  • Parental monitoring supervision
  • Community participation
  • School attendance
  • Prosocial lifestyle

General Protective Factors (Additional)
  • Poor parent-child relationships
  • Neglect
  • Coercive child-rearing
  • Lack of warmth and affection
  • Inconsistent parenting
  • Violence
  • Sexual Abuse
  • Disrupted attachments
  • Family antisocial values
  • Harsh parental discipline
  • Lack of parental monitoring
  • Feeling of emotional distress that is impairing
  • Neurological impairments
  • Substance use

Specific Protective Factors
Youth Personality
  • Easy tempo approach
  • Positive Disposition
  • Active coping skills
  • Positive self-esteem
  • Good social skills
  • Internal locus of control
  • Balance between autonomy help-seeking

Specific Protective Factors
  • Secure attachment
  • Supportive family environment
  • Household rules/structure
  • Parent monitoring
  • Extended family help and support
  • Parental model good coping skills
  • High family expectations
  • High parental education

Specific Protective Factors
  • Positive relationships with family members
  • Opportunities for personal growth development
  • Supportive and nurturing relationship with at
    least one parent
  • Cohesiveness and expressiveness
  • Consistent family discipline
  • Rules in planning and operating the home

Strength-based Factors
  • A belief in the goodness of individuals-instead
    of viewing the youth who does not display skills
    as deficient it is believed the youth has not
    had the experiences or opportunities to mastering
    essential skills. Given the skills, youth are
    able to transcend their current situation.
  • A belief that youth are motivated by how others
    respond to them. When adults accentuate the
    positive areas in a youths life, this may result
    in heightened motivation.

Strengths-based Factors
  • A focus on the internal and external resources of
    individuals rather the solely the youths
  • Explicitly seeking and building upon the
    individual strengths rather than the individuals
  • Less focus on pathologies and deficits
  • A focus on past successes and ways in which the
    successes were achieved.
  • A focus on survivor skills rather than victim

Strength-based Factors
  • A focus on personal accomplishments and the
    accompanying steps to achieve such
  • Recognition of interpersonal strength
    (i.e.-accepts and gives criticism)
  • Involves family involvement (a sense of belonging
    to the family)
  • A focus on intrapersonal strength
    (i.e.-demonstrates a sense of humor, provides
  • A focus on affective strength (i.e.-asks for
    help, some insight into self-awareness)

Key Clinical Issues
  • The specific issues relevant to an individuals
    offense and the individuals mental health and
    substance abuse characteristics must be
  • Multiple sources of information should be
  • Specialized psychometric instruments should be
  • A series of screenings and assessment should be
  • Differentiating personality disorders from mental
    health and substance abuse disorders is critical.

Key Clinical Issues - Cont.
  • When screening and assessing the juveniles
    appropriateness for community-based programming,
    it should include a review of his/her living
    arrangements, family warmth, boundaries,
    supervision and structure.
  • History of sexual psychological and physical
    victimization should be carefully gathered and
  • Awareness of cultural differences is essential.

Trends in Evidence-based Community-based Treatment
What is Residential Treatment?
  • Provides specialized assistance to individuals
    requiring professional clinical support to assist
    with behavioral change and growth.
  • Residential services attempt to remove the youth
    from the home setting, and place them in a
    structured, supervised, therapeutic environment.
  • Depending on the need, residential placement may
    assist with youth struggling with specific issues
    including sexual aggression, firesetting,
    chemical dependency, emotional and behavioral
    issues, or severe as transitional programs for
    youth going back into the community with their

  • Treatment often includes individual, group, and
    family therapy structured recreational
    activities vocational training skill
    development and educational support.
  • Despite the wide use of residential treatment
    programs for adolescents the evidence-base is
    very weak. Most of the empirical evidence for
    residential treatment stems from two
    quasi-experimental studies, conducted over 20
    years ago

What is Community Treatment?
  • Community programs may consist of system
    diversion, non-system diversion, and residential
    community corrections.
  • System diversion programs include those services
    that fully divert youth from the juvenile justice
  • Examples of these programs may include family
    counseling, crisis counseling, vocational
    training, and Big Brother Big Sister related

What is Community Treatment?
  • Conversely, non-system diversion programs include
    services that are formally part of the juvenile
    justice system. These services may include court
    ordered family counseling, skills training, and
    informal probation. Community corrections
    programs refer alternatives to incarceration,
    such as independent living, work programs,
    probation, parole, and other programs designed to
    manage adolescents in the community.

What is Community Treatment?
  • Effective community programs must simultaneously
    balance three major goals (1) ensure public
    community safety, (2) hold youth accountable for
    their actions, and (3) provide an environment in
    which youth can develop into capable, productive,
    and responsible citizens

What Is Community Treatment?
  • Post-release treatment programs should rely on
    the following
  • Utilization of clear cut and objective diagnostic
  • Utilization of family intervention services that
    is inclusive and culturally relevant.
  • - Utilization of treatment interventions that
  • are empowering for youth their families.

What Is Community Treatment?
  • Implementation of ongoing reliability and
    validity studies.
  • Utilization of reliable and accurate treatment
    protocols that have sound empirical research with
    demonstrated effectiveness.
  • Use of multiple interventions that address a
    variety risk factors (family,
  • school, peer, school, community, etc.).

What Is Community Treatment?
  • Utilization of mental health providers, not
    correctional staff as primary treatment
  • Collaboration between juvenile justice, mental
    health, substance abuse and education systems.

Trends in Evidence-based treatment
  • Recidivism rates of sample juveniles are lower
    than untreated groups.
  • Integrated treatment is most effective for
    co-occurring disordered youth.
  • Multisystemic therapy, Functional family
    therapy, Multi-dimensional therapeutic foster
    care have demonstrated empirical evidence.
  • Dialectical behavior therapy has undergone
    investigation and seems reliable

Trends in Evidence-based treatment
  • Effective Programs Are
  • Reliable and valid.
  • Rigorously applied.
  • Systematically measured.
  • Focuses on ecology.
  • Reduces known risk factors.
  • Highly structured.
  • Closely supervised and monitored.
  • Curricula-based
  • Skill-based

Trends in Evidence-based treatment
  • Effective Programs Are
  • Integrated service oriented.
  • Strengths based.
  • Individualized and targeted.
  • Undergone clinical trials.
  • Community-based.
  • Aware of protective factors.
  • Replicable.

Common Commuity Models Types of Treatment
Types of Treatment
  • Cognitive-behavioral.
  • Problem-solving.
  • Task centered.
  • Ecological.
  • Behavioral modification.

Types of Treatment
  • Cognitive-Behavioral therapy
  • Focuses of thoughts and beliefs.
  • Addresses internal belies and values.
  • Addressed internal dialogue.
  • Thinking impacts behavior.
  • Focuses on perception.
  • Focuses on learned behavior.

Types of Treatment
  • Positive reinforcement.
  • Active treatment style.
  • Focuses primarily on here and know.
  • Individual responsibility must be taught.
  • Focuses on relationships.

Types of Treatment
  • Motivational Interviewing Enhancement
  • Applying stages of change.
  • Resolving ambivalence.
  • Reframing techniques.
  • Support compliance.
  • Establishes partnership.
  • Consistent feedback.
  • Going beyond resistance.

Types of Treatment
  • Multisystemic Treatment
  • Brief strategic family systems.
  • Strengths as levers for change.
  • Ongoing evaluation.
  • Promotion for responsibility.
  • Establishes partnership.
  • Consistent feedback.
  • Going beyond resistance.

Types of Treatment
  • Functional Family Therapy
  • Strengths-based platform.
  • Treats individual and family.
  • Emphasis on engagement and motivation.
  • Works in youths environment.
  • Flexible curriculum.
  • Culturally competent.

Types of Treatment
  • Multi-Dimensional Therapeutic Foster Care
  • Multidimensional perspective for symptom
  • Enhancement on prosocial skills.
  • Parental investment.
  • Parental commitment.
  • Structured treatment approach.
  • Structured supervision.

Types of Treatment
  • Dialectical Behavior Therapy
  • Behavioral and cognitive.
  • Acceptance in change of self.
  • Balanced ways of thinking, feeling and
  • Teaches emotional regulation.
  • Decreases self-injurious behavior.
  • Targets behavior that interferes with quality of

Types of Treatment
  • Relapse Prevention
  • Self-regulation.
  • Awareness of high risk factors.
  • Self-monitoring.
  • Improve coping skills.
  • Tapering supervision patterns.
  • Focus on community safety.

Types of Treatment
  • Trauma Treatment
  • Trauma informed staff.
  • Address characteristic of helplessness.
  • Overcome developmental disruptions.
  • Teach survival skills and strategies.
  • Dealing with situational contradictions.
  • Emotional regulation and well-being.

Summary of Best Practices
  • Outcome-based.
  • Prevention based.
  • Community-based.
  • Motivational-based.
  • Evidence-based.
  • Inclusive-based.
  • Trauma reduction based.

Summary of Best Practices
  • Includes risk and protective factors.
  • Family, parent and sibling interventions.
  • Structured and consistency.
  • Treating the whole person.
  • Education and work programs.
  • Solution focused.

Cultural Competency Self-Reflection Awareness
  • Culturally Biased Assumptions
  • See handout

  • Culturally Biased Assumptions
  • We all share a single measure of Normal
  • Individuals are the basic building blocks of
  • Problems are defined by a framework limited by
    academic discipline boundaries.
  • Others will understand our abstractions in the
    same way as we intend.
  • Independence is desirable and dependence is

  • Formal systems of support are more helpful than
    natural informal support systems
  • Everyone depends on linear thinking to understand
    the world around them. (Cause and Effect)
  • Individuals need to change to fit the system, not
    the system needs to fit the individual
  • History is not relevant for a proper
    understanding of current events.
  • We already know all of our assumptions.

Intervention Considerations
  • Become Profoundly Disgusted with Self
  • Establish Responsible Thinking
  • Full Disclosure
  • Receptivity to Others Point of View
  • Maintaining On-going Activities
  • Discontinue Random Opening Closing Channels of
  • Think Seriously About a New Language of
  • Raise Questions Discuss ideas

Interview/Intervention Cont.
  • Terminate When Anger Becomes Hurtful or Blocking
  • If You Use a Confrontative Style, Be Direct and
  • Expect to Repeat the Same Point in Different Ways
  • Dont Play Sherlock Holmes

Interview/ Intervention Considerations Cont.
  • Take a Its Your Life Counseling Stance
  • Do not Anger, Ridicule, Chide or Use Sarcasm
  • Ask Self, What Do I Expect to Accomplish? , Is
    it Realistic?
  • What Would Happen If I Did Nothing?
  • Be Directive, Polite and Firm

Autobiography in Five Short Chapters
  • (1) I walk down the street.
  • Theres a hole in the sidewalk.
  • I fall in.I am lost.I am helpless
  • It isnt my fault.
  • It takes forever to find a way out.

  • (2) I walk down the same street.
  • Theres a deep hole in the sidewalk.
  • I pretend I dont see it.
  • I fall in again.
  • I cant believe I am in the same place again.
  • But, it isnt my fault.
  • It still takes a long time to get out.

(3) I walk down the same street. Theres a
deep hole in the sidewalk. I SEE it is there.
I still fall in.its a habitbut.. my eyes
are open.I know where I am. It is my
fault. I get out immediately.
(4) I walk down the same street. Theres a deep
hole in the sidewalk. I walk around it.
(5) I walk down another street. Portie Nelson
Final Thought
  • I have come to a frightening conclusion.
  • I am the decisive element in the treatment
  • of probationers. It is my personal approach
  • that creates the climate. It is my daily
  • mood that makes the weather. As a
  • DPO, I possess tremendous power to
  • make a probationers life miserable or joyous.
  • I can humiliate or humor, hurt or heal. In
  • all situations, it is my response that decides
  • whether a crisis will be escalated or de-
  • escalated, and the youth humanized or
  • de-humanizedHaim Ginnott, 1977

Any Questions?