Gene Griffin, J.D., Ph.D. Northwestern University Feinberg School of Medicine January 9, 2012

Transcription

1 Gene Griffin, J.D., Ph.D. Northwestern University Feinberg School of Medicine January 9, 2012

2 I. Prevalence of Mental Illness in Older Youth in Child Welfare II. Child Trauma III. Mental Health and Child Trauma IV. Treating Youth in Child Welfare V. Recommendations for Child Welfare Agencies

3 Diagnosis Percentage in the Past Year Major Depression 18% Conduct/Oppositional 17% ADHD 10% PTSD 8% Mania 6% McMillen et al., 2005, Journal of the American Academy of Child and Adolescent Psychiatry

4 The experience of an event by a person that is emotionally painful or distressful which often results in lasting mental and physical effects. Event Experience Effect NIMH, 2005

5 C o m p l e x i t y

6 DSM IV Diagnostic Criteria for Posttraumatic Stress Disorder (PTSD) After experiencing the event, the person must exhibit symptoms of Re-experiencing (one or more) Avoidance (three or more) Hyperarousal (two or more) Duration of more than one month

7 Most children who have experienced traumatic events will not qualify for a diagnosis of PTSD Even most children who have experienced traumatic events and demonstrate a traumarelated symptom will not qualify for a diagnosis of PTSD

8 Age N (14,103) % 0 6 yo 8, yo 2, yo 2, yo Sex Female 6, Male 7, Race African American 6, Non-Hispanic White 6, Hispanic Other Based on an initial assessment using the Child and Adolescent Needs and Strengths (CANS)

9 Potentially Traumatic Events % Neglect Family Violence Traumatic Grief/Separation Physical Abuse Emotional Abuse Witness to Criminal Activity Medical Trauma 9.69 Sexual Abuse 8.63 Community Violence 3.46 School Violence 1.58 Natural Disaster 0.65 War Affected 0.25 Terrorism Affected 0.18

10 Trauma Symptoms % of Children Adjustment To Trauma Re-experiencing 8.08 Avoidance 8.69 Numbing 6.13 Dissociation 2.12 Any Trauma Symptom 28.12

11 Child Trauma 0 6 years old 7-12 years old years old 17+ years old All Children 1a. Any Suspected Traumatic Event 93.15% 98.25% 97.93% 98.22% 95.14% 1b. Any Actionable Traumatic Event 69.90% 83.78% 84.38% 88.30% 75.69% 2. Any Trauma Symptom 15.32% 42.34% 51.24% 57.51% 28.12% 3. Potential PTSD 1.25% 4.50% 5.98% 6.87% (McMillen 8%) 2.88%

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13 The child behaviors and symptoms that present management difficulties can be interpreted as signs of mental health issues or a signs of child trauma Mental health issues and child trauma are not mutually exclusive

14 Mental Illness Overlapping Symptoms Trauma 1. Attention Deficit/ Hyperactivity Disorder 2. Oppositional Defiant Disorder 3. Anxiety Disorder (incl. Social Anxiety, Obsessive-Compulsive Disorder, Generalized Anxiety Disorder, or phobia 4. Major Depressive Disorder Restless, hyperactive, disorganized, and/or agitated activity; difficulty sleeping, poor concentration, and hypervigilant motor activity A predominance of angry outbursts and irritability Avoidance of feared stimuli, physiologic and psychological hyperarousal upon exposure to feared stimuli, sleep problems, hypervigilance, and increased startle reaction Self-injurious behaviors as avoidant coping with trauma reminders, social withdrawal, affective numbing, and/or sleeping difficulties Child Trauma Child Trauma Child Trauma Child Trauma Griffin, G; McClelland, Holzberg, M; Stolbach, B; Maj, N; & Kisiel, C (In Press). Addressing the impact of trauma before diagnosing mental illness in child welfare. Child Welfare.

15 Mental Illness Overlapping Symptoms Trauma 5. Bipolar Disorder 6. Panic Disorder 7. Substance Abuse Disorder 8. Psychotic Disorder Hyperarousal and other anxiety symptoms mimicking hypomania; traumatic reenactment mimicking aggressive or hypersexual behavior; and maladaptive attempts at cognitive coping mimicking pseudo-manic statements striking anxiety and psychological and physiologic distress upon exposure to trauma reminders and avoidance of talking about the trauma drugs and/or alcohol used to numb or avoid trauma reminders Severely agitated, hypervigilance, flashbacks, sleep disturbance, numbing, and/or social withdrawal, unusual perceptions, impairment of sensorium and fluctuating levels of consciousness Child Trauma Child Trauma Child Trauma Child Trauma Griffin, G; McClelland, Holzberg, M; Stolbach, B; Maj, N; & Kisiel, C (In Press). Addressing the impact of trauma before diagnosing mental illness in child welfare. Child Welfare.

16 Mental Health Symptoms % of Children McMillen Older Youth Depression Attachment Anger Control Attention / Impulse Anxiety Oppositional (with conduct) Affect Dysregulation (Mania) Conduct 5.54 Substance Abuse 4.13 Behavioral Regression 2.91 Eating Disturbance 2.61 Psychosis 1.72 Somatization 1.25

17 # of Significant Trauma Events (N) Average # of Trauma Symptoms 0 (N= 3412) Average # of Mental Health Symptoms 1 (N= 4081) (N= 3039) (N= 1792) (N= 904) (N= 489) (N= 184) (N= 73) (N= 34) (N= 10) * (N= 3) (N= 17) (*no subjects with 10 or 12 trauma events; 65 subjects unavailable) Incident Rate Ratio= Incident Rate Ratio = 1.342

18 # of Trauma Symptoms Average # of Mental Health Symptoms Incident Rate Ratio = 1.74

19 A. Children in Child Welfare, Illinois B. NO Symptoms C. Trauma Symptoms Only D. Mental Health Symptoms Only E. BOTH Trauma and Mental Health Symptoms 0 6 Year Olds % % 7.11 % % 7 12 Year Olds 33.45% 13.81% % 39.18% Year Olds 17.03% 6.93 % % 54.13% 17 + Year Olds % 6.00 % % % All Youth % % % 26.85%

20 100% Trauma and Mental Health Symptoms for Children Entering Care by Age, 90% 80% 70% 13.12% 7.11% 11.76% 39.18% 54.13% 62.00% BOTH Trauma and Mental Health Symptoms Mental Health 60% Symptoms Only 50% 13.56% 40% 30% 68.02% 13.81% 21.92% 15.75% Trauma Symptoms Only 20% 33.45% 6.93% 6.00% NO Symptoms 10% 17.03% 16.25% 0% 0 6 Year Olds 7 12 Year Olds Year Olds 17 + Year Olds Age Range 20

21 It is the adults who decide how to interpret the behaviors and symptoms of youth in the child welfare system These interpretations will drive the treatment Treatment for child trauma may take a very different focus than treatment for mental illness

22 There is a greater focus on context, safety and support They address symptoms and risk behaviors as part of a broader set of reactions They develop resilience and protective factors They focus less on medications They are less stigmatizing

23 Fighting Runaway Substance Abuse Cutting Hyperactivity Over-reacting

24 1. Safety (Placement ) 2. Supportive Adult Relationships (Permanency) *3. Self-Regulation Skills (Therapy and Evidence-Based Practices) 4. Strengths (Resilience and Protective Factors)

25 # of Strengths # of Trauma Symptoms Incident Rate Ratio = 0.82

26 (AF-CBT): Alternatives for Families/Abuse Focused Cognitive Behavioral Therapy (ARC): Attachment, Self-Regulation, and Competency (CBITS): Cognitive Behavioral Intervention for Trauma in Schools (CPC-CBT): Combined Parent-Child Cognitive Behavioral Therapy for Families at Risk for Child Physical Abuse (CPP): Child Parent Psychotherapy

27 (PCIT): Parent-Child Interaction Therapy Sanctuary Model (SPARCS): Structured Psychotherapy for Adolescents Responding to Chronic Stress (TARGET-A): Trauma Affect Regulation: Guidelines for Education and Therapy for Adolescents and Pre-Adolescents (TF-CBT): Trauma-Focused Cognitive Behavioral Therapy

28 Ages Therapy Modality Sessions Time 0-6 CPP Child and Caregiver Dyad 50 1 hour 2-12 PCIT Child and Caregiver Dyad hour 3-18 TF-CBT Child, Parent and Family Therapy Sessions; Min 4 17 CPC- CBT 4-21 Sanctua ry Child, Parent and Family Therapy Sessions; Residential and Systems Model- Staff Training, Supervision and Consultation Min 2 5 years Varies

29 Ages Therapy Modality Sessions Time 5-17 ARC Guidelines for Community Treatment Varies Varies School Age AF-CBT Parallel Individual and Family Therapy Sessions; hour CBITS Group Intervention in a School Setting; 10 1 hour TARGET -A Individual or Group Psychoeducation 4-12 Varies SPARCS Group Intervention hour

30 The National Registry of Evidence-based Programs and Practices (NREPP) National Child Traumatic Stress Network Empirically Supported Treatments and Promising Practices ments-that-work/promising-practices The California Evidence-Based Clearinghouse for Child Welfare (CEBC)