Trauma in Adjudicated Youth and Treatment Strategies

05 Apr 2018

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  • Morgan Carella

Abstract

Research indicates there is a high prevalence of trauma in adjudicated youth (Brown, McCauley, Navalta, & Saxe, 2013; Ford, Steinberg, Hawke, Levine, & Zhang, 2012; Davis, Sheidow, & McCart, 2014; Rosenberg et al., 2014; Stimmel, Cruise, Ford, & Weiss, 2014).

It is possible that effectively addressing trauma could reduce the probability of recidivism. you'll need a statement tying youth with a Hx of trauma to probability of recidivism, not just prevalence in adjudicated youth.

Aggressive behavior, trauma exposure and posttraumatic stress disorder (PTSD) symptoms are highly prevalent in juvenile offenders (Stimmel, Cruise, Ford, & Weiss, 2014)

Keywords: juvenile-justice-involved youth, trauma, PTSD

Prevalence of Trauma in Adjudicated Youth

Rosenberg et al. (2014) surveyed the incidence of trauma in juvenile-justice-involved youth and the psychiatric impact of that trauma. Rosenberg et al. hypothesized that there would be higher rates of trauma exposure, PTSD, depression, and substance abuse in juvenile-justice-involved youth compared to the general population. Rosenberg et al. gathered data from 350 juvenile-justice-involved youth; 269 in New Hampshire and 81 in Ohio using a customized, online survey. The authors combined and modified a number of tests in order to create the web-based Stress and Resources Survey used for this study.

Ninety-four percent of the youth from the sample reported at least one trauma, 45.7% screened positive for PTSD, 49.4% for depression, and 61.2% for substance abuse. In addition, trauma exposure (total trauma) was significantly correlated with PTSD, depression, and substance abuse (Rosenberg et al., 2014). The results of this study confirm the high incidence of trauma in juvenile-justice-involved youth and the need for psychological intervention. Early psychological intervention among juvenile delinquents could lead to more appropriate treatment strategies and decreased recidivism.

Rosenberg et al. (2014) created an online screening tool that could be easily replicated and used for subsequent studies. The Stress and Resources Survey measures a broad range of items in a consolidated, simple tool. The online, self-report survey allowed for uniformity of administration across the testing sites. In addition, by using an online survey, there was no chance for altering how questions were asked, or what order they were asked in. The survey also provides the opportunity for youth to answer survey questions honestly, instead of conducting face-to-face interviewing, where youth may be more prone to lying.

One of the possible concerns about The Stress and Resources Survey created by Rosenberg et al. (2014) was that it abbreviated many existing surveys without necessarily providing enough information on whether or not it is a reliable or valid measure. Rosenberg et al. combined parts of other measures in order to more succinctly measure the information they were trying to obtain. It is not possible to tell whether the customized Stress and Resources Survey used for this study was a valid or reliable measure because there was no pre-test.

Types of Trauma in Adjudicated Youth

Stimmel, Cruise, Ford, & Weiss (2014) investigated the relationship between exposure to different specific types of traumatic events, PTSD symptoms, and aggression. Stimmel et al. were interested in answering the following research questions:

  1. Will juvenile offenders who endorse multiple types of traumatic events exposures endorse greater levels of PTSD symptoms and aggression compared with juvenile offenders who endorse a single type of event exposure?
  2. Among juvenile offenders who endorse multiple types of potentially traumatic events, does PTSD symptom severity account for the relationship between violence exposure and aggression? (p. 185).

Over an 8-month time period, self-reported trauma exposure, PTSD symptoms and aggression were assessed among 66 detained 12-16 year old boys from two juvenile detention centers in a northeastern state.

Results indicate that 57 youth experienced at least one potentially traumatic event, 47 youth experienced at least two potentially traumatic events and the average number of potentially traumatic events endorsed among the sample was three. Participants who experienced multiple types of traumatic events scored three times higher on PTSD symptom severity than the participants who experienced a single type of event (Stimmel et al., 2014).

Types of traumatic event exposure and the event that participants found most-troubling were recorded. This data was further analyzed to see if the event identified as the most-troubling met overall Criterion A for PTSD in the DSM-IV. Nearly fifty-percent of participants (16/33) selected learning about the violent death or serious injury of a loved one as the most troubling event, and of these 16 participants, more than 80% met Criterion A for PTSD. Similarly, when community violence (witnessed or experienced) was recorded as the most troubling event experienced by participants, 54.2% (13/24) met Criterion A for PTSD. Participants who met Criterion A endorsed more severe PTSD symptoms than those who did not meet Criterion A.

In addition, results indicate a significant relationship between reactive aggression and total PTSD severity. Stimmel et al. (2013) define reactive aggression as “acts that occur in response to being provoked or threatened by others.” Reactive aggression was found to be significantly related to endorsement of PTSD Criterion B (intrusive re-experiencing) and Criterion D (hyperarousal) symptoms (Stimmel et al., 2014). These results support the view that it is important to screen for amount and types of trauma exposure in juvenile offender populations.

All data collection occurred in a private room in the detention center, which increased the internal validity of the study. Ninety-one-point-seven percent of the parents and 91.6% of youth with whom contact was made agreed to participate in the study. Self-report measures were used in this study and are subject to state-dependent reporting, as well as under-and over-reporting. Complications involved in obtaining consent from parents reduced the sample size and lowered the generalizability of the results. The sample used for this study was a convenience sample, rather than a random sample, which also lowers the generalizability of the results.

Types of Treatment

Some treatment modalities have been proven more valuable than others. Ford et al. (2012) conducted a randomized clinical trial on the effects of an emotion regulation therapy (Trauma Affect Regulation: Guide for Education and Therapy, or TARGET) and a relational supportive therapy (Enhanced Treatment as Usual, or ETAU) on delinquent girls in the community. Ford et al.’s primary study hypothesis was that TARGET would be more effective reducing the severity of PTSD and enhancing emotion regulation skills. Ford et al.’s secondary hypothesis was that TARGET would also be more effective at reducing symptoms and cognitions associated with PTSD and increasing optimism and self-efficacy. Participants were recruited by announcements and presentations throughout the Hartford, Connecticut metropolitan area. The sample consisted of 59 delinquent girls (ages 13-17) living in the community. A baseline assessment interview was conducted and then participants were randomly assigned to either the treatment condition (TARGET), or the comparison condition (ETAU). Participants then completed a posttest interview at the conclusion of treatment (12 sessions), and 4 months after the baseline interview for individuals who did not complete treatment.

Results indicate that TARGET was more effective than ETAU in reducing intrusive re-experiencing of traumatic events and symptoms of emotional numbing and avoidance. The number of participants assigned to the TARGET treatment group who met full criteria for PTSD dropped from 21 (baseline) to 9 (post-treatment) and those who met partial criteria for PTSD reduced from 12 (baseline) to 7 (post-treatment). The number of participants assigned to the ETAU treatment group who met full criteria for PTSD dropped from 16 (baseline) to 10 (post-treatment) and those who met partial criteria for PTSD reduced from 10 (baseline) to 3 (post-treatment). Results indicate TARGET was associated with reduction in PTSD symptom severity, as well as clinically significant changes in PTSD. Whereas ETAU only achieved small effect size changes, TARGET was associated with medium effect size reductions in anxiety and posttraumatic cognitions. However, individuals assigned to the ETAU treatment group scored higher on gains in optimism/self-efficacy and reduced anger (Ford et al., 2012).

The small sample size and attrition limited the study’s ability to detect statistically significant differences between the therapy interventions. All measures were self report, thus subject to possible expectancy or other biases for which other data sources could offer a valuable counterpoint. One female assessor conducted all pre-and post- therapy assessments and therefore could not be blind to treatment type or phase, which is subject to bias between-group differences and may have inflated the estimates of pre- and post-change. Despite its limitations, the results of the Ford et al. (2012) research suggest TARGET may be a viable treatment approach for delinquent females.

Trauma Systems Therapy (TST)

Trauma Systems Therapy (TST) is a clinical and organizational model for treatment of traumatic stress in children and adolescents. TST was originally created as an outpatient and home-based treatment model, however, providers in residential settings saw its utility for their programs. TST acts to facilitate communication and shared goals among direct care providers, youth and families. TST also emphasizes the importance of functioning among direct care staff, who acts as the youth’s immediate caregivers during residential treatment. Individual, private practice therapists are likely to follow their own approach based on their individual experience and training. In contrast, TST can provide a uniform, systems-based approach and framework agency wide and across staff. TST has been implemented in three residential programs and different sets of outcomes have been tracked in each.

The Boston Intensive Residential Treatment Program (Boston IRTP) is a 20 bed residential treatment center that provides long-term, intensive treatment to children and adolescents with SMHC. “Most residents have had repeated unsuccessful inpatient and residential care treatment before they are admitted to an IRTP setting” (Brown et al., 2013, p. 698). TST was initiated at Boston IRTP in September 2000 and data on total seclusion, restraint and injury episodes was collected until December 2007. Results indicate the number of incidents of seclusion; restraints and staff injury reduced substantially and sustained reduction following the implementation of TST. The Children’s Village (CV) provides short-term residential care for more than 1,200 youth per year in Dobbs Ferry, N.Y (Brown et al., 2013). In 2007, The Children’s Village implemented TST in two residential cottages and after one year, TST became the program treatment model for all 15 residential settings. The Children’s Village has not completed a program evaluation; however, they have tracked clinical outcomes over the course of treatment and used the data to develop treatment. The Child Ecology Check in (CECI) was used to track the child’s emotional regulation capacity and stability of the social environment prior to, and after, putting into place the TST intervention program. Prior to implementation of the TST model, the participant scored high in emotion dysregulation when the environment was distressed. Results indicate that as the environment became more stable post-implementation of TST, participant’s emotion regulation became significantly more stable.

A subpopulation of youth from the Prairie Ridge Psychiatric Residential Treatment Facility in Kansas City received out-of-home services in TST from January 1, 2009 to December 31, 2009. “The overarching goal of the project was to ensure that youth leaving residential care received the same, consistent, child-specific TST services in the community upon discharge” (Brown et al., 2013, p. 699). By the end of the first year, levels of functional impairment scores dropped from 120 to 56 (high scores = lower level of functioning), placement stability for youth increased from 48% to 89%, the average number of placement moves per child dropped from 3.4 to 1.4; and the use of seclusions and restraints within the residential program dropped significantly (Brown et al., 2013).

Multisystemic Therapy for emerging adults (MST-EA)

“The peak years of offending in the general population and among those with serious mental health conditions (SMHC) are during emerging adulthood … individuals with SMHC have greater justice system involvement than those without SMHC, both as juveniles and emerging adults” (Davis et al., 2014). Davis et al., (2014) modifies Multisystemic therapy (MST) for use with emerging adults (ages 17-25) with SMHC and recent justice system involvement. “Multisystemic therapy for emerging adults (MST-EA) targets MH [mental health] symptoms, recidivism, problem substance abuse, and young adult functional capacities” (Davis et al., 2014). Participants were recruited from individuals receiving case management through child welfare or mental health services or receiving juvenile or adult justice system supervision services (e.g., probation) in an urban/suburban region of a Northeastern state.

“MST-EA was the clinical intervention provided to all participants. The state agency charged with treatment of justice-involved adolescents and emerging adults contracted with a private nonprofit provider to offer the MST-EA intervention … Of the 41 participants who enrolled in the study, 21 (51.2%) fully finished the intervention, with 36.5 (range=14.7-64.8) weeks of intervention.”

There was a significant reduction in mental health symptoms, with the median number falling considerably from 20 symptoms to between 5 and 6. The number of criminal and juvenile charges in the 6 months post-intervention (29%) was less than those in the 6 months prior to baseline (12%) (Not statistically significant).

“Recruitment rates into the research were high, and research retention rates were also very strong, as were interview completion rates. Selected measures showed good variability with results generally detecting change. The final fidelity measure captured adequate variability and participants expressed no confusion about final items.”

“…study limitations include the absence of a control group, and the absence of examining the feasibility of randomization of a control condition. The absence of a control group limits understanding the relative strengths or weaknesses of the outcomes; however, that would be the main goal of a larger randomized controlled trial. The absence of employing randomization procedures limits the ability to specifically predict recruitment and retention issues that may arise as a result of either randomization or being assigned to a control condition”

Discussion

References

Brown, A. D., McCauley, K., Navalta, C. P., & Saxe, G. N. (2013). Trauma systems therapy in residential settings: Improving emotion regulation and the social environment of traumatized children and youth in congregate care. Journal of Family Violence, 28, 693-703.

Davis, M., Sheidow, A. J., & McCart, M. R. (2014). Reducing recidivism and symptoms in emerging adults with serious mental health conditions and justice system involvement. Journal of Behavioral Health Services & Research, 1-18.

Ford, J. D., Steinberg, K. L., Hawke, J., Levine, J., & Zhang, W. (2012). Randomized trial comparison of emotion regulation and relational psychotherapies for PTSD with girls involved in delinquency. Journal of Clinical Child & Adolescent Psychology, 41(1), 27-37.

Rosenberg, H. J., Rosenberg, S. D., Ashley, S. W., Vance, J. E., Wolford, G. L., Howard, M. L. (2014). Trauma Exposure, psychiatric disorders, and resiliency in juvenile-justice-involved youth. Psychological Trauma: Theory, Research, Practice, and Policy, 6(4), 430-437.

Stimmel, M. A., Cruise, K. R., Ford, J. D., & Weiss, R. A. (2014). Trauma exposure, posttraumatic stress disorder symptomology, and aggression in male juvenile offenders. Psychological Trauma: Theory, Research, Practice, and Policy, 6(2), 184-191.



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