Children’s Health Services health care people Managing Young People in Youth Detention who suffer from Posttraumatic Stress and associated Mental Health

Children’s Health Serviceshealth • care • people

Managing Young People in Youth Detention who suffer from Posttraumatic Stress and associated Mental Health and Substance Misuse Problems

Assoc. Prof. Stephen StathisConsultant Psychiatrist

Ivan DoolanSenior Social Worker – Forensic

On behalf of the Mental Health Alcohol Tobacco and Other Drugs Service (MHATODS)


“Sometimes it is more important to know what sort of person has a disease, than what sort of disease a person has.”

Sir William Osler, M.D


Outline

• Brief description of Mental Health Tobacco and Other Drugs Service (MHATODS)

• Prevalence of Mental Health Problems and Substance Use for YP in detention

• Treatment of Traumatised YP in detention– Specific issues in this population– Management difficulties & dilemmas– Relatively little on medication


Imagine ……..• Almost all your clients had conduct disorder• Almost all your clients had been abused• Up to 90% use drugs or alcohol• Over half were Indigenous• One third were:

– Depressed– Anxious– ADHD– Significant posttraumatic symptoms – Broad range of “other” mental health problems


What is MHATODS?• Mental Health Alcohol Tobacco and Other Drugs

Service

• First time in Qld. that mental health & drug and alcohol treatment for young people has been integrated

• Run in the Brisbane Youth Detention Centre– Males in detention from Rockhampton to NSW border – All females in Qld


The MHATODS Team • Half time Consultant Psychiatrist • 4+ Allied Health Clinicians specialised in C&YMH and

substance misuse. • Team Leader (½ time clinical load)• Administration Officer• Indigenous Health Worker/s• +/- Psychology Masters students• Psychiatric Registrar from January 2009


Aim of MHATODS

• Provide YP in detention with the same services they could expect if they were to attend a Community Mental Health Clinic or Drug and Alcohol Service

• Some modification due to setting – Limited History– Access to Family– Therapeutic Strategies– Rapid “churn-through”


Case Discussion

ZZ; 15 yr. male with 9 yr. Hx of disruptive behaviours. Seen in juvenile detention.

• Stealing• Some fire setting & graffiti/destruction of public

property• Fighting & suspensions• Entered the JJS at age 13; property offences• Lack of remorse.


Case Discussion

Complicated by:• Low-average IQ (V = 66; P = 78; FS = 71)• Learning problems & school-based behavioural problems

– Left school IX grade• Never sit still in class/fidgety• Poor attention & concentration• Always disruptive

• “Weird”; unusual stereotypical behaviours • Poor peer relationships• Poor awareness of social cues


Case Discussion

Well documented history of physical abuse and neglect: • DV - mother• Repetition of M’s own childhood/ few friends, poor

parenting.• Rarely sees father• M’s current partner is physically abusive when

intoxicated• Reported to DChS ++


Case Discussion

Mums main concerns:

• He is always “hyper” … • He acts “crazy without thinking”• It is getting worse in high school. • He was diagnosed with ADD and the medicines helped

him


Case Discussion In talking with ZZ:

• Admits he gets frustrated and “blows up”• Constantly feels sad • Hx DSI ?? Suicide attempts (x3)• People laugh at him because he is “strange”; never can keep friends• Difficulties sleeping: nightmares (trauma related) and some

flashbacks• Alcohol, occasional marijuana. ecstasy & speed:

– Likes the “rush” – Attempt to get rid of “bad memories”

• People call me a schizo & a retard”• Has heard that he can get “dex” from you


Diagnosis ???

Lots of Co-morbidities here:

• ADHD; Combined type• ODD / Childhood Onset Conduct Disorder• Depressive Disorder• PTSD• Polysubstance abuse • “Aspergers Disorder” / PDD-NOS• Learning Disorder• Borderline Mental Retardation/ V:P mismatch


Multiple Paradoxes

• Rapid assessment required of complex cases vs. Short assessment time frame

• Significant co-morbidity vs. Collateral Hx difficult to obtain

• Medication Seeking vs. Lack of therapeutic relationship• Remand vs. Sentence


Multiple Paradoxes (cont)

• High levels of MH and D&A problems– Precontemplative – Difficult to engage

• Marginalised group of YP where trust in authority figures is rare


Patterns of Substance Use at BYDC


Substance Use in Youth Detention

• Lennings & Pritchard (1999) found 90% of young people in detention had some degree of drug/alcohol use.

• 33% of these believed they had a problem. – Of those, 70% thought they should have treatment

• >50% young people in detention met criteria for a substance use disorder (Teplin et al., 2002)


Reported Substance Use Prior to Admission to BYDC

• Chart audit of admissions in the period 1/1/06 – 31/3/06

• 209 admissions• 174 individual young people• 31 females; 143 males• 78 Indigenous; 96 non-Indigenous• Mean age 15.4 years (+/-1.3)


Reported Substance Use Prior to Admission to BYDC

Reported Drug/Alcohol Use Prior to Admission

19%

61%

72%

4%0.5%

52%

1%

10%

83%

85%

0.00%

10.00%

20.00%

30.00%

40.00%

50.00%

60.00%

70.00%

80.00%

90.00%

Tobacc

o

Amph

etam

ines

Benzo

diazep

hines

Mar

ijuan

a

Barbitu

rate

s

Oth

er

Solve

nts

Any D

rug

(Not T

obacc

o/Alco

hol)

Alcoho

l

Any D

rug/

Alcoho

l (Not

Tob

acco)


Reported Substance Use Prior to Admission to BYDCMales Reported Drug/Alcohol Use Prior to Admission

83.54%

9.49%

1.27%

54.43%

0.00%3.16%

17.09%

62.03%

72.15%

86.08%

0.00%

10.00%

20.00%

30.00%

40.00%

50.00%

60.00%

70.00%

80.00%

90.00%

100.00%

Toba

cco

Amph

etam

ines

Benzo

diaze

phin

es

Mar

ijuan

a

Barbit

urat

esOth

er

Solven

ts

Any D

rug

(Not

Tob

acco

/Alco

hol)

Alcoho

l

Any D

rug/

Alcoho

l (Not

Tob

acco

)


Reported Substance Use Prior to Admission to BYDCFemales Reported Drug/Alcohol Use Prior to Admission

82.86%

14.29%

0.00%

40.00%

2.86%5.71%

25.71%

54.29%

68.57%

82.86%

0.00%

10.00%

20.00%

30.00%

40.00%

50.00%

60.00%

70.00%

80.00%

90.00%

Toba

cco

Amph

etam

ines

Benzo

diaze

phin

es

Mar

ijuan

a

Barbit

urat

esOth

er

Solven

ts

Any D

rug

(Not

Tob

acco

/Alco

hol)

Alcoho

l

Any D

rug/

Alcoho

l (Not

Tob

acco

)


Audit Summary

• Males higher rates for marijuana, alcohol• Females higher rates inhalants, amphetamines• Non-Indigenous higher rates alcohol,

amphetamines• Indigenous higher rates inhalants


MHATODS Programs

• Four Session Individual Substance Use Intervention Program

• Voluntary• Individual one-on-one counselling for

anyone• Aim is to understand substance use in

context of life and experience• Can be referred by Caseworker, Nurse or

VMO


MHATODS Programs

• Four Session Group Relapse Prevention Program

• Voluntary• Group counselling for anyone• Aim is to maximise reducing or ceasing

substance use• Can be referred by Caseworker, Nurse or

VMO


Prevalence of Mental Health Problems at BYDC


MH Problems: YP in Detention

• 2/3 of males and 3/4 females in detention centres will have one or more psychiatric disorders (Teplin et al, 2002)– Similar findings in Australia, Canada, UK &

Europe– Comorbidity is the NORM rather than the

EXCEPTION


PTSD in Youth Detention(Abram et al. 2004)

• ~900 young people in juvenile detention• Diagnostic Interview Schedule for Children,

version IV (DISC IV)• 92.5% experienced 1 or more traumas (mean,

14.6 incidents; median, 6 incidents)• Significantly more males (93.2%) than females

(84.0%) reported at least 1 traumatic experience• 11.2% of the sample met criteria for PTSD in the

past year. • > 50% with PTSD reported witnessing violence

as the precipitating trauma.


Massachusetts Youth Screening Instrument (MAYSI-2)

• Screens for 7 scales of mental health or behavioural problems:– Alcohol and Drug– Angry-Irritable– Depressed-Anxious– Somatic Complaints – Suicide Ideation– Thought Disturbance (males only)– Traumatic Experience (gender specific)


RESULTS – Males vs Females

Percentage of males (n=124) and females (n=40) scoring above screening cut-off on each scale, excluding Traumatic Experiences.


RESULTS

• 75% males and 90% of all females scored above the clinical cut-off on at least one of the scales (excluding Thought Dist. & Traumatic Experiences).

• Females screened for significantly higher mental health problems than males across three scales:– Depressed-Anxious (2 = 9.41; p < 0.01)– Somatic Complaints (2 = 3.89: p < 0.05)– Suicide Ideation (2 = 6.24; p < 0.05)


What About Traumatic Experiences?


TE Subscale- 5 Questions

1. Have you ever in your whole life had something bad or terrifying happen to you?

2. Have you ever been badly hurt or in danger of getting badly hurt or killed?

3. Have you had a lot of bad thoughts or dreams about a bad or scary event that happened to you?

4. Have you ever seen someone severely injured or killed (in person not just on TV)?

5. FEMALE: Have you ever been raped or in danger of being raped?

MALE: Have people talked about you a lot when you’re not there?


RESULTS – TE Subscale

Disturbingly high rates of trauma• 82% females reported at least 1 traumatic

event; Mean 3.4• 67% of males reported at least 1 traumatic

event; Mean 2.2


Correlation between TE and SUD

56.1

73.179.9

70.6

90

0102030405060708090

100

1 2 3 4 5

TE Score

SU

D D

x %


Screening: Implications for practice?

• DO NO HARM• We know there is a high burden of D&A and MH problems• We know there are heaps of traumatised young people in

detention• We know that admission into detention precipitates posttraumatic

symptoms (PTS)– Agitated young people historically poorly tolerated!!

• New environment including loss of (limited) supports• Close living quarters• Stress of court process• ?Withdrawal symptoms• Away from country (Indigenous)

• We don’t know evidence-based ways to treat these young people


Treatment for Trauma

Exposure/Fear Based Trauma– Single episode trauma– Characterised by Intrusive

Thoughts– Few other MH issues– Little SA– Discrete trauma– No Hx prior to index event– Reasonable health

Shame Based Trauma– Prolonged abuse

• Torture/POW• Childhood SA• Interpersonal victimisation

– Trauma has effected the concept of self

– “Complex PTSD”• Associated MH Co-morbidity

– Sx linked to dependence, guilt & humiliation

– Interventions • Therapeutic Relationship*• Need for medication


Evidence Base - Adolescents

• Surprise, surprise.! Very little• Usually associated with natural disasters or

single assaults (fear-based trauma)• Soon after trauma• Few with the types of traumatised YP we see in

detention• Very few “brief” interventions

– 6, 8, 10, 18 weekly sessions– 1-2 hour/session


Evidence Base - Therapies

• Silverman (2008) reviewed 21 treatment studies for children suffering from PTSD and PTSS– Violence, Abuse, Disasters, MVA

• 8 studies using Traumatic-Focused CBT met “Well Established Criteria” for efficacy– Shared the following:

• Working with children individually• Child exposure tasks via narratives, drawings or

imagination

• Most ~ 12 sessions; up to 20• Most 45-90 minutes duration


Dilemma: Highly Transient Population

< 3 Days

3- 28 Days 1 – 6 Months

> 6 Months Total

Ave. Daily Pop. (ADP)

4 15 32 20 72

ADP % 6% 21% 45% 28% 100%

#Admissions/ Year

394 282 98 21 795


The Dilemma Continue

• Highly Transient Population in BYDC– Short and frequent admission

• Environment of BYDC– Contain vs Exacerbate– Need for short term symptom control– Confounding bias

• Co-morbidity is the norm– Need to also treat MH and SU problems


The Dilemma (continued)

• Psychologically minded– Precontemplative– Stimulus to change in BYDC only?– External locus of control and medication … “Give me a pill, doc”– Cognitive Scores skewed to left

• Marginalised group of YP – Lack of trust

• Community Toxicity– Longstanding social disadvantage / Maslow’s Hierarchy– Ongoing trauma after release

• Indigenous– Narrative Approach best


The Dilemma (yes, there is more)

• Inappropriate dismantling of complex defenses– “Professional Voyeurism”

• Ability to extract information from a patient which does not assist in management

• What can you do with the history obtained?!


Conclusion: Need to Develop Our Own Program

• Brief (~ 4 sessions within a month)• Narrative• Focused on Acute symptoms reduction

– Solution Focused

• Psychoeducational– Understanding the meaning behind the Sx

• Cognitive Restructuring– Understanding the negative/intrusive thoughts


Brief Intervention for Trauma Symptoms (BITS)

• Narrative strength based approach• Integrate trauma experience symptomatology• Regain mastery of the parts of their lives

affected by their trauma related symptoms


4 Sessions

1. Psychoeducation

2. Trauma Narrative

3. Cognitive Restructuring

4. Symptom Management


Session 1: Psychoeducation• Re-Experiencing Phenomena• Avoidance Symptoms• Arousal• Mood disturbances• Goal is to normalise the response• Normal/recognised experience to an abnormal

event• “I would expect someone who has experienced

what you have to be having (flashbacks etc…)”• Reassurance they are not going …. crazy, womba

etc


Session 2: Trauma Narrative

• Attempt to get a young person to give you an idea of what they have suffered

• Use of the TSCC• A lot of young people have things happen to

them that are difficult to talk about. Has something like that happened to you?

• eg. If sexual abuse evident– “Sometimes adults touch children in a sex way, or make children touch

them in a sexual way. Has this happened to you?– Sometimes children enjoy these things and then feel really guilty and

bad about it. Has that ever happened to you?


Session 3: Cognitive Re-Structuring

• Aim of this session is to enable the YP to move from a position of self-blame and responsibility for the trauma to a position of being able to place the blame and responsibility with the perpetrator

• Many YP blame themselves for being unable to stop the trauma

• Facilitate YP need to gain a realistic view of their experience


Realistic View

1. YP not to blame for what they have experienced

2. They could not have stopped the trauma from occurring

3. Responding to the trauma in a maladaptive way is allowing the perpetrator to win / retain control


Addressing the Blame

• Question the YP in a manner that challenges their thoughts– “If you were talking to an X yr. old child who

experienced what you have, would you blame them?– “What would you say to them?”– “If you were an X yr. old child and the perpetrator was

an adult, who would be to blame?”


Addressing the Blame (cont)

– “Children are brought up to obey adults. If an adult tells you to do something, are you really going to say no?”

• At what age does this change?

– “Children trust adults. Do you think a child is going to question what an adult says or does?”

• At what age does this change?


Addressing the Maladaption

• Reframe the maladaptive coping mechanism– “How have you coped with what has happened?”

• DSH• Substance use• Promiscuity etc

– “Is this helping or hurting you?”– “What other ways might you cope?”– “What would you suggest to other YP?”


Session 4: Symptom Management

• Aim of this session is to identify strengths and resilience YP possess that has allowed them to survive the trauma

• YP often are unable to see any positives about themselves – Self-blame they have developed about the trauma.– Toxic environment, few supports etc

• The goal in this session is assist the young person to identify these positives.


Focus on the Positive

• What do you do when you have …………. (flashbacks, nightmares, intrusive thoughts, etc.)

• What have you found to help the most?• What would you tell other young people to do?• How have you been able to survive all of this

– What does that tell you about yourself?– Did you ever think you possessed those strengths?

• I am amazed at how you have been able to cope. What other coping methods have you used?


Medication

• Emerging evidence of some SSRIs and atypical antipsychotics

• Quetiapine (low dose)– Sedation– Reduction in re-enactment phenomena– Reduced affective lability

• Blinded trial of Quetiapine and Fluvoxamine


Evaluation

• Pilot program• MAYSI as a screening tool• TSCC beginning and end• ?Other instruments

• Watch this space!


Future

• Medication vs. Therapy alone

• Individual vs. Group Therapy – Group therapy is risky in detention– Not a debrief

• Most of what passes as psychological debriefing has essentially been debunked


Documents

Children’s Health Services health care people Managing Young People in Youth Detention who suffer from Posttraumatic Stress and associated Mental Health