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In Partnership with Juvenile Justice: Humboldts Perspective On Creating A Continuum of Care

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Presenters Jeremy Nilsen Sr. Program Manager for Children & Family Services. Jeremy is a MFT and has worked at C&FS for 12 years. Previously worked as a clinician providing Functional Family Therapy (FFT),Trauma-Focused Cognitive Behavioral Therapy (TF-CBT), and as a Supervising MH Clinician. Also served as a FFT clinical lead, TF-CBT supervisor, and FFT State Consultant. Megan Gotcher Supervising Probation Officer of the Juvenile Field Unit. Megan originally began her career as a Juvenile Corrections Officer in the Regional Facility Program. She went on to work in the Adult and Juvenile Field. Megan has worked with the Probation Department for 15 years. Trained Facilitator in ART and EPICS Coach.

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About Us Humboldt County has a long history of cooperative and integrated program development between Health and Human Services and Probation to provide services to youth involved in the Juvenile Justice System.

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Presentation Objectives Discuss how Juvenile Justice involved youth and families in Humboldt County benefit from the use of Evidence Based Practices and Integrated MH and Probation programs. Discuss the evolution of services, treatment approaches, and view outcome data. How to overcome implementation challenges and the lessons learned as weve worked together to stabilize and maintain youth in our community.

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Department of Health and Human Services Social Services Mental Health/Alcohol and Other Drugs Public Health Transition-Age Youth Programs Humboldt County Transition Age Youth Collaboration (HCTAYC) Independent Living Skills Programs Employment Training Veterans Services Public Guardian Environmental Health Healthy Communities Emergency Preparedness & Response Mobile Outreach Program

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Probation Provides a screening function for the Juvenile Court Maintains intake services Detention facility for 602s Provides intake and referral to local services for 601s Provides the Court with impartial study of minors home situation Provides supervision to minors as ordered by the Court

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Section 602 of the Welfare and Institutions Code (WIC) Any person under the age of 18 years when he/she violates any law of this state or of the United States or any ordinance of any city or county of this state defining crime other than an ordinance establishing a curfew based solely on age, is within the jurisdiction of the Juvenile Court, which may adjudge such person to be a ward of the Court.

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Goals For Youth Family reunification is the primary goal. To stabilize and maintain youth in least restrictive and appropriate placement. Rehabilitation for youth and family utilizing evidence based practices: PACT, FFT, ART, A-CRA, TIP, EPICS, TFCBT, and others Comprehensive behavioral health services. Treatment provided through integrated team approach. Education success.

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Treatment through Integrated Team Approach Team Decision Making Meeting TDM Family Intervention Team - FIT Wraparound Interdisciplinary Staffing Treatment Team Meetings Mental Health Services provided in Juvenile Hall Youth Centered Educational Services

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Evidence-Based Practices Evidence-Based Practices According to the Institute of Medicine, its the integration of the best research evidence with clinical expertise and patient values. Integrating research, practice, and consumer satisfaction to ensure the best possible results for all involved.

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We are able to shift service delivery and implement changes based on what research shows is effective We can avoid under/over serving clients We need to use our dollars carefully and invest in effective programs and interventions When a program is working, everyone wins. Clients win, employees win, and taxpayers win. Why Is this Important?

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Probations Utilization of EBPs Detention Risk Assessment Instrument (DRAI) Positive Achievement Change Tool (PACT) Effective Practices in Community Supervision (EPICS) Thinking for a Change (T4C) Aggression Replacement Training (ART) Moral Reconation Therapy (MRT)

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EBPs used at Children & Family Services Adolescent Community Reinforcement Approach (A- CRA) Aggression Replacement Training (ART) Functional Family Therapy (FFT) Incredible Years (IY) Nurse-Family Partnership (NFP) Parent-Child Interaction Therapy (PCIT) SafeCare Transition to Independence Process (TIP) Trauma-Focused Cognitive Behavioral Therapy (TF-CBT) Wraparound

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PACT The Positive Achievement Change Tool (PACT) is an evidence-based assessment tool designed to determine a youths risk for re-offending. The PACT analyzes static factors and dynamic factors. Static factors are events in a youths life that are historic and cannot be altered. Dynamic factors are circumstances or conditions in a youths life that can potentially be changed. The PACT generates a score which identifies the youths level of risk to re-offend.

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Continuum of Care Home with active support services Healthy Alternatives Foster Care Relative Care/NREFM Residential Treatment Regional Facility Program Department of Juvenile Justice

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Juvenile Hall Services Medication Management Mental Health Services Clinicians meet with youth on a regular weekly schedule, upon staff referral, or when there is a self referral. Community Supports Social Skills Weekly Class(EPICS)

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Team Decision Making Meeting Definition: The Probation Department hosts a meeting that brings together people who are involved with the family to make a decision about the care and placement of the youth. Goal: To identify the least restrictive placement that is in the best interest of community safety and the youth.

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Family Intervention Team A multi-agency team designed to facilitate inter- departmental and inter-agency collaboration. The focus is on at-risk children and youth with the goal of utilizing available resources, managing clinical and fiscal risk, to coordinate treatment, and to monitor client outcomes. FIT includes staff from CWS, Probation, Mental Health, Education, and Public Health.

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Out of County Placement Monthly Treatment Team Meetings Monitor Placement Referrals for services upon returning home

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Outpatient Services at C&FS Screening & Assessment Adolescent AOD Individual/Family Counseling Targeted Case Management Medication Support Supplemental services include Therapeutic Behavioral Services (TBS), Intensive Care Coordination (ICC), and Intensive Home Based Services (IHBS).

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Adolescent Community Reinforcement Approach (A-CRA) For youth between the ages of 12-19 with substance abuse issues. Behavioral intervention that seeks to replace environmental contingencies that have supported use with healthy community activities and behaviors. Service includes evaluation, parent/family involvement, 10-14 intensive outpatient sessions.

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Incredible Years (IY) Parent training program focused on strengthening parenting skills. Effective for decreasing aggression, reducing disruptive behaviors, increasing academic engagement, improving conflict management, and increasing socialization. 12-16 weeks of classes for parents of children ages 3-8. Classes offered throughout various locations in the county.

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Nurse-Family Partnership (NFP) Nurse-led maternal health and home visitation program. Targets low-income, first-time mothers. Services start early in pregnancy and support continues through childs 2 nd birthday. Goal is to help mothers have a healthy pregnancy, improve childs health and development, and become more economically self-sufficient. Provided through the Public Health division.

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Parent-Child Interaction Therapy (PCIT) Training intervention with live coaching that teaches specific behavior management techniques to parents. Focused on improving caregiver-child relationship and increasing positive behaviors. Approximately 20 sessions for children ages 2-7 exhibiting behavioral concerns. Provided through our Healthy Moms and Transition Age Youth programs.

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SafeCare In-home parenting curriculum teaching parents how to: Interact in a positive manner with their children Recognize hazards in the home Recognize and respond to symptoms of illness and injury Targets parents of children zero to five, who are reported or at risk of child maltreatment. Weekly home visits over the course of 15-20 weeks. Provided through Public Health division.

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Transition to Independence Process (TIP) Goal is to provide support and services for youth ages 16-26 to make a successful transition into adulthood. Engages youth in a futures planning process, facilitates greater self-sufficiency, and achievement of goals related to specific Transition Domains. TIP model core practices are used by trained facilitators in our TAY program.

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Trauma-Focused Cognitive Behavioral Therapy (TF-CBT) For youth ages 4-18 displaying PTSD, depression, anxiety, and other trauma- related symptoms. 12-20 individual and family sessions focused on teaching skills to manage symptoms, processing traumas, and addressing cognitive distortions. Used in a variety of settings throughout C&FS.

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Wraparound Wraparound is a team-based, strengths- oriented, solution finding process. Goal is to help families stabilize, identify long- term, sustainable solutions to family needs, and achieve goals set by the team. Facilitation done by Probation and MH staff as part of the Regional Facility aftercare and with Adoptions cases.

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HEALTHY ALTERNATIVES A Program for Youth and Families

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Collaborative Partners Humboldt County Probation Department Superior Court Judge Department of Health and Human Services Humboldt County Office of Education Community Partners

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Probationer/Client Goal: To address the needs of youth who are open to or are eligible for Mental Health services and enter the criminal justice system, while allowing them to remain in their own home in the community.

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Entrance and Referral Criteria Youth must be 602 WIC Ward of the Court age 11-18 Referred as result of 602 Petition or VOP Probation assesses eligibility and refers the matter to C&FS if appropriate for screening

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Entrance Criteria Cont Primary Mental Health Diagnosis under DSM-IV Mental Health Assessment completed by C&FS Court must order minor and family to participate in program

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Healthy Alternatives Overview Minor attends weekly meetings with Probation Minor attends bi-monthly Court appearances (therapeutic Court model) Minor submits to random drug testing

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Overview Cont Probation monitors school attendance and behavior Probation encourages minors to become involved in the community through pro- social activities and community service work

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Overview Cont Probation and C&FS empower parents to participate in the minors academic success and pro-social activities. Probation and C&FS consult on a regular basis, attend monthly program meetings, and hold quarterly program review meetings.

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Program Goals Graduate from the Healthy Alternatives program and terminate successfully from Probation Education Goals identified and developed Employment services utilized Family connected to services to sustain positive changes

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Goals Cont Family participating in pro-social activities on a consistent basis Victim restoration completed Reduction in negative impact of minors behavior on the family and in the community

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Program Phases and Treatment Components Length of program varies depending on needs of family and individualized case plan Orientation Phase: Youth and family complete assessment and begin attending Court

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Phases Cont Phase I: Functional Family Therapy Phase II: 100 hours of CSW and/ Pro- Social Activities, Individual Counseling/Adolescent AOD (as needed) Phase III: Referrals to community programs as needed, Booster Sessions of FFT as needed

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Functional Family Therapy Research-based prevention and intervention program for at-risk adolescents and their families Targets Youth Age 11-18 Short-term, family-based program at family home or C&FS office

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FFT Cont Average of 12 to 15 sessions Provides specific skills to families such as communication, problem solving, conflict management, negotiation, and supervision Booster sessions offered as needed Sessions can be done in home Appointments scheduled to fit with a familys work and school schedule

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FFT Components FFT has three phases which last 4 to 5 sessions each: Engagement/Motivation Behavioral Change Generalization

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FFT Focuses On Externalizing Adolescent Behavior Disorders Conduct Disorder Oppositional Defiant Disorder Drug use/abuse Other Behavior Problems Parent-Child/family conflict issues

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What is Success? FFT success defined as obtainable change. 50% - 60% completion rates Families relate to each other better Rates of drug use are reduced Recidivism (re-offending) rates reduced

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FFT Outcome Monitoring

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Youth Outcome Questionnaire (YOQ) Subscales Pre/Post

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Youth Outcome Questionnaire (YOQ) Total Scores Pre/Post

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Youth Outcome Questionnaire- Self Report (YOQ-SR) Subscales Pre/Post

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Youth Outcome Questionnaire- Self Report (YOQ-SR) Total Scores Pre/Post

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Client Outcome Measures (COM) Adolescent-A, Parent-P, Therapist-(TOM)

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Program Overview The New Horizons program is provided to all youth in the facility and is a collaborative effort between County Probation Department, Humboldt County Office of Education and the Department of Health and Human Services Mental Health Branch. At any one time, there can be 18 youths in the program.

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Target Population Adolescents 12 18 Who show, or are at risk for, aggressive behaviors History of placement failures History of traumatic events, perhaps neglect or abuse School related problems

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Target Population Cont Are juvenile wards of the court With co-occurring disorders Behavior disorders Substance abuse Other mental health disorder Have been court ordered into New Horizons

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Treatment Program Four phases, 4 to 6 month intensive in-custody mental health treatment followed by 6 months of aftercare. Structured behavior management, individual and family therapy, group counseling, substance abuse counseling, independent living skills. Individualized and strength based youth and family case plans developed utilizing the Wraparound model. 57

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New Horizons Program Structure and Staffing Procedure 4 phases Phase 1: 2 weeks Phase 2: 4 weeks Phase 3: 8 weeks Phase 4: 4 - 6 weeks Through each phase of the program probation, mental health, school and correctional staff communicate and staff the youth.

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Aggression Replacement Training at New Horizons Evidence-based, comprehensive intervention strategy for aggressive youth New Horizons staff trained by experienced trainers Implemented with fidelity/fidelity measures to ensure quality control Utilization and reinforcement of ART principles and skills throughout the Regional Facility programmingProbation, Mental Health, Schools

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ART - Expected Results ART is an Evidence Based Practice (EBP) that began in 1987 and has been tested in schools, community, and detention environments. The majority of youth show substantial changes in the following areas: Improved social skills Development/improvement of moral reasoning skills Decreased aggressive behaviors Reduction in recidivism

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ART Program Components Skill Streaming To teach social-skills and alternatives to aggression. Anger Control Training To help youth behave less aggressively less often. Youth learn to reduce angry outbursts and to improve self control. Moral Reasoning Training To improve moral development and reduce the use of cognitive distortion or thinking errors. 61

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Anger Control Training ABCs Triggers 1. External 2. Internal CuesReducers RemindersSelf-Evaluation Skill Streaming Skill UseFull Sequence

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ART Outcome Monitoring

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Aggression Questionnaire (AQ) Pre/Post

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Skills Taught to Regional Facility Youth Knowing Your Feelings Expressing Your Feelings Understanding the feelings of others Dealing with Someone Elses Anger Expressing Affection Dealing with Fear Rewarding Yourself 65

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Skillstreaming Checklist: Parent Pre/Post

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Skillstreaming Checklist: Student Pre/Post

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Skillstreaming Checklist: Staff Pre/Post

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Moral Reasoning Dilemma discussion groups designed to teach youth how to: Think about moral issues. Deal with moral situations that do not have clear-cut solutions. Use principles of fairness and justice in their interactions with others. 69

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Moral Reasoning Goals Increase the moral reasoning stage of the trainees and teach more balanced ways of thinking. Help the trainees use newly learned and more advanced reasoning skills in the real world. 70

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AOD Groups in the Regional Facility Modified Matrix curriculum used for the substance abuse treatment component of the New Horizons treatment program. Features of the A-CRA model are presented in groups and used as part of the aftercare program. Groups held twice weekly. 71

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Youth Outcome Questionnaire (YOQ) Subscales Pre/Post

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Youth Outcome Questionnaire (YOQ) Total Scores Pre/Post

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Youth Outcome Questionnaire- Self Report (YOQ-SR) Subscales Pre/Post

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Youth Outcome Questionnaire- Self Report (YOQ-SR) Total Scores Pre/Post

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How I Think (HIT) Problem Area Scores Pre/Post

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How I Think (HIT) Summary Scores Pre/Post

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Regional Facility Aftercare Individual and Family Counseling Case management Wraparound meetings Probation support Pro-social activities A-CRA

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Program Re-Incarcerations Since program implementation, 58 (21%) of the 270 youth who have participated in the New Horizons program have been re- incarcerated in the Regional Facility. The table on the next slide shows the elapsed time between incarcerations.

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Time Between Incarcerations 0-3 months3-6 months6-12 months> 12 monthsTotal 1st repeat1417161158 2nd repeat514414 3rd repeat11002 4th repeat00101

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Goals Attained by Humboldt County Inter-Agency Collaboration Several EBPs built into programs serving Juvenile Justice involved youth (A-CRA, FFT, TF- CBT, Wraparound) Co-location of Case Manager at Probation Department (AOD) Critical Incident Training(Multiple County Agencies have participated) Hostage Negotiation Team(Mental Health and Law Enforcement)

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Challenges Lack of community resources Shortage of out-ofhome placements Staff turnover/transitions Fidelity of Evidence Based Practices

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Lessons Learned Its hard! flexibility is mandatory. Frequent inter-disciplinary staff meetings are important. Can be mutually beneficial reduced recidivism, shared burden, input from differing perspectives, and responsibility. Client services improved right amount of services, the right service, at the right time. Better able to help families navigate the system.

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Questions or Comments? 84