EBP for Highly Complex Cases

Dr. Kathy Seifertk.seifert@espsmd.com

http://care2systems.com

Targets of InterventionsTypes of Interventions

Intensity of Interventions

objectives1. Participants will be able to name 5 risk

factors for violence2. Participants will be able to name 2 EBP

for Highly Complex Cases

Suicide Risk vs. Self Harm

Danger to self

"one-size treatment" does not fit all – Berman, et al.

using more treatment options in a synthesized manner is superior to rigidly adhering to only one or two approaches – Berman, et al.

Treatment

EBP

•Case management•Multi-system integration•Family Therapy•Developmental approaches with skill building•CBT•Role playing•Dosage is important•Holistic approaches•Neuro-feedback & CES•Wrap-around

Evidence based treatment for complex cases

Each client is assessed for risk of dangerousness at regular intervals, or as

needs change•Clients at risk of dangerousness are identified and charted•Immediate safety needs of others are addressed•Treatment and monitoring strategies to ensure procedures for safety of others are implemented•Treatment and monitoring strategies are individualized and documented in the client’s health record•Outcomes of strategies are charted

Danger to Others

Interventions must provide1.Healthy, safe environment2.Healthy developmental experiences

Trauma Interferes with Child Development

6 Core Concepts of Child Developmento Children are always learning and

development has a sequence that must be followed and age is not a determinate of developmental level (roll over, sit up, crawl, stand up, walk)

o Skill building usually follows developmental sequences and be taught best within the context of a healthy, nurturing, dependable relationship.

o Attachment experiences (good, bad, or ugly) and trauma change the brain.

Corrective developmental experiences and healthy relationships

can also change the

brain.

The balance between

healthy and unhealthy

biology (including

genes), environment

and experiences will determine the health of development.

Healthy skill development is necessary to function

effectively in the world of

people.

Child development - 2

What Developmental areas may need intervention

o Problem solvingo Self managemento Moral reasoningo Logico Affect regulationo Interpersonal relatednesso Task behavioro Concentrationo Impulsivityo Effective Communication

Stage I – Ages 0-2. Immediate Gratification

Stage II – Ages 2 -7. Reciprocity begins to develop

Stage III – Ages 8 – 11. Empathy Develops. More organized , less impulsive.

Stage IV (12-18) Learning the importance of group membership and the “Golden Rule”

Can be blocked by Trauma

Can be blocked by Trauma

Can be blocked by Trauma

Trauma Negatively Affects Moral Development, Kohlberg, 1969 (Expanded from Piaget)

Erikson’s Stageso 1 Hopes: Trust vs. Mistrust (Oral-sensory, Birth-2 years) (Safe Base)o 1.2 Will: Autonomy vs. Shame & Doubt (Muscular-Anal, 2-4 years)

(Exploration from Safe Base)o 1.3 Purpose: Initiative vs. Guilt (Locomotor-Genital, Preschool, 4-5 years

) (I can do things on my own)

o 1.4 Competence: Industry vs. Inferiority (Latency, 5-12 years) (I am Competent)

o 1.5 Fidelity: Identity vs. Role Confusion (Adolescence, 13-19 years) (Who am I?)

o 1.6 Love: Intimacy vs. Isolation (Young adulthood, 20-24) (Establishing a family/ career)

Trauma can interrupt the sequences of development

Promising Practiceso Trauma and attachment worko Routine and structureo Healthy, safe environmentso Narrative Therapy

o Change to an Empowerment Ending to the Story

Provide interventions that match the child’s developmental level.

o Many severely traumatized children are at the immediate gratification stage of development and are seeking a safe base.o Immediate gratification and needs of the self are primaryo Must learn perspective taking and reciprocity before empathyo If the youth is still seeking a safe base, that must be

established before exploration of the world and information gathering

o A safe environment is essential for healthy developmento You need some type of developmental guide for use in your

treatment plan

The Behavior Objective Sequenceo By Sheldon Braatano A developmentally sequenced group of skills in 6

Domains.o Age is not the determiner of skill levelo Provide interventions on the child’s level of

developmento Youth must learn skills in appropriate

developmental sequence.o Find out at what level they have mastered skills

(can do it 90% of the time without prompting)

Adaptive SkillsResponds in a developmentally appropriate

manner to rules and expectationsANDChanges those responses as the circumstances

changeExampleI expect a __ year old to walk into the counseling

office and be able hold a conversation with the counselor AND when the format is changed to group therapy, the youth is able to adapt to the different format and relate to peers in the group, not just counselor.

Adaptive: Responds appropriately toroutine and new expectationsrespond independently to materials for amusementappear alert and able to focus attentionbring no weapons to schooluse amusement materials appropriatelywait for turn without physical interventionuse and return equipment without abuseaccept positive physical contacttouch others in appropriate waysrefrain from stealingrespond when angry without hittingrecognize and show regard for possessionsaccept verbal cue for removal from a situationrespond when angry without abuse of propertyrespond appropriately to substituterespond when angry without threatswalk to timeout without being moved by an adultwork or play without disrupting othersrefrain from inappropriate behavior when otherslose controlrespond to provocation with self-controlrespond when angry with self-removal

Self-Management Skills

Responds appropriately to challenging experiences with self-control in order to achieve success

o (E) Appear alert and able to focus attention on activitieso Wait or take turns when directed without physical intervention –

verbal prompts may be useo Respond when angry without verbal threats or intent to harmo (M) Seek adult help in personal and/or group crisiso Maintain personal control and routinely comply with established

procedures in group situations without reminders.o (H) Maintain self-control when faced with disappointment,

frustration, or failure without adult intervention.o Obey new or temporary authority figure, without presence of

other permanent staff

Communicationo Ability to share with and receive information from other

people to meet a need or affect another person in a positive way.o Speak using a volume appropriate to the situationo Wait until a speaker is finished before respondingo Express feelings about self or others to an adult appropriatelyo Spontaneously participate in group discussionso Maintain appropriate social distance when speaking to anothero Speak courteously to others, using appropriate references, with no

cues.o Describe personal strengths that will enable success

Interacting with others in social and task situations in ways that

meet personal and interdependence needs and

contribute to a sense of belonging•Respond to an adult when his or her name is called•Accept help from an adult when offered•Sit quietly for 15 minutes or more in a group listening activity•Develop positive relationships with more than 1 adult•Share materials and equipment with peers with minimal reminders from adults•Physically or verbally come to the support of another student by offering assistance in a difficult situation•Spontaneously resist negative peer pressure

Interpersonal Behaviors

Task Behaviorso Student engages in task or activity with or without assistance

o Accept assistance from an adult on academic taskso Refrain from inappropriate behavior when asked by an adult to correct

errorso Complete daily assignmentso Choose and actively participate in elective classeso Ignore distractions of others while workingo Self-chart progress in reading or matho Participate in structured role-playing activitieso Complete and turn in assigned homework when due

Personal Behaviors

o Student engages in a counseling dialogue with a helping person, permitting adult to help resolve issues or solve problems or build self esteem.o Express negative feelings to an adulto Follow through with specific directions from an adult to modify

behavior in a given situationo Participate in determining a short term plan for dealing with an

immediate situationo Attend to a peer when a peer is speakingo Express feelings about self to peerso Seek counseling t avoid conflicto Contribute to group rule making and consequenceso Verbally demonstrate knowledge of alternative coping

strategies for managing stress

BOS - Level 3 (skills typically mastered during preschool years):

Focus: Self; Significance; SuccessIssues: Trust; Pleasure; Security; SupportInterventions: Routines; Repetitions; Modeling; Concrete

Rewards; Limit Setting; Consistent and Planned Consequences; Continuous Supervision

Adult Role: “Benevolent Dictator”

Level 2 (skills typically mastered during elementary years):

Focus: Group membership; Competence; Sensitivity to Others; Awareness of Values; Communication Skills

Issues: Applying Skills in Groups; Balancing Personal and Group Needs; Responding to New Settings and People; Managing Movement

Interventions: Routines; Repetitions; Verbal Rewards; Limit Setting with Expanded Choices; Consistency with Group Consequences; Natural and Logical Consequences

Adult Role: “Group Leader”

Level 1 (skills typically mastered during adolescence and early adulthood):

Focus: Belonging; Cooperation; Personal “Power,” IndividualtionIssues: Applying Skills in New Situations; Expanding and Reinforcing

Competencies; Transitions to New EnvironmentsInterventions: “Normal” Expectations; Social Rewards; Expanded Choices;

Group Problem Solving; Self Selected GoalsAdult Role: “Guide/Facilitator”