Healing the Child in Juvenile Court: Applying an Infant Mental Health Approach

1. Healing the Child in Juvenile Court: Applying an Infant Mental Health Approach Judge Cindy Lederman 11th Circuit Juvenile Court, Miami Joy D. Osofsky, Ph.D. LSU Health Sciences Center, New Orleans July 2006

2. Portrait of Young Children in Foster Care in U.S. • Infants comprise 1 in 5 children in foster care and remain in care twice as long • Developmental delay is 4 to 5 times greater than children in general population • Almost 80% have prenatal exposure to maternal drugs • More than half suffer from serious physical health problems

3. Maltreated toddler at play

4. FOSTER CARE Overall Delay: 60% Language – 57% Cognitive – 33% Gross motor – 31% Growth problems – 10% GENERAL POPULATION Overall Delay: 4% to 10% Leslie, L.K. et al (2004) Journal of Developmental and Behavioral Pediatrics Prevalence Rates of Developmental Delay

5. FOSTER CARE -25% to 40% under age 6 have significant behavioral problems, most displaying externalizing behaviors (aggression, anger) GENERAL POPULATION 3% to 6% Leslie, L.K. et al. (2004). Journal of Developmental and Behavioral Pediatrics Prevalence of Psychiatric Problems

6. Consequences of Developmental and Behavioral Problems • Problems in both of these areas have been correlated with longer stays in care • Reduced likelihood of reunification or adoption • School related problems • Adolescent at risk behaviors • Placement changes

8. Trauma for infants and toddlers in foster care • Separation from parents, usually sudden and traumatic • Difficult experiences precipitating placement • Frequently leads to temporary or permanent impairment in all areas of development

9. 11 month old traumatized child

10. Prevention and Intervention Must Start Early • Aggressive, difficult behaviors seen in adolescents who present in juvenile court most often begin much earlier • Abused and neglected infants are at very high risk for poor outcomes • Early interventions can make a difference

11. What We Know • Early interventions increase the odds for favorable developmental outcomes • The developing brain has the ability to compensate for early deprivation • Early intervention can decrease later problems, such as truancy, juvenile arrests, and school dropout

12. Juvenile Court Can Facilitate Healing • Children in child welfare have been beaten, raped, ignored, and abandoned • The juvenile court needs to help these maltreated babies – unfortunately, this may be the first time problems are seen • Together, through partnerships, we must break the intergenerational cycle of abuse and neglect

13. OUR TOOLS:The lawand science

14. Adoption and Safe Families Act of 1997 • Child’s health and safety are paramount concerns in court proceedings • Emphasis on permanency and adoption • Stronger court role in monitoring the process

15. ASFA Regulations • Federal ASFA regulations specifically hold States accountable for providing services to address the "safety, permanency and well-beingof children and families." (45 C.F.R. Part 1357 §1355.33 b (2)) • States must ensure that: • "families have enhanced capacity to provide for their children's needs; • children receive appropriate services to meet their educational needs; and • children receive adequate services to meet their physical and mental health needs." (45 C.F.R. Part 1357 §1355.34 b(1)(iii))

16. A focus on healing while adjudicating the case • Understanding what babies in juvenile court need • Changing the idea that babies are notreally harmed • Introducing evaluations of babies and toddlers • Making referrals for services

17. It is rarely the case that a maltreated infant has no symptomatology.

18. Relationship Specific Traumatization in 2 year old

19. Consequences of Child Maltreatment • Maltreatment places children at risk • INFANCY & TODDLERHOOD (0-5) • poor attachment • delayed developmental milestones • SCHOOL AGE (6-12) • aggressive behavior • social isolation • learning problems • ADOLESCENCE (13-18) • school failure and school dropout • delinquency and later criminal behavior

20. From Neurons to Neighborhoods: The Science of Early Childhood Development Committee on Integrating the Science of Early Childhood Development Board on Children, Youth, and Families Institute of Medicine National Research Council

21. Core Concepts of Development • Early environments matter and nurturing relationships are essential • Human relationships and their effects are the building blocks of development. • Effective interventions in early childhood by can alter development by changing the balance between risk and protection • Both biology and experience matter : nature and nurture. From Neurons to Neighborhoods,2000

22. How childrenfeel is as important as how they think, and how they are treated is as important as what they are taught Social and emotional development are both crucial with respect to a child’s readiness to succeed in school.

23. How Early Experiences Affect Brain Development • Parents play a crucial role in providing the nurturing and stimulation that children require • A child’s experience in the first few years determines how his brain will develop • Parents need information and support to develop good parenting skills • Starting Smart: How Early Experiences Affect Brain Development. • An Ounce of Prevention Fund and Zero to Three Paper, 1998.

25. Early experiences, both positive and negative, have a decisive impact on how the brain is wired. EXPERIENCES

26. Pruning Early Childhood Later Childhood Newborn

28. At what age do you think a child can experience real depression? Six months or younger

29. The Still Face

30. At what age do you think a baby can begin to sense whether his parent is depressed or angry and can be affected by his parent’s mood? One to three months

31. True A 6 month old or younger child who witnesses violence, such as seeing her father often hit her mother, can suffer long term effects from the experience, because children that young have a long term memory

32. A child’s capacity for learning is pretty much set from birth and cannot be influenced by how their parents deal with themFalse

33. Studies have found an association between prenatal and perinatal complications, early developmental risk and later delinquent or criminal behavior. True

34. At what age do most children develop their sense of self-esteem? • The seeds of self-esteem are planted in infancy • By age two children begin to gain a sense of their own self worth Case, 1991

35. Signs in the baby that emotional needs are not met • Sad affect • Lack of eye contact • Weight loss • Lack of responsiveness • Sensory processing problems • Rejects being held or touched

36. Signs of emotional problems In toddlers/ preschoolers • Very aggressive behavior • Attentional problems and deficits • Lack of attachment • Sleep problems or disorders

37. Conditions of the caregivers that contribute to baby’s emotional problems • Drug addictions • Untreated depression • Domestic violence • Parent’s own past history and experiences • Otherwise emotional unavailability

38. Depressed Caregiver

39. Empirical Findings • Well designed interventions can enhance the short term performance of children living in poverty • The impact on the cognitive development of at risk young children is greater when the intervention is goal-oriented and child-directed • Fade-out phenomenon exists

40. The Infant Health and Development ProgramAn 8 site clinical trial designed to evaluate the efficacy of comprehensive early intervention in reducing developmental and health problems in low birth weight, premature infants • 985 infants • 5 ½ pounds or less • Gestational age of 37 weeks or less • 3 year study

41. Random Assignment • INTERVENTION GROUP • Pediatric surveillance • Home visits (weekly for first year, biweekly thereafter) • Infant enrolled in Child Development Center • Parent education meetings • FOLLOW-UP GROUP • Pediatric surveillance

42. Results • The Intervention Group children showed a significant difference in cognitive development: from 6 to 13 IQ points higher • The Intervention Group mothers reported significantly fewer child behavior problems • The Intervention Group children did not have more health problems despite their participation in group care

43. The Chicago Child-Parent Center (CPC) Program 15 year longitudinal study of the effects of early childhood interventions on educational achievement and juvenile arrest Reynolds, Temple Robertson and Mann, JAMA, May 9, 2001

44. Results • Higher rate of high school completion (49.7% vs. 38.5%) • More years of completed education (10.6 vs. 10.2) • Lower rates of juvenile arrest (16.9% vs. 25.1%) • Less violent arrests (9% vs. 15.3%) • Fewer school dropouts (46.7% vs. 55%)

45. Prenatal and Infancy Home Visitation Olds, et al. 1997, 1998, 2002, 2004

46. Elmira Home Visitation Program:the mother • 79% fewer verified cases of child maltreatment • 33% fewer subsequent births • Longer intervals between births • Less substance abuse • 81% fewer arrests and convictions • 30 fewer months on welfare

47. HOME VISITATION: the child (at 15 years) • Fewer sex partners • Reduced cigarette smoking • Reduced alcohol consumption • 50% decrease in delinquency through age 15 • 60% decrease in running away • 56% fewer arrests • 81% fewer convictions and probation violations

48. Replication of Home Visitation Findings • Three trials conducted with different populations –Elmira, Memphis, Denver • Fewer subsequent pregnancies and births • Some impact on intellectual and language functioning, esp. for low resource mothers • Generally more duration of partner relationships and less domestic violence • Effects due to improved prenatal, parental caregiving and maternal life course

49. Juvenile Court Can Facilitate HealingThe Court Teams Program • Children in child welfare have been beaten, raped, ignored, and abandoned • The juvenile court needs to help these maltreated babies • We must break the intergenerational cycle of abuse and neglect

50. The Case of Katrina