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 Joy D. Osofsky, Ph.D. LSU Health Sciences Center, New Orleans In collaboration with Judge Cindy Lederman 11th Circuit Juvenile Court, Miami University of Oregon Law School, March, 2006

2. Portrait of Young Children in Foster Care in U.S. • Children under age 5 are the fastest growing population in child welfare • Infants comprise 1 in 5 children in foster care • Infants remain in foster care twice as long

3. 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

4. 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

5. 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

7. 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

8. 11 month old traumatized child

9. 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 juvenile arrests and school dropout

10. OUR TOOLS:The lawand science

12. 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

13. 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))

14. 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

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

16. Relationship Specific Traumatization in 2 year old

17. 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

18. 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

19. Core Concepts of Development • Early environments matter and nurturing relationships are essential • Human relationships, and the effects of those relationships, are the building blocks of development. • The course of development can be altered in early childhood by effective interventions that change the balance between risk and protection • Both biology and experience matter : nature and nurture. From Neurons to Neighborhoods,2000

20. How children feel is as important as how they think, and how they are treated is as important as what they are taught, particularly with respect to their readiness to succeed in school.

21. 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 • They 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.

23. Pruning Early Childhood Later Childhood Newborn

25. The Still Face

26. 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

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

28. 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

29. Depressed Caregiver

30. 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

31. 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

32. 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

33. 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

34. 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

35. 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%)

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

37. 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

38. 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

39. 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

40. 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 • We must break the intergenerational cycle of abuse and neglect

41. The Case of Katrina

42. Katrina as a child • Born 1984 • Six siblings • Removed from mother first in 1994, reunified and removed again in 1997 • IQ of 68, diagnosed with adjustment disorder

43. “The children of this family have been exposed to chronic emotional neglect and are experiencing symptoms of depression, emotional impoverishment and low self-esteem, low academic achievement and aggression. There are strong indications that they have been exposed to long term family and community violence.”

44. home unfit for human habitation filthy insect infested foul odor no food children dirty 7 year old retarded sibling left alone Mother gave food stamps to her boyfriend home site of drug related activities children begging for food allegations of physical abuse by boyfriend Reasons for removal

45. Katrina as a mother • Charles born February 1999 • Removed from Katrina in May 1999 after Katrina ran away from foster home and left Charles with her mother • Father unknown • Termination of Parental Rights petition filed in December 2000

46. Interventions:Parent-Child Evaluation • Affect neutral to positive • Unable to allow exploration and initiation • Speech & articulation poor • Minimal play interactions- Mo. attempts to label and teach

47. Pre and post-test measures indicate that therapy and other support services provided through the infant mental health interventions had a positive impact on both the infant and the caregiver. Pre and post observational measures of the infant-caregiver relationship indicated important improvements in both parental sensitivity to the children and in the children’s emotional responsiveness and behaviors. Parent Effectiveness

48. More positive emotions Less withdrawal Less depression Less irritability Less anger More compliance Increased enthusiasm More persistence Increased emotional and behavioral responsiveness Changes in the child

49. Parents’ Reports of Satisfaction 95% improved relationship with baby 83% positive changes in child 77% improved parenting 73% improved family life

50. Additional Benefits Of the first 59 children involved in this project, it is important to note that the mothers had a total of156children and the fathers had a total of 138children.