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

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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

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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

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Maltreated toddler at play
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Prevalence Rates of Developmental Delay

• 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

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Prevalence of Psychiatric Problems

• 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

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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

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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

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11 month old traumatized child
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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

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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

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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

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OUR TOOLSThe lawand science
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Adoption and Safe Families Act of 1997

• Childs health and safety are paramount concerns
  in court proceedings
• Emphasis on permanency and adoption
• Stronger court role in monitoring the process

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ASFA Regulations

• Federal ASFA regulations specifically hold States
  accountable for providing services to address the
  "safety, permanency and well-being of 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))

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A focus on healing while adjudicating the case

• Understanding what babies in juvenile court need
• Changing the idea that babies are not really
  harmed
• Introducing evaluations of babies and toddlers
• Making referrals for services

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It is rarely the case that a maltreated infant
has no symptomatology.
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Relationship Specific Traumatization in 2 year old
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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

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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
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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

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• How children feel 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 childs readiness to succeed in
  school.

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How Early Experiences Affect Brain Development  

• Parents play a crucial role in providing the
  nurturing and stimulation that children require
• A childs 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.

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Early experiences, both positive and negative,
have a decisive impact on how the brain is wired.
EXPERIENCES
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Pruning
Early Childhood
Later Childhood
Newborn
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At what age do you think a child can experience
real depression?

• Six months or younger

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The Still Face
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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 parents mood?

• One to three months

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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

• True

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A childs capacity for learning is pretty much
set from birth and cannot be influenced by how
their parents deal with themFalse
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Studies have found an association between
prenatal and perinatal complications, early
developmental risk and later delinquent or
criminal behavior.

• True

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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

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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

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Signs of emotional problems In toddlers/
preschoolers

• Very aggressive behavior
• Attentional problems and deficits
• Lack of attachment
• Sleep problems or disorders

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Conditions of the caregivers that contribute to
babys emotional problems

• Drug addictions
• Untreated depression
• Domestic violence
• Parents own past history and experiences
• Otherwise emotional unavailability

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Depressed Caregiver
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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

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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

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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

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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

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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

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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)

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

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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

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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

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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

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The Case of Katrina
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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

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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.
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Reasons for removal

• 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

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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

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InterventionsParent-Child Evaluation

• Affect neutral to positive
• Unable to allow exploration and initiation
• Speech articulation poor
• Minimal play interactions- Mo. attempts to label
  and teach

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The Dyadic Therapy
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Parent Effectiveness

• 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 childrens emotional
  responsiveness and behaviors.

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Changes in the child

• More positive emotions
• Less withdrawal
• Less depression
• Less irritability
• Less anger
• More compliance

• Increased enthusiasm
• More persistence
• Increased emotional and behavioral responsiveness

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Parents Reports of Satisfaction

• 95 improved relationship with baby
• 83 positive changes in child
• 77 improved parenting
• 73 improved family life

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Additional Benefits

• Of the first 59 children involved in this
  project, it is important to note that the mothers
  had a total of 156 children and the fathers had a
  total of 138 children.

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OutcomesFor those that completed treatment
No further abuse or neglect reports in 100 of
the cases.
100 rate of reunification
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What Courts Can Do
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Read the research Science can inform our work
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It includes our attachment and bonding experience
in the first 18 months of life, as well as how
exploration and aggressiveness were handles
during toddler hood (terrible twos) and how we
learned self-control or self-regulation of
impulses by the time we turned five and went to
kindergarten. Because it is not until school
that most of the problems show up on the radar
screen. For a few of the most severe, we can
spot them by age three or four. They are the
ones being kicked out of daycare and preschool
for uncontrollable behaviors. But for the
majority, we dont identify them up until they
start failing in school, or get involved in the
juvenile justice system, or become a teen
parent. However, we are NOT saying that all
mental disorders are a result of what happens in
the first few year of life. Some mental
illnesses are rooted in genetics and/or
biochemistry, such as schizophrenia, bipolar
disease, and other neurophysiological disorders
such as autism. NOR are we saying that all
children who have bad experiences during the 0-3
years turn into toast or become criminals. We
cannot oversimplify human development. It is
complex, transactional, and unique. What we ARE
saying is that the experience and quality of
caregiving received by infants and young children
during those critical first few years of life
when the brain is being wired, so to speak, has
long lasting impact on the future of that child.
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Make sure all babies under the age of 3 are
referred for a Part C screening pursuant to the
Individuals with Disabilities Act (IDEA)
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Part CIndividuals with Disabilities Education
Act

• Multidisciplinary evaluation for children age 3
  and younger
• When established conditions have a high
  probability of resulting in developmental
  disabilities or delays
• Must be a 25 delay in at least one area of
  development
• No cost to family

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Refer pregnant women and children into the
Healthy Start or home visitation program in your
community
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Make Appropriate Child Care ReferralsEARLY
HEAD STARTHEAD START
In Miami there are 1300 day care centers and only
120 are accredited. This is a consistent problem
across the country.
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Early Head Start Research

• Higher scores for language development
• Higher Bayley (developmental) scores
• Positive parenting outcomes
• Fewer at risk scores
• Fewer subsequent births
• Positive father-child interactions
• DHHS,
  June 2002

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Refer to Quality Parenting Programs
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Parenting Programs

• Lessons learned What they are and what they are
  not

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BAD

PARENTING?
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Parenting Programs What They Should Include

• Evidence based
• Pre test and post test
• Measured observations of parent with child at
  least twice during program
• Uniform detailed reports provided to the court
  with testing and observational scale included
• No more Certificates of Completion

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Conclusions

• The complexity of the problems caused by
  traumatization of infants toddlers must be
  matched by the comprehensiveness of efforts to
• minimize suffering
• reduce developmental deviations
• enhance development
• promote competence
• support parents/caregivers

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WEBSITES

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