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Psychosocial Interventions for Traumatized Youth in the Juvenile Justice System: Research, Evidence Base, and Clinical/Legal Challenges

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Abstract

Psychosocial interventions for posttraumatic stress reactions increasingly are recognized as a key component in the provision of juvenile justice services. This article provides an overview of the research; clinical and legal successes; and challenges emerging from the development, evaluation, and implementation of trauma-focused psychosocial therapeutic interventions (TF-PTI) in juvenile justice systems. Four TF-PTI models that have empirically demonstrated effectiveness with justice-involved youth are described. Clinical and legal precautions are discussed to inform practitioners, policymakers, administrators, and the judiciary when utilizing or adopting these and other TF-PTIs as one component of trauma-informed juvenile justice programming. The review highlights potential benefits that may accrue to public safety, as well as to the health and positive development of youth and families when juvenile justice programs provide access to evidence-based TF-PTIs in a systematic, equitable, and culturally competent manner.
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OJJDP Journal of Juvenile Justice
Psychosocial Interventions for Traumatized Youth in the
Juvenile Justice System: Research, Evidence Base, and
Clinical/Legal Challenges
Julian D. Ford
University of Connecticut School of Medicine, Farmington, Connecticut
Patricia K. Kerig
University of Utah, Salt Lake City, Utah
Neha Desai
National Center for Youth Law, Oakland, California
Jessica Feierman
Juvenile Law Center, Philadelphia, Pennsylvania
Julian D. Ford, Department of Psychiatry, University of Connecticut School of Medicine; Patricia K.
Kerig, Department of Psychology, University of Utah; Neha Desai, National Center for Youth Law,
Oakland, California; Jessica Feierman, Juvenile Law Center, Philadelphia, Pennsylvania.
The writing of this article was funded in part by grants from the Substance Abuse and Mental Health
Services Administration (5U79SM061273-03) and the Department of Justice (2012-IJ-CX-0046) to the
first author and from the National Institute of Justice (2014-90914-UT-IJ) to the second author. Dr. Ford
reports a potential conflict of interest as the co-owner of Advanced Trauma Solutions, Inc., the sole
licensed distributor of the TARGET intervention by the copyright holder, the University of Connecticut.
Correspondence concerning this article should be addressed to Julian D. Ford, 263 Farmington Ave.,
MC1410 UConn Health Center, Farmington, CT 06030. E-mail: jford@uchc.edu.
Keywords: traumatic stress, psychosocial therapy, evidence base, juvenile justice
Abstract
Psychosocial interventions for posttraumatic
stress reactions increasingly are recognized as
a key component in the provision of juvenile
justice services. This article provides an overview
of the research; clinical and legal successes; and
challenges emerging from the development,
evaluation, and implementation of trauma-
focused psychosocial therapeutic interventions
(TF-PTI) in juvenile justice systems. Four TF-PTI
models that have empirically demonstrated
effectiveness with justice-involved youth are
described. Clinical and legal precautions are
discussed to inform practitioners, policymakers,
administrators, and the judiciary when utiliz-
ing or adopting these and other TF-PTIs as one
component of trauma-informed juvenile justice
programming. The review highlights potential
benefits that may accrue to public safety, as well
as to the health and positive development of
youth and families when juvenile justice pro-
grams provide access to evidence-based TF-PTIs
in a systematic, equitable, and culturally compe-
tent manner.
45
OJJDP Journal of Juvenile Justice
Introduction
Psychosocial interventions for posttraumatic
stress reactions increasingly are recognized as
a key component in the provision of services to
youth involved in or at risk for involvement in the
juvenile justice system (Danielson, Begle, Ayer, &
Hanson, 2012; Ford, Chapman, Mack, & Pearson,
2006; Ford, Kerig, & Olafson, 2014; Kerig, 2012).
Research has demonstrated that more than
80% of juvenile justice–involved youth report
a history of exposure to at least one traumatic
event at some point in their lives (e.g., childhood
maltreatment, domestic or community violence,
severe accidents, traumatic deaths of family or
friends), and typically these youth have endured
multiple types of traumatic exposure (Abram
et al., 2004; Dierkhising et al., 2013; English,
Widom, & Brandford, 2002; Ford, Hartman,
Hawke, & Chapman, 2008; Ford, Grasso, Hawke,
& Chapman, 2013; Stimmel, Cruise, Ford, & Weiss,
2014; see Kerig & Becker, 2010, 2012, 2014 for
reviews). Such polyvictimization places youth
at significant risk for ongoing emotional, devel-
opmental, academic, and behavioral problems.
Persistent posttraumatic stress can lead to seri-
ous long-term mental health problems for youth,
including posttraumatic stress disorder (PTSD),
substance abuse, anxiety, disordered eating,
depression, self-injury, conduct problems, and
revictimization, all of which further increase the
likelihood of involvement in delinquency, crime,
and the justice system (Becker & Kerig, 2011;
Ford, 2010; Ford et al., 2006; Ford, Elhai, Connor,
& Frueh, 2010; Ford et al., 2013).
In addition to the preponderance of youth
entering the justice system with histories of
prior exposure to traumatic events, the juvenile
justice system itself may expose youth to addi-
tional traumatic stressors, such as peer violence,
abuse by staff, and shackling and restraints
(Dierkhising, Lane, & Natsuaki, 2014; Mendel,
2011). Retraumatization of youth in justice set-
tings increases their risk for PTSD and could also
cause problem behaviors that may endanger
other youth and adults (DeLisi et al., 2010; Ford &
Blaustein, 2012). Therefore, effective therapeutic
interventions provided on a timely basis and
matched to the specific needs and life circum-
stances of each traumatized youth are an essen-
tial component of a trauma-informed juvenile
justice system. To this end, this article provides
an overview of the state of the art in current
research on the development and implementa-
tion of psychosocial interventions for trauma-
tized youth who are involved in the juvenile
justice system or are at risk due to delinquency.
Working With Traumatized Youth in the Juvenile
Justice System: Six Challenges
A growing evidence base supports in general
the effectiveness of therapeutic interventions for
adolescent PTSD and the related psychosocial
problems that follow from exposure to traumatic
stress (e.g., Cary & McMillen, 2012; Connor, Ford,
Arnsten, & Greene, 2014; de Arellano et al., 2014).
However, there are several reasons why justice-
involved youth might be considered a special
population in need of services targeted specifi-
cally to their needs and characteristics. These
youth and the professionals and staff who work
with them face six key challenges: (a) the over-
representation of youth of color and of lesbian,
gay, bisexual, transgender, questioning, and gen-
der nonconforming (LGBTQ/ GNC) youth in the
juvenile justice system; (b) the high prevalence of
traumatic exposure and polyvictimization among
justice-involved youth; (c) the adverse impact
that PTSD symptoms have on youth participation
in and benefit from rehabilitative services; (d)
the difficulty of involving family and other sup-
port system members in justice-involved youth
services; (e) justice-involved youths’ ongoing risk
of exposure to violence, losses, and other threats
that can reactivate or exacerbate PTSD symp-
toms; and (f) the potentially coercive context of
involuntary rather than voluntary participation
created by law enforcement and judicial man-
dates on youth. These six challenges’ relevance
to providing targeted services addressing youth
PTSD and associated psychosocial and behavioral
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OJJDP Journal of Juvenile Justice
problems are described in more detail in the
paragraphs below.
First, the disproportionate minority contact with
law enforcement has led youth from underserved
communities of color to be overrepresented
in U.S. juvenile justice systems and to receive
disparate responses (e.g., more frequent arrests
and confinement, harsher legal sanctions) at
each level of that system. Additionally, LGBTQ/
GNC youth are disproportionately represented
in the juvenile justice system. It is estimated that
about 5–7% of the national youth population
identifies as LGBTQ (Office of Juvenile Justice and
Delinquency Prevention [OJJDP], 2014), but about
20% of all youth in the juvenile justice system
identify as LGBTQ/GNC (Brown, Canfield, & Irvine,
2014). Among girls in juvenile detention, an
astonishing 40% identify as LGBTQ/GNC (Irvine,
2015). Researchers believe the true percentage
of LGBTQ/GNC youth among justice-involved
populations is even greater because many youth
avoid disclosing their sexual orientation or gen-
der identity to reduce the risk of discrimination
or abuse (OJJDP, 2014). Given these overrepre-
sentations, effective interventions for these youth
and their families (who are frequently economi-
cally disadvantaged as well) need to be to be
designed and implemented so as to mitigate the
risks of disparate treatment (e.g., to reduce the
likelihood of these youth being stigmatized or
subjected to disproportionate sanctions), as well
as to be culturally competent, relevant to diverse
populations (e.g., subgroups of youth of color of
different linguistic or cultural backgrounds and
of LGBTQ youth based upon different forms of
sexual identity), and accessible in ways that might
challenge traditional methods of mental health
service delivery.
Second, research suggests that youth in the
justice system differ from their peers by virtue of
the number, kinds, and multiciplicity of traumatic
exposure they have endured (Ford et al., 2010;
Ford et al., 2013). For example, in one of the few
studies to directly compare justice-involved and
community youth, Wood and colleagues (2002)
found that detained youth had on average expe-
rienced twice as many traumatic events as their
high school peers. In particular, justice-involved
youth reported a significantly greater likelihood
than community youth of having lost a loved
one to a violent death, having witnessed some-
one being killed, having both witnessed and
experienced sexual assault, and having someone
threaten their lives with a knife or gun. Even
higher rates of traumatic stressor exposure and
posttraumatic stress reactions are found among
the subset of youth in the justice system who are
gang-involved (e.g., Harris et al., 2012), especially
among gang-involved girls (e.g., Kerig, Chaplo,
Bennett, & Modrowski, in press; Kerig, 2014). Thus,
interventions for justice-involved youth must be
prepared to respond to significant levels of poly-
victimization and revictimization and the result-
ing complex developmental dyregulations that
ensue from exposure to chronic interpersonal
traumatic stressors among these youth (Ford &
Cloitre, 2009; Ford, Chapman, Connor, & Cruise,
2012; Kerig, Vanderzee, Becker, & Ward, 2012).
Third, a growing body of work is emerging that
suggests traumatic stress reactions may contrib-
ute to youths’ involvement in the justice system
through specific posttraumatic mechanisms.
In particular, recent theory and research has
emerged suggesting that, beyond symptoms
such as reexperiencing and hyperarousal, which
are commonly understood and readily recog-
nized as posttraumatic reactions, many justice-
involved youth display another constellation of
symptoms that is more vulnerable to misidentifi-
cation. Posttraumatic coping strategies involving
experiential avoidance—including emotional
numbing, acquired callousness, dissociation,
and self-harming behavior—are frequently seen
among youth in the justice system and have
been implicated specifically in adolescent delin-
quency (Allwood, Bell, & Horan, 2011; Bennett,
Kerig, Chaplo, McGee, & Baucom, 2014; Bennett
& Kerig, 2014; Bennett, Modrowski, Kerig, &
Chaplo, 2015; Ford et al., 2006; Kerig, Bennett,
Thompson, & Becker, 2012; Plattner et al., 2003).
47
OJJDP Journal of Juvenile Justice
Research also shows that this spectrum of post-
traumatic reactions may complicate treatment
due to being disproportionately associated with
difficult comorbid problems such as substance
abuse (Carrion & Steiner, 2000) and suicidality
(Bennett et al., 2014) and can interfere with the
effectiveness of evidence-based traumatic stress
interventions (Taylor et al., 2001). Therefore,
these symptoms may require special attention in
treatments for justice-involved adolescents.
Fourth, it may be challenging to include caregiv-
ers and other supportive adults in treatment,
especially for youth with behavioral/emotional
problems (Garfinkel, 2010) and those placed
outside the home, particularly in facilities geo-
graphically distant from their home communi-
ties. Anecdotal reports suggest that this may be
a particularly acute problem for girls: Because
the number of system-involved girls tends to be
low, some jurisdictions economize by closing
small local girls’ units to merge them into larger
facilities that are miles, or even states, away from
the girls’ home communities, creating significant
barriers to caregiver involvement (Smith, Leve, &
Chamberlain, 2011). The inclusion of caregivers
has been empirically demonstrated to enhance
the effectiveness of traumatic stress treatment
for youth (Cohen & Mannarino, 2000), but inter-
ventions targeting justice-involved youth may
have to meet the challenge of achieving posi-
tive outcomes in their absence or with limited
involvement on their part.
Fifth, whereas some therapy models advise clini-
cians to begin trauma-focused components only
when a youth is in a position of safety, this may
not be realistic when working with traumatized
justice-involved youth. Many of these youth are
living in, or are returning to, communities with
high rates of violence, and youth in detention
or secure care may be witnesses to or victims of
recurring potentially traumatizing events while
institutionalized. Moreover, incarceration itself
may threaten youth safety (Aebi et al., 2015). For
these youth, traumatic stress treatment must be
designed and delivered in order to assist them
in therapeutic processing of traumatic memories
from the distant past as well as intrusive memo-
ries, re-experiencing of recent traumatic events,
and ongoing traumatic exposures (Ford & Cloitre,
2009).
And sixth, many of these youth may not perceive
participation as—and it may not in actuality be—
wholly voluntary. Research on informed assent
shows that youth often do not believe they have
the right to choose when participation is invited
by an adult in authority (Bruzzese & Fisher, 2003),
and some institutional programming is indeed
compulsory. Further, in some jurisdictions, judges
and probation officers mandate psychosocial
interventions, including traumatic stress treat-
ment, in disposition plans for youth (Kendall,
2007). Even when traumatic stress treatment
is not technically mandatory, justice staff may
expect, and youth may assume, that therapists
will provide regular reports about youths’ prog-
ress. This may undermine the perceived voluntari-
ness of the treatment and may threaten youths
perceived or actual privacy, especially when trau-
matic stress treatment requires them to provide
a detailed narrative account of their experiences.
Although other kinds of psychosocial interven-
tions for justice-involved youth have demon-
strated that their effectiveness is not reduced
when delivered in contexts of court-mandated
treatment compared with voluntary treatment
(e.g., Alexander, Robbins, Waldron, & Neeb, 2013),
this issue may complicate traumatic stress treat-
ment in ways that have not been assessed.
In summary, given these ways in which the juve-
nile justice system presents a distinctive context
for traumatic stress treatment—both regarding
the presenting problems of this population of
traumatized youth and their families and the
challenges of service delivery—it is important
that interventions be tried, tested, and proven
effective in this context. We therefore will review
the evidence base for treatments targeting
traumatic stress that have evidence of efficacy
or effectiveness specifically in a juvenile justice
context.
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OJJDP Journal of Juvenile Justice
The Evidence Base Supporting Psychosocial
Interventions for Traumatized Juvenile Justice-
Involved or Delinquent Youth
We identified four therapeutic psychosocial inter-
ventions that have published peer review reports
of randomized trial efficacy or quasirandomized
design effectiveness studies with youth involved
in juvenile justice systems. Each of these inter-
ventions provides a detailed manual with step-
by-step instructions designed to guide training
of interventionists, the delivery of each session
and activity, and the monitoring of fidelity and
competence of implementation.
Trauma Affect Regulation: Guide for Education and
Therapy (TARGET)
TARGET (Ford, 2015) is a 4!12-session educational
and therapeutic intervention for traumatized
youth and adults designed to be provided in either
a one-to-one or group format by behavioral health
clinicians. Nonclinical line sta are trained to serve
as coleaders in the group modality in juvenile
justice settings, as well as to deliver TARGET on a
24-hour, 7-days a week basis as a milieu interven-
tion in congregate programs (Ford & Blaustein,
2012; Ford & Hawke, 2012). When delivered in the
group format, either one leader or two colead-
ers may conduct groups of 4 to 10 youth. TARGET
groups are designed to be gender-specic, with
discussion topics and activities tailored to boys’
and girls’ diering interests and experiences, but
both genders receive the same core skills set.
TARGET teaches a seven-step sequence of
self-regulation skills summarized by the acro-
nym FREEDOM. The rst skills, Focusing and
Recognizing triggers, provide a foundation for
shifting from stress reactions driven by hypervigi-
lance to proactive emotion regulation. Four sub-
sequent skills are designed to enable participants
to dierentiate Emotions, Evaluative cognitions,
Deliberate goals, and Options for action, and to
determine whether they are based on stress reac-
tions or are grounded in the participants’ core per-
sonal values. A nal skill, Making a contribution,
is intended to enhance participants’ reective
mentalizing skill (Allen, Fonagy, & Bateman, 2008)
by providing a practical approach to monitoring
day-to-day applications of the rst six FREEDOM
steps and recognizing how this enriches the lives
of participants and other people.
A randomized clinical trial with justice-involved
girls with dual diagnosis PTSD, substance use,
or other disorders (e.g., oppositional-defiant,
depressive, panic) showed that a 10-session
individual TARGET intervention was superior to
relational psychotherapy in reducing PTSD and
depression and improving emotion regulation
(Ford, Steinberg, Hawke, Levine, & Zhang, 2012).
Additional evidence for TARGET’s effectiveness
as a group and milieu therapeutic intervention
with detained boys and girls was provided by
two quasi experimental studies. These studies in
secure juvenile detention facilities and locked
inpatient units in juvenile justice mental health
centers showed reductions in violent behavioral
incidents and coercive restraints and in PTSD
and depression symptoms, and increased hope/
engagement in rehabilitation following TARGET’s
delivery (Ford & Hawke, 2012; Marrow, Knudsen,
Olafson, & Bucher, 2012).
Trauma and Grief Components Therapy for Adolescents
(TGCTA)
TGCTA (Layne, Saltzman, Pynoos, & Steinberg,
2002) is a four-module 8 to 24-session group
psychosocial intervention first developed for,
disseminated to, and evaluated in a random-
ized trial for adolescent war survivors in Bosnia
in the 1990s (Layne et al., 2008). It has since
been implemented successfully in open tri-
als with detained youth in Ohio (Olafson et al.,
2016), urban, gang-involved, and at-risk youth in
California (Saltzman, Pynoos, Layne, Steinberg,
& Aisenberg, 2001), and delinquent youth in
Delaware schools (Grassetti et al., 2014). In both
the randomized trial in Bosnia and the open
trial research studies in the United States, TGCTA
was associated with reduced PTSD, depression,
and maladaptive grief reactions and improved
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OJJDP Journal of Juvenile Justice
behavior (Layne et al., 2008; Olafson et al., 2016;
Saltzman et al., 2001).
TGCTA’s four modules address: (a) foundational
knowledge and skills to enhance posttraumatic
emotional, cognitive, and behavioral regulation
and to improve interpersonal skills; (b) group
sharing and processing of traumatic experi-
ences; (c) group sharing and processing of grief
and loss experiences; and (d) resumption of
adaptive developmental progression and future
orientation. Each session contains step-by-step
instructions for implementation, including sug-
gested scripts for the exact language to use while
conducting groups. Groups of 8 to10 youth are
generally led by two coleaders. Although single
gender groups are recommended, some imple-
menters have reported successful implementa-
tion with mixed gender groups.
TGCTA is similar to TARGET in several respects,
including educating youth about the role that
traumatic experiences and posttraumatic stress
reactions can play in behavioral, emotional,
interpersonal, and legal problems; and provid-
ing youth with skills for recognizing, coping
actively and nonavoidantly with, and reducing
the distress associated with posttraumatic stress
reactions. Where TARGET emphasizes processing
of current episodes of posttraumatic stress reac-
tions using the FREEDOM skills, TGCTA empha-
sizes processing memories of past traumatic
experiences as a means to reduce the distress
elicited by those memories and the self-defeat-
ing avoidance that occurs when traumatized
youth feel unable to tolerate posttraumatic stress
reactions. TGCTA also provides a unique module
designed to enable youth to process grief associ-
ated with traumatic losses.
Cognitive Processing Therapy (CPT)
CPT is offered as both a one-to-one or group
treatment that teaches cognitive restructuring
skills designed to enable clients to examine and
rework beliefs about their self/identity, relation-
ships, the world, and their futures, which may
have become maladaptive as a result of trau-
matic experiences (Resick & Schnicke, 1993).
Two versions of CPT have been developed and
tested. The original CPT was designed to enable
traumatized clients to create, with the supportive
guidance of a therapist, a detailed spoken and
written account (referred to as a narrative) of a
specific traumatic event. Over the course of 16
to 20 sessions, the narrative is used as a basis for
the client to revise core personal beliefs about
the meaning of the traumatic experience in light
of a new ability to recall the event without avoid-
ance, hyperarousal, or intolerable emotional
distress. An alternate form, CPT-C, involves creat-
ing what is referred to as an impact statement, a
brief written summary describing the effect that
the traumatic event has had on the client’s life,
without requiring a detailed narrative account.
Research suggests that the two versions are
equally effective and that CPT-C may be advanta-
geous by facilitating more rapid treatment gains
with fewer dropouts from therapy (Resick et al.,
2008; Walter, Dickstein, Barnes, & Chard, 2014).
The efficacy of CPT with traumatized youth has
been demonstrated in a randomized clinical trial
that included adolescents (e.g., Chard, 2005), and
a revised version of CPT has been developed spe-
cifically for youth (Matulis, Resick, Rosner, & Steil,
2014). This longer (31 session) developmentally
adapted CPT includes emotion regulation and
interpersonal effectiveness skills that are similar
in intent—although different in actual practice—
to those in TARGET. The adapted CPT showed
evidence of reductions in PTSD and depression in
an open trial with 10 female and 2 male adoles-
cents who had child abuse–related PTSD (Matulis
et al., 2014). Of particular relevance to the cur-
rent review of evidence for the treatment’s effec-
tiveness with justice-involved youth, an 8-session
group version of CPT with incarcerated boys
was found to be superior in reducing PTSD and
depression symptoms as compared to a control
condition in which youths received the standard
facility services while they waited to receive CPT
(Ahrens & Rexford, 2002).
50
OJJDP Journal of Juvenile Justice
Trauma-Adapted Multidimensional Treatment Foster Care
(TA-MTFC)
MTFC was developed to provide an alternative to
residential care for youth with chronic and severe
antisocial behavior and mental health problems
that put them at high risk for future incarceration
or hospitalization (Chamberlain, Saldana, Brown,
& Leve, 2011). With the active support of a clini-
cal team, therapeutic foster parents are trained
to implement a highly structured behavioral
program in the home that includes active adult
monitoring, fair and consistent discipline, provi-
sion of a positive relationship with a caregiving
adult, and redirection toward prosocial activities
and away from antisocial peers. Randomized con-
trolled trials have shown high levels of effective-
ness in reducing youths’ delinquent behaviors
and mental health problems (Chamberlain, Leve,
& DeGarmo, 2007; Chamberlain et al., 2011).
MTFC research also revealed gender differences
related to girls’ high rates of mental health disor-
ders, family discord, and traumatic stress expo-
sure (Chamberlain & Moore, 2002). Consequently,
a gender-responsive version of the intervention
was developed that was further enhanced by
the inclusion of trauma-focused modules based
on the principles of Trauma-Focused Cognitive
Behavioral Therapy (Cohen, Mannarino, &
Deblinger, 2006). The trauma-related compo-
nents focus particularly on psychoeducation
about traumatic stress exposure and reactions,
and they affect regulation, healthy sexuality,
and the development of adaptive skills for cop-
ing with traumatic stress. A small randomized
clinical trial involving 30 adolescent girls with
histories of justice involvement found that, at a
12-month follow-up session, girls who received
the integrated MTFC plus traumatic stress treat-
ment demonstrated significantly lower levels
of trauma-related mental health problems and
delinquent behavior when compared to girls
assigned to standard juvenile justice program-
ming (Smith, Chamberlain, & Deblinger, 2012).
Next Steps for TF-PTIs With Youth in Juvenile Justice
Systems
TARGET, TGCTA, CPT, and TA-MTFC have shown evi-
dence of success in enabling justice-involved and
delinquent youth to cope eectively with and be
less distressed by PTSD and related posttraumatic
symptoms, as well as in improving their ability
to regulate their emotions (TARGET), succeed in
school (TGCTA), and safely and optimistically par-
ticipate in juvenile justice detention and inpatient
psychiatric programs (TARGET). Thus, psychosocial
therapeutic interventions appear to provide a basis
for helping traumatized justice-involved or high-
risk youth to manage, and potentially overcome,
posttraumatic stress problems. In so doing, the
interventions also potentially enhance youths’
ability to engage in rehabilitation, resume involve-
ment in prosocial activities, and avoid reoending
(Ford & Hawke, 2012; Layne et al., 2008).
Although promising, in many respects the
evidence-based TF-PTIs available for justice-
involved youth are still at an early stage of devel-
opment (Ford & Blaustein, 2012). Most have been
subjected to a limited number of clinical trials,
often conducted by the developers; thus, broader
dissemination and replication showing evidence
of effectiveness across diverse participants and
contexts are needed. Most also are designed to
be provided only to youth, despite evidence that
supportive family involvement is an important
protective factor mitigating against delinquency
(Garfinkel, 2010). TA-MTFC is a positive exception
in that it includes family therapy and services in
the foster home. Other TF-PTIs that have been
designed or adapted to provide family systems
therapy (e.g., Ford & Saltzman, 2009) should be
evaluated in the context of juvenile justice ser-
vice planning—and specifically tested in con-
junction with evidence-based, in-home family
therapy models for delinquent youth, such as
multisystemic therapy, multidimensional family
therapy, and functional family therapy.
In addition, deeper research probes into
the mechanisms underlying the treatments’
51
OJJDP Journal of Juvenile Justice
effectiveness will be important for revealing the
critical ingredients and components that might
be streamlined for greater efficiency and cost
effectiveness. Dismantling studies that distin-
guish these factors might address questions,
such as which presumed therapeutic compo-
nents most significantly influence TF-PTI out-
comes (e.g., psychoeducation, trauma memory
processing, emotion regulation skills, self-mon-
itoring, social support/modeling, presence of a
caring adult role model/mentor). Clinical trials
comparing the outcomes achieved by differ-
ent forms of service delivery also would inform
us of the relative benefits of group approaches
compared with individual approaches for increas-
ing engagement, preventing dropouts, and
achieving positive outcomes. Such trials would
also determine whether milieu reinforcement of
TF-PTIs by juvenile justice staff (or by parents,
teachers, mentors, or peers in home and com-
munity settings) is either a helpful catalyst or
a requirement for sustained generalization of
behavior change (Ford et al., 2012). Drawing
on the TA-MTFC example, research is needed
to determine whether and under what circum-
stances TF-PTIs can be an adjunct to, integrated
with, or a prerequisite for other evidence-based
interventions targeting youth problem behavior.
For example, once youth who receive a TF-PTI are
coping effectively with the aftermath of trauma,
would they be more receptive to commonly
offered juvenile justice programs targeting other
noncriminogenic or criminogenic risk, need, or
responsivity factors (Ford, Chapman, Connor, &
Cruise, 2012 )?
Clinical and Legal Challenges in Delivering TF-PTIs
for Justice-Involved Youth
A long-standing problem for evidence-based
practice is the gap between what is proven
effective in the laboratory and what is available
to clients in “real world” settings (Weisz, Ng, &
Bearman, 2014). Advances in implementation sci-
ence have made it clear that effective interven-
tions for youth need to be not only developed
but also disseminated in ways that ensure fidelity
and sustainability (Stirman et al., 2012; Weisz et
al., 2014). This may prove particularly challeng-
ing in juvenile justice settings in which there
are stakeholders at many levels of the system—
legislators, judges, administrators, attorneys,
probation officers, line staff—whose buy-in
may prove essential for initial and sustained
TF-PTI implementation. Further, ongoing fidelity
monitoring is essential to the sustainability of
evidence-based treatments (Scheirer & Dearing,
2011). Therefore, stakeholders in systems of care
must be educated about the need for trauma-
informed interventions as well as be willing to
find strategies to bear the costs of investing in a
high-quality, enduring, and accessible method
for delivering TF-PTIs to justice-involved youth
and families. Collaborative partnerships that
cross the aisles traditionally separating the judi-
cial, mental health, and correctional components
of the justice system may be the key to success
(Olafson, Goldman, & Gonzalez, 2016).
Crafting appropriate interventions for justice-
involved youth requires an examination of
broader questions of law and policy, including:
(a) the social structures that lead youth into the
justice system, particularly in light of the chal-
lenges to accessing high-quality, voluntary care
outside the justice system; (b) the stage at which
traumatic stress services are most likely to be
effective for youth in the juvenile justice system;
and (c) the potential legal risks of traumatic
stress treatment and the relevant legal protec-
tions that should accompany such treatment.
Addressing Traumatic Stress Before Youth Become
Embedded in the Juvenile Justice System
Although high-quality targeted interventions
within juvenile facilities are essential, policymak-
ers should begin their consideration of such
services within the broader social and economic
context leading young people into justice sys-
tems. Far too many youth who have mental health
needs, particularly those of color or from poor
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OJJDP Journal of Juvenile Justice
families, are referred into the juvenile justice sys-
tem unnecessarily (Mallett, 2015). Many of these
youths receive no mental health treatment, and
others are involuntarily placed in mental health
services when they could be better served by
voluntary mental health treatment in the commu-
nity (Garcia, Greeson, Kim, Thompson, & Denard,
2015). Youth incarceration rates in the United
States are dramatically higher than in any other
country in the world. The rate at which the United
States holds young people in locked facilities is
estimated to be five times that of South Africa,
which has the second highest rate of incarcerated
youth among all nations (Mendel, 2011). The most
recent data available show that, despite a reduc-
tion of more than 40% over a 10-year period (from
96,531 incarcerated or detained youth in the
United States in 2003 to 54,148 in 2013), thou-
sands of youth still are confined in juvenile justice
residential facilities every year in the United States
(OJJDP, n.d.); many countries do not incarcerate
children or adolescents at all (Mendel, 2011).
Juvenile justice systems in the United States also
arrest, adjudicate, and confine young people of
color at disproportionate rates, despite evidence
of similar offending behavior among other racial
groups (Lauritsen, 2005). In 2013, more than two-
thirds of incarcerated youth were Black, Hispanic,
American Indian, or of mixed racial background
(OJJDP, n.d.). Moreover, at least one study found
that “[t]he likelihood that disorders would be
detected or treated was … lower among racial/
ethnic minorities” than among white peers
(Teplin et al., 2013, p. 11). In addition to ensuring
access to traumatic stress services in facilities,
state and local policies should prioritize ensuring
youth access to high-quality voluntary mental
health services in the community, reducing racial
disparities in the juvenile justice system, and
permitting secure care placement only when
necessary for public safety.
Thanks to successful reform efforts nationally,
many juvenile justice systems have developed
effective and efficient alternatives to incarcerat-
ing youth (Mendel, 2014).
As this juvenile detention reform has decreased
the number of incarcerated juvenile justice
youth, it has become increasingly important to
explore avenues for providing traumatic stress
interventions for nonincarcerated juvenile justice
youth and for offering any needed treatment at
the earliest possible juncture in the trajectory of
a youth’s justice-system involvement (American
Academy of Child and Adolescent Psychiatry,
2005). This may include offering voluntary trau-
matic stress treatment to youth who are in diver-
sion programs or home on probation. It is also
important to look even further upstream (e.g.,
troubled youth identified in school systems),
particularly for the many youth who are at risk for
becoming involved in both the juvenile justice
and child welfare systems.
Addressing Traumatic Stress With Dual Status Youth
An overwhelming percentage of youth in the
juvenile justice system have a history of child-
hood abuse and/or neglect; many of these youth
also were involved with the child welfare system
(Widom, 2003). Youth who become involved in
both the child welfare and juvenile justice systems
are often referred to as “dual status youth. This is
not a monolithic group. In fact, as awareness and
research on dual status youth have grown, so too
has the terminology used to describe them.
“Dually identified youth” refers to youth who
are currently involved in the juvenile justice
system following an arrest and were formerly
involved in the child welfare system due to a
report of parental neglect or maltreatment.
Youth in juvenile detention facilities are more
likely to have experienced abuse or neglect (and
related types of victimization in their families
and communities; Ford et al., 2013) than other
youth in national samples (Ford et al., 2010). As
a result, many of these justice-involved youth
were involved in child protection investigations,
and in some instances, they were placed in foster
homes or congregate care facilities for their own
safety prior to coming to the attention of the law
enforcement and juvenile justice systems.
53
OJJDP Journal of Juvenile Justice
By contrast, “dually adjudicated youth” refers to
youth who have formal (compared with informal
involvement, such as diversionary), concurrent
involvement with both systems (Herz et al., 2012;
Wiig, Tuell, & Heldman, 2013). This refers to youth
who were adjudicated dependent because of
abuse or neglect and are also adjudicated delin-
quent. A third category, “dually involved youth,
includes youth who have concurrent involvement
with both the child welfare and juvenile justice
systems, though involvement with one or both
systems may be informal (e.g., youth adjudicated
dependent and placed in a group hone, arrested
by law enforcement but placed in a diversion-
ary program by a probation officer) (Wiig et al.,
2013). Thoughtful cross-system collaboration can
support early and effective interventions before
youth formally enter the juvenile justice system
and can prevent or reduce juvenile justice sys-
tem–involvement for youth with traumatic stress-
related behavioral and emotional problems (Ford
et al., 2006). Cross-system collaboration involves
proactive sharing of information (within the
bounds of legally mandated privacy regulations)
and coordinated planning of services by person-
nel and agencies serving dual-involved youth
(Marans, Berkowitz, & Cohen, 1998; Morrissey,
Fagan, & Cocozza, 2009). The key systems with
which youth in the juvenile justice system often
are involved include (but are not limited to) law
enforcement, child welfare, schools, develop-
mental disabilities services, mental health ser-
vices, pediatrics services, community recreational
programs, homelessness services, and family/
social services.
Juvenile justice and child welfare systems can
take numerous steps to ensure that such cross-
system collaboration occurs. First, when youth
enter the juvenile justice system, stakeholders
can commit to identifying whether youth have
current or prior child welfare involvement. Early
identification is a critical step forward, given
that in most jurisdictions, this information is not
identified or shared. Staff must exercise cau-
tion to ensure that this sensitive information is
appropriately shared (i.e., consistent with state
and federal protections and ethical boundaries).
Second, once a youth referred to the juvenile
justice system is identified as having current or
historical involvement with the child welfare sys-
tem, both systems can work together to explore
whether underlying traumatic stress problems
can be addressed without the youth becoming
more deeply embedded into the juvenile justice
system. Third, both child welfare and juvenile jus-
tice systems can explore ways in which they can
build high-quality TF-PTIs into the infrastructure
of their response to dual-status youth. This will
require a sustained, coordinated effort between
the systems and a deep commitment to improv-
ing outcomes for dual-status youth.
Providing youth access to TF-PTIs is an important
element of a broader strategy to disrupt the
child welfare to juvenile justice pipeline. Indeed,
an emphasis on earlier intervention may help
persuade decision makers to invest in TF-PTIs
and to sustain such methods. As efforts evolve to
reform treatment for dual status youth, research-
ers should track data to highlight what common
sense suggests: Earlier intervention is more
effective and efficient than services or treatment
provided after problems become chronic and
severe. Such data will further support endeavors
to develop thoughtful TF-PTI-related policies.
Addressing Traumatic Stress When Youth Are
Intensively Involved in Juvenile Justice
Once youth formally enter the juvenile justice
system, policymakers and practitioners face
challenges related to the legal risks that can be
posed by traumatic stress treatment; policies
are needed to ensure that treatment can be
provided to youth safely and without negative
repercussions. A review of case law has revealed
that judges may consider evidence of childhood
trauma histories as aggravating factors in juve-
nile disposition, transfer decisions, and adult
sentencing (Feierman & Fine, 2014). Moreover,
treatment and screening that involve discussion
54
OJJDP Journal of Juvenile Justice
of a youth’s trauma history may inadvertently
elicit information about past incidents of juve-
nile or criminal offending. Therefore, policies are
needed to ensure that youth can participate fully
in TF-PTI without self-incrimination (National
Juvenile Defender Center, 2014). Screening
or treatment provided during detention or in
a diversion program pose particular risks to
a youth’s delinquency adjudication hearing.
However, even after adjudication, youth may
reveal past actions that could lead to further
adjudications or to a lengthier or more secure
disposition. Protections in state law are the most
effective way to protect confidential informa-
tion (Rosado & Shah, 2007). Such policies protect
young people from being penalized for full
participation in treatment as well as protect the
mental health providers and their relationships
with the youth and capacity to provide effective
treatment.
Additionally, policymakers and mental health
providers can ensure that youth are not penal-
ized for failing to comply with treatment or not
benefitting from treatment. Except for the four
methods described in this review, TF-PTIs have
been developed and tested almost exclusively
with youth who are voluntarily seeking therapy
free from the chronic stress of juvenile justice
sanctions, are living with parent(s) or other adult
primary caregivers who can participate support-
ively, and are not currently exposed to additional
traumatic stressors. In contrast, in secure facili-
ties, youth who are mandated to participate in
treatment are in restrictive settings, are detached
from caregivers and family, have reduced protec-
tion from further traumatic exposures, and are at
risk for punitive sanctions. Indeed, because many
juvenile systems have indeterminate sentencing,
with release granted when the young person
demonstrates appropriate rehabilitation (Nurse,
2010), a youth’s failure to comply with and show
evidence of benefiting from treatment will often
lead to additional time in the system and spe-
cifically in secure facilities. Even in the juvenile
justice systems with determinate sentences or
guidelines, a youth’s failure to comply can lead
to “time adds” or can push a young person’s
disposition to the outer range of the guidelines.
Although it is reasonable to encourage young
people to participate in traumatic stress treat-
ment, the treatments must be delivered in ways
that avoid penalizing young people for whom
coping with ongoing stressors—of both the trau-
matic and chronic day-to-day types—is a more
pressing challenge than addressing the effects of
past traumatic events.
Practitioners should also be aware of the require-
ments around mandatory reporting of child
abuse, and policymakers should ensure that such
requirements are carefully tailored to promote
confidential communications between young
people and mental health professionals. To effec-
tuate these goals, policy makers can craft laws
designed to protect young people from abuse
so that these statutes are not used to impose
juvenile or criminal sanctions on young people.
Thus, for example, sexually active minors could
be protected from being considered “offenders,
and thus triggering mandatory reporting for the
purposes of statutory rape or child abuse (Mallie,
Viljoen, Mordell, Spice, & Roesch, 2012). It is par-
ticularly vital that young people have the oppor-
tunity for open dialogue with their mental health
professionals about their own sexual activity
without risk of punitive consequences. Legal stat-
utes could also provide exceptions for the man-
datory reporter requirement when mental health
professionals are treating juvenile clients who are
victims of sexual abuse, including statutory rape.
These clients, especially, need the opportunity
to seek counseling and pursue sanctions against
abusers when they decide to do so.
Summary and Conclusion
Although there is a rapidly growing array of
evidence-based and evidence-informed, gender
sensitive, developmentally appropriate, and eth-
noculturally acceptable therapeutic interventions
for the treatment and rehabilitation of complexly
55
OJJDP Journal of Juvenile Justice
traumatized children and adolescents (Ford &
Courtois, 2013), only four trauma-focused psy-
chosocial therapeutic interventions have been
adapted for and tested empirically with youth
involved in the juvenile justice system. Because
the potential benefits to youth and to juvenile
justice systems of effective trauma-focused psy-
chosocial therapeutic interventions are substan-
tial, implementation and rigorous evaluation of
the evidence-based models are a priority for the
clinical and justice fields.
Therapeutic interventions that help to establish a
safe milieu and prevent potentially traumatizing
(or traumatic stress reactivating) sanctions (e.g.,
incarceration, physical restraints, seclusion) to
enable young people to recover from emotional
and behavioral problems caused by posttrau-
matic stress, are essential not only for youth but
also their families and communities, and the law
enforcement, court, and juvenile justice staff and
professionals who work with them. When post-
traumatic emotional and behavioral problems are
effectively addressed in all services and programs
within the juvenile justice system, everyone—
troubled youth and their families, adults who are
responsible for public safety, and entire commu-
nities—may become safer and healthier.
About the Authors
Julian D. Ford, PhD, is a clinical psychologist and
professor in the University of Connecticut School
of Medicine Department of Psychiatry and School
of Law. He is the principal investigator and
director of the Center for Trauma Recovery and
Juvenile Justice in the National Child Traumatic
Stress Network.
Patricia K. Kerig, PhD, is a professor of clinical
psychology in the Department of Psychology at
the University of Utah. Her research and applied
work focuses on uncovering sources of risk and
resilience for traumatized youth, particularly
those involved in the justice system.
Neha Desai, JD, is a staff attorney with the
National Center for Youth Law and formerly
the policy advisor of Santa Clara County’s
Dually Involved Youth Initiative. She engages in
litigation; amicus efforts; and policy advocacy
regarding children in dependency proceedings,
commercially sexually exploited children, immi-
grants and refugees, asylum seekers, and bat-
tered women at the federal level and in several
state and county court systems.
Jessica Feierman, JD, is associate director at
the Juvenile Law Center and adjunct professor
in the Temple University School of Law and the
University of Pennsylvania School of Law. She
engages in litigation and amicus efforts related
to juvenile life without parole, institutional
conditions, and adult sentencing. She also is
involved in policy advocacy and public education
on the juvenile justice and child welfare systems,
with a particular focus on the impact of trauma
and adolescent development on juvenile and
child welfare policies.
56
OJJDP Journal of Juvenile Justice
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... Along these lines, research on effective interventions for moral injury in youth is sorely needed. Although the recent advancement of trauma-informed care systems within the juvenile justice system has undoubtedly been a step in the right direction (e.g., Ford et al., 2016), conceptualizations of trauma centered only on victimization may overlook important targets for intervention. As knowledge of moral injury in justice-involved youth expands, treatments should be developed to address the emotional and mental health consequences of offending, institutionalization, family betrayal, and other PMIEs. ...
... Several potential barriers should be considered when adapting such interventions for use with justice-involved youth. Concerns about confidentiality, self-incrimination, and implications for others may deter youth in secure settings from discussing PMIEs in therapy (Ford et al., 2016;gulliver et al., 2010). This concern may be particularly relevant in preadjudication settings when the patient's open charge is a primary source of moral injury. ...
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... With that, the relatively short-term nature of many incarcerations may limit availability of individuals to fully engage and foster a safe environment. Research suggests that many therapeutic skills and interventions that assist people who are incarcerated to recover safely and healthily are essential to them, their families, communities, and peers (Ford et al., 2016). Time and safety may be limited by the required traditional CBT protocols. ...
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Recognition of the high prevalence of trauma exposure and posttraumatic stress reactions among young offenders has led to calls for a shift toward the implementation of trauma-informed approaches in juvenile justice systems. However, meeting the clinical needs of youth in this population not only requires comprehending the profound effects of polyvictimization, developmental trauma, and complex PTSD but also an appreciation of the ways in which traumatic experiences and posttraumatic sequela intersect with diverse youth identities, including ethnicity and race, gender, sexual minority status, developmental stage, and gang involvement, which in turn may affect engagement in treatment. Ethical, legal, and clinical challenges specific to providing services in the context of the juvenile justice system also must be considered, including complications related to confidentiality, protection from self-incrimination, threats to psychological safety, and the potential for secondary traumatic stress among service providers delivering trauma-focused interventions in forensic contexts. This paper reviews those issues and goes on to describe the existing evidence base for interventions for posttraumatic reactions among justice-involved youth, as well as its limitations, and points toward future directions for research and clinical developments that could to expand the precision and reach of mental health services for youth at risk or already involved in the legal system.
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In recent years, increasing attention has been drawn to a population previously overlooked in studies of posttraumatic stress disorder (PTSD), and that is youth involved with the juvenile justice system. Although prevalence rates vary, recent studies reveal that as many as 32% of boys and 52% of girls in detention settings meet DSM-IV criteria for a diagnosis of PTSD (see Kerig & Becker, in press, for a review). However, given that this area of research is relatively new, few studies to date have gone beyond the documentation of prevalence rates to examine the underlying processes that might account for the link between trauma and severe forms of antisocial behavior. The present chapter describes the prevailing theoretical models of the developmental psychopathology of trauma and delinquency and reviews the existing empirical evidence in support of their suppositions. Models discussed include those focusing on emotion processing (e.g., affect dysregulation, emotional numbing, emotion recognition deficits); cognitive processes (e.g., hostile attributions, stigma, alienation); interpersonal processes (e.g., traumatic bonding, antisocial peers); as well as integrative models, including attachment theory and the trauma coping model.
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We describe a multiyear pilot dissemination of a trauma-focused group treatment, Trauma and Grief Component Therapy for Adolescents, coupled with a trauma-informed staff training, Think Trauma, to six residential juvenile justice (JJ) facilities. All staff members were trained in Think Trauma. Seventy-seven youth from four facilities completed the treatment groups and 69 completed all pre- and postgroup assessment measures. The aims of this study were to determine whether trauma-focused interventions (a) could be implemented in complex JJ systems, (b) would be associated with a decrease in posttraumatic symptoms and reactions in youth, and (c) might contribute to reduced Incident Reports in facilities. A related question was whether we would receive feedback that youth who participated in the trauma and/or grief narrative components of the intervention were adversely affected. Pre- and postgroup assessments indicated significant reductions in symptoms of posttraumatic stress, depression, and anger, but not in anxiety or sexual concerns. There were significantly greater reductions in posttraumatic stress disorder (PTSD) among incarcerated youth who completed all modules of the group treatment intervention relative to incarcerated youth who received an abbreviated version. Two of the facilities tracked their Incident Reports and reported reductions. No Incident Reports or therapist feedback documented that the trauma/grief processing components of the intervention were destabilizing to the youth.
Chapter
Practice guidelines for the assessment and treatment of children and adolescents with posttraumatic stress disorders (PTSD) were first developed by an expert panel convened more than a decade ago by Cohen and the American Academy of Child and Adolescent Psychiatry Work Group on Quality Issues. Since the release of that seminal set of practice guidelines, substantial additional validation has been provided in scientific studies of the most robustly evidence-based treatment model, trauma-focused cognitive behavior therapy. Other approaches to the treatment of children and adolescents with PTSD have been sufficiently clinically or scientifically tested to be included as actually or potentially evidence-based in the recent second edition of the International Society for Traumatic Stress Studies (ISTSS) Practice Guidelines, Effective Treatments for PTSD. These include eye movement desensitization and reprocessing, school-based cognitive behavior therapies, psychodynamic therapies, creative arts therapies and psychopharmacotherapy. Family systems therapies were included in the ISTSS Practice Guidelines only for adults, but promising approaches for family therapy with children with PTSD have been developed. Psychotherapies that focus on affective and interpersonal self-regulation also have been identified as promising for children with PTSD by the National Child Traumatic Stress Network. This chapter provides an overview of the evidence based and promising evidence-informed treatments for children and adolescents with PTSD. Case study examples illustrate the use of several of these treatments, with a discussion of the clinical and ethical considerations necessary to ensure the safe and effective application of PTSD treatment for children and adolescents.
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Youth with emotional and behavioral (E/BD) and other disorders, who in many cases have not received needed interventions and supports in school, are overrepresented in the juvenile justice system. This article considers how parents of youth with E/BDs can become more involved in the process when their child is referred to juvenile court, thereby decreasing the likelihood of recidivism. Despite the existing barriers to parental involvement in the juvenile justice system, parents should be informed of their youth's educational rights in school, juvenile court, and out-ofhome correctional settings. In addition, increasing parent involvement and reducing recidivism is an achievable goal; several family-and youth-centered strategies and programs have shown success in keeping youth with E/BDs out of the justice system.
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This chapter focuses on the sequelae in adulthood of traumatic victimization experienced in early childhood (that is, infancy, toddlerhood, and early school years). Adult survivors of early childhood traumatic victimization are at risk for post-traumatic stress disorder (PTSD), and for heightened anxiety, depression and suicidality, addiction, personality disorders, antisocial or violent behavior, serious mental illness and sexual disorders. Several methodological limitations suggest caution in interpreting the findings from studies on the effects of childhood traumatic victimization on adult functioning and health. The impact of psychological trauma and the etiology and course of post-traumatic disorders differ for males and females in several respects, such that gender may moderate the adverse effects of early life psychological trauma. Minority ethno-racial background is consistently associated with increased risk of childhood psychological trauma, including loss, domestic violence and sexual abuse.