Home > Public Resources > Trauma Blog > 2016 - June > Clinician's Corner: Intervening with Traumatized Youth in the Juvenile Justice System: Opportunities Clinician's Corner: Intervening with Traumatized Youth in the Juvenile Justice System: Opportunities and Challenges June 3, 2016 Adolescence is a time of turmoil developmentally, and more than 60 percent of youth in the United States have the additional complication of exposure to traumatic event(s) (Atwoli, Stein, Koenen, & McLaughlin, 2015)—with comparable rates reported in Westernized countries worldwide and higher rates in countries in which poverty and violence are pervasive. Even higher rates (i.e., 80-90+ percent) of trauma exposure are reported by youth involved in juvenile justice, with rates for posttraumatic stress disorder (PTSD) as high as 33 percent (Ford, Kerig, Desai, & Feierman, 2016) compared to five percent in Western nation community samples. Youth in the juvenile justice system commonly have been exposed not only to multiple types of interpersonal victimization (i.e., poly-victimization) but also to adversities (e.g., separation from biological parents/family; poverty) that increase their risk of developing PTSD and a wide range of related emotional, developmental, academic, and behavioral problems (e.g., substance use, affective, anxiety, dissociative, sexual, sleep, and eating disorders; disruptive behavior disorders; suicidality and self-harm). Moreover, the juvenile justice system may expose youth to additional traumatic stressors, such as peer violence, abuse by staff, and shackling and restraints, further exacerbating problem behaviors that may endanger other youths and adults (Ford & Blaustein, 2012). The challenge to providers of traumatic stress interventions for these youths and their families therefore includes—but extends well beyond—remediating or preventing PTSD. We must be ready to help these high-risk traumatized youth cope with chaos. As any parent, teacher, coach, or mentor of teenagers knows, chaos is developmentally normative in adolescence. In addition to raging hormones, a spurt of brain development takes place in cortical regions and pathways supporting executive functions (i.e., logical reasoning, proactive planning, problem-solving, working and episodic memory). Simultaneously, peer and family relationships become more complex and involve shifting balances of obligations, attachments, and loyalties. Pressures to perform and achieve in school, avocations, and social life escalate with the growing imminence of entering adulthood with its many responsibilities as well as prerogatives. For youth who have experienced interpersonal victimization, all of this occurs just when the adverse effects of maltreatment on brain structure and function become manifest and disrupt higher-order brain structures and connections (Teicher & Samson, 2016). These youth are at risk for becoming involved in “delinquency” and with the juvenile justice system largely because they are trying to not only cope with chaos but also simply to survive. Therefore, psychosocial intervention with traumatized youth involved in the juvenile justice must address a wide range of adverse sequelae of traumatic victimization. For some of these youths, trauma memory processing therapies are essential in order to enable them to gain a sense of control and closure over intrusive memories and reminders of specific traumatic events that trigger distress, hypervigilance, flashbacks, avoidance, and bereavement. However, many other traumatized youth involved in juvenile justice are missed or mistakenly classified only as having problems with anger, impulsivity, oppositionality, or psychopathic traits, rather than PTSD. Rather than fear or anxiety, for these teens emotional numbing rather than intrusive re- experiencing is predominant (Allwood, Bell & Horan, 2011): for them, it seems that “nothing really matters” (Kerig, Bennett, Thompson & Becker, 2012). As one youth told me in our first meeting, “I know you want to talk about goals, but I don’t do goals; I don’t have any goals.” Engaging a profoundly distrustful, defensive, and detached youth in therapy requires an approach that explicitly and authentically acknowledges her or his legitimate decision to rely upon hypervigilance as a way of coping with chaos and surviving severe threats and betrayals. It also requires an intervention that elicits, acknowledges, and enhances the youth’s executive function capacities. This is crucial in order to provide a foundation for coping with the chaos of ordinary adolescent life, along with the added challenge posed by PTSD-related triggers and symptoms/reactions—as well as for subsequent trauma memory processing, if this is indicated. Although there have been important advances in the past decade in the identification and assessment of traumatized youth who are involved in the juvenile justice system (Kerig, Ford, & Olafson, 2014), and in empirically-supported psychosocial interventions for traumatized children and youth, the development and empirical evaluation of psychosocial interventions for traumatized youth specifically involved in juvenile justice is still in its infancy (Ford, Kerig, & Olafson, 2014). Several interventions have shown promise, however, and one in particular has been tested in randomized clinical trial and quasi-experimental studies in the juvenile justice arena: 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 that can be done as a one-to-one or group, or conjoint family therapy. Non-clinical line staff also receive training 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 intervention in congregate programs (Ford & Blaustein, 2012). When delivered in the group format, either one leader or two co-leaders may conduct groups of 4 to 10 youth. TARGET groups are designed to be gender-specific, with discussion topics and activities tailored to boys’ and girls’ differing interests and experiences, but both genders receive the same core skills set. TARGET begins with psychoeducation that explains PTSD as a survival adaptation by the brain’s stress response system that makes sense but becomes a problem when the brain’s “alarm” (i.e., the amygdala) becomes stuck in survival mode and hijacks the rest of the brain (notably the “memory filing center”—hippocampus; and “thinking center”—prefrontal cortices) and body. Overcoming PTSD therefore means learning how to re-set the brain’s alarm so that it continues to provide contextually-appropriate vigilance without being stuck in survival mode. TARGET then teaches a seven-step sequence of self-regulation skills to “re-set the alarm” that are summarized by the acronym FREEDOM. The first skills, Focusing and Recognizing triggers, provide a foundation for shifting from stress reactions driven by hypervigilance to proactive emotion regulation. Four subsequent skills are designed to enable participants to differentiate Emotions, Evaluative cognitions, Deliberate goals, and Options for action, and to determine whether they are based on stress reactions or are grounded in the participants’ core personal values. A final skill, Making a contribution, is intended to engage youth (and providers) in recognizing how being able to handle stress reactions in a self-regulated manner is a way that clients can enrich the lives other people and make a positive difference in the world by living their values instead of perpetuating chaos. I designed TARGET originally as a present-centered trauma-focused intervention for adults with co-occurring PTSD and severe mental illness and/or substance use disorders. For these individuals, harnessing executive function and coping with chaos are critical every day challenges. For many, a combination of traumatic victimization and endogenous or acquired vulnerabilities have left them stranded developmentally in adolescence or pre-adolescence—despite often having strong basal abilities and resilience that they have had to devote to coping with internal and external adversities. Adapting TARGET for adolescents therefore required no major substantive changes, but a great deal of reconfiguring of the illustrative examples for psychoeducation and skills practice/rehearsal in order to be relevant for and of interest to teens. These adaptations were formalized in therapist/facilitator manuals and client hand-outs for the group, individual, and conjoint family therapy versions of TARGET for adolescents, as well as in a manual for juvenile justice (and schools or child welfare) line staff that provides the same orientation to stress and the brain but a briefer skill-set (four of the FREEDOM skills) that is feasible for use in moment-to-moment interactions that line staff have with youth 24x7. By providing practical knowledge that is interesting to adolescents – an amazing number of whom would love to be brain scientists, and many others who find knowledge about the brain to be a source of constructive power in their dealings with other people – and a systematic skill set, TARGET is designed to highlight and enhance the youth’s capacities for executive function and emotion regulation under stress. In this way TARGET attempts to address the daunting challenge of helping justice-involved youth to recover from profound post-traumatic numbing and episodic outbursts of hyperarousal- and intrusion-related impulsivity, aggression, and oppositionality that too often get these youths in deep trouble at school, in their families, with peers, and with the law. However, the challenge of traumatic stress treatment does not end there. In addition, to having experienced the kinds of traumatic victimization that can happen to any child, these youths also disproportionately face discrimination, stigma, and exploitation due to their minority ethnoracial background, sexual identity, physical or developmental disabilities, or gender (Ford et al., 2016). Youth of color, gender non-conforming youth (i.e., LGBTQ), youth with disabilities, and girls or young women are disproportionately subjected to traumatic adversities such as law enforcement profiling, hate crimes, bullying, and commercial sexual exploitation or trafficking. They are at risk for sexual assault, isolation, dissociation, suicidality and self-harm, and gang-involvement in their attempts to protect themselves or to find an escape from intolerable entrapment, helplessness, hopelessness, and marginalization. For these youth, TARGET is designed to assist in therapeutic processing (i.e., making sense) of both distant and recent traumatic memories and intrusive memories/re-experiencing of events and recurring experiences that elicit profound shame and demoralization based on injury to their core sense of identity and self-in-relationship to others and society. For many of them, it does make sense to have developed a hypervigilant alarm in order to protect themselves and others who are similarly marginalized and victimized—and they find it affirming and re-moralizing to recognize that they have the capacity to achieve FREEDOM from these endemic stressors by understanding and regulating their internal stress/alarm system despite external adversity. It’s also important to note that it often is difficult to include parents and other supportive adults in treatment, especially for youth placed outside the home, particularly when this is in a facility geographically distant from their home and community. Including adult caregivers in traumatic stress treatment for youth has many potential benefits (e.g., shared processing of the youth’s trauma memories, promoting generalization of learning and behavior change to the natural environment, increasing caregiver role modeling of effective executive function and emotion regulation). When this is not feasible or therapeutically advisable, it is important to provide youth with practical knowledge and skills that they can transport back into their home (and also peer) relationships—particularly if they are living in, or are returning to communities or families that are potentially unsupportive, conflictual, or violent. It is not uncommon for youth in TARGET therapy to become determined to teach others in their lives – parents, peers, teachers, and juvenile justice and law enforcement staff – about the importance of managing the brain’s alarm reactions responsibly. Thus, they become exporters of TARGET into their day-to-day world, and in so doing reinforce and generalize their own use of the knowledge and skills. TARGET is not a panacea, nor a replacement for other empirically-supported approaches to traumatic stress treatment (and cognitive and behavioral rehabilitation) for traumatized youth in the juvenile justice system. It is a template for making traumatic stress transparent and manageable for youth and adults, and as such a complementary and potentially integrative guide for therapists of all theoretical orientations across all therapeutic allegiances. TARGET’s goal is to enable youth and adults to address posttraumatic emotional and behavioral problems at all levels within the juvenile justice system, so that everyone—traumatized youth and their families, adults who are responsible for public safety, and entire communities—can become safer and healthier. About the Author Julian Ford, PhD, is a professor of psychiatry and law at the University of Connecticut and the director for their Center for Trauma Recovery and Juvenile Justice. 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. References Allwood, M. A., Bell, D. J., & Horan, J. (2011). Posttrauma numbing of fear, detachment, and arousal predict delinquent behaviors in early adolescence. Journal of Clinical Child and Adolescent Psychology, 40, 659–667. Atwoli, L., Stein, D. J., Koenen, K. C., & McLaughlin, K. A. (2015). Epidemiology of posttraumatic stress disorder: Prevalence, correlates and consequences. Current Opinion in Psychiatry, 28, 307-311. Ford, J. (2015). An affective cognitive neuroscience-based approach to PTSD psychotherapy: The TARGET Model. Journal of Cognitive Psychotherapy, 29, 68–91. Ford, J. D., & Blaustein, M. (2012). Systemic self-regulation: A framework for trauma-informed services in residential juvenile justice programs. Journal of Family Violence, 28, 655–677. Ford, J. D., Kerig, P. K., Desai, N., & Feierman, J. (2016). Psychosocial interventions for traumatized youth in the juvenile justice system: Clinical, research, and legal perspectives. Journal of Juvenile Justice, 6. Ford, J. D., Kerig, P. K., & Olafson, E. (2014). 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