PART ONE
Byron Alonzo
Byron Alonzo is 13 years old, the youngest of five children. Unlike the rest of his siblings, he has always been impulsive and aggressive. When he was four, Mr. and Mrs. Alonzo took him to the pediatrician “to find out what was wrong,” only to be told that Byron was “a healthy, active boy” and that they should “get help if they could not handle him.” His parents found this comment insulting, reasoning that their other children were all turning out fine, and so “[t]he one who needed help was Byron, not them.” Byron’s father believed his son was a “menace,” and the boy’s first days of kindergarten seemed to prove him right. Byron was aggressive and altogether out of control, physically tormenting his teacher and classmates alike — throwing chairs, stomping on someone’s glasses, pulling a girl’s hair. The Child Find Team determined that Byron had Oppositional Defiant Disorder, Attention Deficit Hyperactive Disorder, and Borderline Intellectual Functioning, and a neurologist concluded that he had a “seizure disorder characterized by explosive episodes.” Byron was put on medication, and his disruptive behavior ceased.
Soon into first grade, it became evident that Byron was struggling academically. His parents concluded that he “was not very smart.” Byron began to grow depressed, and by the third grade he was having suicidal ideations. “Sometimes he thought that he heard voices telling him to jump in front of a moving car.” But Byron did not share this with anyone, and his neurologist began to lessen his medication.
During the fifth grade Byron became addicted to masturbation, an activity he found “calming and enjoyable.” Before long, he and Mike, a six-year-old friend, were regularly masturbating one another. His parents and teacher noticed that Byron suddenly seemed happier, although they had no idea why. By the time Byron reached the seventh grade, he began to fantasize about having sex with younger boys, and he and Mike devised a plan to rape a younger boy. They decided “they would threaten to kill the boy if he told anyone. They would bring an animal along and kill it so the boy would believe it.” Thinking about all this was “so exciting that Byron frequently had an erection.” Soon thereafter, Byron and Mike raped a four-year-old boy and then tortured a hamster to scare the boy from telling anyone else. Byron continued raping little boys, and by eighth grade his number of victims had grown to ten.
For this assignment, I will assume that I am treating Byron as a middle school social worker.
My Initial Reaction
The Alonzo family’s ethnicity might make it difficult for me to work with them. The Alonzos are primarily African American, and this is a group that I have not worked with much before. This inexperience makes me somewhat nervous to work with them. I also feel nervous because American society contains a great deal of hostility between white Americans and African Americans, with many blacks viewing whites with suspicion and vice versa. Therefore, I worry that the Alonzos might view me with suspicion and that earning their trust will be difficult.
Before I begin to work with this family, I need to make sure that Byron has a proper assessment. I have never worked with a client with these types of problems, and at this point I am not sure how to proceed. Once I know Byron’s diagnosis, I will need to read the relevant literature and determine the best course of action. If Byron is in fact a psychopath, I will need to learn more about this condition.
Cultural Competence
My Biases
My biases can be broken down into conscious biases and unconscious biases. First, I’m aware that I often worry that individuals from non-dominant groups view me with suspicion and hostility. I am well-aware that whites in this country have long discriminated against different multicultural groups, and for this reason, when I meet someone from one of these groups, I often find myself worrying that they are judging me. I worry that they think I am another privileged white man who thinks himself superior. I worry that in some ways they feel inferior to me, intimidated by my education and command of formal, proper English. I worry that in other ways they feel superior to me, believing that I lack street smarts, strength, and courage. Consequently, I often have difficulty being my authentic self when around these individuals, intimidated by what I perceive as mistrust and dislike and worried that any misstep on my part, any misinterpreted word or action, will bolster their prejudices against white men.
I also know that I have certain unconscious biases, or implicit biases. Implicit biases are “attitudes or stereotypes that affect our understanding, actions, and decisions in an unconscious manner. These biases, which encompass both favorable and unfavorable assessments, are activated involuntarily and without an individual’s awareness or intentional control” (“Understanding implicit bias,” n.d.). Although I do not consciously discriminate against anyone based on their race or ethnicity, I realize that my unconscious mind still holds prejudice. I say this because I recently took the Implicit Association Test, which is an online test designed by Project Implicit, a collaboration of researchers from six major universities. As described on the Project Implicit website:
[The Implicit Association Test] assesses associations between concepts by measuring how quickly a person can categorize, for example, GOOD words with White faces compared to GOOD words with Black faces. The idea is that the more strongly associated the two concepts are in memory, the more quickly you will be able to categorize words into those paired categories. Your score is reported as an implicit preference for White people compared to Black people if you were faster at categorizing Good words with White faces compared to Black faces. (Project Implicit, n.d.)
I took the test twice. The first time my results showed an automatic preference for European Americans compared to African Americans, and the second time it showed little to no preference for European Americans. What this means is that something deep inside me probably accepts certain stereotypes against individuals from these groups, feeling more reluctant to accept their goodness and capability than I do for whites.
Overcoming My Biases
In order to overcome my conscious biases, I need to remind myself that if the Alzonos present as being sullen or angry, it might have nothing to do with my own ethnicity. They might be angry with their family situation, angry that they have to see a therapist, perhaps suspicious of social workers in general, not because most social workers are white but because they have had a bad history with social workers. By keeping these thoughts in mind, I will be better able to be my authentic self when around the Alonzos and thus better able to help them.
In order to overcome my unconscious biases, I plan to follow the advice of Staats, Capatosto, Wright, and Contractor (2015), who recommend several evidence-based ways to “debias.” These ways include practicing loving-kindness meditation, taking diversity training, increasing contact with members from other groups, and engaging in activities which force one to understand the perspectives of individuals from outside groups (pp. 39-42). These are all great long-term strategies, ones I plan to employ. In order to keep my biases in check for the short-term, I plan to regularly review a cultural checklist designed by the Center for Cultural Competence. This list forces practitioners to examine their own cultural sensitivity and competence with regard to three categories: physical environment, materials, and resources; communication styles; and values and attitudes (“Self-assessment checklist,” n.d.).
Along with working to overcome my biases, another way to prevent the differences that exist between the Alonzos and myself from hindering my work is to bring these differences to the forefront. I might address these differences in our first meeting, saying something like the following: “It’s important to point out that you’re the experts on your own lives. Basically, my job is to just get you all start thinking and talking and to help you to summon your own strengths to do what’s best for your family. There are many things I hope to learn from you, and as we work together I’m hoping that you will teach me what I need to know about your family and your background. I’m obviously a white male. I have a different background and different experiences, and I want you to teach me what I need to know about your family and your background so I can best help you.” I hope that by addressing our differences and asking the family to educate me, I will lay the groundwork for an effective relationship, one in which they feel comfortable sharing their lives with me, enabling me to learn about their culture and background and thus better serve them.
PART THREE
Multidisciplinary Team
In order to properly treat Byron, it will be necessary to form a multidisciplinary team consisting of four individuals. First, I will be a natural choice for the team, as I am Byron’s school social worker and as such have regular contact with him, as well as his teachers and peers. Second, the team must employ a psychologist to perform cognitive tests on Byron to determine if he has any learning abilities that contribute to his academic underachievement. Third, given the severity of Byron’s problems, it will be necessary for him to see a therapist outside of school. If Byron’s problems were less severe, I would be able to provide this service, but give my time limitations as a school social worker, it will be necessary to defer such intensive treatment to someone else. Fourth, a physician is needed to reevaluate Byron’s medications and determine if they are contributing to his problems.
Because of his offenses, Byron has become part of the Colorado Juvenile Justice System. As such, I assume that he has been assigned a case manager to ensure that he receives appropriate treatment. I assume that this case manager will be the leader of the multidisciplinary team described above. As such, this case manager will reach out to different members of the team to coordinate the assessments and services Byron receives.
My role in Byron’s treatment will be threefold. First, I will monitor Byron during the school day. To be more specific, I will regularly check in with Byron, his teachers, and his peers to see how he is doing. Second, I will regularly provide individual counseling to Byron. Since he is already receiving intensive therapy outside school, the focus of my counseling will be limited. Instead of delving deeply into his depression and history of sexual abuse, I will focus on helping him meet behavioral and academic requirements at school. I will also try to be an anchor for Byron, a supportive person he can talk to during especially stressful days. Third, I will regularly communicate with Byron’s family. For the sake of this exercise, I will assume that I have been the social worker at the Alonzo children’s school for several years and have consequently come to know and develop a relationship with Mr. and Mrs. Alonzo. As such, I will be best suited to work with Mr. and Mrs. Alonzo regarding Byron’s treatment.
Given my perspective as a social worker, I believe I will make certain unique contributions to the team. Bentley and Walsh (2013) define the social work perspective as including a person-in-environment perspective and a strengths and empowerment perspective (p. 4). The person-in-environment perspective will help me to “reject unicausality” for Byron’s problems. In other words, this perspective will allow me to see that many external factors have contributed to Byron’s problems. Consequently, fault does not lie solely with Byron, and any solution must involve changing both Byron and eternal factors in his life (p. 4). The strengths and empowerment perspective will help me to see the “capacities, talents, assets, positive traits and qualities, skills, and social supports” of Byron and his family (p. 5). This perspective will also allow me to utilize the family’s strengths to help them overcome their problems.
PART FOUR
Engagement
Based on the first belief, I will try to include several members of the Alonzo family in our first interview. Yanca and Johnson (2008) note that in African American families, “the community is the most important social entity” and that kinship extends “beyond the nuclear family” to include “both extended family and nonfamily members of the community” (p. 74). Given all this, it is likely that throughout his life Byron has had multiple caregivers, and it is likely that they all see Byron’s trouble as their collective trouble and take responsibility for his maturation. If this is the case, it means that Byron has an important support that many adolescents lack.
This first meeting can take place at the middle school, as this seems like a natural setting, although I would be open to meeting somewhere else. If Mrs. Alonzo invites me to meet at her home, I will jump at the opportunity. Such an invitation might be a very significant gesture on her part, a sign that she is in some sense welcoming the team into her family. It would also give us an opportunity to learn more about the family by seeing where they live and how they interact in their home.
I will introduce myself as Byron’s school social worker. I will begin my part of the meeting by pointing out some strengths that I see in both Byron and his family. I do not want the family to see my as some white outsider who is coming in to judge and change the family. I want them to see me as a co-laborer, someone who values them and wants to work with them in supporting Byron. At this point, it might be beneficial to address the elephant in the room and ask the family what they think it would be important for me, a white social worker, to know about them and their culture to best help them.
Another thing I will do to build a culturally competent relationship with the family is to acknowledge the role that spirituality places in their lives. I do not know if Byron shares the Jehovah’s Witness beliefs of his parents, but I know that these beliefs are very important to his parents, and I know that spirituality in general might be important to all of the family members. Additionally, as I begin my relationship with the family, I must be cognizant that African Americans often express themselves differently than White Americans. Yanca and Johnson (2008) quote another author who claims that African American communication allows for a type of “flexibility” that Standard English does not allow, including “highly meaningful nonverbal communication and expression via body language,” which can be seen as “dramatizing that which Standard English fails to communicate” (p. 75).
Assessment
It is important to assess Byron’s risk of reoffending. Rasmussen (2013) writes, “Risk assessment helps prevent low-risk offenders from receiving treatment that is too intense and costly, ensures high-risk offenders receive services commensurate with the danger they present to others and avoids mixing low-risk and high-risk offenders in the same program” (p. 123). To assess for Byron’s risk, we should use MEGA♪, an assessment tool designed specifically for individuals under 19 years of age that has also been shown to work with young people with “low intellectual functioning” (Miccio-Fonseca, 2010, p. 734). MEGA♪ consists of 75 questions, and it has been found to have “strong internal consistency reliability” in a large sample (Miccio-Fonseca, 2010, p. 751).
Additionally, Byron should be given the Youth Self Report (YRS), his mother should be given the corresponding Child Behavior Checklist (CBCL), and one or two of his teachers should be given the corresponding Teacher’s Report Form (TRF). These tools assess for various mental health symptoms, both internalizing and externalizing symptoms. Letourneau et al. (2009) note that these measures are “well-validated and considered among the best for assessing youth mental health functioning.”
Finally, the team’s physician should explore the auditory hallucinations that Byron is having. It is possible that these hallucinations have a pharmacological cause and can be eradicated if his medication is adjusted. If not, we will need to explore whether he has a disorder such as schizophrenia.
Assessing Readiness for Change
Patel, Lambie, and Glover (2008) write that juvenile sex offenders “often appear resistant to change” and that counselors should use the the Transtheoretical Model of Change to assess their readiness for change (p. 88). This model “consists of five or six stages of change (precontemplation, contemplation, preparation, action, maintenance, and, in some cases, termination) through which an individual progresses when changing a problematic behavior” (p. 90). These authors further argue that motivational interviewing is an appropriate approach for such clients, as they “necessitate a counseling approach that allows them to feel accepted and to have a level of safety for expressing their thoughts, feelings, and behaviors” (p. 88).
Strengths, Vulnerabilities, Coping Strategies
Byron’s vulnerabilities include the following: ADHD, ODD, below average cognitive ability, “seizure disorder characterized by explosive episodes,” depression, auditory hallucinations, and poor family support. Byron certainly has strengths, but given the little information I have about him, I am not sure what these strengths are. Byron temporarily used masturbation as a coping strategy, and for a time it seemed to mitigate his depression, but his sexual desires could not be satiated by masturbation, and before long he was engaging in more troubling behavior.
Diagnosis
Although I initially believed Byron to be a psychopath, I now believe that this conclusion is far from clear. I have learned that the adolescent brain is not fully developed, and for this reason, adolescents, relative to adults, have more difficulty exerting self-control, resisting peer pressure, and understanding the consequences of their actions (Bonnie, Johnson, Chemers, & Schuck, 2013, p. 96). Consequently, many adolescent offenders simply outgrow their criminal behavior, and many others respond positively to rehabilitation. Indeed, Carpentier and Proulx (2011) found that only 10 percent of juvenile sex offenders go on to commit more sex offenses (p. 442). Riser, Pegram, and Farley (2013) found that only a minority of juvenile sex offenders could be considered psychopaths (p. 13).
I will assume that Byron’s prior diagnoses were correct and that he has Oppositional Defiant Disorder (ODD) and Attention Deficit Hyperactive Disorder (ADHD). I hypothesize that he does not have Major Depressive Disorder and that his prior depressive episodes can be explained by environmental factors—e.g., inadequate support from his family—and that altering these factors will prevent these episodes from recurring. Needless to say, it will be necessary to test this hypothesis and if it turns out to be incorrect, to make sure to treat his depression.
Intervention
Byron will be given Multisystematic Therapy (MST). (See Appendix A for a copy of Byron’s treatment plan.) The National Institute of Justice (n.d.) describes MST as follows:
Through intense involvement and contact with the family, MST aims to uncover and assess the functional origins of adolescent behavioral problems. It works to alter the youth’s ecology in a manner that promotes prosocial conduct while decreasing problem and delinquent behavior…
MST typically uses a home-based model of service delivery to reduce barriers that keep families from accessing services. Therapists have small caseloads of four to six families; work as a team; are available 24 hours a day, 7 days a week; and provide services at times convenient to the family. The average treatment occurs over approximately 4 months, although there is no definite length of service, with multiple therapist–family contacts occurring each week. MST therapists concentrate on empowering parents and improving their effectiveness by identifying strengths and developing natural support systems (e.g., extended family, neighbors, friends, church members) and removing barriers (e.g., parental substance abuse, high stress, poor relationships between partners). In the family–therapist collaboration, the family takes the lead in setting treatment goals and the therapist helps them to accomplish their goals.
Henggeler, Schoenwald, Borduin, Rowland, and Cunningham (2009) have produced a highly esteemed manual for implementing MST.
Different randomized controlled trials have shown that MST is effective at treating juvenile sex offenders. Letourneau et al. (2009) found that, at a one-year follow-up, MST participants, compared to individuals who received usual community services (UCS), “evidenced significant reductions in sexual behavior problems, delinquency, substance use, externalizing symptoms, and out-of-home placements.” Borduin, Schaeffer, and Heiblum (2009) found that, at a nine-year follow-up, MST participants “had lower recidivism rates than did UCS participants for sexual (8% vs. 46%, respectively) and nonsexual (29% vs. 58%, respectively) crimes. In addition, MST participants had 70% fewer arrests for all crimes and spent 80% fewer days confined in detention facilities than did their counterparts who received UCS” (p. 26).
By helping Ms. Alvarez become a more effective parent, we can also expect MST to fight Byron’s ODD, as several studies show that ODD is best fought by improving parenting skills. If Ms. Alvarez needs additional help improving her parenting skills, I would recommend that she enroll in the Incredible Years parent training program. This program is “guided by the cognitive social learning, modeling and attachment relationship theories as well as cognitive brain development research,” and it emphasizes “developmentally age-appropriate parenting skills known to promote children's social competence and emotional regulation and reduce behavior problems” (Webster-Stratton, 2011, p. 27). Drugli, Larsson, Fossum, and Mørch (2010) studied children whose parents had taken the Incredible Years training and found that, “[w]hile all children qualified for a diagnosis of ODD/CD before treatment, 5–6 years later, two-thirds no longer received such a diagnosis, the same proportion as found at the 1-year follow-up” (p. 559).
Byron’s school counseling sessions should focus on combatting his ADHD. Reid and Johnson (2011) outline five ways to help ADHD children self-regulate. First, these children should be taught to self-monitor, that is, “to self-assess whether or not they are paying attention when cued (typically, cuing is performed through the use of taped tones presented at random intervals), and then to self-record the results on a tally sheet” (p. 205). Second, children should be taught to self-manage, that is, to “self-assess and self-record their rating of a behavior at set intervals. For example, students might rate their behavior on a scale of 1 (did not follow directions or finish work) to 5 (followed all directions and finished all work) at 15-minute intervals during a period and to record the results” (pp. 211-212). Students then compare their ratings to the ratings of their teacher, and if the two ratings match up (or are close), the student receives a reward. Third, students should be taught to set goals. Here, students work with a teacher or social worker to set goals for some behavior (e.g., for staying seated during class) and then monitor their behavior. “Progress toward a goal and achieving a goal is reinforcing. Put simply, it feels good to reach a goal” (p. 215). Fourth, students should be taught self-reinforcement, that is, to reward themselves when a certain goal is met (p. 218). Fifth, students should be taught self-instructions, “the use of self-statements to direct or self-regulate behavior, affect, or cognitions” (p. 218).
Other Approaches
Both cognitive-behavioral and psychosocial educational treatments show promise for treating juvenile sex offenders, but to date they do not have the evidence base that MST does. Fanniff and Becker (2006) note that studies of cognitive-behavioral treatments for juvenile sex offenders generally lack comparison groups, random assignment, and large sample sizes (p. 275). Similarly, Fanniff and Becker (2006) write that educational approaches appear to “change the knowledge or attitudes of juvenile sex offenders,” but they note that “[s]mall sample sizes, and in one study use of non-blind raters of behavior, limit conclusions that can be drawn from this research” (p. 278). If stronger evidence is established showing the efficacy of these approaches with juvenile sex offenders, then they should be compared with MST and evaluated accordingly.
Group Therapy
Group anger-management counseling might also be helpful to Byron. Larson and Lochman (2010) have designed a program that has yielded impressive results. One study showed that aggressive elementary school boys who completed their program “had reductions in independently observed disruptive-aggressive off-task behavior, reductions in parents’ ratings of aggression, and improvements in self-esteem” in comparison with boys who received minimal treatment or no treatment at all (Lochman, Curry, Dane, & Ellis, 2001, p. 71). This study was later replicated, and at a three-year follow-up it was found that the boys who completed the program had “better problem-solving skills, self-esteem gains, and lower levels of substance use than an untreated control condition” (Lochman, Curry, Dane, & Ellis, 2001, p. 71).
Family Therapy
MST is essentially family therapy. It is based on a social ecological theory which holds that the best way to help a young person is to help that person’s family. This involves helping other people in the family to function better individually (for example, encouraging a member to receive support for substance abuse) and helping all members to function better together (for example, improving communication and conflict-resolution skills).
Environmental Factors
Byron’s home life is likely exacerbating his problems. His once big and presumably close-knit family has fallen apart; his parents separated two years ago, and his grandfather, not wanting to be agitated by Byron, rarely visits the family. It is not clear how often Byron sees his father, but it seems that the time they spend together is not helpful to Byron, as Mr. Alonzo has unknown psychiatric problem, a history of physical abuse (definitely with Nikki and likely with the other children), and a history of verbal abuse (declaring five-year-old Byron “a menace” and an embarrassment to the family). Byron, his mother, and his sister now subsist on a “meager existence with little money for clothes or extras” and live in an unsafe neighborhood. We can best help Byron by doing what can be done to mend his family, which might involve providing individual support to some members, helping other members to be reconciled, and recruiting extended family members to play a bigger role in the lives of Byron, his mother, and his sister.
Supervision
I have found that I mostly need supervision when things with a client are not going well. So if Byron does not cooperate with his teachers and if he does not want to overcome his ADHD, then I would ask my supervisor for suggestions to help motivate him. I am not skilled at motivational interviewing, and I could use help learning to “roll with the resistance” and “develop the discrepancy.” I could also use someone to show me if there were things I could do at school to support the work of Byron’s MST therapist’s. I would be fine limiting my work to combating the symptom’s of Byron’s ADHD, but I would also be open to expanding that role if needed.
MST Services (n.d.) states that the effectiveness of MST interventions is “evaluated continuously from multiple perspectives with MST team members being held accountable for overcoming barriers to successful outcomes.” Byron’s case manager will be responsible for regularly checking in with different members of Byron’s team to elicit feedback. I will report how Byron is doing at school and how my intervention to combat his ADHD is going, and Byron’s MST therapist or therapists will report how their more intensive therapy is going with Byron and his family members and other social contacts. The feedback of each team member will be based on what we have personally observed, what Byron has reported to us, and what others in Byron’s life have reported to us; for example, my feedback will in part be based on the feedback of Byron’s teachers and classmates, and the feedback of the MST therapist or therapists will in part be based on the feedback of Byron’s family members and other social contacts.
Letourneau et al. (2009) propose some tools that can be used to evaluate juvenile sex offenders undergoing MST. First, as already discussed, the Youth Self Report (YRS), Child Behavior Checklist (CBCL), and Teacher’s Report Form (TRF) can be used to assess both internalizing and externalizing mental health symptoms. Second, the Adolescent Sexual Abuse Inventory (ASBI) can be used to “assess inappropriate adolescent sexual behaviors from both youth and caregiver perspectives.” “The ASBI has demonstrated adequate reliability (coefficient alphas ranging from .65 to .81) and validity with non-abused youth and with sexually abused youth, of whom a significant percentage reported engaging in sexually abusive acts.” Third, criminal delinquency can be measured by the Self-Report Delinquency Scale (SRD). “The SRD is regarded as one of the best validated measures of self-reported delinquency.” Fourth, substance abuse can be measured by Personal Experience Inventory (PEI). “This subscale combines two items assessing the frequency of adolescent alcohol and marijuana use for the previous 90 days. The PEI is a reliable and well-validated instrument.”
Bentley, K., & Walsh, J. (2013). The social worker and psychotropic medication: Toward effective collaboration with clients, families, and providers (4th edition). Belmont, CA: Cengage Learning.
Bonnie, R. J., Johnson, R. L., Chemers, B. M., & Schuck, J. (Eds.). (2013). Reforming juvenile justice: A developmental approach. Washington, D.C., National Academies Press.
Borduin, C. M., Schaeffer, C. M., & Heiblum, N. (2009). A randomized clinical trial of multisystemic therapy with juvenile sexual offenders: effects on youth social ecology and criminal activity. Journal of Consulting and Clinical Psychology, 77(1), 26-37.
Carpentier, J., & Proulx, J. (2011). Correlates of recidivism among adolescents who have sexually offended. Sexual abuse: a journal of research and treatment, 23(4), 434-455.
Drugli, M. B., Larsson, B., Fossum, S., & Mørch, W. T. (2010). Five‐to six‐year outcome and its prediction for children with ODD/CD treated with parent training. Journal of Child Psychology and Psychiatry, 51(5), 559-566.
Fanniff, A. M., & Becker, J. V. (2006). Specialized assessment and treatment of adolescent sex offenders. Aggression and Violent Behavior, 11(3), 265-282.
Henggeler, S. W., Schoenwald, S. K., Borduin, C. M., Rowland, M. D., & Cunningham, P. B. (2009). Multisystemic therapy for antisocial behavior in children and adolescents. New York: Guilford Press.
Larson, J., & Lochman, J. E. (2010). Helping schoolchildren cope with anger: A cognitive-behavioral intervention. Guilford Press.
Letourneau, E. J., Henggeler, S. W., Borduin, C. M., Schewe, P. A., McCart, M. R., Chapman, J. E., & Saldana, L. (2009). Multisystemic therapy for juvenile sexual offenders: 1-year results from a randomized effectiveness trial. Journal of Family Psychology, 23(1), 89-102.
Lochman, J. E., Curry, J. F., Dane, H., & Ellis, M. (2001). The Anger Coping Program: An empirically-supported treatment for aggressive children. Residential Treatment for Children & Youth, 18(3), 63-73.
Miccio-Fonseca, L. C. (2010). MEGA♪: An ecological risk assessment tool of risk and protective factors for assessing sexually abusive children and adolescents. Journal of Aggression, Maltreatment & Trauma, 19(7), 734-756.
MST Services. (n.d.). Nine principles of MST. Retrieved from http://mstservices.com/what-is-mst/nine-principles
National Institute of Justice. (n.d.). Mutisystematic Therapy (MTS). Retrieved from https://www.crimesolutions.gov/ProgramDetails.aspx?ID=192
Patel, S. H., Lambie, G. W., & Glover, M. M. (2008). Motivational counseling: Implications for counseling male juvenile sex offenders. Journal of Addictions & Offender Counseling, 28(2), 86-100.
Project Implicit. (n.d.). Retrieved from https://implicit.harvard.edu/implicit/Bias Review 2015. Retrieved from http://kirwaninstitute.osu.edu/wp-content/uploads/2015/05/2015-kirwan-implicit-bias.pdf
Rasmussen, L. A. (2013). Young people who sexually abuse: A historical perspective and future directions. Journal of Child Sexual Abuse, 22(1), 119-141.
Reid, R., & Johnson, J. (2011). Teacher's Guide to ADHD. The Guilford Press. Retrieved from http://www.myilibrary.com?ID=330596
Riser, D. K., Pegram, S. E., & Farley, J. P. (2013). Adolescent and young adult male sex offenders: Understanding the role of recidivism. Journal of child sexual abuse, 22(1), 9-31.
Self-assessment checklist for personnel providing behavioral health services and supports to children, youth, and their families. (n.d.). Retrieved from http://nccc.georgetown.edu/documents/ChecklistBehavioralHealth.pdf
Staats, C., Capatosto, K., Wright, R.A., & Contractor, D. (2015). State of the science: Implicit Understanding implicit bias. (n.d.). Retrieved from http://kirwaninstitute.osu.edu/research/understanding-implicit-bias/
Webster-Stratton, C. (2011). The Incredible Years: Parents, Teachers, and Children’s Training Series. Seattle: Incredible Years. Retrieved from file:///C:/Users/dfemmerich/Downloads/The-Incredible-Years-Parent-Teacher-Childrens-Training-Series-1980-2011p.pdf
Yanca, S.J., & Johnson, L.C. (2008). Generalist social work practice with families. New York: Pearson.
By helping Ms. Alvarez become a more effective parent, we can also expect MST to fight Byron’s ODD, as several studies show that ODD is best fought by improving parenting skills. If Ms. Alvarez needs additional help improving her parenting skills, I would recommend that she enroll in the Incredible Years parent training program. This program is “guided by the cognitive social learning, modeling and attachment relationship theories as well as cognitive brain development research,” and it emphasizes “developmentally age-appropriate parenting skills known to promote children's social competence and emotional regulation and reduce behavior problems” (Webster-Stratton, 2011, p. 27). Drugli, Larsson, Fossum, and Mørch (2010) studied children whose parents had taken the Incredible Years training and found that, “[w]hile all children qualified for a diagnosis of ODD/CD before treatment, 5–6 years later, two-thirds no longer received such a diagnosis, the same proportion as found at the 1-year follow-up” (p. 559).
Byron’s school counseling sessions should focus on combatting his ADHD. Reid and Johnson (2011) outline five ways to help ADHD children self-regulate. First, these children should be taught to self-monitor, that is, “to self-assess whether or not they are paying attention when cued (typically, cuing is performed through the use of taped tones presented at random intervals), and then to self-record the results on a tally sheet” (p. 205). Second, children should be taught to self-manage, that is, to “self-assess and self-record their rating of a behavior at set intervals. For example, students might rate their behavior on a scale of 1 (did not follow directions or finish work) to 5 (followed all directions and finished all work) at 15-minute intervals during a period and to record the results” (pp. 211-212). Students then compare their ratings to the ratings of their teacher, and if the two ratings match up (or are close), the student receives a reward. Third, students should be taught to set goals. Here, students work with a teacher or social worker to set goals for some behavior (e.g., for staying seated during class) and then monitor their behavior. “Progress toward a goal and achieving a goal is reinforcing. Put simply, it feels good to reach a goal” (p. 215). Fourth, students should be taught self-reinforcement, that is, to reward themselves when a certain goal is met (p. 218). Fifth, students should be taught self-instructions, “the use of self-statements to direct or self-regulate behavior, affect, or cognitions” (p. 218).
Other Approaches
Both cognitive-behavioral and psychosocial educational treatments show promise for treating juvenile sex offenders, but to date they do not have the evidence base that MST does. Fanniff and Becker (2006) note that studies of cognitive-behavioral treatments for juvenile sex offenders generally lack comparison groups, random assignment, and large sample sizes (p. 275). Similarly, Fanniff and Becker (2006) write that educational approaches appear to “change the knowledge or attitudes of juvenile sex offenders,” but they note that “[s]mall sample sizes, and in one study use of non-blind raters of behavior, limit conclusions that can be drawn from this research” (p. 278). If stronger evidence is established showing the efficacy of these approaches with juvenile sex offenders, then they should be compared with MST and evaluated accordingly.
Group Therapy
Group anger-management counseling might also be helpful to Byron. Larson and Lochman (2010) have designed a program that has yielded impressive results. One study showed that aggressive elementary school boys who completed their program “had reductions in independently observed disruptive-aggressive off-task behavior, reductions in parents’ ratings of aggression, and improvements in self-esteem” in comparison with boys who received minimal treatment or no treatment at all (Lochman, Curry, Dane, & Ellis, 2001, p. 71). This study was later replicated, and at a three-year follow-up it was found that the boys who completed the program had “better problem-solving skills, self-esteem gains, and lower levels of substance use than an untreated control condition” (Lochman, Curry, Dane, & Ellis, 2001, p. 71).
Family Therapy
MST is essentially family therapy. It is based on a social ecological theory which holds that the best way to help a young person is to help that person’s family. This involves helping other people in the family to function better individually (for example, encouraging a member to receive support for substance abuse) and helping all members to function better together (for example, improving communication and conflict-resolution skills).
Environmental Factors
Byron’s home life is likely exacerbating his problems. His once big and presumably close-knit family has fallen apart; his parents separated two years ago, and his grandfather, not wanting to be agitated by Byron, rarely visits the family. It is not clear how often Byron sees his father, but it seems that the time they spend together is not helpful to Byron, as Mr. Alonzo has unknown psychiatric problem, a history of physical abuse (definitely with Nikki and likely with the other children), and a history of verbal abuse (declaring five-year-old Byron “a menace” and an embarrassment to the family). Byron, his mother, and his sister now subsist on a “meager existence with little money for clothes or extras” and live in an unsafe neighborhood. We can best help Byron by doing what can be done to mend his family, which might involve providing individual support to some members, helping other members to be reconciled, and recruiting extended family members to play a bigger role in the lives of Byron, his mother, and his sister.
Supervision
I have found that I mostly need supervision when things with a client are not going well. So if Byron does not cooperate with his teachers and if he does not want to overcome his ADHD, then I would ask my supervisor for suggestions to help motivate him. I am not skilled at motivational interviewing, and I could use help learning to “roll with the resistance” and “develop the discrepancy.” I could also use someone to show me if there were things I could do at school to support the work of Byron’s MST therapist’s. I would be fine limiting my work to combating the symptom’s of Byron’s ADHD, but I would also be open to expanding that role if needed.
Evaluation
MST Services (n.d.) states that the effectiveness of MST interventions is “evaluated continuously from multiple perspectives with MST team members being held accountable for overcoming barriers to successful outcomes.” Byron’s case manager will be responsible for regularly checking in with different members of Byron’s team to elicit feedback. I will report how Byron is doing at school and how my intervention to combat his ADHD is going, and Byron’s MST therapist or therapists will report how their more intensive therapy is going with Byron and his family members and other social contacts. The feedback of each team member will be based on what we have personally observed, what Byron has reported to us, and what others in Byron’s life have reported to us; for example, my feedback will in part be based on the feedback of Byron’s teachers and classmates, and the feedback of the MST therapist or therapists will in part be based on the feedback of Byron’s family members and other social contacts.
Letourneau et al. (2009) propose some tools that can be used to evaluate juvenile sex offenders undergoing MST. First, as already discussed, the Youth Self Report (YRS), Child Behavior Checklist (CBCL), and Teacher’s Report Form (TRF) can be used to assess both internalizing and externalizing mental health symptoms. Second, the Adolescent Sexual Abuse Inventory (ASBI) can be used to “assess inappropriate adolescent sexual behaviors from both youth and caregiver perspectives.” “The ASBI has demonstrated adequate reliability (coefficient alphas ranging from .65 to .81) and validity with non-abused youth and with sexually abused youth, of whom a significant percentage reported engaging in sexually abusive acts.” Third, criminal delinquency can be measured by the Self-Report Delinquency Scale (SRD). “The SRD is regarded as one of the best validated measures of self-reported delinquency.” Fourth, substance abuse can be measured by Personal Experience Inventory (PEI). “This subscale combines two items assessing the frequency of adolescent alcohol and marijuana use for the previous 90 days. The PEI is a reliable and well-validated instrument.”
References
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Bonnie, R. J., Johnson, R. L., Chemers, B. M., & Schuck, J. (Eds.). (2013). Reforming juvenile justice: A developmental approach. Washington, D.C., National Academies Press.
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