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DSAMH Annual Forensic Examiner Training October 17, 2013

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1 DSAMH Annual Forensic Examiner Training October 17, 2013
Evaluator Challenges in Juvenile Competency Evaluations: Report Writing & Attainment Recommendations Ivan Kruh, Ph.D. Forensic & Clinical Psychology – Ossining, NY Intro self… Want to say that I have reserved a great deal of time at the end of the presentation for questions. In an effort to get to present what I have prepared for you today, I am going to ask that you hold off questions until then. Also -- I am going to do my best to call this CTP since that is what you call it here in Utah. In Washington State, where I did most of my work in this area, it is called CST. In New York State, it is called “Capacity.” It is increasingly being referred to as “Adjudicative Competence.” Mouthful to say… Glad won’t have to today. I still slip back to CST – and may well today. DSAMH Annual Forensic Examiner Training October 17, 2013

2 Nice to be here when everyone in SLC is in a well-deserved celebratory mode!!

3 Competency to Proceed – Utah Law
Juvenile Court Act (Chapter 6) 78A-6-105(30). Definitions. “Not competent to proceed” means that a minor, due to a mental disorder, intellectual disability, or related condition as defined, lacks the ability to (a) understand the nature of the proceedings against them or of the potential disposition for the offense charged; or (b) consult with counsel and participate in the proceedings against them with a reasonable degree of rational understanding. Let’s start with a quick review of the relevant laws. First, the basic definition of CTP in juvenile court in Utah

4 Competency to Proceed – Utah Law
Juvenile Court Act (Chapter 6) 78A (7). Juvenile Competency. In conducting the evaluation and in the report determining if a minor is competent to proceed as defined in Subsection 78A-6-105(30) the examiner shall consider the impact of a mental disorder, intellectual disability or related disorder on a minor’s capacity to: (a) comprehend and appreciate the charges or allegations; (b) disclose to counsel pertinent facts, events, or states of mind; (c) comprehend and appreciate the range and nature of possible penalties, if applicable, that may be imposed in the proceedings against the minor; (d) engage in reasoned choice of legal strategies and options; (e) understand the adversarial nature of the proceedings; (f) manifest appropriate courtroom behavior; and (g) testify relevantly, if applicable. And the factors the legislature says must be considered.

5 Conceptualizing Competency to Proceed
Several models to operationalize legal standard A four factor general model summarizes them Factual Understanding Basic, concrete knowledge of the legal process Rational Appreciation Accurate “beliefs” about what is understood about court Assisting Counsel Ability to participate with and meaningfully aid defense counsel in developing and presenting the defense Legal Decision Making Ability to consider legal alternatives and reach adequately contemplated legal choices Conceptualizing CTP has been an ongoing challenge – numerous list of factors and models have been proposed. I have found a four-factor model most helpful, especially in Juv-CTP. Since I will no doubt refer to these four factors during our conversation, want to review. Factual Understanding – Basic, concrete knowledge of the legal process e.g., Understands the court will decide guilt and innocence Understands what punishments are possible Understands the various ways one may plead Of course, youth less likely to have studied or been exposed to how courts work vs. adults. Rational Appreciation - Accurate “beliefs” about what is factually understood about court Is able to rationally apply knowledge in one’s actual case-related situations Traditional threat: Delusion – “I know defense attorney helps me, but my defense attorney is an alien. Juveniles: Immaturity – “I know defense attorney helps me, but I know my PO much better.” “Adults don’t work for a child…” Assisting Counsel - Ability to participate with and meaningfully aid the defense attorney in developing and presenting the defense e.g., Is able to provide a coherent account of the facts of the alleged crime Traditional threat: Disorganized, irrational thinking due to psychosis Juveniles: Immature development of cognitive skills to process and organize information and language skills to express information Legal Decision Making: Ability to consider legal alternatives and reach adequately contemplated legal choices Is able to rationally decide about accepting a plea agreement offer Traditional threat: Psychotic Reasoning – “I’ll take the case to trial so everyone can see I am J.C.” Juveniles – “I’ll take the case to trial because that’s what my mom told me to do.” “I’ll plead guilty because I want to go home.”

6 Evaluation Model (Grisso, 2003)
Functional Are there deficits? Causal What is their cause? Contextual How will any deficits impact this defendant in their case? Conclusory Are the deficits adequately impairing to meet the legal test? Remedial (Attainment) Can the deficits be remediated? Another model that I have found helpful in Juv-CTP evaluation work is the evaluation model proposed by Grisso in 2003 For the same reason, let’s review – so it is mutually shared and understood vocabulary. FUNCTIONAL: If there are no deficits, your evaluation is done. CAUSAL: If you identify appreciation deficits in an 11-year-old (developmental?), your search for the cause of the deficits may be different than if these occur in a 16-year-old (low IQ? ADHD?).

7 Evaluator Challenges in Juvenile Competency Evaluations
Report Writing The first of the two main topics we wanted to focus on today is Report Writing

8 Forensic Evaluation Reports
Everything of importance to forensic psychological assessment culminates in the expert’s report. (Gagliardi & Miller, 2007, p. 539). Doesn’t matter much how high the quality of the evaluation is if it is not appropriately documented and reported to those who need the information! As Tom Grisso has put it: Your evaluation is no better than your report. Your credibility is no better than your report.

9 Primary Purposes of Forensic Evaluation Reports
Inform attorneys and legal decision-makers so that sound legal decisions can be reached. Create a legal record Current Case Judicial Assessment of Veracity of Conclusions Informs Attorney Decision to Challenge Conclusions If so, allows for Meaningful Cross-Examination Structures Direct Examination Reference Resource for Examiners in Testimony Appellate Process Future Cases Examinee is Involved In

10 Primary Purposes of Forensic Evaluation Reports
The Forensic Audience Forensic evaluations are consumed by others who may have no background in mental health Document must be understood by legal professionals and by general public Greater need to educate – on clinical issues and sometimes even legal issues! If attorneys are confused, issues may not be addressed well, or at all, in court Grisso says to write as if the audience was looking over your shoulder. Another way I say that is, “Write with a vision of being challenged in testimony” Even if the case will never require your testimony, pretend it will. Requires some experience with testifying!

11 Secondary Uses of Forensic Evaluation Reports
Reduce the need for expert testimony Professional record of potential clinical value Mechanism for examiner’s analysis Modeling for professional colleagues Mechanism for Examiner’s analysis: “Writing can be a process of hypothesis testing” – Grisso Writing forces us to clearly lay the foundation of our thinking. Writing it helps identifies holes, gaps, inconsistencies, challenges Our thinking gets modified, or we pursue more info, etc. My report writing is an ongoing process that builds as more and more data is obtained.

12 Report Writing High Quality Forensic Evaluation Reports

13 Common Report Writing Errors (Grisso, 2010)
Reviewed reports of ABPP Applicants failed by the expert panel reviewing their work 36 psychologists / 62 reports Psychologists already passed in depth written exam Identified Top 10 List of most common errors ports.pdf

14 Common Report Writing Errors (Grisso, 2010)
#10: Improper test uses Use of inappropriate tests Misinterpretation of test data #9: Language problems Use of jargon lacking meaning to judges & juries Use examples or descriptions to illustrate #8: Over-reliance on a single source of data Did not pursue corroborating sources of information when they were needed Jargon – a commonly overlooked example is medication – give generic and class May assume everyone knows what Prozac or Adderall is…. DAT SOURCES: Collateral interviews with family Mental Health Therapists Past Assessments Residential Placements Hospitals Medical Academic Teacher Interviews IEPs Legal Police reports Detention records Psychological testing

15 Common Report Writing Errors (Grisso, 2010)
#7: Data and interpretation mixed Reader unable to differentiate fact and inference #6: Inadequate data The referral question, case circumstances, or final opinion required additional types of data that were not obtained, were not reported, and for which absence was not explained. #5: Failure to consider alternate hypotheses Data could support alternative interpretations, but report did not explain how they were ruled out

16 Common Report Writing Errors (Grisso, 2010)
#4: Irrelevant data or opinions Data and/or opinions included in the report were not relevant for the referral questions Violates due process, self-incrimination, and/or dignity #3: Organization problems Information was presented in a disorganized manner (lacked a reasonable logic for its sequence) #2: Forensic purpose unclear The legal standard, legal question, or forensic purpose was not stated, not clear, inaccurate, or inappropriate Recommendation: Quote the relevant statute Isn’t this interesting – among ABPP-failing forensic psychologists the #3 most frequent problem they have is a lack of organization in their reports!

17 Common Report Writing Errors (Grisso, 2010)
#1: Opinions without sufficient explanations Major interpretations or opinions were stated without sufficiently explaining their basis in data or logic

18 Keys to High Quality Forensic Mental Health Reports (Grisso, 2008; 2012)
Relevance Speaks directly to the question asked by the court – and no more. Credibility Explains why the reader should believe the examiner. Accurate and Objective Factual Basis Expertise on Issues at Hand Facts and Opinions are Distinguished Links Made Between Facts and Opinions to Explain Opinions Rejection of Competing Opinions Also Explained Clarity Is written clearly so as to be understood by the reader. Writing Style Sequencing & Organization !!!!!!!!!!!!!!!!!!!CONSIDER SKIMMING!!!!!!!!!!!!! Relevance Irrelevant data – CST report – wrote he was sexually abused in childhood. Successfully sued examiner! Why relevant? Credibility Objectivity: No exaggeration, distortion, minimizing – includes openly admitting to contradictions in the data. Requires an openness about the limits of the available data, consistency in the data, limitations, competing hypotheses, etc . Everything is driven by what the court wants to know about the evaluation subject. 2. Pertains to sticking to what is relevant and balancing level of detail accordingly. 3. Create a coherent story in a language the audience can understand. 4. Facts = can be acquired by the senses and can be verified – directly, seen, heard, or read by the examiner, without interpretation “The youth spoke in a sing-songy voice and made frequent reference to children’s cartoons.” Inferences/Opinions = What the facts suggest when understood from the examiners position of expertise. “The youth presented verbally in a manner more consistent with that of a younger child.” 5. Explanations involve teaching how you know, or how you got there. Conect the data to opinions. Explain how the data took on meaning (theory/research) > explanations, not opinions, are the reason that one is an expert Unexplained conclusions invite the need for testimony. Clarity – Style. What do we mean by this? Avoid or explain jargon and colloquialisms Write scientifically, not over-dramatically Avoid language that suggests a bias Use quotes liberally – let the source(s) speak for selves Clearly differentiate facts and opinions Write in a manner that is readable (Grisso, 2008) Use words of fewest syllables (utilize > use; necessities > needs) Sentences of words 8th or 9th grade reading level Use active voice, not passive Avoid typos, errors, and grammatical mistakes!

19 Clarity: Writing Style
Avoid or explain jargon and colloquialisms Write scientifically, not over-dramatically Avoid language that suggests a bias Use quotes liberally – let the source(s) speak Clearly identify sources for facts Clearly differentiate facts and opinions Write in a manner that is readable (Grisso, 2008) Use words of fewest syllables (utilize > use; necessities > needs) Sentences of words 8th or 9th grade reading level Use active voice, not passive Avoid typos, errors, and grammatical mistakes! !!!!!!!!!!!!!!!!!!!!!!!!!!CONSIDER SKIMMING!!!!!!!!!!!!!!!!!!!!!!!!!!!!! Explain jargon when must be used (e.g., Asperger’s Disorder; impulsivity) Avoid jargon that can be (e.g., “Oriented times three” “decompensated”) Bias: Against examinee: “He argued unconvincingly that he hit the boy because he had been mean.” For the examinee: “He felt hurt by the boy’s comments and was finally unable to resist lashing out.” Unbiased: “According to his report, the boy made disparaging comments and then he hit the boy.” Identify the source(s) for your facts. Part of the job of the report is to convince the reader that you know what you are talking about. Show them when you have three sources offering the same fact – make clear when you are relying on one source of questionable credibility. Legally, is within the rightful domain of the court to review all of your original sources – must be able to know what you got from where. Blanket statements like, “The available data showed that….” or “Information in the evaluation revealed…” are not good enough! Grammatical mistakes VERB TENSE – pick one! Don’t hope back and forth. Generally past tense is best. By the time you are writing the report, there is nothing that is happening at that moment. Often see MSE in present tense. “He is able to interpret proverbs.” H was that day. Sure he still can? What if he is drunk right now? Psychotic? “He was able to” is most accurate and safest!

20 Report Writing Clarity: Organization
The key is not that a report uses any specific oragnizing paradigm – But that there is some thoughtful organizing paradigm used!

21 Forensic Report Organization
Introductory Material Why the examiner conducted this evaluation Identifying and referral information Legal question(s) being addressed Informed Consent / Notification of Rights Methods Used and Sources Relied Upon What the examiner did to conduct the evaluation What the examiner wanted to do, but was unable Description of how this information was obtained Identify source(s) – and credibility of source(s)! !!!!!!!!!!!!!!!!!!!CONSIDER SKIMMING!!!!!!!!!!!!!!!!!!!!!!!!!!! A key to successful report writing is strong organization. I often tell trainees, there can be and are many disagreements and preferences for what the organizational approach should be. But there MUST BE AN ORAGNIZATIONAL APPROACH! One way to improve oragnization is to write reports in the way we were always told to write essays and reports growing up— With an outline. An outline that uses LOTS of headings! Today, want to spend time introducing you to one possible “outline” we developed for Utah Juv-CTP reports – our report template. Let’s start broadly – with recommendations general across forensic mental health evaluation reports. Identifying information Name and date of birth of the examinee; case number. Date of the report METHODS USED AND SOURCES RELIED UPON Organize them – Chronoligically; Type Date, duration, and identity of interviewee for each interview conducted. Records reviewed, including the type, source and date span. Name of any psychological tests administered; date and subject of the administration

22 Forensic Report Organization
Observations, Assessment Results & Other Data What the examiner discovered by conducting the evaluation Relevant mental states, capacities, abilities, knowledge, &/or skills relevant to the legal question Opinions What the findings of the evaluation mean in relation to the reason for the evaluation Proposed causal connection between facts obtained and the legal question Interpretations & Conclusions Limits of the Interpretations & Conclusions If necessary, address different versions of the facts !!!!!!!!!!!!!!!!!!!CONSIDER SKIMMING!!!!!!!!!!!!!!!!!!!!!!!!!!! ***Causal connection -- often the tell-tale distinction: “Respondent A is mentally retarded. Therefore, it is my opinion that he is unable to understand the nature of the proceedings or to assist in his defense.” -- WHY? vs. “Respondent A is mentally retarded and as a result has very poor abstraction abilities. His capacity to conceptualize the adversarial nature of the proceedings and the roles specific personnel play within it is very poorly developed. Therefore, it is my opinion that he lacks the capacity to understand the nature of the legal proceedings he faces.” Notice the difference being made between data and opinions. Current recommendations (that are often NOT followed….) Are to separate the two – make clear to the court what the objective facts were that were considered. THEN explain to the court how those facts caused certain opinions to be reached.

23 Juvenile Competency to Proceed Report Organization
Identifying Information & Evaluation Referral Juvenile: Name; Date of Birth; School Grade; Case # Evaluation: Date Interviewed; Date of Report Referral Question: Specific Charges; Referral Source; Reason for Competency Concerns Notification or Preparation of Participants Contents of Notification; Youth’s Understanding of Notification; Others’ Understanding of Notification; Signing of Notification Form(s) Scope & Process of Evaluation Specific Issues of Concern; Examiner’s Understanding and/or Conceptualization of Competency Now let’s get more focused and look at what the field generally recommends for Juv-CTP evaluations Identifying Info & Eval Referral – this is all basic info – don’t want any confusion around this! Notification – Essential to make a record of what happened here – especially in CTP evals as this is both procedural AND data Scope & Process – Allows reader to assess level of agreement with how examiner understands CST; Makes clear it is CST that was evaluated and not some other related forensic concept (infancy; insanity) Less of an issue in Utah since you have the benefit of a clear Juv-CTP statute – many jurisdictions still do not!

24 Juvenile Competency to Proceed Report Organization
Procedures or Database or Information Sources Interview of Youth: Date; Duration; Location; Conditions Psychological Testing: Test Name; Date Administered; Subject of Administration Records Reviewed: Type; Source; Date Span Interviews Conducted: Type; Subject; Date(s); Duration Validity Concerns: Data Source; Specific Concerns; Management of Concerns Unobtained Data: What was Pursued and Not Obtained; Why it was Pursued; Limits Caused by No Access Need a level of detail that lets the reader know exactly what was relied upon. If readers want to obtain all the original sources examiner had to assess agreement with the conclusions, they should be able to. If the examiner did not have access to a critical piece of information – or didn’t event know about it – it should be known. Notice that data concerns should also be discussed – validity, completeness, or absence. Should discuss the limitations these data “problems” place on the evaluation. Not always easy to know! Can always say, if more information is obtained and changes any opinions, an amended report will be submitted.

25 Juvenile Competency to Proceed Report Organization
Data Then Opinions Model Clinical and Developmental Data Competence Data Functional, Causal, Contextual, Conclusory, & Remedial Opinions Clinical Then Forensic Model Mental Health and Diagnostic Opinions Opinion And Supporting Data Model Functional Opinion & Supporting Data Causal Opinion & Supporting Data Remedial Opinion & Contextual Opinion & Supporting Data Supporting Data Conclusory Opinion & Supporting Data In my work across a number of states have seen that there are three main models for organizing the primary content of the Juv-CTP report. Arguments can be made for and against each! Data then Opinions model is probably most common. However, in state’s where a diagnostic threshold must be met – or diagnostic predicate, can be helpful to address that first as if it is not met, the rest of the evaluation is moot. As Utah is one of those States, we decided to take that approach with the template we will discuss.

26 Juvenile Competency to Proceed Report Organization
Background (Clinical and/or Developmental) Relevant History: Family; Early Development; Trauma; Medical; Academic; Social/Recreational; Behavioral; Legal; Mental Health Mental Status Exam: Appearance; Attitude; Motor Functioning; Speech and Communication; Cognition; Thought Process; Affect Current Mental Health Symptoms/Domains of Immaturity Psychological Test Results: Past Testing; New Testing Opinions (Clinical and/or Developmental) Summary of Clinical and/or Developmental Data Diagnoses Assigned and Rationale for Each Diagnoses Ruled out and Manner in Which Ruled Out Domains of Developmental Immaturity EXPLAIN RED TYPE – and NOTE THAT WAS NOT INCLUDED ON THEIR SLIDES BUT ADDED IN LATER FACTS then OPINIONS Relevant History – a context for current functioning Sometimes best when broken down into domains – sometimes best to have a flowing integrated chronology (still must hit each domain) Sometimes high level of details is necessary to understand the context, sometimes not. MSE: Current presentation – both through observation and formal MSE questioning Current Symptoms: Based on available information, what mental health symptoms is the youth experiencing at the time of the evaluation? Test Results: Organize by past/new – or by domain: intelligence; academic; behavioral; etc. Non-detailed presentation of findings – lay audience! Mental Health Opinions / Diagnostic Opinions: May seem obvious to you as a clinician what this is all pointing to – assume it is not to reader Draw the nexus! Walk them through exactly how you translated all that data into diagnostic opinions. What exactly caused you to accept the diagnoses you offer – and what causes you to reject the ones you didn’t.

27 Juvenile Competency to Proceed Report Organization
Competence to Proceed Data Dusky: Capacity to Factually Understand; Capacity to Rationally Understand; Capacity to Rationally Assist Juvenile Adjudicative Competence Interview (JACI): The Juvenile Court Trial and Its Consequences; Roles of the Participants; Assisting Counsel and Decision Making; Participation at a Juvenile Court Hearing Utah Statute: Comprehend and appreciate the charges or allegations; Disclose to counsel pertinent facts, events, or states of mind; Comprehend and appreciate the range and nature of possible penalties; Engage in a reasoned choice of legal strategies and options; Understand the adversarial nature of the proceeding; Manifest appropriate courtroom behavior; Testify relevantly. FACTS! Detail what the youth can and can’t do in the role of a defendant. How this is organized can vary – Could base it broadly on the Dusky standard Could base it on the assessment tool used for the assessment – like the JACI Arguably, the best way to present it is based on the local statue – helps the court directly link the facts to the “test” to be used. Good way to keep this at the level of facts? – offer quotations and direct observations.

28 Juvenile Competency to Proceed Report Organization
Competence Opinions or Competence Conclusions or Competence Interpretations Functional: Summary of Competence-Related Abilities Causal: Clinical & Developmental Causes of Abilities Contextual: Potential Consequences of Deficit Conclusory: Competence Opinion Includes Rationale for Rejecting Alternative Opinions Remedial: Potential for Remediation (Attainment) OPINIONS Clearly identifies the conclusions that were drawn and HOW THEY WERE ARRIVED AT The logic behind the opinion is actually more important than the opinion itself. Allows the court to wrestle with the issues in an informed manner. A simple statement of the opinion does not. The reader should be able to “reason along” with the examiner. Functional: Conceptualization of strengths and weaknesses in abilities. “He is able to…” “She is unable to…” Causal: Based on all of the data, what best explains the functional strengtsh and weaknesses? Contextual: Given what is known about the instant case and situation, how are these strengths and weaknesses likely to impact the youth in court? Conclusory: Might avoid offering – or if do, make clear that ultimately this decision belongs to the court. Remediation: Estimate of the likelihood of successful remediation. May not know if will be found IST – can phrase it conditionally: “If the youth is found not competent, then…”

29 Report Writing Utah Juvenile Competency Evaluation Report Template

30 Forensic Report Templates Can
ENHANCE REPORT ORGANIZATION Serve as a Memory Aide for Best Practices Enhance Report Writer’s Efficiency “Plugging in” new information Enhance Report Reader’s Efficiency Finding information Enhance Report Quality Forces thinking about key issues First question to ask is why offer a report template? We have offered practice standards. Isn’t that enough? Short answer is, yes – it may well be enough. BUT general adherence to a report template can offer some advantages – let’s discuss: A Memory Aide – there are a number of guides to writing good Juv-Comp reports out there now – Grisso (2005), our book in 2008, etc. One goal of a template is to build in the thinking in those guidelines so that, case by case, the evaluator is reminded to consider them. I like to compare this to the Structured-Professional Judgment approach in risk assessment. According to SPJ in RA, there is no magic formula for reaching a risk opinion – but certain factors should be considered each case. SPJ Risk Assessment tools provide the framework for remembering the best practices for that process. Similarly, there is no magic formula for how to write a Juv-Comp report – but certain factors should be considered and discussed each case. Report Templates provide the framework for remembering the best practices for that process. Report Writer: Forensic Evaluations often involve a “trickling in” of information. With report deadlines as they are, often have to “write as you go,” rather than write it all up at the end. Comfort with a report template allows you to plug relevant information in quickly – even if you move it later. Realities of “factor line” evaluating: Some cases are straightforward and need little artistic touch. Sometimes deadlines loom and need to be met. The template can really help with efficiency in those cases Sometimes cases are complex or otherwise unique and need better methods for clarity. Sometimes there is more time to be playful and creative with how information is presented. The template offers a starting point to launch into that process – or just a check for after that all that needed to be hit was hit Report Reader: More an evaluator, or even evaluators, within a jurisdiction use a standardized outline, the more readers know where to find what they want. I am told in Utah, judges wanted the diagnosis on the first page. Why? They simply wanted to be able to find that information. If every report has the same layout, they will be trained to know how to easily find it – or anything else. And remember – evaluator is sometimes the “report reader” – when on the stand, when consulting with attorneys after the evaluation. The greater your comfort with the layout, the more easily you can find information on the fly when you need it. Report Quality: Forensic Evaluation report writing requires unique features. Not always easy to meet the many Best Practice recommendations. A template that incorporates those recommendations increases the likelihood that this wil occur

31 How To Best Use Templates
Templates are Suggested Guides Templates offer a Common Starting Point Templates are Never Written in Stone Templates are Not Intended to Eliminate Evaluator Style of Expression or Creativity Templates are Intended to Assist the Evaluator, Not Limit the Evaluator There is no single way to organize a juvenile CST Report. Different cases call for different approaches – e.g., Hx not in domains, but in full chronology when issues are too intertwined, or have a key point at which all changed (trauma, psychotic break, etc.) Tom Grisso has compared report templates to paint-by-numbers art – may produce a great picture, but it also can steal the artist’s unique expression. The trick is to not let it – do not become overly reliant on the template. It is a tool – not an obstacle.

32 Use of the Template Text Fields
Notes to Evaluator (Bracketed and Italicized) A word about pragmatic use of the template: “Click here and type text” – text fields. Placing the cursor highlights the entire field. Once highlighted, begin typing and the text field is removed and replaced by what you are typing. Advance through them using f11 – allows you to jump through the report filling in the fields.

Provides all of the essential identifying information at the outset – goal is to eliminate any confusion about who conducted the evaluation, who was the subject of the evaluation What was the case in question Who are the legal players involved When the youth was interviewed DISCLAIMER ABOUT RELEASE OF EVALUATION REPORT Makes clear the statute guiding the evaluation and the production of the report. Makes clear statutory guidelines for release have been followed. Makes clear that the report may be used in other ways that are outside the evaluators control. ONGOING PAGE HEADER Basic identifying information about the report – mainly in

34 Reason for Referral Now we are getting into the referral question.
Makes clear who issued the court order for the evaluation, when it was ordered, and when the order was received. When a timeline for an evaluation starts at the time of the order, a delay in sending the order can be problematic. Can be good practice to make any delays evident – one way is to just always report when it was received. Makes clear that the order is for a competency evaluation – and identifies the nature of the charges the issue is raised in reference to. Explains the state’s allegation – this is the official record which provides some point of comparison for assessing the youth’s understanding later Identifies the arrest date and the circumstances of the arrest, as well as the youth’s current location. This can provide some information about the youth’s condition – how much stress has he/she been under? Finally, it is specified who raised the CTP concerns and what was observed or experienced that yielded those concerns. Let’s face it – this kind of information needs to be presented in each case and there doesn’t seem much benefit to re-typing it each time. If you have wording preferences for these “boilerplate” sections, you can certainly change the language and save for a more personalized template.

35 Summary of Opinions Clinical Summary Diagnostic Opinions
Summary of Opinions – Judges requested that diagnostic opinions be put on the first page. We felt the diagnosis on its own could facilitate misunderstanding and misattribution. Felt better to report the diagnosis in the context of the rest of the evaluation opinions. In a way, this is a modified “Opinions and Supporting Data” Model. We present the opinions on the front end – then the data that led to these opinions – which of course every reader will read!! Clinical Summary – What does the evaluator opine is going on clinically with this youth? What are the most salient clinical issues? Diagnostic Opinions – What are the diagnoses, if any, the evaluator has arrived at to explain the clinical findings?

36 Summary of Opinions Opinions About Competency to Proceed
You can see what we used here is a modified “Clinical-then-Forensic Approach” First, the clinical opinions are offered as a foundation for the forensic opinions. Next, the forensic opinions are offered to answer the questions posed by the court order. This approach is modified in that the opinions are being offered first. More typical – Clinical Data > Clinical Opinions; Forensic Data > Forensic Opinions Based on judges request – Clinical Opinions & Forensic Opinions – then, the Clinical Data and Forensic Data that supports the opinions. So now the evaluator lays out his/her opinion about CTP. For purposes of clarity, the Conclusory Opinion is offered first. Conclusory Functional – what he can and can’t do – first based on the two Dusky prongs, then breaking it down by the abilities in Utah statute. Contextual – What is the affect of the dysfunction expected to be? What kinds of problems are expected to be encountered? Because medications may impact these issues in positive or negative ways, this is specified, if applicable. Section ends with a disclaimer – although these opinions have been formed – including even a Conclusory opinion, the ultimate legal determination rightfully belongs to the court. This is how the Ultimate Issue Issue is being handled here – we will give you our bottom line opinion, but please be clear that this is advisory only. This is both an acknowledgement by the evaluator that they understand the limits of their role AND a reminder to the Court that the role of these opinions is limited. This is important as studies of the issue have found extremely high agreement between experts and courts in CTP evaluations. Evaluators may wish to modify if it is a case where developmental factors are at play. “Although they are not recognized as a foundation for a finding of incompetence by Utah statute, this evaluator wishes to alert the Court to concerns about how developmental factors seem to be impacting this youth’s competency-related functioning.” This makes clear to the Court that you know the statute and you know you are providing information outside of it. Credibility! Yet also communicates information that allows the Court to include (or exclude) these factors from consideration.

37 Summary of Opinions Opinions About Attainment of Competency
Obviously if the evaluator reaches an opinion that the youth is clearly competent, offering an opinion about likelihood of successful attainment is moot. If it’s possible that the Court may find the youth not competent, an Attainment opinion becomes necessary. We will be spending the second half of this presentation discussing forming this opinion in great detail – so keep that in mind. Notice, we begin the opinion with the statement: “Should the Court find ____ not competent.” Continued reminder – this is your call, Your Honor, not mine. Research has found extremely high correspondentce between examiner opinions and judicial determinations. Either we are amazing at our job – or they are overly reliant on us. Maybe some of both. Still try to build in to the report reminders that this is not, in the end, our call. Then, provide a “likelihood statement” that attainment will be successful – reminding oneself that the relevant time-frame in Utah is one year. Here, again, offering an “ultimate opinion” need not be black and white. We will discuss more… Then, give an opinion as to the TYPE(S) of intervention(s) that would be expected to be helpful given the types of deficits. Keep this broad – avoid prescriptions. The universe of possible interventions is not always available! Want this recommendations to be reality based and able to be followed. The more specific, the more problems may ensue. e.g., The Court does not have the authority to order what you are prescribing should happen. Again, here, some final disclaimers: Pointing out that research on this issue is limited and there is little if any empirical basis for reaching an opinion. Still, clinical judgment is possible. Problem with risk assessments in the days before good risk research – opinions often offered as “scientific” Here, we are asking you to be clear with the Court. It is scientific based on the sense that the opinion was formed by clinical knowledge. NOT scientific in any way beyond that. This is honest; allows both sides to argue; allows the Court to make the appropriate determination about the admissability of your opinion, as well as how much weight to put on it. 2) Another reminder that, hey your honor, ultimately you have to make the call.

38 Evaluation Data Explanation of Evaluation Procedures and Process
Interview(s) of Juvenile Assessment(s) of Juvenile Parent Report Legal Information Additional Information Now, we turn to the data that supports the opinions that were offered on the front end. We begin by telling the reader how this information was obtained. Remember – must be detailed enough to allow the court to reach independent conclusions. Interview(s) of Juvenile – When did the interview(s) occur; where conducted; how long did they last? Assessment(s) of Juvenile – What assessments tools were administered by examiner – FAIs? Psych Testing? Others? When administered? Parent Report – Remember, Parent Report (or Guardian Report) seen as a non-mandatory collateral data source in adult CST evals. With juveniles, unless unavailable or very strong reasons not to, obtaining parent report in some manner is typically considered essential. May include interviews – when? Where? How long? May include assessment tools – what tool? When administered? Remember to name each informant and indicate how they are related to the juvenile – parent, grandparent, foster parent etc. etc. Legal Information Also generally essential to access legal information – for example, what are the charges? What is the legal peril? Etc. Two main sources of information: Records – what type? Date on the record(s)? Interviews with legal personnel (attorney; PO; detention staff?) – who? When? How long? Additional Information Three additional types of information often accessed: School. Mental Health. Social Services. May be others (e.g., medical) For each, same two ways to access information, generally: Records – What type? Date? Interviews – Who? When? How long? Again, given limited time-frames, extremely common to have your report come due before you have accessed all of the information you have sought. There may be some cases where a piece of critical data is lacking and you deteremine that you cannot reach an opinion without that data. Have to work that out according to local statutes and norms – but there should be SOME way to deal with it. My experience is most courts respect getting a letter saying no report because information is lacking. Even better, is to submit a report with what CAN be said at that point, and what cannot, then making clear what is needed to finish. In other cases, you may feel you have enough information to reach an opinion – and it seems unlikely any new information will change the opinion. Still should tell court what is out there that you wanted but couldn’t access. Even if you have decided you can form opinions, the absence of the information may limit your evaluation in some manner. e.g., don’t know anything about pregnancy and early development. Don’t know anything about a discrete period in the youth’s life. Unable to confirm or disconfirm his history of placement in special education. Unable to access past IQ tests to compare to the current testing. Still – it is ALWAYS possible that new information will contain game-changing information – suggest indicating that were the information to be obtained and were it to change the game, you will notify the court in some manner – addendum probably the best way.

39 Evaluation Data Statement of Forensic Warning
Forensic Evaluator vs. Traditional Mental Health Prof Court is the client. Recipients of report. Juvenile and Family not recipients Report will be used to help determine Competency Court and/or DHS could use in other ways. Evaluator may testify in court Juvenile’s statements cannot be used to incriminate Mandatory reporting requirements Right to refuse participation despite mandatory evaluation Participation assumes assent to be audio or video taped Creating a legal record of what the youth (and others) were told at the outset. Can become a point of argument in the proceedings.

40 Evaluation Data Statement of Forensic Warning
Best Practices are not just to offer the Warning – but to assess their understanding Not because you won’t conduct the evaluation interview if they don’t understand. You may. Or you may call defense attorney with concerns. But if you proceed, assess to: Provide the court with information about what the youth understood so any statements made by the youth can be put in the appropriate context. Because this is data directly relevant to the question of competency. Assessment: Best Practice – first ask open ended question. “I just told you a lot about this evaluation. Can you explain it back to me using your own words?” If not clear they understood based on reply, can ask follow up questions. Open ended. Forced choice, etc. Progressively narrow. Statement about whether the youth agreed to participate – remembering that they have the right to refuse. Best Practice – have the youth and an adult that accompanied them sign a form stating that they agreed to participate. Creates a written record of decision. Identify anyone who was present during the Warning and can attest to it.

41 Evaluation Data Pertinent Developmental & Psychosocial History
Family History Developmental History Trauma History Medical History Academic History Psychosocial History Behavior History Delinquency History Mental Health History This is your Background Information section. Like to use the word “Pertinent” to remind the reader – this isn’t necessarily comprehensive. Could be an invasion of privacy to include information that is not relevant to the task at hand. This is just the background information deemed relevant. Best Practice is to begin with a statement about your assessment of the validity of the data. “There was general consistency across data sources, so the information seems to be reliable and valid.” “Although the juvenile provided information that was discrepant from other data sources, the rest of the information was consistent. Therefore, information obtained from those other than the juvenile were given greater weight, and uncorroborated information provided by the juvenile was considered cautiously.” “The youth and his family provided information that was discrepant from all other data sources. Their reports must be interpreted with caution.” Point being – before you provide the facts you obtained in the evaluation, you are giving your assessment of the believability of those facts. Then you are free to provide the data as you have it. Goal is to decrease the risk of slipping into mixing data and opinions. “Although it was not believable, Johnny denied any past involvement in illegal behavior.” etc. Then the different domains. One way to do this. Certainly far from the only way. If you do it this way, likely to cover what is needed. But no reason can’t use another approach.

42 Evaluation Data Pertinent Developmental & Psychosocial History
For each domain, some suggestions are provided for information you may consider including here – again, a memory aide. Nothing more.

43 Evaluation Data Current Mental Status General Presentation
Psychomotor Activity and Speech Behavior Mood, Emotions and Affect Thought Process and Perceptual Issues Cognition and Intelligence Current Mental Status – your MSE Again, offer one way to organize the domains of an MSE. Not the only way. Again, offer data points to consider discussing within each domain. A memory aide, not a directive.

44 Evaluation Data Assessment of Response Style Psychological Testing
Past Testing Current Testing Then, in a separate section, a discussion of the assessment of response style. Based on statutory mandate that the possibility of malingering is addressed, felt a separate section would help the reader find that information. Might argue that this is part of the MSE and need not be separated out. That is a valid argument and not a problem! Then a Psychological Testing section. Another section that evaluators may not feel is necessary. May want to integrate it into Pertinent Developmental and Psychosocial History. Include testing done at school under Academic History and testing done by therapist under Mental Health History. Could include testing you did to assess behavior problems, say the BASC or CBCL, in the Behavior History. I have found, because Courts are very much used to working with interview data, and much less used to working with psych testing data, a separate section can help them think through the issues and digest it. Again – no one right way to do this!

45 Evaluation Data Competency-Specific Interview
Capacity to Understand the Nature of the Proceedings Against Them With a Reasonable Degree of Rational Understanding Consult with Counsel and Participate in the Proceedings Against Them with a Reasonable Degree of Rational Understanding 1. Capacity to Comprehend and Appreciate the Charges or Allegations 4. Capacity to Disclose to Counsel Pertinent Facts, Events & States of Mind 2. Capacity to Comprehend and Appreciate the Range and Nature of Possible Penalties, if Applicable, that may be Imposed in the Proceedings Against the Juvenile 5. Capacity to Engage in a Reasoned Choice of Legal Strategies and Options 6. Capacity to Manifest Appropriate Courtroom Behavior 3. Capacity to Understand the Adversarial Nature of the Proceedings 7. Capacity to Testify Relevantly, if applicable Now shift from the more general clinical data to the more specialized forensic data – in this case, CTP data. Obviously the primary source of this data for most evaluators and in most cases is the interview of the youth re: court issues. This may include a self-guided interview, use of a competency FAI, some combination of both. This should be specified here. Possible other information was used also – the CTP evaluation of another expert, on this case or a past case. A document that describes the juvenile’s behavior in court, An interview with the defense attorney, etc. As discussed earlier, there are many ways to organize this section. My own preference is to use this as an opportunity to be clear with the court that you understand and utilized the legal framework. Could use the two Dusky prongs. Could use the 7 abilities identified in statute. What we tried to do here is both. The two Dusky prongs as explained in Utah statute with the 7 abilities mapped onto them. AGAIN: No one right way to do this – this is just an approach I have found helpful for translating our work into the legal question the court is addressing.

46 Evaluation Data Competency-Specific Interview
For each domain, the template offers a few things: Some suggestions of issues to consider reporting about in that domain. Space to offer the data in narrative form. Space to offer a broad rating of the quality of the functioning on that particular domain. Pros of the global rating: Assists the evaluator to think about the Functional question in careful, step-by-step process. Offers a graphic – a profile – of the juvenile’s functioning across all the relevant domains. These both feed into forming an opinion for each Dusky prong and/or for CTP overall. Allows the reader to quickly get a sense of your opinion about functioning within each relevant domain. Cons of the global rating: Can be difficult to distill complex cases down to global ratings. Loses the information offered in the narrative. Encourages an overlt simplistic analysis by the reader. A good debate to have – for each evaluator to have. No rule about whether to include or not– or whether can’t be done differently. 5 point Likert Scale? 7 pt? Different anchors? Etc. One point is essential – the global rating should NEVER be offered in lieu of the narrative explaining the data that supports the rating. NEVER!


48 Evaluator Challenges in Juvenile Competency Evaluations
Attainment Recommendations Now let’s turn to the second major area we want to discuss today.

49 Juvenile Competency Evaluation Model (Grisso, 2003)
Functional Are there deficits? Causal What is their cause? Contextual How will any deficits impact this defendant in their case? Conclusory Are the deficits adequately impairing to meet the legal test? Remedial (Attainment) Can the deficits be remediated? Let’s return once again to Grisso’s model for juvenile competency evaluations. Let’s recall that after the opinion regarding CST is formed and offered, unless it is very clear the youth is competent, a remediation opinion is needed. In it’s most basic form, the question being asked is “Can the deficits be remediated?” Or rephrased even more pragmatically, “Should the Court order Attainment Services for this youth?”

50 Breaking Down the Remedial (Attainment) Question
What deficits were identified during the evaluation that yielded the opinion of incompetence? What is the identified cause(s) of each deficit? What intervention(s) offer the best possibility of remediating those deficits? How long is successful intervention expected to take? How does that fit with statutory time-frames? What is the likelihood of successful attainment of each deficit? What is the overall likelihood of successful attainment? It’s helpful to break that question down into sub-questions. Each evaluation requires the evaluator to walk through these questions and answer them in turn to offer opinions that will assist the court. The first two questions are taken from earlier stages of the evaluation: What deficits were identified in the evaluation? (the Functional question) What is causing each deficit? (the Causal question) Then we move into the core Remediation questions (read each aloud)

51 Data Useful in Answering the Remediation Questions
The Clinical and Empirical Literature The Youth: Current Functioning Past Response(s) to Intervention(s) The Nature of Available Attainment Services

52 Data Useful in Answering the Remediation Questions
The Clinical and Empirical Literature

53 Clinical Literature Juvenile Competency Remediation
Certain sources of CST deficits decrease the likelihood of successful attainment: Normal Developmental Immaturity Delayed Development Disorders That Are Less Responsive to Treatment Intellectual Disabilities Autism Disorders That Require Long-Term Interventions Posttraumatic Stress Disorder Receptive & Expressive Language Disorder Grisso, 2005 Otto et al., 2006 Schouten, 2003

54 Clinical Literature Juvenile Competency Remediation
Successful attainment may depend on the area(s) of deficit: Factual Understanding deficits generally more remediable Appreciation, Assisting, and Decision-Making deficits generally less remediable Grisso, 2005; 2013 Peterson-Badali & Abramovitch, 1993 Viljoen & Grisso, 2007 Viljoen & Roesch, 2007 Understanding – Overlearning through repeated exposure has decent likelihood of success even with lower functioning youth Appreciation, Assisting, Decisionmaking – Fostering the development of higher order cognitive abilities (e.g., better abstraction) is highly challenging. This is NOT to say impossible – just more challenging!

55 Empirical Literature Juvenile Competency Remediation
~ 70% Returned to Court Competent Success may depend on: Source of deficits: Mental Illness % Intellectual Disability % Both % Age: Younger Adolescents % Middle Adolescents % Older Adolescents % McGaha, Otto, McClaren & Petrila, 2001 Warren, DuVal, Komarovskaya, Chauhan, Buffington-Vollum & Ryan, 2009 70% deemed competent – actually, 71% and 72%, respectively Why older adolescents less likely than middle adolescents? Most likely more likely ID or more serious MI! THE STUDIES (if need to discuss) McGaha, Otto, McClaren & Petrila (2001) N=471; all Florida juveniles found IST from 5/1997 – 8/2000 and referred to their “Attainment” program Did not include juveniles tried as adults nor juveniles charged with misdemeanor level offenses. Restoration time period: 5-6 months, average. Warren et al. (2009). n = 563; the first Virginia youth ordered to the Virginia Juvenile Competency Program – 1999 – 2006.

56 Empirical Literature Juvenile Competency Remediation
“…developmental and maturity issues that are often focused upon in the discussions of juvenile competence are not as insurmountable as previously thought.” “…many young juveniles can be remediated in their competence- related abilities if they are provided developmentally tailored educational processes provided in the context of a consistent relationship with trained restoration counselors who meet with youth multiple times a week…” “…when the youth suffers from mental retardation, at times combined with severe mental illness, the impact of the interventions is far more limited…” Warren, DuVal, Komarovskaya, Chauhan, Buffington-Vollum & Ryan, 2009

57 Empirical Literature Juvenile Competency Remediation
Studies of time-frames Very brief interventions are rarely successful Cooper, 1997 Viljoen, Odgers, Grisso, & Tillbrook, 2007 Four-Month to Six-Month Period seems Essential: Most youth ordered for attainment successfully attained by 6 months If did not attain by 6 months, likelihood of success drops markedly McGaha et al., 2001 Warren et al., 2009

58 Empirical Literature Child & Adolescent Treatment
Review the treatment literature for the disorder or symptoms causing deficits. But Remember, Successful Attainment Does Not Require: Complete remission of relevant symptoms Complete cure of relevant disorders Only adequate improvement to be competent. Sometimes that will mean targeting the underlying disorder causing the deficit (e.g., psychosis) – but the goal is still to “improve communication,” not “make non-psychotic.” In some cases the two will be one and the same – in other cases they will not. For example, if the defendant has particular deficits in Assisting Counsel caused by language problems, the examiner should consider interventions that would specifically address those language problems. Journal of Clinical Child and Adolescent Psychology (Division 53 Journal) Great 10 year review articles: Evidence Based Psychosocial Treatments for… ADHD, Anxiety Disorders, Depression, Autism, OCD, Trauma Last special issue on this was in 2008 – so beginning to be dated – but still a great place to start. American Academy of Child and Adolescent Psychiatry periodically publishes and updates Practice Parameters for various childhood disorders. Covering issues such as ADHD, CD, ODD, Autism, PTSD, Schiz, Bipolar, etc etc These are available free on their website. Understanding the literature can inform you about the types of interventions now supported in addressing the disorder in question. That allows you to assess the likelihood that type of service can actually be accessed. And allows you to have some sense of the time-frame that is typical for symptom alleviation. I am reminded of a case where the remediation issue came down flat on these types of issues. 14-yo boy with LD who had accidentally shot his best friend fatally after they found a gun in the house. Watched him bleed to death. Had very clear PTSD from the incident and became extremely emotionally dysregulated whenever faced with thinking about the incident. Also had poor foundational knowledge of the court, but court was now wrapped up with the incident and also made him dysregulated. Research has shown that TF-CBT, for example, often yields improvement within a 3-4 month course of treatment. Explained that treatment of PTSD would need to precede typical remediation efforts – so 3-4 months, then begin remediation. Expected traditional remediation would take another 6 months – probably longer since discussion of the case is a trigger for PTSD symptoms. Was able to provide fairly detailed expected treatment course.

59 Data Useful in Answering the Remediation Questions
The Youth

60 Youth Factors to Consider in Answering Remedial Questions
Youth’s Current Functioning Developmental Status Current Mental Health Symptoms Current Mental Status Youth’s Response to Teaching During Evaluation Youth’s Past Response to Relevant Interventions Pharmacological Psychotherapeutic Educational A careful analysis of how the youth is functioning at the moment and what has and has not worked to improve functioning the past

61 Data Useful in Answering the Remediation Questions
Available Attainment Services

62 Types of Attainment Interventions
Pharmacological The “Psychotic Adult” Model Goal: Remission of symptoms causing deficits Less Straightforward with Childhood Disorders Psychotherapeutic Less Common Model with Adults May augment or replace pharmacology There is a literature – should be consulted However: Target in literature is not competence Let’s begin by thinking about the type of attainment interventions that are possible. Pharmacological: Target the symptoms causing deficits with medications. The traditional approach with psychotic adults. Fairly straightforward and frequently successful. Less straightforward with childhood disorders – ADHD, Anxiety/Dep, etc. Psychotherapeutic: Target the symptoms causing deficits with psychosocial interventions. To reiterate what we said before - there is a literature – need to consult it. May also want/need to consult Child Psychiatrists and Psychologists who typically treat the issues at hand. But remember that the benchmarks for typical successful treatment may or may not be the same as those for becoming competent.

63 Types of Attainment Interventions
Educational The “Mentally Retarded” Adult Model Goal: Teaching of skills to alleviate deficits More Widely Applicable with Youth Types of Educational Curricula: Traditional Training Curricula Criticized for focus on memorization of facts 21st Century Training Curricula Multi-Modal and Active-Learning Techniques Systematic and Explicit Instruction Focus on Development of Specific Skills Abstraction Skills with Cognitive Acceleration Communication Skills Training Social Skills Training Educational: Education often a component of Attainment efforts even with psychotic adults, but classically used with cog limitations With adults, research suggests moderately effective. Applicable in cases beyond MR > milder IQ deficits, LD, weaknesses in communication, memory, executive functioning. And of course, developmental-based interference. Historically, educational programs have focused on rote repetition of facts. No research on efficacy with these curricula with youth. However, both experts and courts have agreed that rote memorization of facts is less adequate than ability to meaningfully participate. Goal for the future is more sophisticated approaches: TO TARGET UNDERSTANDING: Multimodal interventions; active-learning techniques > yield deeper process of the information than “chalk-n-talk” Simulations; mock trials; case studies; stories; games; courtroom visits My Cousin Vinny Systematic and Explicit Instruction – From special education literature Knowledge and skills are broken down into smaller subcomponents and re-linked after they are mastered Begin with frequent use of prompts and visual aides – over time, prompts and aides are reduced and eliminated. Enhancing the development of focused skills. Abstraction skills with Cognitive Acceleration (see Adey & Shayer, 2002). Initial Instruction on vocabulary and concepts Problems are offered that challenge their thinking Problems are solved in small groups – encouraged to reflect on their thoughts as they solve. Some evidence it works in general pop with general skills – typically requires 1-2 years of instruction! Communication Skills Training – brief interventions (e.g., Lamb, Bibby & Wood, 1997 – a 12-week program) Social Skills Training – (Spence, 2003 – modeling, role-playing and rehersal; feedback; self monitoring; social problem solving; self-regulation) Very little of this out there and no research on it specific to CST attainment.

64 The “Development Dilemma”
What should be done with youth who need to “grow up” to become competent? Courts torn on how to handle Some courts allow dismissal of charges Some with prejudice Some without prejudice Some courts continue for extended period, allow the youth to grow up, and revisit after Unique complexity of these issues in Utah As Grisso has said, trying to develop Appreciation skills in a youth who has not yet developed abstraction skills is a bit like trying to get an infant to learn to walk before it has begun to sit up or crawl. UTAH: Developmental Immaturity is not recognized as a basis for IST. Still, some youth found IST will have Developmental Immaturity as a contributing factor. e.g., 12-yo with severe untreated ADHD It may be that if the ADHD is successfully treated, the youth will still function poorly re CST because of young age. BUT, since young age is not recognized, this youth is now legally CST. That is, now that the legally recognized predicate for IST has been resolved (the ADHD), there is no longer a legally recognized predicate. So – competent! Becomes much more complicated when we think about more stable, less treatable clinical concerns. 12-yo who has BIQ. Both are contributing. Really no way to tease out where, exactly, the impariments from BIQ end and the impairments from young age begin. Don’t see much option beyond considering “impairments due to a complex and difficult to specify interaction of young age and BIQ” The Utah statute has set up dilemmas like this – and it may take actual cases and possible even appellate cases to resolve.

65 Answering the Remediation Question
The Analysis The goal of the analysis is essentially to conceptualize a basic attainment program and assess the feasibility of its components You are trying to match the needed interventions to the deficits the youth has demonstrated. In other words – what interventions are expected to be the most effective for the specific types of deficit this youth is showing.

66 Analysis of the Remediation (Attainment) Question
What are the specific functional deficits? Factual Understanding Rational Appreciation Assisting Counsel Legal Decision Making What are the sources of those deficits? A treatable mental disorder Weak cognitive skills (normal &/or pathological) Weak psychosocial skills (normal &/or pathological) What types of interventions are most likely to help each deficit? Psychiatric Interventions Psychotherapeutic interventions Educational Interventions How long is intervention expected to require for each deficit? How did youth respond to training efforts during the evaluation? How has youth responded to similar interventions in the past? What does empirical and clinical literature suggest? As with all good treatment plans, restoration services should use a “matching paradigm.” Interventions should be matched to the problem that is being targeted

COMPETENCE DEFICIT SOURCE(S) OF DEFICIT POSSIBLE INTERVENTIONS NEEDED / AVAILABLE TIME-FRAME LIKELI-HOOD OF SUCCESS Poor Appreciation of the Roles of Courtroom Personnel  Poor abstraction skills from young age and Borderline IQ Repeated and Multi-modal teaching of concepts and discussion Need: 6 months to 1 yr Available: 6 months to 1 yr.  Moderate Poor Legal Decision-Making Inattention and Distractibility from untreated ADHD Pharmacological intervention; Focused training in weighing advantages and disadvantages of decisions Need: 3 months High Poor Ability to Engage in Functional Conversations with Attorney  Verbal processing and expression deficits from Mixed Receptive and Expressive Language Disorder Speech and Language Therapies  Need: At least two months Moderate Poor Ability to Understand and Appreciate Plea Agreement Process  Poor frustration tolerance with learning new information related to Learning Disability  Progressive training in concepts related to plea agreements and repeated exposure until mastery is achieved Need: 3 to 6 months  High In formulating the attainment opinion this way, you are essentially using a matching paradigm to develop an attainment plan for the youth. Assessment of Needed Time Frame: Based on the literature, the youth’s current functioning (i.e., level of severity if impairment), and youth’s past response to interventions Clinical Judgment & Rough Estimates Necessary Should be framed by legally mandated intervals Legally mandated intervals: In Washington: 90 days > 90 days > 180 days > DONE In Utah: 6 months > 6 months > DONE In Washington, I would use 90 days as the benchmark. In Utah, I would recommend using 6 months.

68 Maintaining Objectivity
KNOW THE SOURCES OF PRESSURE SO YOU CAN SEE THEM CLEARLY AND MANAGE THEM EFFECTIVELY! Objectivity: Competency Attainment services are a big deal to a state and can cause a variety of pressures. When services are not filled, may be more pressure to send youth to attainment. When services are overwhelmed, may be more pressure to find youth unattainable. RESIST! Other ways threats can arise: * - CST Examiner is also involved in Attainment Services. May have financial interest in more clients. * - Some Attainment services may be delivered inpatient or in detention, and those facilities may resist these cases.

69 Answering the Remediation Questions
Communicating Attainment Opinions

70 The Forensic Mental Health Divide:
The Forensic Mental Health Divide: Bridging the Legal & Mental Health Worlds Differences of conventions Legal System > Definitive Statements Mental Health > Degrees of Certainty Different expectations regarding advocacy Attorneys advocate for an outcome Mental health professionals advocate for a conceptualization (opinions). !!!!!!!!!!!!!!!!!!!!!!!!!!!CONSIDER SKIMMING!!!!!!!!!!!!!!!!!!!!!!!!!!!!!

71 The “Ultimate Issue” Issue
Ultimate Issue = the court’s legal question Is there a substantial probability that the minor may attain competency in the foreseeable future? Ultimate Issue Issue = unresolved debate about whether forensic clinicians should answer it. Against For Answering is the domain of the judge because the answer is a legal, social, moral matter – not clinical The court is aware any opinion is only advisory. Some laws forbid these opinions Many laws allow and many judges demand these opinions Current science is not precise enough to answer these questions Science has advanced so that reasonable answers can be given !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!CONSIDER SKIMMING!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!! UI opinions -- Where law and MH run into problems. Courts want issues to be Black & White; mental health evaluations often identify Grays. Many prominent scholars train to NEVER give UI opinions. Others say can when the issues are crystal clear -- the legal criteria & the repsondent’s meeting of them. When board certified clinicians were asked of UI opinions should be given in 2003, 1/3 said always; 1/3 said never; and 1/3 said acceptable but not mandatory. Luckily, in this case, the phrasing of the question seems to invite some gray: “Likelihood” “Estimated”

72 Communicating Attainment Opinions
If may be found competent, use “if-then” statement Opinions based on clinical judgment Explicitly inform the court Remind yourself! Make Opinion Reasoning Explicit Detail different response estimates with multiple deficits Highlight the complexity when relevant Do your best to offer reasonable guidance… …but also be clear about the limits of what can be said Remember: Your interests Court’s interests “Low Probability of Success” may still be an adequately substantial likelihood “if-then” – If the youth is found not competent, then the following opinion regarding attainment services should be considered. Opinions are based on clinical judgment – very little research to guide the formation of opinions. Remind the court of this explicitly in the report. “These attainment opinions are based on the clinical judgment of this examiner, as there is little research available to guide these opinions.” Remind yourself of this! Be humble with your opinions. Your opinion may be wrong. Be open to that possibility and word your opinions accordingly. “It is possible that…” “It seems likely that” expressing certainty. Across my career I have been surprised in both directions. You will be too! Different response probabilities: “Whereas the youth’s Understanding deficits may be remediable through education, the Appreciation deficits seem unlikely to respond to attainment efforts.” Allows the court to use its own threshold of the importance of each deficit. Maybe the court sees an unattainable deficit as not critical! e.g./ Inability to testify – maybe the court is clear that testimony of the youth will not be needed. Make Opinion Reasoning Explicit: Court needs to know HOW you arrived at the opinion so it can assess its agreement with your approach. “It is my opinion that the likelihood of successful remediation in this case is moderate to high because the juvenile is in late adolescence, has relatively mild deficits in his intelligence that seem to be the source of his CST deficits, is described by teachers as able to learn some complex information when motivated to do so, and demonstrated some initial benefit from the minimal education offered during the evaluation interview. The main modality of attainment in this case will need to be education, as there was no evidence that mental health symptoms were interfering with his CST that migt warrant medication or other psychotherapy. With no need for medications, outpatient attainment services appear to be appropriate. However, given the beradth of domains that are weak in this case, it may take as long as six months or longer of weekly to bi-weekly meetings to obtain adequate functioning.” Highlight the complexity when relavent. More complex cases will inherently be more difficult to opine about. e.g., three disorders feeding into deficits. Can be unclear how they interact, etc – how Tx of one will affect another etc. Be clear about the limits – which may soemtimes mean saying “I don’t know” Sometimes the answer is ‘I can’t answer’ “Given the complex interplay of developmental issues and mental health symptoms, I am unable to state with any certainty the likelihood that remediation efforts will be successful.” Detail how the remedial opinion was reached Allow the court to form its opinion Remember the legal threshold for pursuing attainment in Utah is “substantial likelihood that the minor may attain competency in the foreseeable future” Court gets to decide what that threshold means. Courts are often reluctant to forfeit the opportunity to adjudicate without clear evidence that remediation is unsuccessful. Grisso (2013) noted that a finding that a youth is unremediable at the initial hearing is very rare nationally – usually will wait til first revie

73 Recommending the Least Restrictive Appropriate Setting
Psychiatric Hospitalization Only if treatment of clinical issue typically warrants it Detention Only if youth’s risk to community or potential to abscond warrants it Some Unique Scenarios Vast Majority of Youth Treatable in Community LRAS: Hospitalization is necessary only when the youth’s mental health status is that which would require hospitalization in other contexts. Detention is necessary only when the youth’s level of risk to the community or potential to abscond warrants it. Unique scenarios: Youth with ID whose home provides inadequate care and supervision may warrant placement in res facility for ID Youth with less severe mental health issues who may warrant day treatment or even residential Two available studies of juvenile attainment services in Florida (McGaha, 2001) and Virginia (Warren, 2009) found vast majority can be served on an outpatient basis. w

74 Forensic & Clinical Psychology
Contact Information Ivan Kruh, PhD Forensic & Clinical Psychology P.O. Box 1754 Ossining, NY 10562 PH: (845)

75 Opinions Guided by Evaluation Model
Functional What deficits, if any, were revealed by the CST interview responses and observations? How can the youth’s functioning during the evaluation be corroborated and conceptualized? Causal Are symptoms of a mental illness causing CST deficits? Are cognitive deficits causing CST deficits? Are developmental factors causing CST deficits? Are there “nonclinical” and “nondevelopmental” explanations for apparent deficits? Are there multiple causes of CST deficits interacting with one another?

76 Opinions Guided by Evaluation Model
Contextual Is the case being adjudicated in criminal or juvenile court? How complex will the adjudication be? In what ways? Do the defense attorney’s characteristics matter? Do the characteristics of the courtroom matter? Do the youth’s caregivers make a difference? Conclusory Is an ultimate issue opinion appropriate? Is there additional guidance that can be offered to the court? UI Issue: Policy decision or individual practice decision. Can depend on whether the questions and thresholds feel well-clarified. Can depend on degree of pressure from legal system. Advised to be extra cautious in Juv-CTP because usually key questions remain unanswered (e.g., developmental) If do give UI opinion, good to include a statement that the opinion is advisory only. Additional Guidance: Factors outside traditional CTP that the court may wish to consider – e.g., cultural issues. Suggestions that can be made to improve the youth’s functioning, even if opine competent (e.g., frequent breaks; “check-ins” from defense counsel)

77 The “Ultimate Issue” Issue
Ultimate Issue = the court’s legal question Is he competent to stand trial? Ultimate Issue Issue = unresolved debate about whether forensic clinicians should answer it. Against For Answering is the domain of the judge because the answer is a legal, social, moral matter – not clinical The court is aware any opinion is only advisory. Some laws forbid these opinions Many laws allow and many judges demand these opinions Current science is not precise enough to answer these questions Science has advanced so that reasonable answers can be given SKIP THIS SLIDE UNLESS THEY WANT IT COVERED! UI opinions -- Where law and MH run into problems. Courts want issues to be Black & White; mental health evaluations often identify Grays. Many prominent scholars train to NEVER give UI opinions. Others say can when the issues are crystal clear -- the legal criteria & the repsondent’s meeting of them. When board certified clinicians were asked of UI opinions should be given in 2003, 1/3 said always; 1/3 said never; and 1/3 said acceptable but not mandatory. I have come to the conclusion that, actually, whether or not one offers or avoids the UI opinion is irrelevant of the evaluation is done well. If the evaluation has carefully analyzed the functional, causal, and contextual questions, the Conclusory opinion should be fairly obvious. If refuse to provide it, the reader will still know. If offer it, adds little. This is not to say that the Conclusory opinion is always black and white. Sometimes what is clear from the earlier analyses is that the issues are complex, or not straightforward. In such cases, one can say that the Conclusory opinion is “I don’t know.” Or, if the opinion hinges on how the Court interprets certain issues, that can be made clear with an “If/Then” opinion. “If the Court deems it appropriate to consider his capacity to testify as applicable in the instant case, then it is my opinion that he is not competent. “If the Court deems it appropriate to consider his capacity to testify is not applicable, then it is my opinion that he is competent.”

78 Opinions Guided by Evaluation Model
Remedial (Attainment) Can any of the deficits be remediated? What interventions can remediate the relevant deficits? Where and how can the appropriate remediation services be accessed? How long is successful intervention expected to take? Remedial – or, as you call it in Utah, Attainment. But, basically, restoration models based on adult services often inadequate – medication-based targeting psychosis. Services that target MR ISTs probably comes closer. Teaching based – and can be expected to take longer than with adults. Sometimes the answer is ‘I can’t answer’ “Given the complex interplay of developmental issues and mental health symptoms, I am unable to state with any certainty the likelihood that remediation efforts will be successful.”

79 Model Attainment Services
Florida (Established 1997): Juvenile Incompetence to Proceed (JITP) Program Outpatient Services: Statewide Network of Independent Providers Meet with Clients up to 25 hours/month Services Tailored to Youth Needs Psychoeducation Groups/Medication/Case Management/ Counseling Inpatient Services: Secure Juvenile Forensic Facility Psychiatric, Psychological & Medical Assessments/Treatment 50-Minute Competency Training Class, 5 Days/Week Lectures / Videos / Games / Mock Trials FLORIDA: Psychoeducational groups re: legal system; meds; case management; counseling. Typically outpatient services across the state. Inpatient available as needed.

80 Model Attainment Services
Virginia (Established 1999): Virginia Juvenile Competency Program (VJCP) 100% Community-Based Services: Specially Trained Counselors Travel to Youth Average: 3 Sessions/Week for 90 minutes each Individualized Psychoeducation Based on Set Curriculum, including Interactive CD-ROM Role-Playing & Practice of Decision-Making Case Management Mentoring VIRGINIA: 100% in community, delivered by contractors. Individualized Psychoeducational interventions: interactive education tools, case management, mentoring. Consider discussing Washington as an anti-model! 100% inpatient restoration – much resistance to outpatient…! Tears kids from home settings. Hospitalizes kids with limited psychiatric need. Wastes precious bed-space, etc etc.

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