Rethinking Addiction

Rethinking Addiction

Missed Opportunities: Deconstructing Sandy Hook SAMPLE HEADER Note These blue bars on the left can be resized to fit as needed Goals To understand the events prior to the Sandy Hook shooting on December 14, 2012 where 20 students and 6 teachers were killed To identify how systems may be able to prevent these events from occurring in the future A comparison to what happened at Marjorie Stoneman Douglas High School What we can do to prevent these events from occurring

Basis of this presentation is from the Office of the Child Advocate, State of Connecticut Adam Lanza Born April 22, 1992 In late 1994 underwent first developmental evaluation and determined that he had a significant delay in social-personal development and the evaluator could not understand his language. Recommendation to attend a pre-school to stimulate in all domains 1995 began preschool and was given an Individual Education Plan (IEP). On the IEP they identified speech language and occupational therapy. He only received these services for a short while and family sought out an independent evaluation in 1997.

Adam Lanza Early Childhood In April 1997 they found that he may have Sensory Integration Disorder and he displayed many rituals Difficulties sleeping through the night Made up his own language Did not like to be hugged or touched Severe temper tantrums Teachers reported he was very quiet during group activities This prompted the school to complete their own assessment in May 1997 Adam Lanza Preschool In the May 1997 evaluation, they found that he had a significant discrepancy between expressive and receptive language (42 points difference). That he would not communicate in groups

That he had an auditory process problem had difficulty taking in auditory information and difficulty putting that information out They created an IEP and classified him as Speech and Language Impairment and with focus on expressive language and articulation and there was a strong indication that he may have Autism Services received focused on articulation and not expressive functioning He continued to struggle socially with his peers Adam Lanza - Elementary Move to Connecticut in 1998 part of this was because of job opportunity, part of this was to have a fresh start as they were having difficulties in their marriage Started first grade at Sandy Hook Elementary in September 1998 Adams brother reported that Sandy Hook was Adams life Reports from school is that he was hesitant to interact with friends, no

significant concerns were noted He continued to receive additional services for SLP, articulation, written expression, articulation and Occupational(OT) services for weak fine motor skills In second grade OT services were discontinued Adam Lanza - Elementary It was reported in second grade that his interaction had increase as he was paired with another student Mid year, his sensory goals were removed and only focused on articulation In third grade, continued to improve his articulation, however was reported as being very shy and unable to ask for his needs. It was also reported he was frequently ill We no longer received services in 4th grade, however it was noted the focus

was on articulation and not the expressive language issues Adam Lanza - Elementary An email that Mrs. Lanza wrote to the school May 2001, after IEP services were terminated: AL is a quiet, considerate child with a tendency to withdraw. He has made tremendous strides in your school system and has benefited from speech therapy. He does, however, tend to over focus on rules and can be very hard on himself as a result. This year has been a challenge due, in part, to a slight mismatch in teacher style and student style. I would like to take a moment to praise TEACHERS recognition of this problem, as well as her efforts to resolve the issue. I realize the difficulty of modifying a classroom approach to

accommodate an individual. ANOTHER TEACHER also has been very helpful in keeping ALs stress level at a minimum. I am hoping that next year AL will be placed in a classroom with a more casual feel to it. He responds well to a nurturing environment, and I would like his emphasis to be on learning rather than coping. He focuses on his work, enjoys structure Adam Lanza - Elementary A present day interview of a former classmate revealed that constructing, for a class project, a hand poem where he wrote loser and ugly on his fingers Grade 5 he transitioned to Reed Intermediate School (a school and 6th grades)

for 5 th Wrote a big with a fellow student called The Big Book of Granny. The book text was dramatic, and filled with images and narrative relating to child murder, cannibalism, and taxidermy Interestingly the co-author now has a mental illness and is living in a residential facility It is rumored that he attempted to sell the book for 25 cents Increase in sensory issues and phobias excessive hand washing as identified in a 2003 medical appointment for treatment of obsessive washing behavior Adam Lanza family Mrs Lanza health concerns frequently writing to friends (1999 moved to CT in 98) of her health

concerns and that she had limited time left. She reported to friends that she had MS. However, her autopsy revealed no evidence and there was no medical documentation of this diagnosis other than self report. In a July 1999 neurology medical report that all tests were unremarkable and that Mrs. Lanza was experience significant stress in her life related to her husband. The physician recommended psychotherapy. Parents separated in 2002, Adams 5th grade year Adam Lanza middle school He appeared successful academically, teachers did not identify that he was bullied or teasing him and described him as a shy, quiet boy, who listened and participated in class A neighbor reported: [He was] not connecting with anyone at all . . . he was not

bullied, however, he was just left alone . . . he never associated with others and when he got on the bus he would sit with his headphones and listen to music. [My daughter] tried to be nice by saying hi, but AL would not make eye contact with others. The same neighbor reported that she invited them for Christmas Eve over the years, but that the family only came one time. The mother came multiple times and reported that Adam was sick Adam Lanza middle school Attended Newtown Middle School for grade 7 It was during his 7th grade year that his emotional health began to deteriorate, culminating in his abrupt withdrawal from the middle school at the end of the third quarter, April 2005. No evidence of re-evaluation to keep him in school

He finished 7th grade at a Catholic School. In his 2006 evaluation, no exploration as to the motive of the transfer Adam Lanza middle school From one of his 7th grade teachers in a present day interview: [A]fter my years of experience teaching 7th-grade boys, I know how they are supposed to act. But I saw AL as being not normal with very distinct antisocial issues. AL was a very intelligent boy but he was also very quiet, barely spoke, and never responded to his classmates kindness of trying to help him fit in . . . . I also remember AL never wanting to participate in anything . . . . I truly do not believe that ALs parents were upfront with teachers about ALs mental capacities . . . . I remember giving creative writing assignments to students, instructing them to write a page or two on

whatever they wanted to talk about . . . AL would write ten pages obsessing about battles, destruction and war. I have known 7th grade boys to talk about things like this, but ALs level of violence was disturbing. I remember showing the writings to the principal at the time, ALs creative writing was so graphic that it could not be shared. Adam Lanza middle school In September 2005, Adams 8th grade year, mother took Adam to Danbury Emergency Room for a crisis evaluation Hospital records described him as anxious, withdrawn, and hesitant to be touched. He presented as agitated, hyper-vigilant, and overwhelmed with fear. The clinical consultation resulted in diagnoses of Anxiety Disorder, NOS;46 Rule out Asperger Syndrome; Rule out Autistic Disorder, followed by a discharge diagnosis of Asperger Syndrome and Obsessive Compulsive Disorder. Mrs. Lanza reported that her sole purpose was to obtain medical permission

to allow him to stay home from school indefinitely, the clinical team provided information to her regarding next steps for evaluation and treatment. Mrs. Lanza declined Adam Lanza middle school In the Fall of 2005, Adam began receiving psychiatric services by a local psychiatrist Interestingly, the psychiatrist did not initial remember Adam He reported that he saw him a total of 8 times individual and 1 or 2 times with his mother. Records reflect a total of 20 payments made to the psychiatrist, also a payment for a consultation with the IEP team over a 2 year period of time. Psychiatrist reported that Adam refused to take medications. Psychiatrist reported records were destroyed and did not have any notes or evaluations

Adam Lanza homebound Danbury Hospital gave mother a note excusing 3 days, the community psychiatrist penned a note that Adam should not attend school due to the lack of appropriate placement, and his mounting overwhelming anxiety Psychiatrist further wrote: has agreed to achieve competency in all academic subjects at home. At this point tutoring is not needed and could be viewed as counter- productive both academically and emotionally. School district completed an IEP in December 2005 and offered an evaluation which was declined. The IEP offered up to 10 hours of tutoring. No exploration of the detrimental effects was explored. No formal evaluation was documented in the file. In March 2006, psychiatrist provided a note to excuse Adam from state testing

Adam Lanza High School Adam attended Newtown High School in 2006 Mr. Lanza identifies that Adam is no longer close to his older brother October 24, 2006 was evaluated by Yale Child Study Center through fathers EAP services. Goal of the services was to treat Adams Obsessive Compulsive Disorder Mrs. Lanza was open to the evaluation, but wanted the community psychiatrist to be involved in the treatment planning Adam Lanza Yale Evaluation ALs mother told the Yale psychiatrist that he used to look at people but did not anymore. AL then asked rhetorically, Why should I have to. When the doctor explained all of the information

that a person could learn by looking at a facial expression, such as a smile, AL stated that people could interpret smiles differently: Some primates smile when they are frightened. Asked, What is a friend? AL replied, It is difficult to define -- in whose culture do you refer? Told ALs, he replied, I do not know. Asked whether he would like to have more friends, AL said no. The doctor noted that it was difficult to interpret ALs accelerated social withdrawal. However, the doctor considered that a plausible explanation might be that social engagement (largely focused on activities) in the middle school years makes relatively few demands for social sophistication . . . . As [ALs] peers moved into early adolescence and middle school, the demands of social engagement changed dramatically, leaving AL feeling more inadequate or ostracized, setting off a cycle of withdrawal and avoidance. Adam Lanza Yale Evaluation

ALs mother told the Yale psychiatrist that he used to look at people but did not anymore. AL then asked rhetorically, Why should I have to. When the doctor explained all of the information that a person could learn by looking at a facial expression, such as a smile, AL stated that people could interpret smiles differently: Some primates smile when they are frightened. Asked, What is a friend? AL replied, It is difficult to define -- in whose culture do you refer? Told ALs, he replied, I do not know. Asked whether he would like to have more friends, AL said no. The doctor noted that it was difficult to interpret ALs accelerated social withdrawal. However, the doctor considered that a plausible explanation might be that social engagement (largely focused on activities) in the middle school years makes relatively few demands for social sophistication . . . . As [ALs] peers moved into early adolescence and middle school, the demands of social engagement

changed dramatically, leaving AL feeling more inadequate or ostracized, setting off a cycle of withdrawal and avoidance. Adam Lanza Yale Evaluation The psychiatrist then goes further, emphasizing his own words in italics: Beyond the impact of OCD symptoms on himself and his mother, we are very concerned about ALs increasingly constricted social and educational world. Much of emphasis has been on finding curricular level of instruction. Inability to tolerate even minimal interaction with even older more mature classmates will have grave consequences for his future education and social and occupational adaptation

unless means of remediation are found. Inability to interact with classmates will prove increasingly deleterious to education. We believe it is very important to reframe the discussion with school from issues of curricular content to much more urgent issues of how to accommodate ALs severe social disabilities in a way that would permit him to be around peers and to progress, rather than regress, socially, as well as academically. The psychiatrist went on to say, Understandably, ALs parents have gone to great lengths to compensate for ALs hypersensitivities and social difficulties and aversions by providing home- bound instruction. However we believe that there is a significant risk to AL in creating, even with the best of intentions, a prosthetic environment which spares him having to encounter other students or to work to overcome his social difficulties. Having the emphasis on adapting the world to AL, rather than helping him to adapt to the world, is a recipe for him to be a homebound recluse, unable to attend college or work productively into his twenties and thirties and beyond with mother becoming increasingly isolated and burdened. Adam Lanza Yale Evaluation Finally, the Yale psychiatrist noted that the

family needed tons of parental guidance without that, any office based approach to his [challenges] will fail, certainly if it is without medication. Adam Lanza Yale Evaluation Mrs. Lanza email to Yale Psychiatrist: Thank you for taking the time to meet with AL yesterday . . . . I wanted to let you know that the options you presented are not going to work at this time. I would like to save you any further investment of your time. As I mentioned during the telephone conversation previous to our meeting, ALs OCD component is strongly tied to Asperger Syndrome and

he is adamantly opposed to medication. The OCD component is now based on superstition or in an effort to influence outside events or luck. I thought I had been clear that I was looking for individual intervention, perhaps some sort of behavior modification, for the Asperger Syndrome foremost, sensory integration disorder, and the two OCD like components that are impacting his ability to attend school. His refusal to take medication would make it impossible for him to be part of the study group and will just further agitate him. He was quite angry about the line of questioning that the interview took. As you might expect from an Asperger child, he had no understanding of the metaphors, and was quite disturbed by the fairy godmother scenario you gave him. You mentioned that the wait list for treatment for Asperger is quite lengthy, and that the study group was the alternative. However, participation in a study group, with the implied possibility of medication, will not be helpful in this case. So while I very much appreciate your effort, this is not the right course of treatment for him. The psychiatrist responded that given the reluctance other options can be explored Adam Lanza Treatment In additional emails by Mrs. Lanza she shared with

friends that she felt horrible and that Adam was frustrated, and angry and anxious and said that she felt like he was being tortured Despite that, the family agreed to services with an Advance Practice Registered Nurse (APRN) from October 2006 to February 2007 in the Pervasive Developmental Disorder group There is documentation of collaboration between the community psychiatrist and the APRN Adam Lanza Treatment In January, 2007, Mrs. Lanza wrote to the APRN to give her feedback on the most recent session. It was actually the best meeting AL has had with anyone. He was calm and conversational on the way home, which is very unusual. As far as

his comfort level it isnt just that he is painfully uncomfortablehe actually doesnt feel safe. He often tells me that he is frightened, even in our own home and obviously more so in public. I think it is the fear that paralyzes him. His father will be bringing him over on Thursday so that I can get a couple of hours off, but please let me know if you need any input or if anything needs to be followed up at home. Adam Lanza Treatment In February 2007, Mr. Lanza corresponded with the APRN that Adam did want to continue services. The APRN responded that the community agreed that she should stay involved for a while: not psychiatrist

The process of asking AL to talk with me directly about what is going on is critical. I appreciate that ALs view is that he wouldnt say anything differently if [the father] were in the room, but I think hes wrong. His judgment about how social/family dynamics work in a therapy situation is no more on target than his views regarding doorknobs and hand-washing . . . . He wants to control how the treatment goes because his anxiety is nearly unbearable if he cant feel he knows whats going to happen. I understand that. At the same time, he cant control the treatment because his thinking is distorted and irrational. I cant agree to follow his lead! In fact, when I talk with him alone he has to respond, and last time I pushed him a bit. I am not surprised that he was angry, thats OK . . . . I told AL he has a biological disorder that can be helped with medication. I told him what the medicines are and why they can work. I told him hes living in a box right now, and the box will only get smaller over time if doesnt get some treatment. Im fine to see him this week at 11. I am OK to talk with him and you at the beginning, but the session to address his issues has to be just him and me. Id do it differently if I thought it would help, but Im convinced it wont. Let me know your reactions.

Adam Lanza Treatment Around February, 2007, Mr. Lanza wrote to the APRN that AL seemed to making progress. Mr. Lanza recounted a recent outing to the arcade and the mall with AL, where AL was able to visit a number of different stores. Mr. Lanza wrote that AL ha[d] not wanted to do anything like that for over a year, and seemed to enjoy the outing. Mr. Lanza wrote that it appears the time that you are spending with AL may be paying off. Mr. Lanza said he would follow up with a new appointment date. In late February 2007, Adam agreed to take medications Adam Lanza Treatment The APRN also spent time talking to AL about why he needed

medication, and recommended a couple of books to him on Obsessive Compulsive Disorder. In later police interviews the APRN described ALs mothers response to her recommendations for medication as non-compliant. Immediately after prescribing the medication, the clinician received a call from the mother reporting that AL was unable to raise his arm. Mrs. Lanza stated that AL was attributing this symptom to the medication. An email from Mrs. Lanza to the clinic indicated that AL took the medication for three days. Mrs. Lanza wrote an email that AL experienced immediate and diverse symptoms associated with the medication, including decreased appetitive and nausea . . . dizziness . . . disorientation, disjointed speech, and sweating. She stated that he couldnt think. He sat in his room, doing nothing. The family then terminated services with Yale in agreement with the community

psychiatrist Adam Lanza Treatment In email documentation between January to March 2007 from Mr. Lanza, there were attempts to coordinate care with mental health professionals and the school district. There is no evidence the meeting occurred. In the IEP meeting in Spring 2007, Mr. Lanza inquired about specialized program for Adam. He inquired in May 2007 with the school district that he lived about programs there. The family also explored private alternatives, but ultimately decided not to place him Family ended treatment with community psychiatrist in early 2008 as evidenced by payment.

Adam Lanza High School 9th Adam began high school and agreed that he would have a slow process of re-introducing him into the school environment He continued to be homebound during the re-introducing process In an IEP in January 2007 (while receiving service at Yale) not mention of mental health issues and he was classified as Other Health Impairment There is evidence that he did go into the school, and at time worked in a small group setting Adam Lanza High School 10th Adam wanted to return to school as a typical high school student He reported his motivation was that he did not want to be defective

One of his request was to work with a trusted school employee: the head of security On August 26th, a note from a psychiatrist, covering for the community psychiatrist wrote a note that he was prepared and ready to attend Newtown High School as a full time student He was originally scheduled (8/27/07) to take Sociology, AP U.S. History, AP Chemistry, AP Physics, English, Math, and Latina plan which did not last beyond a few months. Adam Lanza High School 10th AL also joined the Technology Club at the start of 10th grade and his participation in this student group was a notably positive development. Records indicate that AL developed a good relationship with the clubs faculty advisor and that he was able, during this time period, to mix with the other students in

the club and participate in club activities. Certainly at this point, progress had indeed been made since the time when AL would not leave his house and attend school at all. Efforts to de-sensitize AL to his environment and manage his experience in the high school were having some positive effect and may have obfuscated the ongoing need for mental health support and consultation with the educational team. Adam Lanza High School 10th He will not accept any preferential treatment at all. Since he obviously NEEDS preferential treatment, it leaves me scurrying around behind his back fixing things i.e. The gym thing. I actually had to make up a story about liability, bureaucracy, and being out of school for over 12 months, etc. then I have to go to [school staff] and get her to back that up then I have to go to [another school staff], and get him to go along.

Then his teacher slips up and tells him that his IEP allows him to get out of study halls and I have to get her to recant and say it was a misunderstanding on her part. This is a high stress, 24/7 operation of misinformation. He does NOT have to go to lunch, but obviously I have to come up with a story that he will buy and then get everyone on the same page. Thanks for giving me the heads up [about lunch]. I will get on it first thing in the morning. I will think of something. He wants to believe that he is an ordinary student, and I think it is important to let him believe for his self-esteem. In February 2007 he dropped most of his mainstream classes Adam Lanza High School 11th For 11th grade her returned to homebound with 10 hours of tutoring per week His goal was to graduate at the end of the school year He had 11.5 credits at the beginning of the school year, he needed 20 to graduate

and he acquired 21 He did attend Wester Connecticut State University for independent study His GPA was 3.89 Adam Lanza Transition Federal law allow student to receive transition up until age 21 On his final IEP there was documentation of a Job Coach He did have a part-time job and in March 2009 the owner reported that Adam was cordial, professional and displayed expert attributes Adam Lanza Tech Club One youth from Technology Club later described AL in present day interviews as a quiet kid . . . somewhat anxious because of facial expressions and an upright posture when he walked . . . the

only odd behavior [that AL had] was pulling his sleeves over his hands any time he was handed an object from someone. AL wiped [the object] down with his sleeves before he would touch it. The same individual reported that though AL was quiet, he was also sociable as long as he was included in conversation. However, the individual stated that AL would not initiate social conversation. Adam Lanza Tech Club AL was described as quiet, but also very smart. When a question came up [AL] always had an answer. He was described as very smart in math, he typically had a pocket protractor, calculator, almost a stereotype of high school nerd. AL was described as wearing a green plaid button down short sleeved shirt over and over. One individual observed that while AL

participated in the Technology Club activities and parties, it wasnt clear if he had real friends to hang out with. One youth stated that no one appeared to pick on AL, that he tended to keep to himself, and no one had a problem with him at all. He was described by one individual as the smartest kid in tech club. Adam Lanza Tech Club The head of security at the high school was the advisor for the Tech Club and apparently asked some older students to watch out for AL because he was a little odd and very shy. The advisor wanted the other students to help AL socialize more. Former students did not remember AL being bullied or teased, but at least one individual stated that he wouldnt be surprised if [AL] was bullied or teased at high school. Additionally, at least one student stated that the Tech Club really did try to befriend [AL]. Tech Club had lots of odd members, but AL wasnt that

extraordinarily different at that time. He would laugh at the stuff we did or said, would occasionally make jokes with us in Tech Club . . . [AL] seemed to enjoy being with us. AL was observed to attend some of the Tech Club parties and was described by another youth as having a good time. Adam Lanza Tech Club A few former students noted that the Tech Club advisor had taken him under his wing and asked others to be kind and include him. The advisor was terminated from employment in 2008 and at least one former student speculated that this was the reason AL dropped out of school. Adam Lanza Final years fathers correspondence

Sept. 18, 2010: AL, I am very happy to hear from your mother that you are enjoying your classes. I hope that we can spend some time together soon, just let me know when you are available (even if only for a short period of time). Dec. 2, 2010:115 Hi. AL- I miss seeing you. I hope all is well with you. Let me know if and when you would like to shooting or go on a hike. June 16, 2011: AL-Please respond to this email if you like to go on a hike. It would be interesting to see the status of the demolition work on the peninsula in Bridgeport. July 13, 2011: Hi AL-Just a note to say Hi, Please confirm receipt. Adam Lanza Final years Nov.18, 2011: (Mr. Lanza to Mrs. Lanza) . . . I think you should tell [AL] that he should plan to see me once per month to do something (hike, cross country ski, shooting etc.) Nov. 15, 2012 (From Mrs. Lanza to Mr. Lanza): I will talk to him about that but I

didnt want to harass him. He has had a bad summer and actually stopped going out. He wouldnt even go to the grocery store, so its been pretty stressful. Yesterday was the first time in moths [sic] Ive been able to talk him into going to do his own shopping and his car battery was actually dead because it sat so long. I ended up spending most of the day getting it fixed and now I am going to have to start pressuring him to go out all over again. Adam Lanza Final years Parents officially divorced in 2009 He had no further contact with his father from 2010, however Mr. Lanza would email him 8-10 times a year to suggest getting together with just his father or with his brother. He was known as the Dance Dance Revolution kid at the movie theater. He would play alone or with a friend, but to 10 hours at a time The last documentation of being with a friend was summer of 2012 in which he got

into a fight with a friend over a movie Evidence that he was anorexic in 2008 he was 510 and weighed 112 lbs, the doctor prescribed Miralax for constipation. At death he was 6 ft and 112 lbs In 2012 Mrs. Lanza was planning to move to Washington or North Carolina, and that Adam would stay in an RV. Adam Lanza Final years Email evidence that Adam was actively suicidal during 2011 and 2012 He had an obsession with mass killings even having a printed list in his bedroom of the top 100 mass shootings recommendations Silos of care lack of communication between providers When a pediatrician does an actual measurable assessment it significantly increase the follow through on the referral

By asking special education teams to identify the right disability, there is a tendency to focus on that only issue and not look at the child as a whole. Is there a reluctance to serve youths social emotional learning needs in schools? Multiple treatment or service providers were involved and Adam and his family but there was no clear coordination of care or transition planning Adams family relationships and psychological state in adolescence Was deference to the family decision-making appropriate Did helping systems offer the right help The necessity of effective family engagement strategies Nikolas Cruz Parkland 2/14/18 Born 9/24/1998 Was adopted by Roger (61) and Lynda (49) at age 2 with his biological brother (2 months) Father died in 2004 at the age of 67

Mother died in 11/1/2017 at the age of 68 Nikolas Cruz Significant Facts 8/28/12 Cruz is suspended from Westglades Middle School, during that school year he had 26 disciplinary incidents 11/27/12 Cruz is 14, mother calls police due to attacking her with a vacuum 1/15/13 mother called because he threw her up against the wall he was receiving mental health services 2/6/14 was transferred to Cross Creek School and identified as EBD 1/13/16 was transferred to Stoneman Douglas HS began half time and transferred to full time regular classes 2/5/16 neighbor called police about Instagram post 9/20/16 suspended from school for fighting after breakup of girlfriend 9/24/16 Cruz turns 18 years old 9/28/16 reports that he cut himself and had ingested gasoline mental health

organization stated that he was at low risk to harm himself Nikolas Cruz Significant Facts 11/12/16 DCF closes case and determines he is low risk 1/19/17 was suspended from school for low assault 2/8/17 Cruz leaves Stoneman Douglas and enrolls in Off Campus Learning Center 2/11/17 Cruz bought Ar-15 one of at least 10 purchases after turning 18 9/24/17 report from a Mississippi man on YouTube that Nikolas Cruz stated he was going to be a professional school shooter 11/1/17 mother passes away from pneumonia/flu 11/29/17 Cruz was in a fight with the child (22) of the family he was staying with, the mother reported to police that he bought ammo, and she kicked him out of the house 11/30/17 he has moved in with the Sneads (younger brothers foster family) and a report to law enforcement about concerns that Cruz has guns 1/5/18 Another call to the FBI about Cruz owning guns

Reflective Practice Process Question (what, why, how one does things) Function within uncertainty and complexity Emphasize inquiry Hypothesize Suspends judgement Consider consequences Seek alternative keep an open mind

Validate what is given or believed Compare and contrast Synthesize and reset Seek underlying rationales Seek, identify, and resolve problems View from various perspectives Putting into context

Identify and test assumptions Analyze Put into varied contexts Evaluate Ask What if?? Use prescriptive models Adapt and adjust to instability and change Make decision in practice of the profession

Reflective Consultation: A Conceptual Framework for Research and Implementation Ann E. Bailey, M.A., Mary Harrison, Ph.D., Christopher L. Watson, Ph.D., and Karen Storm, Ph.D. Theoretical Approach to Supervision/Consultation:: DIRECTIVE Supervisor as expert Nature of the relationship between

supervisor, interventionist, and client: Interventionist as expert REFLECTIVE PROBLEM-FOCUSED Case Supervisor Interventionist Consultation

as as mentor with Peers mentor Client Supervisor as Reflective Partner Facilitated reflective case consultation

Interventionist as Reflective Partner Client Hypothesized change process between interventionist and client: Implementation Strategy: Knowledge-oriented: Heres what to do

Prescriptive: Guidance of expert Solution-oriented: Have you tried this? Problem-Solving: Exploration of solutions Multiple Perspectives-Oriented: I wonder. . . Mutual Curiosity: Exploring the meaning of behaviors to support reflective functioning and new patterns of interaction

The case presented here is an evaluation study made possible by the Affordable Care Act of 2010 as the creator of the Maternal, Infant, Early Childhood Home Visiting Program (MIECHV), with funding and administration from the US Department of Health and Human Services: Health Resources and Services Administration (USSDHHS/HRSA) and is being conducted in partnership with the Minnesota Department of Health. Adopting a Trauma-Informed Approach Traditional Perspective A youths challenging behaviors are the result of individual deficits (ie whats wrong with you?)

Understands difficult behaviors as purposeful and personal Focuses on changing the individual to fix the problem. Support for youth exposed to trauma is provided by counseling professionals Trauma-Informed Perspective A youths challenging behaviors may be ways of

coping with trauma (ie - what happened to you?) Understands difficult behaviors may be automatic responses to stress Focuses on changing the environment Support for youth exposed to trauma is the shared responsibility of all youth serving systems. Reflective Practice Process Traditional Perspective A youths challenging behaviors are the result of individual deficits (ie whats wrong with you?) Understands difficult behaviors as

purposeful and personal Focuses on changing the individual to fix the problem. Support for youth exposed to trauma is provided by counseling professionals Trauma-Informed Perspective A youths challenging behaviors may be ways of coping with trauma (ie what happened to you?) Understands difficult behaviors may be automatic responses to stress Focuses on changing the environment Support for youth exposed to trauma is the shared responsibility of all youth

serving systems. The Influence of Adverse Childhood Experiences Throughout Life Gun Injury Prevention Research Federal legislation passed in 1997 stated that none of the funds made available for injury prevention and control at the Centers for Disease Control and Prevention (CDC) may be used to advocate or promote gun control. The vague nature of this law, and its 2011 extension to the National Institutes of Health, has effectively prevented federal funding for firearms-related research. In 2013, following the Sandy Hook shooting, former President Barack Obama issued an executive order calling for the CDC to conduct or sponsor research into the causes of gun violence and the ways to prevent it. Despite this and without specific appropriations from U.S. Congress, new research proposals remain unfunded. After the federal legislation preventing firearm research, there were 25 percent fewer publications

on firearms compared to what would have been expected relative to other causes of death in children. In February 2017, the federal courts over ruled the law that passed in Florida in 2011 that doctors could not ask patients about gun safety In March 2018, a new spending bill clarified that the CDC can conduct research into gun violence but did not allocate specific funding toward this effort.

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    Layers. The sun's temperature decreases from core to surface. From the surface of the sun to the outer atmosphere, the temperature increases. The sun's layers are heated by convection. Layers (cont.) Layer/Zone. Temperature (°C) Core. 15,000,000. Radiative Zone. 8,000,000.