Session 55:
Advancing Intensive In-Home Treatment Practice: Clinical
innovations, practice frameworks and supports
Presenters: Joseph Woolston, MD,, Yale
University; Richard Shepler, Ph.D., PCC-
S, David Hussey, Ph.D. & Bobbi Beale,
Psy.D. Case Western Reserve University
Introduction
• Intensive In-Home Treatment (IIHT) is designed to address the complex needs of youth with serious emotional disabilities (SED) who are at risk of out of home placement.
• IIHT is implemented in most states and is an integral part of comprehensive continuums of care.
•The IIHT workforce consists mainly of entry level Master’s level clinicians who are asked to serve the most complex and highest risk youth and families.
•These novice clinicians need additional supports that include in depth training, intensive supervision, and practice frameworks that helps them prioritize interventions and strategies to best meet the presenting needs of youth and families.
INTENSIVE HOME-BASED TREATMENT PRACTICE FRAMEWORK: MATCHING STRATEGIES AND TECHNIQUES TO YOUTH AND FAMILY NEEDS
RICK SHEPLER, PH.D., PCC-S
BOBBI BEALE, PSY.D.
DAVID HUSSEY, PH.D.
CENTER FOR INNOVATIVE PRACTICES
BEGUN CENTER FOR VIOLENCE PREVENTION
Intensive Home-Based Treatment
• IHBT is an intensive, time-limited behavioral health treatment for children and adolescents with significant behavioral health challenges and related functional impairments in key life domains.
• IHBT incorporates a comprehensive set of behavioral health services which are delivered in the home, school and community, with the purpose of stabilizing behavioral health and safety concerns, for youth who are at-risk of placement due to his or her behavioral health challenges, being reunified from placement, or require a high intensity of behavioral health interventions to safely remain in the home.
3/21/2018
Intensive Home-Based Service Delivery Model
Location of Service Home and Community
Intensity Frequency: 2 to 5 sessions per week
Duration: 4 to 8 hours per week
Crisis response & availability 24/7
Active safety planning & monitoring Ongoing
Small caseloads 4 to 6 families per FTE; no mixed caseloads
(e.g. Outpatient & IHBT)
Flexible scheduling Convenient to family
Treatment duration 3 to 6 months
Systemic engagement and community
teaming
Child and family teaming; skillful advocacy;
family partnering; culturally mindful engagement
Active clinical supervision & oversight 24/7 availability; field support; weekly team
meetings
Provider credentials Licensed Behavioral Health Professional: MA
level preferred.
Comprehensive service array: integrated
and seamless; single point of clinical
responsibility
Crisis stabilization, safety planning, skill building,
trauma-focused, family therapy, resiliency &
support-building, cognitive interventions
Cu
ltu
rall
y M
ind
ful E
ng
ag
em
en
t
an
d F
am
ily P
art
ners
hip
sHome-Based Service Delivery
Modality
Comprehensive Treatment
Array Matched to Needs and
Strengths
Cross-System Collaboration
and Service Coordination
Multidimensional Assessment
IHBT Model ComponentsR
esilie
ncy-O
rien
ted
Dev
elo
pm
en
tal P
ers
pec
tive
6
Youth and Families with Complex Needs and Challenges
Youth
SU Disorders
MH Disorders
Family and
Neighborhood
Violence;
Neg. Peers
Trauma
Developmental Factors
(Risk & Protective Factors)
Safety Needs
System Involvement Stressors
(Lack of Support & Connection,
Demands, Pressures, Burden)
Resource Poor
(financial,
transportation,
housing,
supports)
Disparities; Service Access
Language Barriers
Family Stressors, Conflicts,
& Challenges
Multiple Risks Require Multiple Interventions (Sameroff, Gutman, and Peck, 2003)
•Interventions need to be as complex as the multiplicity of risk factors and contexts
•Most interventions in single domains have not produced major reductions in problem behaviors
Most youth experience risks across multiple social contexts
Interventions need to address all the social contexts in which the risks occur
8
Conceptualization Tools
Multidimensional Assessment
I. Diagnoses: youth who meet the criteria for Mental Health Disorder and related symptom manifestation
II. Developmental Functioning: (cognitive, emotional, & behavioral maturity)
III. Contextual Functioning: Individual functioning in relevant life domains, including risk and protective factors, and risk and recovery environments
IV. Safety and Risk Factors: Self and other harm, personal, family, and community safety
10
11
Age Developmental
Assets, Milestones,
and Successes
Significant Life Events
(Trauma, Family,
Legal, School, Peers,
Physical)
Mental Health
Symptoms
Substance
Use
Behavioral Health Timeline
Contextual Assessment and Treatment
School
Family
Peers Community
Informal Supports
+
+
+
+
-
- -
-
Work
+
-
+
-Youth
+ = Protective Factors
- = Risk Factors12 Shepler and
Baltrinic, 2006
Intervention and Conceptualization Strategies
Resiliency
promotion
Crisis and
Safety
Skill Building Cognitive Family Ecological
Strategic
accommodations
Safety
Planning
Emotional &
physical
regulation
CBT Structural Child and
family
teaming
Pro-social peers
& activities
Risk
assessment
Problem solving Trauma-
focused
Solution
focused
Cross-system
collaboration
Strengths
identification
Active
monitoring
Communication MI Behavior
management
Youth and family
supports
24/7
response
Conflict
resolution
Relationship
building
Linkage to
mentors
Crisis
stabilization
Supervision and
Monitoring
Trauma-
focused
Asset building Coping skills
Futures
orientation
Comprehensive Treatment Array
Comprehensive service requires integrative treatment framework
•Services and supports are matched to each family’s presenting needs, strengths and circumstances
•A family need hierarchy is utilized to assist in assessing and prioritizing the youth’s and family needs
•Strategies and interventions are matched to the most salient need, progressing to more complex needs once the primary needs are met
•What key factors if not addressed will lead to relapse or increased behavioral health symptoms or decreased functioning in a key life domain?
15
Integrated and Comprehensive Treatment Matched to Need
Wellness &Resiliency
Eco-systemic Functioning
Basic Skills and Coping
Basic Needs, Safety, and Stabilization
Youth and Family Need Hierarchy (Shepler, 1991, 1999)16
Resiliency
Reduce Risk
Environments and
Behaviors
Increase
Protective Factors
in Multiple
Environments
Risk and Resiliency Focus (Mannes; Shepler)
Safety is FoundationalSafe environments for recovery and resiliency promotion
Establish Positive
Connections &
Functional Success
through Relational
Supports & Strategic
Accommodations
Asset Building,
Futures Orientation,
and Meaningful
Contribution
Basic Needs,
Resources, &
Validation18
(Shepler, 2011)
19
Contextual Functional Analysis
Youth
SU Disorder
MH Disorder
De-stabilizing
Event or Trigger
Risks Factors, Skills,
Resources, and Supports
Trauma Filter
Exacerbating
Response Salient
Behavior/
Symptom
Dispositional
Factors
Contextual & Relational Dynamics:
Family, Peers,
School, Community
Safety
Issue
Escalation Cycle
© 2011, Shepler,
Center for Innovative
Practices
20
Adaptive Systemic Response
Youth
SU Disorder
MH Disorder
Remove triggers
Coping skills and strategies
Emotional regulation skills
Stress reduction
Remove trauma
triggers; Safe
environments
Adaptive,
supportive
response
Coping
response
Health & Wellness:
Mindfulness, etc.
Contextual & relational supports
Behavioral redirection
Change the environment
Pro-social activities
De-escalation Cycle
© 2014, R. Shepler,
Center for Innovative
Practices
Domain Priority
Concerns/ Needs
Barriers Strengths Plan
Individual
Home/Family
School
Community/
Peers
Risk &
Safety
Issues
IHBT Conceptualization and Planning
Workforce Development
• Comprehensive and ongoing training
• Weekly clinical consultation from model developer
• Intensive clinical supervision including field supervision
• Inform clinicians: collect and disseminate outcomes.
• Yearly fidelity monitoring
• Think of this as a post-graduate fellowship experience
IHBT core competency areas
• Family systems
• Risk assessment and crisis stabilization
• Behavior management for children/adolescents with SED
• Cultural & linguistic competence
• Cross-system collaboration and coordination
• Trauma-informed care
• Resiliency-oriented, developmentally focused
• Skill building
• Educational and vocational functioning
• Youth and family engagement and partnering
• Strength-based assessment and treatment planning
• Co-Occurring Disorders
• Ethics in IHBT
• IHBT Supervision
For more Information on IHBT
Bobbi Beale: [email protected]
David Hussey: [email protected]
Rick Shepler: [email protected]
3/21/2018
Intensive, In-home Child &
Adolescent Psychiatric
Service
(IICAPS)
Structuring IHBT to Promote
Quality Improvement
Conflicts of Interest/Disclosures
• Woolston:
– Woolston, J.L., Adnopoz, J., Berkowitz, S.
IICAPS: A Home-Based Psychiatric
Treatment for Children and Adolescents, New
Haven: Yale University Press, 2007.
IICAPS Partnership
IICAPS Providers:19 sites, statewide in CT
IICAPS Services:
-training
-credentialing
-quality assurance
CT State
agencies:
-DCF
-DSS
Families
and
Children
© 2009 Yale University, Child Study Center, IICAPS
Not to be copied without permission of author
-data evaluation
What’s the clinical problem?
Version I: 10/1/2010• Children, 4-18, who have serious,
persistent, multi-domain, behavioral & emotional disturbances
• Who display behaviors that are dangerous to self & others causing high risk for requiring institutional based care
• Who have frequent & multiple “co-morbidities”: Axes I, II, III
• And who live in…
© 2009 Yale University, Child Study Center, IICAPS
Not to be copied without permission of author
A Microsystem Characterized by
SED: “(MP)³ Syndrome”
• M-1: “Multi-problem” children with serious & persistent, out-of-control behavior that is dangerous to self and/or others
• M-2: Living in “multi-problem” multi-generational families
• M-3: Attending “multi-problem” schools and living in “multi-problem”neighborhoods”
© 2009 Yale University, Child Study Center, IICAPS
Not to be copied without permission of author
Parental
stress
Out of
Control behavior
Child emotional &
behavioral problemsInstitutional
service use
Problems in school,
neighborhood,
access to resources
Compromised
Parenting &
Family Management
Practices
Biological, other
vulnerabilities (eg
PDD NOS)
Vicious cycle of (MP)³
Family Domain
School/Environment
Domains
Parental
disability
Child Domain
Ecological Systems Theory
Social Learning Theory
Problem Solving
Training Theory;
Goal Setting, Goal
Striving
© 2009 Yale University, Child Study Center, IICAPS
Not to be copied without permission of author
IICAPS
• Intensive, in-home, relationship based tx, ecologically & family focused
• 2 person clinical team treats 8 families
• 3-4 teams in weekly Rounds co-led by CAP & senior mental health clinician
• Weekly team supervision: 15 min/case
• Manualized: Tools, Domains, Phases
• Funding: Medicaid, fee-for-service
© 2009 Yale University, Child Study Center, IICAPS
Not to be copied without permission of author
IICAPS Service Provision
• Team provides each family approximately
5 hours/week of direct and indirect
services
• Average max. LOS= ~6 months
• Services are provided wherever indicated
to maximize engagement & improvement
in microsystem functioning
• Documentation structures are Medicaid
compliant
IICAPS Theoretical Constructs
• Social Learning Theory ( Bandura) and its
clinical application, Parent Management
Training (Patterson; Kazdin)
• Ecological Systems Theory (Bronfenbrenner)
• Problem Solving Training (D'zurilla)
• Goal Setting/Goal Striving (Oettingen;
Gollwitzer)
IICAPS Interventions
Child Emotional &
Behavioral Problems
Out of Control
Behavior
Institutional
Service Use
Parenting skills
& practices
Parental
Stress
Environmental
Stressors
Intensive Care Management
Problem Solving Training
Problem Solving Training Parenting Skill Building
Mobile Crisis Intervention
Psychiatric Evaluation
& Psychotherapy
© 2009 Yale University, Child Study Center, IICAPS
Not to be copied without permission of author
Growth of the IICAPS Network
© 2010 Yale University, Child Study Center,
IICAPS. Not to be copied without permission of
author
372
579
974
1231
2069
22272340 2371 2309 2289 2246
39 71 100 116 127 140 145 145 142 144 141
14 16 18 19 20 20 20 20 20 20 190
500
1000
1500
2000
2500
20
07
20
08
20
09
20
10
20
11
20
12
20
13
20
14
20
15
20
16
20
17
Closed cases
# IICAPS teams
# IICAPS sites
Fiscal Year
IICAPS Network: Outcomes
Cases Closed between July 1, 2009-June 30, 2017
(FYs 09/10 – FY16/17)
N=17,082
Tx Completers (n=10,848; 67.5%)
Non-completers (n=5,216; 32.5%)
Evaluation Only (n=1,018)
© 2016 Yale University, Child Study Center,
IICAPS. Not to be copied without permission of
author
IICAPS Outcomes Measures
Child Emotional &
Behavioral Problems
Out of Control
Behavior
Institutional
Service Use
Parenting & family
management skills
Parental
Stress
Environmental
Stressors
Service Utilization
Questionnaire (SUQ)
Main Problem Rating
Ohio Scales:
Problem Severity
& Functioning Domains
© 2009 Yale University, Child Study Center, IICAPS. Not
to be copied without permission of author
Ohio Problem Severity:Paired T-test, IICAPS Intake and Discharge
(Treatment Completers; N= 10,848)
Proportional Decrease, Parent Report: 37.6% (p<.0001)
Proportional Decrease, Youth Report: 34.7% (p<.0001)
Proportional Decrease, Worker Report: 36.5% (p<.0001)
© 2016 Yale University, Child Study Center,
IICAPS. Not to be copied without
permission of author
33.5
26.2
31.8
20.9
17.1
20.2
0
5
10
15
20
25
30
35
40
PARENT REPORT YOUTH REPORT WORKER REPORT
Intake Discharge
Clinical cutoff = 20
Decreases in Ohio Scales Problem Severity
Scores over Eight Fiscal Years
for Treatment Completers
© 2016 Yale University, Child Study Center,
IICAPS. Not to be copied without permission of
author
37.5% 36.8% 34.9%
38.8% 38.4% 38.0% 38.2% 36.5%38.1% 37.8% 37.4%
38.7%
35.2% 34.2% 34.5% 32.9%
0.0%
5.0%
10.0%
15.0%
20.0%
25.0%
30.0%
35.0%
40.0%
45.0%
2010 2011 2012 2013 2014 2015 2016 2017
Parent Report Worker Report
Fiscal Year
Ohio Child Functioning:Paired T-test, IICAPS Intake and Discharge
(Treatment Completers; N=10,848)
Proportional Increase, Parent Report: 23.7% (p<.0001)
Proportional Increase, Youth Report: 11.1% (p<.0001)
Proportional Increase, Worker Report: 26.9% (p<.0001)
© 2016 Yale University, Child Study
Center, IICAPS. Not to be copied
without permission of author
39.7
52.2
38.2
49.1
58.1
48.1
0
10
20
30
40
50
60
70
PARENT REPORT YOUTH REPORT WORKER REPORT
Intake Discharge
Clinical cutoff for
parent report = 51
Clinical cutoff for
youth report = 60Clinical cutoff for
worker report = 51
Increases in Ohio Scales Functioning Scores
over Eight Fiscal Years
for Treatment Completers
© 2010 Yale University, Child Study Center,
IICAPS. Not to be copied without permission of
author
24.3% 24.1%22.2% 24.3% 23.4% 23.8% 24.2%
22.6%
26.5% 25.7%27.4% 27.1% 26.2%
24.7% 24.2% 22.9%
0.0%
5.0%
10.0%
15.0%
20.0%
25.0%
30.0%
35.0%
40.0%
2010 2011 2012 2013 2014 2015 2016 2017
Parent Report Worker Report
Fiscal Year
Main Problem Ratings & Scores
Defining Main Problem: co-construction of description of
behavior that puts child at risk for requiring institutional
treatment
Rating Main Problem: 10 point scale with behavioral
anchor points ranging from:
1 - Imminent risk of injury to self or others/gravely
disturbed
to:
10 - No disturbance
© 2009 Yale University, Child Study Center, IICAPS
Not to be copied without permission of author
© 2016 Yale University, Child Study
Center, IICAPS. Not to be copied
without permission of author
Main Problem Rating:Paired T-test Results
Measured at IICAPS Intake and Discharge
Mean Difference, Treatment Completers: 3.5 pts. (p<.0001)
Mean Difference, Non-completers: 1.2 pts. (p<.0001)
3.613.41
7.12
4.58
1
2
3
4
5
6
7
8
9
10
PLANNED DISCHARGES/ TREATMENTCOMPLETERS
UNPLANNED DISCHARGES/ NON-COMPLETERS
Intake Discharge
Imminent
Risk of Out-
Placement
No
Disturbance
Service Utilization Data
• Service Utilization Questionnaire (SUQ): created by the IICAPS developers
• Parent report; excellent validity when compared to claims payment data
• Administered at Intake to collect data on service utilization during the 6 months prior to IICAPS Intake
• Administered at Discharge to collect data on service utilization during the period of the IICAPS Intervention (time variable)
© 2009 Yale University, Child Study Center, IICAPS
Not to be copied without permission of author
Service Utilization Data: Number of
Patients with a Treatment EventTreatment Completers
Proportional Decrease, Pts w/Psych Inpatient Admission: 54.6%
Proportional Decrease, Pts w/ED Visit: 40.3%
© 2016 Yale University, Child Study
Center, IICAPS. Not to be copied
without permission of author
2873
3603
1305
2152
0
500
1000
1500
2000
2500
3000
3500
4000
PTS WITH PSYCHIATRIC INPT ADMISSION PTS WITH ED VISITS
6 mos prior to IICAPS Intake During IICAPS
Service Utilization Data: Total Days of
Psychiatric Inpatient StayTreatment Completers
Proportional Decrease, Days of Psychiatric Inpatient Stay: 65.6% © 2016 Yale University, Child Study Center, IICAPS
Not to be copied without permission of author
50977
17559
0
10000
20000
30000
40000
50000
60000
6 mos prior to IICAPS Intake During IICAPS
Decrease in Psychiatric Inpatient Admissions
and Days over Eight Fiscal Yearsfor Treatment Completers
© 2016 Yale University, Child Study Center,
IICAPS. Not to be copied without permission of
author
56.9%
70.0% 69.4%64.9%
70.4%67.4% 68.5%
61.6%
49.2%
57.6%
51.1% 50.8%56.3% 56.1% 56.7% 54.9%
0.0%
10.0%
20.0%
30.0%
40.0%
50.0%
60.0%
70.0%
80.0%
2010 2011 2012 2013 2014 2015 2016 2017
Inpt Days Reduction Inpt Admission Reduction
Fiscal Year
New Tool; New Data;
New Understanding• Important Childhood Events (ICE) 2014
• Semi-structured activity with parent
involving 20 questions about caregiver’s
experience during childhood:
– 10 questions of adversity (ACE)
– 10 questions resilience (RCE)
• n= 5,213 (4,241 birth parents)
• 80% completion across sites
42.4
37.2
29.6
38.8
17.8
54
28.2
46.1
40.8
23.1
0 10 20 30 40 50 60 70 80 90 100
Emotional Abuse
Physical Abuse
Sexual Abuse
Emotional Neglect
Physical Neglect
Divorce/Separation
Domestic Violence
HH Substance Abuse
HH Mental Illness
HH Member Incarcerated
ACE Items Endorsed
Percent of Families with Endorsed Item
44.7
38.9
31.5
42.3
19
56.4
29.9
47.9
43.7
24.6
32.5
29.5
21.5
28.2
12.7
43.9
20.7
38.1
27.8
16.6
0 10 20 30 40 50 60 70 80 90 100
Emotional Abuse
Physical Abuse
Sexual Abuse
Emotional Neglect
Physical Neglect
Divorce/Separation
Domestic Violence
HH Substance Abuse
HH Mental Illness
HH Member Incarcerated
ACE Items Endorsed - Birth vs Other Parents
Non-birth parents
Birth parents
Percent of Families with Endorsed Item
0
10
20
30
40
50
60
Emotional
Abuse
Physical
Abuse
Sexual
Abuse
Physical
Neglect
Emotional
Neglect
Divorce/Sep HH
Substance
HH Mental Domestic
Volence
HH
Member
Incarcerated
Endors
ed (
Per
centa
ge)
ACEs by Study - IICAPS Birth Parents Only Kaiser/CDC (San Diego, CA)
Urban ACEs (Philadelphia, PA)
Homeless Mothers of 4-6 y/o children
IICAPS - Birth Parents
0
10
20
30
40
50
60
No ACEs 1-4 ACES 4+ ACEs
Endors
ed (
Per
centa
ge)
ACEs by Study - IICAPS Birth Parents Kaiser/CDC
Urban ACEs
Homeless Mothers
IICAPS - Birth Parents
IICAPS: 2016
version 2.0• Intensive, in-home, relationship based tx,
ecologically & family focused, attachment informed
• 2 person clinical team treats 8 families
• 3-4 teams in weekly Rounds co-led by CAP & senior mental health clinician
• Weekly team supervision: 15 min/case
• Manualized: Tools, Domains, Phases
• Funding: Medicaid, fee-for-service
© 2009 Yale University, Child Study Center, IICAPS
Not to be copied without permission of author
Clinical problem (revised)
• But these children aren’t in isolation
• They live in families with multi-
generational trauma/adversity and in
broader microsystems with present and
historic compromised functioning at
multiple levels
• Consistent with Developmental Trauma
Disorder (van der Kolk et al, 2005, 2009)
© 2009 Yale University, Child Study Center, IICAPS
Not to be copied without permission of author
Parental
stress
Out of
Control behavior
Child emotional &
behavioral problems
Ineffective
Parenting:
Compromised
RF &
attachment
Institutional
service useParental coping
problems
Ohio Scales
SUQ
Problematic
social environ
Traumatization
Mal-
treatment
Parental
Hx Child
Maltx
Main Problem
ICE
Problematic
school environ.
IICAPS Theoretical Constructs
• Attachment Theory (Bowlby; Ainsworth; Main );
and its clinical application, Mentalizing (Fonagy; Steele; Steele; Target)
• Social Learning Theory (Bandura)
• Ecological Systems Theory (Bronfenbrenner)
• Goal Setting/Goal Striving (Oettingen;
Gollwitzer)
• Problem Solving Training (D'zurilla)
IICAPS Interventions
Child Emotional &
Behavioral Problems
Out of Control
Behavior
Institutional
Service Use
Parenting skills
& practices
Parental
Stress
Environmental
Stressors
Intensive Care Management
Problem Solving Training
Problem Solving Training Parenting Skill Building; Enhancing Reflective Functioning
Mobile Crisis Intervention
Psychiatric Evaluation
& Psychotherapy
informed by
Developmental
Trauma
© 2009 Yale University, Child Study Center, IICAPS
Not to be copied without permission of author
IICAPS Summary:
8 years of experience• Stat. & clin. significant improvements in:
• Ohio Symptom Severity
• Ohio Functioning
• Main Problem rating
• Stat. & clin. significant decreases in:
• Psychiatric hospitalization admissions and days
• ED visits for psychiatric reasons
• Parental childhood adversity is extremely
prevalent
© 2009 Yale University, Child Study Center, IICAPS Not to be copied without permission of author
What we’ve learned from our
research• 5 RCTs and 2 quasi-experimental design
studies of IHBT show trends indicating
efficacy
• Chronic school absenteeism is a
significant problem in IICAPS population
and may respond well to IICAPS
Next Steps
• Development & implementation:
– Family Cycle: a semi-structured, family activity
to enhance family acknowledgement of
impact of trauma & adversity;
– Clinician Observation Scale of Parental RF
• Latent Class Analysis of Treatment
Completers v. Non-Completers
• Exploratory Analysis of Relationship of
Goal Attainment and Ohio scores
Publications
• Barbot, B., et al. Changes in Mental Health Outcomes with the
Intensive In-Home Child and Adolescent Psychiatric Service: a
Multi-Informant, Latent Consensus Approach. Intern J Methods
Psychiat. Research. DOI:10.1002/mpr. 2015
• Moffett, S., et al. Intensive home-based programs for youth with
serious emotional disturbances: A comprehensive review of
experimental findings. Doi.org/10.1016/j.childyouth.2017.10.004
• Conway, C. A., et al., School functioning as an outcome in child
psychiatry: The effect of intensive home-based family therapy on
school absenteeism in a high-risk clinical population. Submitted for
publication
• Stob, V. et al., The Family Cycle: A Conceptual Tool for Clinicians
and Families. In preparation
Thank you
• IICAPS Services
– Liliya Katsovitch John Sayward, Cecilia Singh,
Joseph Woolston, Jean Adnopoz
• IICAPS Research Group
– Line Brotnow, Samantha Moffett, C. Andrew
Conway, Bridget Torres, Rebecca Kamody,
Kristen Pirog; Olivia Robertson, Jean
Adnopoz, Joseph Woolston