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Diverting Youth with Mental Health Needs from the Juvenile Justice System:
An Overview
National Center for Mental Health and Juvenile Justice
Mission
To promote awareness of the mental health needs of youth in the juvenile justice system and to assist the field in developing improved policies and programs based on the best available research and practice.
National Center for Mental Health and Juvenile Justice
Key Functions:
* Serve as National Resource Center
* Conduct Research
* Foster Policy and Systems Change
Funding:
* John D. and Catherine T. MacArthur Foundation
* Substance Abuse and Mental Health Services Administration (SAMHSA)
* Office of Juvenile Justice and Delinquency Prevention (OJJDP)
1. Large numbers of youth come in contact with the juvenile justice system.
* About 2.2 million youth under 18 were arrested in 2003
* Over 130,000 youth are placed in detention and juvenile correctional facilities
2. Research studies have found high rates of mental disorders among youth in the juvenile justice system
* Series of studies over the past 5 years have consistently found rates between 65% and 70%
* For approximately 20% of justice-involved youth the illness is severe enough to require immediate and significant treatment intervention
* Over half of these youth also experience a co-occurring substance use disorder
3. Many youth are being placed into the justice system because of the lack of community-based mental health services
* 36% of families report placing children to access mental health services (National Alliance for the Mentally Ill, 2001)
* 67% of incarcerated youth with high mental health needs were committed for non-violent offenses (Texas Juvenile Probation Commission, 2003)
* 2/3 of juvenile detention facilities hold youth unnecessarily because of lack of available mental health treatment (Congressional Committee on Government Reform, 2004)
4. Many youth with mental disorders could be, and should be, diverted to community-based services
“The Commission recommends widely adopting adult criminal justice and juvenile justice diversion and re-entry strategies to avoid the unnecessary criminalization and extended incarceration of non-violent adult and juvenile offenders with mental illnesses.” (The President’s New Freedom Commission on Mental Health, 2003)
Status of Diversion
* Long standing strategy within juvenile justice system for general population of youth
* Significant increase in jail diversion programs for adults with mental illness over the past decade
* Despite recent interest, little knowledge and few systematic efforts to foster diversion programs for youth with mental illness.
National Juvenile Diversion Survey
* Conducted by NCMHJJ with support from SAMHSA
* Partnered with NASMHPD and CJCA to survey state mental health and juvenile justice commissioners
* 230 programs responded with descriptions of their diversion programs
* Approximately half identified as “mental health focused programs”
* Telephone interviews and site visits used to identify promising diversion program models
Main Findings from Diversion Survey
* Mental health focused programs differ from general diversion programs in important ways
* A number of promising diversion program models exist
* There appears to be several critical elements that characterize promising diversion programs
* Diversion occurs at a number of key intervention points in the juvenile justice process
Eight Critical Elements of Mental Health Diversion Programs
* Established collaboration across juvenile justice, mental health, substance abuse and other systems
* Systematic assessment of needs of youth
* Clear and standardized procedures for defining and diverting youth
* Ability to provide or link to a range of services
Eight Critical Elements of Mental Health Diversion Programs (cont.)
* Significant family involvement
* “Boundary spanning” individual or strategy
* Stable and established structure and funding base
* Presence of evaluation process/outcome data
Key Points in the Juvenile Justice System for Mental Health Intervention
Program Examples
* Prime Time- comprehensive intervention model for youth in detention
* Crossroads Program- juvenile court program for youth with mental health and co-occurring disorders
National Center for MentalHealth and Juvenile Justice
Contact Information
* Website: www.ncmhjj.com
* Email: ncmhjj@prainc.com
* Phone (toll free) 1-866-9NC-MHJJ
Strategies for Developing Diversion and Transition Programs for Youth with Co-occurring Disorders in Washington State
Juvenile Diversion Programs and Mental Health Courts
GAINS TAPA Net Conference
October 11, 2005
Eric W. Trupin, Ph. D.
University of Washington School of Medicine
Professor & Vice Chair, Department of Psychiatry & Behavioral Sciences
Director, Division of Public Behavioral Health & Justice Policy
Establishing a Context
Juvenile Justice: Diversion
* CJAA: Legislation created a demand for research proven and cost-beneficial programs for juvenile offenders
* Chemical Dependency Diversion Alternative (CDAA)/Juvenile Drug Courts
* Mental Health Disposition Alternative (MHDA)
* Mental Health Disposition Alternative: Purpose of this disposition alternative is to provide funding to County Juvenile Courts to maintain juvenile offenders with mental health disorders within local communities.
* Prime Time
Juvenile Justice: Diversion
* Prime Time Project/Disproportionality
* Co-occurring Disorders
Background
* UW providing Mental Health services in juvenile detention facilities
* Seattle: 7% African American in general population, 35% African American in detention
* African American youth have lower retention rate in mental health and substance abuse treatment
* African American youth are disproportionately detained in juvenile justice system
* Prevalence of co-occurring mental health and substance use problems (Vander Stoep & Trupin, 1998)
Response
* Prime Time Project developed
* Address needs of juveniles with co-occurring mental health and substance abuse
* Emphasize cultural context in approach
Considerations in Developing the Intervention Approach
* Attention to cultural issues
* Primary needs of youth with co-occurring disorders in juvenile justice system
* Evidence-based treatment approaches
Attention to Cultural Issues
* Racism as a stressor
* Applicability of ecological interventions
* Cultural matching
* Adhering to principles of cultural competence
Primary Needs of Youth with Co-occurring Disorders in Juvenile Justice System
* Empower families as primary change agents
* Effective treatment services for substance use and mental health disorders
* Stable living situation
* Integration of services and probation
* School / Job Placement
* Social / recreational activities
Evidence-based Treatment
* Multisystemic Therapy
– Scott Henggeler, Ph.D., Medical University of South Carolina
* Dialectic Behavior Therapy
– Marsha Linehan, Ph.D., University of Washington
* Motivational Enhancement Therapy
– William Miller, Ph.D., University of New Mexico
* Relapse Prevention
– Alan Marlatt, Ph.D., University of Washington
Keys to Providing Effective Intervention
Culturally Competent Approach: Overarching Principles
* Culturally matched/competent therapists
* Model and enhance families’ advocacy skills with systems
* Address historic distrust, passivity, anger and other volatile emotions and use as levers for change
* Respect culture through strength-based, family centered and unconditional approach (Mason, 1998)
Common Goal: Create Environment of Alignment & Engagement Among Providers
* Share goals
* Measurable outcomes
* Commitment to unconditional care
* Shared formulations
* Shared work among systems & providers
Common Goal: Increase Motivation & Engagement
* Motivational Enhancement
* Culturally Competent Treatment
* Family Driven Intervention
* Intensive Case Management
Common Goal: Increase Pro-social Competence
* School Attendance / Achievement
* Employment Vocational Training
* Recreation
* Church
* Recovery Support
Common Goal: Increase Self-Regulation
Dialectic Behavior Therapy (DBT)
* Behavior Therapy (self-monitoring, chain analysis, contingency management)
* Cognitive Therapy (reduce automatic negative thoughts, hostile attributions)
* Relapse prevention
* Medication
Common Goal: Increase Parental Effectiveness
* Increase monitoring
* Increase modeling of responsible behavior
* Contingency management
* Increase positive parent-child interactions
Elements of Multisystemic Therapy
* Finding the fit
* Positive & strength focused
* Increasing Responsibility of family
* Present-focused, action-oriented & well-defined
* Targeting sequences
* Developmentally appropriate
* Continuous effort
* Evaluation and accountability
* Generalization
Elements of Substance Abuse Intervention
* Focus on community intervention
* Monitor use and provide clear contingencies
* Relapse prevention
* Education/support
* Motivate youth and family to change (Motivational Enhancement Therapy)
Motivational Enhancement Therapy (MET)
* Feedback of personal risk or impairment
* Emphasis on personal responsibility
* Clear advice to change
* Provide a menu of options
* Therapist empathy
* Facilitation of client self-efficacy
* Develop discrepancy between current behavior and stated goals
Elements of Mental Health Intervention
* Focus on community intervention
* Build coping skills
* Monitor mood, behavior, anxiety
* Assess need for medication
* Coach system(s) on implications/needs of mental illness
Elements of Culturally Competent Interventions (Bernal, et.al., 1995)
* Language that enhances family’s comfort and understanding is used
* Similarities and differences between client and therapist shape relationship
* Ethnic/cultural symbols part of therapeutic dialogue
* Respect for cultural values and practices
* Goals consonant with culture and context
* Adaptive values and strengths from culture are supported
* Treatment methods adapted to culture
* Cultural context considered in assessment, treatment planning and intervention
Pilot Study Findings
* Reduction in new charges/crimes
* Increased residential stability
* Increased days in school
* Decrease probation violations due to drug/alcohol use
Juvenile Mental Health Courts: Summary of the NCMHJJ Survey
National Center for Mental Health and Juvenile Justice
Juvenile Mental Health Courts
Background
* Growth of specialty courts and rapid spread of adult mental health courts
* Emergence of mental health courts as a strategy for responding to the mental health needs of juvenile justice youth
* NCMHJJ, with support from the MacArthur Foundation, conducted an initial survey to identify and describe courts
* Mental Heath Courts:
– Focus on providing offenders with mental health disorders better access to treatment, consistent supervision, and support to reconnect with their families
* Common Elements Include:
– Cases are handled in a specialized docket
– A designated judge is the center of the treatment and supervision process
– A multidisciplinary team approach is used
– Intensive case management includes supervision of participants, with a focus on accountability and monitoring of each participant’s performance
Advantages and Issues Surrounding Juvenile Mental Health Courts
Perceived Advantages
* Leverage of the court
* Improved identification, triage, and treatment
* Intensive supervision to monitor compliance
* Collaborative identification/attention to service gaps
Issues
* Risk for netwidening
* Diversion of resources away from community mental health
* Potential for coercion
* Possible stigma
Selected Findings
* 14 juvenile mental health courts (JMHCts) are currently operating across seven states
* An additional 15-20 jurisdictions are considering establishing a court
* Most of the existing courts:
– Are new, only two operated before 2003
– Do not formally refer to themselves as mental health courts
– Serve youth post-adjudication
– Link to a variety of services
– Maintain youth in the program anywhere from 3 to 24 months
Crossroads Program
Summit County Court of Common Pleas
Juvenile Division
Summit County, Ohio
The Honorable Linda Tucci Teodosio, Judge
What is Crossroads?
* Diversionary Program
* Post Adjudication
* Voluntary
* Intensive Probation
* For children who have either a diagnosis of a mental illness, substance dependence, or both
* A Gateway to existing services
Why Crossroads?
* Need for early mental health assessment, identification, intervention, and services
* Provide support for families dealing with children with mental health issues and/or substance dependence
* Community Safety: Children are at risk to be a danger to themselves or others
* Need to reduce recidivism
* Value of keeping child with family
* Treatment for both conditions simultaneously
* Community collaboration to allow for most appropriate treatment options
Eligibility Criteria
* Youth 12 to 17 years of age
* No current charge or previous conviction for an offense of violence, except for Domestic Violence charges
* Gang members and sex offenders are excluded
* No current charge or previous conviction for drug trafficking
* Must have a mental health diagnosis in the major affective disorders category (major depression, bi-polar disorder, schizophrenia, dysthymia, or Severe post traumatic stress disorder) and/ or substance dependence.
* Youth with mild mental retardation (or more severe mental retardation) or youth participating in programming for the developmentally handicapped are ineligible
* All first-degree felonies and most second-degree felonies are excluded
Identification of Participants
* GRAD (Graduated Risk Assessment Device)
* V-DISC (Voice Diagnostic Interview Schedule For Children) for youth whose Personality/Behavior or Sociability scores on the GRAD are elevated
* SASSI (Substance Abuse Subtle Screening Inventory)
* SPPI (Structured Pediatric Psychological Interview) or interview with the Court psychologist
How Does a Referral Occur?
* Detention
* Intake
* Defense Attorney, Prosecutor or Family Request
* Disposition
* Traditional Probation
* Upon the failure of less intensive supervision to achieve the desired result
Suitability Process
* Purposes of the Committee:
* To ensure youth meet eligibility criteria
* To ensure Crossroads is the most suitable placement for the child
* To make recommendations for the case plan
Suitability Committee Composition
* Crossroads Administrator
* Felony Disposition Coordinator
* Akron Health Department Representative
* Court Psychologist
* Referring Court Worker
* Crossroads Magistrate
Suitability Considerations
* SASSI results
* GRAD results
* V-DISC results
* SPPI results
* Parent Interview Results
* Willingness and ability of child and family to comply with the program requirements
Acceptance Process
* Magistrate or Judge is notified of acceptance and recommendations for the case plan
* Magistrate or Judge orders youth into Crossroads
* Probation rules, house arrest rules, parent guidelines, and drug use contract rules are reviewed immediately prior to the Youth’s first Crossroads hearing
Programming
* Youth, parent, probation officer, and community providers meet within the first two weeks to develop a case plan
* The Crossroads probation officer serves as the case manager
* Youth and parent report to Court periodically for a review (frequency depends upon phase and compliance)
* Youth, parent and probation officer develop contract goal sheets which record all required activities for each period until the next Court review
Treatment Team
* Representatives from County Agencies meet every two weeks to review each child and make recommendations for appropriate care.
* Team consists of the Crossroads Probation Officers, Administrator, Magistrate & Social Worker; Court Psychologist; Representatives from the County Alcohol Drug Addiction and Mental Health Services Board, Community Health Center (Substance Abuse), Akron Health Dept. (Substance Abuse), Greenleaf Family Services (Mental Health Services), ICT, Oriana House (Halfway House for adolescent males); Representative from other agencies having contact with a particular child or family
Some Treatment Options:
* Intensive Outpatient Treatment
* Short Term Placement at the Halfway House or other treatment facility
* Individual and/or group counseling
* Medical Evaluation and compliance
* Continuation with family’s private treatment provider
* Institutional or residential placement
Intensive Co-occurring Treatment
* Short term intensive counseling for child and family
* On call 24/7 for crisis intervention
* In home services
* Counselors are qualified to provide both substance abuse and mental health counseling
* Community funded
Court Hearings
* All scheduled Participants and Parents are present for all hearings
* Probation Officer, Parents and Child report to Court on progress since last Review
* Court provides encouragement and suggestions
* Rewards and sanctions are given
* School progress is discussed
* Contempt Track for probation violations or new charges while on probation
Program Advancement
* Five Phases
* Contact with the Court decreases as the child progresses through the Program
* The responsibility of the child and the family increases
* Child works on achieving his or her individualized
* Mental Health treatment compliance and sobriety are monitored
Successful Completion and Graduation
Youth who successfully complete the program requirements:
* Pass a “hair test”
* Participate in a graduation ceremony and celebration
* Give a speech and are recognized at the ceremony for their achievements by the staff, family and friends
* Obtain a certificate of completion
* Receive a graduation gift from program staff
* Receive an expungement of the admitting charge (and subsequent probation violations)
Court and Community Benefits
* Services providers have open lines of communication with the Court to assure that the best treatment options are being considered
* Court provides assistance in making appropriate referrals
* Children are not punished simply because they are mentally ill: Focus is on wellness
* Delinquent behavior and/or the severity of the behavior is diminished
* Children and families become connected to community treatment providers that can continue to work with the family long after Court involvement ceases
* Savings to the community and the juvenile justice system as a result of reduced commitments to the Ohio Department of Youth Services (Ohio’s equivalent to prison for youthful offenders)
* Increased satisfaction in dealing with troubled youth for Judge, Magistrate and Court Personnel
SUMMARY
* The number of days youth spends in detention is decreased significantly. This is an indication of improved functionality in the society.
* Youth’s substance use is reduced significantly while in the program. Substance use is eliminated at the end of Crossroads Program.
* Youth’s GPA is improved significantly.
* Significant increase in the employment rate at discharge, achieved the goal to increase youths’ productivity and functionality in the society.
* The higher the positive reinforcement at home in phases 1 and 2, the more likely the youth will successfully complete the Crossroads Program.
Crossroads
Summit County Court of Common Pleas
Juvenile Division
650 Dan Street
Akron, Ohio 44310
Judge Linda Tucci Teodosio
330-643-2995
lteodosio@cpcourt.summitoh.net
Other Sources
* Dawn Jones, Crossroads Administrator
330-643-2910 Djones@cpcourt.summitoh.net
* Global Risk Assessment Device – http://projectgrad.osu.edu/about.cfm
* V-DISC – Diagnostic Interview Schedule for Children – www.teenscreen.org
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