Section One: The Comprehensive Model

Overview

There is a growing body of evidence that suggests that large numbers of youth in contact with the juvenile justice system have identified mental health disorders. Until the last decade, however, there was a paucity of research available documenting the degree to which youth in contact with the juvenile justice system were experiencing mental illness. New research, conducted over the last 10 years, has significantly expanded our collective knowledge and understanding of the nature and prevalence of mental health disorders among the juvenile justice population. These new data have provided the field with a more precise assessment of the problem.

For example, we now know that youth in the juvenile justice system experience substantially higher rates of mental disorder than youth in the general population. (Otto, Greenstein, Johnson & Friedman, 1992; Teplin, Abram, McClelland, Dulcan, & Mericle, 2002; Wierson, Forehand, & Frame, 1992). Studies have consistently found that  among youth in juvenile justice placements, 65 percent to 70 percent have a diagnosable mental health disorder (Wasserman, McReynolds, Lucas, Fisher, & Santos, 2002; Wasserman, Ko, & McReynolds, 2004; NCMHJJ, 2005). Further, it is safe to estimate that approximately one out of every five youth in the juvenile justice system has a serious mental health disorder (Cocozza & Skowyra, 2000).

Many of these youth are detained or placed in the juvenile justice system for relatively minor, nonviolent offenses but end up in the system simply because of a lack of community-based treatment options available to them. A review in Louisiana by the Annie E. Casey Foundation (2003) found that more than 75 percent of Louisiana’s incarcerated youth were locked up for nonviolent and drug offenses. Further, a recent study of mental health problems among youth in the juvenile justice system found that of youth with a mental health diagnosis, only 23.5 percent had committed a violent offense as their most serious offense, with the majority of youth involved with the juvenile justice system for property offenses and probation or parole violations (NCMHJJ, 2005). The placement of these youth in the juvenile justice system is part of a growing trend toward the “criminalization of the mentally ill”—placing individuals with mental health needs in the justice system as a means of accessing mental health services that are otherwise unavailable or inaccessible in the community (Bell & Shern, 2002). While this trend has been evident at the adult level for some time, it is now being observed at the juvenile level as well. Thus, the juvenile justice system is viewed as becoming the “public mental health system” for large numbers of youth who are referred there because there is often no other place to seek help.

The growing crisis surrounding these youth is highlighted by a plethora of independent reports and media accounts over the last several years drawing attention to the large number of justice-involved youth who have significant mental health needs but whose needs are not being met. A series of investigations by the U.S. Department of Justice into the conditions of confinement in juvenile detention and correctional facilities repeatedly found a failure on the part of the facilities to adequately address the mental health needs of youth in their care (U.S. Department of Justice, 2005). In addition, media inquiries and reports documenting the mental health crisis within juvenile justice systems in New Jersey, Arizona, California, Michigan, and Pennsylvania, for example, have drawn national attention to an issue that has not traditionally received much consideration from the media. This unprecedented exposure has resulted in elected officials, policymakers, and practitioners struggling to respond and develop more effective solutions for these youth.

This new knowledge serves not only to illustrate the extent of the problem, but provides a solid empirical base for the development of new policies and practices that effectively respond to the needs of these youth. The new research and work that has been done in this area over the last 10 years documents the problem. In order for the field to move forward, there must be recognition, on the part of both the juvenile justice and mental health systems, that many youth in the juvenile justice system are experiencing significant mental health problems and that responsibility for effectively responding lies with both the mental health and juvenile justice systems.

Purpose of the Comprehensive Model

The increasing awareness and concern about the unmet mental health needs of large numbers of youth in contact with the juvenile justice system has been accompanied over the past few years by the development of improved policies, strategies, and practices for responding to this population. Now, more than ever before, significant energy and resources have been directed to the development of new tools, programs, and resources to help the field better identify and provide appropriate care and treatment to these youth. Yet, despite the pockets of activity that are underway in states and communities throughout the country, to date there has been no attempt made to systematically examine these existing efforts and to comprehensively package this information as a tool that provides guidance and direction to the field. Our goal for this document is to capture this activity and present it in a way that looks at the juvenile justice system as a continuum—from intake to re-entry—summarizing what it is we now know about the best way to identify and treat mental disorders among youth at key stages of juvenile justice processing, and offering recommendations, guidelines, and examples for how best to do this.

Process

In February 2000, the Office of Juvenile Justice and Delinquency Prevention (OJJDP) issued a solicitation for applications to engage in a series of activities designed to improve knowledge about the nature and prevalence of mental health disorders among youth in the juvenile justice system, and to use this information to develop a Comprehensive Model for providing mental health services to this population. In April 2000, the National Center for Mental Health and Juvenile Justice (NCMHJJ), working in partnership with the Council of Juvenile Correctional Administrators (CJCA), submitted a proposal to complete this work, and in June 2001 was awarded the grant for the project.

The project included the following key tasks:

Conducting an extensive review of the research literature to identify and highlight issues and gaps in the existing research base;

• Completing a multi-site prevalence study of mental health needs and services for youth in three different levels of juvenile justice care—juvenile correctional facilities, juvenile detention centers, and community-based facilities;
  
  
• Identifying existing promising practices and programs for providing mental health services to youth at critical points of juvenile justice system contact;
  
  
• Using the data and information collected from these tasks to inform the development of a Comprehensive Model for providing a broad range of mental health services to youth in contact with the juvenile justice system.

To complete these tasks, the NCMHJJ established a Model Development Workgroup, comprising national mental health and juvenile justice experts and researchers, to provide guidance and direction to the NCMHJJ as we embarked on this project. This Workgroup met regularly throughout the course of this project to provide feedback, suggestions, and recommendations for how best to approach, implement, and refine every aspect of this project.

To conduct the mental health problems and services study, we relied on a cadre of researchers from across the country to undertake this challenging task. We identified the sites for the study based on criteria that was included in OJJDP’s original solicitation, which specified that the study be conducted in understudied parts of the South, Southwest and rural Northwest. To this end, we selected three states to participate in the study—Louisiana, Texas, and Washington. In each state, we identified a Principal Investigator to serve as the coordinator for the local data collection and as a liaison to the NCMHJJ over the course of the data collection period. Working with the NCMHJJ, each Principal Investigator identified juvenile justice facilities to participate in the study and hired staff to interview youth and collect the data. After numerous human subject review requirements were satisfied, data collection in all three states began in May of 2003 and ended in April 2004.

The results of the study confirmed that, regardless of level of care or geographic region of the country, the majority of youth in the juvenile justice system meet criteria for at least one mental health diagnosis. Overall, 70.4 percent of youth in the study were diagnosed with at least one mental health disorder. Among males, Disruptive Disorders were most prevalent, followed by Substance Use Disorders. Among females, Anxiety Disorders were most prevalent, followed by Substance Use Disorders. Rates of mental health disorders are presented in Table I below, both overall and separately for males and females. For many of the youth in the study, their mental health status was complicated by the presence of more than one disorder. Of those youth who were diagnosed with a mental health disorder, 79.1 percent met criteria for at least one other mental health diagnosis.

The majority of youth who met criteria for a mental health diagnosis were also diagnosed with a co-occurring substance use disorder. Among those youth with at least one mental health diagnosis, approximately 60 percent also met criteria for a substance use disorder. Co-occurring substance use disorders were most common for youth with a diagnosis of disruptive disorder; however, significant proportions of youth with anxiety disorders (52.3%) and mood disorders (61.3%) also had a co-occurring substance use disorder. A complete description of the study and its findings can be found in Appendix B.

Simultaneous to the data collection, the NCMHJJ actively began development of the Model by reviewing the research literature and identifying existing programs throughout the country that currently provide mental health services to youth involved with the juvenile justice system. Each draft of the Model was shared with the members of our Model Development Workgroup and comments from the group were incorporated into each revised version. Once the data from the prevalence study was analyzed, this information was added to the Model, providing further, quantifiable justification for many of the recommendations included in the document. The final draft of the Comprehensive Model was then circulated to a group of national Expert Reviewers, including mental health and juvenile justice policymakers, practitioners, advocates, and youth for final comment. Comments from the Expert Reviewers were summarized and shared with our Model Development Workgroup, who provided final guidance as to how these comments could best be incorporated into the final document.

Organization of the Model

To develop the Model, it was necessary to establish a set of core directions to guide our work and to provide a framework for the document. First, a set of Core Principles was developed to serve as the underpinning of the comprehensive model and to guide all subsequent efforts to improve the coordination and delivery of mental health screening, assessment, and treatment for youth in contact with the juvenile justice system. From these principles, four Cornerstones emerged that form the foundation of the comprehensive model. These Cornerstones provide the necessary infrastructure and reflect key areas where significant improvements can be made to better serve youth with mental health needs. Finally, these key elements were juxtaposed against select, Critical Intervention Points within the juvenile justice continuum that present, in our estimation, realistic opportunities to improve collaboration, identification, diversion, and treatment strategies for youth with mental health needs.

This conceptual framework for the comprehensive model is presented in Figure I and is described below.

Underlying Principles

The underlying principles guide the model and provide the basis for the recommendations that are put forward in the document. These principles represent the foundation on which a system can be built that is committed and responsive to addressing the mental health needs of youth in its care. The Underlying Principles of the Comprehensive Model include:

1. Youth should not have to enter the juvenile justice system solely in order to access mental health services or because of their mental illness.
2. Whenever possible and when matters of public safety allow, youth with mental health needs should be diverted into evidence-based treatment in a community setting.
3. If diversion out of the juvenile justice system is not possible, youth should be placed in the least restrictive setting possible, with access to evidence-based treatment.
4. Information collected as part of a pre-adjudicatory mental health screen should not be used in any way that might jeopardize the legal interests of youth as defendants
5. All mental health services provided to youth in contact with the juvenile justice system should respond to issues of gender, ethnicity, race, age, sexual orientation, socio-economic status, and faith.
6. Mental health services should meet the developmental realities of youth. Children and adolescents are not simply little adults.
7. Whenever possible, families and/or caregivers should be partners in the development of treatment decisions and plans made for their children.
8. Multiple systems bear responsibility for these youth. While at different times, a single agency may have primary responsibility, these youth are the community’s responsibility and all responses developed for these youth should be collaborative in nature, reflecting the input and involvement of the mental health, juvenile justice, and other systems.
9. Services and strategies aimed at improving the identification and treatment of youth with mental health needs in the juvenile justice system should be routinely evaluated to determine their effectiveness in meeting desired goals and outcomes.

Cornerstones: The Key Elements of a Comprehensive System

The Cornerstones represent the foundation of the model and provide a framework for putting the underlying principles into practice. These Cornerstones reflect the most critical areas of improvement to enhance the delivery of mental health services to youth in contact with the juvenile justice system. These include:

Collaboration
The need for improved collaboration between the juvenile justice and mental health systems.

Identification
The need for improved and systematic strategies for identifying mental health needs among youth in contact with the juvenile justice system.

Diversion
The need for more opportunities for youth to be appropriately diverted into effective community-based mental health treatment.

Treatment
The need for youth in contact with the juvenile justice system to have access to effective treatment to meet their needs.

For each Cornerstone, we offer a policy statement in support of addressing the issue, background information, and a set of recommended actions for addressing the Cornerstone. Examples of efforts that have already been taken in the field to address each of these key elements are included as well.

Critical Intervention Points

In order to provide guidance around the practical application of the recommended actions included for each key element, we identified a series of critical intervention points within the juvenile justice continuum that offer opportunities to make better decisions about mental health needs and treatment. It is recognized that there is tremendous variation across states, and even within states, in how juvenile justice services are organized and provided. Nonetheless, there are some general points in the system where opportunities to improve the delivery of mental health services exist. These critical intervention points are initial contact with law enforcement, intake, detention, judicial processing, disposition (including probation and juvenile correctional placement) and re-entry, as depicted below in Figure II.

The critical intervention points in Figure II represent the primary opportunities for mental health interventions in at least three ways. First, they are points where youth with mental health problems can be identified through various procedures such as the training of law enforcement officials in identifying mental health symptoms at initial contact, the use of standardized screening and assessment instruments at intake and other points, and the use of psychiatric assessments and diagnostic tests. Second, each point also represents an opportunity to divert youth from further penetration into the justice system and into community-based services and programs. This is particularly true at the pre-adjudication stages between initial contact and judicial processing. Third, for youth identified with mental health disorders who are not diverted, these stages represent key points for the provision of mental health services either by the juvenile justice system alone or in conjunction with the mental health treatment system.

For each of the critical intervention points, the Model provides a general description of that stage in the context of the larger juvenile justice continuum, an examination of relevant mental health issues, and case examples of promising programs that respond to the mental health needs of youth at that point in the system. In some instances, the program examples reflect evidence-based interventions, that is, interventions for which there is a strong research base indicating positive outcomes. In other instances, the examples represent promising programs that are consistent with the cornerstones of the Model, and reflect, in a general sense, what is considered to be best practice in the field.

Cross-referencing the Cornerstones against individual points of contact within the juvenile justice system offers a comprehensive approach to improving mental health identification and treatment across the entire continuum. However, it also presents an opportunity to consider how improvements can be made in smaller, more incremental steps, for instance within detention settings or as part of a plan to improve aftercare services for all youth leaving a juvenile correctional placement. In essence, the model serves a dual role. It offers a comprehensive blueprint for how mental health issues can be better addressed within the juvenile justice system as a whole, offering communities a plan for re-tooling the entire system. At the same, the model also effectively compartmentalizes the system into discrete points of contact, allowing communities to consider implementing individual components of the model as a first step in an effort to improve their system.

Target Audience

While much of what is presented in this document will have implications for policymakers, clinicians, and line staff, the model is not primarily oriented to these groups. Rather, it is targeted to state and county juvenile justice and mental health administrators and program directors who are responsible for establishing, modifying, and overseeing services affecting youth with mental health needs in contact with the juvenile justice system. The model is not a clinical implementation document, but serves as a “change agent” to spur the development of improved strategies to better identify mental health needs among youth in contact with the juvenile justice system, as well as to improve the delivery of services to these youth. The model provides state and county juvenile justice administrators and program directors, and their counterparts in the mental health system, with a blueprint for how to affect positive change, recognizing that certain limitations exist and that any modifications or improvements to the system must be made in the context of current political and economic realities.

Boundaries of the Model

While this document represents the most comprehensive attempt to date to describe and provide guidelines for how mental health screening, assessment, and treatment can best be provided to youth in contact with the juvenile justice system, there are a number of remaining issues that go beyond the scope of the Model presented here. These issues are important to highlight because they present challenges to the field and, at some point, will need to be more thoroughly addressed. This model does not attempt to solve these issues. Rather, the model offers recommendations for comprehensive improvement in key areas that could positively affect some of the larger and remaining “systems” issues.

A. Existing tension between the juvenile justice and mental health systems. First, it is recognized that there is a great deal of underlying tension between the juvenile justice and mental health systems when it comes to determining responsibility for this population of youth. Despite the fact that existing prevalence data suggest that the vast majority of youth involved with the juvenile justice system have mental health problems, the reality is that the existing juvenile justice system is not designed, nor does it have the capacity or specific mandate, to respond to all youth with mental health problems. This issue gets at the heart of the conflict between the juvenile justice and mental health systems. There is general agreement that the juvenile justice system should not become the designated mental health provider to the large numbers of youth who enter the system with mental health needs. Yet, the juvenile justice system is very often where many of these youth end up, and their needs cannot be ignored. This “responsibility by default” has led to a high degree of tension (and sometimes resentment) between the juvenile justice and mental health systems. This reality is recognized by the authors of this document, and it was within this context that we set out to begin the process of outlining the most critical ways the two systems can work together to develop more collaborative strategies and partnerships for responding to these youth. In this document, we identify a set of recommendations for improving coordination between the juvenile justice and mental health systems. At the same time, however, we recognize that resolving the existing tension will require much more work in the future to successfully address this complex issue.

B. The lack of available mental health services. A second reality facing both the juvenile justice and mental health systems is the fact that all youth who may need services cannot get services. The 2000 Surgeon General’s report on children’s mental health found that approximately 20 percent of children and youth in the general population experience a diagnosable mental health disorder, with 10 percent of youth experiencing illness severe enough to cause impairment (USDHHS, 2000). It is estimated that as few as 10 percent of youth with severe mental illness will receive the treatment that they need (USDHHS, 2000). There simply are not enough mental health services available to treat all of the youth who need such services, including youth in the juvenile justice system. Further, the juvenile justice system simply does not have the resources to respond to every child who may need services. There are numerous practical reasons for placing some limits on the obligation to respond to every youth’s mental disorder, including the enormous financial and professional resources necessary to do this, as well as the potential risk for net-widening and longer sentences or periods of confinement for youth (Grisso, 2004). The current reality is that the juvenile justice and mental health systems use their existing (and often limited) resources to identify and treat only a small proportion of those children who need services.

C. Determining levels of mental health need. Increasing the supply of mental health services available to youth would only solve part of the problem. Research indicates that anywhere from 65 to 70 percent of youth in the juvenile justice system have a diagnosable mental health disorder (Teplin et al., 2002; Wasserman et al., 2002; Wasserman et al., 2004; NCMHJJ, 2005). While not all of these youth require a high level of service, clearly all could benefit from some type of mental health treatment or intervention, with some requiring more intense services than others. The question becomes, how do you identify those youth who are most seriously disordered and who are in greatest need of services? Attempts to estimate the exact prevalence of severe mental illness within the juvenile justice population are difficult given the lack of consensus on how best to measure this. Some measures limit the definition to certain psychiatric diagnoses; others focus on the degree of impairment; while others use service utilization as an indication of severity (Narrow, Reiger, Goodman, Rae, Roper, Bourdon, Hoven & Moore, 1998). It has been estimated, based on extrapolations from the prevalence of severe mental illness in the general youth population, that approximately 20 percent of justice-involved youth experience illness severe enough to require immediate and significant treatment (Cocozza & Skowyra, 2000). Using data collected as part of the study to develop this Model, the prevalence of severe mental illness was examined using each of the above approaches. The results suggest that the rate of severe mental illness may be even higher, with 17–27 percent of youth meeting criteria for serious mental illness, depending on the definition used (NCMHJJ, 2005).

Currently, there is no clear, objective, scientifically based formula to distinguish between the different levels of need or seriousness in order to determine which youth should receive services. This document does not attempt to resolve the issue. Until there is some objective measure to determine a youth’s level of need, it is our recommendation that triage decisions be based on sound clinical judgment, with consideration given to a youth’s diagnosis, level of impairment, and receptivity to treatment.

D. Focus on mental health. There is emerging empirical evidence to support the assertion that large numbers of youth in the juvenile justice system have co-occurring mental health and substance use disorders. The results of the study undertaken as part of the development of this model found that of those youth with a mental health diagnosis, 58.5 percent of males and 65.6 percent of females also had a co-occurring substance use disorder. Despite significant gains that have been made on this issue recently, the knowledge and research base on the extent of the problem within the juvenile justice population, and how best to treat co-occurring disorders among justice-involved youth, is generally less available. More research and work on the development of effective identification and treatment strategies for youth with mental health and co-occurring substance use disorders is necessary. While this document begins to address some of the issues associated with co-occurring mental health and substance use disorders, the document focuses more heavily on mental health and does not address issues pertaining to youth with only substance use disorders in the juvenile justice population. There has been much work done to develop a strong research base on substance abuse among juveniles, and many programs and interventions have been developed to effectively treat substance abuse among youth. However, per the terms and specifications put forward by the Office of Juvenile Justice and Delinquency Prevention, the clear focus of the work was to develop a Comprehensive Model for addressing the mental health needs of the juvenile justice population. As a result, this document does not directly address the issue of youth with substance use disorders.

E. Recommendations targeted to the juvenile justice and mental health systems. It is explicitly recognized that youth in contact with the juvenile justice system often have interactions and contact with a number of systems, not simply the mental health system. Minimally, many of these youth are simultaneously known to the education system and to the child welfare system as well. Youth typically “flow” through these systems and as such, different agencies have different responsibilities at varying points in time. The authors of this document recognize that any effective and sustainable collaboration between the juvenile justice and mental health systems should include representatives from other child-serving systems as well as families. These “extended collaborations” can help to ensure that efforts to improve services and linkages are as holistic and coordinated as possible. However, for the purposes of the Comprehensive Model, it was necessary for the authors to target the majority of the discussion and recommendations to the two primary systems in question—juvenile justice and mental health. This is not meant, in any way, to minimize the role that other child serving systems should play in the development and implementation of strategies to improve the delivery of mental health services to this population of youth. It is meant to underscore the fact that any meaningful and positive changes that take place within a community to improve the way youth in contact with the juvenile justice system are identified and treated for mental health needs must begin, at a minimum, with the juvenile justice and mental health systems.