Cornerstone #3: Diversion

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3.1  Whenever possible, youth with mental health needs should be diverted to community treatment. There are large numbers of youth involved with the juvenile justice system who have significant mental health problems. Many of these youth end up in the juvenile justice system for behavior brought on by or associated with their mental disorder. Some of these youth are charged with serious offenses; the majority, however, are in the juvenile justice system for relatively minor, nonviolent offenses. Whenever possible and when matters of public safety allow, efforts should be made to divert these youth into community-based services. Mental health experts and administrators across child-serving systems agree that it is preferable to treat children and youth with serious mental disorders outside of institutional settings in general, and outside of the correctional system in particular (Koppleman, 2005). Diversion to treatment offers youth their best hope of receiving effective services to address their mental health issues as well as the behaviors that brought them to the attention of the juvenile justice system. Community treatment affords families the opportunity to be involved with their child’s care and provides a cost-effective alternative to juvenile detention or correctional placement.

3.2  Procedures must be in place to identify those youth who are appropriate for diversion. A formal screening and assessment mechanism must be instituted to identify youth with mental health needs who may be appropriate for diversion. The results of this needs assessment must be linked to any risk assessment performed on the youth to determine their potential suitability for diversion. Systematic assessment of needs and risks provides the foundation for effective intervention (Borum, 2003). These procedures must be instituted at key decision-making points within the juvenile justice continuum where referral to treatment diversion could be considered, such as at probation intake, at detention, at adjudication, and at disposition. Once youth are identified for diversion to treatment, referral mechanisms must be created to allow for the efficient referral of a youth to services.

In 2002, the NCMHJJ developed a Composite Need/Risk Index for the assignment of services and supervision to assist the Miami-Dade Juvenile Assessment Center (JAC) in making decisions about the appropriate level of services and sanctions for youth referred to a diversion program. The index consists of need and risk categories and is intended to serve as an objective decision-making system that matches mental health and substance abuse need and delinquency risk, to services, interventions, and intensity of diversion supervision. For example, youth with the highest levels of need and risk, as evidenced from the results of both the needs and risk assessments, would receive the highest level of services, as well as the most intensive levels of supervision.

3.3  Effective community-based services and programs must be available to serve youth who are diverted into treatment. In order for diversion programs to be effective, there must be not only procedures and mechanisms in place to identify and refer youth, but as importantly, the availability of effective community-based services to which youth can be referred. Simply having a diversion mechanism in place is not enough. Diversion programs can only be successful when there are effective community-based mental health service providers available to serve these youth. Linkages must be established with community-based treatment providers to ensure that youth referred from the juvenile justice system will have immediate access to treatment.

Often, youth referred from the juvenile justice system will continue to have some level of juvenile justice involvement, typically in the form of probation supervision or requirements for community service. On-going communication and collaboration between the juvenile justice and treatment systems is essential during the diversion period in order to monitor a youth’s participation in treatment, provide necessary updates to the court on progress, and provide joint case management or oversight as necessary.

3.4  Diversion mechanisms should be instituted at virtually every key decision-making point within the juvenile justice processing continuum. Ideally, diversion opportunities should occur at the earliest stages of juvenile justice processing to allow youth with identified mental health needs to be referred into community-based settings and to prevent further involvement with the juvenile justice system. However, diversion mechanisms can be instituted at later stages of justice processing to prevent further penetration into the system and expensive out of home placements. The programs listed below are examples of diversion programs that have been instituted at both the pre- and post-adjudication stages of juvenile justice processing.

Pre-Adjudication Diversion
The Special Needs Diversionary Program, in Harris County, Texas, uses a team approach involving probation officers and clinicians who jointly supervise youth on their caseloads. Youth are typically referred to the program at probation intake after undergoing a screen and comprehensive assessment. Based on the results of the assessment, youth are provided individualized treatment using a wraparound approach and the majority of services are provided to youth in their homes and in their schools.

Family Intervention Specialists (FIS) in Douglass County, Georgia, is a diversion program that provides intensive family intervention services to youth referred by probation intake or the juvenile court. The program serves youth with mental health or substance use disorders who are at risk of out home placement or who are currently in out of home placement returning home. Probation officers, who are specially trained to identify youth with mental health or substance abuse needs, administer a standardized screening tool to screen for disorders. Upon referral to the program, youth undergo comprehensive evaluation and are provided Brief Strategic Family Therapy (BSFT), as well as other services and supports.

Post-Adjudication Diversion
The Integrated Community and Home-Based Treatment (ICT) Model, Akron, Ohio, is specifically designed to serve youth with co-occurring mental health and substance use disorders. The ICT program is both a reintegration program (for youth returning from placement) as well as a placement diversion program for youth referred from the court as a condition of probation. Program clinicians are available to youth (and their families) 24 hours a day, 7 days a week and use a treatment stage approach to meet a youth and family’s primary presenting needs prior to proceeding to more complex needs.

Pre- and Post-Adjudication Diversion
The Indiana Family Project, Bloomington, Indiana, uses Functional Family Therapy as the primary intervention for youth involved with the juvenile justice system. Referrals come from the probation intake if a youth is diverted pre-adjudication, or from the Family Court if the youth is diverted post-adjudication. All services are provided by specially trained therapists under the guidance of an FFT clinical supervisor. Probation officers work with the therapists to monitor the youth while they participate in the program and report back to the court on progress.

Onondaga County, New York, employs a comprehensive and holistic approach to linking justice-involved youth to evidence-based community services. The county probation department contracts with a private MST provider, Liberty Services, to provide MST services to youth at multiple stages of juvenile justice system involvement: probation intake, detention, and family court. In addition, the state’s juvenile justice agency contracts with the MST provider to provide re-entry services for youth returning to Onondaga County from juvenile correctional placement, creating a full continuum of care for youth. Referral mechanisms at key processing points allow youth to be diverted from formal juvenile justice system involvement or out of placement to MST services.

3.5  Consideration should be given to the use of diversion programs as alternatives to traditional incarceration for serious offenders with mental health needs.  It is critical that judges have a range of alternatives to secure correctional placement to consider when making dispositional decisions for youth with mental health needs so that youth can be diverted into community-based settings whenever possible. For serious offenders with mental health needs, any diversion strategy should include a combination of supervision, sanctions, and treatment. Some communities have instituted community-based programs for this population of youth that serve as an alternative to traditional incarceration for youth with mental health needs. Multi-Dimensional Treatment Foster Care (MTFC) is an evidence-based alternative to incarceration for youth with histories of chronic and severe antisocial or delinquent behavior and emotional disturbance. Community families are recruited, trained, and closely supervised to provide youth placed in their care with treatment and intensive supervision at home, in school, and in the community. Host families undergo intensive training and receive on-going support and supervision from the program coordinator. Youth participate in a structured daily behavior modification program and receive individual therapy. School attendance, behavior, and homework completion are closely monitored, and interventions are provided in the school as needed. The youth’s biological or adoptive family receive therapy while the youth is participating in MTFC with the ultimate goal of returning the child to the family.

From a conceptual perspective, intensive probation programs with a strong treatment component may offer a safe and effective alternative to institutional care for some youth. Some communities have begun to blend the role of a traditional probation officer with that of a case manager. This expanded role of a probation officer continues to carry the leverage of the juvenile court in terms of compliance and sanctions, but also provides a case management function to ensure that youth have access to, and participate in, treatment. Lorraine County, Ohio, as part of their Linkages program, used Probation Officers/Case Managers (PO/CM’s) to supervise youths’ participation in a placement diversion program. The PO/CM’s, who work in conjunction with treatment providers, function as a combined probation officer and case manager; they maintain smaller caseloads in order to provide intensive supervision to youth receiving mental health and substance use treatment. Each PO/CM has a caseload of 15 to 20 youth and work flexible hours to accommodate evening and weekend contact with their clients (Cocozza & Stainbrook 1999).

This role is not unlike those of the probation officers who are part of the Harris County, Texas, Special Needs Diversionary Program. Specialized juvenile probation officers and licensed professional staff from the mental health agency work together to provide intensive community-based case management services to prevent further involvement with the juvenile justice system. While this program targets youth at the front-end of the processing continuum, as well as youth returning from placement, there is reason to believe that this expanded juvenile probation function could be employed as a post-dispositional alternative to correctional placement.

Juvenile mental health courts are emerging as an alternative to traditional juvenile court settings for youth with mental health needs (see page 55 for more detailed discussion about these courts). Some juvenile mental health courts have very strict exclusionary criteria for youth participation, barring youth who have committed serious or violent felonies or sex offenses, while others use broader criteria and discretion when making determinations about youth participation. For example, while the Los Angeles County, California, juvenile mental health court has no formal exclusion criteria with respect to a youth’s current charges, the judge, working in conjunction with a team of juvenile justice, mental health and school officials, uses discretion when dealing with very serious felonies.

3.6  Diversion programs should be regularly evaluated to determine their ability to effectively and safely treat youth in the community. Decision-makers such as judges and agency administrators need to feel confident about diverting youth into the community. Data should be routinely collected to track both short-term outcomes, in terms of treatment compliance and impact, as well as longer term outcomes such as the program’s effect on juvenile recidivism. Data collected should aim to answer such questions as: “What percentage of youth referred to the program in a given year successfully complete the program? What percentage of youth who successfully complete the program re-offend within 6 months of program completion?” Evaluation data can help build support for the use of diversion programs as a way to effectively treat youth with mental health needs in a community setting, and can build community confidence in the use of such interventions.

Cost benefit analysis, while more complicated to complete, can demonstrate the financial savings that occur when youth are served in the community rather than in institutional settings, and can help decision-makers to allocate limited public resources. The Washington State Institute on Public Policy has conducted numerous cost-benefit reviews of interventions used with the juvenile justice population to reduce crime (Aos, Phillips, Barnoski, & Leib, 2001). Many of the reports that the Institute has released have focused on the comparative economics of certain policies, violence prevention programs, and other efforts to reduce particular at-risk behaviors. Among the programs reviewed are Multi-Systemic Therapy, Treatment Foster Care, and Functional Family Therapy. These reports, and the documented methodologies used to complete the analyses, could be useful to policymakers or administrators interested in establishing similar programs or policies.