Cornerstone #3: Diversion

3.  Whenever possible, youth with identified mental health needs should be diverted into effective community-based treatment.

Background

On any given day, over 130,000 youth are being held in custody in juvenile justice facilities across the country, either awaiting trial in detention centers or having been placed in residential facilities after being adjudicated delinquent (Sickmund, 2004). The placement of these youth in juvenile justice facilities is part of a growing tendency toward the “criminalization of the mentally ill.” This phrase refers to the increasing trend of placing individuals with mental health disorders in the justice system. Often, the placement is seen as a means of accessing mental health services that are otherwise unavailable or inaccessible in the community.

While this trend has been evident at the adult level for some time, it is now being observed at the juvenile level as well. For example, a 1999 survey by the National Alliance for the Mentally Ill (NAMI) found that 36 percent of their respondents reported having to place their children in the juvenile justice system in order to access mental health services that were otherwise unavailable to them (National Alliance for the Mentally Ill [NAMI], 2001). A more recent study conducted by the U.S. General Accounting Office (GAO) found that in 2001, parents placed over 12,700 children into the child welfare or juvenile justice systems in order to access mental health services (United States General Accounting Office [GAO], 2003). Thus, the juvenile justice system is viewed as becoming the “public mental health system” for large numbers of youth. Simply warehousing them in juvenile facilities with no access to treatment will only exacerbate their conditions and create a more dangerous situation for youth and the staff who are responsible for supervising them. While it is recognized that some youth in the juvenile justice system have committed serious crimes and may not be appropriate for diversion to the community, many youth are in the system for relatively minor offenses but have significant mental health needs, and simply end up there because there is nowhere else to go. Given the needs of these youth and the documented inadequacies of their care within the juvenile justice system, there is a growing sentiment that whenever possible, and when matters of public safety allow, youth with serious mental health disorders should be diverted into effective community-based treatment.

Over the last several years, there has been increasing focus on the issue of diversion for both youth and adults with mental health disorders. The 2003 final report of the New Freedom Commission on Mental Health called for the wide adoption of diversion programs to reduce unnecessary court involvement on the part of children and adults with mental illness (New Freedom Commission, 2003). Following the release of the New Freedom report, the Campaign for Mental Health Reform, which comprised 16 national mental health advocacy and service organizations, released a report in July 2005 detailing a constructive set of steps necessary to implement the recommendations in the New Freedom report. One recommended step was to stop making criminals out of those whose mental illness results in inappropriate behavior by eliminating “warehousing” of youth with mental disorders in juvenile justice facilities.

The growth in specialized treatment courts, such as drug and mental health courts, is another example of the increasing interest in diversion. These courts can be viewed as “diversion” programs to the extent that they are used to successfully connect individuals to treatment in lieu of further processing or placement within the juvenile or criminal justice systems. While most of the growth of mental health courts has occurred at the adult level, there are an increasing number of juvenile mental health courts developing across the country. There is a great deal of variation in terms of how these courts are organized and who they serve, with some courts seeking to serve lower level offenders and others seeking to serve more high risk youth with complicated treatment and justice histories. The commonality is that they strive to ensure a youth receives and participates in treatment in lieu of a more punitive sanction, such as out of home placement, using the power of the court as leverage.

It is recognized that not all youth in contact with the juvenile justice system will need, or are necessarily appropriate for, diversion to treatment. Many youth do not have significant mental health needs and are diverted from the juvenile justice system, but not to community-based treatment. There are also youth who have mental health needs, but because of their security risks will be maintained in a secure facility and are not seen as appropriate for diversion in general or diversion to treatment. Clearly, both a youth’s level of risk and mental illness should be considered when determining whether a youth can be appropriately diverted into community-based treatment. It is also recognized that diversion into community-based treatment sometimes involves on-going monitoring or supervision on the part of the juvenile justice system, in order to ensure compliance with the terms of the referral or the court order. In order to clarify and define the population of youth that we are focusing on for diversion to community-based treatment, it is helpful to view the mental health needs and risk levels of the juvenile justice population on a continuum. On one end of the continuum are youth who present no or very low mental health needs and no or very low risk levels. On the other end of the continuum are youth who present very high levels of mental health need and very high risk levels. This continuum is presented below in Table II.

Table II A Continuum of Mental Health Need and Risk Levels Among the Juvenile Justice Population

Youth who have low severity on this continuum in terms of mental health needs represent those youth for whom diversion to community-based treatment would not necessarily be needed or appropriate. Youth with both low mental health needs and low delinquency risks are represented in Quadrant I of the diagram. Typically, these are youth who should not be in the juvenile justice system at all and who require no further formal mental health interventions. Many of these youth are simply diverted from the juvenile justice system and never seen again. We know from research that over half of all males (54%) and almost three-quarters of females (73%) who are arrested will have no further involvement with the juvenile justice system (Austin, Johnson, & Weitzer, 2005). Youth in Quadrant II have low mental health needs and high delinquency risks. Typically, these would be youth, who by virtue of the seriousness of their current offense or their risk for re-offending, are considered high risk and who require some level of juvenile justice system involvement. However, their mental health needs are low and they may not require mental health interventions. Broadly speaking, while some of these youth may be diverted out of the juvenile justice system, youth represented in Quadrants I and II would not be prioritized for diversion to community-based mental health treatment.

Youth falling on the high end of the continuum of mental health needs are the primary target for the recommendations included in this section. These are youth who present high mental health needs, but varying levels of delinquency risk. Youth who fall into Quadrant III include those whose risk levels are low—they may have been charged with a relatively minor or nonviolent offense, have no or a very limited prior juvenile justice record and present a very low risk for violence or re-offending. They do, however, present considerable mental health needs and require intervention or treatment. Based on recent reports, these youth are often referred to the juvenile justice system in order to access treatment or services that are unavailable or inaccessible in the community. A report issued by Congress in July 2003 documenting the inappropriate use of detention for youth with mental health needs found that in 33 states, youth were reported held in detention with no charges against them (U.S. House of Representatives, 2004). This is a population of youth for whom diversion to treatment should be considered. The potential benefits of diversion for these youth include:

• reducing recidivism,
• providing more effective and appropriate treatment,
• decreasing overcrowding of detention facilities,
• facilitating the further development of community mental health services,
• increasing the safety of detained youth,
• improving working relationships of cross-system groups,
• expediting court processing of youth into services, and
• encouraging family participation in treatment (Arredondo, Kumli, Soto, Colin, Ornellas, Davilla, Edwards, & Hyman, 2001; Cocozza & Skowyra, 2000).

Family and community-based treatment have been found to be the most effective form of intervention for successfully treating youth with mental health disorders and reducing recidivism, and every attempt should be made to keep youth in their home and community environments while providing a comprehensive array of services that respond to their mental health and related problems. A 2000 review of the research on the characteristics of effective treatments for youth in the juvenile justice system found that community-based treatment and programs are generally more effective than incarceration or residential placement in reducing recidivism, even for serious and violent juvenile offenders (Lipsey, Chapman, & Landenberger, 2001). Further, numerous reviews of new, evidence-based treatment interventions, such as Multi-Systemic Therapy, Functional Family Therapy and Multi-Dimensional Treatment Foster care, have consistently found positive outcomes associated with their use with youth referred from the juvenile justice system, including decreased psychiatric symptomatolgy and reduced long-term rates of re-arrest (Elliot, Henggeler, Mihalic, Rone, Thomas, & Timmons-Mitchell, 1998). These evidence-based interventions are all family and community-based models, and are being used throughout the country for youth referred from the juvenile justice system. Diverting youth into effective treatment that addresses their mental health needs and reduces the likelihood of further delinquency offers a more effective alternative than simply locking them up with limited access to effective treatment. This is a group of youth who could safely and appropriately be diverted to community-based services with only minimal juvenile justice system involvement, most typically in the form of probation supervision.

Youth represented in Quadrant IV are the most challenging group of juvenile offenders. This includes youth who have committed a serious or violent offense requiring juvenile justice system involvement, and who also have significant mental health needs. Frequently, these youth are placed in secure juvenile justice facilities. While some correctional facilities have the capacity to identify and appropriately treat mental disorders among youth in their care, many facilities do not, raising significant concerns around the appropriateness of incarceration for youth with significant mental health needs. Many juvenile justice scholars agree that juvenile correctional settings should be reserved only for a small number of chronic or serious juvenile offenders, with graduated or community-based options used for all other offenders (Redding, 2000). There is evidence that traditional incarceration, scared straight programs, wilderness programs, and boot camps are typically not effective for youth with mental illness, and that youth have a better chance of success when receiving services and treatment in the least restrictive setting possible, generally within the context of their homes or communities (Coalition for Juvenile Justice, 2000). The general philosophy of interventions with children and adolescents is to provide appropriate services in the least restrictive setting possible (Rogers, 2003). Community-based interventions involve a youth’s family and community, and focus on helping a youth function more effectively in their natural environment. Recently, communities have begun to use community-based alternatives to placement for serious offenders with mental health needs. Diversion strategies used for this population of youth link youth with treatment but also employ strict supervision strategies to monitor the youth in the community to ensure compliance with the terms of the referral or court order.