Cornerstone #2: Identification

Recommended Actions

2.1  Every youth who comes in contact with the juvenile justice system should be systematically screened for mental health needs to identify conditions in need of immediate response, such as suicide risk, and to identify those youth who require further mental health assessment or evaluation. While a screen is considered most critical at a youth’s earliest point of contact with the juvenile justice system, for example at probation intake, it should also be employed periodically to monitor a youth’s mental health status at all stages of justice system involvement, particularly after transitions from one setting to another (e.g., detention to secure corrections).

Some states require that all youth entering the juvenile justice system be administered a mental health screen. For example, in 2001, Texas mandated that all juvenile probation departments in the state administer the Massachusetts Youth Screening Instrument (MAYSI-2) to all youth entering probation intake (Texas Juvenile Probation Commission, 2003). The MAYSI-2 is a 52-item self report instrument that identifies potential mental health and substance use needs of youth at any entry or transitional placement point within the juvenile justice system. The instrument has been widely tested and demonstrates strong validity and reliability when used with the juvenile justice population.

In 2004, the Minnesota state legislature enacted statewide mental health screening for child welfare and juvenile justice populations (Wyss, 2004). This legislation, however, allows for exemptions under certain conditions, such as if a youth has undergone a mental health screen within the last 180 days, or if a parent objects to their child undergoing a mental health screen and communicates this concern to the court in writing. The state has opted to use both the MAYSI-2 as well as the Problem-Oriented Screening Instrument for Teenagers (POSIT) with youth in the juvenile justice system. The POSIT, which takes approximately 25 minutes to administer, is a 139 item self-report screening instrument that measures a variety of problem areas, including mental health and substance abuse, and also includes questions about mental health and juvenile justice system contacts (Grisso & Underwood, 2004).

2.2   The mental health screening process should include two steps—the administration of an emergency mental health screen as well as a general mental health screen. The first step in the process involves an initial “emergency” screen whose purpose is to identify any immediate mental health crisis, the potential risk of suicide or harm to self or others, and to determine whether the youth is currently on any type of psychotropic medication. It is recommended that this initial screen be conducted within the first hour of a youth’s contact with the system, regardless of the setting. Often, these questions are included within an overall health intake screen conducted immediately upon intake. However, they can be asked separately as part of a mental health intake process.

The second step of the screening process involves the administration of a mental health screen, whose purpose is to identify any mental health concerns that require further evaluation or assessment. This screen should be brief in nature and easily administered by non-clinical staff within a variety of juvenile justice settings. Mental health screening is conducted to determine short-term needs. Screening results alone should not be used to make long-term treatment planning decisions, but to make informed decisions about the need for immediate service or follow-up evaluation. A mental health screen should be administered to youth anywhere from 24 to 48 hours after initial contact with the juvenile justice system.

Some jurisdictions are using the MAYSI-2 to screen for emergency mental health needs, as well as to determine the need for further mental health evaluation. Other jurisdictions use a separate emergency mental health screen, and then follow-up with a mental health screen. For example, Washington State uses the Youth Suicide Risk Assessment (SRA) to determine whether a youth has immediate mental health needs that need to be addressed, and then administers the MAYSI-2 as the mental health screen.

2.3  Access to immediate mental health services should be available for all youth who, based on the results of the emergency screen or the mental health screen and staff observations, indicate a need for emergency services.  Crisis conditions typically involve youth who are believed to be at risk of harm to self or others, youth who are at immediate risk of substance use consequences (e.g., withdrawal), youth in acute mental or emotional distress, and youth who are at risk of discontinued medication (Grisso, 2004). Youth identified as “in crisis” must be provided immediate access to psychiatric and other medical services. This can include immediate referral to a mental health facility or hospital, or placement of the youth in a separate and specialized unit of a detention or correctional facility (if such conditions are available within the facility) for psychiatric care and close staff monitoring. All probation intake units and detention centers should have referral procedures in place for youth in need of immediate psychiatric placement or hospitalization, and should have access to a psychiatrist and a pharmacy to ensure continued medication administration for youth already on psychotropic medication.

2.4  A mental health assessment should be administered to any youth whose mental health screen indicates the need for further assessment. This assessment should be based on a review of information from multiple sources (for example, mental status examination, case records, family interviews) and must measure a range of mental health concerns. A mental health assessment will yield more detailed, and sometimes diagnostic, information about a youth’s mental health status and can be used to form the basis of treatment recommendations.

The Voice Diagnostic Interview Schedule for Children (Voice DISC) is one example of a mental health assessment instrument that was designed specifically for use with youth in juvenile justice settings (Grisso & Underwood, 2004). This is a structured youth self-report interview, administered on a computer that provides provisional DSM-IV diagnoses on a range of disorders, including anxiety disorders, mood disorders, disruptive disorders, and substance use disorders. It has been extensively tested on the juvenile justice population and is being used in juvenile justice settings (probation, detention and corrections) in 13 states.

2.5  Instruments selected for identifying mental health needs among the juvenile justice population should be standardized, scientifically sound, have strong psychometric properties, and demonstrate reliability and validity for use with youth in the juvenile justice system. In addition, it is important to recognize that the developmental needs of younger adolescents are different from those of older adolescents, and care should be taken to select instruments that are developmentally appropriate for the target group of youth who will be screened and assessed.

• A number of excellent resources are available to help guide the selection of screening and assessment instruments. These resources include:
• The National Center for Mental Health and Juvenile Justice Research and Program Brief on Screening and Assessing Mental Disorders Among Youth in the Juvenile Justice System (2003);
• OJJDP’s Screening and Assessment Resource Guide for Practitioners (2004)
• The Handbook of Mental Health Screening and Assessment for Juvenile Justice by Thomas Grisso, Gina Vincent, & Daniel Seagrave (2005).

2.6  Mental health screening and assessment should be performed in conjunction with risk assessments to inform referral recommendations that balance public safety concerns with a youth’s need for mental health treatment. Assessing a youth’s risk for future violence or re-offending is a critical function of the juvenile justice system and is necessary in order for the system to satisfy its obligations to ensure public safety. Mental health screening and assessment must be linked to the administration of risk assessments, to fully inform decision-makers about the risks and needs that each youth presents. The combined results of these screens and assessments should be used to guide decisions that not only ensure the appropriate level of security or supervision, but that also ensure that youth have access to the services and treatment that they need. The Washington State Juvenile Court Assessment (Washington State Institute for Public Policy, 2004), and the Global Risk Assessment Device (GRAD) (Gavazzi, Slade, Buettner, Partridge, Yarcheck, Andrews, 2003) are both examples of risk assessment instruments for youth in the juvenile justice system.

2.7  All mental health screens and assessments should be administered by appropriately trained staff. Most instrument developers provide guidelines for the level of training and/or education needed in order to appropriately administer the instrument. Often, screening instruments for use in juvenile justice settings, such as probation, detention or corrections are designed to be administered by non-clinical staff, such as juvenile justice staff who are trained on how to administer and interpret the instrument. Assessments, on the other hand, typically require more extensive and individualized data collection and most often (although not always) require the expertise of a mental health professional.

2.8  Policies controlling the use of screening information may be necessary to ensure that information collected as part of pre-adjudicatory mental health screen is not used inappropriately or in a way that jeopardizes the legal interests of youth as defendants. Legally, there are concerns about the appropriateness of having youth disclose information in a pre-adjudication setting, such as detention, that could be used against them in court (Grisso, 2004). There is a concern that a youth’s responses to a mental health screen, for example their admission to using drugs, tendencies toward anger or poor attitudes about school, could be used in plea bargaining at trial or to argue for more restrictive dispositions after adjudication. Information disclosed to detention staff during a mental health screen or assessment may not be confidential. Facilities that are responsible for managing youth prior to adjudication must balance the need to provide mental health care with the responsibility to protect youth from self-incrimination (Wasserman et al., 2003).

Two potential solutions to this problem are offered by Grisso. The first is to select screening tools, in part, on the basis of the degree of jeopardy associated with their content and questions, selecting tools that minimize the potential prejudice as much as possible while still meeting primary objectives. The second solution is to develop a policy that restricts the use of pre-trial mental health screening information to the use for which it was intended—to identify any immediate mental health concerns and the need for further evaluation. In Texas, this issue was resolved by having a clause inserted in state juvenile justice legislation prohibiting the use of mental health screening information in any legal proceeding against youth. Other communities have resolved the issue by developing agreements between the prosecutor and the juvenile defense bar that place limits on the use of this information (Grisso, 2004). Strong judicial leadership on this issue is considered essential. In almost all instances where agreements have been reached to limit the use of screening data and protect youth from this information being used during adjudication, judges have played a pivotal role in establishing the policy (Grisso, 2004).

2.9  Mental health screening and assessment should be performed routinely as youth move from one point in the juvenile justice system to another, for example from pre-trial detention to a secure correctional facility. Since screening provides a view of a youth’s short-term and immediate needs, it is recommended that it be performed repeatedly, as youth transition within or out of the juvenile justice system (say from detention to corrections or corrections to the community), as well as periodically during long sentences to monitor any changes that may occur in a youth’s mental status.

As more jurisdictions implement mental health screening measures for youth involved with the juvenile justice system, new questions have arisen about the need for repeat mental health screens as youth move through the system. How frequent is too frequent? How much time should pass between screenings? Can screening information be passed on between points of contact within the system so that repeat screenings are unnecessary? These questions are playing out in communities across the country that have implemented screening mechanisms. For example, one jurisdiction, following local rules, was re-screening youth who were returning to detention following a court appearance because local rules called for all youth to be screened who were entering detention from the community. One might interpret this as unreasonable—the youth had only been “in the community” for several hours in court and there would be no reason to re-screen. Another interpretation might make a re-screen necessary if the court appearance had gone badly and the youth was despondent or emotionally upset as a result of the appearance. Research is currently underway in the field that hopefully, will begin to provide more guidance around these types of issues and questions. Until then, we would argue that systems employ a standard that errs on the side of caution but recognizes the need for flexible and refined application as necessary.

2.10  Given the high rates of co-occurring mental health and substance use disorders among this population, all screening and assessment instruments and procedures should target both mental health and substance use needs, preferably in an integrated manner. There have been advances made to develop instruments that identify the presence of mental health and co-occurring substance use disorders among youth. The MAYSI-2 and the POSIT, both mentioned earlier, can be used to screen for mental health and co-occurring substance use needs. Another example is the Global Appraisal of Individual Needs (GAIN), which is an evaluation instrument that includes questions for documenting substance use and mental health disorders (Grisso & Underwood, 2004). Designed for use in diverse settings, including juvenile justice, the instrument is organized into sections that assess current symptoms over the past year and the frequency of symptoms over the last 90 days.

2.11  Existing screening and assessment instruments may need to be adapted for critical groups of youth, particularly youth of color and girls, pending further research.  While the field has seen significant advances in the general area of mental health screening and assessment over the last decade, more needs to be done to develop mental health measures that are responsive to the needs of specific populations of youth within the juvenile justice system. There continues to be substantial evidence that youth of color (especially black youth) are overrepresented at virtually every key processing point within the juvenile justice system (Snyder & Sickmund, 1999) in comparison to their proportions in the general population (Snyder, 2003). Studies have found that youth of color in the juvenile justice system experience substantial rates of mental health disorders (NCMHJJ, 2005). Many mental health screening and assessment tools currently being used with youth were originally developed with samples of youth in which the majority of youth were non-Hispanic white (Grisso et al., 2004). If these instruments perform differently when used with youth of color, it could result in the under-identification or misidentification of mental health needs (Grisso, et al., 2004). Given the large numbers of youth of color in the juvenile justice system and the expected growth of minority youth in the general youth population over the next decade (Snyder & Sickmund, 1999), it is imperative that more research be directed to increasing the availability of culturally valid mental health screening and assessment tools that are tested and analyzed on youth of color. These tools will lead to the better identification of mental health needs, and ultimately the development of more informed treatment plans to ensure that these youth have access to the most appropriate and effective interventions.

Until better tools are available, it is important to select screening and assessment instruments whose validation samples included substantial numbers of youth of color. It is also important to determine if the developer of the instrument provides data on ways in which different minority groups score on average on the instrument’s scales, and whether the instrument has been translated into languages that are relevant to the population of youth being evaluated. (Grisso, 2004). Beyond the selection of culturally valid instruments, it is important that screening and assessment be performed in a way that is sensitive to the influences of each youth’s culture, heritage and ethnicity (Underwood, 2002).

Girls represent one of the fastest growing segments of the juvenile justice population (Greene, Peters and Associates, 1998). Between 1990 and 1999, the number of delinquency cases involving males increased by 20 percent while the number of delinquency cases involving girls increased by 60 percent (U.S. Department of Justice, 2003). Juvenile court statistics indicate that between 1990 and 1999, the number of cases in which courts ordered delinquent girls to be placed in a residential facility increased by 64 percent, while the number of formal probation cases increased by 53 percent (U.S. Department of Justice, 2003). There is a strong body of evidence indicating that the majority of girls in the juvenile justice system have significant mental health and substance abuse needs. The study conducted as part of the development of this Model found that over 81 percent of girls in the sample, as compared to 66.8 percent of boys, met criteria for at least one mental health disorder. Girls were at significantly higher risk for anxiety disorders, mood disorders, and substance use disorders (NCMHJJ, 2005). These findings are consistent with prior research documenting high rates of mental disorders among female juvenile detainees (Teplin, Abram, McClelland, Dulcan, & Mericle, 2002).

Despite the steady increases in the number of girls involved with the juvenile justice system, many of the mental health screening and assessment instruments designed for use in juvenile justice settings traditionally were developed for boys. This tradition is changing but is still in evidence (Grisso & Underwood, 2002). We know from the research that there are other girl-specific issues that should be taken into consideration such as a history of trauma and abuse and the presence of children. Further, the literature suggests that many disorders common among girls, such as depression and anxiety, tend to go unnoticed. Screens and assessments must be designed to ensure that disorders not typically associated with aggressive behaviors are identified (Veysey, 2003).