Cornerstone #1: Treatment

Recommended Actions

4.1  Youth in contact with the juvenile justice system who are in need of mental health services should be afforded access to treatment. This includes youth who are diverted into the community as well as youth who cannot be diverted and are placed in residential programs. The Coalition for Juvenile Justice, in their 2000 Annual Report, “Handle with Care: Serving the Mental Health Needs of Young Offenders” identifies the following as important characteristics of treatment programs:

• Highly structured, intensive, and focused on changing specific behaviors
• Emphasize the development of basic social skills
• Provide individual counseling that directly addresses behavior, attitudes, and perceptions
• Sensitive to a youth’s race, culture, gender, and sexual orientation
• Use community-based treatment rather than institutional-based programs
• Involve family members in the treatment and rehabilitation of their children
• Provide individualized services, support, and supervision to each child and family
• Within institutions, use mental health professionals, rather than corrections staff, as treatment providers
• Offer developmentally driven services that recognize adolescents think and feel differently than adults, especially when under stress
• Include an aftercare component
• Focus on measuring program effectiveness and meeting quality standards.

4.2  Regardless of the setting, all mental health services provided to youth should be evidence based. Enormous advances have been made in this area over the last decade, and there are now evidence-based interventions, including improved psychosocial approaches, medication therapies, and family and community-based models, that are well documented and proven effective for treating mental disorders among youth (Hoagwood, 2005).

Examples of some of the most effective interventions are identified below.

A) Home and Community-Based Models. Family and community-based treatments have been found to be effective forms of intervention for successfully treating youth with mental health disorders and reducing recidivism. 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 offenders (Lipsey, Chapman, & Landenberger, 2001). Examples of these models include:

Multi-Systemic Therapy: This is an intensive, family-based intervention for juvenile offenders with serious antisocial behavior who are at imminent risk of out of home placement. MST therapists collaborate with the family to determine the factors in the youth’s “social ecology” that are contributing to the identified problems and design strategies for addressing these problems. Ultimately, the goal of MST is to empower families to cope with the challenges of raising children with emotional problems and to empower youth to cope with family, peer, school, and neighborhood difficulties (Henggeler, 1997).

Functional Family Therapy: This is a family-based prevention and intervention program therapy for youth who have demonstrated the entire range of maladaptive, acting out behaviors and syndromes. It is designed to improve family communication and problem-solving skills and includes phases that build on each other. These phases include engagement and motivation, assessment, behavior change, and generalization (Sexton & Alexander, 2001).

Multi-Dimensional Treatment Foster Care: This is a family-based foster care program used as an alternative to institutional care for juvenile offenders with severe antisocial behavior. 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 in order to closely supervise youth who are placed in their care. 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 (Chamberlain, 1998).

B)  Psychosocial Therapies. Psychosocial treatments, sometimes called talk therapy, are used to provide guidance and support to persons with mental illness. They are typically provided by trained professionals, including psychologists, psychiatrists, social workers, or counselors. The type and duration of the treatment will vary depending on the needs of the youth and the individual treatment plan that is developed. Some examples include:

Cognitive Behavioral Therapy: This is a relatively short-term, focused psychotherapy that combines two forms of therapy—cognitive therapy and behavior therapy—to address a wide range of psychological problems. It is action-oriented and helps youth gain independence and effectiveness in dealing with real life problems (Burns, Hoagwood, & Mrazek, 1999)

Brief Strategic Family Therapy: This is a time-limited, family-based therapy that attempts to change family interactions and cultural/contextual factors that influence a youth’s behavior problems. It targets unsuccessful family interaction patterns that are directly related to the youth’s behavior problems and establishes a practical plan to help the family develop more effective patterns of interaction (USDHHS, 2004).

Aggression Replacement Therapy: This is an intensive life skills intervention that is designed to alter the behavior of aggressive youth, reduce antisocial behavior and offer alternative pro-social skills. ART has three main components—Structured Learning Training, which teaches social skills; Anger Control Training, which teaches youth a variety of ways to manage their anger; and Moral Education, which helps youth develop a higher level of moral reasoning (Goldstein, Glick, Reiner, Zimmerman, Coultry, & Gold, 1986).

Dialectical Behavior Therapy: This is a mode of treatment designed for individuals with borderline personality disorder particularly those with suicidal behavior. Dialectical behavioral therapy aims to help people validate their emotions and behaviors, examine those behaviors and emotions that have a negative impact on their lives, and make a conscious effort to bring about positive changes (Swenson, Torrey, & Koerner, 2002).

C)  Medication Therapies. Advances have been made to improve medication therapies for treating specific disorders in children and youth, such as attention deficit hyperactivity disorders (ADHD), depression, and certain anxiety disorders (Hoagwood, 2005). These advances have significantly improved the quality of life for many youth and have enabled them to remain in the community in the least restrictive and most natural living arrangement possible (Burns & Hoagwood, 2002).

Many of the psychosocial and medication therapies can and are being used with youth who are committed to secure care, and there are efforts underway to abstract elements of community-based models for use in correctional settings. Washington State’s Juvenile Rehabilitation Administration (JRA), recognizing the sizable portion of youth with mental health needs in their system, created a program that incorporates best practice interventions for youth with mental health needs. The Integrated Treatment Model (ITM) takes the evidence-based components of Cognitive Behavioral Therapy, Dialectical Behavioral Therapy and Functional Family Therapy and uses these therapies to provide individual treatment and skill development to youth from the point that they are admitted to a secure facility through their release back to the community (Juvenile Rehabilitation Administration, 2002). Staff within JRA’s correctional and community-based facilities were extensively trained to use cognitive-behavioral treatment interventions to address the multiple treatment needs of youth and prepare youth for their return to the community. Wanting to maximize the positive changes begun in residential care using this new cognitive-behavioral approach, JRA also redesigned its aftercare program to gear aftercare service to families, as opposed to individual youth. Parole counselors were trained in a new service delivery model, called Functional Family Parole, based on Functional Family Therapy, which focuses on techniques for motivating and engaging families in the rehabilitation process, and teaching families to recognize and support positive changes made by the youth (JRA, 2002).

4.3  Responsibility for providing mental health treatment to youth involved with the juvenile justice system should be shared between the juvenile justice and mental health systems, with lead responsibility varying depending on the youth’s point of contact with the system.  In light of the growing awareness around the large numbers of youth in the juvenile justice system with mental health needs and the increasing pressure on the juvenile justice system to respond to these youth, it is necessary to clarify the roles and responsibilities that each system has for responding to the treatment needs of these youth. Currently, there is a great deal of confusion in the field about who is responsible for providing mental health treatment to youth involved with the juvenile justice system and how this treatment is best provided. It is recommended that responsibility for treatment be shared between the two systems, with primary responsibility shifting between the two agencies depending on the point of contact within the juvenile justice system. Examining the juvenile justice system as a continuum and identifying the general stages of activity can provide a context in which to begin to determine responsibility. Earlier in the document, we presented the seven key points within the juvenile justice continuum for mental health intervention (see pages 5–6). For the purposes of determining responsibility for mental health treatment, these key points have been grouped into three stages, depicted below in Figure III.

Stage 1 includes pre-adjudicatory processing; Stage 2 includes placement in a secure correctional facility or on probation supervision; and Stage 3 represents re-entry to the community following a juvenile correctional placement. Using this framework, the mental health system would have primary responsibility for providing treatment at the front and back ends of the continuum, with the primary locus of care being community or home-based settings. The juvenile justice system, in turn, would have primary responsibility for mental health treatment in the middle of the continuum, for youth who are committed to secure care and placed on probation supervision, according to the diagram.

For example, youth who are diverted to community-based treatment at probation intake, detention or juvenile court would most likely be diverted to a community-based mental health provider. While the juvenile justice system might still have supervision and oversight responsibilities for these youth, the mental health system would assume primary responsibility for treatment.

Youth with mental health needs who cannot be diverted from juvenile detention and remain in custody until the dispositional hearing should be afforded access to mental health treatment during this period. However, given the short-term nature of these placements, it does not make sense for detention centers to create long-term mental health treatment capacity within their facilities. Doing so could inadvertently result in more youth being placed in detention solely to access treatment services, a phenomenon referred to as net-widening. Rather, the recommended approach is that detention centers be able to systematically identify mental health needs among youth entering the detention system and have the capacity to link with community-based providers to provide treatment. Youth could receive treatment in one of two ways: they could be referred out of detention to receive mental health treatment over the course of their detention stay or mental health providers could come in and provide services to youth in the facility. Under this arrangement, the juvenile justice system would have primary responsibility for ensuring that youth have access to short-term treatment, but actual mental health service delivery would primarily fall to the mental health system. (Examples of programs that have been developed to provide mental health services to youth in detention can be found on pages 65–97).

Adjudicated youth with mental health needs who are placed on probation supervision would likely be referred to a community-based mental health treatment provider, per the terms of the dispositional order. While the juvenile justice system would monitor and supervise the youth in the community as part of probation supervision plan, primary responsibility for mental health treatment would fall to the mental health system. For youth who are committed to a secure juvenile justice facility, a higher level of responsibility for providing mental health services to youth would fall to the juvenile justice system. Youth are typically placed in these settings for longer periods of time, creating an opportunity to capitalize on the period of confinement to provide treatment that aids in a youth’s rehabilitation, and prepares them for their eventual return home.

There are different models for providing treatment to youth in juvenile justice facilities. New York State, for example, operates Mobile Mental Health teams to provide mental health services and treatment to youth in the state’s juvenile correctional system. Executed through an annual Memorandum of Understanding (MOU) between the NYS Office of Mental Health and the NYS Office of Children and Family, teams of mental health professionals are deployed throughout the state to provide on-site assessment, crisis intervention, and counseling services to youth incarcerated in juvenile correctional facilities. In addition, mental health team members conduct case consultation with OCFS facility staff and provide staff training as necessary. Other states, such as Ohio and Texas, have chosen to create specialized mental health facilities within the state’s juvenile justice system. Youth are typically referred to these specialized facilities after undergoing a comprehensive evaluation at a centralized intake or reception center. Youth receive intensive clinical and other services during their incarceration by treatment staff who are employed by the state juvenile justice agency.

At the back end of the continuum, as youth are released from secure care and transition home, primary responsibility for mental health treatment would fall to the mental health system. Youth in need of mental health services would be referred to community-based mental health providers as part of their re-entry plan. While the juvenile justice system would retain responsibility for supervising youth as part of an aftercare plan (in the form of probation or parole), responsibility for providing mental health treatment would fall primarily to the mental health system.

4.4  Qualified mental health personnel, either employed by the juvenile justice system or under contract through the mental health system, should be available to provide mental health treatment to youth in the juvenile justice system. Regardless of the setting and which agency has primary responsibility for treatment, all mental health services available to youth involved with the juvenile justice system should be provided by qualified mental health personnel. These include psychiatrists, psychologists, psychiatric nurses, social workers, and others, who by virtue of their credentials, are permitted by law to evaluate and care for the mental health needs of patients (AACAP, 2004).

In community settings, these staff would be employed by the public or private mental health provider. In juvenile facilities, these staff would be employed either by the juvenile justice agency that is responsible for operating the facility, or by a public or private mental health provider that contracts with the facility to provide treatment services. Contractual arrangements are most easily achieved through linkages between the juvenile justice and mental health systems, and these arrangements can vary from consultation and support to the actual delivery of services. Generally, it is not advisable for non-clinical staff, such as line staff within the juvenile justice system, to provide mental health services to youth. Further, many of the new evidence-based interventions call for strict adherence to a standardized set of implementation protocols that often dictate who can provide the intervention and the type of training that is necessary to credentialize a provider.

4.5  Families should be fully involved with the treatment and rehabilitation of their children. In order for families to be actively involved with their child’s mental health treatment, they need to be informed about the juvenile justice system and the mechanisms for their participation in its proceedings. Families can provide a strong source of support for their children, serve as advocates to make sure youth get the care they need, and work in partnership with the juvenile justice and treatment staff by providing them with information that can aid in a child’s treatment.

As part of the development of the Model, a series of focus groups were convened with families to learn more about how the juvenile justice and mental health systems can be improved to better respond to youth with mental health needs. These focus groups revealed the following:

• Support to families was viewed as critical to help them effectively navigate the juvenile justice system and better understand their rights and responsibilities;
• Families view the treatment services within the juvenile justice as largely inadequate. One of the few exceptions was wraparound services that link community services with in-home services; and
• Families want to be more involved with the process and viewed as potential resources and sources of support by juvenile justice staff and treatment providers.

In order for families to be actively involved, they need information. It is reasonable to believe that when families feel supported and have an understanding of what they can expect to happen to their child, they will be more inclined to support and participate in their youth’s treatment than families who are not provided essential information about the process. The NCMHJJ Research and Program Brief, Involving Families of Youth Who Are in Contact with the Juvenile Justice System (2003), provides specific and concrete examples of ways in which family involvement can be supported at each stage of juvenile justice processing. Examples include asking parents how they want to be involved, ensuring that parents understand the adjudication process, and asking parents about the supports they may need to comply with the conditions of release and assisting them in accessing those supports.

Many families are capable of being strong advocates for their children while they are involved with the juvenile justice system and are actively involved with their child’s mental health treatment. It must be noted, however, that some families do not have the capacity to be involved in their child’s treatment; in other instances, the involvement of the family could actually be damaging to a youth. In these situations, it is important that a youth’s opportunity to participate in treatment not be jeopardized by their family’s lack of involvement. Every effort should be made to ensure that there is someone available to support and advocate for the youth, and be actively involved with their rehabilitation. The National Federation of Families for Children’s Mental Health, in their definition of family driven mental health care, calls for all children and youth to have a biological, adoptive, foster or surrogate family voice advocating on their behalf. If a biological family member is not available, it is important that steps be taken to identify someone else who could serve as an advocate for the child while they are involved with the juvenile justice system, and support the youth’s involvement in mental health and other types of treatment (Federation of Families for Children’s Mental Health, 2005).

4.6  Juvenile justice and mental health systems must create environments that are sensitive and responsive to the trauma-related histories of youth. Many youth in the juvenile justice system have been exposed to numerous traumatic events at some point in their life, either as witnesses or as victims (Mahoney, Ford, Ko, & Siegfried, 2004). Many of these youth are the victims of physical or sexual abuse (National Clearinghouse on Child Abuse and Neglect, 2005). As a result, many of these youth develop post-traumatic stress disorder (PTSD) and other mental disorders that impact their ability to achieve normal developmental milestones in a timely manner (Arroyo, 2001). Studies have documented high prevalence rates of post-traumatic stress disorder among youth in the juvenile justice system, and indicate that trauma and PTSD appear to be more prevalent among juvenile detainees than in community samples, and more common among girls than boys (Abram, Teplin, Charles, Longworth, McClelland, & Duncan, 2004; Saigh, Yasik, Sack, & Koplewicz, 1999). For some youth, the juvenile justice experience itself can be a traumatic event, and can trigger memories and reactions to previous traumatic experiences (Mahoney et al., 2004). This is especially true for girls, where traditional methods of juvenile justice management and control (such as seclusion, restraint, and other physically confrontational approaches) can exacerbate feelings of loss of control and result in re-traumatization (Hennessey, Ford, Mahoney, Ko, & Siegfried, 2004).

Youth exposed to traumatic events can exhibit a wide range of symptoms, presenting not just internalizing problems, such as depression or anxiety, but also externalizing problems as well, such as aggression, conduct problems, and oppositional or defiant behavior patterns (Caporino, Murray, & Jensen, 2003). Very often, externalizing problems associated with trauma manifest themselves in behaviors that bring youth to the attention of the juvenile justice system. As such, it is increasingly important for juvenile justice and mental health staff to understand that there are multiple pathways to similar symptom patterns, and staff should be trained to routinely inquire about a history of trauma in their encounters and interactions with youth who present behavior problems (Caporino et al., 2003). The research tells us that trauma exposure puts youth at risk for PTSD as well as other mental health disorders (Albert, Chapman, Ford, & Hawke, overheads). Therefore, it is recommended that trauma-related questions be included as part of the mental health screening and assessment process used with youth involved with the juvenile justice system. Some instruments, such as the MAYSI-2 and the V-DISC, include questions about traumatic experiences. Other instruments have been designed to specifically address trauma among children and youth. These include the Traumatic Events Screening Inventory for Children (Ford et al., 2000), the UCLA PTSD Index (Pynoos et al., 1998), the Trauma Symptom Checklist for Young Children (Briere, 2005), and the Childhood Trauma Questionnaire (Bernstein, Ahluvalia, Pagge, & Handelsman, 1997).

In terms of trauma-focused treatment, Cognitive Behavioral Therapy has emerged as the best validated therapeutic approach for children and adolescents who experience trauma-related symptoms, particularly symptoms associated with anxiety or mood disorders (Caffo & Belaise, 2003). The National Child Traumatic Stress Network reports that Cognitive Behavioral Therapy for PTSD (Cohen, Mannarino, & Deblinger, 2003) received the highest rating for adolescent trauma treatment in a 2003 U.S. Department of Justice publication on treatment for victims of physical or sexual trauma (Mahoney et al., 2004). Other therapies that do not address PTSD directly but have empirical support that they effectively target symptoms and functional problems associated with PTSD include Behavioral Parent Training, Multi-Systemic Therapy, Functional Family Therapy, Multi-Dimensional Treatment Foster Care, and Brief Strategic Family Therapy (Mahoney et al., 2004).

4.7  Gender-specific services and programming should be available for girls involved with the juvenile justice system. There is growing evidence that large numbers of girls in the juvenile justice system have significant mental health needs (NCMHJJ, 2005; Teplin et al., 2002). In order to effectively respond to these girls, it is important to understand the gender-related issues that impact their experiences in the juvenile justice system. First, girls often present very complicated clinical profiles as a result of the pervasive violence they have experienced in their lives (Prescott, 1997). Girls are three times as likely as boys to have experienced sexual abuse, which is often an underlying factor in high-risk behaviors that lead to delinquency (Greene et al., 1998). Girls who have been abused or neglected are nearly twice as likely to be arrested as juveniles as those who have not (Widom, 2000). Research shows that girls and boys respond to different experiences differently and have different pathways to delinquency. Girls tend to get into trouble more quietly than boys (Greene et al., 1998) by manifesting internalizing disorders, such as depression and anxiety (Veysey, 2003), and may hurt themselves by abusing drugs, prostituting themselves, or mutilating themselves (Belknap, 1996). Because these behaviors may not seem dangerous to society, their mental health needs may be overlooked or untreated (Greene et al., 1998)

Significant research has been done within the last several years to better understand these gender differences. This research has led to a greater understanding of the importance of providing gender-specific services to girls involved with the juvenile justice system. Gender-specific services refer to program models or services that comprehensively address the special needs of a targeted gender group, such as adolescent girls. These services foster positive gender identity development, recognizing the risk factors that are most likely to affect girls, as well as the protective factors that can build resiliency and prevent delinquency (Greene et al., 1998).

The PACE (Practical and Cultural Education) Center, in Florida is a non-residential, gender-specific, school-based prevention and diversion program for adolescent girls ages 12 to 18. Referrals to the program are accepted from many sources, including the Florida Departments of Juvenile Justice and Children and Families, as well as from schools, community providers, and family members. THE PACE Center also provides training and technical assistance to the juvenile justice system and community providers to help them develop gender-responsive programs for at-risk girls (PACE, 2005).

4.8  More research is necessary to ensure that evidence-based interventions are culturally sensitive and designed to meet the needs of youth of color. Despite the advances that have been made to develop and implement evidence-based mental health treatments for youth in general and youth in contact with the juvenile justice system, some significant gaps remain. The U.S. Surgeon General’s Report on Culture, Race and Ethnicity, prepared as a supplement to the Surgeon General’s Report on Mental Health, found the gap between evidence-based research and practice to be particularly problematic for racial and ethnic minorities (USDHHS, 2001). An analysis conducted as part of the preparation of the report revealed that clinical research trials, used to generate professional treatment guidelines, did not conduct specific analyses for any minority group (USDHHS, 2001). It is critical that ethnic-specific analyses be routinely conducted in clinical research to ensure that treatment is effective for a diverse range of individuals who could benefit from such treatment. This is particularly necessary for youth in the juvenile justice system, given the fact that minority youth are over represented at virtually every key processing stage (Snyder &Sickmund, 1999).

There is also a need for investment in research to develop new evidence-based treatment interventions for specific minority populations. There is evidence indicating that programs that specialize in serving identified minority communities are successful in encouraging minorities to enter and remain in treatment (USDHHS, 1999). These programs appear to succeed by maintaining active, committed relationships with community institutions and leaders and making aggressive outreach efforts; by maintaining a familiar and welcoming atmosphere; and by identifying and encouraging styles of practice best suited to the unique problems of racial and ethnic minority groups (USDHHS, 1999). Investment in clinical research to determine the extent to which these programs improve treatment outcomes for youth and families is necessary.

4.9  All youth in juvenile justice placement should receive discharge planning services to arrange for continuing access to mental health services upon their release from placement. Ideally, planning for a youth’s re-entry into the community should begin shortly after a youth’s arrival in placement. The goal of the placement is to successfully rehabilitate the youth for their eventual reintegration into society. Critical to this is recognizing a youth’s need for mental health services, providing effective services while a youth is in care, and ensuring that linkages are in place to allow for continued access to quality mental health care upon release. All re-entry planning should include efforts to ensure a youth’s enrollment in Medicaid or some other type of insurance plan to pay for services upon release. A more detailed discussion of re-entry services for youth with mental health needs can be found on page 62.