Cornerstone #4: Treatment

4.  Youth with mental health needs in the juvenile justice system should have access to effective treatment to meet their needs.

Background

Youth who require mental health treatment should be afforded access to treatment regardless of the setting in which they reside. Clearly, as indicated in the prior chapter, every attempt should be made to divert youth with mental disorders into appropriate and effective community-based care. However, it is recognized that diversion will not be an option for all youth. For those youth who cannot be diverted and who remain in juvenile detention or correctional settings, access to quality mental health treatment must be provided to aid in their rehabilitation.

The 2000 Surgeon General’s Report on Children’s Mental Health indicated 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 in the general population with severe mental illness will receive the treatment that they need (USDHHS, 2000). There is simply not enough mental health treatment capacity in this country to respond to the need.

The situation for youth in the juvenile justice system is worse, where an estimated 65 to 70 percent of youth meet criteria for a mental health disorder. Investigations by the U.S. Department of Justice of juvenile detention and correctional facilities across the country have consistently found a lack of appropriate mental health screening, assessment and treatment services available to youth, a lack of qualified mental health personnel available to these youth, the inappropriate use of medications, and inappropriate responses to suicide threats (US DOJ, 2005). The results of the study conducted as part of this project validate these findings. Of those youth with a mental health diagnosis, only 64 percent reported receiving mental health services while in their current juvenile justice placement. The adequacy of substance abuse treatment appears to be even more problematic. Only 35 percent of those youth diagnosed with a substance use disorder reported receiving any substance abuse services (NCMHJJ, 2005).

Up until about 10 years ago, there was a general sense that “nothing works” for youth with mental health needs in the juvenile justice system. Since that time, significant research advances have broadened our understanding of the nature of mental health disorder among youth and have led to an improved understanding of the characteristics of effective treatment and intervention programs (Redding, 2000). Much of this work has centered on the development of demonstrated, effective interventions, commonly referred to as evidence-based practices (EBPs). EBP’s involve standardized treatments that have been shown through controlled research to result in improved outcomes across multiple research groups. These advancements have occurred in both the mental health and juvenile justice fields. On the mental health side, there have been a number of studies and meta-analyses reviewing the effectiveness of treatment for mental disorders in children and adolescents (Burns, Hoagwood, & Mrazek, 1999; USDHHS, 2000; Hoagwood, Burns, Kiser, Ringeisen, & Schoenwald, 2001). Similarly, there have been efforts in juvenile justice to identify effective programs, most notably the Blueprints for Violence Prevention work (Mihalic, Irwin, Fagan, Ballard, & Elliot, 2004).

These efforts confirm that effective interventions do exist. Further, evidence-based practices can be found in different intervention categories, including psychosocial approaches such as Cognitive Behavioral Therapy (Rhode, Clarke, Mace, Jorgensen, & Seeley, 2004), community-based approaches such as Multi-Systemic Therapy (Elliot et al., 1998) and Functional Family Therapy (Alexander & Sexton, 1999), and medication therapy (Jensen & Potter, 2003). Some of these interventions, particularly the community-based approaches, are found in both the mental health and juvenile justice research literature. However, a major obstacle to the wider use of evidence-based practices lies in the lack of dissemination and implementation efforts to replace existing services with services that are empirically based.

In an attempt overcome this obstacle, some states have created centers to promote the implementation of evidence-based practices for youth with mental health disorders in communities throughout their states. These centers provide information, assistance, and training to communities interested in implementing EBP’s and often serve as liaisons to the EBP developers to ensure that implementation efforts are structured and adhere to the recommended protocols associated with each particular intervention. These centers are typically supported by a combination of public and private funds. States that have created such centers include Connecticut, Ohio, Pennsylvania, and Colorado (Blau, Cocozza, Bernstein, Williams, & Kanary, 2004).

Other states have gone so far as to pass legislation requiring that public funds allocated to state agencies for services to youth in the juvenile justice, mental health, and child welfare systems be spent on evidence-based practices. For example, the state of Oregon recently passed legislation that requires the state juvenile justice, mental health, and child welfare agencies to document that 25 percent of their budget, including both Federal and state dollars, be spent on evidence-based practices. This requirement, which is being phased in over a four year period, increases to 50 percent in the second phase, and ultimately reaches 75 percent at the end of the four-year period (Oregon Department of Human Services, 2005).

Despite the recent attention being paid to EBP’s, Scott Henggeler, the developer of MST, estimates that less than 1 percent of the youth who could benefit from evidence-based services currently receive them (Henggeler, 1997). It is recognized that the vast majority of mental health services and programs currently available to treat youth involved with the juvenile justice system are not evidence based, including many of the programs that are highlighted in this model. More research is necessary to develop new EBP’s to treat youth in their homes and communities, especially youth who have co-occurring mental health and substance use disorders, and more work needs to be done to promote the wider use of EBP’s with justice-involved youth.