Cornerstone #1: Collaboration

1. In order to appropriately and effectively provide services to youth with mental health needs, the juvenile justice and mental health systems should collaborate in all areas, and at all critical intervention points.

Background

The increasing number of youth in the juvenile justice system with identified mental health needs is placing a strain on the juvenile justice system in ways never seen before. The growing awareness of the needs of this population, and the concern over their care and treatment while involved with the juvenile justice system, documented in numerous advocacy, media, and government reports, has created a “mental health crisis” for juvenile justice administrators across the country. The Executive Director of the Coalition for Juvenile Justice (CJJ) has called mental health “the number one emergent issue as far as juvenile justice is concerned” (Coalition for Juvenile Justice, 2000). Further, mental health was cited as the single most pressing issue facing juvenile justice administrators in a recent meeting of state juvenile justice agency directors.

Despite the large numbers of youth with mental health needs in the juvenile justice system, the current landscape of service delivery for these youth is often fragmented, inconsistent, and operating without the benefit of a clear set of guidelines specifying responsibility for the population. In the search for better responses, it is important to stress that no one system bears sole responsibility for caring for these youth. Full responsibility for meeting the complex needs of juveniles with mental disorders cannot fall to any one system or agency. An effective response must include the development of collaborative approaches involving both mental health and juvenile justice systems.

The juvenile justice system was never intended to serve as the primary provider of mental health services for youth. The system lacks the necessary resources, expertise, and training to be able to do this on its own and is not interested in “transforming” itself into the mental health provider for youth. What distinguishes the juvenile justice system from other child serving systems, such as mental health or education, is the fact that the juvenile justice system cannot say “no”—they cannot refuse to accept a child. This responsibility to serve and protect places the juvenile justice system in a very difficult situation when a large proportion of the youth that they are responsible for serving and protecting are mentally ill.

The juvenile justice system is not looking for new mental health business. Nor would it be reasonable to suggest that the mental health system is solely responsible for addressing this issue as well. Instead, a more balanced solution is required, one that involves both the juvenile justice and mental health systems as partners in all efforts to identify and respond to the mental health needs of these youth. Recognition of the problem on the part of both systems is the crucial first step. Taking joint responsibility for addressing the problem is the next and equally, if not more, important step.

Recent Federal efforts have resulted in the creation of a national climate that is increasingly supportive of collaboration between the juvenile justice and mental health systems. The Comprehensive Community Mental Health Services for Children and their Families Initiative (referred to as the Systems of Care model) was created in 1992 by the Substance Abuse and Mental Heath Services Administration (SAMHSA) as a way to promote more effective ways to organize, coordinate, and deliver mental health services and supports to youth and their families (SAMHSA, 2005). The program encourages the development of multi-agency partnerships involving the mental health, juvenile justice, child welfare, and education systems to provide services using a strength-based approach that is driven by the individual needs of the youth and family. Some communities have used this funding to create and enhance service delivery strategies for youth in the juvenile justice system, including such well-known programs as WrapAround Milwaukee, the Dawn Project in Indiana, and Project Hope in Rhode Island.

The President’s New Freedom Commission on Mental Health, in their report released in July 2003, called for the transformation of the nation’s mental health system, and included numerous recommendations for improving the organization and delivery of mental health services. The report also references the need for the wide adoption of diversion and re-entry strategies to avoid the unnecessary criminalization of adult and juvenile offenders with mental illness. Building on these recommendations, SAMHSA and other Federal agencies, such as the Department of Justice, followed up with the release of an action agenda for putting the recommendations in the report into action. The Federal Mental Health Action Agenda, released in July 2005, includes five principles to guide the mental health transformation process, along with specific action steps detailing immediate activities that the Federal government will initiate to begin this process. Principle B calls for increased “focus on community models of care that effectively coordinate the multiple health and human service providers and public and private payers involved in mental health treatment and delivery of services” (SAMHSA, 2005). One action step for this principle includes building on and expanding criminal and juvenile justice and mental health collaborations by establishing a new cooperative agenda between the Federal Department of Health and Human Services and the Department of Justice. This cooperative agenda directs the Office of Justice Programs (OJP) and SAMHSA to continue to develop and support juvenile justice diversion and reintegration programs for youth.

The push for more collaboration can be seen not only on the mental health side, but also on the juvenile justice side. The 2003 reauthorization of the Juvenile Justice and Delinquency Prevention (JJDP) Act puts into place new provisions that allow for and encourage the use of funds to support mental health treatment to delinquent youth or youth at risk of delinquency. Guidelines concerning the use of Juvenile Justice Delinquency Prevention Block Grant program funds were broadened to allow for the support of projects that provide mental health treatment to juvenile offenders or youth who are at risk of becoming juvenile offenders, and their families, to reduce the likelihood that youth will commit violations of the law. Funds may also be used to support comprehensive juvenile justice and delinquency prevention projects that meet the needs of youth through collaboration with other local systems, including, among others, the mental health system. Changes made to the Juvenile Accountability Block Grant (JABG) program call for the establishment of interagency information-sharing systems that enable the juvenile justice system to make more informed decisions regarding the early identification, supervision, and treatment of juveniles. JABG purpose areas also call for the establishment of programs to conduct risk and need assessments of juvenile offenders that allow for effective early intervention and the provision of comprehensive services, including mental health screening and treatment. These changes reflect the growing awareness of the importance of addressing mental health needs among youth in the juvenile justice system and providing support for the establishment or expansion of juvenile justice and mental health system collaboratives.

Wider Multi-System Collaboration

While the juvenile justice and mental health systems must clearly be involved in any attempt to improve the coordinated response to youth in the juvenile justice system with mental health needs, there are other systems that also play a critical role in responding to the multiple needs of justice-involved youth. The substance abuse system is a stakeholder system that has a responsibility to provide treatment services to youth. There is a significant body of evidence indicating that large numbers of youth in the juvenile justice system have substance use disorders, with studies suggesting that about 50 percent of justice-involved youth meet DSM-IV criteria for a substance use disorder (NCMHJJ, 2005; Teplin, 2002; Wasserman, 2002). In many states, the mental health agency is responsible for providing both mental health and alcohol and other drug services (National Association of State Mental Health Program Directors, 2004). In other states, the substance abuse agency is a separate, standalone entity. Under either scenario, it is critical that the substance abuse system be involved in any attempt to improve services for youth involved with the juvenile justice system, particularly given the documentation of the frequency of co-occurring mental health and substance use disorders.

The term co-occurring disorder refers to co-occurring substance-related and mental disorders (Center for Substance Abuse Treatment, 2005). While the research base on co-occurring disorders is still emerging, existing studies suggest that the rates of co-occurring mental health and substance use disorders among the juvenile justice population are high (Abram, Teplin, McClelland, & Dulcan, 2003; Jensen & Potter, 2003; Neighbors, Kempton, & Forehand, 1992). The study conducted as part of the development of this Model found that among youth with a mental disorder, 60.9 percent also met criteria for a co-occurring substance use disorder. An earlier study of youth in the Cook County, Illinois detention center found that among juvenile detainees with major mental disorders, 58.4 percent of females and 73.8 percent of males also had a substance use disorder (Abram, et al., 2003). Youth with co-occurring mental health and substance use disorders are best served through an integrated screening, assessment, and treatment planning process that addresses both substance use and mental disorders, each in the context of the other (CSAT, 2005).

The education system is a key stakeholder whose participation should be sought when developing improved strategies for identifying and treating mental health disorders within the juvenile justice population. The need for strong linkages between the juvenile justice system and the education system is compelling. First, evidence suggests that large numbers of youth involved with the juvenile justice system have education-related disabilities, and as many as 20 percent of students with emotional disabilities are arrested at least once before they leave school (Burrell & Warboys, 2000). The majority of youth who enter juvenile correctional facilities come into the system with a broad range of intense educational, mental health, medical, and social needs (National Center on Education, Disability and Juvenile Justice, 2005), and many of these youth are marginally literate or illiterate and have frequently experienced school failure and grade retention (Center on Crime Communities and Culture, 1997). Zero tolerance policies, instituted in school districts across the country, have resulted in schools referring more youth to the juvenile justice system for behaviors that used to be handled by school administrators (Rimer, 2004). Many of these referrals involve students with special education needs whose behavior is often related to their disability (Lynagh & Mancuso, 2004). Information about a youth’s disability may be relevant at every stage of juvenile justice processing, and can help determine whether formal juvenile justice processing should proceed or if other strategies should be employed (Burrell & Warboys, 2000). Many of these youth are eligible for special education and related services (which can include psychological services) as part of an Individualized Education Plan (IEP) under the Federal Individuals with Disabilities Education Act (IDEA). It is important for probation officers, judges, juvenile correctional staff, mental health professionals, and families to be knowledgeable about special education issues and processes to ensure that youth receive the services they need, both in community settings, as well as institutional settings, such as detention and corrections (Burrell & Warboys, 2000).

Second, the education system plays a crucial role for youth who are transitioning from juvenile correctional placement back to their homes and communities. Many youth re-entering the community perform below grade level and have histories of truancy and suspension (Roy-Stevens, 2004). Partnerships between the juvenile justice system and education system are critical to help youth transition back into appropriate community education settings.

The child welfare system is another key system whose clients frequently overlap with those in both the juvenile justice and mental health systems (Wiig & Tuell, 2004). A National Institute of Justice study indicated that being abused or neglected as a child increased the likelihood of arrest as a juvenile by 59 percent (Widom & Maxfield, 2001). Not only are there behavioral consequences for children and youth who have been abused or neglected, there are also psychological consequences. Studies have found abused and neglected children to be at least 25 percent more likely to experience problems such as delinquency, teen pregnancy, low academic achievement, drug use, and mental health problems (Kelly, Thornberry, & Smith, 1997). One long-term study found that as many as 80 percent of young adults who had been abused met diagnostic criteria for at least one psychiatric disorder at age 21, exhibiting problems, including depression, anxiety, eating disorders and suicide attempts (Silverman, Reinherz & Giaconia, 1996). Given the increasing body of evidence suggesting links between child abuse and neglect, involvement in the juvenile justice system, and the development of psychological problems stemming from abuse, the child welfare system should be a key partner in any collaborative effort designed to strengthen and improve mental health service delivery for youth in contact with the juvenile justice system.

How to Collaborate

The basic goal of improving services to a population of youth is sometimes not enough of an incentive to embark on multi-system collaboration. Often, the creation of an interagency task force or coalition is in direct response to a crisis in the community, a lawsuit in which a facility or system is sued, or new funding opportunities that require systems to blend funding in order to receive new funding (National GAINS Center, 1999). Whatever the motivator, there are some first steps that a jurisdiction can take to establish multi-system collaborations. These include:

• Organize a coordinating body or task force that includes representatives from the involved systems as well as consumers, family members, and advocates.
  
  
• Designate a strong leader with good communication skills who understands the systems and related informal networks.
  
  
• Decide on a common goal or goals for the work and develop clear objectives and strategies for meeting the identified goals.
  
  
• Emphasize strategic planning that is aimed at producing immediate but sustainable results.
• Recruit political support from community leaders, such as judges or legislators.
  
  
• Develop a financing plan to support the group’s proposed objectives and strategies, and refer back to this plan frequently to update it or modify it based on the availability of existing or new funding.
  
  
• Explore multiple funding opportunities at the local, state, and Federal levels. (National GAINS Center, 1999).

Creating multi-system partnerships should be viewed as a fluid process that evolves and intensifies over time. One way of approaching this is within the context of a continuum, with points on the continuum representing the different levels (and intensity) of interagency work. Konrad (1996), in a paper that provides a framework for viewing such interagency efforts, identifies a series of benchmarks on a continuum for defining the different levels and strengths of interagency partnerships. Konrad’s benchmarks include:

Information Sharing and Communication: This represents a very informal relationship in which entities share general information about programs, services, and clients. Communication may or may not occur on a regular basis and is largely dependent on the functions and authority of the staff involved. Examples include sharing of newsletters, brochures, educational presentations, and joint staff meetings.

Cooperation and Coordination: This level is still largely informal representing a loosely organized attempt by autonomous agencies and programs to work together or change procedures or structures to make all affected programs successful. Examples include reciprocal client referral and follow-up processes between agencies and programs, verbal agreements to conduct joint staff meetings, mutual agreements to provide priority responses or joint lobbying for legislation.

Collaboration: This level is usually formalized and activities are shared. Still autonomous agencies and programs work together as a whole with a common goal, product, or outcome. Partners are equal. Examples include partnerships with written agreements, goals, formalized operational procedures, and possibly joint funding, staff cross-training, and shared information systems.

Consolidation: A consolidated system is often represented by an umbrella organization with single leadership in which certain functions are centralized but line authority is retained by categorical divisions. Often, there is a high degree of cross-program collaboration, coordination, cooperation, and information sharing. Examples include government agencies with responsibility for numerous human service programs.

Integration: A fully integrated system has a single authority, is comprehensive in scope, operates collectively, addresses client needs in an individualized fashion, and is multi-purpose and cross-cutting. Categorical lines are transparent, activities are fully blended, and funding is pooled. Eligibility requirements for all services are simple and uniform. Examples include one-stop shops in which unified intake, assessment, case management, and services are provided in one location, and one entity has sole responsibility for management and operational decisions.

This continuum, and the defined benchmarks, can be used to help systems realistically assess their readiness for multi-agency partnerships, and offers concrete examples of the kinds of activities that are associated with the different levels of multi-system work.

The state of Connecticut, which has significantly transformed its approach to providing mental health care to youth involved with the juvenile justice system.  Its experience highlights several critical elements important to successful juvenile justice and mental health collaboration. Click here to access the Connecticut Case Study.