Title: Breaking the Cycle of Drug Use Among Juvenile Offenders. Series: Final Technical Report Author: Duane C. McBride, Curtis J. VanderWaal, Yvonne M. Terry, and Holly VanBuren Published: National Institute of Justice, November 1999 Subject: Juvenile courts, drug offense sanctions and penalties, adjudication--juveniles, juvenile substance abuse, and court management 120 pages 296,000 bytes ------------------------------- Figures, charts, forms, and tables are not included in this ASCII plain-text file. To view this document in its entirety, download the Adobe Acrobat graphic file available from this Web site. ------------------------------- Breaking the Cycle of Drug Use Among Juvenile Offenders Duane C. McBride, Ph.D. Curtis J. VanderWaal, Ph.D. Yvonne M. Terry, M.S.A. Holly VanBuren, M.S.W. November 1999 NCJ 179273 ------------------------------- The Authors and This Report The authors, all from Andrews University, prepared this report for the National Institute of Justice (NIJ) under contract number OJP-96-C-004. Dr. Duane C. McBride is Professor and Chair, Behavioral Sciences Department, and Research Director, Institute for the Prevention of Addictions. Dr. Curtis J. VanderWaal is Associate Professor, Social Work Department. Yvonne M. Terry and Holly VanBuren are Research Associates. This Web-only report is based on a literature review completed by the authors in August 1999. An article by them summarizing this report is scheduled to appear in the May 2000 issue of The Journal of Behavioral Health Services and Research. In addition, a shorter, practitioner-oriented print version of this online report is under preparation by NIJ, a component of the U.S. Department of Justice's Office of Justice Programs, which also includes the Bureau of Justice Assistance, the Bureau of Justice Statistics, the Office of Juvenile Justice and Delinquency Prevention, and the Office for Victims of Crime. Points of view, research findings, and conclusions expressed in this document are those of the authors and do not necessarily reflect official positions or policies of the U.S. Department of Justice. ------------------------------- Contents The Authors and This Report Introduction and Purpose --Background and context --Purpose --Substance use terminology The Juvenile Drug-Crime Cycle and the Juvenile Substance-Using Population Juvenile Justice System Conceptual Underpinnings and Developments --Conceptual underpinnings --Conceptual developments The Juvenile Justice System Process --System contact: the juvenile justice system and court supervision at intake --Social investigation: assessment, case management, management information systems, and collaboration o Assessment -- Culturally sensitive assessment -- Co-occurring addictive and mental disorders -- Community assessment centers -- Assessment instruments o Case management -- Youth Evaluation Services (YES) -- The Amity Project -- The Iowa Care Management Model -- The Case Management Enhancements Project (CME) o Management information systems and confidentiality issues o Collaborative structures and strategies -- Collaborative elements -- Optimum collaboration structure -- Collaboration and the juvenile justice system o Dismissal and/or diversion programs --Fact-finding hearings and adjudication: judicial processing --Disposition o The graduated sanctions continuum o Sentencing options o Supervision monitoring: biologic testing o Range of treatment options -- Treatment correlates -- Treatment programs -- Overall treatment program evaluation issues -- Treatment modalities -- Meta-analysis of treatment effectiveness -- Culturally sensitive intervention and treatment programming o Continuing care services: beyond and within the juvenile justice system General Recommendations for Future Intervention Research Summary and Recommendations --A conceptual model --Guiding principles --Systems flow: what a model program might look like o Single point of entry o Immediate and comprehensive assessment o Cross-systems case management o Continuum of care o Judicial decision making o Systems collaboration o Treatment o Utilization of traditional services o Continuing care o Evaluation --An integrated model --Implementation at the local level Conclusion Endnotes Appendix A: Conducted Interviews Appendix B: Assessment Tools --Screening tools --Mid-range comprehensive assessment instruments o Comprehensive addiction severity index for adolescents o Adolescent chemical dependency inventory--corrections version o Other comprehensive assessment instruments List of Abbreviations References ------------------------------- Introduction and Purpose Background and context For more than two decades, researchers, clinicians, and juvenile justice program administrators have been aware of the consistent relationship between alcohol and other drug (AOD) use and juvenile crime (a list of abbreviations is at the end of this report). There have been many attempts to document, understand, and intervene in what is often called the juvenile drug-crime cycle (while the term AOD is probably the more accurate descriptive term for substance use, the phrase drug-crime cycle is commonly used in the literature to encompass the use of alcohol and other illegal substances in conjunction with criminal acts). While these attempts have usually promised much, their success is often unknown or not documented with methodologically rigorous scientific research. The consequences of the juvenile drug-crime cycle are severe. AOD use among juvenile delinquents appears to be strongly related to other social and psychological problems, including lowered school performance, poor family relationships, and increased interactions with AOD-using peers (Howell et al., 1995). AOD use also appears to be associated with a number of delinquent behaviors. Arrestee Drug Abuse Monitoring Program (ADAM) data strongly suggest that a high proportion of juveniles (likely the majority) processed by the juvenile court have recently used illegal substances. Juvenile AOD use appears to be related to recurring, chronic, and violent delinquency that continues into adulthood (Dembo et al., 1987, 1997; Sickmund et al., 1997). The juvenile justice system is, therefore, a viable point of entry for a comprehensive collaborative service system designed to break the juvenile drug-crime cycle. Very few juvenile justice jurisdictions provide appropriate substance abuse treatment services for youth. Thornberry et al. (1991) found that treatment for adolescent substance offenders was available in less than 40 percent of the 3,000 public and private juvenile detention, correctional, and shelter facilities across the United States (see also Dembo et al., 1993). Jurisdictions that provide treatment generally limit access to support group services, such as Alcoholics Anonymous (AA) and Narcotics Anonymous (NA), as well as AOD testing (Schonberg, 1993). While a few settings conduct individual or group sessions for substance-abusing juveniles, these facilities do not generally conduct comprehensive treatment needs assessments or plan and carry out individualized treatment programs along a continuum of care. New interventions within the system are needed to address these deficiencies; such programming must be clearly aware of and logically incorporate the etiology, correlates, and consequences of the drug-crime cycle. Purpose The two primary purposes of this report are to summarize existing knowledge about programmatic attempts to intervene in the juvenile drug- crime cycle and, based on that review, to propose intervention models with the greatest likelihood of successfully addressing the cycle. Specifically, the report will: 1. Provide a brief overview of the juvenile drug-crime cycle and a description of the juvenile substance-using population. 2. Review programmatic attempts to break the drug-crime cycle for juvenile offenders, including an examination of juvenile justice system processes and the graduated sanctions continuum. 3. Recommend intervention models or modalities that have received the strongest empirical support for effectiveness. 4. Based on the review of intervention programs, present a proposed comprehensive intervention model that will include a focus on the specific elements of successful interventions as well as programs that combine various successful intervention elements. This report is based on an extensive review of existing literature and research reports as well as interviews with researchers who are active in developing and evaluating programs designed to break the drug-crime cycle among juveniles. Many of these researchers were recommended by either the National Institute of Justice (NIJ) or the National Institute on Drug Abuse (NIDA) and all have extensive research and/or practice experience in addressing adolescent substance use and/or delinquency issues. Please see Appendix A for a listing of conducted interviews. Substance use terminology Before proceeding further, the authors feel it is important to discuss the terminology used in this document. The authors will use substance and AOD interchangeably in addition to the previously defined use of the phrase drug-crime cycle. Further, most substance abuse experts make a distinction between the terms use, abuse, and dependence. For the purposes of this report, the term substance use includes the occasional and nonproblematic use of alcohol as well as other illegal substances, such as marijuana and cocaine. The American Psychiatric Association (1994) defines substance abuse as a "maladaptive pattern of substance use manifested by recurrent and significant adverse consequences related to the repeated use of substances," including "repeated failure to fulfill major role obligations, repeated use in situations in which it is physically hazardous, multiple legal problems, and recurrent social and interpersonal problems" (182). Substance dependence is further defined as "a cluster of cognitive, behavioral, and physiological symptoms indicating that the individual continues use of the substance despite significant substance- related problems. There is a pattern of repeated self-administration that usually results in tolerance, withdrawal, and compulsive drug-taking behavior" (American Psychiatric Association, 1994:176). Such definitional distinctions are important because use, abuse, and dependence categories are clinically different and have unique implications for substance abuse treatment and other interventions. For example, a juvenile who episodically uses alcohol or marijuana does not necessarily require traditional AOD treatment programming. However, it is important to note that any AOD use (even if statistically normative) is illegal for juveniles and may result in juvenile justice system processing and some type of program intervention. Given that alcohol and marijuana can be considered gateway substances into harder substance use (Golub & Johnson, 1994), attempts to intervene with AOD treatment services early in a youth's substance use history seem warranted. Additionally, since alcohol is clearly the substance used most prevalently by juveniles, it is critical that detection, assessment, and treatment efforts address alcohol use, abuse, and dependence. However, it is also important to note that it is difficult to utilize use, abuse, and dependence diagnostic categories with precision due to adolescents' relatively short histories of substance use (compared to adults). Further complicating the issue, few normative data exist to set adolescent age- appropriate levels of tolerance and withdrawal (Greenbaum et al., 1996). Despite these barriers, juvenile AOD treatment interventions must be based on carefully conducted assessments of a juvenile's AOD use and then tailored to each adolescent's individualized needs. This being said, most AOD treatment providers downplay the distinctions between alcohol and other psychoactive substances. Miller (1995) maintains that "There is an enormous overlap between addiction to alcohol and addiction to other drugs. Polydrug addiction is the norm, not the exception, and, except for specific pharmacologic issues and timelines, the processes of progression, treatment, recovery, and relapse are nearly identical for addiction to alcohol and other drugs" (84). Within this framework, most AOD treatment centers treat addictions to alcohol and other substances in nearly identical ways. While detractors might call for more careful differentiations between different classes of substances, current treatment center realities make such distinctions unlikely. The Juvenile Drug-Crime Cycle and the Juvenile Substance-Using Population The existence of the drug-crime cycle among juveniles is broadly recognized and accepted. Researchers examining the relationship generally conclude that it is very complex and involves a wide variety of associated behaviors, socio-demographic and economic characteristics, and other situational variables (McBride & McCoy, 1993). Development and implementation of successful intervention programs must include a knowledge of the unique characteristics of the juvenile AOD-using population as well as known correlates affecting juvenile AOD use and treatment outcomes. Adolescents present a very specific treatment population. Compared to adult alcoholics and addicts, adolescent AOD abusers have shorter substance use histories (De Leon & Deitch, 1985), are less involved with opiates and have more involvement with alcohol and marijuana (Johnston et al., in preparation), and report greater binge drinking and more polydrug abuse (Friedman et al., 1986; Leccese & Waldron, 1994). The extent of juvenile AOD use and its relationship to delinquent behavior has been documented by both self-report and biologic data (such as urine and hair testing) in a wide variety of national and local studies. Prevalence data from the Monitoring the Future study show that among 12th grade students, 32 percent have consumed five or more drinks in a row in the last 2 weeks (Johnston et al., 1998). Twelve percent of 8th graders report use of any illicit substance in the past 30 days. For 10th graders, this percentage rises to almost 22 percent, and for 12th graders, the percentage climbs to almost 26 percent. Rates of marijuana use in the past 30 days are 10 percent, 19 percent, and 23 percent for 8th, 10th, and 12th graders, respectively (Johnston et al., 1998). Recently reported data also show that daily marijuana use among 10th graders increased from less than 1 percent in 1992 to almost 4 percent in 1997 and 1998. The data further show that cocaine use in the last 30 days among 10th graders increased from less than 1 percent in 1992 to 2 percent in 1997 and 1998 (Johnston et al., in preparation). While no large-scale epidemiological studies have been conducted to determine diagnosable adolescent substance use disorder rates, some limited community surveys indicate that lifetime prevalence of any AOD disorder ranges from 3 to 5 percent in 15-year-olds and 10 to 32 percent in 17- to 19-year-olds (Kashani et al., 1987; Reinherz et al., 1993). It is reasonable to assume that AOD rates for juvenile delinquents are even higher. In 1992, Cocozza estimated that nearly 320,000 male juvenile detainees met diagnostic criteria for at least one substance use disorder. Analyses of data from the National Youth Survey show a strong correlation between serious substance use and serious delinquent behavior (Johnson et al., 1993). Johnson and his colleagues (1993) found that only 3 percent of nondelinquents use cocaine, whereas 23 percent of those with multiple delinquency index crimes are current cocaine users[1]. Data from the 1998 ADAM Annual Report show the extensive prevalence of substance use among juvenile male arrestees/detainees in many cities across the United States. The 1998 ADAM report shows that between 1996 and 1998, cities such as Denver, Cleveland, Los Angeles, and Washington, D.C., reported that about 60 percent or more of their juvenile arrestees had an illegal substance in their urine. Even the lowest substance prevalence cities (St. Louis, San Jose, and Indianapolis) reported that over 40 percent of their juvenile arrestees tested positive for illegal substances (ADAM, 1999). While marijuana was by far the most common substance found, in many cities such as Cleveland, Denver, Indianapolis, Los Angeles, Phoenix, and Portland, 10 to 20 percent of the juvenile arrestees had used cocaine during 1998 (ADAM, 1999). It should also be noted that there are significant local variations in use patterns among juvenile arrestees. West Coast juvenile arrestees are more likely to have methamphetamine in their urine than in other cities. For example, in San Diego, the proportion of juvenile arrestees testing positive for methamphetamine (around 10 percent in 1998) is higher than for cocaine (ADAM, 1999; see also Penell et al., 1999). The report further notes that male juvenile arrestees who are in school are less likely to test positive for substances than juveniles who are not in school (ADAM, 1999), suggesting that those outside of school systems would be even more likely to test positive for illicit substances. In a study of nonincarcerated delinquents in Miami, Florida, Inciardi and his colleagues (1993) found that about three-fourths of both males and females self-report cocaine use at least weekly. Comparing self-reported use with hair analysis results, Dembo and associates (1996) found that adolescents accurately report their use of soft substances such as marijuana but underreport use of hard substances such as heroin, suggesting that the self-report rates of the Miami youth could be even higher. Overall, these epidemiological reports document frequent AOD use among juveniles, recent increases in AOD use frequency, and the correlation between frequent AOD use and extensive and sustained delinquent behavior. These data suggest a strong need to intervene in the juvenile substance use and delinquency cycle. Juvenile Justice System Conceptual Underpinnings and Developments An examination of the current juvenile justice system requires a brief review of its conceptual underpinnings and current conceptual developments as well as a review of the system's usual operational practices. These reviews have implications for how programmatic interventions may occur in the juvenile drug-crime cycle. Conceptual underpinnings The juvenile court system arose from attempts to develop a justice system for juveniles that differed from the adult system. From its very beginnings in Cook County (Chicago), Illinois, the juvenile justice system defined itself as a caring parent as opposed to punishing judge. While the developing juvenile system involved classic elements of the adult system in that it operated in the framework of laws regulating behavior and utilized aspects such as prison-like punishment, the primary focus was on rehabilitation. At times, this conceptual underpinning resulted in a lack of careful attention to constitutional due process rights. Beginning in the 1960s, the juvenile court increasingly found itself under constitutional review regarding the application of due process criminal court elements. A classic illustration of problems with due process occurred in the case of 15-year-old Gerald Gault. In 1964, Gault and a friend were taken into custody by police based on a verbal complaint. Gault's parents were never informed of his being taken into custody. Neither Gault nor his parents were ever given notice of the charges or his basic constitutional right to remain silent. In addition, Gault was not even present at the formal juvenile court hearings in which a judge adjudicated him delinquent and sent him to a state industrial/training school until he was 21. In 1967, the Supreme Court ruled that juveniles have the right to basic constitutional due process, including knowing the charge against them, being informed of their constitutional rights, and actually being present at their own hearings (Re Gault, 387 U.S. 1, 18 L. Ed. 2d 527, 87 S Ct. 1428, 1967). The 1970s saw a continuing application of Federal constitutional rights to juveniles and major movements to close State industrial/training schools (Bartollas, 1997). During the 1980s, American society experienced a very large increase in the rate of juvenile crime, with a particular increase in the rate of violent juvenile crime. This trend resulted in increasing willingness on the part of Federal and State governments to try juveniles accused of serious (violent) crime as adults (Bartollas, 1997; Strom et al., 1998; Sickmund, 1994). However, while there appears to be an increased willingness to define juveniles as adults, there continues to be strong support for incorporating a rehabilitative philosophy with community protection and justice models based on the initial caring parent approach of the early juvenile justice system. Conceptual developments While the concept of using the justice system to address human behavior problems is not new, it has received new impetus in recent years. A recent issue of the Notre Dame Law Review (Hora et al., 1999) is entirely devoted to the concept of therapeutic jurisprudence and how its application can and is revolutionizing America's response to the drug-crime cycle. Therapeutic justice advocates suggest that psychological, sociological, cultural, and other factors should be fully considered in law applications, and that the goal of the courts should be not only protecting the community and punishing the offender but also addressing the underlying reasons for criminal/problem behavior. Within this framework, key players in the justice system (including judges, prosecutors, and defense attorneys) transition from adversarial roles to problem solvers as part of a collaborative team while at the same time continue to perform traditional roles of community protection, applicators of law, and protectors of due process (Spangenberg & Beeman, 1998). Therapeutic jurisprudence appears to be very consistent with the philosophical underpinnings of the juvenile justice system. As Hora and her colleagues (1999) note, the juvenile court applies therapeutic jurisprudence in its broadest sense by including the family and a wide variety of other relevant factors in decision making. Within the juvenile justice system, a perspective called Balanced and Restorative Justice (BARJ) has emerged in the last few years that provides a useful framework for examining and developing programmatic interventions to address the juvenile drug-crime cycle (Office of Juvenile Justice and Delinquency Prevention, or OJJDP, 1998). The BARJ perspective attempts to integrate the traditional rehabilitative philosophy of the juvenile court with increasing concerns about victim rights and community safety. Specifically, the model focuses on: 1. Offender accountability, which enables the offender to make amends to victims and the community. 2. Competency development, which helps a juvenile change his or her behavior and have the skills necessary to function in today's society and economy. 3. Community safety, which involves protecting the community by monitoring juvenile behaviors and implementing graduated sanctions. This model suggests that any response to youth crime must strike a balance between the needs of victims, offenders, and the community. Further, it suggests that victims, offenders, and the community should be as involved in the justice process as possible (Bazemore & Nissen, in press). Rather than asking the question "What should be done to punish the offender?" restorative justice asks the following questions (Zehr, 1990): --What is the nature of the harm resulting from the crime? --What needs to be done to "make it right" or repair the harm? --Who is responsible for the repair? This process takes place through collaborative involvement of key players in the juvenile justice system and community and, if desired, the victim. BARJ has become a guiding principle in juvenile justice system change for at least 12 States (OJJDP, 1998). Illinois provides an excellent example of a strongly proactive attempt to use the model in system reorganization. A recent publication of the Cook County, Illinois, State's Attorney's office describes how BARJ has changed the current system, including required interagency collaborative agreements and practices that are monitored by the State's Department of Human Services (Devine, 1998). The BARJ model is relatively new and has not been subjected to extensive evaluation. However, it is an important part of a developing framework in the justice system. While the BARJ model is used as part of the background material of this report, it has not been formally integrated into the evaluation presented on interventions. The focus of this report is on reviewing the effectiveness of interventions at various points of the juvenile justice system and suggesting guiding principles and a possible model for applying those principles. Where this is consistent with the BARJ model or seems implied by that model, it is noted. The BARJ model provides a general framework rather than a detailed critical analysis of intervention systems and collaborative models. An additional and related trend in juvenile justice is the recent emergence of the strengths-based approach. Juvenile justice systems in general, and AOD treatment centers in particular, have historically been based on models which emphasize an individual's deficits and problems: "...it appears that many treatment programs are based on the assumption that offenders can be 'fixed' in isolation from the rest of the world. This is due to an all-too-familiar and well-rooted history of treatment grounded in a medical model that suggests that therapeutic intervention acts as a kind of emotional surgery" (Bazemore & Nissen, in press:9-10). Bazemore and Terry (1997) suggest that the juvenile justice system has been designed to see youth either as victims or villains while ignoring the natural capacities of both the youth and their communities. These programs fail to address the role of relationships and the institutional and community contexts which nurture criminal behaviors. Rather than focus on what is wrong with individuals, the strengths-based perspective suggests that youth have internal resources and community- based supports which can be tapped to encourage appropriate functioning within the community. As such, strengths-based approaches focus on what youth are good at, who their naturally occurring, positive community supports are, what they want which is positive and interesting to them, and what they can be in spite of their past histories (Bazemore & Nissen, in press; Nissen, submitted for publication). The approach seeks to incorporate concepts such as respecting and looking for client strengths, engaging client motivation for change by tapping into those strengths, seeing the environment as full of resources, and being a collaborator with the client in therapeutic work (Saleebey, 1992). These concepts can be integrated into the entire juvenile justice continuum and have recently been introduced in some drug courts, case management systems, and multidimensional family approaches to intervention. Each of these areas, including program outcome results, will be reviewed later in this report. The Juvenile Justice System Process With the foregoing conceptual trends and frameworks in mind, a brief overview of the juvenile justice system process will provide a context for understanding where and how substance abuse services may be appropriately offered (substance abuse treatment services can be and are offered at any stage of the process).[2] The juvenile justice system is composed of six main phases: --Intake. A preadjudication intake officer at a local juvenile court decides to release a juvenile into parental custody, place him or her on informal probation, or detain the youth in a detention facility. Many juveniles are also counseled by the intake officer and diverted into other community agencies. --Social investigation. A probation officer examines the juvenile's family, education, history of delinquency, etc., for the juvenile court. Some investigations are supplemented by reports from child advocates or court- appointed social workers. --Fact-finding hearing. A juvenile appears before a judge who reviews the complaint and the social investigation. Special juvenile drug courts have been established in some locations to facilitate the evaluation and adjudication of AOD-related offenses. --Adjudication. Based on the fact-finding hearing, the court determines if the juvenile is delinquent. The judge's decision is strongly influenced by the intake officer's recommendations. --Disposition. If the juvenile is determined to be delinquent, a hearing is held where the judge decides case disposition. Options include releasing the delinquent with a warning, community supervision, or commitment to a specialized treatment or detention facility, such as a State training school, boot camp, or community residential facility. Recent trends favor placing youth in detention facilities (Schonberg, 1993). --Continuing care. After the juvenile has completed the court's recommendations, he or she is often released to the supervision of a variety of continuing care providers. Provider services include counseling, school dropout prevention, structured social activities, etc. Each of these phases will be examined relative to their role in breaking the juvenile drug-crime cycle. As juvenile justice system phases and their relationship to AOD treatment interventions are described, it is important to recognize three overarching concepts and strategies that affect each phase: case management, systems collaboration, and graduated sanctions. These concepts/strategies are raised and discussed in this report within the juvenile justice system phase where each would be primarily applied. Case management and systems collaboration are discussed during the social investigation phase, and graduated sanctions are discussed in the disposition phase. System contact: the juvenile justice system and court supervision at intake Intake is the first point of official system contact between youth and the juvenile justice system. The etiology of youth access into the system is varied and may include parental referral based on incorrigible youth behavior, teacher referral, arrest as a result of an accusation within an ongoing criminal investigation, or arrest as a result of an observed legal infraction of the law. As noted above, juvenile justice system involvement at this stage involves preadjudication intake officers of the local juvenile court. Decisions to dismiss, divert to various collaborative community agencies, or move to disposition/detention are usually made by the intake officer. OJJDP's National Juvenile Justice Action Plan (Coordinating Council on Juvenile Justice and Delinquency Prevention, 1996) outlines several characteristics which any system must include in order to adequately address the comprehensive needs of juvenile offenders. The three characteristics relating to the intake process follow: 1. The system must include a single point of entry which screens and assesses the needs of AOD-involved youth at the time of intake. Currently, most systems of treatment are decentralized with multiple points of entry; this decentralization often results in provision of inappropriate services, unnecessary duplication of services, and major gaps in problem identification, assessment, referral, and overall access to services by youth in need of AOD treatment (Coordinating Council on Juvenile Justice and Delinquency Prevention, 1996). 2. The Action Plan calls for immediate and comprehensive assessment. Supporting this contention, OJJDP's study of risk assessment in 14 States found that, on average, 31 percent of incarcerated youth could be safely placed in less secure settings, resulting in more appropriate rehabilitation in a less restrictive environment. Considerable financial savings would be an added bonus. 3. Assessment should be culturally sensitive and designed to identify environmental, familial, personal, and systemic factors which contribute to delinquency and substance use (Bilchik, 1995). Social investigation: assessment, case management, management information systems, and collaboration Assessment AOD treatment services can be provided at several points along the juvenile justice continuum. At the point of entry into the juvenile justice system (intake), the preadjudication intake officer provides a critical gatekeeping function in identifying and intervening with substance abuse problems. Such problems are usually enmeshed within a wide variety of other issues; thus, comprehensive assessment is necessary in order to successfully address substance abuse. Hoge (1999) notes that juvenile justice systems may make poor decisions about juvenile placement because they fail to gather adequate assessment information. Considerable discretion is afforded to personnel who collect such information, and there is often heavy dependence on informal and unsystematic assessment and decision procedures that may result in invalid inferences about clients. Because the recommendations of the preadjudication intake officer often heavily affect judicial decisions, it is imperative that intake personnel be thoroughly trained in the use of comprehensive assessment tools. More careful screening mechanisms not only will help identify services most needed by juveniles but also will prevent system duplication leading to inefficient and poorly coordinated service delivery. By properly assessing and coordinating point-of-entry services, the juvenile justice system can more effectively work toward preventing increasing levels of future delinquency. However, in order to make appropriate assessment and treatment decisions, assessment personnel must consider and incorporate issues of culture and ethnicity into comprehensive juvenile evaluations, as well as be prepared for the complexities of clients with multiple diagnoses. Culturally sensitive assessment. Statistics indicate that a disproportionate number of juvenile detainees are minorities. Minority group membership is often characterized by social injustice, differential treatment by society, and a sense of personal impotence and powerlessness. Comprehensive program development should address these and other issues of ethnicity and how they relate to assessment, intervention, and treatment in juvenile populations. Because of the danger of overgeneralization and its accompanying stereotypes and prejudices, broad guidelines will be introduced both here and in later sections of this report dealing with intervention and treatment that focus on increased awareness of cultural differences and how they might affect a juvenile's progress through the justice system. Since both formal and informal assessments are initiated at the juvenile's first point of contact with the system, cultural competencies need to be developed with all front-line staff, including law enforcement, justice system professionals, assessors, case managers, and any others who become involved early in the process. While cultural competence is desirable at all points in the continuum of care, it is crucial that the people making decisions about how the juvenile will be initially processed have an understanding of the roles of ethnicity and culture. Validation of screening and assessment instruments has typically been based on European-American values (Canino & Spurlock, 1994; Ho, 1992; Paniagua, 1994). Culturally sensitive practitioners should select instruments shown to have the least bias with the minority population encountered. According to Flaherty and colleagues (1988), in order to be valid, assessment instruments must have content, semantic, technical, criterion, and conceptual equivalence across cultures (for lists of recommended instruments, please see Canino & Spurlock, 1994; Paniagua, 1994). An assessment model developed by R.H. Dana (as summarized by Paniagua, 1994) suggests that the following elements are needed in culturally sensitive assessment: assessing degree of acculturation, providing culturally specific service delivery styles, using the client's preferred language when possible, selecting appropriate assessment measures and methods, and displaying cultural sensitivity when informing clients about findings resulting from assessment. Paniagua (1994) summarizes various assessment methods according to their degree of bias, recommending that the least biased method be used whenever possible. Methods which reflect the least cultural bias include physiological assessment, direct observation of behaviors, self-monitoring or behavioral self-reporting scales and instruments, and clinical interviews. Methods more prone to bias include trait measures, self-report of psycho- pathology, and projective tests. Some general guidelines for culturally sensitive assessments include asking culturally appropriate questions, focusing on ethnic identification rather than race, addressing socio- economic status as it interacts with ethnicity, and self-awareness of prejudices, biases, and stereotypes which may lead to faulty conclusions about the client (Canino & Spurlock, 1994; Paniagua, 1994). Co-occurring addictive and mental disorders. Assessment of AOD abuse is further complicated by the co-occurrence of mental disorders (also referred to as dual diagnoses). Both mental health and substance abuse treatment providers have long known that AOD abuse and mental disorders often coexist in the same individuals. A recent study based on data from the National Household Survey on Drug Abuse (Substance Abuse and Mental Health Services Administration, 1999) determined that adolescents who self-reported emotional problems were nearly four times more likely to be dependent on alcohol or illicit substances than other adolescents. They were also four times more likely to have used marijuana and were seven times more likely to have reported use of other illicit substances in the previous month. Treatment for a client with co-occurring addictive and mental disorders is typically hard to obtain. Clinicians often find it difficult to diagnose both disorders due to mixed and overlapping symptoms. However, both psychiatric and chemical dependency treatment centers routinely refuse to admit individuals who are judged to have coexisting disorders. If a client is admitted to one type of center who later is found to have significant symptoms of the other disorder, he or she can be told they are no longer an appropriate treatment subject. Such problems occur for several reasons: --Treatment providers feel inadequately trained and equipped to deal with the unique problems associated with co-occurring disorders. --The unique contributions of each disorder to the existing functional impairment are often difficult to determine, thus complicating both assessment and treatment interventions. --Differing philosophies of what has caused the disorder lead clinicians from both professions to downplay the importance of the other disorder. --Acting-out behaviors associated with both disorders can be difficult for many facilities to handle. Large-scale epidemiological studies of co-occurring disorders have not yet been undertaken for adolescents. However, a major review of smaller scale general population and clinical studies has been conducted in both inpatient psychiatric and addictions settings (Greenbaum et al., 1996). While many of the studies reviewed contained numerous methodological problems, results show that approximately half of all adolescents receiving mental health services also have co-occurring substance abuse problems. Conduct disorder and depression are the two most frequently reported co- occurring mental disorders, with most clinicians considering depression to be a major element of dual diagnoses. In a review of 16 clinic- and community-based studies, Winters (1998) found that diagnosable substance use disorders are two to five times more prevalent among youth with a conduct disorder diagnosis than among control group youth. In addition, Winters, Latimer, et al. (in press) reported that a general delinquency factor is responsible for nearly 50 percent of the variance in AOD use severity in an AOD-clinic referred sample for both boys and girls across all ethnic groups. Other less commonly reported co-occurring psychiatric disorders include bipolar disorder, anxiety disorder, and attention deficit/hyperactivity disorder (ADHD) (Thompson et al., 1996). When ADHD and conduct disorders co-exist in the same youth, researchers estimate that co-occurring substance use disorder rates range from approximately 30 to 60 percent (Wilens et al., 1994). Pharmacotherapy treatments for these co-occurring disorders have not been well researched for adolescents (see Solhkhah & Wilens, 1998, for a review of studies on the effects of medication for treating children or adolescents with AOD disorders). One further difficulty in assessing and treating juveniles with co-occurring disorders is the lack of a coordinated and centralized approach to assessment. Community assessment centers provide one solution to this problem. Community assessment centers. While the OJJDP Action Plan calls for the establishment of community assessment centers, few jurisdictions currently provide a single point of system entry or comprehensive screening and assessment for juveniles during the intake process. Notable exceptions are Target Cities programs, Treatment Alternatives for Safe Communities (TASC), and the Juvenile Assessment Center (JAC). 1. Target Cities. Target Cities programs (supported through the Center for Substance Abuse Treatment, or CSAT) provide comprehensive screening and assessment. Target Cities sites are required to improve coordination among relevant human service agencies, establish or enhance a Central Intake Unit (CIU) and referral services, include quality monitoring, and focus on treatment services for at least one specified subpopulation, which may include adolescents (Department of Health and Human Services, or DHHS, 1995; Scott et al., forthcoming; Cleveland C.A.R.E.S., 1999; Kraft & Dickinson, 1997). Juvenile offenders are served at two Target Cities sites (Albuquerque, New Mexico, and Cleveland, Ohio). 2. TASC. TASC programs follow a case management model, including single-point-of-entry assessment and diagnosis; specialized service planning and treatment matching; intervention, service referrals, and placement; and monitoring and reporting (Baille & Breslin, 1996). 3. JAC. The JAC began in Tampa, Florida, but has spread to nine other Florida locations. While services in each location vary, the basic elements and functions of the model include centralized location of relevant agencies which can conveniently provide needed services to at-risk youth; screening, diagnosis, and, if appropriate, linkage of arrested and high-risk youth with area service providers; case management of juveniles assigned to diversion programs within the juvenile justice system; and tracking, which is usually limited to the purpose of determining referral disposition (Dembo & Rivers, 1996). Ideally, the JAC is designed to move juveniles through the system in the following way: --Law enforcement officers bring the arrested youth to the JAC where he or she is processed by Department of Juvenile Justice detention intake and JAC assessor personnel. --JAC assessors conduct breathalyzer and urine tests for substance use; substance abuse and mental health histories are also collected. In addition, the juvenile undergoes preliminary screening using the NIDA Problem Oriented Screening Instrument for Teenagers (POSIT) to identify potential problems in 10 different psychosocial functioning areas (the POSIT is described in greater detail below). Based on the results of this preliminary screening process, indepth assessments are conducted in problem areas such as AOD abuse, mental illness, physical and sexual victimization, and delinquency. --On the basis of assessment findings, current charges, and arrest history, intake staff determine whether the youth should be placed in secure detention, home detention, or released into the care of a parent, guardian, or responsible relative. --When a minor is not appropriate for detention, he or she is assigned to the misdemeanor case management staff at the JAC. This unit reviews the arrest histories and current charges of the youth to determine his or her eligibility for arbitration or various diversion programs within the local juvenile justice system. --JAC misdemeanor case managers follow the case until the juvenile successfully completes the program to which he or she is assigned. If the program is not successfully completed, the case manager has the option to file a delinquency petition, and the case is turned over to the Department of Juvenile Justice case manager. One obvious component of a successful community assessment center is the use of valid and reliable screening instruments. The following section describes a number of assessment instruments for adolescents that the research literature suggests are considered valid and commonly used. Assessment instruments. The number of adolescent AOD assessment tools has grown rapidly in recent years (Farrow et al., 1993; Winters & Stinchfield, 1995), with over 30 tools currently available for both screening and assessment. This increasing growth has made selection of an appropriate screening instrument more difficult than ever before: "The rate of development of this new generation of measures has out-paced efforts to critically evaluate them, leaving the field somewhat at a loss as to their absolute and relative merits" (Stinchfield & Winters, 1997:63). Recognizing that alcohol is the mood-altering substance most commonly used by juveniles, most of these instruments assess alcohol as well as other substance use, abuse, and dependence. Substance abuse assessment tools are commonly divided into screening and comprehensive assessment instruments. Several full-range assessment systems have also been designed to combine screening, diagnostic evaluation, and comprehensive assessment in one package. The primary purpose of screening is to determine if the need for a more comprehensive assessment exists. Thus, it is inappropriate to use screening instruments to formulate a diagnosis or decide treatment needs. If the screening instrument indicates an AOD problem, a more comprehensive assessment is indicated. At minimum, the comprehensive assessment should include: (1) an in-depth examination of the severity and nature of the AOD abuse identified by the screening process, (2) a more thorough assessment of additional problems flagged during the screening and additional inquiry into problems that may not have been included in the screening, and (3) a strong effort to use multiple methods and sources with special emphasis on including the youth's family in the assessment, using standardized assessment instruments, and obtaining prior assessments and other relevant records (Winters & Stinchfield, 1995). Appendix B includes an overview of a number of stand-alone substance abuse screening tools and mid-range instruments. It is recommended that both screening tools and mid-range substance abuse instruments be supplemented with more comprehensive assessments of the juvenile's broader psychosocial needs.[3] Assessment systems integrate screening, diagnosis, and comprehensive assessment into one package. Advantages include rapid referral of adolescents to more indepth assessment, standardization of the assessment and referral process, assurance that an adolescent's comprehensive needs have been adequately addressed, and evaluation of client needs with adequate referral to appropriate adjunctive services. Disadvantages include higher costs for commercial assessment instruments and the need for staff expertise and training to administer and interpret the instruments (Winters & Stinchfield, 1995), as well as comparatively longer time periods for administration than non-comprehensive assessment instruments. Two full- range assessment systems commonly used with juvenile delinquent populations are discussed below: 1. Adolescent Assessment/Referral System (AARS). NIDA initiated the AARS in order to identify reliable and valid assessment instruments that could be used to assess the broad psychosocial problem areas of AOD- involved youth and guide treatment decision development (Rahdert, 1991). The AARS includes three components plus a treatment plan, which are described below. --The POSIT. The POSIT is available in both Spanish and English and is a 139-item, yes/no, self-administered instrument which explores difficulties in 10 high-risk areas of functioning: AOD use/abuse, physical health status, mental health status, family relationships, peer relations, educational status, vocational status, social skills, leisure and recreation, and aggressive behavior and delinquency. The POSIT is designed to quickly identify problems in any functional area requiring further assessment and/or treatment. A reliability study indicates that the POSIT consistently identifies potentially troubled youth who are in need of indepth assessment and intervention or treatment services (Dembo et al., 1996). NIDA is currently pilot-testing an HIV/STD-risk mini-questionnaire designed to be administered alone or as a supplement to the POSIT (Rahdert, 1999). This questionnaire will provide valuable information on juveniles' high-risk sexual practices. Early evaluation supports internal consistency and test-retest reliability, as well as content and criterion (predictive and concurrent) validity. --The Client Personal History Questionnaire (CPHQ). The CPHQ is included with the POSIT and identifies client demographics, history of juvenile justice and mental health contacts, school performance, health care utilization, and current life stressors. Academic information and school discipline information are gathered when available. Collateral information is also collected from parents or guardians using the Problem Oriented Screening Instrument for Parents (POSIP). This information is useful in helping assessment professionals corroborate juvenile claims. --The Comprehensive Assessment Battery (CAB). The CAB includes a variety of psychometrically validated assessment tools which probe more deeply into each of the 10 problem areas identified by the POSIT. Examples of recommended CAB assessment instruments are the Personal Experience Inventory (PEI) and the Adolescent Diagnostic Interview (ADI) for AOD abuse (Winters, 1991; 1992; Winters & Henly, 1989), and the Family Assessment Measure (FAM) for family relations (Skinner et al., 1983). --Treatment planning. The AARS recommends that staff develop a treatment plan after completing the assessment phase. The AARS manual guides programs in developing their own local directory of adolescent services, which assists the case manager or referral agent in locating appropriate resources and placing troubled youth in services which match their treatment needs. 2. Minnesota Chemical Dependency Adolescent Assessment Package (MCDAAP). Like the AARS, the MCDAAP attempts to provide both screening and more intensive assessment. However, the MCDAAP differs from the AARS in several ways: "The MCDAAP tools are primarily geared to measure drug abuse characteristics and related problems and only screens [sic] for coexisting mental and behavioral disorders; the MCDAAP screening tool contains fewer items than the POSIT; and the MCDAAP does not include resources related to additional assessment and treatment referral" (Winters & Stinchfield, 1995:153). The MCDAAP has three components, described below. --The Personal Experience Screening Questionnaire (PESQ). The PESQ (Winters, 1991; 1992) is a 40-item, self-report screening instrument primarily designed to estimate the potential need for AOD treatment services among adolescents. The instrument evaluates problem severity (18 items), psychosocial problems (8 items), substance use history (4 items), defensiveness or faking good (5 items), and infrequency or faking bad (3 items). The index measures behaviors, attitudes, and consequences related to AOD use by adolescents. The PESQ's advantages include its format, brevity, and relatively easy reading level (fourth grade). Evaluation indicates internal consistency, reliability, accurate prediction of comprehensive AOD assessment need, and follow-through of referral.[4] --Adolescent Diagnostic Interview. The ADI assesses symptoms found in substance use disorders as described in the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV). The interview format includes a substance abuse history and signs of abuse or dependence in all major AOD categories. The ADI also screens other mental health disorders and several domains of functioning (e.g., school performance, peer and family relationships, legal problems, and leisure activities) (Winters & Stinchfield, 1995). Evaluation supports interrater and test-retest reliability, as well as criterion validity.[5] --Personal Experience Inventory. The PEI is a multiscale instrument which identifies problems and makes referral and treatment recommendations based on a differential diagnosis of a client's problems. It is divided into two sections: chemical involvement problem severity and psychosocial risk factors. The PEI measures AOD misuse problem severity and use frequency as well as psychosocial and environmental correlates of adolescent AOD abuse (e.g., negative self-image, social isolation, physical and sexual abuse, and estrangement from family). Several additional clinical problems are also measured, including eating disorders, suicide potential, other mental health symptoms, and parental history of substance abuse. "PEI scores have been found to be highly correlated with other measures of drug abuse problem severity and psychosocial risk factors, independent recommendations regarding need for drug abuse treatment, and independent clinical diagnoses" (Winters & Stinchfield, 1995:9). The PEI is recommended by a NIDA publication for use in comprehensive evaluation of adolescent substance use/abuse (Rahdert, 1991). Case management Whatever assessment instrument is chosen, it is crucial to use the assessment for the development of a comprehensive intervention/treatment plan. Such a plan must be housed within an organizational structure including roles that facilitate meeting the identified needs of the juvenile. Case management provides one way for juvenile justice systems to coordinate meeting the comprehensive needs of adolescents. The function of the case manager (CM) is "to secure and coordinate continued social, mental health, medical, and other services for a client" (Healey, 1999:1). The approach has emerged as an intake, during-treatment, and posttreatment strategy which can connect clients (adults and juveniles) to needed resources throughout the service continuum resulting in more rapid access to services (Bokos et al., 1992), higher levels of goal attainment (Godley et al., 1994; Rapp, 1997), longer lengths of stay in treatment (Rapp et al., 1997), improved AOD treatment outcomes (Rapp, 1997), improved employment functioning (Siegal et al., 1996), and improved connection to needed resources over time (Dennis et al., 1992; Godley et al., 1994; Schlenger et al., 1992) when compared to standard treatment services. Due to its individualized nature, case management appears particularly effective in meeting the needs of special populations, such as homeless persons (Conrad et al., 1993; Perl & Jacobs, 1992), injection drug users (Falck et al., 1994), persons with AIDS (Lidz et al., 1992; McCoy et al., 1992), youth with dual diagnoses (Evans & Dollard, 1992), and juvenile delinquents (Enos & Southern, 1996). Research suggests that case management may be useful as an adjunct to substance abuse treatment for two reasons: (1) retention in treatment is generally associated with better outcomes, and one of case management's primary goals is to keep the adolescent engaged in the treatment process (Kolden et al., 1997; Siegal et al., 1995), and (2) treatment is more likely to succeed when a youth's non-substance abuse problems (e.g., school performance, family problems, etc.) are also being addressed (Westermeyer, 1989). According to a recent NIJ examination of case management within the criminal justice system (Healey, 1999), optimum case management models currently combine two broad approaches: strengths-based and assertive. Strengths-based case management focuses on a client's self- identified strengths and talents when developing a service plan, assuming a client's ability to use these strengths in order to move toward "socially acceptable choices" (Enos & Southern, 1996:44-45). Within the criminal justice setting, CMs combine support and positive regard for a client's strengths with clear disapproval of the behaviors leading to justice system involvement. Assertive case management requires active involvement of the CM in seeking out and delivering services to clients as opposed to passive service provision (Inciardi, 1996; Healey, 1999). Many current versions of case management methodologies have followed a passive approach to service provision, providing clients with referral information but not actively engaging in obtaining such services for the client. According to much of the research, by combining strengths-based and assertive case management, aggressive service provision based on a client's own strengths and talents can best support client success. Case managers support and reinforce treatment continuum goals by providing five major functions: 1. Engagement. CMs orient, support, and meet immediate adolescent needs, as well as serve as linkages to resources and services. 2. Assessment. CMs assess the appropriateness and eligibility of both internal and external resources. Some CMs provide the majority of assessment services, including the collection of information from family, school, and court systems (Babor et al., 1991). 3. Planning, goal-setting, and implementation. CMs are not treatment providers but instead focus on the longer term recovery needs of juveniles while assisting in the maintenance of the treatment plan as devised by the treatment service provider(s). CMs follow youth as they move through and at times beyond the treatment continuum, acting as system guides to ensure that youth obtain needed resources and stay motivated to maintain treatment progress. 4. Linking, monitoring, and advocacy. CMs can enhance adolescents' commitment to seek needed resources, help implement plans derived from such contacts, troubleshoot obstacles which may prevent client success, and model, rehearse, and summarize the implementation of those plans (Ballew & Mink, 1996). CMs can also help navigate the often confusing social service system and advocate for needed resources where necessary. 5. Disengagement. CMs help youth summarize and review progress toward goals, with a focus on treatment gains and planning for youth to continue to access services on their own. At posttreatment, the CM might help the adolescent reintegrate with his or her family or an out-of-home placement, coordinate care between staff and services at other agencies, and/or help with reintegration into the school system. In addition, CMs may intervene in crisis situations or assist youth in finding work and/or appropriate substance-free friends and leisure activities. Intensive case management services are most critical during the vulnerable 2-month period following discharge from primary treatment with the purpose of providing continuity of care while simultaneously working to move the adolescent toward independence (Spear & Skala, 1995). While a CM can help a juvenile navigate through an interconnected array of treatment services, it is also clear that such services must occur within the context of the juvenile justice system. System representatives, such as drug courts or probation offices, will maintain primary responsibility for a juvenile's movement through the juvenile justice system via the use of graduated sanctions. The graduated sanctions process allows the judge or probation officer to maintain an appropriate balance between community protection and juvenile rehabilitation (graduated sanctions will be discussed in greater detail below). However, judges generally have neither the time nor training to ensure that juveniles receive a continuum of services. It should be noted that if a community has Intensive Probation Supervision (IPS) services, IPS probation officers are likely able to fulfill the case management role if trained in clinical and evaluation methodology. However, the reality of traditional probation case loads (as well as potential limitations from collective bargaining agreements) may prevent probation officers from serving in case management functions to provide the vital role of linking adolescents to needed and appropriate interconnected community resources including AOD treatment services. Case management in the criminal justice system requires unique methodologies of service provision. Healey (1999:2) notes that criminal justice case management often involves a conscious blurring of roles between CMs, mental health providers, substance abuse counselors, domestic violence program counselors, and other social service providers. Significant cross-training is often necessary to allow such blurring to take place without confusion of appropriate role responsibility. Therefore, role expectations should be clearly negotiated between service providers before service provision begins. In addition, it is critical that philosophical differences between criminal justice personnel and AOD treatment and mental health service providers be shared and discussed in order to ensure smooth communication and successful treatment for the client (Healey, 1999; McBride & VanderWaal, 1997). While case management has been used in the delivery of residential (Godley et al., 1994) and inpatient (Siegal et al., 1995) substance abuse treatment services, little is known about its effectiveness in juvenile justice settings. Conceptually, case management could be an important part of the juvenile justice system, providing a coordinated control point for implementing judicial decisions and reporting back to the court. Three promising case management programs designed to assist high-risk, AOD abusing adolescents are described below, as well as one program with potential applicability to juvenile justice settings. Youth Evaluation Services (YES) (Del Boca et al., 1995). YES is an integrated assessment and case management system. Its primary goal is to coordinate services for youth with substance abuse problems; in addition, the system collects data on treatment utilization, service costs, and outcomes. Adolescents are screened and comprehensively assessed using the AARS (described earlier). This information is supplemented by data gathered from parents, CMs, and schools. YES personnel formulate a treatment plan based on the results of the assessment process utilizing a Treatment Matching Criteria system. Finally, adolescents are referred to various substance abuse treatment services. Following acceptance of the treatment plan by the youth and his or her parents, CMs begin performing a variety of client-specific functions, including monitoring the adolescent's progress, linking him or her to appropriate services, coordinating continuing care services, and advocating for his or her needs. Formal monitoring of treatment and progress toward recovery continues at regular intervals for up to 18 months (treatment outcomes were not available). The Amity Project (Healey, 1999; Stiles & Mullen, 1993; Adult Probation Department, 1994, 1995). This model was a collaborative effort between Amity, Inc., and the Pima County (Arizona) Department of Probation. Minorities and younger offenders at high risk of probation revocation due to continued substance abuse were served in a day-and-evening program resembling a therapeutic community. A graduated sanctions approach incorporating case management and a variety of other services (including educational/vocational training, health services coordination, and continuing care) was provided at a community-based site. Two years after initiation of the program, reductions in AOD use relapse were observed, as well as increases in employment. Positive urine screens (part of program monitoring) fell by over 50 percent in the first year of program operation. Funding issues caused the closure of this program. The Iowa Case Management Model (Hall, 1997). This model assists juveniles in maintaining an AOD-free lifestyle following discharge from an inpatient treatment facility. The CM targets both individual and environmental outcomes for change in the youth's social system. The Iowa Case Management philosophy emerges from the principles of strengths- and solution-based therapeutic models. Client-driven goals are described in behavioral terms using solution-oriented language emphasizing the presence of positive behaviors rather than the elimination of negative ones. The program is divided into three primary phases conducted over a 1-year period: active case management with regular CM/adolescent meetings, transitional case management with less frequent meetings, and self- directed case management. Case management functions include: 1. Assessment and monitoring. Using assessments to discover the adolescent's strengths, resources, ambitions, goals, and past successes, as opposed to problems and past failures. 2. Negotiating and contracting. Together with the youth, jointly developing a solution plan including involvement and responsibilities of each party. 3. Solution-based problem solving, and planning and referral. Using an individual solution plan to develop referrals to necessary services. 4. Evaluation of process and outcomes. Monitoring and providing feedback on activity or goal achievement. As of this writing, the Iowa Case Management Model was still undergoing evaluation relative to its effectiveness for juveniles. The Case Management Enhancements Project (CME) (Siegal et al., 1996). This NIDA demonstration project is designed to examine the impact of community-based aftercare and strengths-based case management on retention and outcomes related to adult AOD treatment. It is described in this report because of the program's strengths-based approach (Rapp, 1997) and its potential applicability to juvenile justice settings. Case management within the CME is designed to supplement an existing medically based, disease concept-oriented treatment program. Clients are first evaluated using a strengths assessment covering nine life domains; within each domain, CMs ask participants to describe specific incidents where they successfully demonstrated skills and abilities. CMs then help participants set their own goals and strategies, including target and review dates. Researchers (Rapp et al., 1998) randomly assigned AOD-using Veterans Hospital participants to a CME experimental case management group (n=313) or a control group (n=319; approximately 75 percent of participants were retained at 6-month follow-up). Multivariate analyses revealed that case-managed clients stayed longer in aftercare programs than noncase-managed participants, leading to improved substance use treatment outcomes. Cluster analysis data suggested that providing strengths-based case management was associated with retention in aftercare treatment for over one-third of the group (Siegal et al., 1997). While researchers caution that case management by itself should not be expected to have a direct impact on substance-using behavior, it may indirectly improve treatment outcomes by retaining clients in treatment. How case management is organized in the juvenile justice system is an important question. Challenges to offender case management include: how to provide continuous service to juveniles who are returning to the community, how to best apply graduated sanctions in ways that optimize service participation while avoiding unnecessary incarceration, and how to measure program effectiveness (Healey, 1999). Most of the examples given previously are based in a treatment program-centered case management system. That is, the CM is structurally located in a treatment program or some other type of human service agency. In many ways, probation officers have provided case management services within the justice system. They carry out and manage court orders regarding conditions of probation, including ensuring the obtainment of needed mental health and other social services. It has recently been argued (Healey, 1999) that case management can be effectively located and applied within the criminal justice system. The literature suggests that the courts have utilized other administrative structures, such as drug courts, and other programs, such as TASC, to provide case management apart from probation (Inciardi et al., 1996). Healey (1999) has suggested that a criminal justice CM may (at least in some cases) be a part of a team of CMs who coordinate service delivery and achievement of criminal justice goals. The structural location of a CM in a particular community will depend on a variety of local conditions, including available community resources, probation case loads, or the existence of a successful drug court or a TASC program that would have the expertise and resources to provide case management. Management information systems and confidentiality issues Effective use of assessment data within a case management framework requires a complex information system that can ensure the availability of relevant information to those involved in service provision. Many of the current attempts to intervene in the juvenile drug-crime cycle have included a management information system (MIS) as part of the necessary infrastructure to support principles of client confidentiality and juvenile justice system responsibility. According to the Office of Justice Programs' (OJP) Drug Courts Program Office, MIS development should include the following key characteristics (Mahoney et al., 1998:2): rapid recording and transmittal of a variety of data on individuals involved in court processing; effective integration with all involved service providers and the justice system; ability to provide detailed information on an individual from the point of intake onward; design specifications to provide information aiding decision making at all stages of the justice system process; ability to expand and modify as needed; user-friendliness for a variety of levels of technology sophistication; proficiency in monitoring and evaluation use; and location- specificity regarding cost, size, and scope needs. Examples of MIS approaches include both adaptations of existing software and development of new programs. For example, drug court MIS programs such as both the Jacksonville Drug Court MIS and Buffalo Drug Court MIS use the Microsoft Access software (Mahoney et al., 1998), while the Brooklyn Treatment Court MIS, the Washington, D.C. Pretrial Real-time Information System Manager, and the Washington/Baltimore High Intensity Drug Trafficking Area Treatment Tracking System have all developed specialized systems (Mahoney et al., 1998). Recent efforts by OJP to determine the success of these programs have resulted in the recognition of three required MIS functions (Mahoney et al., 1998:16-17): 1. To facilitate initial decision making, such as program admission, treatment level, and testing (current charge, criminal and AOD abuse history, detoxification needs, insurance eligibility, basic socio- demographic data including employment, housing and family situation, and assessment results). 2. To support ongoing participant supervision (AOD test results, treatment service level, treatment participation and compliance, medical and family issues, major life events, new arrest data, and relapse information). 3. To support provision of treatment services (court-ordered decisions affecting treatment provision). Target Cities projects have also developed advanced MIS programs, including the Person Tracking System (PTS) within the Philadelphia Target Cities project (System Design Associates, 1996). The PTS involves a central registry (for screening and identification) and the following eight modules: (1) intake (for demographics and other pertinent data), (2) assessment (including the Addiction Severity Index), (3) evaluation (assisting CMs in combining information gained through previous modules for the purpose of determining an appropriate level of client care and other needed services), (4) service plan (facilitating placement of the client by summating available treatment modalities and provider capacities), (5) slot/capacity registry (real-time monitoring of patient care service slots in the collaborative area), (6) service tracking, (7) case management, and (8) discharge (including data on coordination of needed continuing care services). An additional component is also available that includes various justice department data, such as the tracking of court petitions, assignment of parole officers, etc. Sharing of information and MIS development must precede coordinated planning, budgeting, service delivery, and meaningful program evaluation. Recognizing that information systems are crucial to successful program design, it must also be stated that one of the most difficult barriers to the development and execution of coordinated and intensive services for AOD-involved juveniles is the necessity to comply with the special confidentiality requirements involved in juvenile proceedings. As electronic storage and retrieval of participant information becomes more widespread, threats to confidentiality increase. Confidentiality becomes particularly important when a participant is connected to several systems. For example, it is common for drug court participants to have contact with judges, prosecutors, defense attorneys, probation officers or CMs, child protection workers, and various treatment providers and coordinators. In such circumstances, the juvenile could rightly fear that his or her personal disclosures in, for example, an AOD treatment facility would lead to further sanctions in the criminal justice setting. Confidentiality laws relating to AOD treatment were originally created to encourage substance abusers to obtain help with their AOD problems. The most significant Federal confidentiality law is Section 290dd-2 of Title 42 of the United States Code. Under this law, covered information acquired by affected programs is kept confidential subject to exceptions described in the statute and accompanying regulations.[6] Lawmakers reasoned that such laws would make it more likely that substance abusers would enter treatment if they were assured that information about their AOD use would not readily be available to the public, including employers and the media. Assurances of confidentiality also make it more likely that the substance abuser will communicate freely in a therapeutic setting. Consent by participants who are under 18 years of age raises a special concern. Some States require the consent of a parent or guardian for a minor to enter a treatment facility. However, even in those States, Federal confidentiality laws protect minors who have sought treatment. Under this provision, treatment or drug court practitioners may not approach a child's parents or guardians to ask them to approve a child's request for admission unless the child authorizes disclosure of that request or lacks the ability to make the choice. Once a parent/guardian has agreed to treatment and the child has been admitted, further disclosures again require the consent of both the child and the parent/guardian (National Drug Court Institute, or NDCI, 1999b). Because information sharing is necessary to facilitate multiple system involvement, it is important that the participant give his or her consent to communications between systems. Improper disclosures of information covered by confidentiality laws can result in criminal prosecutions and civil lawsuits. The simplest way to ensure that such communications do not violate Federal and State confidentiality laws is to obtain valid consent from the participant (examples of consent forms can be found in NDCI, 1999b). Information sharing between various systems can best be facilitated using a memorandum of understanding (MOU). MOUs serve to facilitate trust and communication between systems by ensuring that all parties are aware of how other organizations will access, share, and use participant information. MOUs can also be used to explain to participants how information will be distributed between systems. MOUs should specify the following: --Discussions in team meetings are confidential. --All parties are bound by redisclosure provisions, meaning that any information an agency receives from another agency remains confidential and cannot be passed on to other entities without participant consent. --The prosecutor's office will not use the information to prosecute a participant (with exceptions made for child abuse or neglect and crimes committed at the treatment center or against treatment personnel). --Parameters are described for sharing and refusing to share information. --Rules are set governing storage of and access to written and automated records. In addition to the use of MOUs, some States are revising their juvenile justice reform provisions to address confidentiality issues. Effective January 1, 2000, lawmakers in Illinois have moved to clearly limit the disclosure of juvenile case and clinical records to judges, parties involved and their attorneys, probation officers and court-appointed special advocates, custodial bodies, placement providers, law enforcement officers and prosecutors, prisoner review boards, authorized military personnel, and members of the Illinois General Assembly (Devine, 1998).[7] These revisions were made to replace previous legislation allowing broader disclosure at the discretion of the Department of Children and Family Services Director. Record storage is a particularly important issue in this era of computerized records. Federal laws require that written records be stored in a secure room or locked container. However, these laws do not address computerized records. The NDCI (1999b) recommends that all computerized records covered by Section 290dd-2 be password-protected, with the password guarded in the same manner as a key to a file cabinet. Computers which are networked to one another in the same system or between two or more systems should be protected by both passwords and encryption systems. Fears of data tampering within a system or between systems can be addressed in greater detail by utilizing a computer consultant with knowledge of security systems (Gelman et al., 1999). One of the most important uses of an effective MIS is the coordination of services among the different agencies or community groups that are used to meet the assessed service needs of juveniles. If services are to be effectively integrated, it is crucial that intake, assessment, and progress information be shared and not be needlessly duplicated. Such information can play a major role in increased service delivery efficiency and outcome. A recent article by Taxman (1998) provides an excellent illustration of how an MIS can be use for seamless case management in the justice system. Collaborative structures and strategies A restorative justice model, as advocated in a BARJ approach, calls for a community response to the juvenile drug-crime cycle. However, as long ago as the early 1960s, service providers were frustrated by a lack of coordinated response to multiple-needs clients, such as substance-abusing juvenile delinquents (Agranoff, 1991). The lack of communication was (and still is) complicated by the lack of an effective MIS as well as by increasingly fragmented services, high numbers of multiple-needs families, poor cross-systems communication, increased specialization, and inadequate funding. Such factors have forced human services professionals at all levels to rethink and reform service delivery structures and systems. Interest in systems collaboration has been further strengthened by the devolution and decentralization of resource control at Federal, State, and local levels. In addition, managed care models have emerged at both State and county levels, forcing service providers to compete, subcontract, and collaborate with other agencies in efforts to cut costs, avoid duplication of services, and survive in the competitive environment. In 1994, CSAT called for solutions to such coordination problems to be built on a systems perspective, stating that "The problem of AOD abuse absolutely defies a solution by an individual agency or program" (Crowe & Reeves, 1994:153). As a result of widespread recognition of such conditions, communities are increasingly forming interorganizational collaboratives (also known as multipurpose collaboration, comprehensive service provision, or systems integration). Collaborative partners share expertise, resources, and responsibility while working together to meet identified needs. Dembo (1996:87) has specifically addressed the importance of systems integration with juveniles, calling for "...linkages and coordination among various community agencies dealing with 'high- risk' youth--including law enforcement, the courts, schools, human service agencies, and treatment programs. Such an effort would reduce duplication of services and barriers to treatment, and respond to youth in a comprehensive manner." Community-based collaborative efforts will ensure that services are accessible to the target population, be relevant to the community's unique needs and structures, build on community-specific strengths, and increase ownership and accountability with all parties (North Central Regional Educational Laboratory, 1996). In addition, collaboratives can impact public policy through a larger and stronger advocacy base, increase funding options by accessing funds that require collaborative partnerships, and reduce wasteful duplication of services (Bailey & Koney, 1996). Many of the successful interventions designed to address substance use within the juvenile justice system are built on a foundation of collaborative structures, including juvenile drug courts, Target Cities projects, and TASC programs. A key concept of drug courts (including juvenile drug courts) is that "forging partnerships among Drug Courts, public agencies, and community-based organizations generates local support and enhances Drug Court effectiveness" (Tauber & Huddleston, 1999:6). Target Cities provide an example of collaboration in provision of AOD treatment systems, calling for "model infrastructures to coordinate and enhance local treatment networks" (DHHS, 1995:1). Target Cities projects typically involve collaborative efforts with AOD abuse, health, mental health, education, law enforcement, judicial, correctional and human services agencies (Scott et al., forthcoming). Observed success of Target Cities collaborative efforts may be due, in part, to the pressure from outside funding sources to both develop and formalize interagency agreements (Kraft & Dickinson, 1997). TASC programs emphasize the need to develop an integrated care system for juveniles. Such a system requires successful collaboration, including identification of expectations, realities of service provision limitations and resources, utilization of established community collaboration methods, and a dedication to making sure all stakeholders are involved in collaborative plan development (Mull, 1998). When developing a collaborative specifically for the purpose of linking treatment and juvenile justice systems, CSAT (McPhail & Wiest, 1995:27- 29) has focused on five major issues that need to be successfully addressed by collaborative members: community decisions; juvenile justice decisions; AOD abuse treatment decisions; physical, mental health, and social services decisions; and management system decisions. Specific issues included in each type of decision are summarized below: 1. Community decisions. These include identifying stakeholders to be involved in the process, agreeing on community accountability, anticipating locational differences, defining family roles and expectations, and planning for community diversity. 2. Juvenile justice decisions. Included here are developing and implementing education and training programs for court personnel regarding treatment resources and effectiveness, helping other collaborative members understand the flow of the justice system, establishing AOD abuse treatment responses for the judiciary, defining the juvenile justice system target population, defining treatment noncompliance and completion, identifying outcomes measures for decision making, and developing supervision ability for the treatment process. 3. AOD abuse treatment decisions. These decisions involve defining and identifying the needed services continuum, treatment modalities, treatment expectations, and supervision roles of providers. Also needed are decisions to define and locate services, establish eligibility and acceptance criteria, develop the assessment process to be used, and specify procedures for dealing appropriately with culture, gender, and ethnicity. 4. Physical, mental health, and social services decisions. These include defining physical, mental health, and social services needed for youth and their families, and deciding on linkages between these systems and the AOD treatment system as it is integrated with the juvenile justice system. 5. Management decisions. Two types of decisions are included in this group: ethical and legal decisions as well as management decisions. Ethical and legal decisions include deciding what information is appropriate to exchange, agencies/individuals appropriate to receive such information, MIS and between-agency confidentiality issues, and compliance procedures for local, State, and Federal reporting requirements. Other management decisions relate to funding and cost considerations, communication assistance between collaborative members, assurance of program management capabilities, cooperation and collaboration, preparation of training and public education, system oversight and evaluation, feedback analysis and outcomes reporting, and definition of ongoing data requirements (including demographics). Before beginning a discussion of the various components that have been identified as important considerations within collaborative development, it is important to clearly state that all successful community collaborative efforts will have one thing in common: they will be specific to the communities they are in. The literature on collaborative development repeatedly maintains that no single system can function effectively for all locations (OJJDP, 1998; Join Together, 1999) and that collaborative guides should not be used as blueprints for organizing new groups (Mull, 1998). With this in mind, the following components are presented as a springboard from which collaborative organizers can move toward formalizing an approach best suited for their own distinct communities and issues. Collaborative elements. In developing and/or seeking out collaboratives, local juvenile justice systems should be aware of interrelated elements that guide and affect interorganizational collaboratives. Each element is equally important and should be considered in collaboration development (Bailey & Koney, 1996; Gutierrez et al., 1996; Chrislip, 1995; Rosenblum et al., 1995; Weinstock, 1995; Markze & Both, 1994). 1. Ownership. Leadership within a collaborative body is a delicate issue. By definition, a collaborative group should be made up of members who are equally able to participate in discussion and dialogue. However, the current discussion of treatment reform within the juvenile justice system calls for recognition of (1) the primary role the justice system will play in monitoring adolescents along the graduated sanctions continuum and (2) the primary role substance abuse treatment services will play in providing appropriate and effective treatment services. Ownership of successful collaborative efforts to provide AOD treatment services with the juvenile justice setting will vary by community depending on available community resources and programs. In point of fact, ownership of the program will likely emerge as a result of the level of involvement in program development. While all key stakeholders will share in the ownership of the collaborative, there will likely be a lead agency that provides the majority of the energy and drive to form the group. TASC and Target Cities programs maintain that optimum organization would place a neutral group (i.e., one that is not involved in direct service provision) in the position of managing partner in order to ensure unbiased service organization referrals, case management, and collaborative organization. For example, TASC fills this role, while a single State agency, or SSA, is advocated in Target Cities programs. Program ownership success in individual communities will be affected by the managing partner's level of community trust and respect, past patterns of community authority, experience, expertise, and understanding of funding opportunities. A policy committee should be established at each collaborative site, chaired by a representative from the managing partner (such as the SSA) and made up of a member of the funding agency in addition to juvenile justice and treatment provider staff. The presence of the funding agency is critical to the agency's understanding of program needs and effectiveness. Such a model has proven successful in both Target Cities and TASC programs (DHHS, 1995; Rivers, 1997; Mull, 1999) and would be adaptable to the formation of community collaboratives focusing on service provision within both the juvenile justice and substance abuse treatment systems. Within drug court collaboratives, political leadership of community collaboratives follows various formats. Some jurisdictions utilize a cochair (from both the court and treatment provider services), while others prefer a rotating chair (where the private sector holds the position for one year and the public sector the next). Regardless of the entity that acts as the managing partner, it is crucial that this lead agency actively include all stakeholders from the beginning of design and implementation of the proposed program. 2. Funding. External funding for program development requiring collaborative applications may provide valuable incentives for the development of successful juvenile justice collaboratives (evaluations of the Target Cities programs indicate that external funding requirements helped hold the collaborative together during initial formation struggles) (Kraft & Dickinson, 1997). Such funding has been sought in the form of block grants for drug court programs (such as the Juvenile Accountability Incentive State Block Grant funded through OJJDP), primary and relapse prevention funding through Title V Incentive Grants for Local Delinquency Prevention Programs (or the Community Prevention Grants Program, also funded through OJJDP), as well as private foundations such as The Annie E. Casey Foundation. Federal demonstration grants are also available (such grants supported the development of TASC and Target Cities programs). Some communities have developed pooled funds from various sources such as child welfare, juvenile justice funds budgeted for residential treatment, Medicaid capitation, and mental health funds (Milwaukee County Mental Health Division Child and Adolescent Services Branch, 1998). Depending on the nature and structure of the collaborative, application for funds can be made through the managing entity (TASC, the SSA, or the collaborative as a whole) but only after all key stakeholders within the collaborative have been involved with proposal development. Such funds are necessary for program start-up, but collaboratives should seek to utilize evaluation data and networking efforts to attain legislative budget line-item support to continue programs with demonstrated success. The following is a brief overview of general funding options as summarized by Crowe and Reeves (1994:159-160; see also Romig & Rasmussen, 1991): Federal funding. Grants (such as the State block grants noted above), entitlement programs (Medicaid, Medicare, supplemental security income, Social Security disability insurance), and other programs (including the Drug Free Schools and Communities Program). State and local funding. State general fund revenues, State Medicaid funds for substance abuse services, substance taxes, seized assets from AOD crimes, property tax revenues, sales taxes, and court fines/assessments imposed on intoxicated drivers. Private sector funding. Insurance coverage, client fees, private foundations, donations, and United Way fund appropriations. 3. Membership formation. Collaborative formation should include partners who contribute resources, perspectives, expertise, and diversity to the overall effort. Membership should represent as complete and as wide a spectrum as possible of knowledge and experience relative to the community's needs and systems (Mull, 1998). In addition, membership should strive to include two types of individuals: "1) those who understand and have an interest in the broad and specific problems of community welfare, juvenile justice, AOD abuse, and health and social services and 2) community leaders who can ensure that productive change occurs" (McPhail & Wiest, 1995:28). Such membership might include judges, probation and social services representatives, the State/district attorney as well as private attorneys, the public defender, and representatives of the following systems: law enforcement, child welfare, State and local corrections, child advocates, families and family advocates, managed behavioral healthcare, community treatment, the health department, State/local managed care initiatives, and the welfare agency (Mull, 1998:7). Additional members to consider are public and private sector employers, consumers, elected officials, religious and other community leaders, nonprofit organizations, administrators, and adolescents. Efforts should be made to involve all key stakeholders in the planning and implementation of collaborative agendas. Individual members must have some level of authority and credibility within their own agencies as well as within the collaborative. They must also acknowledge and be committed to the interdependence of collaborative partnerships and develop effective conflict negotiation skills. 4. Visioning based on issue identification. Collaborative visioning should include identifying needs, developing a joint vision and goals to meet such needs, and creating or strengthening strategies that bring together resources to address identified needs. 5. Role clarifications, cross-training, and communication. For membership within collaborative structures to be productive, it is essential that all parties clearly understand the roles each play within the group, as well as the basic processes involved in each role. Mull (1998) suggests that during the collaboration establishment process, each party should inform all other parties of the flow of their system, including usual service gateways, admission criteria, service levels (with accompanying time and outcomes expectations), and system goals. Points at which services from other collaborative partners might be warranted would also be discussed. It is important that collaborative members remain open to being educated by other groups. For example, those in the treatment community need to educate judges on the nature of addictions, the approach of seeing a legal infraction as part of a larger behavioral problem, and the perception of a defendant as a client with his or her own strengths and resources. Judges have the need to educate the treatment community on the legitimacy of community safety. Such communication efforts that familiarize collaborative partners with each other's systems and theoretical foundations help the various groups to anticipate the effects of their actions on other members and can improve overall collaborative efforts (Crowe & Reeves, 1994). The NDCI has recognized this cross-training need and has established a training series to educate the various members of drug court teams, including judges, prosecutors, drug court coordinators, treatment providers, and defenders. For example, juvenile drug court judges receive training in substance abuse issues, AOD testing, sanctions, incentives, community resources, ethics and confidentiality, the drug court environment, MIS development and use, adolescent development, eligibility and screening, sanctions, and incentives (NDCI, 1999a). It is worth noting that collaborative efforts will likely require significant changes in service provider roles. The traditional adversarial court environment will not support the collaborative and therapeutic team nature of successful partnerships (Hora et al., 1999). For example, judges in drug courts "must assume, according to [Judge] Tauber, 'the role of confessor, task master, cheerleader, and mentor'" (Setterberg, 1994), as well as of team leader as opposed to the traditional position of referee (Drug Strategies, 1999). Prosecutors will need to act as change agents, ascertaining if a juvenile is appropriate for the program (as opposed to sole focus on the likelihood of winning a case), while the defense attorney will need to place energy into keeping a client in treatment versus attempting to minimize the legal ramifications on the juvenile (Hora et al., 1999; Drug Strategies, 1999). Judge, prosecution, and defense must work together as part of the treatment team. 6. Decision-making processes. Effective collaboration is best achieved through consensus building. In recommending methods for combining treatment and diversion programming within the juvenile justice system, CSAT encourages consensus-building decision making. This flows from the approach's emphasis on dialogue that brings the various collaborative members together to reach common ground: "Consensus builds ownership and does not require absolute agreement on every point" (McPhail & Wiest, 1995:27). 7. Structures and strategies. Agreed-upon structural connections, including those with the greater community and society, allow goal setting, strategy development, and desired outcome achievement. These linkages provide two-way streams of information, funds, and services without which the collaborative cannot be effective. The goals of strategy development are to share work and experience among partners to improve or increase the impact of services and programs. Regular assessment of intervention effectiveness should occur that considers how various interventions fit into the collaborative's larger vision. 8. Ongoing support for collaborative efforts. Management and administrative support within the various partner agencies must be obtained. Examples of such support include pledging existing funds or working together to obtain funds to provide ongoing training to keep staff engaged in the collaborative process and aware of resources outside of their own agencies or organizations. 9. Resource development. Collaboratives must effectively utilize existing resources and outline strategies to replenish them as needed. By having a managing partner as the representative of the original funding application, sustainability will be enhanced as this body will then be able to take a lead role in seeking project continuation after the initial funding period is completed. Such activity might include the assessment of, application for, and establishment of interagency funding pools, Federal grants or matching funds, Federal or State demonstration funds, block-grant applications, private foundation funding, and local contributions as well as efforts to establish legislative line-item support. Optimum collaboration structure. A variety of approaches exist for the start-up of collaborative groups. However, a recent survey of coalitions formed to prevent substance abuse and gun violence points to the possibility that coalitions demonstrating success in fighting substance abuse in their communities share some similar characteristics. Among those coalitions reporting that the substance use problems in their communities were improving, the following community resources were reported: a responsive local government, community institution involvement, and improved treatment service access (Join Together, 1999:20). Further, successful collaboratives reported the following characteristics specifically related to coalition formation/structure: the existence of a strategic plan (including specific coalition goals, an outline of programs related to achieving those goals, evaluation methods, regular public progress updates, and a description of goal and program review and change); growth in membership; a large number of volunteers; increases in the range of and intensity of effort given to problems; and current or former Center for Substance Abuse Prevention funding (Join Together, 1999:4,22). In addition, it may be helpful for communities considering collaborative development to refer to documents that outline broad goals and tasks to accomplish in the process, such as Developing a Managed Care Response for Juvenile Justice: A Guide (Mull, 1998), and Development and Implementation of Drug Court Systems (Tauber & Huddleston, 1999). Once collaborative system connections are in place, adolescents require assistance to help them access services throughout those systems. CMs can effectively serve this function. Collaboration and the juvenile justice system. The juvenile justice system can integrate with a collaborative model in a variety of ways, including diversion, adjudication, or a juvenile probation program. As will be noted in the following sections on supervision and treatment programs, mandated treatment appears to be related to treatment retention and positive outcome. The leadership and monitoring of the juvenile justice system could play a crucial role in the successful functioning of a collaborative model by helping to ensure that assessment recommendations are carried out and that the juvenile actually receives the recommended and/or mandated services. It is important that in its leadership/monitoring role, the juvenile justice system recommend and utilize the professional services available through community collaborative agencies. Such agencies are integral partners in providing collaborative resources and expertise to the system. Dismissal and/or diversion programs At the conclusion of intake and assessment, intake officers and/or CMs generally have the option of dismissal of the case with no further action, utilization of diversion programs, or referral to further juvenile justice system processing. Diversion programs include sending juveniles home in parental custody, placing them on informal probation, or diverting them to another facility or community program. Although judges and police officers often utilize diversion programs, the most common utilization of such programs is through intake officers after completion of assessment. Diversion programs generally fall under the category of early intervention in that a juvenile's behavior is not yet serious enough to merit formal entry into the juvenile justice system. This period offers a crucial time in which to provide interventions with the potential to successfully move high-risk adolescents away from more serious substance-abusing or delinquency behaviors. Dembo et al. (1993) argue that resources are best placed in assessing and providing needed services to adolescents and their families at the earliest, and preferably the first, point of contact with the juvenile justice system. These services are more likely to be cost-efficient and effective than those targeted toward juveniles who have already had repeated exposure to the juvenile court system. Several reviewers (Hawkins et al., 1992; Kumpfer, 1989; Henggeler, 1997a) have gone further to maintain that prevention and early intervention services should be specifically targeted toward high-risk youth. This makes good social and economic sense since "the determinants of drug abuse are generally the same as the determinants of delinquency, school dropout, and unprotected sexual activity" (Henggeler, 1997a:261). In a major review of early intervention literature, Klitzner and his colleagues (1991; see also Dembo et al., 1993) found a lack of consensus in defining what constitutes early intervention and determining how it differs from prevention or treatment. Those concerns aside, Klitzner and his colleagues concluded that early intervention programs are ideally targeted toward individuals or groups whose AOD use puts them at high risk for problem behaviors and related consequences, whose AOD use has created clinically significant dysfunction or outcomes, and who demonstrate certain problem behaviors that lead to AOD use (e.g., spending time with AOD-using peers) (see also Brewer et al., 1995, for a comprehensive review of early intervention programs). Klitzner and his colleagues found relatively few preadjudication or postadjudication early intervention programs in the juvenile justice system, perhaps because the system does not become concerned over the behavior of adolescents until they have appeared in court several times (Dembo, 1997). The majority of the programs which did exist at the time of the review had not been formally evaluated.[8] Fact-finding hearings and adjudication: judicial processing One of the possible outcomes of the petition (charge) made against the juvenile is formal referral to the juvenile court and formal adjudication. A decision to refer a juvenile for formal hearings is usually based on a combination of the seriousness of the charge, previous offenses, social investigation results, and some type of assessment. Judges will generally use the assessment and arrest report as well as other facts to determine disposition and, if necessary, sentencing. In most jurisdictions, fact- finding and adjudication take place in a conventional juvenile court system. However, in recent years, a specialized court called the juvenile drug court has evolved. While juvenile drug courts utilize the general juvenile justice processes described elsewhere in this report (including the possible use of case management, systems collaboration, and graduated sanctions), it is important to briefly examine the unique aspects of this new and developing trend in juvenile justice. In an attempt to play a more active role in breaking the linkage between substance use and crime, the judicial system developed the drug court. Drug courts allow judges to take a more active role than that provided by previous options, such as mandated lengthy sentences.[9] Judges draw on a variety of professionals in assessing needs and recommending services and are then actively involved in the decision-making process of what services are to be received, monitoring compliance, and applying sanctions when a lack of compliance is evident.[10] Thirty-eight states currently operate some type of juvenile drug court (including the District of Columbia and Guam) for a total of 69 programs under way and an additional 48 in the planning stages as of June 1999 (American University, 1999a). A recent American University report indicates that 20 percent of drug courts in the United States serve juveniles either as a separate program or as part of an overall community drug court program (1999b). The general philosophy of drug courts--including an emphasis on an active judicial role in service decisions and management--was developed within an adult framework. However, this philosophy is consistent with the traditional role and function of juvenile courts and juvenile court judges. As noted previously, juvenile courts have traditionally focused on service interventions designed to change problem behavior rather than on punishing criminal behavior. Given this role, a recent publication of the OJJDP (Roberts et al., 1997) indicated that six approaches appeared to be more common to juvenile drug courts than regular juvenile court procedures: 1. Much earlier and more comprehensive intake assessment procedures. Procedures usually involve initial screening and later comprehensive assessment designed to identify a wide variety of environmental, family and psychosocial functioning problems. Typically, screening and assessment provide the basis for referral and service decisions. 2. Greater focus on juvenile and family functioning throughout the juvenile court process. There is a recognition that the emergence of juvenile delinquency and AOD use usually occurs within the context of significant family functioning problems. 3. Closer integration of information obtained during the assessment process as it relates to the juvenile and the family. This includes collecting information on individual characteristics and well as on family behavior, interaction, and functioning. Assessment is designed to result in the integration of individual and family intervention services. 4. Greater coordination between the court, treatment community, school system, and other community agencies in responding to the needs of the juvenile and the court. This strongly implies recognition of the need for active case management to try to ensure barrier-free integration and coordination of needed services. 5. More active and continuous judicial supervision of the juvenile's case and treatment process. To a significant degree, this results in the judge playing the role of CM in assessing service needs, making referral decisions, and monitoring progress. 6. Increased use of immediate sanctions for noncompliance and of progress incentives for both the juvenile and family. From the judicial perspective, these options provide the rationale for the effectiveness of judicial involvement. Judges often argue that it is within their power to provide immediate sanctions to help ensure compliance with required services. Such power significantly increases the probability of improved service effectiveness through increased retention of participants in programs. Overall evaluations of juvenile drug courts have not occurred, perhaps due to their relatively short history. The research that does exist has tended to focus primarily on formative and process evaluation rather than impact evaluation. However, a recent report on the last decade of drug courts notes a high level of program retention (over 70 percent) and participant satisfaction with the drug court experience (American University, 1998; see also Turner et al., 1999). There are also very positive reports about lower rates of AOD use and criminal justice recidivism. A number of presentations made at the 1999 National Association of Drug Court Professionals Annual Training Conference suggested that drug courts meet the needs of key system participants, including giving judges a strong sense of active involvement in addressing a very complex problem. For district attorneys, drug courts may provide an effective means of addressing the underlying causes of criminal behavior while at the same time providing for community safety. Public defenders and defense attorneys appear to support drug courts because the approach keeps their clients out of jail/detention and, if they are successful in the program, generally they do not have a felony conviction or were not adjudicated delinquent. Treatment program providers often see the drug court carrot (no criminal/delinquent record) and stick (incarceration/adjudication on the original criminal charge) approach as an important part of ensuring client participation in treatment. While drug court personnel are often very enthusiastic about the program, researchers and the Government Accounting Office (GAO) have been critical of some aspects of drug court evaluation research methodology, leading to significant questions regarding drug court effectiveness conclusions. Inciardi and his colleagues (1996), as well as the GAO (1997), expressed considerable concern regarding a lack of appropriate comparison groups in drug court evaluation research, the widely varying populations involved in drug courts, and lack of consistent standards for assessment and referral. The GAO concluded that the 20 evaluation studies reviewed "...did not permit the GAO to reach definitive conclusions concerning the overall impact of drug courts. " (13). Despite these concerns, positive initial perceptions of drug court effectiveness have strongly encouraged their application to the juvenile justice system as evidenced by the recent increases in juvenile drug courts noted earlier. While it is likely too early to adequately evaluate effectiveness, a literature is emerging suggesting that like adult drug courts, juvenile drug courts are being successfully implemented, are receiving positive responses from all system and client participants, and seem to result in lower rates of AOD use and recidivism (Shaw & Robinson, 1999). It is expected that over the next few years, there will be further increases in the number of juvenile drug courts and hopefully prospective scientific evaluations measuring the behavioral change impact of juvenile drug courts. Disposition Both the conventional juvenile justice system and the juvenile drug court system utilize the adjudication process to determine case disposition and, if necessary, sentencing. Case disposition generally takes place within the framework of a graduated sanctions continuum. The graduated sanctions continuum The material presented in this report focuses primarily on the need for comprehensive assessment, appropriate referral, effective interventions, and effective services along a continuum of care within a case management framework in a community with systems collaboration. Within this therapeutic framework and consistent with the BARJ philosophy, there exists a responsibility to hold juveniles accountable for their actions and to protect the community. Even with the very best assessment, services, interventions, and case management, there will be youth who do not respond to therapeutic interventions and who continue to engage in substance use and delinquent behavior. Within the concept and application of graduated sanctions, accountability and community protection needs are integrated with assessment, referral, service provision, and case management. Assessment techniques are used to incorporate offense history and other behaviors to determine community risk from the juvenile and probability of recidivism. This information then informs final judicial decisions on the types of services to be received and the delivery location (State training school, a detention center, or in the community). Within the framework of case management, the graduated sanctions continuum is used as part of a carrot-and-stick approach to treatment progress. The concept of graduated sanctions applies to (1) the initial type of treatment intervention (outpatient, residential, or types of collaborative services), (2) the sentencing context of service delivery (from community diversion to incarceration in a State training school), (3) overall intervention/treatment program outcome goals, and (4) progress within the program. The lowest levels of juvenile justice sanctions and therapeutic/service interventions generally occur for first-time offenders with minimal AOD use from two-parent families. Higher initial sanction levels and increasingly intensive therapeutic/service interventions are likely to be applied to repeat offenders with extensive AOD use histories involving cocaine and/or opiates. If a participant successfully completes a mandated treatment program (recognizing the need for continuing care), his or her charge may not be filed in the juvenile court or, if adjudicated, the charge may be dismissed (forming the carrot part of sanctions). If the participant fails in treatment and/or is referred again to the juvenile court for a new charge, the stick aspect of sanctions may result in formal processing of the original referral/charge and the carrying out of the previously imposed sentence. Based on an individual's progress, sanctions and therapeutic/service interventions can become more or less intense.[11] If AOD use and/or delinquency recidivism occur at any particular point in the treatment process, the application of graduated sanctions generally involves placing the individual in a higher security, more intensive therapeutic environment. Avoiding the application of graduated negative sanctions (and thus decreased freedoms) is seen as an incentive for treatment progress. If the program participant is making good progress in treatment, the application of positive graduated sanctions generally means increased freedom or other rewards designed to provide personal and public recognition of a juvenile's achievements. This may involve more freedom of movement, fewer treatment or supervision contacts, rewards within a token economy, or public recognition, such as applause in open court. It is important to recognize that all entry points into the justice and treatment intervention systems should be integrated into a comprehensive sanctions program. Many AOD treatment providers are suspicious of treatment coerced by the justice system. Conventional wisdom in the treatment community has generally maintained that providing treatment services to participants against their wishes will generate resistance from the participant and ultimately lead to treatment failure. However, many researchers have determined that court-ordered treatment is as effective as or more effective than voluntary treatment (Anglin & Hser, 1990; Hubbard et al., 1989; Collins & Allison, 1983). Compared to individuals in voluntary treatment, individuals legally mandated for treatment have been found to stay in treatment longer and are more successful in posttreatment measures (Allison & Hubbard, 1985; De Leon, 1985; Siddall & Conway, 1988). Few specific evaluations of the effectiveness of graduated sanctions as a separate and distinct program have been conducted. One of the few exceptions is a basic study comparing an adult program using graduated sanctions to a regular court process in a pretrial intervention program (Harrell, 1998). The graduated sanctions program involved substance use testing and, based on urinalysis results, could result in a range of graduated sanctions from additional program activities to time in jail. The regular court process also included substance use testing but used the results only for sentencing without a graduated sanctions framework. The study reported that those in the graduated sanctions program had a lower rearrest rate for both short- and long-term (1 year) follow-up. In addition, Lipsey and Wilson (1998) recently performed a meta-analysis on the effectiveness of juvenile intervention programs. Overall, they concluded that the most successful intervention programs incorporated graduated sanctions as part of a comprehensive intervention strategy. Such inclusion was associated with both lower AOD use and delinquency recidivism rates. Generally, Lipsey and Wilson found these programs reported recidivism rates between 30 and 50 percent lower than those of comparison groups. However, Lipsey and Wilson (1998), as well as Krisberg and Howell (1997), noted some qualifications to such findings. Youth who experienced significant damage to their self-concept through incarceration did not appear to reduce recidivism. Thus, less severe sanctions may reduce recidivism more than incarceration. It may be that when the level of sanctions stipulating incarceration is applied, problem behavior patterns are strongly established; sufficiently intensive therapeutic/service intervention strategies have perhaps not yet been developed. All of these researchers further argue that well-structured community programs may be able to offer sufficient community security without the apparently negative consequences of incarceration. Results of research on the comparative cost benefits of comprehensive graduated sanctions programs have been positive. Greenwood and Turner (1993) imply that such programs are as effective at serious crime reduction as California's three-strikes law at only 20 percent of the cost. Analysis by Rivers and Trotti (1995) found that in South Carolina, reducing the movement from probation to incarceration by just 5 percentage points could save the State $37 million per year. In an era of increasing demands for juveniles to be tried as adults and imprisoned if convicted, the above findings on the effectiveness of graduated sanctions, particularly in a community setting, provide an important counterbalance to the current emphasis on incarceration. According to some research, a comprehensive program including graduated sanctions could be more effective than incarceration and much less costly. Since many researchers argue for an intervention program that incorporates graduated sanctions, it is important to briefly review the range of sentencing options that are used as part of a comprehensive graduated sanctions program or as stand-alone interventions. Specifically, brief examinations of both supervision and treatment options will be provided. Sentencing options The graduated sanctions continuum utilizes two broad intervention tracks operating simultaneously to affect juvenile offenders: supervision options and treatment options. While supervision and treatment will be discussed separately in this report, both operate concurrently along their own continua and should be viewed as complementary and essential aspects of any judicial processing and sentencing methodology. All supervision and treatment programs take place within the framework of graduated sanctions and thus should be considered as part of the whole as well as programs in and of themselves. Supervision options range from light to intensive and include monitoring through various means. This review will follow a light-to-intensive continuum including juvenile TASCs, intensive probation, boot camps, and State training schools. 1. Juvenile TASCs. TASC programs seek to provide a linkage between the justice system and the treatment system. TASC attempts to provide screening, assessment, referral, case monitoring, and reporting to the justice system. A number of juvenile TASC sites exist in the United States, and a recent TASC evaluation by Anglin and his colleagues (1996) included a juvenile site in Orlando, Florida. This quasi-experimental evaluation focused on changes in AOD use, crime, and HIV risk behaviors. The study compared a TASC group with a comparison group in which participants were placed on probation and received services associated with that status. The analysis found that juvenile TASC participants were significantly more likely to obtain needed services than those in the comparison group. In addition, TASC participants were found to have significantly reduced their sexual risk behaviors in comparison to the control group. The reduced sexual risks included increased use of condoms and a significant reduction in sex while high on various substances. However, the analysis did not find significant differences in AOD use change measures. In addition, no differences were found for any type of criminal behavior recidivism. The evaluation by Anglin and his colleagues concluded that TASC, including juvenile TASC, has an overall positive benefit. However, they note that problems with comprehensive case management, community intervention resources, and the lack of a coordinated continuum of care likely result in limited impact. It was further suggested that community TASC programs be integrated with local drug courts. It is important to note that very few TASC programs were evaluated in this study and only one juvenile program was assessed. In addition, that assessment did not involve a tightly controlled experimental design. 2. Intensive probation supervision. Probation is the most widely used form of case disposition in the juvenile court. Nonintensive probation involves a set of conditions the juvenile must adhere to, often including behavioral and association requirements as well as receiving needed services. Assuring compliance with these conditions is the task of a probation officer. Historical concerns regarding probation supervision include overburdened probation officers with exceedingly large case loads, high rates of recidivism, lack of appropriate assessment, lack of available needed services, overcrowding of services, and limited resources to pay for services. Indeed, data do not suggest that regular juvenile probation services are effective at preventing recidivism or addressing the underlying causes or correlates of delinquent behavior (Armstrong, 1991; Palmer, 1991). Both adult and juvenile probation programs are now trying to combat high recidivism by utilizing intensive social control approaches and close monitoring. Monitoring techniques may include electronic monitoring, urine monitoring, and monitoring through personal visits and telephone calls. Commentators have often noted that the mere fact of being watched so closely will likely result in increased detection of minor or technical violations. Such increases should be considered when evaluating heightened monitoring programs. Juvenile probation has made some important additions to the probation system focusing on assessment, use of community agencies, and use of volunteers. In addition to intensive monitoring, assessment is recommended to determine the therapeutic and human service needs of the juvenile and to find available community services. The process may involve coordinating and utilizing a wide variety of professional services available in the community including citizen groups and volunteers. Within this framework, juvenile community probation/corrections operates not just as a monitoring office protecting the public and ensuring compliance, but also as comprehensive assessor, resource broker, and advocate to and for existing services. Such operations require comprehensive plans that allow juvenile community correction officers to have the skills and resources necessary to conduct assessments; to undertake a resource inventory of the community, including its mental health and substance treatment resources; and to match the juvenile to needed services. Meeting identified needs must include addressing the causes of the drug-crime cycle (for example, see Catalano et al., 1990/91), and requires officers to be able to link the existing justice system to other agencies and systems in the community. Throughout this process, juvenile community correction officers must continue to use monitoring and possible sanctions to increase retention and, thereby, treatment effect.[12] An example of this type of program was reported in the literature by Pennell and Curtis (1990). Near the end of 1982, the San Diego County Probation Department and the county district attorney's office initiated an interagency program to serve less serious first-time offenders. The probation department ente