Given these findings, it is not surprising that juvenile justice officials regard the care of youth with serious mental health problemsand the multiple and complex issues surrounding the treatment of these youthas among their greatest challenges. Efforts to address these problems confront numerous barriers, including the following:|
The confusion across multiservice delivery and juvenile justice systems, at both the policy and practice levels, as to who is responsible for providing service to these youth.
Inadequate screening and assessment.
The lack of training, staffing, and programs necessary to deliver mental health services within the juvenile justice system.
The lack of funding and clear funding streams to support services.
The dearth of research that adequately addresses the level and nature of mental health disorders experienced by these youth and the effectiveness of treatment models and services.
If one considers other complicating trends, such as managed care, the privatization of services, and the diagnostic and treatment issues surrounding particular populations such as youth of color (Issacs, 1992) and girls (Prescott, 1997), one quickly gets a sense of how great a challenge any change will be.
At the same time, a clear set of comprehensive strategies that appear to be critical to any progress is emerging. These strategies are consistent with many of the actions recommended by leading national experts (Whitbeck, 1992), State officials (Virginia Policy Design Team, 1994; Ohio Department of Rehabilitation and Correction, Youth Services, Mental Health, and Alcohol and Drug Addiction Services, 1995), and advocates (National Mental Health Association, 1999). They are being implementedoften in a less than ideal mannerfor a limited number of youth and in only a few locations. Described below are some of these strategies and examples of supporting policies, programs, and services that are developing across the Nation as systems and communities begin to better address the needs of the growing number of youth with mental health disorders entering the juvenile justice system.
A clear set of comprehensive strategies is emerging.
Collaborating Across Systems
Cross-system collaboration must form the basis for all solutions. The field is beginning to understand that the needs and issues surrounding individuals with mental health disorders cannot be placed at the doorstep of any single agency or system (Steadman, McCarthy, and Morrissey, 1989). Systematic efforts to examine and improve the response to these youth, whether at the national (Whitbeck, 1992) or State level (Virginia Policy Design Team, 1994), reach the same conclusions. Although an individual system can help to improve the care and treatment of youth with mental illness in the juvenile justice system, effective solutions require that multiple relevant agencies coordinate and integrate strategies and services. Collaborative efforts can include coordinated strategic planning, multiagency budget submissions, implementation of comprehensive screening and assessment centers, cross-training of staff, and team approaches to assessment and case management. Further, such efforts can be employed at varying points in the juvenile justice processfrom intake through adjudication, disposition, and aftercare.
Whenever possible, youth with serious mental health disorders should be diverted from the juvenile justice system.
At the Federal level, the systems of care concept developed by the Center for Mental Health Services (CMHS) has encouraged the coordination of services for youth with SED in a number of communities across the Nation (Center for Mental Health Services, 1996). Most sites have not focused heavily on the juvenile justice population, but those that have, such as the Wraparound Milwaukee program, have observed positive results. Wraparound Milwaukee is a collaborative county-operated health maintenance organization that provides comprehensive care to youth referred from both the child welfare and juvenile justice systems and their families. The program is designed to provide community-based alternatives to residential treatment and psychiatric hospitalization (Wraparound Milwaukee, 1998; see Bruce Kamradt's article on Wraparound Milwaukee). In addition, OJJDP and CMHS have collaborated for the past 2 years to increase juvenile justice system involvement in systems of care. Under this interagency agreement, OJJDP has provided funds to the CMHS technical assistance grantee to promote inclusion of youth with mental health needs involved in the juvenile justice system in other systems of care.
At the State level, there also have been attempts to foster more coordinated approaches. In Ohio, four State agenciesthe Ohio Departments of Alcohol and Drug Addiction Services, Mental Health, Rehabilitation and Correction, and Youth Servicesallocated funds for the Linkages Project. This project supports local efforts to improve the coordination of the criminal and juvenile justice, mental health, and substance abuse service systems to reduce incarceration and improve offender access to mental health services. One funded county, Lorain, used the funds to create the Project for Adolescent Intervention and Rehabilitation (PAIR), which targets youth placed on probation for the first time for any offense. Youth are screened and assessed for mental health and substance abuse disorders, and individual treatment plans are developed. Youth are then supervised by probation officers/case managers in conjunction with treatment providers. An evaluation of the PAIR program found that it provides an important service and coordinating function for youth, the courts, and the service systems involved (Cocozza and Stainbrook, 1998).
Diverting Youth From the Juvenile Justice System
Whenever possible, youth with serious mental health disorders should be diverted from the juvenile justice system. Given community concerns about safety, there are youth who, regardless of their mental health needs, will need to be placed in the juvenile justice system because of their serious and violent offenses. For other youth, however, their penetration into the juvenile justice system and placement into juvenile detention and correctional facilities will serve to further increase the number of mentally ill youth in the Nation's juvenile facilities who are receiving inadequate mental health services. At the adult level, efforts to stem this tide have begun to focus on developing collaborative programs to divert individuals with serious mental illness into community-based services (Steadman, Morris, and Dennis, 1995).
Diverting appropriate youth from the juvenile justice processwhether at first contact with law enforcement officials, at intake, or at some other point prior to formal adjudicationcan reduce the growing number of these youth entering the juvenile justice system and reduce the likelihood that their disorders will go untreated. Diversion to services, however, requires a multidisciplinary partnership involving the justice and treatment systems and a comprehensive range of services to which youth can be diverted.
The Persons in Need of Supervision (PINS) Diversion Program in New York is an example of how to implement such a diversion initiative. In 1985, the New York State PINS Adjustment Services Act was enacted on behalf of persons alleged to be in need of supervision in order to prevent inappropriate or unnecessary court intervention. Counties participating in the PINS Diversion Program must submit a plan containing interagency strategies for diverting youth from court and providing youth with community-based services. Upon State approval of the plan, the county is authorized to deny access to family court and to divert potential PINS and their families to assessment and adjustment services. Participating counties are required to create a multiagency Designated Assessment Service (DAS) to provide comprehensive assessments of the service needs of PINS youth and their families and to develop treatment plans based on assessment results. An interagency planning process encourages collaboration among the local and State agencies whose programs and resources target this population.
Mental Health Screening
One of the major obstacles in recognizing and treating youth with mental health disorders in the juvenile justice system is the lack of screening and assessment. All youth in contact with the juvenile justice system should be screened and, when necessary, assessed for mental health and substance abuse disorders. The screening should be brief, easily administered, and used to identify those youth who require a more comprehensive assessment to further define the type and nature of the disorder. The screening also should occur at the youth's earliest point of contact with the juvenile justice system and should be available at all stages of juvenile justice processing.
A major obstacle has been the absence of reliable, valid, and easy-to-use screening tools to help the juvenile justice system identify signs of mental illness. Grisso and Barnum (1998), however, recently developed a new tool, the Massachusetts Youth Screening Instrument (MAYSI). It is a short, easily administered inventory of questions that has been normed and tested on a number of juvenile justice populations and appears to provide a promising, standardized screen for use in juvenile justice settings (i.e., probation intake, detention, correctional facilities).
Effective community-based alternatives should be used whenever possible. Over the past decade, a number of community-based approaches have been developed as alternatives to institutional care for children with serious mental health disorders, which is often more costly. These approaches are designed to keep youth in their homes, schools, and communities while providing a comprehensive set of services that respond to their mental health needs and related problems.
Standards should provide the field with meaningful guidance in providing effective mental health services.
A number of communities have implemented the systems of care initiatives noted previously and related efforts such as Wraparound services (Clark and Clarke, 1996). One approach that has demonstrated positive outcomes is Multisystemic Therapy (MST) (Henggeler, 1997; Henggeler and Borduin, 1990). Developed by Scott Henggeler and his colleagues, MST is a family- and community-based treatment model that provides services in the home and community settings and addresses a range of family, peer, school, and community factors. Research, most of which has been conducted on youth with serious antisocial behavior, has found that MST is a successful and cost-effective clinical alternative to out-of-home placements. The use of this therapy has resulted in positive outcomes in a number of dimensions, including the prevalence of recidivism, psychiatric symptomatology, and drug use (Henggeler, 1999).
It is critical that youth with mental health disorders who are placed in juvenile correctional facilities receive appropriate treatment. Even with greater emphasis on diversion and increased reliance on community-based alternatives, many such youth will be placed in juvenile correctional facilities because of the nature and severity of their acts. Clearly, for youth assessed as being seriously disordered, it is reasonable to expect that a mental health treatment plan will be developed and implemented by qualified, trained staff. Investigations by the U.S. Department of Justice's Civil Rights Division, as has been noted, indicate that this is not always the case.
With funding from OJJDP, the Council of Juvenile Correctional Administrators (1998) is developing and testing new performance-based standards for these youth that include treatment guidelines promulgated by a group of mental health and substance abuse experts. These standards should provide the field with meaningful guidance in providing effective mental health services.
Part of the difficulty in providing mental health services to incarcerated youth centers around larger issues concerning the relative responsibilities of the juvenile justice and treatment systems for these youth. Some jurisdictions have responded to the increasing number of youth with mental health disorders by making more secure beds available within the mental health system and transferring the more seriously disturbed youth back and forth between the two systems. Other jurisdictions have created a continuum of mental health services within the juvenile corrections system itself to address the needs of these youth (Underwood, Mullan, and Walter, 1997).
Although empirical data on the relative success of different approaches is lacking, a collaborative approach that involves both systems in planning, cross-training, and the delivery of services appears to be preferable. Such an approach builds on the strengths of each system and helps to establish connections that are critical to aftercare and community reintegration following release. In New York, for example, Mobile Mental Health Treatment Teams, supported by State juvenile justice and mental health agencies, serve youth with identified mental health needs in juvenile correctional facilities. Six regional teams provide onsite assessments, training, counseling, and other clinical services to youth in these facilities.