Who are they and why are they there? The Youth of Texas

Juveniles Behind Bars: Meeting Treatment Needs Through a Statewide Academic and Correctional Managed Care PartnershipAcademic & Health Policy Conference on Correctional Health ChicagoMarch 22, 2013

Ohiana Torrealday, PhD CCHPAdministrative Director, Mental Health-Youth ServicesUniversity of Texas Medical Branch-Correctional Managed Care

Joseph Penn, MD CCHPDirector of Mental HealthUniversity of Texas Medical Branch-Correctional Managed Care

AcknowledgementsUniversity of Texas Medical Branch-Correctional Managed Care (CMC) Youth Services

Pharmacy Services-University of Texas Medical Branch-CMC Amy Jo Harzke, DrPH, Jacques Baillargeon, PhD, Gwen Baillargeon, MS, Joseph Penn, MD (UTMB-CMC)

Texas Juvenile Justice Department

No Financial DisclosuresObjectivesDiscuss public health issues, medical and mental health care evaluation and treatment needs of high risk youth who enter the juvenile correctional system;

Discuss increased challenge of covering a large geographic area while maintaining a high level of care and follow best practice in a cost-effective/conscious manner;

Discuss opportunities and challenges in the implementation of a statewide correctional health care system utilizing an academic and state agency partnership and funding model.

Correctional Managed CareA Strategic Partnership between:The Texas Department of Criminal JusticeThe University of Texas Medical Branch at GalvestonTexas Tech University Health Sciences CenterFocused upon a shared Mission:To develop a statewide health care network that provides TDCJ offenders with timely access to a constitutional level of health care while also controlling costsManaged by a statutorily established body:The Correctional Managed Health Care Committee

CMHCC-9 membersTwo Physicians and One Public Member appointed by the GovernorA Physician and Administrator from TDCJ appointed by TDCJ Executive DirectorA Physician and Administrator from the University of Texas Medical Branch appointed by the President of the UniversityA Physician and Administrator from Texas Tech Health Sciences Center appointed by the President of the Health Sciences Center

4Correctional Managed Care (CMC)

CMC is a division of the University of Texas Medical Branch (UTMB) community health services, established in 1994.

CMC divided into two sectors: TDCJ offenders served by UTMB (80% of population) and Texas Tech (20% of population).

Provides medical, dental, nursing, and mental health services to offenders within the Texas Department of Criminal Justice (TDCJ)

Provides medical, dental, nursing and psychiatric services to juvenile offenders in custody of the Texas Juvenile Justice Department (formerly TYC)

5Youth services since 95 but psychiatry added in 08; psychology exception56

Adult and Juvenile Correctional Units Served by UTMB-CMC

Advantages for the Criminal and Juvenile Justice SystemsProvides statewide network of providers to cope with prison system expansion

Provides access to credible, quality health care

Assures medical management standards

Provides cost-effective services

Sharing of risk8correctional managed health care system has provided a reliable and well trained network of health care providers, both at the unit level and to university based specialists.Correctional Managed Care (CMC)-Youth Services Mental Health Services OverviewPsychiatric diagnostic evaluationsPsychotropic medication managementTelepsychiatryEvaluation for CSU admissionEmergency state hospital commitment evaluationsUnit, school based and off-site consultations

Clinical/case consultationsPsychopharmacological consultationPsychotropic on-call/emergency services available statewide 24/7Discharge planningStaff training and development on mental health issues

Evaluation/review for CSU admission9

Juvenile Justice Population in TexasU.S. vs. Texas

U.S. Juvenile Arrest Rates for All Crimes6,318 arrests for every 100,000 youth

2.11 million arrests of juveniles in 2008 134,575 youthful arrests in Texas In 2008

99,114 youthful arrests in Texas in 2011

*In TX, a juvenile is legally defined as a person under seventeenwww.txdps.sate.tx.us/crimereports6,318 arrests for every 100,000 youth

2.11 million arrests of juveniles in 2008 1,161,830 million arrests of juveniles in 2009Urban areas highest rates12Texas Juvenile Justice Department

Al Price and MARTTJJD Facilities

Statewide:

-6 hardware secure facilities

3 closures in 2011

-9 Halfway HousesJuvenile Justice in TX

Major changes in system as result of turmoil: greater focus on community diversion, felony, upper age 19, SB103 requirementsUltimate result in substantial decrease in population

15www.tyc.state.tx.us/researchCommitments decreased significantlyCounties wary of system and more willing to manage lower risk youth in community placements/servicesDespite substantial decrease in population, data has shown that youth remain have significant and complex needs. Services maintained same level and even increased in other areas. Big challenge is educating decision-makers that this is how it actually is.half the population does not equal have the money

16Youth Movement in System

TJJD Youth

Country of Origin: Greatest percentage from Mexico, Honduras, El Salvador89% Males

Median Age at Commitment: 16

84% of youths parents were never married, or divorced or separated

43% come from families with histories of criminal behavior

44% admitted gang members

35% had >1 felony adjudication

-TJJD, 2011Hispanic*African AmericanCaucasianMedian grade completed- 8th grade

Median reading level- 6th grade

35% special education eligible

44% in need of mental health treatment

38% had documented history of abuse/neglect

72% in need of alcohol or other drug treatment

Reading level 4 years behind peers20

Reasons for Commitment to TYC in FY 2009www.tyc.state.tx.us/research

Reasons for Commitment20092012Burglary-23% (334)Aggravated Robbery-10% (152)Aggravated Assault-9% (133)Drug Offense-8% (118)Simple Assault-8% (114)Sexual Assault-7% (107)Burglary-22% (190)Simple Assault-11% (93)Aggravated Assault-10% (85)Aggravated Robbery-10% (82)Sexual Assault-8% (70)Drug Offense-6% (52)Prevalence of Mental Illness in the U.S. Juvenile Justice System 65-70% of youth meet criteria for > 1 disorderShufelt & Cocozza, 2006; Teplin et al., 2006; Wasserman et al., 2002; Wasserman et al., 2004

Many enter the Juvenile Justice system without having been diagnosed or treated

Studies examining rates of psychopathology have been inconsistent:Major affective disorders 5 to 88%Substance use disorders 20 to 88%Psychosis 12 to 45%Teplin et al, 200623Prevalence of Mental Illness in the Juvenile Justice System in the U.S.Even higher rates of comorbidity for femalesStudies range from 79-99% (virtually all females)

Females have higher rates of any single and comorbid psychiatric disorders including:major depressive episodessome anxiety disorders PTSDsomatization disordersborderline personality disorder substance use disorder other than alcohol and marijuana

PTSD among youth in juvenile justice similar to youth in mental health and substance abuse systems (3-50%) BUT up to 8x higher than same aged youth in the community population

Veysey, 2003; Wasserman, et al., 2003; Grisso, 2004; Grisso & Underwood, 2004; Teplin et al., 2002, 2004; OJJDP, 2006

Prevalence Studies: Recent Meta-analysesColins, et al., 201015 studies using structured diagnostic interviews Multicountry (10), detained male adolescents (N=3401)70% met criteria for >1 disorderMean prevalence for CD-46.4%, SUD-45.1%, ODD 19.8%, ADHD-13.5%, MDD-12%; SAD-10.7%; PTSD-10%, psychotic disorders-1.4%

Fazel, et al., 200825 psychiatric surveysMulticountry (8), detained males (N=13,778) & females (N=2,972)Mean prevalence for CD-52.8% both, ADHD-11.7% boys, 18.5% girls, MDD-10.6% boys/29.2% girls; psychotic disorders- 3% both

Colins-10 countries; studies in peer-reviewed journalsFazel-8 countries; 89% of youth were from US detention facilitiesincluded grey literature and studies that also used nonstructured interviews clinical interviews)12 surveys with info on psychotic illnesses (3 small studies for girls), 18 major depression, 13 ADHD, 15 CD25Karnik et al., 2010650 males/140 femalesIncarcerated 9 months in California DJJUsed SCID, DICA & SIDP-IVAny psychiatric disorder:Boys < 16: 97%Boys >17: 98%Girls < 16: 100%Girls > 17: 97%

SCID-structured clinical interview for DSM-IV: substance use, mood, anxiety and personality dxsDICA-diagnostic interview for children and adolescents: ODD, ADHD, separation anxietySIDP-IV-structured interview for DSM-IV personality: conduct dx26Unfortunate Reality The juvenile justice system has become the default placement for many youth with mental health disorders who are not receiving appropriate psychological and psychiatric treatment in the community. -Boesky, L. M. (2002)

the juvenile justice system is becoming the dumping ground for these kids. Cocozza, cited in Bender (2002)

Many enter JJ system without having been diagnosed or treated

Why the increase?Juvenile justice professionals more skilled at recognizing youthSeverity of problems exhibited by youth entering systemActual increase in number of mentally ill youth becoming involved with juvenile justicePatterns of alcohol and drug useGrowing numbers of females entering the juvenile justice systemLack of parity in insurance coverage for mental illnessAbsence of coordinated systems of care across state health, social services, education, child welfare & juvenile justice service systems, particularly in low-income areas*Inability of some low-income families to qualify for MedicaidShortage of child & adolescent psychiatrists and other childrens mental health professionals

27

How Does Texas Compare?What is the Prevalence of Psychiatric Disorders Among Youth Incarcerated Statewide?Prevalence Study of Texas Juvenile Justice Incarcerated PopulationStudy Period: January 1, 2004- December 31, 2008Retrospective analysis of data from UTMB-CMC Electronic Medical Record & TYC Information SystemAll youth committed to TYC secure facilities from 10-21 years of ageSample size of 11,603 youth

-Harzke et al., 2012Although some unit have closed since the time frame of study, at that time there were 12 units29Population CharacteristicsTotal population: 11,603 youth

90.2% Male

71.3% > 16 years at time of commitment

34% African American & 42.6% Hispanic

Nearly half of first referred to Probation when