current status of youth with co-occurring disorders in the juvenile justice system eric w. trupin,...

Current Status of Youth with Current Status of Youth with Co-Occurring Disorders in the Co-Occurring Disorders in the

Juvenile Justice SystemJuvenile Justice SystemEric W. Trupin, Ph.D.Eric W. Trupin, Ph.D.

Department of Psychiatry and Behavioral SciencesDepartment of Psychiatry and Behavioral SciencesUniversity of WashingtonUniversity of Washington

School of MedicineSchool of Medicine

Birmingham, AlabamaBirmingham, AlabamaApril 20, 2006April 20, 2006

Scope of the ProblemScope of the Problem


Over 125,000 youth detained in Over 125,000 youth detained in Juvenile Justice Facilities nationwideJuvenile Justice Facilities nationwide

Over 60% have Psychiatric or Over 60% have Psychiatric or Substance Use Disorder, or bothSubstance Use Disorder, or both

Disproportionality – over Disproportionality – over representation of minoritiesrepresentation of minorities

Increasing numbers of youth Increasing numbers of youth adjudicated as adultsadjudicated as adults


Over 50% recidivism rates common Over 50% recidivism rates common for juvenile offendersfor juvenile offenders

Costs to keep youth in secure Costs to keep youth in secure facilities. California: $125,000. New facilities. California: $125,000. New York: $85,000. Louisiana: $55,000. York: $85,000. Louisiana: $55,000. Washington State: $57,000.Washington State: $57,000.

6 states spend more on prisons and 6 states spend more on prisons and detention facilities than on colleges detention facilities than on colleges and universitiesand universities

Unmet NeedUnmet Need

Unmet need for mental health care Unmet need for mental health care is as high now as it was before the is as high now as it was before the expansion of the knowledge base on expansion of the knowledge base on effective interventions (Sturm, 2000)effective interventions (Sturm, 2000)

Unmet need highest among minority Unmet need highest among minority youthyouth

Mental Disorders Among Mental Disorders Among YouthYouth

in the General Populationin the General Population

20% of children and adolescents 20% of children and adolescents experience a mental disorderexperience a mental disorder

10% suffer illness severe enough to 10% suffer illness severe enough to cause impairmentcause impairment

Less than half receive treatmentLess than half receive treatment

Surgeon General’s Reporton Children’s Mental Health

Critical Issue: Selected Critical Issue: Selected FindingsFindings

Congressional Survey: Over a 6-Congressional Survey: Over a 6-month period,15,000 youth with month period,15,000 youth with mental health needs unnecessarily mental health needs unnecessarily incarcerated awaiting services (each incarcerated awaiting services (each day, 2,000 youth wait in detention day, 2,000 youth wait in detention for services ~7% of all youth in for services ~7% of all youth in detention) (Waxman/Collins, 2004)detention) (Waxman/Collins, 2004)

System Failure…System Failure…

DisparitiesDisparities Youth of Color:Youth of Color:

Are 1/3 of adolescent population; yet 2/3 of Are 1/3 of adolescent population; yet 2/3 of juveniles in detention and state correctional juveniles in detention and state correctional systemssystems (Snyder & Sickmund, 1999)(Snyder & Sickmund, 1999)

Experience disparities at all stages of juvenile Experience disparities at all stages of juvenile justice involvement (arrest, detention, processing, justice involvement (arrest, detention, processing, disposition) – leads to “cumulative disadvantage” disposition) – leads to “cumulative disadvantage” and disproportionate minority confinementand disproportionate minority confinement (Males & (Males & Macallair, 2000)Macallair, 2000)

Youth of color more likely than white youth to Youth of color more likely than white youth to receive out-of-home placement; white youth more receive out-of-home placement; white youth more likely placed on probationlikely placed on probation (Snyder and Sickmund, 1999)(Snyder and Sickmund, 1999)

African American and Latino youth receive more African American and Latino youth receive more punitive treatment than white peers charged with punitive treatment than white peers charged with same types of offensessame types of offenses (Villarruel and Walker, 2002)(Villarruel and Walker, 2002)

DisparitiesDisparities Youth of color:Youth of color:

Tend to receive mental health services through Tend to receive mental health services through juvenile justice and child welfarejuvenile justice and child welfare systems more often systems more often than through schools or mental health settingsthan through schools or mental health settings (Alegria, (Alegria, 2000)2000)

In juvenile and adult corrections less likely than white In juvenile and adult corrections less likely than white youth to undergo psychological assessment or receive youth to undergo psychological assessment or receive therapeutic treatmenttherapeutic treatment (Huang & Arganza, 2003)(Huang & Arganza, 2003)

Are more likely to receive diagnosis of conduct Are more likely to receive diagnosis of conduct disorder, antisocial personality disorder or substance disorder, antisocial personality disorder or substance abuse disorder than an anxiety or depressive disorderabuse disorder than an anxiety or depressive disorder (Dembo, 1988, etc.)(Dembo, 1988, etc.)

Dual Pathway: Dual Pathway: White youth more likely to be diverted from jj system White youth more likely to be diverted from jj system

to mental health system for “treatment;” whereas to mental health system for “treatment;” whereas minority youth processed in jj system for minority youth processed in jj system for “punishment”“punishment” (Krisberg etc., Mason and Gibbs, 1992; Kotler, 2001)(Krisberg etc., Mason and Gibbs, 1992; Kotler, 2001)

Growing Sense of CrisisGrowing Sense of Crisis Increasing number of youth with Increasing number of youth with

mental disorders entering the mental disorders entering the juvenile justice systemjuvenile justice system 27% increase between 1995 to 2001 in 27% increase between 1995 to 2001 in

Texas.Texas. Juvenile justice is becoming the Juvenile justice is becoming the

system of last resortsystem of last resort NAMI survey found 36% of youth placed NAMI survey found 36% of youth placed

in justice in order to access servicesin justice in order to access services

Growing Sense of Crisis Growing Sense of Crisis (cont.)(cont.)

Documented failure to adequately Documented failure to adequately address mental health needs of justice address mental health needs of justice youthyouth Uncoordinated systems and unclear policiesUncoordinated systems and unclear policies DOJ investigations highlight inadequate DOJ investigations highlight inadequate

services, inappropriate use of medication, services, inappropriate use of medication, etc.etc.

Increasing sense of urgency surrounding Increasing sense of urgency surrounding these youth, their care, and system these youth, their care, and system responsibility issuesresponsibility issues

Status of Mental Health System Status of Mental Health System

and Evidence-Based and Evidence-Based TreatmentsTreatments

President’s Commission reports President’s Commission reports public mental health system is “in a public mental health system is “in a shambles” shambles” (President’s New Freedom Commission (President’s New Freedom Commission Report, 2004)Report, 2004)

90% of public mental health services 90% of public mental health services do not deliver treatments programs do not deliver treatments programs or services that have empirical or services that have empirical support support (Elliot, 1999; Henggeler et al., 2003)(Elliot, 1999; Henggeler et al., 2003)

Status of Mental Health System Status of Mental Health System

and Evidence-Based and Evidence-Based TreatmentsTreatments

More than 550 different psychotherapies More than 550 different psychotherapies exist as well as an increasing number of exist as well as an increasing number of empirically supported programs for multi-empirically supported programs for multi-problem youth problem youth (Kazdin, 2003)(Kazdin, 2003)

Many of the above treatments, services Many of the above treatments, services and programs are “evidence-based and programs are “evidence-based practices” practices” (Hoagwood, Burns, et.al. 2001)(Hoagwood, Burns, et.al. 2001)

Startling discrepancies between high Startling discrepancies between high quality clinical promise and poor clinical quality clinical promise and poor clinical practice practice (Hoagwood, et. al. in press)(Hoagwood, et. al. in press)

Evidence-Based Treatments Evidence-Based Treatments Poorly DisseminatedPoorly Disseminated

Simplistic strategies for understanding Simplistic strategies for understanding process of implementationprocess of implementation

Lack of attention to theories and methods Lack of attention to theories and methods from other fields (Marketing, anthropology, from other fields (Marketing, anthropology, organizational behavior) that could organizational behavior) that could enhance methods for adopting new enhance methods for adopting new approachesapproaches

Characteristics of Empirically Characteristics of Empirically Supported Treatments with Supported Treatments with

ChildrenChildren Focus on the development of skills, not on Focus on the development of skills, not on

catharsis or insightcatharsis or insight Utilization of manuals emphasizing Utilization of manuals emphasizing

adherence and fidelityadherence and fidelity Consistent supervision of cliniciansConsistent supervision of clinicians Homework or out-of-session workHomework or out-of-session work Focus on problems and solutions, rather Focus on problems and solutions, rather

than changing personalitythan changing personality Active engagement and empowerment of Active engagement and empowerment of

family or caregiverfamily or caregiver

FactsFacts Seventy percent of the nation’s mental Seventy percent of the nation’s mental

health dollars for children and adolescents health dollars for children and adolescents are spent on out-of-home placements.are spent on out-of-home placements.(Burns & Friedman, 1990)(Burns & Friedman, 1990)

No scientific evidence indicates that the No scientific evidence indicates that the most restrictive and expensive out-of-home most restrictive and expensive out-of-home placements (psychiatric hospitalization, placements (psychiatric hospitalization, criminal justice detentions) bring out criminal justice detentions) bring out desired clinical outcomes.desired clinical outcomes.(Sondheimer et al., 1994)(Sondheimer et al., 1994)

FactsFacts Traditional office-based outpatient Traditional office-based outpatient

mental health care shows little mental health care shows little evidence of effectiveness with children evidence of effectiveness with children with serious emotional disorders. with serious emotional disorders. (Weisz, (Weisz, Weiss, and Donenberg, 1992)Weiss, and Donenberg, 1992)

Emerging community-based services Emerging community-based services are being disseminated without the are being disseminated without the necessary support and consistent necessary support and consistent supervision needed by community-supervision needed by community-based clinicians.based clinicians.

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10

20

30

40

50

60

70

80

90

% of Caseload Qualifying as "SED"*

Prevalence of Serious Emotional Disturbance (SED) in Washington State

* Percent of Cases "Not different from" the profile of an SED child, based upon f ive clinical and environmental indices; α = .01

Kids speak for Kids speak for themselves…themselves…

Legal and Constitutional Legal and Constitutional ContextContext

Examples of Investigatory Examples of Investigatory FindingsFindings

Staff placed a minor in handcuffs and she Staff placed a minor in handcuffs and she began sobbing and screaming that she began sobbing and screaming that she would kill herself. Staff warned her, that would kill herself. Staff warned her, that if she did not stop sobbing, she would be if she did not stop sobbing, she would be “OC sprayed” (Oleoresin Capsicum). “OC sprayed” (Oleoresin Capsicum). Staff tried to spray youth when she tried Staff tried to spray youth when she tried to push a staff member, after which 2 to push a staff member, after which 2 staff members held the girl while the staff members held the girl while the other staff member sprayed her.other staff member sprayed her.


13-year old boy reportedly placed in 13-year old boy reportedly placed in restraint chair to prevent self-mutilation. restraint chair to prevent self-mutilation. No staff approached him and he was not No staff approached him and he was not allowed to attend school or receive allowed to attend school or receive programming, counseling or medication. programming, counseling or medication. Hours before he had been locked naked Hours before he had been locked naked in his empty cell which smelled of urine in his empty cell which smelled of urine and had torn pieces of toilet paper on and had torn pieces of toilet paper on the concrete floor which he had been the concrete floor which he had been using as a pillow.using as a pillow.


Girls punished for acting out or being Girls punished for acting out or being suicidal by being placed in a cell called suicidal by being placed in a cell called the “dark room” – a locked, windowless the “dark room” – a locked, windowless isolation cell. With lights turned out (as isolation cell. With lights turned out (as girls reported they are when room is in girls reported they are when room is in use) the room is completely dark. One girl use) the room is completely dark. One girl reported being placed naked in the dark reported being placed naked in the dark room from Friday thru Monday morning. room from Friday thru Monday morning. The room is stripped of everything but a The room is stripped of everything but a drain in the room which serves as a toilet.drain in the room which serves as a toilet.

Civil Rights of Institutionalized Civil Rights of Institutionalized Persons Act (CRIPA)Persons Act (CRIPA)

Congress enacted CRIPA in 1980 to provide the Congress enacted CRIPA in 1980 to provide the DOJ with the statutory authority to protect DOJ with the statutory authority to protect institutionalized personsinstitutionalized persons

CRIPA authorizes the Attorney General to CRIPA authorizes the Attorney General to investigate conditions in juvenile institutions and investigate conditions in juvenile institutions and bring litigation when necessary, to realize bring litigation when necessary, to realize systemic “fixes” (individuals not represented and systemic “fixes” (individuals not represented and monetary damages not sought)monetary damages not sought)

Congress has called CRIPA, “the single most Congress has called CRIPA, “the single most effective method for redressing systemic effective method for redressing systemic deprivations of institutionalized persons’ deprivations of institutionalized persons’ Constitutional and Federal Statutory rights.”Constitutional and Federal Statutory rights.”


Since inception, DOJ Special Since inception, DOJ Special Litigation Section of Civil Rights Litigation Section of Civil Rights Division has investigated over 100 Division has investigated over 100 juvenile correction facilities in 20 juvenile correction facilities in 20 states (most initiated in last 10 yrs)states (most initiated in last 10 yrs)

Investigate, monitor implementation Investigate, monitor implementation of consent decrees, settlement of consent decrees, settlement agreements, memoranda of agreements, memoranda of understanding and court ordersunderstanding and court orders


To date, most investigations have been To date, most investigations have been resolved without contested litigationresolved without contested litigation

DOJ has focused on 3 sources of DOJ has focused on 3 sources of Federal rights:Federal rights: The ConstitutionThe Constitution Americans with Disabilities Act (ADA)Americans with Disabilities Act (ADA) Individuals with Disabilities Education Act Individuals with Disabilities Education Act

(IDEA)(IDEA)

Areas of Concern in Areas of Concern in Recent DOJ InvestigationsRecent DOJ Investigations

Protection from HarmProtection from Harm Suicide PreventionSuicide Prevention Inadequate Mental Health & Inadequate Mental Health &

Substance Abuse ServicesSubstance Abuse Services Inadequate Medical CareInadequate Medical Care Inadequate Education Instruction of Inadequate Education Instruction of

Youth with DisabilitiesYouth with Disabilities

Protection from HarmProtection from Harm

Prevalence of Adult Corrections ModelPrevalence of Adult Corrections Model Staff violenceStaff violence Unsafe restraint practicesUnsafe restraint practices Youth violenceYouth violence Excessive use of disciplinary Excessive use of disciplinary

isolation/lack of procedural protectionsisolation/lack of procedural protections

Protection from HarmProtection from Harm

Impact of crowdingImpact of crowding Mix of young offenders with older Mix of young offenders with older

juvenilesjuveniles Mix of juveniles w/ minor offenses w/ Mix of juveniles w/ minor offenses w/

those committing serious offensesthose committing serious offenses Other abusive practicesOther abusive practices

Inappropriate staff-youth relationshipInappropriate staff-youth relationship Denial of access to bathroomsDenial of access to bathrooms

Suicide PreventionSuicide Prevention

Insufficient assessment of suicidal youthInsufficient assessment of suicidal youth Inadequate MH services for youth on Inadequate MH services for youth on

suicidal precautionssuicidal precautions Unsafe housing of youth at risk of self-harmUnsafe housing of youth at risk of self-harm Inadequate supervision of youth on suicide Inadequate supervision of youth on suicide

precautions and in seclusionprecautions and in seclusion Lack of preparedness for suicide attempts Lack of preparedness for suicide attempts

and other self-harmand other self-harm

Inadequate Mental Health & Inadequate Mental Health & Substance Abuse ServicesSubstance Abuse Services

Inadequate screening, identification and Inadequate screening, identification and assessmentassessment

Inadequate clinical assessment, treatment Inadequate clinical assessment, treatment planning and case managementplanning and case management

Inadequate psychotropic medication managementInadequate psychotropic medication management Inadequate mental health and substance abuse Inadequate mental health and substance abuse

counseling (i.e., evidence-based practices)counseling (i.e., evidence-based practices) Lack of family involvementLack of family involvement Failure to place youth in court-ordered treatmentFailure to place youth in court-ordered treatment Inadequate staff training in behavior management Inadequate staff training in behavior management

principlesprinciples

Inadequate Medical CareInadequate Medical Care

Inadequate access to medical Inadequate access to medical treatmenttreatment

Inadequate health assessmentInadequate health assessment Inadequate medical treatment of Inadequate medical treatment of

chronic conditions & physical injurieschronic conditions & physical injuries Inadequate medication administrative Inadequate medication administrative

practicespractices Inadequate dental careInadequate dental care

Inadequate Education Inadequate Education Instruction Instruction

of Youth with Disabilitiesof Youth with Disabilities Inadequate assessmentInadequate assessment Inadequate individualized education Inadequate individualized education

programs (IEPs)programs (IEPs) Lack of related servicesLack of related services Lack of adequate instruction for youth Lack of adequate instruction for youth

with disabilitieswith disabilities Inadequate vocational education for Inadequate vocational education for

youth with disabilitiesyouth with disabilities

Inadequate Transition Inadequate Transition PlanningPlanning

Rehabilitative needs/achievements Rehabilitative needs/achievements inadequately communicated to inadequately communicated to parole counselors, families and parole counselors, families and community providerscommunity providers

Inadequate transition of youth to Inadequate transition of youth to community mental health and community mental health and substance abuse servicessubstance abuse services

Focused Behavioral Health Focused Behavioral Health Concerns of DOJ Concerns of DOJ InvestigationsInvestigations

Standards Utilized in Standards Utilized in Department of Justice Department of Justice

InvestigationsInvestigations Screening/Initial AssessmentScreening/Initial Assessment Specialized Mental Health Specialized Mental Health

AssessmentAssessment Treatment PlanningTreatment Planning Case ManagementCase Management Mental Health CounselingMental Health Counseling

Standards Utilized in Standards Utilized in Department of Justice Department of Justice

InvestigationsInvestigations Management of Psychotropic Management of Psychotropic

MedicationsMedications Crisis ManagementCrisis Management

Suicide PreventionSuicide Prevention Physical RestraintPhysical Restraint Chemical RestraintChemical Restraint

Youth Development/Treatment ProgramsYouth Development/Treatment Programs Institutional Practices Raising Mental Institutional Practices Raising Mental

Health ConcernsHealth Concerns

An Example: LouisianaAn Example: Louisiana

Political ContextPolitical Context

Increase in juveniles detained in State – Increase in juveniles detained in State – “Tough on Crime” approach“Tough on Crime” approach

State wants to control costs – movement State wants to control costs – movement to privatize juvenile prison managementto privatize juvenile prison management

Governor makes deals for private Governor makes deals for private interests of “friends”interests of “friends”

Managing contracts emphasized profit, Managing contracts emphasized profit, not provision of services to youthnot provision of services to youth

Political ContextPolitical Context

State obligated to maintain census at State obligated to maintain census at facilities, or pay management companyfacilities, or pay management company

Juvenile Justice Project of Louisiana Juvenile Justice Project of Louisiana becomes aware of abuses in facilities, becomes aware of abuses in facilities, initiates class-action suit against State, initiates class-action suit against State, brings media light to allegationsbrings media light to allegations

Civil Rights of Institutionalized Persons Civil Rights of Institutionalized Persons (CRIPA) investigation begun by (CRIPA) investigation begun by Department of Justice (DOJ)Department of Justice (DOJ)

Louisiana: The SituationLouisiana: The Situation

Among the highest rate of juveniles in Among the highest rate of juveniles in jails/groups homes in US: 582 juveniles jails/groups homes in US: 582 juveniles per 100,000 residentsper 100,000 residents

$62 m. spent on youth prisons/yr: 45% $62 m. spent on youth prisons/yr: 45% on security, 16% on rehab and educationon security, 16% on rehab and education

4 large juvenile prisons, fostering 4 large juvenile prisons, fostering unsafe, inhumane conditionsunsafe, inhumane conditions

73% of youth incarcerated for non-73% of youth incarcerated for non-violent offensesviolent offenses

Louisiana: The SituationLouisiana: The Situation

73% of youth incarcerated for non-73% of youth incarcerated for non-violent offensesviolent offenses

Almost 60% with sentences of 3 yrs Almost 60% with sentences of 3 yrs or more, 16% with 5 yrs or more. or more, 16% with 5 yrs or more. One-third sentenced to 3 or more One-third sentenced to 3 or more years for non-violent offensesyears for non-violent offenses

DOJ AllegationsDOJ Allegations

Every child interviewed reported being Every child interviewed reported being hit or kicked by officershit or kicked by officers

Minor offenses – talking back, looking Minor offenses – talking back, looking the wrong way, walking out of line – the wrong way, walking out of line – elicited assaults from officerselicited assaults from officers

Children reported being assaulted while Children reported being assaulted while sleepingsleeping

Staff confirmed that children are afraid Staff confirmed that children are afraid to report abuse, for fear of more abuseto report abuse, for fear of more abuse


Juveniles & staff report that officers Juveniles & staff report that officers “paid” children (w/ cigarettes, food, “paid” children (w/ cigarettes, food, soap, special protection) to beat up soap, special protection) to beat up other children. other children.

Practice of “Take Five” sanctioned, Practice of “Take Five” sanctioned, where guards agree to ignore where guards agree to ignore situation when a child is beaten by situation when a child is beaten by other children.other children.


In 5-mo. period at one facility for 178 children, In 5-mo. period at one facility for 178 children, 40 children required treatment in ER for 40 children required treatment in ER for orthopedic injuries or lacerations requiring orthopedic injuries or lacerations requiring stitchesstitches

Reports of physical/sexual assaults at night in Reports of physical/sexual assaults at night in dormitories. Report of coercion for oral sex dormitories. Report of coercion for oral sex between 2 boys in classroom, while officer between 2 boys in classroom, while officer slept. Younger children & those w/ low IQ slept. Younger children & those w/ low IQ frequent targets. Suspicions of sexual abuse frequent targets. Suspicions of sexual abuse by female officersby female officers

Key Components of Key Components of Complaint Filed by DOJComplaint Filed by DOJ

Failure to provide:Failure to provide: Adequate medical, dental, mental health careAdequate medical, dental, mental health care Reasonably safe conditionsReasonably safe conditions Adequate rehabilitative servicesAdequate rehabilitative services Adequate general/vocational educational Adequate general/vocational educational

svcssvcs Adequate educational accommodations and Adequate educational accommodations and

assessment of those requiring special assessment of those requiring special accommodationsaccommodations

Key Components of Key Components of Complaint Filed by DOJComplaint Filed by DOJ

Subjecting juveniles to unreasonable Subjecting juveniles to unreasonable isolation and restraintsisolation and restraints

Denying qualified, disabled juveniles to Denying qualified, disabled juveniles to facility services, programs and activitiesfacility services, programs and activities

Failure to comply with 14Failure to comply with 14thth Amendment, Amendment, Americans with Disabilities Act & Americans with Disabilities Act & Individuals with Disabilities Education Individuals with Disabilities Education ActAct

Response to ComplaintResponse to Complaint

Federal judge agrees with content of Federal judge agrees with content of complaint, requires State to initiate complaint, requires State to initiate remedies, which may avoid trialremedies, which may avoid trial

Judge recommends involvement of Judge recommends involvement of LSU in providing remedies to LSU in providing remedies to charges, and improving servicescharges, and improving services

The Negotiated SettlementThe Negotiated Settlement

September 2000: “Over 100 pages of September 2000: “Over 100 pages of detailed obligations and responsibilities that detailed obligations and responsibilities that the State of Louisiana agreed to, with time the State of Louisiana agreed to, with time tables and monitoring mechanisms…” tables and monitoring mechanisms…” (Bill (Bill Lann Lee, Acting Assistant Attorney General for Civil Rights, NY Lann Lee, Acting Assistant Attorney General for Civil Rights, NY Times, 9/8/00)Times, 9/8/00)

If State has not fulfilled obligations after 2 If State has not fulfilled obligations after 2 and a half years, DOJ can re-fileand a half years, DOJ can re-file

March 2006: State in full compliance with March 2006: State in full compliance with SettlementSettlement

What WorksWhat Works

Characteristics of Empirically Characteristics of Empirically Supported TreatmentsSupported Treatments

Focus on the development of skills, Focus on the development of skills, not on catharsis or insightnot on catharsis or insight

Continuous assessment of progressContinuous assessment of progress Homework or out-of-session workHomework or out-of-session work Focus on problems and solutions, Focus on problems and solutions,

rather than changing personalityrather than changing personality Recognition of the importance of Recognition of the importance of

therapeutic relationshiptherapeutic relationship

Early InterventionEarly Intervention

Targets youth who are beginning to Targets youth who are beginning to engage in antisocial behavior and are at engage in antisocial behavior and are at a high risk of having that behavior a high risk of having that behavior continue and escalate into more serious continue and escalate into more serious criminal activitycriminal activity

Focus is on identifying and intervening Focus is on identifying and intervening with negative influences in youths’ lives with negative influences in youths’ lives that contribute to antisocial behavior.that contribute to antisocial behavior.

Diversion ProgramsDiversion Programs

Designed to minimize negative impacts of Designed to minimize negative impacts of incarcerationincarceration

Divert youth involved in first-time or minor Divert youth involved in first-time or minor offenses into treatment, rather than secure offenses into treatment, rather than secure facilitiesfacilities

Target risk factors for recidivism, such as parent-Target risk factors for recidivism, such as parent-child conflict and poor problem solving skillschild conflict and poor problem solving skills

Can include assessment, counseling, tutoring, Can include assessment, counseling, tutoring, job training, substance abuse treatment, job training, substance abuse treatment, community service, restitution, psychoeducation community service, restitution, psychoeducation

Examples of Diversion Examples of Diversion Programs in King County, Programs in King County,

WashingtonWashington Prime Time ProjectPrime Time Project Community Juvenile Accountability Act Community Juvenile Accountability Act

(CJAA)(CJAA) Chemical Dependency Diversion Chemical Dependency Diversion

Alternative (CDAA)/Juvenile Drug CourtsAlternative (CDAA)/Juvenile Drug Courts Mental Health Disposition Alternative Mental Health Disposition Alternative

(MHDA) (MHDA) Treatment CourtTreatment Court

Community Based Community Based Treatment Treatment

Provide rehabilitation services to Provide rehabilitation services to youth and families in their homes youth and families in their homes and communities.and communities.

Views families as partners in creating Views families as partners in creating an environment that supports an environment that supports change.change.

Functional Family Therapy Functional Family Therapy (FFT)(FFT)

A program designed to prevent the A program designed to prevent the escalation or continuation of violent escalation or continuation of violent or serious externalizing behavior.or serious externalizing behavior.

Targets youth at risk of incarceration Targets youth at risk of incarceration or other out-of-home placement due or other out-of-home placement due to behavior.to behavior.

Family behavioral intervention.Family behavioral intervention.

Phases of FFTPhases of FFT

Motivation and EngagementMotivation and Engagement Goals: develop alliance, reduce negativity, Goals: develop alliance, reduce negativity,

minimize hopelessness, reduce dropout, minimize hopelessness, reduce dropout, increase motivation for changeincrease motivation for change

Behavior ChangeBehavior Change Goals:Goals: develop and implement develop and implement

individualized change plans, change presenting individualized change plans, change presenting delinquency behavior, build relational skillsdelinquency behavior, build relational skills

GeneralizationGeneralization Goals: maintain and generalize change, relapse Goals: maintain and generalize change, relapse

prevention, engage community supports prevention, engage community supports

FFT OutcomesFFT Outcomes

FFT significantly reduces recidivism FFT significantly reduces recidivism for juvenile offendersfor juvenile offenders In Washington State, youth treated by In Washington State, youth treated by

competent FFT therapists had a 38% competent FFT therapists had a 38% reduction in felony recidivism at 18-reduction in felony recidivism at 18-months post-releasemonths post-release

Multisystemic Therapy Multisystemic Therapy (MST)(MST)

Targets youth engaged in serious Targets youth engaged in serious antisocial behavior and their familiesantisocial behavior and their families

Based on of the idea that behavior is Based on of the idea that behavior is determined by the various systems determined by the various systems that affect and individual, including that affect and individual, including the family, school, peer group, and the family, school, peer group, and community. community.

MST ContinuedMST Continued

Goal is to change the systems that create Goal is to change the systems that create and sustain high-risk behavior. and sustain high-risk behavior. Therapist works with family to identify function Therapist works with family to identify function

of problematic behavior and the factors that of problematic behavior and the factors that contribute to it.contribute to it.

Therapist works to change factors that Therapist works to change factors that contribute to and reinforce problematic contribute to and reinforce problematic behaviorbehavior

Therapy takes place in the youth’s natural Therapy takes place in the youth’s natural environment. environment.

MST: Parents are seen as key MST: Parents are seen as key agents of changeagents of change

A major goal is to enhance parents’ ability A major goal is to enhance parents’ ability to monitor manage youth’s behavior, and to monitor manage youth’s behavior, and give effective rewards and consequences. give effective rewards and consequences.

MST OutcomesMST Outcomes

Randomized controlled trials with Randomized controlled trials with youth post-incarceration indicate youth post-incarceration indicate that MST is effective at reducing that MST is effective at reducing number of re-arrests, number of days number of re-arrests, number of days incarcerated, peer-directed violence, incarcerated, peer-directed violence, and increasing family cohesion and and increasing family cohesion and the number of youth who did not the number of youth who did not recidivate at all.recidivate at all.

MST Outcomes: RecidivismMST Outcomes: Recidivism

In a randomized study of 200 In a randomized study of 200 juvenile offenders, youth who juvenile offenders, youth who participated in MST had a lower participated in MST had a lower (22.1%) rate of recidivism than did (22.1%) rate of recidivism than did youth who participated in individual youth who participated in individual therapy (71.4%) at 4-year follow-up. therapy (71.4%) at 4-year follow-up. (Borduin, Mann, Cone, Henggeler, Fucci, Blaske, & Williams, 1995)(Borduin, Mann, Cone, Henggeler, Fucci, Blaske, & Williams, 1995)

Treatment Within Juvenile Treatment Within Juvenile Justice SettingsJustice Settings

Juvenile Rehabilitation Juvenile Rehabilitation Administration’s Integrated Administration’s Integrated

Treatment ModelTreatment Model

Used in JRA’s residential programsUsed in JRA’s residential programs Framework for treatment planning Framework for treatment planning

across continuum of careacross continuum of care

Parameters of the Integrated Parameters of the Integrated Treatment Model (ITM)Treatment Model (ITM)

Cognitive-behavioral basisCognitive-behavioral basis Family-focusedFamily-focused Evidence-based approaches Evidence-based approaches

implementedimplemented Skill-basedSkill-based

Integrated Treatment Model: Integrated Treatment Model: AssessmentAssessment

Identification and prioritization of treatment Identification and prioritization of treatment needs is a major goalneeds is a major goal

Use of standardized, valid diagnostic measures Use of standardized, valid diagnostic measures (Diagnostic Interview Schedule for Children)(Diagnostic Interview Schedule for Children)

Treatment hierarchy is established, targetingTreatment hierarchy is established, targeting Threats of harm to self or othersThreats of harm to self or others Physical or sexual aggressionPhysical or sexual aggression Escape ideation or attemptsEscape ideation or attempts Treatment-interfering behaviorsTreatment-interfering behaviors Motivation and engagementMotivation and engagement Quality-of-life interfering behaviorsQuality-of-life interfering behaviors Significant treatment considerations Significant treatment considerations

Integrated Treatment Model: Integrated Treatment Model: Methods of ChangeMethods of Change

Behavior Modification: Reinforcement, Behavior Modification: Reinforcement, punishment, shaping, extinction, contingency punishment, shaping, extinction, contingency management, cue removal and exposuremanagement, cue removal and exposure

Coaching and role playingCoaching and role playing Motivation enhancementMotivation enhancement ValidationValidation Cognitive restructuringCognitive restructuring Skills training (Dialectical Behavior Therapy)Skills training (Dialectical Behavior Therapy)

Components of Integrated Components of Integrated Treatment ModelTreatment Model

Dialectical Behavior TherapyDialectical Behavior Therapy Substance abuse treatmentSubstance abuse treatment Relapse preventionRelapse prevention Sex-offender treatmentSex-offender treatment Aggression-replacement therapyAggression-replacement therapy Functional family therapyFunctional family therapy Family Integrated TreatmentFamily Integrated Treatment

Dialectical Behavior Dialectical Behavior TherapyTherapy

Developed by Marsha Linehan for the Developed by Marsha Linehan for the treatment of Borderline Personality treatment of Borderline Personality Disorder (BPD)Disorder (BPD)

Goal is to reduce problems Goal is to reduce problems associated with emotional associated with emotional dysregulationdysregulation

Emotional DysregulationEmotional Dysregulation

The inability to monitor, evaluate, and The inability to monitor, evaluate, and change emotional responseschange emotional responses

ImpulsivityImpulsivity Intense emotional responsesIntense emotional responses Slow return to normal after emotional Slow return to normal after emotional

arousalarousal

Emotional Dysregulation Emotional Dysregulation

A hallmark symptom of Borderline A hallmark symptom of Borderline Personality DisorderPersonality Disorder

Also related to a range of problems Also related to a range of problems commonly seen in the Juvenile Justice commonly seen in the Juvenile Justice PopulationPopulation Substance abuse, depression, anxiety, poor Substance abuse, depression, anxiety, poor

impulse control, poor anger managementimpulse control, poor anger management DBT: a promising treatment for juvenile DBT: a promising treatment for juvenile

offenders?offenders?

What is DBT?What is DBT?

Emphasis on mindfulnessEmphasis on mindfulness Behavioral therapy componentsBehavioral therapy components

Goal-focused interventionsGoal-focused interventions Behavior chain analysis is used to identify Behavior chain analysis is used to identify

antecedents and consequences of antecedents and consequences of behavior, and to prompt consideration of behavior, and to prompt consideration of alternative courses of actionalternative courses of action

Recognition that one needs to change Recognition that one needs to change one’s behavior in order to change one’s one’s behavior in order to change one’s feelingsfeelings

DBT SkillsDBT Skills

Core Mindfulness Core Mindfulness Emotion Regulation Emotion Regulation Distress ToleranceDistress Tolerance Interpersonal EffectivenessInterpersonal Effectiveness

Dialectics: Acceptance vs. Dialectics: Acceptance vs. ChangeChange

ValidationValidation Patients’ emotional, cognitive, and behavioral Patients’ emotional, cognitive, and behavioral

responses are understandable in the context of responses are understandable in the context of the environment and the patient’s skill levelthe environment and the patient’s skill level

Patient may not have created his/her Patient may not have created his/her problems, but he/she is responsible for problems, but he/she is responsible for solving themsolving them

Therapist coaches patient on more Therapist coaches patient on more effective behavioral responseseffective behavioral responses

DBT in Juvenile Justice DBT in Juvenile Justice SettingsSettings

Delivered through groups, individual Delivered through groups, individual therapy, and daily interactions with therapy, and daily interactions with staffstaff

Teaches behavioral analysis, Teaches behavioral analysis, cognitive restructuring, skills cognitive restructuring, skills coachingcoaching

Integrated into the culture of the Integrated into the culture of the institutioninstitution

Is DBT effective in juvenile Is DBT effective in juvenile justice settings?justice settings?

Outcome research is limitedOutcome research is limited Girls in mental health cottage who received Girls in mental health cottage who received

DBT had significantly lower 12 month DBT had significantly lower 12 month felony recidivism rate than those who were felony recidivism rate than those who were residents of the cottage before the DBT residents of the cottage before the DBT program began(10% vs. 24%). program began(10% vs. 24%). (WSIPP, 2002)(WSIPP, 2002)

Punitive actions by staff in mental health Punitive actions by staff in mental health cottage decreased when cottage began cottage decreased when cottage began implementing DBT. implementing DBT. (Trupin, Stewart, Beach & Boesky, 2002)(Trupin, Stewart, Beach & Boesky, 2002)

Transitioning Youth From Transitioning Youth From Incarceration to the Incarceration to the

CommunityCommunity How can we give youth with co-How can we give youth with co-

occurring disorders the skills they will occurring disorders the skills they will need to avoid recidivating?need to avoid recidivating?

Family Integrated Transitions Family Integrated Transitions (FIT)(FIT)

A family- and community-based A family- and community-based treatment for youth with co-occurring treatment for youth with co-occurring mental health and substance abuse mental health and substance abuse diagnoses who are being released diagnoses who are being released from secure institutions in from secure institutions in Washington State’s Juvenile Washington State’s Juvenile Rehabilitation AdministrationRehabilitation Administration

FIT targets the multiple FIT targets the multiple determinants of antisocial determinants of antisocial

behaviorbehavior Multisystemic Therapy framework to Multisystemic Therapy framework to

change the systems that create the change the systems that create the reinforcement contingencies for behaviorreinforcement contingencies for behavior

Dialectical Behavior Therapy to promote Dialectical Behavior Therapy to promote emotional and behavioral regulationemotional and behavioral regulation

Motivational Enhancement Therapy to Motivational Enhancement Therapy to promote engagement in treatmentpromote engagement in treatment

Relapse Prevention to give youth skills to Relapse Prevention to give youth skills to promote sustained abstinencepromote sustained abstinence

Family Integrated Transition Family Integrated Transition (FIT): Target Population(FIT): Target Population

Ages 11 to 17 at intakeAges 11 to 17 at intake Substance abuse or dependence disorder Substance abuse or dependence disorder

ANDAND Axis I Disorder OR currently prescribed Axis I Disorder OR currently prescribed

psychotropic medication OR demonstrated psychotropic medication OR demonstrated suicidal behavior in past 6 monthssuicidal behavior in past 6 months

At least 4 months left on sentenceAt least 4 months left on sentence Residing in service areaResiding in service area

Effects of Participation in FIT Effects of Participation in FIT on Recidivismon Recidivism

Recidivism of youth who participated Recidivism of youth who participated in FIT was compared with recidivism in FIT was compared with recidivism of youth were eligible for FIT, but of youth were eligible for FIT, but lived outside of the service arealived outside of the service area

At 18 months post-release, felony At 18 months post-release, felony recidivism was 34% lower for FIT recidivism was 34% lower for FIT clients (27%) than for comparison clients (27%) than for comparison youth (41%).youth (41%).(Washington State Institute of Public Policy, 2004)(Washington State Institute of Public Policy, 2004)

Cost-Effectiveness of FITCost-Effectiveness of FIT

Savings in criminal justice costs: Savings in criminal justice costs: $11,749$11,749

Savings in avoided criminal Savings in avoided criminal victimizations: $16,466victimizations: $16,466

Total savings per participant: $28,215Total savings per participant: $28,215 Total cost per participant: $8,968Total cost per participant: $8,968 Benefit to cost ratio: $3.15Benefit to cost ratio: $3.15

(Washington State Institute of Public Policy, 2004)(Washington State Institute of Public Policy, 2004)

How do the different How do the different approaches to treating youth approaches to treating youth in the juvenile justice system in the juvenile justice system compare with each other? compare with each other?

-12%

-13%

-31%

-14%

-4%

-8%

10%

-5%

-2%

-1%

-31%

-25%

-18%

-37%

-27%

-5%

0%

-4%

-14%

13%

-17%

-15%

-12%

10%

-80% -60% -40% -20% 0% 20% 40%

Early Childhood Education for Disadvantaged Youth (N = 6)

Seattle Social Development Project (N = 1)

Quantum Opportunities Program (N = 1)

Children At Risk Program (N = 1)

Mentoring (N = 2)

National Job Corps (N = 1)

Job Training Partnership Act (N = 1)

Diversion with Services (vs. Regular Court) (N = 13)

Diversion-Release, no Services (vs. Regular Court) (N = 7)

Diversion with Services (vs. Release without Services) (N = 9)

Multi-Systemic Therapy (N = 3)

Functional Family Therapy (N = 7)

Aggression Replacement Training (N = 4)

Multidimensional Treatment Foster Care (N = 2)

Adolescent Diversion Project (N = 5)

Juvenile Intensive Probation (N = 7)

Intensive Probation (as alternative to incarceration) (N = 6)

Juvenile Intensive Parole Supervision (N = 7)

Coordinated Services (N = 4)

Scared Straight Type Programs (N = 8)

Other Family-Based Therapy Approaches (N = 6)

Structured Restitution for Juvenile Offenders (N = 6)

Juvenile Sex Offender Treatment (N = 5)

Juvenile Boot Camps (N = 10)

Lower Recidivism Higher Recidivism

The number in each bar is the "effect size" for each program, which approximates a percentage change in recidivism rates.

The length of each bar are 95% confidence intervals.

Type of Program, and the Number (N) of studies in the Summary

Source: Meta-analysis conducted by the Washington State Institute for Public Policy

The Estimated Effect on Criminal Recidivism for Different Types of Programs for Youth and Juvenile Offenders

Economic Estimates From National ResearchFor Adult & Juvenile Justice and Prevention Programs

Pre

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-$20,000 $0 $20,000 $40,000 $60,000 $80,000 $100,000

Net Gain Per Person in ProgramBreak-EvenPoint

Net Loss

Drug CourtsTher. Commun. w/AftercareIn-Prison Non Res.Drug TX

Sex Off. Prog, Cog. Beh..Intensive Super, no TX

Int Super, w/TXAdult Basic Ed.Vocational Ed.

Intensive Super. ProbationFunctional Family

TherapyMultiSystemic TherapyAggression Replacemnt Trng

Coordinated ServicesScared Straight Programs

Intensive Super. ParoleTreatment Foster Care

Boot Camps

Nurse Home VisitationEarly Childhood EducationSeattle Soc. Devlp. Project

Quantum OpportunitiesJob Training Part. Act

Mentoring

Ad

ult

Off

end

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Implementation ChallengesImplementation Challenges Conflicting roles of the juvenile justice Conflicting roles of the juvenile justice

system: punishment versus treatmentsystem: punishment versus treatment Variable commitment to treatment among Variable commitment to treatment among

institution staffinstitution staff Challenges of conducting treatment Challenges of conducting treatment

outcome research with incarcerated youthoutcome research with incarcerated youth Intensive training and supervision needsIntensive training and supervision needs Logistical difficulty in implementing family Logistical difficulty in implementing family

based treatments in rural settingsbased treatments in rural settings

current status of youth with co-occurring disorders in the juvenile justice system eric w. trupin,...

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