1. Juvenile Justice Reform and Best Practices in Juvenile Systems
NAMI 2005 Annual Convention
Austin, Texas
Eric W. Trupin, Ph.D.
Department of Psychiatry and Behavioral Sciences
University of Washington
School of Medicine

2. Status of Mental Health System and Evidence-Based Treatments
President’s Commission reports public mental health system is “in a shambles” (President’s New Freedom Commission Report, 2004)
90% of public mental health services do not deliver treatments programs or services that have empirical support
(Elliot, 1999; Henggeler et al., 2003)

3. Status of Mental Health System and Evidence-Based Treatments
More than 550 different psychotherapies exist as well as an increasing number of empirically supported programs for multi-problem youth (Kazdin, 2003)
Many of the above treatments, services and programs are “evidence-based practices” (Hoagwood, Burns, et.al. 2001)
Startling discrepancies between high quality clinical promise and poor clinical practice (Hoagwood, et. al. in press)

4. Evidence-Based Treatments Poorly Disseminated
Simplistic strategies for understanding process of implementation
Lack of attention to theories and methods from other fields (Marketing, anthropology, organizational behavior) that could enhance methods for adopting new approaches

5. Characteristics of Empirically Supported Treatments with Children
Focus on the development of skills, not on catharsis or insight
Utilization of manuals emphasizing adherence and fidelity
Consistent supervision of clinicians
Homework or out-of-session work
Focus on problems and solutions, rather than changing personality
Active engagement and empowerment of family or caregiver

6. Facts
Seventy percent of the nation’s mental health dollars for children and adolescents are spent on out-of-home placements.
(Burns & Friedman, 1990)
No scientific evidence indicates that the most restrictive and expensive out-of-home placements (psychiatric hospitalization, criminal justice detentions) bring out desired clinical outcomes.
(Sondheimer et al., 1994)

7. Facts
Traditional office-based outpatient mental health care shows little evidence of effectiveness with children with serious emotional disorders. (Weisz, Weiss, and Donenberg, 1992)
Emerging community-based services are being disseminated without the necessary support and consistent supervision needed by community-based clinicians.

9. Increased Focus
Numbers of detained youth have tripled in last 2 decades
50-80% have Psychiatric or Substance Use Disorders, or both
1 in 3 African American males, ages 16-27, are in jail, correctional facilities, on probation or parole

10. Increased Focus
Over 70% recidivism rates common for juvenile offenders
Costs to keep youth in secure facilities: New York: $85,000. Louisiana: $50,000.
6 states spend more on prisons and detention facilities than on public colleges and universities

11. Recidivism Rates
58% of youth released from Washington’s Juvenile Rehabilitation Administration in were convicted of new felonies or misdemeanors within 18 months. (Source: Washington State Institute for Public Policy)
45% were convicted of a new felony

12. Legal Mandates Results of case law:
The right of access to care
The right to receive care that is ordered
The right to a professional medical judgment
Federal Individuals with Disabilities Education Act (IDEA)
Conditions of Confinement Litigation

13. Legal Mandates
Civil Rights of Institutionalized Persons Act (CRIPA) – 1997
US Attorney General can investigate and litigate on conditions of confinement in state operated institutions
Special Litigation Section investigates for patterns or practices of violations of residents’ federal rights (not specific cases)
Methods include settlements, consent decrees

14. Standards Utilized in Department of Justice Investigations
Screening/Initial Assessment
Specialized Mental Health Assessment
Treatment Planning
Case Management
Mental Health Counseling

15. Standards Utilized in Department of Justice Investigations
Management of Psychotropic Medications
Crisis Management
Suicide Prevention
Physical Restraint
Chemical Restraint
Youth Development/Treatment Programs
Institutional Practices Raising Mental Health Concerns

16. Difficulties estimating prevalence of mental health disorders among youth in the juvenile justice system
Regional variation
Use of standardized assessment tools limited
Under-sampling of certain populations
Youths’ report of mental health status may vary as a function of how long and in what environment they have been incarcerated
Youth, families, and institutional staff may be suspicious of research
Inconsistent scope and quality of records to provide historical information supporting diagnoses

17. “Mental Health and Juvenile Justice: Building a Model for Effective Service Delivery”
Coordinated by Policy Research Associates
Focus on determining the mental health status of youth, extent to which services are available and meeting needs, and level of satisfaction
Multiple sites (Texas, Louisiana, and Washington)
Sampled from different “levels” of juvenile justice system (Detention, Secure, Group Homes)
Used standardized data collection instruments

18. Preliminary Results
76.7% of participants met screening criteria for a mental health or substance use disorder
Of those that met screening criteria, 85.8% met criteria for at least 1 diagnosis
64.5% met criteria for a substance use disorder

19. Characteristics of Empirically Supported Treatments
Focus on the development of skills, not on catharsis or insight
Continuous assessment of progress
Homework or out-of-session work
Focus on problems and solutions, rather than changing personality
Recognition of the importance of therapeutic relationship

20. Stages of Intervention with Youth Engaging in Criminal Behavior
Prevention of escalation of criminal behavior
Diversion
Mentoring
Community-Based Treatment Programs
Transition
Dialectical Behavior Therapy
Families In Transition

21. Early Intervention
Targets youth who are beginning to engage in antisocial behavior and are at a high risk of having that behavior continue and escalate into more serious criminal activity
Focus is on identifying and intervening with negative influences in youths’ lives that contribute to antisocial behavior.

22. Diversion Programs
Designed to minimize negative impacts of incarceration
Divert youth involved in first-time or minor offenses into treatment, rather than secure facilities
Target risk factors for recidivism, such as parent-child conflict and poor problem solving skills
Can include assessment, counseling, tutoring, job training, substance abuse treatment, community service, restitution, psychoeducation

23. Examples of Diversion Programs in King County, Washington
Prime Time Project
Community Juvenile Accountability Act (CJAA)
Chemical Dependency Diversion Alternative (CDAA)/Juvenile Drug Courts
Mental Health Disposition Alternative (MHDA)
Treatment Court

24. Community Based Treatment
Provide rehabilitation services to youth and families in their homes and communities.
Views families as partners in creating an environment that supports change.

25. Functional Family Therapy (FFT)
A program designed to prevent the escalation or continuation of violent or serious externalizing behavior.
Targets youth at risk of incarceration or other out-of-home placement due to behavior.
Family behavioral intervention.

26. Phases of FFT 1. Motivation and Engagement 2. Behavior Change
Goals: develop alliance, reduce negativity, minimize hopelessness, reduce dropout, increase motivation for change
2. Behavior Change
Goals: develop and implement individualized change plans, change presenting delinquency behavior, build relational skills
3. Generalization
Goals: maintain and generalize change, relapse prevention, engage community supports

27. FFT Outcomes
FFT significantly reduces recidivism for juvenile offenders
In Washington State, youth treated by competent FFT therapists had a 38% reduction in felony recidivism at 18-months post-release

28. Multisystemic Therapy (MST)
Targets youth engaged in serious antisocial behavior and their families
Based on of the idea that behavior is determined by the various systems that affect and individual, including the family, school, peer group, and community.

29. MST Continued
Goal is to change the systems that create and sustain high-risk behavior.
Therapist works with family to identify function of problematic behavior and the factors that contribute to it.
Therapist works to change factors that contribute to and reinforce problematic behavior
Therapy takes place in the youth’s natural environment.

30. MST: Parents are seen as key agents of change
A major goal is to enhance parents’ ability to monitor manage youth’s behavior, and give effective rewards and consequences.

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

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

33. Treatment Within Juvenile Justice Settings

34. Juvenile Rehabilitation Administration’s Integrated Treatment Model
Used in JRA’s residential programs
Framework for treatment planning across continuum of care

35. Parameters of the Integrated Treatment Model (ITM)
Cognitive-behavioral basis
Family-focused
Evidence-based approaches implemented
Skill-based

36. Integrated Treatment Model: Assessment
Identification and prioritization of treatment needs is a major goal
Use of standardized, valid diagnostic measures (Diagnostic Interview Schedule for Children)
Treatment heirarchy is established, targeting
Threats of harm to self or others
Physical or sexual aggression
Escape ideation or attempts
Treatment-interfering behaviors
Motivation and engagement
Quality-of-life interfering behaviors
Significant treatment considerations

37. Integrated Treatment Model: Methods of Change
Behavior Modification: Reinforcement, punishment, shaping, extinction, contingency management, cue removal and exposure
Coaching and role playing
Motivation enhancement
Validation
Cognitive restructuring
Skills training (Dialectical Behavior Therapy)

38. Components of Integrated Treatment Model
Dialectical Behavior Therapy
Substance abuse treatment
Relapse prevention
Sex-offender treatment
Aggression-replacement therapy
Functional family therapy
Family Integrated Treatment

39. Dialectical Behavior Therapy
Developed by Marsha Linehan for the treatment of Borderline Personality Disorder (BPD)
Goal is to reduce problems associated with emotional dysregulation

40. Emotional Dysregulation
The inability to monitor, evaluate, and change emotional responses
Impulsivity
Intense emotional responses
Slow return to normal after emotional arousal

41. Emotional Dysregulation
A hallmark symptom of Borderline Personality Disorder
Also related to a range of problems commonly seen in the Juvenile Justice Population
Substance abuse, depression, anxiety, poor impulse control, poor anger management
DBT: a promising treatment for juvenile offenders?

42. What is DBT? Emphasis on mindfulness Behavioral therapy components
Goal-focused interventions
Behavior chain analysis is used to identify antecedents and consequences of behavior, and to prompt consideration of alternative courses of action
Recognition that one needs to change one’s behavior in order to change one’s feelings

43. DBT Skills Core Mindfulness Emotion Regulation Distress Tolerance
Interpersonal Effectiveness

44. Dialectics: Acceptance vs. Change
Validation
Patients’ emotional, cognitive, and behavioral responses are understandable in the context of the environment and the patient’s skill level
Patient may not have created his/her problems, but he/she is responsible for solving them
Therapist coaches patient on more effective behavioral responses

45. DBT in Juvenile Justice Settings
Delivered through groups, individual therapy, and daily interactions with staff
Teaches behavioral analysis, cognitive restructuring, skills coaching
Integrated into the culture of the institution

46. Is DBT effective in juvenile justice settings?
Outcome research is limited
Girls in mental health cottage who received DBT had significantly lower 12 month felony recidivism rate than those who were residents of the cottage before the DBT program began(10% vs. 24%). (WSIPP, 2002)
Punitive actions by staff in mental health cottage decreased when cottage began implementing DBT. (Trupin, Stewart, Beach & Boesky, 2002)

47. Transitioning Youth From Incarceration to the Community
How can we give youth with co-occurring disorders the skills they will need to avoid recidivating?

48. Family Integrated Transitions (FIT)
A family- and community-based treatment for youth with co-occurring mental health and substance abuse diagnoses who are being released from secure institutions in Washington State’s Juvenile Rehabilitation Administration

49. FIT targets the multiple determinants of antisocial behavior
Multisystemic Therapy framework to change the systems that create the reinforcement contingencies for behavior
Dialectical Behavior Therapy to promote emotional and behavioral regulation
Motivational Enhancement Therapy to promote engagement in treatment
Relapse Prevention to give youth skills to promote sustained abstinence

50. Family Integrated Transition (FIT): Target Population
Ages 11 to 17 at intake
Substance abuse or dependence disorder AND
Axis I Disorder OR currently prescribed psychotropic medication OR demonstrated suicidal behavior in past 6 months
At least 4 months left on sentence
Residing in service area

51. Effects of Participation in FIT on Recidivism
Recidivism of youth who participated in FIT was compared with recidivism of youth were eligible for FIT, but lived outside of the service area
At 18 months post-release, felony recidivism was 34% lower for FIT clients (27%) than for comparison youth (41%).
(Washington State Institute of Public Policy, 2004)

52. Cost-Effectiveness of FIT
Savings in criminal justice costs: $11,749
Savings in avoided criminal victimizations: $16,466
Total savings per participant: $28,215
Total cost per participant: $8,968
Benefit to cost ratio: $3.15
(Washington State Institute of Public Policy, 2004)

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

54. Type of Program, and the Number (N) of studies in the Summary
The Estimated Effect on Criminal Recidivism
for Different Types of Programs for Youth and Juvenile Offenders
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
-12%
Early Childhood Education for Disadvantaged Youth (N = 6)
-13%
Seattle Social Development Project (N = 1)
-31%
Quantum Opportunities Program (N = 1)
-14%
Children At Risk Program (N = 1)
-4%
Mentoring (N = 2)
-8%
National Job Corps (N = 1)
10%
Job Training Partnership Act (N = 1)
-5%
Diversion with Services (vs. Regular Court) (N = 13)
-2%
Diversion-Release, no Services (vs. Regular Court) (N = 7)
-1%
Diversion with Services (vs. Release without Services) (N = 9)
-31%
Multi-Systemic Therapy (N = 3)
-25%
Functional Family Therapy (N = 7)
-18%
Aggression Replacement Training (N = 4)
-37%
Multidimensional Treatment Foster Care (N = 2)
-27%
Adolescent Diversion Project (N = 5)
-5%
Juvenile Intensive Probation (N = 7) 0%
Intensive Probation (as alternative to incarceration) (N = 6)
-4%
Juvenile Intensive Parole Supervision (N = 7)
-14%
Coordinated Services (N = 4)
13%
Scared Straight Type Programs (N = 8)
-17%
Other Family-Based Therapy Approaches (N = 6)
-15%
Structured Restitution for Juvenile Offenders (N = 6)
-12%
Juvenile Sex Offender Treatment (N = 5)
10%
Juvenile Boot Camps (N = 10)
-80%
-60%
-40%
-20% 0%
20%
40%
Source: Meta-analysis conducted by the
Washington State Institute for Public Policy
Lower Recidivism Higher Recidivism

55. Economic Estimates From National Research
For Adult & Juvenile Justice and Prevention Programs
Drug Courts
Ther. Commun. w/Aftercare
In-Prison Non Res.Drug TX
Adult Offender
Programs
Sex Off. Prog, Cog. Beh..
Intensive Super, no TX
Int Super, w/TX
Adult Basic Ed.
Vocational Ed.
Intensive Super. Probation
Functional Family Therapy
MultiSystemic Therapy
Aggression Replacemnt Trng
Juvenile Offender
Programs
Coordinated Services
Scared Straight Programs
Intensive Super. Parole
Treatment Foster Care
Boot Camps
Prevention
Programs
Nurse Home Visitation
Early Childhood Education
Seattle Soc. Devlp. Project
Quantum Opportunities
Job Training Part. Act
Mentoring
-$20,000 $0
$20,000
$40,000
$60,000
$80,000
$100,000
Net Loss
Net Gain Per Person in Program
Break-Even
Point

56. Implementation Challenges
Conflicting roles of the juvenile justice system: punishment versus treatment
Variable commitment to treatment among institution staff
Challenges of conducting treatment outcome research with incarcerated youth
Intensive training and supervision needs
Logistical difficulty in implementing family based treatments in rural settings

57. “Vision without action is a daydream
“Vision without action is a daydream. Action without vision is a nightmare.”
Japanese Proverb