Presentation on theme: "Juvenile Justice Reform and Best Practices in Juvenile Systems"— Presentation transcript:
1 Juvenile Justice Reform and Best Practices in Juvenile Systems NAMI 2005 Annual ConventionAustin, TexasEric W. Trupin, Ph.D.Department of Psychiatry and Behavioral SciencesUniversity of WashingtonSchool 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 implementationLack 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 insightUtilization of manuals emphasizing adherence and fidelityConsistent supervision of cliniciansHomework or out-of-session workFocus on problems and solutions, rather than changing personalityActive engagement and empowerment of family or caregiver
6 FactsSeventy 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 FactsTraditional 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 FocusNumbers of detained youth have tripled in last 2 decades50-80% have Psychiatric or Substance Use Disorders, or both1 in 3 African American males, ages 16-27, are in jail, correctional facilities, on probation or parole
10 Increased FocusOver 70% recidivism rates common for juvenile offendersCosts 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 Rates58% 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 careThe right to receive care that is orderedThe right to a professional medical judgmentFederal Individuals with Disabilities Education Act (IDEA)Conditions of Confinement Litigation
13 Legal MandatesCivil Rights of Institutionalized Persons Act (CRIPA) – 1997US Attorney General can investigate and litigate on conditions of confinement in state operated institutionsSpecial 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 AssessmentSpecialized Mental Health AssessmentTreatment PlanningCase ManagementMental Health Counseling
15 Standards Utilized in Department of Justice Investigations Management of Psychotropic MedicationsCrisis ManagementSuicide PreventionPhysical RestraintChemical RestraintYouth Development/Treatment ProgramsInstitutional Practices Raising Mental Health Concerns
16 Difficulties estimating prevalence of mental health disorders among youth in the juvenile justice systemRegional variationUse of standardized assessment tools limitedUnder-sampling of certain populationsYouths’ report of mental health status may vary as a function of how long and in what environment they have been incarceratedYouth, families, and institutional staff may be suspicious of researchInconsistent 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 AssociatesFocus on determining the mental health status of youth, extent to which services are available and meeting needs, and level of satisfactionMultiple sites (Texas, Louisiana, and Washington)Sampled from different “levels” of juvenile justice system (Detention, Secure, Group Homes)Used standardized data collection instruments
18 Preliminary Results76.7% of participants met screening criteria for a mental health or substance use disorderOf those that met screening criteria, 85.8% met criteria for at least 1 diagnosis64.5% met criteria for a substance use disorder
19 Characteristics of Empirically Supported Treatments Focus on the development of skills, not on catharsis or insightContinuous assessment of progressHomework or out-of-session workFocus on problems and solutions, rather than changing personalityRecognition of the importance of therapeutic relationship
20 Stages of Intervention with Youth Engaging in Criminal Behavior Prevention of escalation of criminal behaviorDiversionMentoringCommunity-Based Treatment ProgramsTransitionDialectical Behavior TherapyFamilies In Transition
21 Early InterventionTargets 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 activityFocus is on identifying and intervening with negative influences in youths’ lives that contribute to antisocial behavior.
22 Diversion ProgramsDesigned to minimize negative impacts of incarcerationDivert youth involved in first-time or minor offenses into treatment, rather than secure facilitiesTarget risk factors for recidivism, such as parent-child conflict and poor problem solving skillsCan include assessment, counseling, tutoring, job training, substance abuse treatment, community service, restitution, psychoeducation
23 Examples of Diversion Programs in King County, Washington Prime Time ProjectCommunity Juvenile Accountability Act (CJAA)Chemical Dependency Diversion Alternative (CDAA)/Juvenile Drug CourtsMental 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 change2. Behavior ChangeGoals: develop and implement individualized change plans, change presenting delinquency behavior, build relational skills3. GeneralizationGoals: maintain and generalize change, relapse prevention, engage community supports
27 FFT OutcomesFFT significantly reduces recidivism for juvenile offendersIn 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 familiesBased 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 ContinuedGoal 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 behaviorTherapy 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 OutcomesRandomized 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)
34 Juvenile Rehabilitation Administration’s Integrated Treatment Model Used in JRA’s residential programsFramework for treatment planning across continuum of care
35 Parameters of the Integrated Treatment Model (ITM) Cognitive-behavioral basisFamily-focusedEvidence-based approaches implementedSkill-based
36 Integrated Treatment Model: Assessment Identification and prioritization of treatment needs is a major goalUse of standardized, valid diagnostic measures (Diagnostic Interview Schedule for Children)Treatment heirarchy is established, targetingThreats of harm to self or othersPhysical or sexual aggressionEscape ideation or attemptsTreatment-interfering behaviorsMotivation and engagementQuality-of-life interfering behaviorsSignificant treatment considerations
37 Integrated Treatment Model: Methods of Change Behavior Modification: Reinforcement, punishment, shaping, extinction, contingency management, cue removal and exposureCoaching and role playingMotivation enhancementValidationCognitive restructuringSkills training (Dialectical Behavior Therapy)
38 Components of Integrated Treatment Model Dialectical Behavior TherapySubstance abuse treatmentRelapse preventionSex-offender treatmentAggression-replacement therapyFunctional family therapyFamily 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 responsesImpulsivityIntense emotional responsesSlow return to normal after emotional arousal
41 Emotional Dysregulation A hallmark symptom of Borderline Personality DisorderAlso related to a range of problems commonly seen in the Juvenile Justice PopulationSubstance abuse, depression, anxiety, poor impulse control, poor anger managementDBT: a promising treatment for juvenile offenders?
42 What is DBT? Emphasis on mindfulness Behavioral therapy components Goal-focused interventionsBehavior chain analysis is used to identify antecedents and consequences of behavior, and to prompt consideration of alternative courses of actionRecognition that one needs to change one’s behavior in order to change one’s feelings
44 Dialectics: Acceptance vs. Change ValidationPatients’ emotional, cognitive, and behavioral responses are understandable in the context of the environment and the patient’s skill levelPatient may not have created his/her problems, but he/she is responsible for solving themTherapist coaches patient on more effective behavioral responses
45 DBT in Juvenile Justice Settings Delivered through groups, individual therapy, and daily interactions with staffTeaches behavioral analysis, cognitive restructuring, skills coachingIntegrated into the culture of the institution
46 Is DBT effective in juvenile justice settings? Outcome research is limitedGirls 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 behaviorDialectical Behavior Therapy to promote emotional and behavioral regulationMotivational Enhancement Therapy to promote engagement in treatmentRelapse Prevention to give youth skills to promote sustained abstinence
50 Family Integrated Transition (FIT): Target Population Ages 11 to 17 at intakeSubstance abuse or dependence disorder ANDAxis I Disorder OR currently prescribed psychotropic medication OR demonstrated suicidal behavior in past 6 monthsAt least 4 months left on sentenceResiding 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 areaAt 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: $11,749Savings in avoided criminal victimizations: $16,466Total savings per participant: $28,215Total cost per participant: $8,968Benefit 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 Recidivismfor Different Types of Programs for Youth and Juvenile OffendersThe 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 theWashington State Institute for Public PolicyLower Recidivism Higher Recidivism
55 Economic Estimates From National Research For Adult & Juvenile Justice and Prevention ProgramsDrug CourtsTher. Commun. w/AftercareIn-Prison Non Res.Drug TXAdult OffenderProgramsSex Off. Prog, Cog. Beh..Intensive Super, no TXInt Super, w/TXAdult Basic Ed.Vocational Ed.Intensive Super. ProbationFunctional Family TherapyMultiSystemic TherapyAggression Replacemnt TrngJuvenile OffenderProgramsCoordinated ServicesScared Straight ProgramsIntensive Super. ParoleTreatment Foster CareBoot CampsPreventionProgramsNurse Home VisitationEarly Childhood EducationSeattle Soc. Devlp. ProjectQuantum OpportunitiesJob Training Part. ActMentoring-$20,000$0$20,000$40,000$60,000$80,000$100,000Net LossNet Gain Per Person in ProgramBreak-EvenPoint
56 Implementation Challenges Conflicting roles of the juvenile justice system: punishment versus treatmentVariable commitment to treatment among institution staffChallenges of conducting treatment outcome research with incarcerated youthIntensive training and supervision needsLogistical 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