Youth with Co-Occurring Disorders: National Trends and Needed Directions Joseph J. Cocozza, Ph.D. National Center for Mental Health and Juvenile Justice Policy Research Associates, Inc. Second Annual Evidence-Based Strategies in Identification and Treatment of Co-Occurring Disorders in Adolescents Conference Birmingham, Alabama April 20-21, 2006

President’s New Freedom Commission on Mental Health Part of transformation of the existing mental health system is recognition that: – “children, adults and older adults with mental disorders are seen in multiple systems and sectors” –for children and adolescents these include, “schools, primary health clinics, child care programs, the child welfare system and the juvenile justice system”

Youth in Contact with the Juvenile Justice System About 2.2 million youth under 18 were arrested in 2003 Over 600,000 youth a year are placed in detention centers Over 100,000 youth reside in secure juvenile correctional settings

There is a growing sense of crisis surrounding the mental health needs of justice involved youth at all points of the system. Mental health is “the number one emergent issue as far as juvenile justice is concerned” (Coalition for Juvenile Justice, 2000).

Key Points in the Juvenile Justice System For Mental Health Interventions Initial Contact Intake Detention Court Processing Disposition: Placement Disposition: Probation Re-entry

Factors Fueling the Crisis Research studies have consistently found high rates of mental health disorders among youth in the juvenile justice system –Recent NCMHJJ study confirms high rates – regardless of geographical location or type of residential setting

Prevalence of Mental Disorders (n=1437) (%) At Least One Positive Diagnosis70.4 No Diagnosis29.6 NCMHJJ Multi-State Prevalence Study Prevalence Rate

Comparison of Prevalence Findings From Recent Juvenile Justice Studies Positive Diagnosis Current Study (NCMHJJ)70.4% Teplin et al. (2002)69.0% Wasserman et al. (2002)68.5% Wasserman, Ko, McReynolds (2004)67.2%

Types of Disorders by Gender (n=1437) Overall % Males % Females % Any Disorder Anxiety Disorder Mood Disorder Disruptive Disorder Substance Abuse Disorder

More than half (55.6%) of youth met criteria for at least two diagnoses; 37.5% of youth in the sample had both a mental health disorder and substance use disorder. About 27% of justice involved youth have disorders that are serious enough to require immediate and significant treatment Number and Severity of Disorders

Factors Fueling the Crisis (cont.) The number of youth with mental health disorders entering the juvenile justice system appears to be increasing –Texas data show a 27% increase of youth with high mental health needs over a six year period Often, youth are being placed into the justice system because of the lack of community-based mental health services –2/3 of juvenile detention facilities’ youth held unnecessarily because of unavailable services

Factors Fueling the Crisis (cont.) There is little evidence to suggest that youth in the juvenile justice system are routinely provided with adequate or effective mental health services –Series of DOJ investigations documenting poor training, inadequate clinical services, inappropriate use of medication, etc.

Recent National Trends 1.Greater national recognition of and support for addressing the mental health needs of juvenile justice youth –SAMHSA support for MH/JJ Policy Academies –CMHS’s System of Care priority on juvenile justice youth –OJJDP’s Mental Health Initiative –Congressional support for Mentally Ill Offender Act

Recent National Trends (cont.) 2.Rapid implementation of standardized, scientifically-based screening and assessment instruments –MAYSI-2 most widely used screen in juvenile justice settings, used systemwide in 39 states –Diagnostic assessment instruments adapted for juvenile justice- Voice DISC-IV in place in 14 states

Recent National Trends (cont.) 3.Increasing interest in EBP’s/Research Based Interventions –Expansion of EBP’s (eg., MST, FFT, MDTFC, CBT) across and within states. –Development of state centers and legislative mandates to support diffusion –Evaluation of new approaches- e.g. Juvenile Mental Health Courts

Recent National Trends (cont.) 4.Stronger emphasis on systems change as a strategy –SAMHSA’s Policy Academies –Mac Arthur Foundation’s Models for Change: Systems Reform in Juvenile Justice Initiative –NCMHJJ’s Comprehensive Systems Change Initiative

Recent National Trends (cont.) 5.Identification, integration and dissemination of best available information –Establishment of the National Center for Mental Health and Juvenile Justice –Development of The Blueprint for Change: A Comprehensive Model for the Identification and Treatment of Youth with Mental Health Needs in Contact with the Juvenile Justice System

The Blueprint for Change Provides a comprehensive and integrated blueprint that offers practical guidelines, examples and recommendations for change. Developed by NCMHJJ through grant from OJJDP. Multi-year effort involving literature review, site visits, data collection and informed by key stakeholders and a National Advisory Board. Targeted to juvenile justice and mental health administrators and program directors.

Key Components Underlying Principles that serve as the underpinning of the Model and provide the basis for the recommendations put forward Cornerstones that provide the necessary infrastructure for the model and reflect areas where key improvements can be made to better serve youth with mental health needs Critical Intervention Points that identify places within the juvenile justice system where opportunities exist to implement or address the Cornerstones Program Examples that illustrate existing efforts to provide services to youth in contact with the JJ system

Examples of Underlying Principles Represent the foundation on which a system can be built that is committed and responsive to addressing the mental health needs of youth in its care Youth should not have to enter the JJ system solely to access mental health services Whenever possible and matters of public safety allow, youth should be diverted into evidence- based treatment in community settings

Cornerstones Collaboration: The JJ and MH systems must work jointly to address the issue Identification: Systematically identify needs at all critical stages Diversion: Whenever possible divert youth to community based services Treatment: Provide youth with effective treatment to meet their needs

Recommended Actions 33 action-oriented recommendations organized by Cornerstones Provide guidance and specific direction for addressing the issues of improved collaboration, identification, diversion and treatment Include program and other examples of how this can be done

Program Examples Over 50 programs are referenced Descriptions and contact information are provided for all Highlighted program examples include: –Alabama Juvenile Court Liaison Initiative, Tuscaloosa and Walker Counties, Alabama –Mental Health Diagnostic and Evaluation Units, Jefferson County, Alabama

Conceptual Framework of the Comprehensive Model

Blueprint for Change Completed document under review by OJJDP Web-based version available in May 2006 through our website:

Despite progress, much more needs to be done. 1.The fact that there are large numbers of youth with serious mental disorders in the juvenile justice system-often placed there because of the lack of community-based services-must be more fully recognized and addressed. 2.Many of these youth could be better served through the development of treatment diversion programs.

3.Effective community-based services must be available for youth who are diverted from the juvenile justice system. 4.All youth coming in contact with the juvenile justice system should be screened and, when necessary, fully evaluated. 5.For those youth placed in secure facilities, their mental health needs must be better addressed through effective services, appropriate staffing and training and enhanced re-entry services.

6.Evidence-based practices should be expanded at all points in the juvenile justice system. 7.Policies, funding, services, and responsibilities of the justice and treatment systems must be clarified and coordinated. 8.Technical assistance and training must be provided to systems and communities to foster their review and implementation of effective strategies, models and interventions.