1. Transforming Juvenile Justice: Integrating Systems, Practice, and Policy Daniel J. Flannery, PhD Institute for the Study and Prevention of Violence Kent State University

2. 2 Behavioral Health and Juvenile Justice  First BH/JJ project 1994-1997; 3 sites in Ohio State Departments of Mental Health & Youth Services  Strengthening Communities & Youth Juvenile offenders with substance use issues  Second BH/JJ project 2004-current; 6 sites in Ohio Three new sites exclusively focus on females  Project TAPESTRY SAMHSA Funded, Mental Health side  Integrated Co-occurring treatment (ICT) Pilot projects

3. 3 Behavioral Health and Juvenile Justice 1994-1997 Violent juvenile offenders with serious mental health issues not treatable by state juvenile justice system 61% taking 1-3 medications or more at intake Mood (56%) and behavior disorders (23%) Axis I Full Psychological Evaluations on n= 88 youth Significant parent mental health issues Youth victimization and suicide risk IQ and Learning Disability issues

4. 4 Strengthening Communities- Youth (SCY) SAMHSA funded initiative (CSAT) with county office of Justice Affairs, Public Defender, and Catholic Charities

5. Strengthening Communities – Youth (SCY) CSAT funded 2002-2007 to address gaps in the substance abuse treatment delivery system for adjudicated youth  Youth 12 to 17 admitted to Detention Center with a new arrest  Screened for substance use by Public Defender’s office Global Appraisal of Individual Needs (GAIN)  Clinical recommendations presented to court prior to disposition  Referred to treatment (vs. detention) and followed at 3, 6, and 12 months (84% 12 month follow-up rate for study)

6. SCY Demographics  N= 232  82% male  53% were African-American, 29% were Caucasian  Average age=15.7 years (range 12-17)  64% were Medicaid eligible  54% lived in the city of Cleveland

7. 7 Arraignment Charges

8. 8 Substance Use At intake:  (87%) reported using marijuana in the past 90 days  (59%) reported using alcohol in the past 90 days  13.1 years old the first time they got drunk or used any drugs

9. Mental Health Indices Internal Mental Distress Somatic Symptoms Depressive Symptoms Homicidal- Suicidal Thought Anxiety Symptoms Traumatic Stress Youth Moderate/Severe+ 90 (39%) 117 (50%) 148 (64%) 57 (25%) 103 (44%) 81 (35%) Boys Moderate/Severe^ Girls Moderate/Severe^ 64 (34%) 26 (62%)* 89 (47%) 28 (67%)* 113 (59%) 35 (83%)* 42 (22%) 15 (36%) 79 (42%) 24 (57%) 59 (31%) 22 (52%)* Behavior Complexity Attention Deficit Hyperactivity Disorder Inattentive Disorder Hyperactivity Disorder Conduct Disorder Youth Moderate/Severe+ 162 (70%) 123 (53%) 95 (41%) 40 (17%) 163 (70%) Boys Moderate/Severe^ Girls Moderate/Severe^ 127 (67%) 35 (83%)* 98 (52%) 25 (59%) 73 (38%) 22 (52%) 26 (14%) 14 (33%)* 129 (68%) 34 (81%)

10. DSM-IV Mental Disorders Diagnosis^Gender%1%1 %2%2 %3%3 Mood Disorders: depression, cyclothymic, bipolar, dysthymic, mood disorder NOS M: 5069%22%26% F: 2231%9.5%52%* Total=72100%31% Generalized Anxiety DisorderM: 2265%9.5%12% F: 1235%5%29%* Total=34100%15% Disruptive Disorders: conduct disorder, ADHD, ODD M: 9877%42%52% F: 2923%12.5 % 69%* Total=127100%55% Adjustment DisorderM: 4100%2% F: 00% Total=4100%2% ^ Categories are not mutually exclusive 1 Percent of total with that diagnosis 2 Percentage of N=232 3 Percent of males (n=190) and of females (n=42) * higher females vs. males, p<.05

11. 11 Comorbidity  63% have a DSM-IV mental disorder (are comorbid) in addition to a DSM-IV substance use disorder  A significantly higher proportion of females than males were comorbid (79% v. 60%)

12. Externalizing and Internalizing Disorders by Gender

13. 13 Primary Offender Types  62% classified as felons  36% classified as misdemeanants  1% classified as status offenders  Did not differ by racial/ethnic group or age at first adjudicated delinquent charge  Males (71%) significantly more likely than females (25%) to be classified as felons

14. 14 Youth with Domestic Violence Charges  43% had at least one domestic violence charge  41% had at least one adjudicated domestic violence charge  Of the total adjudicated domestic violence charges, 90% were misdemeanor level and 10% were felony level  A higher proportion of females than males had adjudicated domestic violence charges

15. 15 Environmental Risk

16. 16 General Victimization  Youth reported first time they were victimized at 11 years old  Significantly more females than males report sexual victimization and emotional abuse at the hands of someone close to them or that they trusted  Significantly more males than females report being attacked with a weapon

17. 17 General Victimization

18. 18 Victimization  64% of youth report any victimization on the GAIN  47% of youth had a substantiated/ indicated incident of maltreatment  If considered together, 80% of all SCY youth have a history of some type of victimization

19. 19 Child Welfare Involvement (DCFS data)  The majority of SCY youth (69%) had at least one allegation of any type of maltreatment (neglect, physical abuse, sexual abuse, emotional maltreatment)  Almost half (47%) of youth had a substantiated or indicated maltreatment incident in their lifetime  On average, SCY youth were 7.7 years old at the time of first maltreatment allegation

20. 20 Out-of-Home Placements  24% of SCY youth had experienced at least one out-of-home placement (OHP) in their lifetime  On average, youth who had experienced any OHP had 3 out-of-home placements (median=2)  Most commonly, placement was in foster/adoptive homes or community residential centers

21. Cross-system Involvement  Juvenile Justice, Alcohol and Drug, Mental Health, Special Education, DCFS  12% of youth were involved with only the juvenile justice and alcohol and drug systems  88% were involved in at least one other system  32% involved in 3 systems, 40% involved in 4 systems, 15% involved in all five systems

22. Cross-system Involvement System involvement in addition to Juvenile Justice and Alcohol and Drug (N=232) N (%) Mental Health131 (56%) Special Education67 (29%) DCFS (any contact) Any allegations Any Substantiated/Indicated Out of home placement 173 (75%) 159 (68%) 108 (47%) 56 (24%) Mental Health and Special Education41 (18%) Mental Health and DCFS104 (45%) Special Education and DCFS57 (25%) Mental Health, Special Education, and DCFS36 (15%)

23. Tapestry Cross System Involvement

24. Substance Problems Scale Over Time  Statistically significant decrease: Intake to 3 months Intake to 6 months Intake to 12 months  Statistically significant increase: 3 months to 6 months

25. 25 Substance Use Over Time

26. 26 Abstinence  Youth reporting abstinence: Intake - 16 youth (7%) 3 months - 113 youth (49%) 6 months - 102 (44%) 12 months - 103 (44%)  Overall, only 18% (n=42) of youth reported abstinence at all follow-up periods (3, 6, and 12 months)

27. 27 Urinalysis Data  Of 42 youth who reported abstinence on the GAIN at 3, 6, and 12 months, 31 had urine screen data available  Of these 31 youth: 7 (23%) did not have corroborating urine screen data (had positive screens) 24 (77%) had abstinence corroborated by urine screen data (had all negative screens)

28. Emotional Problems Scale Over Time Statistically significant decrease: Intake to 3 months Intake to 6 months Intake to 12 months 6 months to 12 months

29. General Crime Scale Over Time  Statistically significant decrease: Intake to 3 months Intake to 6 months Intake to 12 months

30. 30 Behavioral Health and Juvenile Justice 2004- current Similar population of violent juvenile offenders (age 10 to 18) in 6 urban and rural counties Evidence-based treatment program Female offenders On-site data managers

31. 31 Preliminary Data  429 enrolled Cuyahoga – 35 Fairfield – 11 Franklin – 119 Logan/Champaign – 189 Montgomery – 57 Union – 18  Gender 51.5% male  Average Age = 16 years  64% Caucasian; 29% African-American

32. 32 Victimization Data QuestionFemalesMales Has the child ever been physically abused? 25%17% Has the child ever been sexually abused?36%6% Has the child ever had a problem with substance abuse? 45%40% Has the child ever talked about committing suicide? 52%38% Has the child ever attempted suicide?24%9% Has the child ever witnessed domestic violence? 50%42%

33. 33 Diagnoses  At intake, 31% of the children were already on medication for emotional/behavioral symptoms  At intake, 30% of the youth have co- occurring mental health and substance abuse diagnoses Females ODD, Cannabis use, ADHD, bipolar, PTSD Males ADHD, Cannabis use, CD, ODD, depression

34. 34 Substance Abuse Have you ever had an alcoholic beverage?Yes: 66% Have you ever been drunk?Yes: 69% Have you ever smoked a cigarette?Yes: 69% Have you ever smoked marijuana?Yes: 70% Have you ever used cocaine?Yes: 14%

35. 35 Substance Abuse  Average Age of initial use: Cigarette: 11.8 years Alcoholic drink: 13.1 years Marijuana: 13.0 years Cocaine: 14.6 years

36. 36 Substance Abuse Change  In the past 6 months, how often did you drink an alcoholic beverage? Once a month or not at all  Intake: 65%  6 months: 81%  Discharge: 80%

37. 37 In the past 30 days, how many days have you used:

38. 38 Ohio Scales * statistically significant differences between Intake and last measurement

39. 39 Ohio Scales *statistically significant differences between Intake and last measurement

40. 40 Ohio Scales *statistically significant differences between Intake and last measurement

41. 41 Ohio Scales *statistically significant differences between Intake and last measurement

42. 42 Integrated Co-occurring treatment (ICT)

43. 43 Home-Based Service Delivery Model  Location of Service:Home & Community  Intensive: 2-5 sessions/wk  Crisis Response24/7  Small caseloads: 3-6 families  Flexible:Convenient to family  Treatment Duration:12-24 weeks

44. 44 ICT YouthUsual Services Comparison Group Size of Difference in commitment and/or recidivism rates  56 youth  25% recidivism rate  29 Youth  72% commitment rate Chi Square (1, 29): 17.74 Level of significance:.001 Results of ICT Study (2001-2002)

45. 45 Ohio Scales Gain Scores (2005 – October 2006) General Clinical Population (Statewide)ICT Participants 30 days180 daysGain30 days180 daysGain Problem Severity Adult 28.6022.74 5.86 31.2819.38 11.90 Problem Severity Child 23.9318.85 5.08 30.3319.48 10.85 Hopefulness Adult 12.2910.60 1.69 13.5210.88 2.64 Hopefulness Child 10.609.44 1.16 13.0910.18 2.91 Satisfaction Adult 8.876.42 2.45 10.257.25 3.00 Satisfaction Child 10.608.53 2.07 10.138.05 2.08 Functioning Adult 44.9848.65 3.67 36.2044.71 8.51 Functioning Child 55.7559.34 3.59 49.4258.76 9.34 Total = 27 youth; 3 ODYS Commitments  For "Functioning", the higher the score the better - for all others, the lower the score the better  Clinical cutoffs= 20 for problem severity and 51 for parent rating functioning and 60 for youth rated functioning

46. 46 Implications and next steps  Growing population of offenders with MH and SA issues  Community-based care vs. incarceration  Evidence-based treatment using comprehensive assessments of risks and strengths  Collaboration across systems can work!  Data driven decisions for practice and policy  Shared vision can help plan for sustainability  Infrastructure and funding for integrated treatment  Cultural competency matters in treatment decisions