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Factors Associated With Mental
Health and Juvenile Justice
Involvement Among Children
With Severe Emotional Disturbance
Kelly N. Graves
Bennett College for Women

James M. Frabutt
Terri L. Shelton
University of North Carolina at Greensboro

Recent research has highlighted the fact that there is an overrepresentation of children with
mental health problems in the juvenile justice system. Thus, this study uses a clinical sample of
children receiving mental health services to examine demographic (e.g., age, ethnicity), person-
level (e.g., anxious and/or depressed), family-level (e.g., number of transitions in living situa-
tions), and school-level factors associated with being involved in the mental health and juvenile
justice service systems (i.e., dual involvement). Analyses were conducted separately by gender
to investigate differences in dual involvement and possible differences in the predictors of dual
involvement. For boys and girls, older adolescents and a higher number of living transitions
were associated with dual involvement. For girls only, depression and/or anxiety and social
problems were associated with dual involvement. The findings highlight the need for greater
collaboration among service systems given the strong overlap between mental health and juve-
nile justice involvement for many children.

Keywords: juvenile justice; mental health; serious emotional disturbance; system of care

According to the Surgeon General’s report on mental health, more than four millionchildren suffer from a major mental illness (Office of the Surgeon General, 2001).
Researchers have documented that between 40% to 90% of children and adolescents involved
in the juvenile justice system also suffer from a mental illness compared to 18% to 22% of
the general youth population (Cocozza, Stern, & Blau, 2005; Kazdin, 2000; Teplin, 2001;
Teplin, Abram, McClelland, Dulcan, & Mericle, 2002). Thus, it is likely that children’s men-
tal health problems play a major role in their offending behaviors. Despite these concerns, lit-
tle is known about clinically related factors that might be associated with dual involvement in
mental health and juvenile justice systems. The current study uses a subsample of children
receiving community-based mental health services to examine factors that are associated with
dual involvement. Furthermore, because relatively little attention has been given to differ-
ences in clinically relevant factors based on gender, the current study examines these factors
separately by gender to predict whether a child with mental health problems also will become
involved in the juvenile justice system.

Youth Violence and
Juvenile Justice

Volume 5 Number 2
April 2007 147-167

© 2007 Sage Publications
10.1177/1541204006292870

http://yvj.sagepub.com
hosted at

http://online.sagepub.com

147

Many children and adolescents who access community-based mental health services are
diagnosed with a serious emotional disturbance (SED). SED is defined as having a clinical
diagnosis, a functional impairment, and disturbances in multiple domains within the child’s
life (e.g., school, home, community, etc.; Pumariega & Winters, 2003). The SED population
is estimated to encompass approximately 4.5 to 6.3 million children (6% to 8%) in the
United States (Friedman, Katz-Leavy, Manderscheid, & Sondheimer, 1999). By definition,
these children and adolescents experience problems across multiple domains and often
require coordinated, multiple-systems intervention (Hansen, Litzelman, & Marsh, & Milspaw,
2004). Previous research using community samples has indicated that almost 46% to 88%
of children involved with the juvenile justice system also were diagnosed with a SED
(Lyons, Baerger, Quigley, Erlich, & Griffin, 2001).

Based on Bronfenbrenner’s (1979) theory of social ecology, these children exemplify the
postulation that behavior can be multiply determined. The social ecology concept posits that
behavior can stem from internal biological and psychological mechanisms as well as exter-
nal interactions with others across family, peer, and school domains. Because development
has numerous contextual influences, the current study examines factors across a variety
of domains (in addition to demographic factors such as gender and ethnicity), including
person-level, family-level, and school-level factors to identify comprehensive, clinically rel-
evant factors related to dual involvement. In doing so, the current study also adheres to best
practice guidelines, which have been recommended by the President’s New Freedom
Commission (2002) and many other researchers (e.g., Greene, Peters, & Associates, 1998;
Hansen et al., 2004).

Recent research has found that examining factors across multiple domains may be more
insightful when trying to understand antisocial behavior, particularly because there may be
gender differences in the predictors of risk (Gorman-Smith & Loeber, 2005). In that study,
antisocial behavior among girls was more influenced by parenting variables such as parental
monitoring than among boys, whereas antisocial behavior among boys was more influenced
by deviant peers than among girls. Those findings hint at the possibility that particular eco-
logical systems (e.g., family vs. school) might have unique, gender-based influences on
development. Thus, the current study expands on this possibility by examining whether there
also might be different predictors based on gender for dual involvement with an SED sam-
ple using factors that represent the multiple ecological systems within a child’s life.

Demographic Factors

Although the violent crime index declined in 2003 for the ninth consecutive year (falling
48% from its 1994 peak), there continues to be areas of concern with respect to arrest rates.
For example, between 1980 and 2003, arrest rates for simple assault increased 269% for
females and 102% for males (Snyder, 2005). Although boys repeatedly are reported to be
more violent than girls (Kashani, Jones, Bumby, & Thomas, 1999), that trend is changing,
with rates of violence among girls quickly approaching the rates of violence among boys
(Snyder, 2005). Even given these statistics, some research indicates the existence of chival-
rous treatment of female offenders in the initial stages of criminal processing (Visher,
1983), with girls receiving “lighter” punishments for illegal behaviors.

148 Youth Violence and Juvenile Justice

Those findings bring to the forefront the significant controversy regarding dispropor-
tionate minority contact with the juvenile justice system. In Visher’s (1983) study, older,
European American girls were less likely to be arrested than were younger, African American
girls. However, the published statistics indicate that antisocial behavior and juvenile justice
involvement disproportionately involve minorities, with African American children and ado-
lescents reported to engage in more violent behaviors compared to European American or
Hispanic children and adolescents (Blum, Ireland, & Blum, 2003; Earls, 1994; Kashani et al.,
1999; Snyder, 2005). Of the estimated 1,400 murder arrests in 1999 and 2003, 49% and 48%
were African American adolescents, respectively (Snyder, 2005; U.S. Department of Justice,
2000). In fact, some have reported that ethnicity has a very strong effect size in terms of pre-
dicting violent behaviors across age ranges (d = .17, p < .01; Lipsey & Derzon, 1998).
However, the federal Office of Juvenile Justice and Delinquency Prevention (OJJDP) repeat-
edly has raised the concern that the percentage of minority youth involved in the juvenile jus-
tice system is disproportionate to their representation in the general population. Specifically,
recent estimates report that minority youth represent 34% of the juvenile population in the
United States, but 62% of the nation’s detained youth (Hsia, Bridges, & McHale, 2004).
National and state data (Ekpunobi, Wilson, Chunn, Huang, & Davis, 2002; Frazier & Bishop,
1995; Leiber, 2002; Snyder, 2005) consistently report finding systemwide disproportionate
minority contact. Thus, it is unclear whether ethnicity is a true risk indicator, is associated
with some other risk indicator (e.g., poverty, access to prevention services), and/or whether
systemwide problems exist in terms of the overidentification of African American youth for
juvenile justice involvement.

Person-Level Factors

Although there is a myriad of person-level factors that might be associated with dual
involvement, the current study selected three factors that previous research has identified as
strongly and consistently linked with involvement in the juvenile justice system. These three
factors are anxious and/or depressed, depressed and/or withdrawn, and inattention and/or
hyperactivity symptoms.

Research has indicated that involvement with the juvenile justice system often co-occurs
with internalizing symptoms such as depression and anxiety, particularly among girls
(Simmons, 2002; Teplin et al., 2002). It is possible that high levels of internalizing symp-
toms increase the likelihood of “lashing out” behaviors that might increase the risk for juve-
nile justice contact. For example, girls are at a higher risk for suicidal ideation compared to
boys, and suicidal ideation and suicide attempts are associated with an increased likelihood
of antisocial behaviors (Chandy, Blum, & Resnick, 1996). From a socialization perspective,
it is possible that because girls are socialized away from aggression throughout their lives,
the outlet for internalized anger often is unrefined, resulting in overt, impulsive, and some-
times aggressive acts rather than healthy methods of exposing internalized feelings such as
assertiveness or problem-solving strategies (Simmons, 2002). Furthermore, when females
do attempt to address intense feelings through physical aggression, they often are punished
more than males for doing so (e.g., Stueve, O’Donnell, & Link, 2001) without being taught
alternate forms of conflict resolution. Consistent with the frustration–aggression hypothesis,

Graves et al. / Dual Involvement 149

or that frustration can trigger aggression (Berkowitz, 1989), it is at that point that aggression
might manifest itself among boys and girls. However, for some girls, increased consequences
and social ridicule may lead to increased shame and guilt. Such isolation stifles their con-
tinued development and places them at further risk for developing psychological sequale
such as clinical depression and/or anxiety (Orbach-Isreal, 2003). Because of the different
socialization influences on development (Maccoby, 1990), and because of the more intense
accumulation of multiple risks (Gorman-Smith, Tolan, Loeber, & Henry, 1998; McCord,
1982), it is hypothesized that the links between internalizing symptoms (i.e., anxious and/or
depressed, depressed and/or withdrawn) and dual involvement will be stronger for girls than
for boys.

Antisocial behavior also has been linked with higher rates of attention-deficit/hyperactiv-
ity disorder (ADHD; Zoccolillo, 1993) and more general attention problems (e.g., Loeber,
Green, Keenan, & Lahey, 1995). The combination of antisocial behavior, inattention, and
hyperactivity–impulsivity sets into motion a pattern of person–environment interactions
between the child and others, which often fosters and maintains individual differences among
hyperactive and impulsive children compared to children who do not display such character-
istics (Moffitt, Caspi, Rutter, & Silva, 2001). Although each of these factors has been linked
to juvenile justice involvement individually, when combined, children can exhibit a general
personality profile of disinhibition that can increase the risk for police contact (i.e., calls to
the police, arrest decisions, court intake decisions). That possibility has been empirically val-
idated, indicating that children who have hyperactivity, impulsivity, and attention problems
(manifested as a general syndrome of disinhibition), and a history of conduct problems, are
at the greatest risk for perpetuating antisocial behavior (Carlson, Tamm, & Gaub, 1997;
Lynam, 1996, 1999).

Family-Level and School Factors

Children involved in the juvenile justice system often come from families with overex-
tended resources. For example, high levels of caregiver strain have been linked with comor-
bid diagnostic profiles and greater psychological distress (Brannan & Heflinger, 1997;
Garland, Aarons, Brown, Wood, & Hough, 2003); however, different patterns based on child
gender have not been empirically investigated. Furthermore, research has indicated that as the
number of living transitions increases, child functioning decreases (particularly in the school
environment; Simmons, Burgeson, Carlton-Ford, & Blyth, 1988). If levels of functioning and
school success decrease, there may be an increased likelihood of antisocial or delinquent
behavior, raising the risk of becoming involved with the juvenile justice system. More gener-
ally, statistics indicate that family stressors such as a high number of living transitions and
limited resources increases the risk of juvenile justice involvement (U.S. Department of
Justice [USDoJ], 1995).

School failures characterized by high absenteeism and poor academic performances have
been identified as risk factors for juvenile justice involvement (USDoJ, 1995). Some
research indicates that this relationship might be stronger for girls compared to boys (e.g.,
Rankin, 1980; Thornton, Craft, Dahlberg, Lynch, & Baer, 2002). For example, some studies
have documented that educational failure is an almost-universal correlate of delinquent girls,

150 Youth Violence and Juvenile Justice

whereas that is not necessarily the case among delinquent boys (Thornton, Craft, Dahlberg,
Lynch, & Baer, 2002). Explanations for this difference are not immediately clear. However,
some have speculated that girls who experience school failure resort to adopting a “bad girl”
image to gain status because school success status appears unattainable (Koroki & Chesney-
Lind, 1985). Thus, school failure might set into motion a pattern of peer rejection and con-
frontation with teachers and parents, resulting in the increased likelihood that those children
will gravitate toward deviant peer groups to achieve a sense of acceptance. Because girls
tend to emphasize social relationships to a greater degree than boys, it is likely that school
failure might be a stronger factor for dual involvement for girls compared to boys.

However, some have argued (e.g., Hawley, 1999; Vaughn, Vollenweider, Bost, Azria-
Evans, & Snider, 2003) that aggression can be adaptive in certain social contexts because it
creates “dominance status.” This dominance status sometimes functions to increase cohesion
among the social group (Strayer & Trudel, 1984). Thus, if girls place more emphasis on social
relationships and can achieve cohesion in a social group through aggression, it may be more
likely that girls will resort to aggressive behaviors, raising the likelihood of juvenile justice
contact. In contrast, some studies have indicated that school success is related to increased
aggression among boys (but not among girls; Heimer & Matsueda, 1994). The hypothesized
process is that a general increase in self-esteem, social acceptance, and admiration results in
a decreased perceived likelihood of being punished for antisocial or risk-taking behaviors
(Heimer & Matsueda, 1994). Thus, whereas school failure was related to increased likelihood
of antisocial behavior among girls, school success was related to an increased likelihood of
antisocial behavior among boys in some cases. It is hypothesized that school functioning will
be differentially related to juvenile justice involvement for boys and for girls among clinically
referred samples as well.

Hypotheses

In summary, the current study uses a clinical sample of youth identified with SED to
determine what factors are related to dual involvement (i.e., mental health and juvenile jus-
tice system involvement) separately among boys and girls. The use of a clinical sample is
important in the current investigation because it allows for the examination of factors across
multiple ecological systems within the context of a clinically referred population. Because
it is important to remove any variance accounted for by general delinquency behaviors when
predicting dual involvement, delinquent behaviors are controlled in all analyses. It is hypoth-
esized that a larger proportion of boys would be dually involved than girls (Hypothesis 1).
Based on the previous research reviewed above, each of the proposed factors (i.e., anxious
and/or depressed, depressed and/or withdrawn, social problems, ADHD-type symptoms,
caregiver strain, high number of living transitions, and low school functioning) is hypothe-
sized to be positively associated with dual involvement (Hypothesis 2). In addition, the family-
level factors (caregiver strain and number of living transitions) are hypothesized to
be equally important among boys and for girls in terms of their relationships to dual
involvement (Hypothesis 3). However, based on previous research (e.g., Charles, Abram,
McClelland, & Teplin, 2003; Simmons, 2002; Snyder, 2005), it is hypothesized that the
person-level factors of anxious and/or depressed, depressed and/or withdrawn, and social

Graves et al. / Dual Involvement 151

problems would be stronger predictors of dual involvement for girls than for boys
(Hypothesis 4). Although previous findings have been somewhat inconsistent (Gorman-
Smith & Loeber, 2005; Loeber & Farrington, 2000; Rankin, 1980; Thornton et al., 2002), it
is hypothesized that school functioning would be a stronger predictor of dual involvement
for girls than for boys (Hypothesis 5).

Method

Data Source

The current study uses a nationwide, representative subsample of children and adolescents
receiving community-based mental health services through the Comprehensive Mental
Health Services for Children and Their Families Program (funded by the federal Substance
Abuse and Mental Health Services Administration, Center for Mental Health Services
[CMHS]). More than 50,000 children and adolescents have entered this national program
and received mental health services since 1993. The goal of that nationwide program is to
provide services that are child-centered and family-focused, strengths-based, community-
based, and culturally competent. The data used in the current study represents participants
in this program between 1993 and 2002. Eligibility criteria for enrollment previously was
determined by CMHS for purposes of the demonstration site grants and included: (a) being
between age 5 and 18 years at intake (although only those at least age 11 years are included
in the current study), (b) being a local county resident, (c) having a clinical diagnosis, (d)
being separated or at risk of being removed from the home because of extreme behavioral
or emotional difficulties, and (e) having multiple agency needs. The program also included
an evaluation component that assessed system development and individual outcomes for
children and families. All data collection protocols were established nationally. A full
description of the national evaluation protocol and data-collection procedures is provided
elsewhere (see Holden, Friedman, & Santiago, 2001).

Sample Selection

The current cross-sectional study focuses on European American and African American
clinically referred children age 11 to 17 years who participated in the outcome study (N =
1,168). All children had at least one clinical diagnosis, with the most common diagnosis
being a mood disorder (31%) followed by ADHD (22%). See Table 1 for percentages of
children listed across all diagnostic categories. More than 68% of children had multiple
diagnoses, with the average number of diagnoses being 1.86. In terms of psychotropic med-
ication, 83% of children reported taking psychotropic medication on entry into the service
system. The specific type of psychotropic medication was not identified in data collection
and thus could not be reported here.

Procedures

Children were referred to their local community mental health program from a variety of
sources, including caregivers, child-serving agencies (e.g., Department of Social Services,

152 Youth Violence and Juvenile Justice

Department of Juvenile Justice, Department of Public Health), and schools. Consent forms
for treatment and for participation in the evaluation process were signed by the primary care-
giver (or legal guardian if different from the caregiver) and the child. Families were informed
that an interviewer would be contacting them within a few days to schedule an interview.
Interviews were scheduled as soon as possible, but no later than 30 days after the initiation of
services.

Trained evaluators conducted in-home interviews lasting approximately 2 hrs for care-
givers and 2 hr for children. All instruments were read to children and their caregivers to
minimize possible error due to differential reading abilities. Caregivers received U.S. $25
for their participation; children received gift certificates donated from local fast food
restaurants.

Measures

Demographic Information Questionnaire (DIQ; Center for Mental Health Services
[CMHS], 1997). The DIQ is a 37-item caregiver-reported questionnaire that measures child

Graves et al. / Dual Involvement 153

Table 1
Descriptive Statistics for the Sample (N == 1,168)

Indicator % M SD Range

Age 13.86 1.78 11.00 – 17.00
Male 63
African American 22
Custody status

Two-parent family 25
Single-parent family 53
Grandparents 6
Adoptive and/or foster parents 5
State custody 9
Other relatives 4

Caregiver education level
Not a high school graduate 24
High school graduate 35
Attended some college 41

Family income
Less than U.S. $15,000 46
Above $15,000 54

Clinical diagnoses
Mood disorder 31
Attention-deficit/hyperactivity disorder 22
Oppositional defiant disorder 15
Conduct disorder 7
Adjustment disorder 7
Anxiety disorder 2
Substance use disorder 3

and family characteristics such as age, race, ethnicity, risk factors, family structure, physi-
cal custody, referral source, presenting problems, family income living arrangements, edu-
cation, household composition, physical health, and medications.

Person-Level Factors (Attention Problems, Social Problems, Anxious and/or
Depressed, Depressed and/or Withdrawn)

All caregivers and children reported on the level of attention problems, social problems,
anxious and/or depressed problems, and depressed and/or withdrawn problems using the
Child Behavior Checklist (CBCL; Achenbach, 1991a) for caregivers, and the Youth Self
Report (YSR: Achenbach, 1991b) for children. Caregiver and child reports of each construct
were correlated highly with one another (at least r = .20, p < .001). Therefore, based on pre-
vious research using this procedure (Loeber et al., 2000), and the author’s recommendation
to combine reports (Achenbach, 1991a), composite scores were created by averaging the
T-scores across caregiver and child reports for each construct separately. This composite
score was used as the indicator of each person-level factor. Internal reliability (> .82), test–
retest reliability (> .87 for all scales), and validity have been demonstrated in previous stud-
ies (Achenbach, 1991a).

Attention and hyperactivity and/or impulsivity. To assess levels of attention and hyper-
activity, the current study utilized the Attention Problems subscale on the CBCL and YSR,
which includes 20 items related to inattention, hyperactivity, and impulsivity. Sample
items include, “Now or within the last six months, my child can’t sit still, is restless, or is
hyperactive” and “Now or within the last six months, I often act without thinking.” It is
important to note that the measure used taps not only attention problems but also hyper-
activity and/or impulsivity. However, because the author of the measure titled the subscale
“Attention Problems” in the analyses, the label of that scale is used but refers to attention
and hyperactivity and/or impulsivity problems. Caregivers and children responded to each
item on a 3-point scale, from 0 = not true through 2 = very true or often true. Caregiver
and adolescent reports were correlated .32 (p < .001). The current study used the T-score
composite from the Attention Problems subscale, with higher T-scores indicating higher
levels of attention problems.

Anxious and/or depressed. Caregivers and adolescents reported levels of adolescent anx-
ious and/or depressed using the Anxious/Depressed subscale from the CBCL for caregivers
and the Anxious/Depressed subscale from the YSR for adolescents. The CBCL contains 14
items (e.g., “Now or within the past six months, my child has been unhappy, sad, or
depressed,” or “Now or within the past six months, my child has felt worthless or inferior”),
and the YSR contains 16 items (e.g., “Now or within the past six months, I cry a lot,” or
“Now or within the past six months, I feel lonely”). Caregivers and adolescents responded
on a 3-point scale, from 0 = not true through 2 = very true or often true. Caregiver and ado-
lescent reports were correlated .28 (p < .001). The current study used the T-score compos-
ite from the Anxious/Depressed subscale, with higher T-scores indicating higher levels of
anxiety and depression.

154 Youth Violence and Juvenile Justice

Social problems. Caregivers and adolescents reported levels of adolescent social problems
using the Social Problems subscale from the CBCL for caregivers, and the Social Problems
subscale from the YSR for adolescents. The CBCL and YSR contain 8 items, including
“Now or within the past six months, my child gets teased a lot,” and “Now or within the past
six months, my child is not liked by other kids.” Caregivers and adolescents responded on a
3-point scale, from 0 = not true through 2 = very true or often true. Caregiver and adoles-
cent reports were correlated .42 (p < .001). The current study used the T-score composite
from the Social Problems subscale, with higher T-scores indicating higher levels of social
problems.

Depressed and/or withdrawn. Caregivers and adolescents reported levels of adolescent
depression and withdrawal using the Depressed/Withdrawn subscale from the CBCL for
caregivers and the Depressed/Withdrawn subscale from the YSR for adolescents. The CBCL
contains 8 items (e.g., “Now or within the past six months, complains of loneliness,” and the
YSR contains 6 items (e.g., “Now or within the past six months, I cry a lot,” or “Now or
within the past six months, feels that nobody loves me”). Caregivers and adolescents responded
on a 3-point scale, from 0 = not true through 2 = very true or often true. Caregiver and ado-
lescent reports were correlated .20 (p < .001). The current study used the T-score composite
from the Depressed/Withdrawn subscale, with higher T-scores indicating higher levels of
depression and withdrawal.

Family-Level Factors

Caregiver strain. Caregivers reported on their levels of strain on the Caregiver Strain
Questionnaire (CGSQ; Brannan & Heflinger, 1997). The CGSQ has 21 items that assess the
degree to which a caregiver feels strained related to caring for a child with mental health
needs. Items include, “interruption of personal time,” “financial strain,” and “feeling socially
isolated.” Caregivers respond on a 4-point scale, with higher scores indicating more strain.
The current study utilizes a composite strain score that is an average of the 21 items.

Living transitions. On the DIQ mentioned above, caregivers responded to the question,
“How many times has the child changed living residences in the past six months?” Caregivers’
responses to that question were used as the indicator of the number of living transitions for
each child.

School-Level Factors

To assess school functioning, caregivers completed the Child and Adolescent Functional
Assessment Scale (CAFAS; Hodges, 1994). The current study utilized the School Role sub-
scale, which assesses the degree of impairment in school functioning. Items included, “non-
compliant behavior which results in persistent or repeated disruption,” “frequently truant,”
and “disruptive behavior.” The CAFAS is rated on a 30-point scale (0 = no impairment,
10 = mild impairment, 20 = moderate impairment, 30 = severe impairment). Thus, higher
scores indicate greater impairment in school functioning. Interrater reliability and validity

Graves et al. / Dual Involvement 155

have been demonstrated in previous studies (Hodges & Wong, 1996), and mental health
professionals were trained to achieve high interrater correlations (> .80) between their rat-
ings and criterion ratings established by the author (Hodges, 1994).

Dual Involvement

To assess dual involvement, one dichotomized item from the Delinquency Survey (DS;
CMHS, 1994) was utilized. That item was, “Have you ever been told to appear in court for
something you were suspected of doing?” On this instrument, questions are directed toward
the youth because previous research indicates that youth more accurately recall and report
their own delinquent behaviors than do their caregivers or other adults (CMHS, 1994).
Children responded 1 = no and 2 = yes.

Control Variable

Delinquency. Caregivers and adolescents reported levels of adolescent delinquent behav-
iors using the Delinquency subscale from the CBCL for caregivers and the Delinquency
subscale from the YSR for adolescents. The CBCL contains 11 items (e.g., “Now or within
the past six months, sets fires,” and the YSR contains 11 items (e.g., “Now or within the
past six months, I have been cruel to animals”). Caregivers and adolescents responded
on a 3-point scale, from 0 = not true through 2 = very true or often true. Caregiver and
adolescent reports were correlated .38 (p < .001). The current study used the T-score com-
posite from the Delinquency subscale, with higher T-scores indicating higher levels of
delinquency.

Analytical Approach

Preliminary descriptive statistics were conducted to determine the percentage of children
and adolescents who were dually involved and the demographic configuration of those indi-
viduals compared to those who were not dually involved. Zero-order correlation analyses
examined whether dual involvement was related to demographic, person-level, family-level,
and school-level clinical variables of interest. To study the possibility that there may be dif-
ferences in clinically relevant factors to predict dual involvement based on gender, two logis-
tic regressions were conducted.

Results

Descriptive Statistics

Among the 1,168 children who participated in the current study, 545 (46.7%) indicated
that, in addition to being involved in the mental health system, they also were involved with
the juvenile justice system (623 were not involved). Chi-square analyses indicated that the
proportion of boys who were dually involved (376 of 737, 51%) was significantly higher than

156 Youth Violence and Juvenile Justice

the proportion of girls who were dually involved (169 of 431, 39.2%), χ2(1, n = 1,168) =
15.23, p < .001. Thus, Hypothesis 1 was confirmed. In terms of other demographic variables,
chi-square analyses indicated that the proportion of African American children who were
dually involved (51.4%) was only slightly higher than the proportion of European American
children who were dually involved (45.3%), χ2(1, n = 1,168) = 2.93, p < .10. Independent
samples t tests indicated that there were no group differences based on socioeconomic status,
t(1,168) = –1.39, ns. Zero-order correlations are reported in Table 2.

Independent samples t tests indicated that there were group differences based on age, with
older children more likely to report having been involved with the juvenile justice system,
t(1,168) = 10.48, p < .001. Using the total eight-scale score from the CAFAS, follow-up
independent t tests indicated that among those children who were dually involved, girls had
significantly higher levels of impairment (M = 122.08) compared to boys that were dually
involved (M = 113.08), t(499) = –2.00, p < .05, and also compared to girls who were not
dually involved (M = 105.43), t(384) = –3.43, p < .001. Among those children who were not
dually involved, there were no significant gender differences in terms of levels of impair-
ment, t(545) = –1.03, ns. Thus, preliminary analyses suggest that the mental health status
among girls involved in the juvenile justice system is more severe than the mental health sta-
tus of boys.

To test Hypotheses 2 through 5, two cross-sectional logistical regressions were conducted,
one regression for each gender.1 In Model 2, the demographic factors and control variables
were entered (age, ethnicity, delinquency). In Model 2, all person-level factors were entered
(inattention, social problems, anxious/depressed, depressed/withdrawn). In Model 3, all
family-level factors were entered (number of living transitions, caregiver strain). In Model 4,
the school-level factor was entered (school functioning).

Logistic Regression Model for Boys

The logistic regression models to examine the factors associated with dual involvement for
boys and for girls are presented in Tables 3 and 4, respectively. For boys, the significant fac-
tors associated with dual involvement were age (odds ratio [OR] = 1.37, p < .000), with older
boys more likely to be dually involved than younger boys, and delinquency (OR = 1.07, p <
.001), with boys who had higher levels of delinquency more likely to be dually involved.
Ethnicity was not associated with dual involvement when examined separately for boys and
for girls. The overall model was significant at the .000 level according to the model chi-square
statistic and predicted 64.7% of the responses correctly.

Block 2 included four additional person-level factors hypothesized to be associated with
dual involvement. According to the block chi-square statistic, Block 2 was superior to
Block 1 in terms of overall fit. The Social Problems factor was marginally significant in
terms of its predictive ability (OR = .95, p < .10), with higher levels of social problems
linked with a decreased likelihood of dual involvement. The added person-level factors
listed in Table 3 increased the predictive power of the model. Block 2 was superior to the
previous model at the .001 level, accounting for 65.9% of the responses correctly.

Block 3 included two additional family-level factors hypothesized to be associated with
dual involvement. Within this block, a higher number of living transitions were associated

Graves et al. / Dual Involvement 157

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with an increased risk for dual involvement (OR = 1.22, p < .05). However, levels of care-
giver strain were not associated with dual involvement. According to the block chi-square
statistic, Block 3 was superior to the previous models and was significant at the .001 level,
accounting for 67.9% of the responses correctly.

Block 4 included an indicator that assessed school functioning and its possible link with
dual involvement. According to the block chi-square statistics, Block 4 did not increase the
predictive power of the model, indicating that school functioning was not associated with
dual involvement among boys.

Logistic Regression Model for Girls

For girls, the significant demographic factors associated with dual involvement were age
(OR = 1.52, p < .000), with older girls more likely to be dually involved than younger girls,
and delinquency (OR = 1.08, p < .001), with girls who had higher levels of delinquency more
likely to be dually involved. These findings were consistent with the findings for boys.
However, unlike the findings for boys, the logistic regression for the girls indicated that eth-
nicity was a significant predictor (OR = .75, p < .05), with African American girls more likely
to be dually involved than European American girls. The overall model was significant at the

Graves et al. / Dual Involvement 159

Table 3
Cross-Sectional Logistic Regression Model to Predict

Dual Involvement Among Boys (n == 737)a

Predictor β (SE) eβ p

Demographic factors
Age 0.31 (0.06) 1.37 .000
Ethnicity –0.14 (0.11) 0.87 .21
Delinquency 0.06 (0.02) 1.07 .000

Person-level factors
Inattention –0.01 (0.02) 0.99 .49
Social problems –0.02 (0.02) 0.98 .10
Anxious and/or depressed –0.02 (0.02) 0.98 .20
Depressed and/or withdrawn –0.01 (0.02) 0.99 .40

Family-level factors
Living transitions 0.20 (0.08) 1.22 .02
Caregiver strain 0.14 (0.12) 1.15 .26

School-level factors
School functioning –0.01 (0.01) 1.00 .78
Constant –4.01 (1.36)
Omnibus model χ2 116.46
df 10 .000
-2 Log likelihood 707.78
Cox & Snell R2 0.18
Nagelkerke R2 0.24

Note: eβ = exponentiated β.
a. The statistics reported are for the full model (i.e., Block 4).

.000 level according to the model chi-square statistic and predicted 70.1% of the responses
correctly.

Block 2 included four additional person-level factors hypothesized to be associated with
dual involvement. Within this block, anxious and/or depressed was linked with a decreased
likelihood that a girl was dually involved (OR = .94, p < .01), as was the social problems fac-
tor (OR = .95, p < .01). According to the block chi-square statistic, Block 2 was superior to
Block 1 and was significant at the .001 level, accounting for 72.4% of the responses correctly.

Block 3 included two additional family-level factors hypothesized to be associated with
dual involvement. Within this block, a higher number of living transitions were associated
with an increased risk for dual involvement (OR = 1.31, p < .001). Caregiver strain was not
associated with dual involvement. According to the block chi-square statistic, Block 3 was
superior to the previous models and was significant at the .001 level, accounting for 74.4%
of the responses correctly.

Consistent with the logistic regression for boys, Block 4 included an indicator that
assessed school functioning and its possible link with dual involvement. According to the
block chi-square statistics, Block 4 did not increase the predictive power of the model, indi-
cating that school functioning was not associated with dual involvement among girls.

160 Youth Violence and Juvenile Justice

Table 4
Cross-Sectional Logistic Regression Model to Predict Dual Involvement

Among Girls (n == 431)a

Predictor β (SE) eβ p

Demographic factors
Age 0.42 (0.09) 1.52 .000
Ethnicity –0.29 (0.16) 0.75 .05
Delinquency 0.08 (0.02) 1.08 .001

Person-level factors
Inattention 0.03 (0.03) 1.07 .30
Social problems −0.06 (0.02) 0.95 .01
Anxious and/or depressed –0.06 (0.02) 0.94 .01
Depressed and/or withdrawn 0.02 (0.02) 1.02 .42

Family-level factors
Living transitions 0.28 (0.09) 1.31 .01
Caregiver strain −0.01 (0.17) 0.99 .97

School-level factors
School functioning 0.01 (0.01) 1.00 .82
Constant –6.44 (1.90)
Omnibus model χ2 111.01
df 10
Significance 0.000
-2 Log likelihood 367.62
Cox & Snell R2 0.27
Nagelkerke R2 0.36

Note: eβ = exponentiated β.
a. The statistics reported are for the full model (i.e., Block 4).

Discussion

The purpose of the current study was to extend research on factors that contribute to an
increased likelihood for children’s dual involvement in the mental health service system and
the juvenile justice system. By taking a social ecological approach and exploring a variety of
factors across domains (demographic factors, person-level factors, family-level factors, and
school-level factors), the current study examined the possibility that clinically relevant factors
associated with dual involvement might differ by gender.

Consistent with Hypothesis 1, boys were more likely to be dually involved than were girls.
However, the girls who were dually involved had significantly lower levels of functioning
than dually involved boys and girls who were not dually involved. Thus, girls who were
dually involved had significantly more severe mental health problems, raising the question of
whether we are waiting too long to intervene for this population. Are we missing the early
warning signs among girls that might lead to involvement in the juvenile justice system?
Although that might be the case, other research would posit that this finding is not sur-
prising. For example, Silverthorn and Frick (1999) posited that when a girl engages in a pre-
dominantly “male” event (i.e., delinquency), she tends to be more severely impaired. Other
researchers have found that girls who are involved in the juvenile justice system have higher
rates of mental health problems compared to boys (National Mental Health Association,
2004). Indeed, this seems to be the case within the current sample.

In regard to Hypotheses 2 and 3, the findings from the current study also illuminate several
clinically relevant factors that are associated with whether a child who has mental health
problems also is involved in the juvenile justice system, although not all of the predicted rela-
tionships were significant. For boys and girls, children who were older and had more transi-
tions in their living situations were more likely to be dually involved. The observed link
between juvenile justice involvement and a high number of living transitions among boys and
girls suggests the need to create stability in the lives of children and the possibility that with
increasing caregiver burnout multiple placements may result (caregiver strain and number of
living transitions correlated r = .21, p < .001 in the current sample).

There was some support for Hypothesis 4 that person-level factors of internalizing symp-
toms (i.e., anxious and/or depressed) and social problems would be stronger predictors of
dual involvement for girls than for boys. Although the findings did not indicate unique fac-
tors for boys, several additional factors were found to be significantly related to whether girls
become dually involved. Specifically, social problems significantly decreased the likelihood
of dual involvement. Explanations for this finding were not immediately clear. However, the
items within the Social Problems subscale indicate more peer rejection and isolation rather
than social problems that are more related to deviant peer association. We know that asso-
ciation with deviant peers is linked strongly and consistently with antisocial behaviors
(Catalano & Hawkins, 1996; Lipsey & Derzon, 1998), and that girls who have higher levels
of social problems become more isolated (Dishion, Nelson, & Yasui, 2005). Thus, under these
conditions, it might be less likely that these girls engage in antisocial behaviors that make
them more likely to have contact with juvenile justice as part of a group of peers due to the
decrease in frequency that they are within a peer group. The cross-sectional nature of the cur-
rent study does not allow for the examination of whether these girls eventually gravitate

Graves et al. / Dual Involvement 161

toward a deviant peer group, a possibility that recent research indicates may occur for girls to
gain a sense of acceptance and belongingness (Dishion et al., 2005).

The anxious and/or depressed variable also was a significant predictor of dual involvement,
but only for girls. However, the finding was opposite than predicted, with a higher level of anx-
ious and/or depressed symptoms linked with a lower likelihood that girls will become involved
in the juvenile justice system. Although research has indicated that anxiety and depression can
contribute to antisocial behavior (Obeidallah & Earls, 1999), the opposite was true in the cur-
rent study. Perhaps the link between depression and antisocial behavior is longitudinal in
nature; however, when examined simultaneously, the link between these two constructs is not
apparent. Or, perhaps high levels of anxiety and/or depression make it less likely that a person
will take the risks involved in acts that might get one involved with the juvenile justice system.

Hypothesis 5 was not confirmed as levels of school functioning were not related to
an increased likelihood of becoming dually involved among either boys or girls. However,
follow-up logistic regression analyses indicated that school functioning does predict dual
involvement (OR = 1.02, p < .001), but only when delinquency is not included as a control
variable. Thus, it appears that there is overlapping variance between delinquency and lev-
els of school functioning, with the correlation between these variables significant at the
.001 level. These analyses are consistent with previous research (e.g., Loeber & Farrington,
2000), indicating that there is a strong likelihood that if levels of school functioning are low,
delinquency behaviors may be more likely to occur.

Strengths, Limitations, and Implications

There are several strengths to the current study, including a closer empirical examination
of clinical factors across a variety of domains that are associated with a child having not only
mental health challenges but also involvement in the juvenile justice system. Also, to date,
there are no known studies that have explored clinical factors across a variety of domains
that might predict dual involvement in a clinical SED sample. An additional strength is the
use of multiple reporters (e.g., caregivers and youth) to assess person-level factors such as
anxious and/or depressed symptoms, attention, and social problems. Because different
reports of externalizing symptoms were used, and because these reports were similar across
reporters, there is confidence that the composite measures were more accurate than they
would be otherwise (Loeber et al., 2000).

One limitation of the current study is that dual involvement was assessed with a single,
child-reported question that asks whether he or she has ever been told to appear in court. It is
unclear how participants interpreted this question and what it means in terms of how they
were involved in the juvenile justice system. It is not known how deeply these children pen-
etrated the juvenile justice system and whether their ultimate disposition was an adjudication,
diversion, entry into secure custody, or probation. In future work, it would be informative to
examine different reasons why children become involved in the juvenile justice system
because it is possible that different clinical factors are more related to certain charges (i.e.,
reasons to appear in court) than others. Furthermore, future research should examine whether
the same links hold for other populations of children because not all children with SED have
been removed, or are at risk of being removed, from their homes (which was an eligibility

162 Youth Violence and Juvenile Justice

criterion in the current study). Thus, the findings from the current study should be general-
ized only to those children who have SED and are at risk of being removed from their homes
because of their emotional or behavioral difficulties. Given the characteristics of the sample
(e.g., low-income, high-risk neighborhoods), it is possible that these areas are policed more
aggressively to offset the higher concentrations of crime and/or altercations. When this occurs,
a lack of community resources (e.g., limited hospitalization coverage or alternative treatment
locations) might contribute to more aggressive placement decisions and might make it more
likely that these youth are detained rather than referred for mental health treatment. If this
occurs, estimates of dual involvement could be erroneously inflated. In addition, the current
study’s use of cross-sectional data might be problematic if reciprocal causation is a possibil-
ity. It may be that juvenile justice decisions require mental health involvement rather than
mental health problems making youths more likely to become involved in the justice justice
system. Regardless of which comes first, the co-occurrence of mental health problems and
juvenile justice involvement deserves more empirical attention. Thus, future resarch would
benefit from using longitudinal data to examine clinical factors that might predict future
involvement in the juvenile justice system among SED populations.

Finally, future research also would benefit from teasing apart the possible confounded
influences of ethnicity, socioeconomic status, and system polices in relation to dual involve-
ment. Until systemwide investigations can be conducted, it is unclear whether ethnicity is a
true risk indicator, is associated with some other risk indicator (e.g., poverty, access to pre-
vention services), or whether systemwide problems exist in terms of the overidentification of
African American youth for juvenile justice involvement.

A number of important implications are derived from the current study. For example, the
current study supports previous research (e.g., Foster, Qaseem, & Connor, 2004) high-
lighting the need for greater systemwide collaboration for children and adolescents with
SED. Such collaboration could be achieved in many ways, including strategic planning,
cost sharing, comprehensive screening and assessment, integrated management informa-
tion systems, and cross-training of staff. Given the clear overlap between mental health and
juvenile justice involvement for many children, mental health and juvenile justice must
work together in multidisciplinary teams using clinical variables to help guide placement
decisions (e.g., MacKinnon-Lewis, Kaufman, & Frabutt, 2002). Thus, the current study is
in line with the recent legislation by advocating for comprehensive mental health treatment
planning and cross-system service planning in which juvenile justice personnel can partici-
pate and have mental health staff housed within juvenile justice facilities. Unfortunately,
the current system structure results in some parents having to give up their parental rights
through placement of their children in other service systems (e.g., juvenile justice or child
welfare) to receive mental health services (President’s Freedom Commission, 2002). Clearly,
this should not be the norm for treating children and adolescents.

A stronger understanding of the mental health needs of children and adolescents involved
in the juvenile justice system could help in coordination and comprehensive treatment plan-
ning for our youth. In addition, the current study illuminated several gender-specific factors
related to dual involvement. Thus, for both genders, increased attention to mental health
assessments within the juvenile justice system will help to guide prevention and intervention
strategies for our youth.

Graves et al. / Dual Involvement 163

Notes

1. There are some limitations to using logistic regression analytic techniques. For example, normally distrib-
uted dependent variables are not possible because the dependent variable (dual involvement) takes on only two
values, which counterindicates a classical regression assumption (Peng, Lee, Ingersoll, 2002). Logistic regression
solves this problem, however, by applying the logit transformation to the dependent variable (for more informa-
tion on this procedure, see DeMaris, 1995 or Peng et al., 2002).

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Kelly N. Graves, PhD, assistant professor, Department of Psychology, Bennett College for Women, Greensboro, North
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Graves et al. / Dual Involvement 167

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 RESEARCH AND PRACTICE 

Objectives. We evaluated how improved mental health services affect justice
involvement among juveniles treated in the public mental health system.

Methods. Our analyses were based on administrative and interview data col-
lected in 2 communities participating in the evaluation of a national initiative de-
signed to improve mental health services for children and youths.

Results. Results derived from Cox proportional hazard models suggested that
better mental health services reduced the risks of initial and subsequent juvenile
justice involvement by 31% and 28%, respectively. Effects were somewhat more
pronounced for serious offenses.

Conclusions. Our findings suggest that improved mental health services reduce
the risk of juvenile justice involvement. (Am J Public Health. 2004;94:859–865)

Can Better Mental Health Services Reduce the
Risk of Juvenile Justice System Involvement?
| E. Michael Foster, PhD, Amir Qaseem, MD, PhD, MHA, and Tim Connor, MS

generally increase the use of community-
based alternatives (e.g., day treatment or
partial hospitalization) to restrictive inpa-
tient hospitalization, and they can involve
services, such as multisystemic therapy,9–17

targeted specifically to young people with a
history of serious delinquency.

Taken together, these elements of the sys-
tem of care work to reduce juvenile justice in-
volvement. As a result of system integration,
youths with emotional and behavioral prob-
lems who break the law or engage in other
offenses may have their problems identified
more quickly and may be diverted into the
mental health system. By targeting underlying
mental health problems (such as aggression),
mental health services may reduce the likeli-
hood of a subsequent offense and contact
with the juvenile justice system.

At present, little research exists on how sys-
tems of care affect juvenile justice involve-
ment. One possible basis for such research is
the Comprehensive Community Mental
Health Services for Children and Their Fami-
lies Program (the “Children’s Program”)
funded by the Substance Abuse and Mental
Health Services Administration. This program
is fostering public sector systems of care
throughout the country.

In several of the communities involved in
the Children’s Program, juvenile justice is well
integrated within the system of care. In Stark

Current research on youths treated in US
public mental health systems reveals that
many have been or will be involved in the ju-
venile justice system (E. M. Foster and T. Con-
nor, unpublished data, 2002).1,2 Other re-
search suggests that the obverse is also true:
many youths in the juvenile justice system
suffer from mental health problems.3–6 While
these conditions may have been preexisting,
entry into the juvenile justice system probably
exacerbates them. Many observers fear that
time spent in juvenile justice residential facili-
ties further traumatizes these young people
and only worsens their mental health prob-
lems.7 Such findings suggest that keeping
youths with emotional and behavioral prob-
lems out of the juvenile justice system should
be a public heath priority.

The overlap between the juvenile justice
and mental health systems raises difficult
questions surrounding service delivery to the
children and youths straddling the 2 systems.
One strategy for addressing these issues in-
volves integration of and coordination be-
tween the mental health and juvenile justice
systems. Such system-level coordination and
collaboration is the focus of the so-called
“system of care” approach to the delivery of
mental health services, an approach that re-
flects a public health perspective on mental
health problems.

Under a system of care, responsibility for
meeting the mental health needs of children
and youths resides at the community level
rather than with a single agency. Various
child-serving agencies, such as mental health
and juvenile justice, coordinate and integrate
service delivery. Such collaboration can in-
volve strategic planning, interagency budget-
ing and cost sharing, implementation of com-
prehensive screening and assessment, case
management, and cross-training of staff.8

When implemented, systems of care also
involve changes in the types of mental
health services delivered. These changes

County (Canton), Ohio, for example, juvenile
justice is integrated with the system of care at
several levels: program administration, financ-
ing, service delivery, and training for juvenile
justice personnel. Administratively, the system
of care operates under the aegis of the Stark
County Family Council,18 whose board of
trustees includes a juvenile justice official.
The council administers pooled funds con-
tributed by multiple child-serving agencies,
including juvenile justice.

At the level of service delivery, the target
population for the system of care comprises
youths who are at risk of out-of-home place-
ment and who are involved in multiple
child-serving sectors, including juvenile jus-
tice. Furthermore, there is a cross-system ser-
vice planning process in which juvenile jus-
tice personnel can participate, and mental
health staff are stationed at juvenile justice
facilities. Finally, the mental health agency
provides juvenile justice personnel with train-
ing in mental health issues (e.g., principles of
multisystemic therapy).

Stark County and 66 other communities
are participating in an evaluation of the Chil-
dren’s Program. This evaluation comprises
both quantitative and qualitative elements;
the former includes a longitudinal study of
the children and youths served at each site.
As a means of providing a group of compari-
son children and youths, 3 system-of-care

American Journal of Public Health | May 2004, Vol 94, No. 5860 | Research and Practice | Peer Reviewed | Foster et al.

 RESEARCH AND PRACTICE 

TABLE 1—Descriptive Sample Statistics, by Ohio County

Mahoning County Stark County

No. of No. of
Observations Mean or % SD Observations Mean or % SD P a

Child age, y 216 11.51 3.27 232 11.13 3.10 .21

Female, % 216 31 0.46 232 35 0.48 .33

Household income, $ (100s) 215 137.67 119.89 229 178.06 157.63 .00

Race/ethnicity, %

Hispanic 216 8 0.28 231 1 0.11 .00

African American 216 53 0.50 232 29 0.46 .00

Mental health status

Symptomatology (CBCL) 215 70.17 9.69 232 68.93 9.48 .17

Functioning (CAFAS) 215 78.09 24.64 227 70.75 25.45 .00

Family structure, %

Caregiver married 215 25 0.43 232 29 0.46 .27

Parent in household 215 82 0.38 229 80 0.40 .52

Grandparent in household 215 11 0.31 229 10 0.30 .70

Caregiver education (omitted category: 215 232

caregiver some college), %

High school dropout 49 0.50 58 0.50

High school diploma 17 0.38 15 0.35 .17

Some college 34 0.47 28 0.45

Caregiver employment (omitted 213 232

category: not working), %

Not working 57 0.50 49 0.50

Employed part time 20 0.40 18 0.39 .18

Employed full time 23 0.42 33 0.47

Child educational status, %

Receiving failing grades 212 37 0.48 228 32 0.47 .21

Repeated a grade 215 42 0.49 231 42 0.49 .98

Currently not in school 216 1 0.10 232 1 0.09 .94

Note. CBCL = Child Behavior Checklist; CAFAS = Child and Adolescent Functional Assessment Scale.
aP values pertain to the null hypothesis of no between-site difference. Values less than .05 are shown in boldface.

sites were matched with comparison commu-
nities. One pair involves the Stark County sys-
tem and a comparison site in Mahoning
County (Youngstown), Ohio. Using data from
these sites, we examined whether the system
of care can eliminate or delay involvement in
juvenile justice among youths receiving men-
tal health services. Our analyses employed
hazard models to examine the timing of first
involvement with the juvenile justice system
and the likelihood of recidivism. Analyses in-
corporated prestudy differences in demo-
graphic characteristics and risk of juvenile
justice involvement.

METHODS

Since 1994, the Center for Mental Health
Services (CMHS) within the US Department
of Health and Human Services has funded
the development of systems of care through
the Children’s Program. The CMHS program
provides communities with seed money to
establish a system of care administrative
structure. Communities draw on Medicaid,
block grants, and other sources to actually
fund services.

Design of Comparison Pairs Study
CMHS also has funded a national, multi-

site evaluation. This evaluation, which pro-
vided the data for the present study, in-
cluded a quasi-experimental study matching
and comparing 3 system-of-care communi-
ties with 3 similar communities. As just de-
scribed, 1 pair involved 2 Ohio communities.
As part of the evaluation, a sample of 449
children and adolescents aged 6 to 17 years
who had serious emotional and behavioral
problems and were using mental health ser-
vices were recruited for a longitudinal study.
Study enrollment began in September 1997
and continued through October 1999, with
follow-up data collection continuing through
December 2000.

In the case of most of the study children
and adolescents, entry into the study coin-
cided with entry into the mental health ser-
vice system. According to the core service
data described subsequently, fewer than 1 in
4 participants had received mental health ser-
vices more than 90 days before study entry.
Among youths who had received services in

the past, therefore, entry into the study coin-
cided with a new episode of care.

Data Source and Study Samples
Interview data. Data on youths’ mental

health status and family demographic charac-
teristics were collected through face-to-face
interviews conducted with caregivers and
their children. Interviews were conducted at
study entry and then at subsequent 6-month
intervals. A comparison of baseline demo-
graphic characteristics revealed that the chil-
dren enrolled in the study were relatively sim-
ilar across the 2 communities (Table 1).
Participants did differ, however, in regard to
race/ethnicity and family income. Children in
the system of care community were less likely

to be African American and to have a family
income of more than $15 000 per year. Other
family characteristics, such as caregiver edu-
cation and employment, were similar between
the communities.

The caregiver interviews incorporated well-
accepted measures of child mental health,
such as the Child and Adolescent Functional
Assessment Scale (CAFAS) and the Child Be-
havior Checklist (CBCL). The CAFAS assesses
child functioning in 8 domains, while the
CBCL assesses behavioral symptoms. As with
the demographic data, these measures re-
vealed both similarities and differences
among the children in the 2 communities
(Table 1). The participants had similar levels
of overall clinical symptoms at intake (CBCL),

May 2004, Vol 94, No. 5 | American Journal of Public Health Foster et al. | Peer Reviewed | Research and Practice | 861

 RESEARCH AND PRACTICE 

TABLE 2—Involvement in the Juvenile Justice System in Ohio, by County

Mahoning County Stark County

No. of No. of
Observations Mean or % Observations Mean or % P a

Ever involved in juvenile justice, % 217 47 232 39 .08

Characteristics among those involved in juvenile

justice during study period

Average age at firstb offense 103 13.17 91 13.27 .75

First offense occurred after study entry, % 103 83 91 77 .25

First offense serious,c % 103 50 91 57 .29

aP values pertain to the null hypothesis of no between-site difference.
bFirst offense refers to the first offense occurring during the 1997–2000 period (see text for discussion).
cSerious offenses are those that involve violent crimes, property crimes, alcohol and drug offenses, weapons offenses, criminal
damaging and trespassing, and sexual offenses.

but children in the comparison community
had higher levels of functional impairment
(CAFAS).

Management information system data. The
participating mental health centers in the 2
communities are behavioral health treatment
organizations. Core mental health service data
were derived from each agency’s manage-
ment information system, which is used for
billing purposes. Services included in the data
obtained from both communities were as fol-
lows: intake and assessment, case manage-
ment, medication monitoring, and individual
and group counseling. The system of care
also offered day treatment, and the alterna-
tive system operated a short-term crisis resi-
dential center.

Data regarding juvenile justice involvement.
To assess study participants’ contact with ju-
venile justice systems, we extracted data
from management information systems
maintained by juvenile courts in the 2 com-
munities for the years 1997 through 2000.
The juvenile courts maintain current and
historical information on all juvenile of-
fenses, including offense type, date of court
referral, adjudication, and disposition. A
wide range of offenses are recorded in each
management information system, examples
being violent crimes, property crimes, crimi-
nal trespassing, disorderly conduct, alcohol-
and drug-related offenses, weapons-related
offenses, truancy and curfew violations, and
probation violations.

Both official and unofficial cases are in-
cluded in the management information sys-

tem data. Official cases funnel juveniles
through the entire court process, including a
court hearing, adjudication, and a final dispo-
sition. Unofficial cases involve actual offenses,
but the cases are handled informally through
agreements involving the youth’s parents, a
judge, and a probation officer.

These data allowed us to examine the tim-
ing of first and subsequent offenses and to
differentiate offenses as “serious” or other. Se-
rious offenses involve violent crimes, property
crimes, alcohol and drug offenses, weapons
offenses, criminal damaging and trespassing,
and sexual offenses. Because some offenses
may have occurred before the period for
which juvenile justice data were available, the
first and subsequent offenses may have repre-
sented the first and subsequent offenses that
occurred during the 1997 to 2000 period
only. However, this situation probably applied
to a relatively small portion of the sample.
Seventy-five percent of the participants were
12 years or younger at the beginning of the
data collection period (more than half [55%]
were 10 years or younger).

Hazard Model
Because they incorporate key data features,

hazard (or event history) models were appro-
priate for our analysis of timing in regard to
juvenile justice involvement.19–21 In particular,
a hazard analysis incorporates the fact that
participants in a given study enter and exit
the observation period at different ages. In
addition, such an analysis reflects the fact that
the experiences of some individuals are “cen-

sored” (in the present case, the timing of fu-
ture offenses was unknown). Furthermore,
hazard analyses allowed us to incorporate the
fact that youths entered this study in the
midst of the risk period. Hazard analyses can
incorporate study entry accurately by treating
study participation as a time-varying covari-
ate. This allowed the risk of juvenile justice
involvement to rise or fall after study entry.

Hazard models can be implemented in sev-
eral forms. We used the Cox proportional
hazards model. A major advantage of this
semiparametric model is that it does not im-
pose a specific functional form for the base-
line hazard profile (or the risk profile across
age). The model does allow for the hazard to
be shifted up or down by covariates. The re-
sulting parameter estimates are best exponen-
tiated and interpreted as hazard ratios (in the
present case, the proportional effects of co-
variates on the risk of juvenile justice involve-
ment). A hazard ratio greater or less than 1
corresponds to a characteristic that raises or
lowers the risk of involvement.

The analyses described subsequently in-
cluded a range of covariates. Our focus here
is on 3 of these covariates: a site indicator, a
“pre–post” indicator pertaining to study entry,
and an interaction between these 2 factors.
The first covariate captured between-site dif-
ferences among participants before study
entry. We interpreted preexisting between-site
differences in juvenile justice involvement as
reflecting differences between sites in regard
to (1) underlying risk factors and (2) mental
health referral patterns. (Even though the sys-
tem of care was in place throughout the pe-
riod, we did not interpret preentry differences
as reflective of the system of care per se be-
cause the individuals involved were generally
not receiving mental health services.) The sec-
ond key covariate captured the difference in
risk before and after study entry (and often
into mental health services) for the compari-
son site. The interaction term captured the ef-
fect of interest: the between-site difference in
the effect of study entry.

We also included a range of child and
family characteristics as covariates (enumer-
ated in Table 1 and described subsequently).
Although only a handful of these character-
istics exhibited between-site differences, we
included them in the analyses to improve

American Journal of Public Health | May 2004, Vol 94, No. 5862 | Research and Practice | Peer Reviewed | Foster et al.

 RESEARCH AND PRACTICE 

TABLE 3—Predictors of Juvenile Justice Involvement, by Number and Type of Offenses

First Offenses Second Offenses

Predictor Statistic All Serious All Serious

Site (Stark County = 1; Mahoning Hazard ratio 1.26 1.30 1.21 1.20

County = 0) SE 0.27 0.33 0.33 0.55

t statistic 1.08 1.06 0.70 0.39

Time (poststudy entry = 1) Hazard ratio 0.78 0.95 0.78 1.42

SE 0.26 0.36 0.27 0.59

t statistic –0.75 –0.15 –0.71 0.84

Time × Site interaction Hazard ratio 0.58 0.46 0.64 0.32
SE 0.19 0.17 0.26 0.18

t statistic –1.68 –2.11 –1.11 –2.03

Covariate

Child age Hazard ratio 0.91 0.96 1.14 1.15

SE 0.10 0.11 0.17 0.21

t statistic –0.82 –0.38 0.88 0.75
Gender (female) Hazard ratio 0.55 0.45 0.83 0.35

SE 0.10 0.09 0.19 0.11

t statistic –3.34 –4.04 –0.81 –3.27
Household income Hazard ratio 1.00 1.00 1.00 1.00

SE 0.00 0.00 0.00 0.00

t statistic –0.40 0.03 –0.68 –1.26
Race/ethnicity

Hispanic Hazard ratio 1.63 1.02 1.11 1.64

SE 0.54 0.45 0.47 0.94

t statistic 1.47 0.04 0.25 0.86
African American Hazard ratio 1.51 1.39 1.16 1.30

SE 0.29 0.29 0.27 0.39

t statistic 2.18 1.59 0.62 0.86
Mental health status

Symptomatology Hazard ratio 1.01 0.99 1.02 1.05

SE 0.01 0.01 0.01 0.02

t statistic 0.67 –0.68 1.07 2.39
Functioning Hazard ratio 1.00 1.00 1.00 0.99

SE 0.00 0.00 0.01 0.01

t statistic 0.08 0.01 –0.46 –0.90
Family structure

Caregiver married Hazard ratio 0.98 1.00 1.23 1.86
SE 0.18 0.21 0.30 0.69

t statistic –0.11 0.02 0.87 1.68
Parent in household Hazard ratio 1.50 1.49 0.56 0.94

SE 0.46 0.58 0.16 0.51
t statistic 1.32 1.03 –2.02 –0.11

Grandparent in household Hazard ratio 1.07 1.18 0.53 0.78
SE 0.43 0.60 0.25 0.66

t statistic 0.17 0.33 –1.35 –0.29
Caregiver education (dummy coded;

omitted category: care giver
some college)

High school dropout Hazard ratio 0.57 0.63 0.87 1.05
SE 0.11 0.14 0.22 0.30

t statistic –2.82 –2.08 –0.56 0.19

Continued

and ensure between-site comparability.
Stata22 software was used in calculating all
parameter estimates.

RESULTS

Tables 1 through 3 and Figure 1 present
the results of our analyses. Table 1 describes
the sample in terms of demographic and men-
tal health characteristics. On average, the
study children were 11 years of age at base-
line, and the majority were male. Given that
the children were being treated in public sys-
tems, socioeconomic status was low. Family
incomes averaged less than $20 000 at the 2
sites. Roughly half of the caregivers were high
school dropouts (49% and 58% in Mahoning
and Stark counties, respectively); only a mi-
nority were working full time. Most of the
children lived with a single parent. (Roughly
80% of the households in which youths
resided included a parent. In most of these
households [approximately 70%], the care-
giver was not married.)

As one would expect, the youths involved
in the study were struggling. At baseline,
42% reported having repeated a grade
(Table 1); roughly 1 in 3 reported receiving
failing grades. Furthermore, juvenile justice
involvement was common (Table 2): 47%
and 39% of the Mahoning and Stark county
youths, respectively, were involved in the ju-
venile justice system during the course of the
study. The average age at which these youths
first encountered the juvenile justice system
was 13 years. A majority first entered the ju-
venile justice system after study entry: 83%
and 77% in Mahoning and Stark counties, re-
spectively. This difference was not statistically
significant; however, the fact that more
youths had preentry contact with the juvenile
justice system in Stark (23%) than in Mahon-
ing (17%) probably reflected the integration
of the mental health and juvenile justice sys-
tems in the former. Table 2 also provides
basic data on offense severity. At both sites,
50% or more of first offenses were serious.

Figure 1 presents the key findings from
the hazard analyses. (The full results are de-
scribed subsequently and presented in
Table 3.) The first 2 pairs of bars represent
the risk of juvenile justice involvement after
study entry relative to the prestudy period.

May 2004, Vol 94, No. 5 | American Journal of Public Health Foster et al. | Peer Reviewed | Research and Practice | 863

 RESEARCH AND PRACTICE 

TABLE 3—Continued

Completed high school Hazard ratio 0.65 0.64 0.89 0.96

SE 0.17 0.19 0.27 0.41

t statistic –1.68 –1.52 –0.37 –0.09

Caregiver employment (dummy coded;

omitted category: not working)

Caregiver employed part time Hazard ratio 0.99 1.24 1.50 2.14

SE 0.24 0.32 0.44 0.78

t statistic –0.05 0.84 1.36 2.09

Caregiver employed full time Hazard ratio 1.19 1.18 1.30 2.64

SE 0.23 0.27 0.31 0.86

t statistic 0.89 0.72 1.09 2.98

Child educational status

Receiving failing grades Hazard ratio 1.32 1.39 1.82 0.97

SE 0.24 0.28 0.42 0.26

t statistic 1.51 1.62 2.57 –0.10

Repeated a grade Hazard ratio 1.08 0.96 1.12 1.62

SE 0.19 0.20 0.27 0.49

t statistic 0.41 –0.18 0.47 1.58

Not in school Hazard ratio 7.37 3.87 1.70 3.82

SE 3.40 1.65 0.85 2.49

t statistic 4.32 3.18 1.06 2.06

Previous juvenile justice involvement

Age at first offense Hazard ratio . . .a . . .a 1.00 1.00

SE . . .a . . .a 0.00 0.00

t statistic . . .a . . .a 2.17 0.53

Whether first offense was “severe” Hazard ratio . . .a . . .a 0.68 . . .b

SE . . .a . . .a 0.14 . . .b

t statistic . . .a . . .a –1.83 . . .b

No. of observations 420 420 227c 186d

Note. Covariates significant at the .05 level are shown in boldface.
aThese covariates are not included here because the analyses focused on the first offense.
bThis covariate is not included here because the first offense that defined the at-risk period for a subsequent offense was
limited to the severe offense category.
cThese analyses were limited to individuals who committed an initial offense.
dThese analyses were limited to individuals who committed an initial serious offense.

At both sites, the risk of initial juvenile justice
involvement dropped after study entry. This
decrease was greater in Stark County (−54%)
than in Mahoning County (−22%). (We calcu-
lated these figures using the hazard ratios de-
scribed subsequently. For example, the sec-
ond bar, representing the 22% risk reduction
in Mahoning after study entry, pertained to a
time variable hazard ratio of 0.78. The figure
for Stark corresponded to the product of the
hazard ratio for the time variable [0.78] and
the Time × Site interaction [0.58], which was
0.46. This hazard ratio implied a 54% re-
duction in risk. The significance level of the

between-site difference was that associated
with the Time × Site interaction.)

The between-site difference was significant
at a marginal level (P = .09). However, in the
case of serious crimes the between-site differ-
ence was substantially greater and statistically
significant (P = .03). While the likelihood of
youths committing a serious crime after study
entry remained largely unchanged in Mahon-
ing, this likelihood dropped by 57% in Stark.

The second 2 pairs of bars represent recidi-
vism, or the likelihood of the occurrence of a
second offense. These analyses were limited
to youths who had committed a first offense.

A similar pattern emerged for offenses of all
types. Hazard ratios fell after study entry at
both sites, with a greater reduction occurring
in Stark. The between-site difference in regard
to serious crimes was especially large. The risk
of a second, serious offense actually increased
after study entry in Mahoning.

The full set of results is presented in
Table 3, which includes hazard ratios for all of
the covariates assessed. It can be seen in the
first column that the hazard ratio for site was
greater than 1 (1.26), indicating that children
in Stark County were at greater risk of juve-
nile justice involvement before study entry. As
discussed earlier, this difference was expected
given the system of care philosophy; intera-
gency coordination should result in the juve-
nile justice system referring more children into
services. The hazard ratio for time was less
than 1 (0.78), indicating a reduction in risk
after study entry. Finally, the interaction term
was also less than 1 (0.58), indicating a greater
reduction over time in Stark County.

Table 3 also includes hazard ratios for the
child and demographic characteristics de-
scribed earlier. Results showed that female
youths were 45% less likely than male youths
to be involved in the juvenile justice system
(column 1; hazard ratio = 0.55). In addition,
non-White youths were 51% more likely than
White youths to be involved (hazard ratio of
1.51). The effect of the covariates did vary
somewhat across outcomes. For example, re-
ceipt of failing grades at baseline was associ-
ated with higher hazard ratios for all covari-
ates other than recidivism in regard to serious
crimes (the effect was greatest [and statisti-
cally significant] for the risk of recidivism).

DISCUSSION

This study examined the impact of coordi-
nated and integrated mental health services
on juvenile justice involvement among youths
served in the public mental health system.
Using data from a quasi-experiment, we as-
sessed between-site differences using hazard
models. As mentioned, these models were
well suited to addressing the research ques-
tion of interest here because they can accom-
modate key data features, principally, in the
present case, the fact that youths entered the
study (and mental health services) during the

American Journal of Public Health | May 2004, Vol 94, No. 5864 | Research and Practice | Peer Reviewed | Foster et al.

 RESEARCH AND PRACTICE 

Mahoning CountyStark County

–54% –57%
–50%

–55%

–22% –22%

42%

–5%

–80

–60

–40

–20

0

20

40

60

All (P=.09) Serious (P=.03) All (P=.27) Serious (P=.04)

H
az

ar
d

, %

Initial Involvement Subsequent Involvement

FIGURE 1—Risk of juvenile justice involvement: hazard analysis results.

midst of the period in which they were at risk
for involvement in the juvenile justice system.

While previous research has examined the
mental health needs of youths involved in
the juvenile justice system, relatively little at-
tention has been focused on whether system
integration can reduce such involvement.
Our results were derived from only 2 com-
munities and are subject to other limitations,
but they suggest that community-based care
coordinated across child-serving agencies
can reduce or delay entry into the juvenile
justice system as well as recidivism among
those who have been involved in the system.
These relationships were stronger for more
serious offenses.

Our study also links juvenile justice in-
volvement to a range of other youth and fam-
ily characteristics. The relationships we found
were generally consistent with those revealed
in other research. We found, for example,
that juvenile justice involvement is more
likely for boys and for non-White youths.
Also, youths who are struggling in school
tend to have a higher risk of involvement.
However, there were some surprising rela-
tionships as well. For example, youths living
with a grandparent were more likely to be in-
volved in the juvenile justice system. In this
case, causality could have been reversed: the
youth’s behavior may have led to the grand-
parent moving into the household.

Although provocative, our results are sub-
ject to several limitations. Principal among
these limitations are possible between-site dif-
ferences in children and youths receiving
mental health services. Youths in Stark County
may have been less likely to become involved
in the juvenile justice system for reasons not
captured here. This possibility is counterintu-
itive, however: the system of care there at-
tempted to draw youths involved in the juve-
nile justice system into the mental health
system. If anything, one would expect youths
in Stark to have been otherwise more likely to
become involved in the juvenile justice sys-
tem; thus, our results may be conservative.

In any case, we did adjust between-site com-
parisons with a variety of baseline character-
istics, including mental health symptomatology
and functioning. Furthermore, our analyses in-
corporated information on juvenile justice in-
volvement before study entry. Nevertheless,
the results presented here should be inter-
preted as preliminary, and they require replica-
tion in other communities and with other study
designs (perhaps including randomization).

An important question for future research
is whether a public health–oriented strategy
of avoiding juvenile justice placements among
youths with emotional and behavioral prob-
lems is cost-effective. A full economic analysis
would depend on how the costs of identifying
and treating the mental health problems of a

large group of at-risk youths compare with
those related to detaining a subset of such in-
dividuals in the future. The answer to this
question awaits future research.

About the Authors
E. Michael Foster and Amir Qaseem are with the Depart-
ment of Health Policy and Administration, Pennsylvania
State University, University Park. Tim Connor is with
Opinion Research Corporation (ORC), Atlanta, Ga.

Requests for reprints should be sent to E. Michael Fos-
ter, PhD, Department of Health Policy and Administration,
Pennsylvania State University, 114 Henderson Bldg, Uni-
versity Park, PA 16801 (e-mail: [email protected]).

This article was accepted July 17, 2003.

Contributors
E. M. Foster conceived the study and was responsible
for all analyses and for writing the article. A. Qaseem
assisted in the analyses and in preparation of the article.
T. Connor assisted in preparation of the article.

Acknowledgments
Data were collected through the national evaluation of
the Comprehensive Community Mental Health Services
for Children and Their Families Program (Grant
280–94–0012) funded by the Center for Mental
Health Services.

We would like to thank personnel in the participat-
ing Stark County and Mahoning County agencies, as
well as Paula Clarke and the study’s Ohio field staff, for
their work in providing us with the necessary data and
budget information.

Human Participant Protection
This study, which involved analyses of secondary data,
was approved by the Pennsylvania State University of-
fice for research protections. The original study was ap-
proved by the Office of Management and Budget and
the institutional review board of ORC Macro Inc. All
study participants signed informed consent forms.

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WR01J7

Collaboration Between Community Mental Health
and Juvenile Justice Systems: Barriers and Facilitators

Stephen A. Kapp • Christopher G. Petr •

Mary Lee Robbins • Jung Jin Choi

Published online: 2 April 2013

� Springer Science+Business Media New York 2013

Abstract Recent studies have confirmed a high prevalence of youth with diag-
nosable mental health disorders within the juvenile justice system, as well as the

vulnerability of youth in the mental health system who enter the juvenile justice

system. This high prevalence of dual system involvement has spawned challenges of

collaboration between the mental health and juvenile justice systems to provide

needed services to youth and their families. Seventy-two in-depth interviews were

conducted with 18 youth and their parents/guardians, mental health professionals

from five different community mental health centers, and juvenile justice profes-

sionals in urban and rural communities in a Midwest state in the United States.

Professionals, youth and parents identified several important factors that facilitated

collaboration, as well as a myriad of barriers that needed to be overcome. Findings

suggest ways to improve partnerships between the two systems and the development

of supportive policies and procedures.

Keywords High-risk youth � Community mental health � Juvenile justice �
Collaboration � Collaboration barriers

Research has indicated that the majority of the youth in the juvenile justice system

have mental health disorders (Skowyra 2006). Out of the *2.2 million youth
arrested per year, *600,000 are processed through juvenile detention centers and
more than 100,000 are placed in secure juvenile correctional facilities (Shufelt and

S. A. Kapp (&) � C. G. Petr � M. L. Robbins
School of Social Welfare, University of Kansas, Twente Hall, 1545 Lilac Lane,

Lawrence, KS 66044, USA

e-mail: [email protected]

J. J. Choi

Department of Youth Studies, Kyonggi University, Seoul, South Korea

123

Child Adolesc Soc Work J (2013) 30:505–517

DOI 10.1007/s10560-013-0300-x

Cocozza 2006; Sickmund 2004; Snyder 2003; Skowyra and Cocozza 2007). Recent

studies consistently document that from 65 to 70 % of these youth met criteria for a

diagnosable mental health disorder (Skowyra and Cocozza 2007; Teplin et al. 2002;

Wasserman et al. 2004). In addition, many youth in the mental health system

eventually commit offenses that result in adjudication in the juvenile justice system

(Foster et al. 2004), so that the prevalence of youth involved in both systems is

driven from both directions. This situation has engendered a need for collaboration

between the mental health and juvenile justice systems, if youth needs are to be met.

In this study we pose two critical research questions: (1) what are the barriers to

collaboration between the mental health and juvenile justice systems? and (2) what

are ways of facilitating collaboration and overcoming barriers between the two

systems? The data for this study was collected as part of a larger, more

comprehensive qualitative study that sought to better understand the experiences of

youth, their parents, and their providers. We begin with an overview of the

literature, and proceed to describe the research methods and findings from the study.

Finally, we conclude with a discussion on the implications of the study, including its

limitations and suggestions for further research.

Literature Review

The following section focuses on reviewing selected research studies to address

specific issues of:

(1) prevalence of youth requiring services from both mental health and juvenile

justice systems and

(2) collaboration between juvenile justice and mental health.

Youth Requiring Services from Both Mental Health and Juvenile Justice

Systems

Shufelt and Cocozza (2006) conducted the most comprehensive study to date

regarding the prevalence of mental health and substance use disorders among youth

involved with the juvenile justice system. They collected information on 1,400

youth from 29 different programs and facilities in three understudied areas of the

country–Louisiana, Texas, and Washington. The authors collected data from three

different juvenile justice settings: community-based programs, detention centers,

and secure residential facilities. Girls and certain minority youth, e.g., Hispanics and

Native Americans, were oversampled to improve the knowledge base of these

groups. The results of this study indicate that, from 65 to 70 % of youth in the

juvenile justice system meet criteria for at least one diagnosable mental health

disorder. This rate is consistent with other studies by Teplin et al. (2002),

Wasserman et al. (2003, 2004). It is important to note that Teplin et al. (2006)

excluded conduct disorder from those with mental health diagnoses in their study

and determined that 60 % of males and 70 % of female youth still met the

diagnostic criteria for one or more psychiatric disorders. Shufelt and Cocozza

506 S. A. Kapp et al.

123

(2006) further determined that over 60 % of youth met criteria for three or more

diagnoses. Girls are significantly at higher risk (80 %) than boys (67 %) for a

mental health disorder, with girls demonstrating higher rates of internalizing

disorders than boys. Substance abuse problems continued to be high, with 60.8 % of

youth with a mental health diagnosis also meeting criteria for a substance use

disorder. Despite the high prevalence, referrals for mental health services are

infrequent, with one study finding a referral rate of only 6 % (Rogers et al. 2001).

Youth can also begin services as a mental health client, and then commit some

offense which results in adjudication in the juvenile justice system. Evens and

Vander Stoep (1997) examined the factors associated with juvenile justice system

referrals among children in a public mental health system. Of the 645 children who

entered the mental health system in 1992, 118 were involved with the juvenile

justice system at the time of entry, and another 150 became involved with the

juvenile justice system prior to 1995. This study concluded that the primary risk

factors for juvenile justice system involvement among youth already in the mental

health system were ethnicity, history of physical abuse, parental incarceration, and

drug/alcohol involvement.

Collaboration Between Mental Health and Juvenile Justice Systems

The John D. and Catherine T. MacArthur Foundation launched an ongoing,

ambitious multi-state juvenile justice reform initiative, Models for Change, in 2004

with the purpose of advancing replicable models of effective, fair and develop-

mentally sound juvenile justice policies and practices (Models for Change: Systems

reform in juvenile justice 2012). One of the points of emphasis in this initiative was

provision of access to mental health services through successful assessment/

screening efforts and diversion programs. The Pennsylvania state plan specifically

identified that one of the reasons the mental health needs of court-involved youth

were not being met was the decline of the state’s public community-based mental

health system. The plan outlined the five following barriers to collaboration with

mental health, but solutions were not addressed: (1) lack of coordination between

agencies; (2) absence of placement/re-entry services; (3) inadequate identification

and diagnosis of youth; (4) lack of access to services; and (5) problems collecting

and sharing information across systems (Models for Change: Pennsylvania

workplan 2012).

Foster et al. (2004) examined whether a comprehensive, coordinated system of

care could eliminate or delay involvement in juvenile justice among youths

receiving mental health services for their serious emotional and behavioral

problems. The researchers compared one system-of-care community (Stark County)

with one demographically similar community (Mahoning County), Ohio, the United

States. In Stark County, the juvenile justice system was integrated within the broad

system of care at several levels: program administration, financing, service delivery,

and training for juvenile justice personnel. The findings indicated that although the

risk of initial juvenile justice involvement dropped in both counties after study

entry, the decrease was greater in Stark County (-54 %) than in Mahoning County

(-22 %). While the likelihood of youth committing a serious crime after study

Collaboration Between Community Mental Health and Juvenile Justice 507

123

entry remained largely unchanged (-5 %) in Mahoning County, the likelihood

dropped by 57 % in Stark County. While the risk of a second offense decreased by

55 % in Stark County, the risk actually increased in Mahoning County by 42 %.

The researchers concluded that community-based care coordinated across child-

serving agencies can reduce or delay youth’s entry into the juvenile justice system

as well as recidivism among those who have already been involved in the system.

This study confirms the importance of community-based prevention and treatment

services that coordinate the mental health and juvenile justice systems to meet the

needs of youth simultaneously involved in them.

The mental health and juvenile justice fields have initiated some responses to

meet the needs of youth in the dual systems. Strategies being developed include: (1)

strengthening community-based services to facilitate early detection and treatment

to increase the chances of avoiding the juvenile justice system; (2) using screening

and assessment tools by police officers, juvenile courts, and detention facilities to

identify mental health problems; (3) testing programs that would divert children

from detention to community-based programs, and (4) increasing the quality of

mental health care for those whom must be incarcerated (Skowyra and Cocozza

2007). To insure lasting improvements, these efforts require agency collaboration

(Koppelman 2005).

In summary, the high prevalence of youth who need the services of both the

mental health and juvenile justice systems has drawn the attention of researchers

and policymakers. One of the critical recommendations to handle the current crisis

is to enhance the collaboration between the mental health and juvenile justice

systems, and at least one study has demonstrated the positive results of a

comprehensive, collaborative system of care (Foster et al. 2004). Yet, the barriers

and facilitators of collaboration have not been clearly identified, especially in

research that reflects both consumers (i.e., youth and their parents/guardians) and

professionals’ voices regarding their experiences with the partnership between the

two systems. In the following, we describe a qualitative study that examined both

the barriers to collaboration and the factors that facilitate collaboration between the

two service systems.

Method

This article reports on data taken from a larger study that was designed to

investigate the experiences of adjudicated youth with mental health needs, as well as

the perspectives of their parents and their service providers (Kapp et al. 2008). In

this research, which employed a grounded theory, qualitative approach, a total of 72

in-depth semi-structured interviews were conducted with 18 youths and their

parents/guardians, mental health professionals, and juvenile justice professionals

from one Midwestern state in the United States. For this article, only the data that

pertained to collaboration are reported.

Five different Community Mental Health Centers (CMHC) and their respective

judicial districts served as study sites, representing a range of urban to rural

population density. Three sites were urban counties (150? persons per square mile

[ppsm]); one site was semi-urban (40–150 ppsm); and one CMHC site involved a

508 S. A. Kapp et al.

123

four-county catchment area consisting of one densely-settled rural county

(20–40 ppsm), two rural counties (6–20 ppsm), and one frontier county (6 ppsm)
(O’Brien and Holmes 2008).

To ensure the research design provided adequate protections for the participants,

approval was obtained from an academic Institutional Review Board prior to

participant recruitment, as well as from each CMHC and judicial district. Because

youth involved in both the mental health and juvenile justice systems did not appear

in sufficient numbers to utilize traditional random techniques (Berg 2004), the

research team developed a ‘‘convenience’’ sample from the five CMHCs.

Researchers asked each CMHC administrator to identify youth clients who were

receiving intensive community-based services and who were involved with the

juvenile justice system of varying ages, gender and background. The final sample

consisted of 18 youth involved in the dual systems: 14 males and 4 females; 15

Caucasians and 3 African-Americans; 5 ages 11 or 12, 9 ages 14 or 15, 4 ages 16 or

17; 11 were in custody of their parents, 5 were in custody with the state juvenile

justice authority, and 2 were in custody of the state child welfare authority.

For each youth, separate interviews were conducted with the youth, a parent, the

most knowledgeable mental health professional, and the youth’s juvenile justice

professional. Interviewers recorded all interviews with written consent from all

participants. Two interviewers conducted the interviews. Depending on the

circumstances of the participants, interviews were usually conducted either at

youth’s and parent’s home, or the office of the professional being interviewed.

Interviews averaged between 1 and 1� h. A total of 72 interviews from the five
CMHCs were conducted and transcribed. These interviews represented 18 unit, with

each site contributing either 3 or 4 unit, and with each unit comprised of a youth,

their parents, mental health professional and juvenile justice professional.

Data Analysis

All recorded and transcribed interviews were analyzed by using ATLAS.ti version

5.0 2nd edition, a visual qualitative analysis data software program (Muhr 2004).

Researchers used a team approach in facilitating the analysis process, with an

identified lead researcher (Erickson and Stull 1998). Consistent with Miles and

Huberman (1994), qualitative study methods descriptions, data reduction, data

display, and conclusion drawing and verification techniques were used to distill the

prominent thematic patterns from the data. The foundation for this data analysis is

the triangulation method of using multiple sources of data to attempt to delineate

various themes, patterns, dynamics and exceptions across sites and youths’

experiences with both systems. None of the specific data elements are intended to

stand alone. Accordingly, there was no extensive analysis of a specific item, i.e.,

statistical analysis or a content analysis of one type of respondent interviews.

Researchers met on a weekly basis to determine appropriate themes, codes, and

code families that derived from the research questions (MacQueen et al. 1998).

First, all interview transcripts and field notes were organized by case unit, and a

code (name) was assigned to each unit. Second, two researchers established inter-

coder agreement by independently coding five transcripts which they then

Collaboration Between Community Mental Health and Juvenile Justice 509

123

compared. There was substantial agreement between researchers regarding the

coding and Code Book. We discussed each code that differed, established

agreement, and changed code definitions accordingly in the process of developing

the Code Book. After researchers finished the remaining transcripts, the lead

researcher reviewed all of the transcripts and corrected remaining code errors, thus

further increasing consistency. Strategies were also developed for analyzing memos

and open coding to capture those relevant content areas that were not expected nor

anticipated prior to the interview process. Third, after an initial analysis, researchers

began a systematic comparison of codes between and within CMHC sites, and

between and among various perspectives. This approach facilitated identification of

categories, sub-categories, and themes (Muhr 2004). Finally, case unit summaries

were developed from a plot summary method adapted from Kapp (2000). This way

of organizing the data allowed for accurate and in-depth summaries of each youth’s

case from multiple perspectives, as well as ‘‘bundling’’ of cases for each CMHC site

to ascertain potential site-specific elements.

Study Findings

The following two categories of findings describe the nature of the barriers to

collaboration and factors promoting collaboration.

Barriers to Collaboration

Barriers to collaboration were identified by parents, youth and professionals in both

systems. Thirteen of the eighteen case examples, from across all five sites, were

categorized as having little or no collaboration. This finding was expected, as the

perceived lack of collaboration was the impetus for funding and conducting the

study. Major barriers identified were lack of formal service protocols; lack of

informal relationships and structures, different philosophies, high caseloads and

mental health staff turnover; and timeliness of decisions and communications.

Lack of Formal Service Protocols

We found that the lack of formal service protocols leads to misunderstandings,

miscommunications and a general lack of knowledge about the others’ way of

working as reported by participants.

For example, one court services officer shared a major misunderstanding that

resulted in a dearth of referrals for services. This court services officer believed that

intensive mental health services could only be accessed from a CHMC for her client

prior to adjudication and probation. This court services officer said that a mental

health case manager told the court services officer, incorrectly, that an adjudicated

youth cannot receive intensive mental health services from the CMHC, and this

misinformation became the common belief for all court services officers in that

county’s Court Services Department. As a result, untold numbers of youth received

no mental health services from the CMHC.

510 S. A. Kapp et al.

123

Another example of insufficient agency protocols had to do with when and how

releases of information are secured. Obtaining the properly signed releases of

information forms from parents and across agencies at the beginning of probation

and treatment services has been problematic for both sides of the service arena.

Without proper and timely parental consent from both juvenile justice and mental

health, neither side can ethically or legally discuss nor even acknowledge the

youth’s case, making it virtually impossible to collaborate. These releases can be

difficult to obtain at the initial stages since a formal relationship has not been

established and may not be a priority at juvenile intake, court proceedings, or mental

health intake prior to case manager assignment to a case.

Lack of Informal Relationships and Structures

Higher population density presented a barrier to forming informal working

relationships with cross-systems staff. One juvenile justice worker stated:

The [CMHC] are such a big county, they got so much going on…[and they do
hospital] screenings without talking to me and I just find that not right…I
don’t experience that with too many counties and that really irritates me.

In contrast, in smaller communities where workers know each other on a more

personal level, mutual cooperation is prevalent. One juvenile justice worker from a

rural site said:

If I have a barrier, I’d go and find that person and talk to ‘em. And I know that

person because it’s such a small community, they are either my neighbor or

some other way that I know them anyway, so I’m able to break through that

barrier with a personal contact…if there’s a barrier with the Mental Health
Center, you just go talk to them.

Both juvenile justice and mental health professionals made numerous comments

about their degree of contact with each other being dependent on the personalities of

the individual staff members. Workers described some staff as being more receptive

and reciprocal than others which formed the basis for whether much partnering took

place between the two systems. This idiosyncratic way of interrelating to the other

system also indicates a lack of structured formal ways of facilitating partnering,

such as interagency agreements and cross training of staff, in which each system

would learn about the other’s procedures, policies, routines and culture.

Different Philosophies

Another barrier to collaboration is the different philosophies about how youth and

their problems should be addressed. From the mental health perspective, the

juvenile justice system is often viewed as inflexible and unrealistic in its

expectations for youth with serious mental disorders and their parents. The juvenile

justice system was viewed as treating all youth alike, with little focus on the

individual needs of youth and families. From the juvenile justice perspective, mental

health workers are perceived as being too focused on treatment, and not focused

Collaboration Between Community Mental Health and Juvenile Justice 511

123

enough on setting limits and ensuring safety for the community. Quotes from

juvenile justice workers echoed this perception:

I understand [youth] has mental health issues, but it’s still a legal issue—

whether you have these issues or not, society as a whole is not going to

tolerate it. Mental health sometimes addresses that, but never as much as they

should.

Juvenile justice is more to keep the community safe and get services for the

juvenile, while mental health is to provide mental health services and help the

child work on those issues.

Case managers and juvenile justice workers noted their experiences with ‘‘turf

issues’’ between the two systems, involving who is responsible for various functions

and decisions. For example, one probation officer described a disagreement over

which one of them should be called when youth needs an intervention at the school,

with the probation officer thinking the school should call her, but instead they called

the case manager, who then did not inform the probation officer. Other mental

health professionals reported several instances of juvenile justice’s perceived lack of

respect for their expertise and input regarding the legal decisions made that affect

their mutual clients.

High Case Loads and Mental Health Staff Turnover

The most frequently discussed barrier pertained to high case loads and staff turnover

in both systems. A mental health worker said high caseloads for mental health and

juvenile justice make them ‘‘really busy’’ so ‘‘communication and tracking each

other down on cases can be challenging at times.’’

A juvenile justice worker identified a barrier as the

communication level…perhaps that is due to a high case load, having so many
kids they’re working with and case managers just running around all over,

active all over the whole county or their large district.

One outpatient mental health therapist explained,

I don’t have the time to pick up the phone and let the juvenile justice worker

know her client didn’t show up for an appointment or other scheduled

services.

Closely related to high case loads are high staff turnover. Several professionals

and parents discussed the serious effects of high mental health staff turnover on

workers and clients. One parent articulated this point well when she said turnover

with her child’s staff made ‘‘consistency and stability difficult.’’ For these reasons,

she no longer used some CMHC services, instead taking her child to a private

practitioner and had someone else coming to their home for the youth’s medication

management.

512 S. A. Kapp et al.

123

Timeliness of Decisions and Communications

Professionals from both systems complained about the lack of timeliness from their

cross-system counterpart. Mental health workers discussed the lengthy period of

time between youth’s offense and adjudication/sentencing court dates. One case

manager said, ‘‘It can be too long, stretching to 6–8 months… [and youth] don’t
have the attention span to link the behavior with the punishment.’’ So this mental

health professional pointed out that youths’ developmental stage requires a faster

consequence from the court system.

Many juvenile justice workers complained about not receiving youth update

reports in a timely manner, so they had to file court reports without mental health

input. These mental health services are included in their conditions of probation so

the youth could be in violation of their probation when they are not getting services.

One probation officer put it this way: ‘‘…it is difficult to get reports by email or
paper and [we] need to know if the youth is participating in services.’’

Another barrier to collaboration identified by juvenile justice workers was the

lack of timely mental health services within the probation time period. It could

sometimes take weeks and months to begin mental health services, long after the

youth’s crisis is over. Such a delay is not quick enough to allow for treatment to

work for the youth within the usual probation time period.

Factors Promoting Collaboration

Although collaboration was found in only five of the eighteen case units, those

participants reported specific factors which facilitated collaboration: common

clients and goals; formal policies, procedures, and structural mechanisms; informal

relationships; and staff’s personal characteristics.

Common Clients and Goals

Participants reported that collaboration is facilitated by a sense of shared

responsibility for clients. This attitude supports the belief that a client does not

‘‘belong’’ to one system or the other, but to both, and that both share responsibility.

Collaboration also occurred because both systems have similar goals for the client.

One juvenile justice worker summed it up this way,

We have in common to get the kids their services and what they need…the
more information we can get to help each other with that is better for the

clients.

Formal Policies, Procedures, and Structural Mechanism

Participants pointed out that often formal policies and procedures prompted

collaboration between the two systems. Examples of these are categorized as

Collaboration Between Community Mental Health and Juvenile Justice 513

123

follows: (1) agency-level representatives and teams meet together on a regular basis;

(2) written interagency agreements are in place; (3) mental health staff send

progress reports to juvenile justice professionals on a quarterly basis; (4) release of

information forms are filled out immediately by both systems, to allow information

flow between systems while protecting confidentiality; (5) liaisons and specialist

professionals are assigned to mental health/juvenile justice clients; and (6) regular

cross-training of professionals occurs.

Informal Relationships

The hallmark of informal relationships is mutual respect, built over time and

through regular contacts, resulting in interpersonal interactions marked by a level of

trust and consistency, which allows information sharing and relationships to be

sustained. The importance of trust and consistency was stated well by another

juvenile justice worker who shared that juvenile justice staff trusts that the CMHC

staff is providing youth with what’s needed because they are ‘‘professionals.’’

In addition, trust is built and sustained when mental health and juvenile justice

staff call each other about once a week to talk informally about strategies or their

problems with youth. A juvenile justice worker said:

‘‘The therapist sends me a quarterly report stating how [youth] are doing, a

checklist of a variety of things with a few sentences at the end. They always call me

if he’s having a problem.’’ So the written quarterly reports are formal, but the follow

up with informal discussions seemed critical to these professionals.

In some instances, a productive informal relationship was possible from years of

living and working in the same geographic area and knowing each other personally.

One juvenile justice case manager put it this way:

I’ve been involved with Youth Services a long time so I have a good rapport

with CMHC staff.

Although informal, CMHC and juvenile justice systems have learned what works

best for them over time in terms of effective collaboration with each other. These

practices are not haphazard or random, but may not be written down or formally

taught. Instead these are routines and ways that work for their particular culture and

history and more than likely developed through a trial-and-error process. One

juvenile justice worker said he collaborated well with mental health because of

‘‘those little things’’ such as having the therapist’s direct phone number, knowing

the office hours, and nurturing the relationships as they waxed and waned.

Staff’s Personal Characteristics

Mental health professionals were appreciated for initiating contact, accompanying

clients to juvenile justice meetings, keeping juvenile justice updated on client

progress, and providing training to juvenile justice staff. Participants identified

specific characteristics of juvenile justice professionals who collaborate well.

First, they are responsive to requests.

514 S. A. Kapp et al.

123

Probation officers will come here to give services. When we call, they are right

there, you can get through to the person immediately. When you give your

name they know who you are.

Second, they follow through with youth consequences, yet remain connected and

involved:

I’ve seen probation officers who follow through with consequences and who

are still kind and are interested in having us at appointments and open to

calling us to give feedback…

This probation officer started off ready, really good with the child. He came at

her from a point of view, yet he had enough firmness with her that she

understood there are some limits and expectations. He was very gentle with

her and she responds to that.

Third, probation officers are open to suggestion, friendly, interested, and

attentive:

Probation officers are open to coordinating suggestions and they would contact

us, a friendly attitude and demeanor, as opposed to being flat, inattentive, and

uninterested.

Conclusions and Recommendations

Some of the findings here regarding barriers to collaboration resonate strongly with

those recently identified by the Technical Assistance Partnership for Child and

Family Mental Health, which identified the most challenging barriers as

philosophical, structural, language and communication, and staff resistance (Shufelt

et al. 2010). Our study provided specific details of these broad categories, including

informed consent issues, different views of how to address the youth’s problems,

and turf issues regarding disagreements about who makes which decisions. In

addition, our study identified the lack of informal relationships as an important

barrier, one which could be addressed by agencies in a variety of ways, including

sponsoring joint social events in which staff and their families could get to know

each other on a more informal basis.

The above mentioned Technical Assistance Partnership also suggested solutions to

overcoming barriers that included the use of ‘‘boundary spanners,’’ such as hiring

liaisons or coordinators, to facilitate system linkages; ensuring that the juvenile

justice system is involved early in the treatment planning process; facilitating sharing

of information, such as co-locating staff, while ensuring that youths’ self-incrimi-

nation rights are protected; developing shared program manuals; and providing

adequate staff training. In addition to these recommendations, our study supports the

development of formal written interagency agreements and service protocols. Formal

service protocols across systems can reduce the miscommunications and mispercep-

tions that can readily occur when the involved professionals and families must rely on

their own subjective and politically influenced interpretations.

Collaboration Between Community Mental Health and Juvenile Justice 515

123

To be most effective, these agreements should include content on particular

issues. First, they should acknowledge that successful interagency collaboration

includes all levels of the organizations (Bolland and Wilson 1994), and thus should

include agreements about expectations for both administrators and front line staff.

Second, they should clearly identify the shared vision and goals to which the

agencies aspire. Third, in line with resource dependence theory (Rivard and

Morrissey 2003), interagency agreements should acknowledge the interdependence

of the agencies, recognizing that for organizations to meet their goals, they must

rely on other organizations for such resources as referrals and expertise.

In addition, study findings also suggest a need to incorporate evidence based and

best practices mental health treatment models since treatment modalities varied

across and within CMHC sites. The Models for Change initiative research stressed

the need to integrate collaborative efforts with mental health by using Multisystemic

Therapy, Functional Family Therapy and Multidimensional Family Therapy

(Models for Change: Evidence based practices 2012). In addition, the wraparound

philosophy and process is perhaps the most commonly known way to promote

collateral participation and collaboration through the treatment planning and

implementation process. Pullmann et al. (2006) focused on recidivism reduction and

used Cox regression survival analyses to determine the effectiveness of wraparound

in a targeted program. The authors found that wraparound program youth were

significantly less likely to recidivate at all, less likely to recidivate with a felony

offense, and served less detention time.

Given the limits of this study (i.e., the exploratory nature and the lack of

generalizability), additional research is needed to continue to expand the validity of this

line of research and to further explicate the crucial features of collaboration as well as its

relative role in effective service provision. A critical area of research is to examine the

relationship between collaboration and outcome in a systematic way. Therefore, the

findings related to collaboration in this study are best described as tentative and require

additional exploration with a greater number of cases in additional settings.

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August 2004J. Robert Flores, Administrator

U.S. Department of Justice

Office of Justice Programs

Office of Juvenile Justice and Delinquency Prevention

Access OJJDP publications online at www.ojp.usdoj.gov/ojjdp

with inadequate psychometrics, the failure
to consider comorbidity (i.e., co-occurring
conditions), problems with identifying
sample characteristics, and a lack of infor-
mation regarding when the assessments
were conducted. They note that previous
studies often did not define the timeframe
for symptoms. However, distinguishing
between lifetime and current symptoms
is important not only for determining the
prevalence of disorders but also in plan-
ning for immediate service needs.

Although great advances have been made
in reliable mental health assessment of
children and adolescents (Jensen et al.,
1995; Shaffer et al., 1996), assessment prac-
tices in juvenile justice settings remain
highly variable and generally have not
used evidence-based, scientifically sound
instruments (Cocozza and Skowyra, 2000;
LeBlanc, 1998; Nicol et al., 2000; Towber-
man, 1992; Wiebush et al., 1995). A com-
mon practice has been to rely on a youth’s
history of using mental health services as
an indicator of whether the youth current-
ly needs services. However, research
suggests that the juvenile justice system
cannot rely on other systems to provide
information on the previous use of mental
health services for all youth at entry. For
example, Novins and colleagues (1999)

Assessing the Mental Health
Status of Youth in Juvenile
Justice Settings

Gail A. Wasserman, Susan J. Ko, and Larkin S. McReynolds

Youth in the juvenile justice system are at
high risk for mental health problems that
may have contributed to their criminal
behavior and that are likely to interfere
with rehabilitation (Loeber et al., 1998;
Lynam, 1996). Emotional impairment due
to an untreated mental disorder may con-
tribute to an adverse reaction to confine-
ment, which in turn may result in a poor
adjustment during incarceration. Poor
adjustment can have a negative impact
on behavior, discipline, and on a youth’s
ability to participate in available program
components designed to address mental
health, emotional, physical, and academic
needs. Together, all of these factors may
increase the risk for recidivism.

In a review of 34 studies on mental health
needs and services in the juvenile justice
system, Otto and colleagues (1992) found
that rates of mental disorders were sub-
stantially higher among youth involved in
the justice system than among youth in
the general population. They also found
that rates of disorder were higher in stud-
ies that assessed youth in person than in
those that assessed youth by chart review.
These authors suggested that existing stud-
ies of the prevalence of mental disorders
among youth in the juvenile justice system
were limited by the use of instruments

A Message From OJJDP
Serious mental health and substance
use disorders can interfere with the
rehabilitation of youth who come into
contact with the juvenile justice sys-
tem and increase their risk for recidi-
vism. Too often, the needs of these
youth have gone unrecognized and
untreated because of inadequate
screening and assessment.

One obstacle to assessing the mental
health needs of youth in the juvenile
justice system has been the dearth
of reliable, easy-to-use assessment
instruments. This Bulletin reports the
results of a study of the Voice
DISC–IV, a version of the Diagnostic
Interview Schedule for Children
(DISC) that is self-administered using
a computer and headphones. The
DISC is an extensively tested child
and adolescent diagnostic interview
that has been evaluated in clinical
and community settings. The self-
administered Voice DISC offers sev-
eral advantages for use within the
juvenile justice system—notably,
minimal staff support requirements,
immediate scoring that generates
provisional DSM–IV diagnoses, and
the assurance of privacy that can en-
hance the willingness of youth to dis-
close sensitive personal information.

Based on their findings and those of
other researchers, the authors recom-
mend best practices in assessing the
mental health of juvenile offenders.
This Bulletin provides guidance to
juvenile justice professionals seeking
to establish guidelines for mental
health assessment in juvenile justice
facilities.

O f f i c e o f J u s t i c e P r o g r a m s • P a r t n e r s h i p s f o r S a f e r C o m m u n i t i e s • w w w. o j p . u s d o j . g o v

2

third edition revised (DSM–III–R), and of
the World Health Organization’s Interna-
tional Statistical Classification of Diseases
and Related Health Problems, 10th revision
(ICD–10). The DISC–IV provides a detailed
assessment of impairment based on re-
sponses to six sets of questions about
the effect of symptoms on the youth’s
relationships with his or her caretakers,
family, or peers and at school.3

The psychometrics of the DISC have been
evaluated extensively in a variety of set-
tings. Five studies of psychiatric disor-
ders in youth in various juvenile justice
settings have reported rates based on
systematic assessment using the DISC
(Atkins, Pumariega, and Rogers, 1999;
Duclos et al., 1998; Garland et al., 2001;
Randall et al., 1999; and Teplin et al.,
2002). Except for the study by Garland
and colleagues, all of these investigations
were based on earlier, now superseded,
versions of the DISC, and none used the
recently developed Voice DISC, which is
self-administered using a computer and
headphones. Several aspects of the Voice
DISC make it well suited for use within
the juvenile justice system:

◆ Minimal staff support requirements.

◆ Immediate scoring, with a printout
of provisional DSM–IV diagnoses and
symptom counts available for followup
by a clinician.

◆ Increased likelihood of disclosure,
especially for suicidality and substance
use. (The enhanced privacy of the
self-administered format contributes
to the willingness of youth to disclose
sensitive personal information.)

Preliminary data show that the reliability
of the Voice DISC is comparable to that of
other versions of the DISC (Lucas, 2003).

In contrast to many other assessment
instruments, the Voice DISC provides pro-
visional diagnoses for the youth assessed.
Because diagnosis drives mental health
treatment, having information about a
youth’s diagnosis is critical. Most evidence-
based treatment services have been de-
signed for specific disorders and have
been shown to be effective only when
they are provided to youth who have
those disorders. The Voice DISC generates
provisional diagnoses of disorders present
in the past month, which makes it espe-
cially useful within juvenile justice settings,
where prompt identification of youth who
need immediate treatment is important.

found that only 34 percent of a sample
of juvenile detainees with a documented
anxiety, affective (mood), or disruptive
behavior disorder had previously received
services for those disorders. Similarly,
the Policy Design Team (1994) found that
approximately 50 percent of the juvenile
detainees in Virginia showed mental
health problems of moderate severity
or higher and that 8.5 percent showed
“severe” problems, but that only 15 per-
cent of the detainees who exhibited men-
tal health problems were receiving mental
health services while in custody. A study
of youth in South Carolina found that
despite higher rates of disorder, incarcer-
ated youth were significantly less likely
to have received outpatient mental health
services previously than were youth
enrolled in a community mental health
service (Pumariega et al., 1999). Other
research suggests that minority youth
and youth of low socioeconomic status
are less likely to have a history of using
mental health services (Pumariega et al.,
1998).1

This Bulletin reports the results of a
study that used a computerized, self-
administered version of the Diagnostic
Interview Schedule for Children (DISC) to
screen for psychiatric disorders in youth
newly admitted to juvenile assessment
centers in Illinois and New Jersey. The
study assessed rates of psychiatric disor-
ders and tested the feasibility of using this
assessment instrument among youth in
the juvenile justice system.2 Recommenda-
tions are also offered for “best practices”
for mental health assessment in juvenile
justice settings based on a comparison of
the rates of psychiatric disorder identified
in this study with those found in other
studies in which earlier versions of the
DISC were used in juvenile justice settings.

Diagnostic Interview
Schedule for Children
The Diagnostic Interview Schedule for
Children (DISC) is an extensively tested
child and adolescent diagnostic interview
that has been evaluated in both clinical
and community samples (Shaffer et al.,
1996). A family of highly structured psy-
chiatric interviews designed to assess
more than 25 different mental disorders
in children and adolescents, the DISC
incorporates the diagnostic criteria of
the American Psychiatric Association’s
Diagnostic and Statistical Manual of Mental
Disorders, fourth edition (DSM–IV) and

Study Method
The executive director of the Council
of Juvenile Correctional Administrators
(CJCA) helped to solicit collaboration
from juvenile facilities by announcing the
study at the Council’s 1998 annual confer-
ence. The directors of the Illinois Depart-
ment of Corrections, Juvenile Division,
and the New Jersey Juvenile Justice Com-
mission provided access to the St. Charles
Reception Center in Illinois and the New
Jersey Training School for Boys. The study
provided training, technical assistance,
assessment materials, and funding for reim-
bursement of staff time. Local staff agreed
to collect assessments for 100 randomly
selected male youth in Illinois and 200 in
New Jersey.

Altogether, 320 youth were asked to par-
ticipate; of these, all but 5 agreed. Twelve
assessments were not included for techni-
cal and logistical reasons. Seven parents
withdrew their child’s data. Data were
available, then, for 296 youth (94 in Illinois
and 202 in New Jersey), reflecting a re-
sponse rate of more than 92 percent for
youth approached in both sites.4

For all youth who agreed to participate,
the data collector briefly demonstrated
the operation of the computer program
and made sure the youth was comfortable
proceeding independently after the first
module, which gathers demographic data.
The data collectors remained available at
a distance (to ensure privacy) throughout
the assessment.

Background information (age, race/
ethnicity, school grade, admission date,
number of prior offenses, and current
offense) was abstracted from reception
center files in each location. Because a
youth could have more than one current
offense, up to four current offenses were
provided from justice records for each
youth.

Results
The average participant in the study was
17 years old and in the 9th grade (i.e., 2
years behind the expected grade), and
more than half (53.7 percent) of the youth
were African American (tables 1 and 2).
Eighty-eight percent of the youth were
assessed within 4 weeks of their admis-
sion to the facility, with 40 percent being
assessed within 2 weeks of admission.
Most of the youth had previous contact
with the juvenile justice system; 28 percent
had committed one or more substance-
related offenses.

3

the sample were examined: youth who
met criteria for a substance use disorder
only (n = 68), those who met criteria for a
disorder other than substance use (n = 53),
and those with no evidence of a disorder
(n = 97).5 Sixty-five of these 218 youth were
incarcerated for a substance use offense:
28 who had only a substance use disorder,
10 who had a disorder other than sub-
stance use, and 27 who had no diagnosed
disorder. Of these 65 youth, those with a
substance use disorder were significantly
more likely to have been incarcerated for
a substance-related offense than the youth
in either of the other two groups (see the
figure on page 4).

Discussion

Prevalence of Psychiatric
Disorder in Justice System
Youth
Arriving at a DSM diagnosis requires
consideration of the extent of a youth’s
impairment (i.e., deficits in functioning)
across a number of different domains.
Because the DISC uses the logic of the
DSM–IV, it also provides an impairment
score. For several reasons, the findings
presented in this Bulletin are based on
diagnostic criteria only and do not con-
sider the level of impairment.6

The assessment inquired about 20 psychi-
atric disorders and took an average of 60
minutes to complete. As would be expect-
ed, the youth in whom more disorders
were diagnosed needed more time to com-
plete the assessment. Unsolicited, five
youth commented that they felt safer dis-
closing information to the computer than
to a person.

Table 3 presents the number of youth who
met the criteria for each disorder in the
preceding month. Because suicidality is
of great concern for management in resi-
dential programs, information on reported
suicidal ideation and attempts is presented
in table 4.

Table 3 shows high current rates for many
disorders in the sample as a whole. Beyond
the expectably high numbers of youth
meeting criteria for substance use or con-
duct disorders, the rates of current mood
and anxiety disorders were also high (9.1
percent and 18.9 percent, respectively). In
addition, 9.1 percent of the youth report-
ed suicidal ideation in the past month and
2.7 percent reported having attempted to
commit suicide during the past month.

To examine the degree to which a Voice
DISC–IV diagnosis of a substance use dis-
order corresponded to a record of sub-
stance use offenses, three groups within

Table 1: Demographic and Offense
Characteristics of the
Study Sample

Characteristic Mean SD

Age (years) 17.04 1.39
Current school

grade 9.63 1.39
Number of prior

convictions 4.7 4.4
Number of days

since admission 18.7 12.6

Table 2: Race/Ethnicity of the Study
Sample

Race/Ethnicity Number Percent

African American 159 53.7
White 81 27.4
Hispanic 49 16.6
Other 7 2.4

Note: Percents do not sum to 100 because of
rounding.

Table 3: Prevalence of Psychiatric Disorders Within the Past Month

Number of Youth
Disorder (N = 296) Percent*

None 97 32.8

Any anxiety disorder† 56 18.9
Anxiety disorder only 17 5.7
Agoraphobia 13 4.4
Generalized anxiety 6 2.0
Obsessive-compulsive 13 4.5
Panic 13 4.5
Posttraumatic stress 13 4.5
Social phobia 7 2.4
Specific phobia 25 8.5

Any mood disorder 27 9.1
Mood disorder only 1 0.3
Manic episode 6 2.1
Hypomanic episode 2 0.7
Major depressive 21 7.2
Dysthymic‡ 2 0.7

Any disruptive disorder 94 31.8
Disruptive disorder only 21 7.1
ADHD 6 2.3
Conduct§ 89 31.7
Oppositional defiant 8 2.8

Any substance use disorder 146 49.3
Substance use disorder only 68 23.0
Alcohol dependence 38 12.9
Alcohol abuse 47 17.0
Marijuana dependence 72 25.7
Marijuana abuse 42 15.0
Other substance dependence 36 12.8
Other substance abuse 11 3.9

Note: Diagnoses are based on DSM–IV criteria only.

* The prevalence for some diagnoses is based on a slightly reduced number because some youth
did not complete the entire DISC interview (e.g., because they were transferred).

† Separation anxiety disorder either not assessed or not included.
‡ Current DISC and DSM–IV criteria necessitate that youth with major depressive disorder do not
also receive a diagnosis of dysthymia.

§ Past 6 months.

4

Although its assessment of disorder
criteria is straightforward, the self-
administered nature of the Voice DISC
relies on a youth’s awareness of the social
and personal consequences of his or her
disorder to determine impairment.
Because the social judgment of youth
found guilty of delinquent or criminal be-
havior may be particularly poor, the Voice
DISC may substantially underreport the
level of impairment in these youth. A cli-
nician considering impairment for the
purpose of making a diagnosis should rely
on multiple informants and various pieces
of information to determine the level of
impairment.

Comparison With Other
Studies
As shown in table 5, the rates of disorder
found in the present study are somewhat

lower than those reported by previous
studies that used the DISC in juvenile
justice populations. However, the earlier
studies used earlier versions of the DISC.
Consideration of four basic differences in
instrumentation and sample characteris-
tics between the present study and the
previous investigations puts the differ-
ences in the results into context:

◆ Participants in the present study re-
sponded to questions about the month
preceding the interview, a period con-
siderably shorter than the 6-month
reporting timeframe of most of the
earlier studies. In some cases, the rates
of disorder found in the present study
were correspondingly somewhat lower
than those found in the studies that
used a longer timeframe (Atkins,
Pumariega, and Rogers, 1999; Duclos
et al., 1998; Randall et al., 1999; Garland
et al., 2001; Teplin et al., 2002).

◆ The present study evaluated youth
who recently had been sent to secure
placement (likely after they had spent
weeks in juvenile detention). The youth
assessed by Teplin and colleagues
(2002) were being held in detention—
that is, they recently had been in the
community, where they had the oppor-
tunity to offend. Garland and col-
leagues (2001) assessed “wards of the
court” without regard to whether they
were in the community or in custody.
By intent, secure placement limits mis-
behavior. The more structured and
controlled the setting, the less opportu-
nity youth have to engage in the behav-
iors characteristic of conduct and sub-
stance use disorders. Therefore, rates
for those disorders might be expected
to be lower for the youth in the present
study than for the youth evaluated in
the earlier studies.

◆ The present study relied exclusively on
self-report, whereas Garland and col-
leagues (2001) pooled diagnostic infor-
mation received from parents as well as
youth, a procedure that results in in-
creased prevalence rates (Bird, Gould,
and Staghezza-Jaramillo, 1992). Pa-
rental informants are more likely than
youth to report symptoms of disrup-
tive behavior disorders such as atten-
tion deficit/hyperactivity disorder
(ADHD) and conduct disorder (Jensen
et al., 1999), and this may account for
the variability in the reported rates of
disorder across the studies.

◆ Because many youth entering secure
care will recently have been removed
from their homes, their endorsement of
separation anxiety symptoms may not
reflect enduring disorder. Therefore, in
contrast to the earlier studies, the pres-
ent investigation did not inquire about
separation anxiety disorder. This deci-
sion may have caused the rates for
overall anxiety disorders observed in
the present study to be somewhat
lower than those in the earlier studies.

The rate of suicide attempts in the past
month (2.7 percent) reported by youth in
the present study is comparable to the
rate of suicide attempts by youth in the
past month that was reported by facilities
in the Conditions of Confinement study
(2.5 percent) (Parent et al., 1994), lending
further support to the validity of the Voice
DISC assessment.

Although the prevalence of conduct disor-
der in the study sample was high (31.7
percent), the prevalence rates for other

Note: SUD, substance use disorder.

P
e
rc

e
n
t

Diagnostic Grouping

No disorder SUD only No SUD
0

10

20

30

40

50

41.2

27.8

18.9

Percent of Youth Incarcerated for a Substance Use Offense Relative to
Disorder Status as Diagnosed by the Voice DISC–IV

Table 4: Prevalence of Suicide Ideation or Attempt

Suicide Ideation Number of Youth
or Attempt (N=296) Percent*

Ideation (past month) 27 9.1
Attempt

Past month 8 2.7
Lifetime 35 11.8

Note: Diagnoses are based on DSM–IV criteria only.

* The prevalence for some diagnoses is based on a slightly reduced number because some youth did
not complete the entire DISC interview (e.g., because they were transferred).

5

disruptive behavior disorders—ADHD
(2.3 percent) and oppositional defiant
disorder (2.8 percent)—were lower than
might be anticipated. In clinical samples,
as many as 75–90 percent of children with
conduct disorder have also been found to
have ADHD (Abikoff and Klein, 1992). Other
studies have reported a link between the
impulsivity of ADHD and delinquency
(Mannuzza et al., 1993; Masse and Trem-
blay, 1997; McGee, Williams, and Feehan,
1992; Tremblay et al., 1994).

The rates of self-reported ADHD in other
studies of juvenile justice populations that
used the DISC are similarly low—between
1 and 7 percent (Atkins, Pumariega, and
Rogers, 1999; Randall et al., 1999; Teplin
et al., 2002). In the study done by Garland
and colleagues (2001), who combined
information from parental and youth
reports, almost 13 percent of the youth
received a diagnosis of ADHD, but this
rate is still lower than expected. However,
the rates of mood and anxiety disorders
are high in the present study (9.1 percent
and 18.9 percent, respectively) and across
all five of the other DISC studies in juve-
nile justice populations (10–35 percent).
Zoccolillo (1992) noted a high rate of
comorbidity between mood and anxiety
disorders and conduct problems in com-
munity samples of youth. Further, studies
that used the DISC–2.3 to assess clinic-
referred children found associations be-
tween anxiety symptoms (“trait anxiety”)
and both conduct problems and aggression

(Frick et al., 1999) and between mania and
conduct disorder (Biederman et al., 1999).

Although a determination of juvenile delin-
quency is not synonymous with a diagno-
sis of a disruptive disorder, the results of
the present study and the existing research
indicate systematic underreporting of
ADHD symptoms by youth in the justice
system. This suggests that self-reported
information should be supplemented by
reports from another informant (e.g., a
parent or teacher), especially as parents’
reports are more consistent with other
indicators of conduct disorder, such as
school suspension and police contacts,
than youth’s reports (Loeber et al., 1991).7

Recommendations for
Juvenile Justice Mental
Health Assessment
The findings of the present study shed
light on the prevalence of mental health
disorders among youth in the juvenile jus-
tice system. Consideration of the ways in
which case identification is affected by
the assessment method used suggests the
following best practices for clinical assess-
ment in different justice settings:8

◆ Mental health assessments should be
based on multiple methods of evalua-
tion and on the input of multiple in-
formants. A structured interview is
one important component of a mental
health assessment. Other important

components include direct observa-
tion, a mental status examination, chart
review, an interview with parent(s) or
caregiver(s), and obtaining a family psy-
chiatric and psychosocial history.

◆ Assessments should be based on
reliable and valid instruments. Use
of a common assessment “language”
eliminates uncertainty about the crite-
ria used to determine diagnoses and
enables comparison across studies
and facilities.

◆ Assessments should include parental
input. Parental input is valuable in
diagnosing certain disorders, particu-
larly ADHD. Incorporating parental
reports into mental health assessments
of youth in the justice system is com-
plicated by several factors, including
parents’ unavailability or reluctance to
incriminate their children. The accu-
racy of parental reports may also be
limited due to parent-child separation.
However, when parental and youth
reports of ADHD symptoms are com-
bined, increased rates of this disorder
are detected (Garland et al., 2001).

◆ Assessments should focus on recent
symptoms in order to determine cur-
rent treatment needs. Depending on
the purpose of the assessment and the
setting in which it takes place, the time-
frame for diagnostic status might vary
from the past year to the past month.
Assessments should be driven by

Table 5: Comparison of Rates of Mental Health Disorders Found in the Present Study With Those Found in Earlier
Studies Using the DISC

Number
Rate of Disorder (percent)

Question of Youth
DISC Format and Study Timeframe Evaluated Disruptive Substance Mood Anxiety

Administered by interviewer
Duclos et al. (1998)* Past 6 months 150 21 38† 10 7
Atkins, Pumariega,

and Rogers (1999) Past 6 months 75 43 20 24 33
Randall et al. (1999)‡ Past 6 months 118 45 NA 14 36
Garland et al. (2001)* Past 6 months 478 48§ NA 7 9
Teplin et al. (2002) Past 6 months 1,826 42 50 19 22

Self-report (Voice DISC)
Present study Past month 296 32 49 9 19

Note: NA, not assessed.

* Study used impairment criteria in the determination of diagnostic status. That is, in addition to meeting diagnostic criteria, youth had to endorse
a response to one of three impairment questions at the end of individual disorder modules to receive a diagnosis.

† Assessed on the Composite International Diagnostic Interview (Robins et al., 1988).
‡ Aggregate data provided by the authors.
§ Includes responses of both youth and parental informants.

6

practical decisions that take into
consideration needs at various stages
of justice system processing. For exam-
ple, assessments might aim to accu-
rately identify at least two groups of
youth: (1) those whose mental health
needs should be met quickly, such as
youth who recently have attempted
suicide or who currently suffer from a
panic disorder or substance depend-
ence, and (2) those who need close
supervision and regular reassessment,
such as youth with less severe disor-
ders (e.g., depression or posttraumatic
stress disorder) that may worsen under
the stress of confinement.

◆ Some youth should be reassessed peri-
odically. Youth should be reassessed
regularly when they are held in custody
over an extended period of time, as
symptom profiles may shift. Mood dis-
orders and anxiety disorders, in partic-
ular, may wax and wane over time.

Conclusions
The study reported in this Bulletin repre-
sents the first investigation of the Voice
DISC–IV in juvenile justice settings. The
results demonstrate that use of a system-
atic instrument for assessing psychiatric
disorders is feasible in juvenile justice set-
tings. The assessment was well tolerated
by youth and their parents and by the
agency/institution staff who were involved
in administration procedures. Two find-
ings provide initial support for the validity
of the Voice DISC–IV assessment:

◆ Youth who met the Voice DISC–IV
criteria for substance use diagnoses
had been incarcerated for substance
offenses.

◆ The rate of suicide attempts in the past
month reported by youth in this study
is comparable to the rate of suicide
attempts by youth in the past month
reported by facilities in the Conditions
of Confinement study.

Thus, this initial feasibility study demon-
strates that a comprehensive, scientifical-
ly sound diagnostic instrument can be a
valuable part of mental health assessment
for youth in the juvenile justice system.

For Further Information
More information on the authors’ research
using the Voice DISC–IV and on other
assessment-related research is available
online at www.promotementalhealth.org,

the Web site of the Center for the Promo-
tion of Mental Health in Juvenile Justice.

Endnotes
1. The rate of mental health services
received by youth in the juvenile justice
system prior to detention has not been
compared with the rate of previous men-
tal health services for youth in a similar
population (as opposed to the general
youth population).

2. For a more comprehensive earlier
report, see Wasserman et al., 2002.

3. In addition to the self-report version
of the DISC for youth, a parent-report
version is available. Some juvenile justice
facilities may find this useful when assess-
ing a youth’s mental health.

4. The data reported here include data
for four youth who inadvertently were
not included in an earlier report of this
research by Wasserman and colleagues
(2002). Inclusion of the additional data
does not alter the findings.

5. Youth who had a substance use disor-
der plus some other disorder (n = 78) were
not included in these analyses.

6. See Wasserman et al., 2002, for further
discussion of this issue and for rates that
take impairment into account.

7. Although more research is needed, it is
likely that youth also underreport ADHD
symptoms in other arenas, such as the
child welfare system and the educational
system. Unidentified behavior disorders
can contribute to a youth’s coming into
contact with the juvenile justice system.

8. For an expanded discussion of these
recommendations, see Wasserman et al.
(2003).

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This Bulletin was prepared under grant num-
bers 1998–JB–VX–0115 and 1999–JR–VX–0005
from the Office of Juvenile Justice and Delin-
quency Prevention, U.S. Department of Justice.

Points of view or opinions expressed in this
document are those of the authors and do not
necessarily represent the official position or
policies of OJJDP or the U.S. Department of
Justice.

The Office of Juvenile Justice and Delinquency
Prevention is a component of the Office of
Justice Programs, which also includes the
Bureau of Justice Assistance, the Bureau of
Justice Statistics, the National Institute of
Justice, and the Office for Victims of Crime.

U.S. Department of Justice

Office of Justice Programs

Office of Juvenile Justice and Delinquency Prevention

Washington, DC 20531

Official Business
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Acknowledgments
Gail A. Wasserman, Ph.D., is Director of the Center for the Promotion of Mental
Health in Juvenile Justice, Division of Child Psychiatry, Columbia University, New
York State Psychiatric Institute, New York, NY. Larkin S. McReynolds, M.P.H., is
Senior Data Analyst at the Center. Susan J. Ko, Ph.D., Clinical Director at the Cen-
ter at the time of this study, is currently Director of the Service Systems Core at the
National Center for Child Traumatic Stress, University of California, Los Angeles.

*NCJ~202713*

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Research and Program Briefs are periodic publications aimed at improving policy and practice for youth
with mental health disorders in contact with the juvenile justice system. This publication is supported
by a grant from the John D. and Catherine T. MacArthur Foundation.

June 2006

Research and
Program Brief

Visit the Ncmhjj website at www.ncmhjj.com

National Center for
Mental Health and Juvenile Justice

NCMHJJ

Background

Over the last decade, concern has escalated over the number
of youth with significant mental health needs involved with
the juvenile justice system. The presence of these youth
in the juvenile justice system poses significant challenges
to the juvenile justice and mental health systems both at
the policy and program level and is seen as presenting a
major crisis for the juvenile justice system (Coalition for
Juvenile Justice, 2000). Until recently, little has been
known about the exact prevalence and types of mental
health disorders among this population. According to
a 1992 comprehensive review of the research literature,
studies examining the prevalence of mental health disorders
among justice-involved youth were methodologically weak
and produced estimates that varied widely. This variation
resulted from a number of factors, including inconsistent
definitions of mental disorders, non-standardized measures,
and problematic study designs (Cocozza, 1992). The lack
of information about the mental health needs of justice-

Youth with Mental Health Disorders in the Juvenile Justice System:
Results from a Multi-State Prevalence Study

Jennie L. Shufelt, M.S.
Joseph J. Cocozza, Ph.D.

involved youth has hindered the juvenile justice system’s
ability to understand the needs of the youth in its care and
develop appropriate responses.

Significant steps forward have been made in recent
years, particularly with respect to the development of
standardized screening and assessment instruments tested
for use with this population. These instruments represent
an important advancement for research because they allow
for comparisons among studies that utilize them, as well as
among subpopulations within the juvenile justice system.
Researchers have begun utilizing these tools, thereby
capitalizing on the opportunities they present. Their use
in research has expanded the knowledge base with respect
to the prevalence of mental health disorders among justice
involved youth, and have yielded more consistent estimates,
ranging from 65% to 70% among youth in residential
juvenile justice facilities (Wasserman et al., 2002; Teplin
et al., 2002). Research utilizing these instruments with
non-residential juvenile justice populations (i.e. youth

2

at probation intake) has found mental health prevalence
estimates of approximately 50% (Wasserman et al.,
2005).

While this new research has overcome many of the
limitations cited in the 1992 review, several issues remain.
Many of these studies have drawn their sample from one
region of the country or from one level of care within the
juvenile justice system, such as just pre-adjudication youth
in short-term detention centers. Therefore, it has been
suggested that the high prevalence rates found in these
studies may not be representative of the juvenile justice
population nationwide and may instead be attributable to
the particular geographic region or facility in which the
study was conducted. Furthermore, these studies have been
limited by the fact that they often contained very small
samples of girls and certain ethnic minorities.

Overview of Study

In response to the perceived need for new research to
overcome these remaining limitations, the National Center
for Mental Health and Juvenile Justice (NCMHJJ), in
collaboration with the Council of Juvenile Correctional
Administrators (CJCA), conducted the most comprehensive
mental health prevalence study to date on youth involved
with the juvenile justice system. The NCMHJJ prevalence
study was funded by the Office of Juvenile Justice and
Delinquency Prevention (OJJDP). This paper summarizes
the results of the NCMHJJ study.

The primary goal of this research endeavor was to
comprehensively examine the prevalence of mental health
and substance use disorders among youth involved with
the juvenile justice system by collecting information on
youth from three previously understudied areas of the
country. As a result, three states – Louisiana, Texas, and
Washington – were selected to represent these understudied
areas. In each state, data were collected on youth from
three different juvenile justice settings: community-
based programs, detention centers, and secure residential
facilities. Overall, data were collected on over 1,400 youth
from 29 different programs and facilities. In addition,
girls and certain minority youth (Hispanics and Native
Americans) were oversampled in an effort to improve the
knowledge base regarding these understudied populations.

Additional information on the study methodology and
sample characteristics is available upon request from the
NCMHJJ.

Prevalence of mental health and Substance
Use Disorders

The data collected during this study clearly indicate that
the majority (70.4%) of youth in the juvenile justice system
meet criteria for at least one mental health disorder1. A
shown in Table 1 below, the rate of mental health disorder
found in this study is consistent with the findings of other
recent studies.

Table 1. Comparison of Mental Health Prevalence
Findings From Recent Juvenile Justice Studies

Authors (Year)

% with a
Positive Diagnosis

NCMHJJ Prevalence Study (2006) 70.4%
Teplin et al. (2002) 69.0%
Wasserman et al. (2002) 68.5%
Wasserman et al. (2004) 67.2%

In addition, the results of this study indicate that youth
in contact with the juvenile justice system experience high
rates of disorder across the various types of mental health
disorders. Disruptive disorders (46.5%) such as conduct
disorder are most common, followed by substance use
disorders (46.2%) such as alcohol abuse, anxiety disorders
(34.4%) like obsessive-compulsive disorder, and mood
disorders (18.3%) such as depression.

Questions have been raised around whether the high
prevalence rates that have been found in recent studies are
actually due to the fact that the criteria used to identify
certain disruptive disorders (e.g., conduct disorder), which
are the most common types of disorders among youth
in the juvenile justice system, are very similar to the
characteristics of delinquent youth in general. However,

1 Mental health disorders were identified using the
Diagnostic Interview Schedule for Children – Voice Version IV
(Voice DISC-IV; Shaffer et.al, 2000). The Voice DISC-IV is a
structured contingency-based interview designed to measure
the presence of over 30 different psychiatric diagnoses common
among adolescents. All analyses exclude Separation Anxiety
Disorder.

3

upon analysis, it was evident that the high rate of these
types of disorders does not account for the high rate of
mental health disorders in general. This is because, even
after removing conduct disorder from the analysis (i.e.
calculating the prevalence of any mental health disorder
except conduct disorder), 66.3% of youth still met criteria
for a mental health disorder other than conduct disorder.

Similarly, it was possible that many of these youth were
adjudicated for drug-related offenses and that, as a result,
substance use diagnoses accounted for the high prevalence
of disorder. However, after removing substance use
disorders from the analysis, 61.8% of youth still met
criteria for a mental health disorder other than a substance
use disorder. In fact, even if both conduct disorder and
substance use disorders are removed from the analysis,
almost half (45.5%) of the youth were identified as having
a mental health disorder. Clearly, neither conduct disorder
nor substance use disorders by themselves adequately
account for the high prevalence rate of mental illness found
in this study.

comorbidity and co-Occurring Disorders

Another criticism of past research has been that the studies
were only able to identify one diagnosis among youth. As a
result, there was a lack of information about the extent to
which youth experience multiple mental health disorders,
or co-occurring mental health and substance use disorders.
This study was designed to overcome this limitation by
assessing the presence of multiple diagnoses.

In this study, the vast majority of youth who meet criteria
for a DSM-IV diagnosis actually meet criteria for multiple
disorders. In fact, 79% of youth who met criteria for at
least one mental health disorder actually met criteria for
two or more diagnoses. What is particularly striking is that
over 60% of these youth were diagnosed with three or more
mental health disorders. Figure 1 below depicts the number
of diagnoses among youth with at least one disorder.

For many youth in the juvenile justice system, their mental
health needs are significantly complicated by the presence
of a co-occurring substance use disorder. In fact, among
those youth with a mental health diagnosis, 60.8% also
met criteria for a substance use disorder. Co-occurring
substance use disorders were most frequent among youth
with a disruptive disorder, followed by youth with a mood
disorder.

Youth with comorbid and co-occurring disorders pose a
unique challenge to the juvenile justice system. Not only
is the intensity of their needs likely to be greater, but
proper response to their multiple needs requires increased
collaboration, continuity of care, and the ability to recruit
and retain providers with the ability to treat multiple needs.
This is particularly true for those youth with both mental
health and substance use needs (Abram, Teplin, McClelland,
& Dulcan, 2003).

Figure 1. Number of diagnoses among youth with at least one disorder.

21%

17%
19%

43%

1 Diagnosis

2 Diagnoses

3 Diagnoses

4+Diagnoses

4

Gender Differences in the Prevalence of
mental health Disorders

Over the past decade, the proportion of female offenders
in the juvenile justice system has steadily risen (American
Bar Association and National Bar Association, 2001). The
growth of this population has brought with it new and
unfamiliar challenges to the juvenile justice system. Justice-
involved girls are at higher risk for mental health disorders
than boys2 (Wasserman, et. al., 2005). In this study, more
than 80% of the girls in this sample met criteria for at least
one disorder, in comparison to 67% of boys. Much of this
difference is attributable to higher rates of internalizing
disorders (i.e. anxiety and mood disorders) among girls. In
contrast, girls and boys experience more comparable rates
of disruptive disorders and substance use disorders. For
many of these girls, histories of trauma further complicate
the effective response on the part of the juvenile justice
system (Hennessey, et. al. 2004). Figure 2 depicts the
prevalence of anxiety, mood, disruptive and substance use
disorders for males and females in this sample.

2 Controlling for age, race/ethnicity, type of facility, and
state.

Severe mental health Disorders

Severe mental disorders are those that are serious enough
to require significant and immediate treatment. However,
there is no standard operational definition of severe mental
illness for youth. Definitions may be based on level of
impairment, diagnosis, or service utilization (Narrow et
al., 1998). As a result, there has been no clear picture of
the exact prevalence of severe disorders among youth with
mental health disorders in the juvenile justice system.

However, researchers have estimated that the prevalence
of severe disorders among this population is approximately
20% (Cocozza & Skowyra, 2000). The results of this study
suggest that the prevalence of severe mental illness (i.e.
they meet criteria for certain severe disorders, or have been
hospitalized for a mental disorder) may be even higher.
Approximately 27% of the overall sample had a mental
disorder severe enough to require significant and immediate
treatment. This suggests that more than a quarter of youth
should be receiving some form of mental health services
while involved in the juvenile justice system.

Figure 2. Prevalence of mental health disorders among males and females in the juvenile justice system.

5

conclusion

This study confirms the high rates of mental health
disorders found by other recent studies and suggests that
regardless of geographic area or type of juvenile justice
facility, the vast majority of youth involved with the
juvenile justice system, from 65% to 70%, have at least one
diagnosable mental health disorder. Strikingly, over 60% of
youth met criteria for three or more diagnoses. Girls are at
significantly higher risk (80%) than boys (67%) for a mental
health disorder, with girls demonstrating higher rates of
internalizing disorders than boys. Substance use continues
to be a major problem for many youth in the juvenile
justice system, with 60.8% of youth with a mental health
diagnosis also meeting criteria for a substance use disorder.
This new information broadens the collective understanding
of the prevalence of these disorders among the juvenile
justice population, and can serve to help juvenile justice
and mental health administrators and policy makers make
more informed decisions about effective interventions for
these youth. This multi-state study confirms the high rate
of disorder found in earlier studies that often were limited
to a particular site or level of care, and provides further
support for the critical need for improved mental health
services for justice involved youth.

About the Authors
Jennie L. Shufelt, M.S. is the Division Manager of
the Juvenile Justice Division of Policy Research
Associates and assists with the operation of the
National Center for Mental Health and Juvenile
Justice and the implementation of all Center
projects. Joseph J. Cocozza, Ph.D. is the Director of
the National Center for Mental Health and Juvenile
Justice and Vice President for Research at Policy
Research Associates, Inc., and previously directed the
National GAINS Center for People with Co-occurring
Disorders in the Justice System.

References

Abram, K.M., Teplin, L.A., McClelland, G.M., & Dulcan, M.K.
(2003). Comorbid psychiatric disorders in youth in juvenile
detention. Archives of General Psychiatry, 60, 1097-1108.

American Bar Association and National Bar Association. (2001).
Justice by gender: The lack of appropriate prevention,
diversion and treatment alternatives for girls in the justice
system. Washington, DC: American Bar Association and
National Bar Association.

Coalition for Juvenile Justice. (2000). Handle with care: Serving
the mental health needs of young offenders. Annual report.
Washington, DC: Coalition for Juvenile Justice.

Cocozza, J. (1992). Responding to the mental health needs of
youth in the juvenile justice system. Seattle, WA: The
National Coalition for the Mentally Ill in the Criminal
Justice System.

Cocozza, J. & Skowyra, K. (2000). Youth with mental health
disorders: Issues and emerging responses. Office of Juvenile
Justice and Delinquency Prevention Journal, 7(1), 3-13.

Hennessey, M., Ford, J., Mahoney, K., Ko, S., & Siegfried,
C. (2004). Trauma among girls in the juvenile justice
system. Los Angeles, CA: National Child Traumatic Stress
Network.

Narrow, W., Regier, D., Goodman, S., Rae, D., Roper, M.,
Bourdon, K., Hoven, C., & Moore, R. (1998). A comparison
of federal definitions of severe mental illness among children
and adolescents in four communities. Psychiatric Services,
49(12), 1601-1608.

Shaffer, D., Fisher, P., Lucas, C., Dulcan, M., & Schwab-
Stone, M. (2000). NIMH Diagnostic Interview Schedule
for Children Version IV (NIMH DISC-IV): Description,
differences from previous versions, and reliability of some
common diagnoses. Journal of the American Academy of
Child and Adolescent Psychiatry, 39, 28-38.

Teplin, L., Abran, K., McClelland, G., Dulcan, M., & Mericle A.
(2002). Psychiatric disorders in youth in juvenile detention.
Archives of General Psychiatry, 59, 1133-1143.

Wasserman, G., McReynolds, L., Ko, S., Katz, L., & Carpenter,
J. (2005). Gender differences in psychiatric disorders at
juvenile probation intake. American Journal of Public
Health, 95, 131-137.

Wasserman, G., McReynolds, L., Lucas, C., Fisher, P., & Santos,
L. (2002). The Voice DISC-IV with incarcerated male
youths: Prevalence of disorder. Journal of the American
Academy of Child and Adolescent Psychiatry, 41, 314-321.



6

About the National Center for Mental
Health and Juvenile Justice

Recent findings show that large numbers
of youth in the juvenile justice system have
serious mental health disorders, with many
also having a co-occurring substance use
disorder. For many of these youth, effective
treatment and diversion programs would
result in better outcomes for the youth and
their families and less recidivism back into
the juvenile and criminal justice systems.
Policy Research Associates has established
the National Center for Mental Health and
Juvenile Justice to highlight these issues.
The Center has four key objectives:

• Create a national focus on youth with
mental health disorders in contact with
the juvenile justice system

• Serve as a national resource for the
collection and dissemination of evidence-
based and best practice information to
improve services for these youth

• Conduct new research and evaluation to
fill gaps in the existing knowledge base

• Foster systems and policy changes at the
national, state and local levels to improve
services for these youth

For more information about the Center, visit
our website at www.ncmhjj.com.

Joseph J. Cocozza, PhD
Director

For more information…
about this study, the following agencies and services

may be helpful:

National Center for Mental Health and
Juvenile Justice

Policy Research Associates, Inc.
345 Delaware Avenue
Delmar, NY 12054

Phone: 518-439-7415
Email: [email protected]
Website: www.ncmhjj.com

Office of Juvenile Justice and Delinquency
Prevention (OJJDP)
810 7th Street, NW

Washington, DC 20531
Phone: 202-514-9395

Last updated: July 2017 www.ojjdp.gov/mpg

Office of Juvenile Justice and Delinquency Prevention www.ojjdp.gov 1

Intersection between Mental Health and the Juvenile Justice
System
Mental health disorders are prevalent among youths in the juvenile justice system. A meta-analysis by
Vincent and colleagues (2008) suggested that at some juvenile justice contact points, as many as 70
percent of youths have a diagnosable mental health problem. This is consistent with other studies that
point to the overrepresentation of youths with mental/behavioral health disorders within the juvenile
justice system (Shufelt and Cocozza 2006; Meservey and Skowyra 2015; Teplin et al. 2015). However,
prevalence varies depending on the stage in the justice system at which youths are assessed. In a
nationwide study, the prevalence of diagnosed disorders increased the further that youths were
processed in the juvenile justice system (Wasserman et al. 2010).

While there appears to be a prevalence of youths with mental health issues in the juvenile justice system,
the relationship between mental health problems and involvement in the system is complicated, and it
can be hard to disentangle correlational from causal relationships between the two (Shubert and
Mulvey 2014).

This literature review will focus on the scope of mental health problems of at-risk and justice-involved
youths; the impact of mental health on justice involvement as well as the impact of justice involvement
on mental health; disparities in mental health treatment in the juvenile justice system; and evidence-
based programs that have been shown to improve outcomes for youths with mental health issues.

Defining Mental Health and Identifying Mental Health Needs
Defining Mental Health. According to the U.S. Department of Health and Human Services, mental
health includes a person’s psychological, emotional, and social well-being and affects how a person
feels, thinks, and acts. Mental disorders relate to issues or difficulties a person may experience with his
or her psychological, emotional, and social well-being. As Stein and colleagues explained, “each of the
mental disorders is conceptualized as a clinically significant behavioral or psychological syndrome or
pattern that occurs in an individual and that is associated with present distress (e.g., a painful symptom)
or disability (i.e., impairment in one or more important areas of functioning) or with a significantly
increased risk of suffering death, pain, disability, or an important loss of freedom” (2010, 1).

The Diagnostic and Statistical Manual of Mental Disorders, 5th Edition is a standard classification tool for
mental disorders used by many mental health professionals in the United States (American Psychiatric
Association 2013). It includes 20 chapters of mental health disorders, including the following:

Suggested Reference: Development Services Group, Inc. 2017. “Intersection Between Mental Health and the Juvenile Justice

System.” Literature review. Washington, D.C.: Office of Juvenile Justice and Delinquency Prevention.

https://www.ojjdp.gov/mpg/litreviews/Intersection-Mental-Health-Juvenile-Justice.pdf
Prepared by Development Services Group, Inc., under cooperative agreement number 2013–JF–FX–K002. Points of view or
opinions expressed in this document are those of the author and do not necessarily represent the official position or policies of
OJJDP or the U.S. Department of Justice.

Office of Juvenile Justice and Delinquency Prevention www.ojjdp.gov 2

 Substance-related and addictive disorders

 Bipolar and related disorders

 Depressive disorders

 Anxiety disorders

 Obsessive-compulsive disorders

 Trauma- and stressor-related disorders such as posttraumatic stress disorder and adjustment
disorders

 Disruptive, impulse control, and conduct disorders

 Neurodevelopmental disorders, which includes intellectual disabilities,1 attention
deficit/hyperactivity disorder, and autism spectrum disorders

A broader categorization divides mental health disorders into two categories: internalizing and
externalizing. Internalizing disorders, which are negative behaviors focused inward, include depression,
anxiety, and dissociative disorders. Externalizing disorders are characterized by behaviors directed
toward a youth’s environment and include conduct disorders, oppositional defiant disorder, and
antisocial behaviors.

Tools to Identify Mental Health Needs. Juvenile justice systems use a variety of tools to identify mental
health needs, although most fall into one of two categories:

 Screening. The purpose of screening is to identify youths who might require an immediate
response to their mental health needs and to identify those with a higher likelihood of requiring
special attention (Vincent 2012). It is similar to a triage process in a hospital emergency room.
Although there are numerous screening instrument options, two commonly used are the
Massachusetts Youth Screening Instrument—Version 2 (MAYSI-2; Grisso and Barnum 2006)
and the Diagnostic Interview Schedule for Children (Wasserman, McReynolds, Fisher, and
Lucas 2005). In addition to tools that screen for multiple mental health-related issues, there are
also tools that screen for specific problems, such as the Children’s Depression Inventory (Kovacs
1985) or the Suicidal Ideation Questionnaire (Reynolds 1988), which can help determine if a
youth should be monitored for suicide attempts upon entry to detention or residential facility.

 Assessment. The purpose of assessment is to gather a more comprehensive and individualized
profile of a youth. Assessment is performed selectively with those youths with higher needs,
often identified through screening. Mental health assessments tend to involve specialized
clinicians and generally take longer to administer than screening tools (Vincent 2012). There are
numerous mental health assessments. One widely studied assessment is the Achenbach System
of Empirically Based Assessment (Achenbach and Rescorla 2001), which includes three
instruments completed by youths (Youth Self-Report), parents (Child Behavior Checklist), or
teachers (Teachers Report Form)2.

Scope of the Problem
Multiple studies confirm that a large proportion of youths in the juvenile justice system have a
diagnosable mental health disorder. Studies have suggested that about two thirds of youth in detention
or correctional settings have at least one diagnosable mental health problem, compared with an

1 A separate Model Programs Guide literature review on intellectual/development disabilities among youths in the justice
system can be accessed here: https://www.ojjdp.gov/mpg/litreviews/Intellectual-Developmental-Disabilities.pdf
2 For more information on Risk/Needs Assessments for Youths, please see the literature review on the Model Programs
Guide: https://www.ojjdp.gov/mpg/litreviews/RiskandNeeds.pdf

Office of Juvenile Justice and Delinquency Prevention www.ojjdp.gov 3

estimated 9 to 22 percent of the general youth population (Schubert and Mulvey 2014; Schubert,
Mulvey, and Glasheen 2011). The 2014 National Survey on Drug Use and Health found that 11.4 percent
of adolescents aged 11 to 17 had a major depressive episode in the past year, although the survey did
not provide an overall measure of mental illness among adolescents (Center for Behavioral Health
Statistics and Quality 2015). Similarly, a systematic review by Fazel and Langstrom (2008) found that
youths in detention and correctional facilities were almost 10 times more likely to suffer from psychosis
than youths in the general population.

These diagnoses commonly include behavior disorders, substance use disorders, anxiety disorder,
attention deficit/hyperactivity disorder (ADHD), and mood disorders (Chassin 2008; Gordon and
Moore 2005; Shufelt and Cocozza 2006; Teplin et al. 2003). The prevalence of each of these diagnoses,
however, varies considerably among youths in the juvenile justice system. For example, the Pathways
to Desistance study (which followed more than 1,300 youths who committed serious offenses for 7
years after their court involvement) found that the most common mental health problem was substance
use disorder (76 percent), followed by high anxiety (33 percent), ADHD (14 percent), depression (12
percent), posttraumatic stress disorder (12 percent), and mania (7 percent) (Schubert, Mulvey, and
Glasheen 2011; Schubert and Mulvey 2014). A multisite study by Wasserman and colleagues (2010)
across three justice settings (system intake, detention, and secure post-adjudication) found that over
half of all youths (51 percent) met the criteria for one or more psychiatric disorders. Specifically, one
third of youths (34 percent) met the criteria for substance use disorder, 30 percent met the criteria for
disruptive behavior disorders, 20 percent met the criteria for anxiety disorders, and 8 percent met the
criteria for affective disorder.

Many of these youths are also diagnosed with multiple disorders. For example, the Pathways to
Desistance study found that 39 percent of youths met the threshold for more than one mental health
problem (Schubert, Mulvey, and Glasheen 2011). Similarly, the Northwestern Juvenile Project (a
longitudinal study that followed over 1,800 youths who were arrested and detained in Cook County,
Illinois) found that 46 percent of males and 57 percent of females had two or more psychiatric disorders
(Teplin et al. 2013). In a study of youths in contact with the juvenile justice systems (including
community-based programs, detention centers, and secure residential facilities), in Texas, Louisiana,
and Washington, Shufelt and Cocozza (2006) found that 79 percent of the youths diagnosed for one
mental health disorder also met the criteria for two or more diagnoses.

Impact of Mental Health Problems on Juvenile Justice Involvement
As previously mentioned, the relationship between mental health problems and involvement in the
juvenile justice system is complex. As Schubert and Mulvey explained, “although these two problems
often go hand in hand, it is not clear that one causes the other. Many youths who offend do not have a
mental health problem, and many youths who have a mental health problem do not offend” (2014, 3).
There has been research to show how mental health diagnoses and problem behaviors are associated
with each other. But as is often emphasized, correlation does not mean causation. In addition, certain
risk factors could increase the occurrence of both mental health and problem behaviors in youths. For
example, exposure to violence can increase mental health issues, such as posttraumatic stress, in youth
and increase the occurrence of delinquent behavior (Finkelhor et al. 2009). However, although the
research can point to a relationship between mental health issues and juvenile justice involvement, it
remains difficult to determine the exact correlation.

Research on individual risk factors often focuses on how certain mental health problems may be
associated with delinquency, violence, and justice system involvement. Researchers have found that
some externalizing disorders (e.g., conduct disorders, oppositional defiant disorder, and antisocial

Office of Juvenile Justice and Delinquency Prevention www.ojjdp.gov 4

behaviors) and substance use disorders do increase the likelihood of delinquency, violence, and contact
with the justice system (Barrett et al. 2014; Hawkins et al. 2000; Huizinga et al. 2000).

For instance, in their meta-analysis of predictors of youth violence, Hawkins and colleagues (2000)
found evidence that psychological factors—such as aggression, restlessness, hyperactivity,
concentration problems, and risk taking—were consistently correlated with youth violence. However,
they also found that internalizing disorders—such as worrying, nervousness, and anxiety—were either
unrelated to later violence or reduced the likelihood of engaging in later violence. A recent meta-
analysis by Wibbelink and colleagues (2017) also examined the relationship between mental disorders
(including internalizing, externalizing, and comorbid disorders) and recidivism in juveniles. Similar to
the findings from the Hawkins and colleagues (2000) meta-analysis, Wibbelink and colleagues (2017)
found that externalizing disorders were significantly related to recidivism, while internalizing
behaviors were not related to recidivism (and in some cases, internalizing behaviors had a buffering
effect on recidivism).

This link between certain mental health problems and delinquency has also been studied for youths in
certain subpopulations. Among maltreated youths living in out-of-home care, the presence of a mental
health disorder was significantly associated with juvenile justice system involvement, and conduct
disorder was the strongest predictor (Yampolskaya and Chuang 2012). A study of psychiatric-inpatient
adolescents found that having a disruptive disorder, a history of aggressive behavior, and using cocaine
were all predictors of juvenile justice system involvement (Cropsey, Weaver, and Dupre 2008).

Trauma or exposure to violence may also increase the likelihood of juvenile justice involvement.
Multiple studies show a connection between childhood violence exposure and antisocial behavior,
including delinquency, gang involvement, substance use, posttraumatic stress disorder, anxiety,
depression, and aggression (Wilson, Stover, and Berkowitz 2009; Finkelhor et al. 2009). In the
Northwestern Juvenile Project, 92.5 percent of detained youths reported at least one traumatic
experience, and 84 percent reported more than one (Abram et al. 2013). Other studies that have looked
at past traumatic exposures in juvenile justice populations have also found high rates (e.g., Romaine et
al. 2011; Rosenberg et al. 2014).

Impact of Justice System Involvement on Mental Health Problems
Entry into the juvenile court system may exacerbate youths’ existing mental health problems for many
reasons. For instance, there is inconsistency across some of the decision points of the juvenile justice
system (including in the court systems and residential facilities) in providing referrals to treatment and
appropriately screening, assessing, and treating juveniles with mental health conditions. There are also
the difficulties that many juveniles face when detained or incarcerated, the increased odds of
recidivating once youths are involved in the justice system, and the perceived barriers to services that
can prevent youths from seeking or receiving treatment (National Mental Health Association 2004).

Lack of Referrals for Treatment. Among youths involved in the juvenile justice system (including those
who have been referred to court or those who have been adjudicated and placed in a residential facility),
only a small percentage of those in need of services can access treatment. For example, a 2014 juvenile
residential facility census found that 58 percent reported they evaluated all youths for mental health
needs, 41 percent evaluated some but not all youths, and 1 percent did not evaluate any youths
(Hockenberry, Wachter, and Sladky 2016). However, it is unknown how many of the evaluated youths
received referrals for treatment. In a study of juvenile courts in Tennessee, Breda (2003) found that
fewer than 4 percent of juveniles who had committed offenses (regardless of diagnosis) were referred
for mental health services. A study of a southern California correctional facility also found that only 6

Office of Juvenile Justice and Delinquency Prevention www.ojjdp.gov 5

percent of youths were referred for mental health services (Rogers et al. 2001).

Even among youths who have been diagnosed, treatment is not guaranteed. The Pathways to
Desistance Project found overall low rates of services provided to youths; however, this depended on
both the type of facility in which youths had been placed (i.e., state-run juvenile corrections facilities,
contract residential settings, detention centers, and jails/prisons) and the diagnosable mental health
issue (Schubert and Mulvey 2014). Similarly, the Northwestern Juvenile Project found that only 15
percent of youths diagnosed with psychiatric disorders and functional impartment received treatment
while in detention (Teplin et al. 2013). A study of mental health delivery patterns in Maryland found
that only 23 percent of the youths diagnosed with a mental disorder received any treatment (Shelton
2005). A national study found that even if juvenile justice facilities reported having the capacity to
provide services to youths in their care, youths with a severe mental health disorder often did not
receive any emergency mental health services (Shufelt and Cocozza 2006). Finally, numerous studies
have revealed disparities in regard to which youths are more likely to be referred for treatment (see
Disparities in Mental Health Treatment below for more information).

Impact of Detention/Confinement. Juvenile detention and correctional facilities may impact youths
with mental health issues due to overcrowding, lack of available treatment/services, and separation
from support systems (such as family members and friends). In addition, for juveniles in correctional
facilities, being placed in solitary confinement or restrictive housing also has the potential to worsen
mental health issues (National Institute of Justice 2016).

Greater Likelihood of Recidivism. Given the aforementioned limitations of the juvenile justice system,
having a mental health problem while involved in the system can increase youths’ likelihood of
recidivating or engaging in other problem behavior (e.g., Yampolskaya and Chuang 2012). This link
has been documented most frequently for externalizing disorders (Barrett et al. 2014; Constantine et al.
2013; McReynolds, Schwalbe, and Wasserman 2010) and for substance use disorders (Baglivio et al.
2014; Hoeve et al. 2013; Schubert and Mulvey 2014).

For example, in their study of Florida youths who had completed juvenile justice residential
placements, Baglivio and colleagues (2014) found that current substance use was a predictor of re-
arrest. In their study of youths who were previously placed in a detention facility, Mallett and
colleagues (2013) found that having a conduct disorder diagnosis and a self-reported previous suicide
attempt predicted subsequent recidivism to detention placement. In their study of almost 100,000
youths whose cases had been processed by the South Carolina Department of Juvenile Justice, Barrett
and colleagues (2014) found that an early diagnosis of an aggressive disorder was the strongest
predictor of recidivism.

Perceived Barriers to Treatment among Youth. Abram and colleagues (2015) surveyed youths with
alcohol, drug, and mental health disorders in detention and found that the most frequently cited barrier
to services was that youths believed their problems would go away without getting any help. Other
reported perceived barriers were that youths were unsure whom to contact or where to go for help, and
believed it was too difficult to obtain help. Perceived barriers can impact whether youths pursue
treatment in the first place, as well as whether they participate and remain in treatment (Abram et al.
2015).

Disparities in Mental Health Treatment in the Juvenile Justice System
Researchers have also found disparities—particularly by race/ethnicity, gender, and age—in who is

Office of Juvenile Justice and Delinquency Prevention www.ojjdp.gov 6

referred for treatment in the juvenile justice system.

Race/Ethnicity. Racial disparities exist among mental health diagnoses and treatment in both the
community and the juvenile justice system. In the community, researchers have found that youths of
color are less likely to receive mental health or substance use treatment (Dembo et al. 1998; Garland et
al. 2005). Researchers have also found that minority youths receive fewer services than white youths in
the foster care and child welfare populations (Garland and Besinger 1997; Horwitz et al. 2012). Among
youths being served by mental health systems, youths of color are more likely to be referred to the
juvenile justice system than white youths (Cauffman et al. 2005; Evens and Vander Stoep 1997; Scott,
Snowden, and Libby 2002; Vander Stoep, Evens, and Taub 1997).

Once in the juvenile justice system, minority youths are less likely to be treated for mental health
disorders than white youths (e.g., Dalton et al. 2009; Herz 2001; Rawal et al. 2004). According to a 2016
systematic review of articles that examined racial disparities among referrals to mental health and
substance abuse services from within the juvenile justice system, most of the studies published from
1995 to 2014 found that there was at least some race effect in determining which youths received
services, even when including statistical controls for mental health or substance use diagnosis or need
(Spinney et al. 2016).

For example, an examination of detained youths in Indiana found that both African American and
Hispanic youths were less likely than white youths to receive contact with a mental health clinician
within 24 hours of detention center intake and to receive a referral to mental health services upon
detention center discharge—even after incorporating statistical controls for age, gender, detention
center site, and whether the youth had a positive MAYSI–2 screening (Aalsma et al. 2014). Additionally,
in a study of mental health delivery patterns in the Maryland juvenile justice system, Shelton (2005)
found that while 42.6 percent of white youths who met diagnostic criteria received mental health
services, only 11.9 percent of the African American youths who met diagnostic criteria received these
services. She concluded that the data reflected a racial bias in the provision of services.

Gender-Related Factors. As the proportion of girls involved in the juvenile justice system grows
(Espinosa, Sorensen, and Lopez 2013; Odgers et al. 2005), researchers are increasingly looking at how
gender differences impact the receipt of mental health care within the system. They are reporting a
higher rate of referrals for females than males overall (Teplin et al. 2003; Cauffman et al. 2007; Fazel and
Langstrom 2008; Herz 2001). In a study on juvenile offenders in Texas, Daurio (2009) found that girls
were more likely than boys to receive mental health placements than incarceration, as a disposition
outcome. Gunter-Justice and Ott (1997) also found that family court judges recommended mental health
placements more frequently for girls, compared with boys. Once within the system, girls are also more
likely to be referred for treatment by facility staff, which, as Rogers and colleagues (2001) suggested,
may have to do with the staff members themselves being female. Finally, although girls in the juvenile
justice system are referred for mental health treatment more frequently than boys, they are usually not
referred for further follow-up treatment upon community reentry (Aalsma, Schwartz, and Perkins
2014).

The following differences between boys and girls may explain why gender is a significant predictor of
mental health placement:

1. Girls are most often detained for status offenses and technical violations.
2. Girls report mental health symptoms and are more willing to use psychiatric services than boys.

Office of Juvenile Justice and Delinquency Prevention www.ojjdp.gov 7

3. Girls are more likely to exhibit internalizing disorders—such as anxiety, depression, and
suicidality—than externalizing disorders such as aggression, bullying, and oppositional
behaviors (Huizinga et al. 2000; Espinosa et al. 2013; Teplin et al. 2006).

Odgers and colleagues (2005) also found that the rates of comorbidity of disorders increase
exponentially for girls in the juvenile justice system. Regardless of their higher levels of referral as
compared with boys, girls are still undertreated in the system given their high need (Espinosa et al.
2013).

Age-Related Factors. Age is often a determinant for who receives mental health services within the
juvenile justice system. As various studies have indicated, younger juveniles (usually under 15 years of
age) are more likely to be referred for mental health placements (Herz 2001; Daurio 2009). Rogers and
colleagues (2001) found that of the youths in a Southern California juvenile correctional facility, those
who had been arrested before the age of 14 were more likely to have been referred for treatment than
youths arrested after the age of 14. Herz (2001) posited that this referral disparity indicates evidence of
a “two-tiered system,” in which older adolescents receive a more punitive than rehabilitative approach
than younger adolescents.

Outcome Evidence
Some programs and treatment approaches for justice-involved youths, particularly those involving
cognitive–behavioral therapy (CBT), have shown positive results. CBT is designed to help youths adjust
their thinking and behaviors related to delinquency, crime, and violence (Little 2005; Beck 1999). CBT
programs have also been shown to be effective in reducing recidivism rates (Jeong, Lee, and Martin
2014). Research on other program types that specifically target youths with mental health needs, such
as mental health diversion initiatives, have also shown positive results (Colwell, Villarreal, and
Espinosa 2012; Cuellar, McReynolds, and Wasserman 2006).
The following are examples of evidence-based programs from the Model Programs Guide that have
demonstrated positive outcomes for youths with specific mental health needs, the first two of which
specifically draw on the strategies of CBT.

Functional Family Therapy. Functional family therapy (FFT) is a family-based prevention and
intervention program for high-risk youths ages 11–18. It concentrates on decreasing risk factors and
increasing protective factors that directly affect adolescents who are at risk for delinquency, violence,
substance use, or behavioral problems such as conduct disorder or oppositional defiant disorder. FFT
is conducted over 8–12, 1-hour sessions for mild cases; it includes up to 30 sessions of direct service for
families in more difficult situations. Sessions generally occur over a 3-month period and can be held in
clinical settings as an outpatient therapy model or as a home-based model.
In one large-scale study on FFT, which was delivered by community-based therapists, Sexton and
Turner (2010) found that when adherence to the FFT model was high, FFT resulted in a significant
reduction in felony crimes and violent crimes and a nonsignificant decrease in misdemeanor crimes. In
addition, a study by Celinska and colleagues (2013) found that FFT had a positive effect on youths in
the areas of reducing risk behavior, increasing strengths, and improving functioning across key life
domains.

Multisystemic Therapy. Multisystemic Therapy (MST) is designed to help adolescents ages 12–17 who
have exhibited serious clinical problems such as drug use, violence, and severe criminal behavior.
Through intense family involvement, MST aims to assess the origins of adolescent behavioral problems
and change the youth’s ecology to increase prosocial behavior while decreasing problem and
delinquent behavior. MST typically uses a home-based model of service delivery to reduce barriers that

Office of Juvenile Justice and Delinquency Prevention www.ojjdp.gov 8

keep families from accessing services. The average treatment occurs over approximately 4 months,
although there is no definite length of service, with multiple therapist–family contacts occurring each
week.

In one evaluation of MST, Henggeler and colleagues (1992) found that, at 59 weeks post-referral, the
group that received MST had just more than half the number of re-arrests than the comparison group,
which received treatment as usual. Another study showed significant differences between treatment
and comparison groups 4 years after the end of their probation: 71.4 percent of the individual therapy
comparison group participants were arrested at least once, compared with 26.1 percent of MST
participants (Borduin et al. 1995).

Jefferson County Community Partnership. The Jefferson County Community Partnership in
Birmingham, Ala., offers services for youth with serious emotional disturbances, which are accessible,
community-based, individualized, culturally competent, and include an individual’s family in the
planning and delivery of treatment. Overall, the goal of this collaborative approach is to reduce youths’
contact with the juvenile justice system. This includes reducing the odds of future offending and
decreasing the seriousness of offenses, if they were committed (Matthews et al. 2013). The Jefferson
County Community Partnership is not a program; rather, it is a collaborative framework that operates
within a system-of-care concept. An evaluation of the Jefferson County Community Partnership found
a significant reduction in contact with the juvenile justice system among youths in the Birmingham
system-of-care community, compared with the comparison community (Matthews et al. 2013).

Special Needs Diversionary Program. Based on the theory of therapeutic jurisprudence, the Special
Needs Diversionary Program (SNDP) provides intensive supervision and treatment for juvenile
probationers (ages 10–17) who display low levels of conduct and mental health disorders. The goal of
the program is to rehabilitate the youths and prevent them from further involvement in the justice
system. SNDP offers mental health services (including individual and group therapy), probation
services (including life skills, mentoring, and anger management), and parental education and support.
Specialized juvenile probation and professional mental health staff from the local mental health centers
work together to coordinate intensive case-management services. The program follows procedures
based on typical wraparound strategies. Services provided to juveniles include individual and family
therapy, rehabilitation services, skills training, and chemical dependency.

In their study on SNDP, Cuellar and colleagues (2006) evaluated re-arrests for juveniles who
participated in the program. They found that there were 63 fewer arrests per 100 youths served by the
program over a 1-year period, compared with youths who had not been enrolled in the program.

For more information on these programs, click on the links below.

Functional Family Therapy

Jefferson County Community Partnership (Birmingham, Ala.)

Multisystemic Therapy

Special Needs Diversionary Program

Conclusion
The research presented shows that many youths with mental health issues in the justice system are in
need of treatment. Substance use disorders are particularly prevalent. However, the intersection

Office of Juvenile Justice and Delinquency Prevention www.ojjdp.gov 9

between mental health and the juvenile justice system represents a challenging area for policymakers
and practitioners, because the exact relationship between mental health issues and problem behaviors
(such as delinquency) is not always clear (Schubert and Mulvey 2014). The research indicates there are
shared risk factors for mental health issues and juvenile justice involvement; however, the research is
less conclusive about whether mental health problems increase the odds of youth involvement in the
justice system or whether being a part of the justice system increases youths’ mental health problems.

Despite the prevalence of mental health disorders among justice-involved youths, particularly for those
processed further into the system, many do not receive services to meet their needs (Teplin et al. 2013).
In addition, there are discrepancies in referrals for treatment, particularly regarding race and gender
(Teplin et al. 2003; Spinney et al. 2016).

However, there are several evidence-based programs that specifically target youths with mental health
needs in the juvenile justice system and focus on reducing delinquency and other related problem
behaviors by properly addressing both criminogenic risk factors and the mental health needs of these
youths (Cuellar et al. 2006; Matthews et al. 2013).

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Justice and Delinquency Prevention.

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Vander Stoep, Ann, Carina C. Evens, and Jennifer Taub. 1997. “Risk of Juvenile Justice System
Referral among Children in a Public Mental Health System.” Journal of Mental Health
Administration 24(4):428–42.

Vincent, G. M., Thomas Grisso, Anna Terry, and Steven M. Banks. 2008. “Sex and Race Differences in
Mental Health Symptoms in Juvenile Justice: The MAYSI-2 National Meta-Analysis.” Journal of
the American Academy of Child and Adolescent Psychiatry 47(3):282–90.

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Research and Program Briefs are periodic publications aimed at improving policy and practice for youth
with mental health disorders in contact with the juvenile justice system. This publication is supported
by a grant from the John D. and Catherine T. MacArthur Foundation.

June 2006

Research and
Program Brief

Visit the Ncmhjj website at www.ncmhjj.com

National Center for
Mental Health and Juvenile Justice

NCMHJJ

I. Setting the Stage
Over 2.3 million youth are arrested each year. Approximately
600,000 of these youth are processed through juvenile
detention centers and more than 100,000 are placed in secure
juvenile correctional facilities (Sickmund, 2004). Until
the last decade, there was a lack of data and information
available documenting the degree to which youth involved
with the juvenile justice system were experiencing mental
illness. New research, conducted over the last ten years, has
expanded our collective understanding of the nature and
prevalence of mental disorders among the juvenile justice
population and has provided the field with a more precise
assessment of the problem.

It is now well established that the majority of youth
involved with the juvenile justice system have mental
health disorders. For example, we now know that youth
in the juvenile justice system experience substantially
higher rates of mental disorder
t h a n yo u t h i n t h e g e n e r a l
population (Otto, Greenstein,
Johnson & Friedman, 1992;
Wierson, Forehand & Frame,
1 9 9 2 ) . S t u d i e s c o n s i s t e n t ly
document that anywhere from
65% to 70% of youth in the
juvenile justice system meet
criteria for a diagnosable mental

A Blueprint for Change: Improving the System Response to Youth
with Mental Health Needs Involved with the Juvenile Justice System

Kathleen Skowyra

Joseph J. Cocozza, Ph.D.

health disorder (Shufelt & Cocozza, in press); Teplin,
Abram, McClelland, Dulcan & Mericle, 2002; Wasserman,
McReynolds, Lucas, Fisher & Santos, 2002; Wasserman, Ko,
& McReynolds, 2004). Further, recent estimates suggest
that approximately 25% of youth experience disorders so
severe that their ability to function is significantly impaired
(Shufelt & Cocozza, in press).

In a recent multi-state mental health prevalence study
conducted by the National Center for Mental Health and
Juvenile Justice on youth in three different types of juvenile
justice settings, over 70% of youth were found to meet
criteria for at least one mental health disorder. Disruptive
disorders were most common, followed by substance use
disorders, anxiety disorders and mood disorders. The
majority of youth had multiple diagnoses. For example,
over 90% of youth with conduct disorder also met criteria
for another disorder (Shufelt & Cocozza, in press).

Many of these youth are
detained or placed in the
juvenile justice system
for relatively minor, non-
violent offenses but end
up in the system simply
b e c a u s e o f a l a c k o f
community-based mental
health treatment. A review
in Louisiana by the Annie

It is now well established that the

majority of youth involved with the

juvenile justice system have mental

health disorders.

�

E. Casey Foundation (2003) found that more than 75
percent of Louisiana’s incarcerated youth were locked
up for non-violent and drug offenses. A 1999 survey by
the National Alliance for the Mentally Ill (2001) found
that 36% of respondents reported having to place their
children in the juvenile justice system in order access
mental health services that were otherwise unavailable to
them. More recently, a report issued by Congress in July
2004 documenting the inappropriate use of detention for
youth with mental health needs found that in 33 states,
youth were reported held in detention with no charges- they
were simply awaiting mental health services (US House of
Representatives, 2004).

The growing crisis surrounding these youth is further
underscored by a plethora of independent reports and
media accounts over the last several years drawing attention
to the unmet needs of these youth. Investigations by the US
Department of Justice into the conditions of confinement
in juvenile detention and correctional facilities throughout
the country have repeatedly found a failure on the part of
the facilities to adequately address the mental health needs
of youth in their care (US Department of Justice, 2005).
In addition, media inquiries and reports documenting the
mental health crisis within the juvenile justice systems in
numerous states including New Jersey, Arizona, California,
Michigan and Pennsylvania, among others, have drawn
national attention to an issue that has traditionally
not received much consideration from the media. This
unprecedented exposure has put new public pressure on
elected officials, policy makers and practitioners to develop
more effective responses for these youth.

As a result of this pressure and attention, significant energy
has been directed to the development of new tools, policies
and strategies to help the field better identify and respond
to the mental health needs of these youth. These developing
resources and trends include:

Greater recognition, on the part of both the juvenile
justice and the mental health systems, of the extent
of the problem and the need for both systems to
respond;

The wider use of standardized mental health
screening and assessment procedures for justice-
involved youth, such as the MAYSI-2 and the Voice
DISC- IV;

The increasing reliance on evidence-based and
promising practices, such as Multi-Systemic
Therapy and Functional Family Therapy, to treat
mental disorders among youth in the juvenile justice
system; and







The development of collaborative programs and
strategies, involving both juvenile justice and mental
health agencies, across the country.

Yet, despite these trends and improvements, there had been
no attempt made to date to systematically examine these
existing efforts, summarizing what it is we now know about
the best way to identify and treat these disorders among
youth at key stages of juvenile justice processing, and
comprehensively package this information as a tool that
provides guidance and direction to the field.

II. A Blueprint for change: The
comprehensive model

Recognizing this, the Office of Juvenile Justice and
Delinquency Prevention (OJJDP) launched their largest
investment ever in mental health research in 2001, aimed
at providing the field with guidance to help address the
problem and to improve the lives of children and youth with
mental health needs who end up involved with the juvenile
justice system. Blueprint for Change: A Comprehensive
Model for the Identification and Treatment of Youth with
Mental Health Needs in Contact with the Juvenile Justice
System (Skowyra & Cocozza, in press), offers a conceptual
and practical framework for juvenile justice and mental
health systems to use when developing strategies and
policies aimed at improving mental health services for youth
involved with the juvenile justice system.

The Model was developed by the National Center for
Mental Health and Juvenile Justice in partnership with
the Council of Juvenile Correctional Administrators, with
guidance from an advisory group of key national experts,
and reviewed by a panel of mental health and juvenile
justice administrators, practitioners, advocates and youth.
It is designed to capture the current activity of the field
and present it in a way that examines the juvenile justice
system as a continuum, identifying the best ways to respond
to youth with mental disorders at key points of contact
and providing recommendations, guidelines and examples
for how best to do this. The key features of the Model are
illustrated in Figure 1 and are described more fully below.

Key Features of the Model

A. Underlying Principles
The Model is centered around a set of Underlying Principles
that represent the foundation on which a system can be built
that is respectful of youth and responsive to their mental



�

Initial
Contact

and
Referral

Intake

Detention

Judicial
Processing

Residential
Placement

Probation

Aftercare

Critical Intervention Points

FIGURE 1.
CONCEPTUAL FRAMEWORK

OF THE COMPREHENSIVE M ODEL

Underlying Principles
As the basis for the development of

Cornerstones
That provide the infrastructure and reflect key

areas for improvements at

Program Examples
Used to supplement and provide concrete

examples of the implementation of key elements at
each critical intervention point

�

health needs. These Principles provide a philosophical
framework for the Model and provide the basis for the
recommendations that are put forward. They include:

1. Youth should not have to enter the juvenile justice
system solely in order to access mental health services
or because of their mental illness.

2. Whenever possible and when patters of public safety
allow, youth with mental health needs should be
diverted into evidence-based mental health treatment
in a community setting.

3. If diversion out of the juvenile justice system is not
possible, youth should be placed in the least restrictive
setting possible, with access to evidence-based
treatment.

4. Information collected as part of a pre-adjudicatory
mental health screen should not be used in any way
that might jeopardize the legal interests of youth as
defendants.

5. All mental health services provided to youth in contact
with the juvenile justice system should respond to issues
of gender, ethnicity, race, age, sexual orientation, socio-
economic status and faith.

6. Mental health services should meet the developmental
realities of youth. Children and adolescents are not
simply little adults.

7. Whenever possible, families and/or caregivers should
be partners in the development of treatment decisions
and plans made for their children.

8. Multiple systems bear responsibility for these youth.
While at different times, a single agency may have
primary responsibility, these youth are the community’s
responsibility and all responses developed for these
youth should be collaborative in nature, reflecting the
input and involvement of the mental health, juvenile
justice and other systems.

9. Services and strategies aimed at improving the
identification and treatment of youth with mental
health needs in the juvenile justice system should be
routinely evaluated to determine their effectiveness in
meeting desired goals and outcomes.

B. Cornerstones
From the principles emerged four Cornerstones that form
the infrastructure of the Model and provide a framework
for putting the underlying principles into practice. The
Cornerstones reflect those areas where the most critical
improvements are necessary to enhance the delivery of
mental health services to youth involved with the juvenile
justice system, and include Collaboration, Identification,
Diversion and Treatment. The Model includes a discussion
of each Cornerstone, as well as detailed Recommended
Actions that provide direction on how to implement
or address each of these four issues. A brief summary
of each Cornerstone is presented below, along with the
accompanying Recommended Actions.

Collaboration. In order to appropriately respond and
effectively provide services to youth with mental health
needs, the juvenile justice and mental health systems should
collaborate in all areas and at all critical intervention
points.

Despite the large numbers of youth with mental health
needs in the juvenile justice system, the current landscape
of service delivery for these youth is often fragmented,
inconsistent and operating without the benefit of a
clear set of guidelines specifying responsibility for the
population. In the absence of such direction, a balanced
solution is required, one that recognizes that an effective
response must include the development of collaborative
approaches involving both the mental health and juvenile
justice systems.

The Recommended Actions for addressing Collaboration
include:

Blueprint for Change: A Comprehensive

Model for the Identification and Treatment

of Youth with Mental Health Needs in

Contact with the Juvenile Justice System

(Skowyra & Cocozza, in press), offers a

conceptual and practical framework for

juvenile justice and mental health systems

to use when developing strategies and

policies aimed at improving mental health

services for youth involved with the

juvenile justice system.

�

1. The juvenile justice and mental health systems should
recognize that many youth in the juvenile justice system
are experiencing significant mental health problems and
that responsibility for effectively responding to these
youth lies with both the mental heath and juvenile
justice systems.

2. The juvenile justice and mental health systems
should engage in a collaborative and comprehensive
planning effort to thoroughly understand the extent
of the problem at each critical stage of juvenile justice
processing and to identify joint ways to respond.

3. Any collaboration between the juvenile justice and
mental health systems should include family members
and caregivers.

4. The juvenile justice and mental health systems should
jointly identify funding mechanisms to support the
implementation of key strategies at critical stages of
juvenile processing to better identify and respond to
the mental health needs of youth.

5. The juvenile justice and mental health systems should
collaborate at every key stage of juvenile justice
processing, from initial contact with law enforcement
to re-entry.

6. Cross-training should be available for staff from the
juvenile justice and mental health systems to provide
opportunities for staff to learn more about each system
to understand phrases and terms common to each
systems and to participate in exercises and activities
designed to enhance systems collaboration.

Identification. The mental health needs of youth should
be systematically identified at all critical stages of juvenile
justice processing.

The development of a sound screening and assessment
capacity is critical in order
to effectively identify and
ultimately respond to mental
h e at h t r e at m e n t n e e d s .
Screening and assessment
should be routinely performed
at a youth’s earliest point of
contact with the system
and be conducted using
standardized instruments.
Further, the results of any
mental health assessment
should be linked to the
results of any risk assessment

performed to help guide decisions about a youth’s suitability
and need for diversion to community-based services.

The Recommended Actions for addressing Identification
include:

1. Every youth who comes in contact with the juvenile
justice system should be systematically screened for
mental health needs to identify conditions in need
of immediate response, such as suicide risk, and to
identify those youth who require further mental health
assessment or evaluation.

2. The mental health screening process should include
two steps- the administration of an emergency mental
health screen as well as a general mental health
screen.

3. Access to immediate, emergency mental health services
should be available for all youth, who based on the
results of the emergency screen or the mental health
screen, indicate a need for emergency services.

4. A mental health assessment should be administered to
any youth whose mental health screen indicates a need
for further assessment.

5. Instruments selected for identifying mental health
needs among the juvenile justice population should
be standardized, scientifically sound, have strong
psychometric properties, and demonstrate reliability
and validity for use with youth in the juvenile justice
population.

6. Mental health screening and assessment should be
performed in conjunction with risk assessments to
inform referral recommendations that balance public
safety concerns with a youth’s need for mental health
treatment.

7. All mental health screens and assessments should be
administered by appropriately
trained staff.

8. Policies controlling the
use of screening information
may be necessary to ensure
that information collected as
par t of a pre-adjudicatory
mental health screen is not used
inappropriately or in a way that
jeopardizes the legal interests
of youth as defendants.

9. Mental health screening
a n d a s s e s s m e n t s h o u l d b e

The Cornerstones reflect those areas

where the most critical improvements

are necessary to enhance the delivery of

mental health services to youth involved

with the juvenile justice system, and

include Collaboration, Identification,

Diversion and Treatment.

�

performed routinely as youth move from one point in
the juvenile justice system to another, for example, from
pre-trial detention to a secure correctional facility.

10. Given the high rates of co-occurring mental health
and substance use disorders among this population,
all screening and assessment instruments should target
mental health and substance abuse needs, preferably
in an integrated manner.

Diversion. Whenever possible, youth with identified mental
health needs should be diverted into effective community-
based treatment.

Many youth end up in the juvenile justice system for
behavior brought on by or associated with their mental
disorder. Some of these youth are charged with serious
offenses; many, however, are in the system for relatively
minor, non-violent offenses. Given the needs of these youth
and the documented inadequacies of their care within the
juvenile justice system, there is a growing sentiment that
whenever possible and matters of public safety allow, youth
with mental health needs should be diverted into effective
community treatment. Mental health experts agree that
it is preferable to treat youth with mental disorders outside
of juvenile correctional settings (Koppleman, 2005). At the
same time, however, a youth’s mental illness and level of
risk to community safety must both be taken into account
when determining whether a youth can be safely diverted
into community-based treatment. It is also recognized
that diversion into community-based treatment sometimes
involves on-going monitoring or supervision on the part of
the juvenile justice system in order to ensure compliance
with the terms of the referral or court order.

The Recommended Actions for addressing Diversion
include:

1. Whenever possible, youth with mental health needs
should be diverted to community treatment.

2. Procedures must be in place to identify those youth
who are appropriate for diversion.

3. Effective community-based services and programs
must be available to serve youth who are diverted into
treatment.

4. Diversion mechanism should be instituted at virtually
every key decision-making point within the juvenile
justice processing continuum.

5. Consideration should be given to the use of diversion
programs as alternatives to traditional incarceration
for serious offenders with mental health needs.

6. Diversion programs should be regularly evaluated to
determine their ability to effectively and safely treat
youth in the community.

Treatment. Youth with mental health needs in the juvenile
justice system should have access to effective treatment to
meet their needs.

Enormous advances have been made in this area over the
last decade and there are now evidence-based interventions
that are well-documented and proven effective for treating
mental disorders among youth (Hoagwood, 2005). These
include psychosocial approaches such as Cognitive
Behavioral Therapy (Rhode, Clarke, Mace, Jorgensen &
Seeley, 2004); community-based approaches such as Multi-
Systemic Therapy (Elliot et. al., 1998) and Functional
Family Therapy (Alexander & Sexton, 1999); and
medication therapy (Jensen & Potter, 2003). Currently,
however, the vast majority of mental health services
and programs available to treat youth involved with the
juvenile justice system are not evidence-based. More work
is necessary to promote the wider use of evidence-based
practices with justice-involved youth.

The Recommended Actions for addressing Treatment
include:

1. Youth in contact with the juvenile justice system who
are in need of mental health services should be afforded
access to treatment.

2. Regardless of the setting, all mental health services
provided to youth should be evidence-based.

3. Responsibility for providing mental health treatment to
youth involved with the juvenile justice system should
be shared between the juvenile justice and mental health
systems, with lead responsibility varying depending on
the youth’s point of contact with the system.

4. Qualified mental health personnel, either employed by
the juvenile justice system or under contract through
the mental health system should be available to provide
mental health treatment to youth in the juvenile justice
system.

5. Families should be fully involved with the treatment
and rehabilitation of their children.

�

Initial Contact and Referral: Often, a youth’s disruptive or
delinquent behavior is the result of a mental health problem
that has gone undetected and untreated. The problem may
manifest itself in behavior that brings the youth to the
attention of law enforcement. Police response at this initial
contact has significant implications in determining what
happens next. An opportunity exists at this point for law
enforcement, upon an encounter with a youth who appears
to have a mental health problem, to connect the youth with
emergency mental health services or refer the youth for
follow-up mental health screening and assessment.

Program Example: The Rochester, NY Community
Mobile Crisis Team responds to calls from the police,
as well as parents and schools, regarding youth
experiencing a mental health crisis in order to provide
these youth with immediate access to mental health
services. They perform assessments and facilitate
access to a range of intensive and coordinated mental
health services that are available through Youth
Emergency Services (YES) including outpatient,
home-based and mobile mental health services. The
team also conducts follow-up with the youth.

6. Juvenile justice and mental health systems must create
environments that are sensitive and responsive to the
trauma-related histories of youth.

7. Gender-specific services and programming should be
available for girls involved with the juvenile justice
system.

8. More research is necessary to ensure that evidence-based
interventions are culturally sensitive and designed to
meet the needs of youth of color.

9. All youth in the juvenile justice system should receive
discharge planning services to arrange for continuing
access to mental health services upon their release from
placement.

C. Critical Intervention Points and Program
Examples
The Cornerstones of the Model were then applied to the
juvenile justice processing continuum to identify places
within the entire continuum- from intake to re-entry-
where opportunities exist to make better decisions about
mental health needs and treatment. This examination
resulted in the identification of seven Critical Intervention
Points, shown in Figure 2, where the Cornerstones could be
addressed or implemented. These points include:

Initial
Contact

and
Referral

Intake

Detention

Judicial
Processing

Secure
Placement

Probation
Supervision

Re-entry

Figure 2: Critical Intervention Points

�

Program Example: The Bernalillo County, New
Mexico Juvenile Detention Center (BCJDC) developed
an intake process that identifies youth with mental
health needs and diverts these youth to a community
mental health clinic, the Children’s Community
Mental Health Clinic, which is located 200 yards
away from the detention center. The clinic serves
all youth in the county and accepts referrals from
the juvenile detention center, care providers, parents
and others, thereby reducing any incentive to refer
youth to detention simply in order to access mental
health services. Youth brought to the detention center
undergo a comprehensive intake screen to identify any
mental health problems. Youth identified as in need
of immediate services or further evaluation are walked
to the clinic, where they receive a variety of clinical
services including individual therapy, medication
management, substance abuse services and case
management. Services are provided to youth while
they are in detention, as well as in their homes after
they are released.

Judicial Processing: It is of critical importance that judges
have sufficient information about a youth’s mental health
treatment history and current needs in order to determine
how a youth’s mental health disorder may have contributed
to the problem behavior or offense, and to make an informed
dispositional decision. Ideally, information on a youth’s
mental health status should be collected prior to the youth’s
case being referred to the court for an adjudicatory hearing,
and the information used to divert the youth to treatment
earlier in the process. However, for many youth, these
diversion opportunities do not exist and the first attempt
to identify any mental health concerns come at the time
when a youth has been adjudicated and intake staff are
developing recommendations to the court. Every effort
must be made to ensure that a youth’s mental status is
thoroughly evaluated at this stage so that this information
can be presented to the court and considered as part of the
dispositional plan.

Intake: Intake is very often viewed as the “gatekeeper”
to family court and represents an ideal opportunity to
intervene early and identify the need for mental health
and other types of rehabilitative services. Considering
the potential influence that intake decisions can have
on subsequent juvenile justice processing, it constitutes
one of the most critical points within the juvenile justice
continuum for applying prevention and early intervention
strategies (Kelly & Mears, 1999). These strategies include
the use of standardized mental health screening and
assessment measures on all youth entering intake, as well
as the institution of diversion mechanisms and programs
so that youth in need of mental health services can be
appropriately diverted into community-based treatment.

Program Example: Family Intervention Specialists
(FIS) of Georgia provide intensive family intervention
services to youth with mental health disorders, who
are at risk of out of home placement. At intake,
specialized probation officers, who are trained to
identify mental health and substance use disorders
among youth, use the MAYSI-2 to screen all youth
at intake. Youth diverted to the program undergo
further evaluation and receive Brief Strategic Family
Therapy as the primary intervention. Services are
provided by FIS staff who work closely with probation
throughout the period of involvement.

Detention: Juvenile detention can be a traumatic experience
for all youth but the situation can be much worse for youth
with mental health needs. Feelings of depression, anxiety
and hopelessness are heightened for all youth in detention,
some of whom are experiencing their first separation from
parents or caregivers, but can be more intense for youth
with mental health problems. Detention can also mean an
interruption in both medication and therapeutic services
for youth who receive these things in the community.
Employing standardized mental health screening and
assessment measures for all youth entering detention
is critical. The institution of diversion mechanisms at
detention is also recommended to identify those youth who
could be safely diverted to community-based treatment.
Finally, in order to ensure access to treatment, linkages
between the detention center and community-based mental
health providers should be established to provide treatment
to youth while they are in detention.

�

The Model provides a detailed blueprint

for how to achieve these goals. What it

cannot do, however, is actually affect

the change. That must come from the

leaders in the juvenile justice and mental

health fields who have been struggling to

develop solutions for these youth.

Program Example: The Cook County, Illinois Juvenile
Court Clinic is responsible for providing a variety
of services to judges and court personnel regarding
clinical information in juvenile court proceedings. A
multidisciplinary staff of psychologists, psychiatrists,
social workers and lawyers provide consultation
regarding requests for clinical information, forensic
clinical assessments and information regarding
community-based mental health resources. With a
clinical coordinator present in the court room, the
Court Clinic is able to provide guidance to judges
and probation staff about whether an evaluation is
necessary and whether a youth’s needs can be met in
a community-based program or setting.

Secure Correctional Placement: The most restrictive
sanction a juvenile court can impose entails committing a
youth to a secure juvenile correctional facility. Traditional
juvenile correctional facilities have not been found to be
effective in running rehabilitative programs (Greenwood,
Model, Rydel & Chiesa, 1996), or at reducing recidivism
(Howell, 1998). Further, recent government investigations
have documented the failure of many facilities to meet even
the most basic of mental health needs of youth in their
care (US Department of Justice, 2005). It is critical that
future efforts focus on the development and implementation
of evidence-based mental health treatments that can be
provided to youth during their incarceration.

Program Example: Recognizing the sizable population
of youth with mental health needs in their system,
the Washington State Juvenile Rehabilitation
Administration (JRA) created a prog ram that
incorporates best practice interventions for youth
with mental health needs. The Integrated Treatment
Model (ITM) takes the evidence-based components
of Functional Family Therapy, Cognitive Behavioral
Therapy, and Dialectical Behavior Therapy and uses
these therapies to provide individual treatment and
skill development to youth from the point that they
are admitted to the facility through their release
back to the community (Juvenile Rehabilitation
Administration, 2002). Staff within the facilities
are extensively trained to use cognitive-behavioral
treatment interventions to address the multiple needs
of youth and prepare them for their return home.
JRA also redesigned its aftercare program, creating
a new service delivery model based on Functional
Family Therapy, which gears aftercare services to the
entire family, not just the youth.

Probation Supervision: Probation supervision is the
sanction most often applied to adjudicated youth in a
dispositional hearing. Often, a judge will impose a period
of probation with other conditions, such as participation
in treatment, as well as restitution or community service.
This represents an ideal opportunity to link a youth with
treatment, while at the same time, affording the leverage of
the juvenile court to ensure that the youth complies with
the terms of the disposition.

Program Example: The Integrated Co-Occurring
Treatment Program in Akron, Ohio is an intensive
home-based treatment model specifically designed
to treat mental health and co-occurring substance
use disorders among youth referred by the court as a
condition of probation. Program clinicians, who work
with the youth’s probation officers, are available to
youth and their families 24 hours a day, 7 days a week
and use individual and family therapy interventions
to focus on skill development and asset building while
simultaneously addressing risk reduction. Services are
delivered in the home, school and community.

Re-Entry: The goal of a placement is to successfully
rehabilitate youth for their eventual return home. Critical
to this is recognizing a youth’s need for mental health
services while in custody, providing effective treatment

10

while a youth is in care, and ensuring that linkages are
securely in place to allow for continued access to mental
health care upon release. Ideally, planning for a youth’s
re-entry into the community should begin shortly after a
youth’s arrival in the facility, and should include efforts
to ensure a youth’s enrollment in Medicaid or some type
of insurance plan to pay for services once the youth is
released.

Program Example: Project Hope, originally supported
by a federal Systems of Care grant, is an aftercare
program in Rhode Island that targets youth with
serious emotional disturbances who are returning to
their communities from the Rhode Island Training
School (RITS). All youth with a mental health
diagnosis are eligible to participate. Project Hope
services are accessed by youth transitioning out of
the training school through the RITS clinical social
worker 90 to 120 days prior to the youth’s discharge.
Family service coordinators work closely with the
clinical social worker while the youth is incarcerated
and with the youth’s probation officer when the youth
returns to the community. Individualized service
plans are modified as necessary and a case manager
is assigned to ensure implementation of the plan for
a period of 9 to 12 months following discharge.

III. Affecting change:
What happens Next?

The Comprehensive Model provides a conceptual and
practical framework for responding to the large numbers
of youth in the juvenile justice system with mental health
needs. This challenging project has culminated in the
first-ever systematic review of the juvenile justice system
in its entirety to identify ways in which mental health
service delivery strategies can be strengthened. While the
document is targeted to state and county administrators
and program directors from the juvenile justice and mental
health systems, all staff within those systems can benefit
from the information and examples provided. The Model
also serves a dual role. It offers a blueprint for how mental
health issues can be better addressed within the juvenile
justice system as a whole; it also compartmentalizes the
system into discreet points of contact, allowing jurisdictions
to consider implementing individual components of the
Model as a first step in improving their system.

The premise of the Model is not complicated: stronger
partnerships between the juvenile justice and mental health
systems can result in better screening and assessment
mechanisms at key points of juvenile justice system
contact; enhanced diversion opportunities for youth with
mental health needs to be treated in the community; and
increased access to effective mental health treatment. The
Model provides a detailed blueprint for how to achieve these
goals. What it cannot do, however, is actually affect the
change. That must come from the leaders in the juvenile
justice and mental health fields who have been struggling to
develop solutions for these youth. The Model provides the
tool to move forward. The energy, hard work and political
will to make this happen must come from them.

(For an electronic copy of the Model, please visit the National Center for
Mental Health and Juvenile Justice website at www.ncmhjj.com).

References
Alexander, J. & Sexton, T. (1999). Functional Family

Therapy: Principles of clinical intervention, assessment,
and implementation. Henderson, NV: Functional Family
Therapy, Inc.

Elliot, D., Henggeler, S., Mihalic, S., Rone, L., Thomas, C.,
& Timmons-Mitchell, J. (1998). Blueprints for violence
prevention: Book six – Multisystemic Therapy. Boulder, CO:
Center for the Study and Prevention of Violence.

Greenwood, P., Model, K., Rydel, C., & Chiesa, J. (1996).
Diverting children from a life of crime: Measuring costs and
benefits. Arlington, VA: RAND Corporation.

Hoagwood, K. (2005). Research and policy update: Evidence-
based practices for youth with mental health problems and
implications for juvenile justice. Unpublished manuscript.
Delmar, NY: National Center for Mental Health and
Juvenile Justice.

Howell, J. (1998). NCCD’s survey of juvenile detention and
correctional facilities. Crime & Delinquency, 44(1), 102-
109.

Jensen, J., Potter, C. (2003). The effects of cross-system
collaboration on mental health and substance use problems
of detained youth. Research on Social Work Practice, 13(5),
588-607.

Kelly, W. & Mears, D. (1999). An evaluation of the efficiency and
effectiveness of juvenile justice initial assessment and referral
process in Texas. Austin, TX: Hogg Foundation for Mental
Health.



11

About the authors…

Kathleen Skowyra is a Senior Consultant to, and
previous Associate Director of, the National Center
for Mental Health and Juvenile Justice at Policy
Research Associates. Joseph J. Cocozza, Ph.D. is the
Director of the National Center for Mental Health
and Juvenile Justice and Vice President for Research
at Policy Research Associates. Ms. Skowyra and
Dr. Cocozza are the authors of the Center’s report
Blueprint for Change: A Comprehensive Model for the
Identification and Treatment of Youth with Mental
Health Needs in Contact with the Justice System.

Koppelman, J. (2005). Mental health and juvenile justice:
Moving toward more effective systems of care. Washington,
DC: National Health Policy Forum.

Juvenile Rehabilitation Administration. (2002). Integrated
Treatment Model report. Olympia, WA: Washington State
Department of Social and Health Services.

National Alliance for the Mentally Ill. (2001). Families on the
brink: The impact of ignoring children with serious mental
illness. Arlington, VA: National Alliance for the Mentally
Ill.

Otto, R., Greenstein, J., Johnson, M., & Friedman, R. (1992).
Prevalence of mental disorders among youth in the juvenile
justice system. In J. Cocozza (Ed.). Responding to the mental
health needs of youth in the juvenile justice system. Seattle,
WA: National Coalition for the Mentally Ill in the Criminal
Justice System.

Rhode, P., Clarke, G., Mace, D., Jorgensen, J., & Seeley, J. (2004).
An efficacy/effectiveness study of cognitive-behavioral
treatment for adolescents with comorbid major depression
and conduct disorder. Journal of the American Academy of
Child and Adolescent Psychiatry, 43(6), 660-668.

Shufelt, J.S. & Cocozza, J.C. (in press). Youth with mental health
disorders in the juvenile justice system: Results from a multi-
state, multi-system prevalence study. Delmar, NY: National
Center for Mental Health and Juvenile Justice.

Sickmund, M. (2004). Juveniles in corrections. Juvenile offenders
and victims national report series. Washington, DC: U.S.
Department of Justice, Office of Justice Programs, Office
of Juvenile Justice and Delinquency Prevention.

Skowyra, K. & Cocozza, J. (in press). Blueprint for change: A
comprehensive model for identification and treatment of youth
with mental health needs in contact with the juvenile justice
system. Washington, DC: US Department of Justice,
Office of Justice Programs, Office of Juvenile Justice and
Delinquency Prevention.

Teplin, L., Abram, K., McClelland, G., Dulcan, M., & Mericle,
A. (2002). Psychiatric disorders in youth in juvenile detention.
Archives of General Psychiatry, 59(12), 1133-1143.

Wasserman, G., Ko, S., & McReynolds, L. (2004). Assessing the
mental health status of youth in juvenile justice settings.
Juvenile Justice Bulletin, (August),1-7.

Wasserman, G., McReynolds, L., Lucas, C., Fisher, P., & Santos,
L. (2002). The Voice DISC-IV with incarcerated male youths:
Prevalence of disorder. Journal of the American Academy of
Child and Adolescent Psychiatry, 41(3), 314-321.

Wierson, M., Forehand, R., & Frame, C. (1992). Epidemiology
and treatment of mental health problems in juvenile
delinquents. Advances in Behaviour Research and Therapy,
14, 93-120.

United States Department of Justice. (2005). Department of
Justice Activities Under The Civil Rights of Institutionalized
Persons Act: Fiscal Year 2004. Washington, DC: United
States Department of Justice. Retrieved July 15, 2005 from
http://www.usdoj.gov/crt/split/document/split_cripa04pdf.

United States House of Representatives. (2004). Incarceration
of youth who are waiting for community mental health services
in the United States. Washington, DC: Committee on
Government Reform.

1�

About the National Center for Mental
Health and Juvenile Justice

Recent findings show that large numbers
of youth in the juvenile justice system have
serious mental health disorders, with many
also having a co-occurring substance use
disorder. For many of these youth, effective
treatment and diversion programs would
result in better outcomes for the youth and
their families and less recidivism back into
the juvenile and criminal justice systems.
Policy Research Associates has established
the National Center for Mental Health and
Juvenile Justice to highlight these issues.
The Center has four key objectives:

• Create a national focus on youth with
mental health disorders in contact with
the juvenile justice system

• Serve as a national resource for the
collection and dissemination of evidence-
based and best practice information to
improve services for these youth

• Conduct new research and evaluation to
fill gaps in the existing knowledge base

• Foster systems and policy changes at the
national, state and local levels to improve
services for these youth

For more information about the Center visit
our website at www.ncmhjj.com.

Joseph J. Cocozza, PhD
Director

For more information…
about the Blueprint, contact:

National Center for Mental Health and
Juvenile Justice

Policy Research Associates, Inc.
345 Delaware Avenue
Delmar, NY 12054

Phone: 518-439-7415
Email: [email protected]
Website: www.ncmhjj.com

Office of Juvenile Justice and Delinquency
Prevention (OJJDP)
810 7th Street, NW

Washington, DC 20531
Phone: 202-514-9395

Transition Age Youth With Mental Health

Challenges in the Juvenile Justice System

Transition Age Youth

Transition Age Youth With Mental Health Challenges in the Juvenile Justice System

Kristyn Zajac
Family Services Research Center

Department of Psychiatry and Behavioral Sciences
Medical University of South Carolina

Ashli J. Sheidow
Family Services Research Center

Department of Psychiatry and Behavioral Sciences
Medical University of South Carolina

Maryann Davis
Center for Mental Health Services Research

Department of Psychiatry
University of Massachusetts Medical School

September 2013

Transition Age Youth

About the Technical Assistance Partnership for Child and Family Mental Health

The Technical Assistance Partnership for Child and Family Mental Health (TA

Partnership) provides technical assistance to system of care communities that are currently

funded to operate the Comprehensive Community Mental Health Services for Children and

Their Families Program. The mission of the TA Partnership is “helping communities build

systems of care to meet the mental health needs of children, youth, and families.”

This technical assistance center operates under contract from the Federal Child,

Adolescent and Family Branch, Center for Mental Health Services, Substance Abuse and

Mental Health Services Administration, U.S. Department of Health and Human Services.

The TA Partnership is a collaboration between two mission‐driven organizations:

 American Institutes for Research—committed to improving the lives of

families and communities through the translation of research into best

practice and policy, and

 The National Federation of Families for Children’s Mental Health—dedicated

to effective family leadership and advocacy to improve the quality of life of

children with mental health needs and their families.

The TA Partnership includes family members and professionals with extensive

practice experience employed by either American Institutes for Research or the National

Federation of Families for Children’s Mental Health. Through this partnership, we model the

family‐professional relationships that are essential to our work. For more information on the

TA Partnership, visit the Web site at http://www.tapartnership.org.

Suggested Citation:

Zajac, K., Sheidow, A. J., & Davis, M. (2013). Transition age youth with mental health

challenges in the juvenile justice system. Washington, DC: Technical Assistance Partnership

for Child and Family Mental Health.

Transition Age Youth

Acknowledgments

This publication was supported by funding from the Substance Abuse and Mental

Health Services Administration (SAMHSA, through American Institutes for Research); the

National Institute on Drug Abuse, National Institutes of Health (NIH, Grant K12DA031794);

and the National Institute on Disability and Rehabilitation Research (NIDRR), U.S.

Department of Education (Grant H133B090018). The content is solely the responsibility of

the authors and does not necessarily represent the official views of the NIH, NIDRR, or

SAMHSA.

Transition Age Youth

Foreword

Each year, more than 2 million children, youth, and young adults formally come into contact

with the juvenile justice system, while millions more are at risk of involvement with the

system for myriad reasons (Puzzanchera, 2009; Puzzanchera & Kang, 2010). Of those

children, youth, and young adults, a large number (65–70 percent) have at least one

diagnosable mental health need, and 20–25 percent have serious emotional issues (Shufelt &

Cocozza, 2006; Teplin, Abram, McClelland, Dulcan, & Mericle, 2002; Wasserman,

McReynolds, Lucas, Fisher, & Santos, 2002). System of care communities focusing on meeting

the mental health and related needs of this population through comprehensive community-

based services and supports have the opportunity to not only develop an understanding

around the unique challenges this population presents, but also to decide how best to

overcome those challenges through planned and thoughtful programs, strong interagency

collaboration, and sustained funding.

The Technical Assistance Partnership for Child and Family Mental Health (TA Partnership)

recognizes the many challenges system of care communities face in working to better meet

the needs of all of the children, youth, and young adults they serve. In an effort to help these

communities meet the unique needs of young people involved or at risk of involvement with

the juvenile justice system, the TA Partnership is releasing a resource series focused on this

population. The TA Partnership has contracted with the National Center for Mental Health

and Juvenile Justice (NCMHJJ) and other experts in the field to produce this resource series.

Each brief examines a unique aspect of serving this population, from policy to practice,

within system of care communities.

We hope that this publication will support the planning and implementation of

effective services, policies, and practices that improve outcomes for young adults of

transition age who are involved in or at risk of involvement with the juvenile justice system

as well as their families.

Transition Age Youth 1

Transition Age Youth With Mental Health Challenges in the

Juvenile Justice System

Kimberly, now 18 years old, grew up in a poor neighborhood and experienced a lot of

family conflict as a child. She was placed in foster care as a teenager because of allegations

that her mother was physically abusive. After her foster parents discovered that Kimberly was

involved in prostitution and also had stolen money from the foster family, they reported her

to the police. Due to these charges, Kimberly has been involved with the juvenile justice

system for the past two years. Because of her “problem teen” status, her caseworker was

unable to find a foster family to place her with, and none of her own family members were

willing to take her back in their homes after she was on probation. No other child welfare

placements were available, so Kimberly was placed in a group home for delinquent girls,

where she had a rough time adjusting to the placement. She told her probation officer that

she was having trouble sleeping and having disturbing thoughts about an incident that had

happened to her in one of her foster placements. When her probation officer pressed her for

details, Kimberly disclosed that she had been sexually assaulted when she was out on the

streets. Fortunately, her probation officer recognized that Kimberly was having symptoms

related to her trauma history and helped her to schedule an appointment at a local mental

health clinic. The probation officer also made sure Kimberly made it to her intake

appointment. Unfortunately, after the assessment, the therapist discovered that Kimberly

could not be seen at the clinic because it did not accept Medicaid. The probation officer

helped Kimberly find another clinic in the community that would take her insurance, but her

records from the first clinic were not transferred in time for her first appointment. Kimberly

had to complete another intake and was frustrated that she had to tell her story to another

therapist. Her therapist had a large caseload of adult patients and could schedule Kimberly

for an appointment only every other week; Kimberly felt that her therapist did not really “get”

what her life was like. When Kimberly started therapy, it became clear to her therapist that

she needed a medication evaluation, but the next available appointment was not for two

months. By then, Kimberly had dropped out of care. Kimberly missed three appointments in a

row, and when her therapist tried to reach her, Kimberly’s prepaid cell phone had been

Transition Age Youth 2

turned off. Due to the clinic’s “no-show” policy, Kimberly’s case was closed, and she was not

allowed to return to the clinic.

Kimberly continued struggling with her group home placement. She was not getting

along with her peers, and she wanted a more independent living situation. At 18, she felt she

was too old to be living in a placement. She would leave the group home for days, staying

with friends and wandering the streets. Kimberly’s child welfare social worker found some

information on a program to help former foster care children find and pay for housing. The

one stipulation was that Kimberly would have to participate in supervision through child

welfare until her 21st birthday. The supervision included random drug testing and a group-

based skills development program. Kimberly wanted nothing to do with this type of

supervision. She turned down the opportunity to participate in this program and stayed in the

group home, waiting to age out of the child welfare system and leave.

Kimberly’s social worker remained concerned about her transition from the group

home to independent living because Kimberly had never had a job and didn’t finish high

school. Kimberly would not be able to afford housing without a job, so the social worker

talked her into using the local vocational rehabilitation services in her community. The

social worker told Kimberly that she could get a paid internship right away if she was

willing to use their services. Unfortunately, the vocational rehabilitation center couldn’t

offer Kimberly an appointment until six weeks later. By the time her appointment came

up, she had been moved to a new group home in the next town and was no longer eligible

for the services where her appointment had been scheduled. Her social worker secured an

appointment at the vocational rehabilitation center in Kimberly’s new town, but she had

to go to the back of the waiting list.

Kimberly’s experience represents an all-too-common occurrence for young people

with mental health problems in the juvenile justice system. The current system for

rehabilitation often fails to address or even presents barriers to meeting the multiple needs

of such youth. This is compounded by the multiple transitions in life roles that occur during

this important developmental period. The purpose of this paper is to provide an overview for

mental health practitioners, juvenile justice professionals, and policymakers whose work

Transition Age Youth 3

brings them in contact with transition age youth with significant mental health needs in the

juvenile justice system. Topics reviewed include normative developmental processes during

the transition age, difficulties faced by transition age youth with mental health problems in

the juvenile justice system, policies and programs that have been shown to help with

transition for these youth, and additional suggestions for best practice and policy.

Transition Age Youth 4

Overview

The term transition age youth refers to individuals aged 16 to 25 years. For the

purposes of this review, we focus on ages 16 to 21, as this is the period during which

transition age youth are likely to be involved with the juvenile justice system. Also for our

purposes, our definition of mental health problems includes diagnosable mental health

disorders exclusive of developmental disorders and mental health diagnoses due to a

physical health problem. Substance use disorders will not be included in this definition but

will be discussed as a common co-occurring condition. The most common mental health

disorders among youth in the juvenile justice system are disruptive behavior disorders (e.g.,

attention deficit hyperactivity disorder, conduct disorder), anxiety disorders (e.g.,

posttraumatic stress disorder, generalized anxiety disorder), and mood disorders (e.g., major

depression, bipolar disorder) (Skowyra & Cocozza, 2007). However, there is an important

distinction between disruptive behavior disorders and other mental health problems for

transition age youth. A disruptive behavior disorder diagnosis allows minors to access

services in the child mental health system, but adults presenting solely with a disruptive

behavior disorder are explicitly denied coverage in the adult mental health system (Davis &

Koroloff, 2006). Thus, transition age youth with primarily behavioral disorders are often in

the position of losing access to mental health services as they age out of child systems.

Because this is an important problem for justice-involved transition age youth, differentiation

between disruptive behavior and other disorders will be made throughout this review.

Development During the Transition to Adulthood

The transition from adolescence to adulthood represents a unique developmental

period, with significant changes in educational, vocational, and relational roles and

expectations in the face of reduced family influence and changing social networks (Arnett,

2000). This transitional period presents challenges for even the most well-adjusted youth as

they navigate new roles in educational, vocational, and relationship domains. This is the time

when many youth make long-term decisions about careers and families and move from their

family of origin to more independent living situations. In fact, the capacity to make decisions

for oneself is a critical skill to develop during this stage of life. Further, aspects of executive

Transition Age Youth 5

functioning—including good judgment and decision making in the face of peer influence and

the ability to pursue goals in the face of emotional distractions—also mature through this

social interplay and critically influence behavior and future decision making. The normative

transitions that occur during this age include the completion of schooling or vocational

training, obtaining and maintaining gainful employment, contributing to household income,

developing a social network outside of one’s family, and becoming a productive citizen.

Success in these domains is determined by a complex interplay between youth, their families

and neighborhoods, and available opportunities.

Potential Pitfalls of the Transition Age

The importance of this developmental period lies not only in the important tasks that

are accomplished but also in the risk for substantial impediments. For example, the transition

age is when onset of mental health problems peaks, and the vast majority of mental health

disorders have onset by the early 20s (Kessler et al., 2005; Kim-Cohen et al., 2003; Newman

et al., 1996; Substance Abuse and Mental Health Services Administration [SAMHSA], 2012).

Epidemiological studies have shown an increase in mental health problems beginning in

middle adolescence and peaking in late adolescence and early adulthood, with past-year

prevalence rates of 29 percent to 40 percent between the ages of 18 and 25, when substance

use disorders were included (Newman et al., 1996; SAMHSA, 2012). Rates of serious mental

illness, defined as a diagnosable mental health problem that results in significant functional

impairment, are less common but still are more prevalent during the transition age (7.7

percent) than at any other developmental period (SAMHSA, 2012). At the same time,

utilization of mental health services declines sharply during the transition age, presumably

due to the multiple barriers to care that occur during this period, including loss of health

coverage and the transition from child to adult service systems (Pottick, Bilder, Vander Stoep,

Warner, & Alvarez, 2008).

This transition age also has the highest rates of onset of problematic substance use

and substance use disorders (i.e., abuse, dependence) (Chassin, Flora, & King, 2004; Delucchi,

Matzger, & Weisner, 2008; SAMSHA, 2009). A large majority (90 percent) of young adults

reported having used alcohol in their lifetime, and 61 percent reported lifetime illicit drug

Transition Age Youth 6

use (SAMSHA, 2008). Prevalence of substance use disorders follows a similar pattern, with

the past-year prevalence of 9 percent among youth between the ages of 12 and 17,

increasing to 21 percent among youth aged 18 to 25 years (SAMSHA, 2005). Criminal

behavior tends to peak between the ages of 15 and 19 (Farrington, 2005), although there is

evidence that this peak occurs later for youth with mental health problems (i.e., between 18

and 20) (Davis, Banks, Fisher, Gershenson, & Grudzinskas, 2007). Further, the rise in criminal

activity is compounded by the transition into adulthood, as the justice system no longer

views such behavior with a juvenile lens, and the youth may face criminal rather than

juvenile delinquency charges. For youth who struggle during the transition to adulthood,

having multiple problems is the rule rather than the exception (Osgood, Foster, & Courtney,

2010), as youth who develop one of these problems are at substantial risk for developing

additional related difficulties.

Substantial adversity during this developmental period has the capacity to delay or

derail the achievement of normative transitions, with the potential for setbacks associated

with long-term negative outcomes. Thus, youth struggling with mental health problems and

juvenile justice involvement are at a marked disadvantage compared with their peers as they

enter the transitional age, a developmental period that typically necessitates substantial

resources even under the best circumstances. Further, youth at the highest risk for

experiencing these types of setbacks are those from disadvantaged psychosocial

backgrounds who already have experienced multiple lifetime adversities (Chung, Little, &

Steinberg, 2005). Specifically, these youth have accumulated disadvantage that often

includes poverty, poor relationships with parents and other family members, school failure

and/or dropout, negative peer groups, and the lack of adult role models. These histories of

disadvantage often do not provide the resources necessary to overcome the substantial

challenges faced by multiproblem transition age youth.

There is also compelling evidence that the brain, particularly as it relates to executive

functioning, is not yet fully developed during adolescence and the transition to adulthood

(Albert & Steinberg, 2011). Anatomical studies show that the prefrontal cortex and its links to

other brain regions, including the amygdala and striatum in the limbic system, continue to

develop through early adulthood (Casey, Galvan, & Hare, 2005; Yurgelun-Todd, 2007).

Transition Age Youth 7

Adolescents and transition age youth show deficits in areas of executive functioning,

including impulse control, planning, and decision making, compared with adults (Eshel,

Nelson, Blair, Pine, & Ernst, 2007; Somerville & Casey, 2010). Indeed, tasks that require

behavioral control over responses have a developmental brain maturation trajectory that

continues until the early 30s (Hare et al., 2008; Liston et al., 2006). This continued brain

development partially explains the challenges that many transition age youth face in making

effective decisions, controlling impulsive behavior, and engaging in the long-term planning

needed for success across all life domains.

Mental Health Problems and Juvenile Justice Involvement During the

Transition Age

Transition age youth with mental health problems are at increased risk for

involvement in the justice system compared with their peers (Davis et al., 2007; Grisso,

2004). Further, they represent an important and complex group in the juvenile justice system

as they face both the developmental challenges of this period and present with substantial

barriers to a successful transition to adulthood. They almost always experience multiple

problems that can complicate both rehabilitation and the successful transition to adulthood.

Thus, they have the capacity to incur significant costs to themselves, their families, the

justice system, and their communities.

Juveniles in the Justice System

The very definition of juvenile varies by state, meaning that youth in many states

remain in the juvenile justice system well into the transition age while youth in other states

are transferred to the adult justice system. First, there is variability across states in the upper

age of jurisdiction in the juvenile court—that is, the age at which an individual engaging in a

law-violating behavior would be processed in the juvenile versus adult court system. As

Figure 1 shows, the large majority of states consider crimes committed through the age of 17

as juvenile offenses. A few states have an upper age of 16, and New York and North Carolina

process only crimes committed through the age of 15 in the juvenile system. There also is

variability across states in the age at which juvenile justice system involvement is terminated.

As presented in Table 1, only a few states’ juvenile justice systems end their involvement

Transition Age Youth 8

with youth when they turn 18. It is far more common for youth to remain under juvenile

jurisdiction through the age of 20, with some states allowing for extension up to age 24 or to

the full term of the disposition order. Thus, simply living in a different location can

dramatically impact how a youth’s behavior is addressed.

Views of young people involved in the justice system also have changed substantially

over the past few decades. Separation of the justice system into juvenile and adult courts

began at the state level in the late 1800s (Commission on Behavioral and Social Sciences and

Education, 2001). This movement was based on the recognition that juveniles were

developmentally distinct from adults and, thus, should be held to different standards

regarding criminal behavior. In addition, juvenile justice was seen as an opportunity to

rehabilitate youth rather than solely punish them for criminal behavior. However, during the

peak of violent criminal behaviors among youth in the early 1990s, there was a public call for

a more punitive approach, with the hope that more severe consequences would lead to

decreased recidivism. Unfortunately, this movement has served to suppress rehabilitative

approaches for juveniles and has increased the number of youth transferred to the adult

justice system. These changes likely compound the barriers to effective services for youth

with mental health concerns. Further, transferring youth from the juvenile to adult justice

system can lead to poor outcomes for youth, including increased likelihood of arrest for

future crimes (Centers for Disease Control and Prevention [CDC], 2007; Schubert et al.,

2010). Currently, the juvenile justice system is struggling to find a balance between punishing

delinquent acts and providing rehabilitative services in the best interest of the youth (for a

review, see Weiss, 2013).

Transition Age Youth in the Juvenile Justice System

Transition age youth involved with the juvenile justice system are examples of “the

perfect storm” of the potential perils of this developmental period. First, mental health

problems are quite common in this group; however, it should be noted that due to a paucity

of research on this age group, the majority of what is known about the prevalence of mental

health problems comes from studies of adolescents (i.e., 13- to 17-year-old youth). One

study of youth entering nonresidential juvenile justice settings (e.g., probation) estimated

Transition Age Youth 9

that 45 percent of boys and 50 percent of girls meet diagnostic criteria for at least one

mental health disorder (Wasserman, McReynolds, Ko, Katz, & Carpenter, 2005), and studies

of residential juvenile justice facilities have shown higher rates, between 65 percent and 70

percent (Shufelt & Cocozza, 2006; Teplin, Abram, McClelland, Dulcan, & Mericle, 2002;

Wasserman, McReynolds, Lucas, Fisher, & Santos, 2002). Further, even when behavioral

disorders (e.g., substance use, conduct disorders) were not considered, 45.5 percent of

youth in residential justice settings met criteria for a mental health disorder (Shufelt &

Cocozza, 2006).

Similar to non-justice-involved youth, comorbidity rates are high for justice-involved

youth, with an estimated 79 percent of youth with one mental health disorder also meeting

diagnostic criteria for at least one other disorder, and more than 60 percent meeting criteria

for a substance use disorder (Shufelt & Cocozza, 2006). Often, co-occurring conditions

predict worse outcomes; for example, youth with co-occurring behavioral problems (e.g.,

substance use, conduct disorder) and emotional problems (e.g., anxiety, depression) are at

elevated risk for recidivism (Cottle, Lee, & Heibrun, 2001; Hoeve, McReynolds, & Wasserman,

2013) and committing violent offenses during young adulthood (Copeland, Miller-Johnson,

Keeler, Angold, & Costello, 2007). Given these high rates of mental health and substance use

disorders, juvenile justice programs are responsible for a large proportion of youth who have

mental health needs, highlighting the importance of effective management and treatment by

this system (Cocozza & Skowyra, 2000).

Transition age youth with justice involvement and a mental health disorder often

face other roadblocks to the successful negotiation of the transition age period. For instance,

youth in the justice system often come from economically disadvantaged, single-parent

households (Foster & Gifford, 2005). Successful transitions to adulthood increasingly depend

on financial and other material support from families well beyond adolescence (Settersten,

Furstenberg, & Rumbaut, 2008), an advantage that many justice-involved youth do not have.

In addition, these youth show high rates of learning disabilities as well as a history of school

failure. As a group, justice-involved youth tend to have intellectual functioning in the low-

average to average range, and many show academic deficits in reading, math, and written

and oral language, either due to learning disabilities or lack of educational engagement

Transition Age Youth 10

(Foley, 2001). In one large study of juvenile offenders ages 10 to 20 in long-term custody

settings, almost 20 percent had a specific learning disability, and youth with elevated mental

health symptoms were even more likely to have a learning disability (Cruise, Evans, &

Pickens, 2011). Justice-involved youth also have high rates of involvement with the child

welfare system. More than 60 percent of transition age youth considered “serious offenders”

in juvenile detention had a history of child welfare involvement due to child maltreatment

(Langrehr, 2011). In another study, 58 percent of youth up to age 19 with mental health

problems in the justice system had a family member who was the focus of a child protective

services investigation (Sullivan, Veysey, Hamilton, & Grillo, 2007). Overall, youth with a

substantiated history of maltreatment have approximately 50 percent more contacts with

the juvenile justice system compared with youth without such a history, and approximately

16 percent of youth placed in foster care come into contact with the juvenile justice system

(Ryan & Testa, 2005). Rates of juvenile delinquency are even higher among youth placed in

group home settings as part of their involvement with child welfare (Ryan, Marshall, Herz, &

Hernandez, 2008). Thus, most justice-involved youth with mental health problems have

greatly compromised development and lack the “natural” supports for transitioning to

adulthood. To facilitate successful adult functioning and reduce the likelihood of recidivism,

the juvenile justice system should not only provide mental health treatment but also assess

and provide supports for youth’s impending adulthood.

Incarcerated Transition Age Youth and Reentry

Currently, there is substantial variability in outcomes for youth involved in the

juvenile justice system. Among youth processed and adjudicated delinquent by the juvenile

justice system in 2009, 27 percent were placed in residential settings, 60 percent were

placed on probation, and 13 percent received other sanctions (Knoll & Sickmund, 2012).

Thus, the majority of youth involved in the justice system are not incarcerated. However, the

incarcerated youth make up a significant minority of the juvenile justice population. Many of

the estimated 200,000 juveniles and young adults ages 24 and under returning from

incarceration each year (Mears & Travis, 2004) will face reentry during their transition to

adulthood. For the most part, reentry programs have been developed and studied with adult

populations; thus, little is known about their effectiveness with transition age youth

Transition Age Youth 11

(Farrington, Loeber, & Howell, 2012). Further, the reentry problems faced by transition age

youth with mental health problems are likely to be even greater than those seen in adult

populations. First, youth often lack the education and skills necessary to find gainful

employment. In fact, one study found that only 31 percent of youth were engaged in either

school or work 12 months after their release from juvenile correctional facilities (Bullis,

Yovanoff, Mueller, & Havel, 2002). This may be due to the low likelihood of having obtained a

high school diploma or GED and the lack of opportunity to gain relevant work experiences

because of time spent in a locked facility. The situation is compounded by the fact that, upon

reentry, these young adults often return to their former neighborhoods and rejoin peer

groups that foster criminal behaviors. Incarceration prevents opportunity to develop positive

peer groups, which, coupled with the lack of prosocial activities available upon reentry,

makes the return to the youth’s previous way of life more likely. Further, such youth often

lack positive adult role models to guide them through the transition period from detention

back into their neighborhoods (Steinberg, Chung, & Little, 2004).

Following reentry, transition age youth display low rates of engagement with

community-based services such as mental health treatment and vocational rehabilitation. In

one study, only 35 percent of juvenile offenders had been engaged in such services during

the six months following reentry (Chung, Schubert, & Mulvey, 2007). Barriers to services

include lack of sufficient health care coverage, inability to navigate multiple systems, and, for

some youth, lack of service providers in their communities. Further, transition age youth

often qualify only for adult-oriented care that is not well suited to meet the developmental

needs of youth. Finally, upon reentry, transition age youth often face both the perception

and reality of having “fallen behind” their same-age peers in terms of employment,

education, and family roles, which can lead to hopelessness about their ability to catch up in

these domains.

Successful Transitions from Adolescence to Adulthood for Justice-Involved Youth

Although transition age youth involved in the juvenile justice system are at a great

disadvantage compared with their non-system-involved peers, the long-term goals for

successful adulthood remain the same. Successful transitions involve some combination of

Transition Age Youth 12

academic achievement (ranging from attainment of a high school diploma/GED to an

associate degree, four-year college degree, or graduate degree); development of vocational

skills and acquisition of gainful employment; establishment of stable romantic, peer, and

familial relationships; and formation of a sense of self tied to being a productive member of

families, neighborhoods, and society. However, the immediate goals for justice-involved

youth with mental health problems are often different from many of their peers, with a focus

on reducing recidivism, accessing mental health and substance use treatment, obtaining a

stable housing situation, and completing justice system requirements. The overarching goal

of the systems involved with these youth should be to facilitate the completion of these

crucial immediate goals while providing access to resources that will allow for success in

overarching goals, including those related to education, vocation, and healthy relationships.

Critical Issues Facing Justice-Involved Transition Age Youth With Mental

Health Problems

Transition age youth face a myriad of potential issues with access to services, as they

must deal with child-oriented systems, adults systems, and the connection, or lack of,

between the two. Involvement with multiple systems is the rule rather than the exception

for youth in the juvenile justice system, particularly those with mental health problems. For

example, at least one in five youth involved in community-based mental health systems also

have juvenile justice involvement (Cauffman, Scholle, Mulvey, & Kelleher, 2005; Rosenblatt,

Rosenblatt, & Biggs, 2000; Vander Stoep, Evens, & Taub, 1997). Justice-involved transition

age youth are often involved with child welfare, mental health treatment, vocational

rehabilitation, substance use treatment, the housing authority, and various educational

systems, among others. Although the availability of the various services provided by these

systems may be seen as advantageous, the interplay between such systems is often

counterproductive and can actually prevent youth from having their needs met. In some

cases, services do exist in the community, but youth fail to qualify (e.g., they lack the proper

health care coverage; they are too young or too old). At other times, appropriate services are

completely lacking in the youth’s community. As illustrated by Kimberly’s case, navigating

these separate systems can be incredibly challenging for a young person, particularly those

who lack family support and are experiencing multiple psychosocial problems.

Transition Age Youth 13

System Involvement

Involvement in a number of these systems is common among all ages involved in the

juvenile justice system, but transition age youth also must begin to navigate new systems.

Relevant systems include the following:

 Child Welfare. Youth in the justice system often have current or historical

involvement with child welfare due to a history of maltreatment or neglect and, in

most severe cases, removal from their family of origin and placement with a foster

family or in a group home (Malmgren & Meisel, 2004).

 Special Education. Youth receive these services, including individualized education

programs (IEPs) and alternative school placements, because of learning disabilities,

cognitive delays, and/or emotional/behavioral problems that affect their ability to

learn. Youth with justice involvement are also at risk for school-related sanctions,

including expulsion, due to behavioral problems. These youth are at particularly high

risk for school failure, dropout, and lack of access to quality educational experiences.

 Mental Health Services. During adolescence, youth with mental health and

behavioral problems are often involved with child mental health systems. At age 18,

youth may become ineligible for continued care, as behavioral disorders are often

not a qualifying diagnosis for adult mental health systems. Adult systems have more

stringent qualifying criteria for care, requiring a more severe and debilitating

diagnosis than is necessary in the child system. Transition age youth also sometimes

face a change or loss in their health care coverage upon reaching an adult age, which

can be an additional barrier to care. Even with the pending changes to managed care

stemming from the Affordable Care Act (ACA), there will continue to be age-related

changes in health care coverage that will affect transition age youth. Although state

agencies are required to do outreach to reduce barriers to continuity in coverage for

young people, these efforts have not yet been demonstrated to be effective. In fact,

such programs aimed at adults with mental health problems have not been

successful at ensuring continuity in health care coverage (Capoccia, Croze, Cohen, &

O’Brien, 2013); thus, it remains to be seen whether ACA changes will benefit

transition age youth with mental health problems. Finally, adult mental health

Transition Age Youth 14

providers rarely have specialized training on transition age youth. Therapists’ high

caseloads make it all but impossible to target the unique and high-demand needs of

justice-involved transition age youth. Similarly, after youth reach age 18, privacy law

protections change in a way that is both helpful to them in protecting their health

information and potentially harmful; specifically, adult therapists often fail to engage

transition age youth’s family members in mental health treatment despite their key

role in the youth’s well-being (Osgood et al., 2010).

 Vocational Rehabilitation. Goals of vocational rehabilitation include creating

individualized employment plans; boosting job readiness through education and on-

the-job training; and assisting with job seeking, applications, and retention. While all

state vocational rehabilitation agencies provide some transition support services,

there is wide disparity in intensity, quality, and efficacy. Youth with juvenile justice

histories present additional challenges, as they often lack the basic skills necessary to

maintain employment, including time management, communicating with authority

figures, and professionalism. Many have no past workplace experience, and their

interactions with authority figures have been punitive rather than professional. Also,

due to high demand for services in many communities, there can be long waiting lists

for vocational rehabilitation services as well as inflexible policies regarding

appointment attendance that can alienate transition age youth.

 Independent Housing. Given barriers to successful employment and self-sufficiency,

accessing independent housing is difficult. Public housing applications often cannot

be submitted by youth under age 18, and the wait for housing can take multiple

years. Further, youth who recidivate and receive a felony conviction can be denied

public housing permanently. Although not as common for adjudicated juveniles,

some housing authorities have the ability to deny public housing on the basis of

disqualifying offenses committed by any family members, including juvenile

offenders (Henning, 2004). This can mean that youth are either no longer permitted

to live with their families or that their families are no longer able to live in public

housing.

Services for Detained and Incarcerated Youth

Transition Age Youth 15

The lack of access to mental health care among detained and incarcerated youth is

well documented. Although this group could be considered a “captive audience” for the

delivery of such services, the juvenile justice system is currently not well equipped to provide

effective mental health treatment to the large numbers of youth who require it (Steinberg et

al., 2004; U. S. Department of Justice, 2005). In fact, a large-scale study found that only 15.4

percent of youth with a major mental health problem received mental health treatment

while detained (Teplin, Abram, McClelland, Washburn, & Pikus, 2005). Family involvement in

mental health interventions, a factor that is likely to be key factor in successful treatment, is

rarely available to incarcerated youth. This likely limits both treatment effectiveness as well

as maintenance of gains past the time of incarceration, as the youth return home to their

families. In addition, many mental health treatments in correctional facilities are delivered in

a group format, which by definition means aggregating delinquent peers, a strategy shown to

have an iatrogenic effect on group members due to “deviance training” or the learning of

new delinquent behaviors from more deviant peers (Dishion, McCord, & Poulin, 1999).

Further, there is often a lack of continuity of care for youth with mental health problems as

they transition to treatment providers in the community. After their release, youth face the

same barriers to mental health treatment faced by their peers on probation. Thus, although

incarcerated youth often are screened for mental health problems (Pajer, Kelleher, Gupta,

Rolls, & Gardner, 2007), most enter adulthood without having had access to effective mental

health interventions.

Interplay Between Multiple Systems

A potentially wide array of services is available to justice-involved transition age

youth with mental health problems. However, as noted, these services often are not well

suited to meet this group’s needs. In addition, interacting with multiple systems can be

overwhelming to youth, particularly because of the lack of seamless interplay between the

systems (Davis, Green, & Hoffman, 2009) and youth’s lack of knowledge about systems with

which they previously were not required to interact (e.g., vocational rehabilitation). In

addition, there is often a lack of communication between systems, sometimes even between

child and adult arms of the same system (e.g., child and adult mental health) (Osgood et al.,

2010). This means that goal setting and interventions across agencies can be at odds with

Transition Age Youth 16

one another. In one study of the role of interagency collaboration between child welfare and

juvenile justice, two factors predicted successful coordination of mental health services: (1)

having a single agency held accountable for the youth’s well-being (i.e., either child welfare

or juvenile justice) and (2) interagency sharing of administrative data (Chuang & Wells,

2010). Thus, effective coordination of care and agency accountability are necessary to ensure

that youth do not ”fall through the cracks.” Furthermore, transition age youth are often

simply unable to take full advantage of such services because of a variety of practical

barriers, including lack of transportation, service systems that are not located in close vicinity

of one another, and lack of familial support necessary to follow through on multiple

appointments and responsibilities.

Effective Policies and Practices for Youth With Mental Health Problems

Garrett, age 20, is on probation with juvenile justice because of a long history of drug

possession charges and probation violations. At age 17, he was diagnosed with bipolar

disorder after several episodes of mania during which he took his mother’s car, ran away

from home, and went on drug and alcohol binges. Since his diagnosis, he has received mental

health services from a therapist and psychiatrist housed under one roof at Garrett’s local

child mental health center. Luckily for Garrett, this center has recently started a young adult

program that helps youth transition from the child to adult mental health systems, and his

therapist has some expertise with Garrett’s age group. Garrett’s symptoms have been

stabilized through a combination of medication management and counseling. He sometimes

misses his appointments; although the clinic does not provide home-based services per se, his

therapist has the flexibility to meet with Garrett in his home on occasion, and this has helped

him to stick with treatment. In addition, the therapist recognizes the importance of Garrett’s

relationship with his mother, with whom he lives, and includes her in Garrett’s treatment.

Recently, Garrett had a slip-up and took too many pills when he was hanging out with

his friends. During this binge, Garrett stole one of his mother’s rings and sold it at a pawn

shop for money to buy drugs. Garrett wound up in the hospital because his friends were

worried that he might have overdosed. Garrett swore that it was accidental and that he just

lost track of how many pills he had taken. This incident scared and angered Garrett’s mother.

Transition Age Youth 17

This wasn’t the first time that Garrett had ended up in the hospital, and she felt hopeless

about her ability to help him. She decided that she didn’t want to “enable” Garrett anymore

and that she was going to cut him off from all financial support, including her health

insurance. She also no longer wanted him in her home. The hospital released Garrett to a

friend who offered to let him stay at his place for a while. Fortunately, Garrett’s therapist got

involved and begged his mother to continue his insurance so that he could continue receiving

medication and therapy. Garrett’s mother agreed that this would be important for Garrett’s

safety and continued to provide his health insurance, but no other support.

Garrett spent a significant amount of his adolescence in a juvenile correctional facility

and had fallen behind in his education. He wanted a job in the medical field as a nurse or a

lab technician, but he had not finished high school. Garrett’s probation officer and therapist

worked together to try to get him re-enrolled in his local high school, but Garrett wasn’t

comfortable returning because he was so much older than the other kids. The probation

officer then got Garrett enrolled in an adult education program. Garrett didn’t like this

program either, as he reported it was “full of people who didn’t look like him.” He also

struggled to keep his school materials organized and complete all of his work because he kept

moving from one friend’s house to the next.

Because of Garrett’s bipolar diagnosis, the probation officer knew Garrett would be

eligible for vocational rehabilitation services, so the officer arranged an intake appointment.

Unfortunately, when the meeting occurred, Garrett was reluctant to admit that he had a

mental health condition and answered questions in ways that made him ineligible for

services. Garrett’s probation officer continued to be persistent. He set Garrett up with a

program that paid justice-involved transition age youth minimum wage when they spent

hours volunteering at select sites. The probation officer ensured that Garrett got a volunteer

slot at a hospital that would provide him with some experience in the medical field. The

monetary incentive and work experience were enticing to Garrett, and he was able to build

some job experience and get a work reference for his resume. The job also filled his free time

and limited his opportunity to spend time with his friends, some of whom continued to get in

trouble with the law. Although Garrett no longer had much contact with his mother, the

probation officer helped him reconnect with a former teacher whom Garrett had admired.

Transition Age Youth 18

This teacher became a mentor to Garrett, helped him complete some job applications, and

provided some advice about his work behavior. The work program, coupled with Garrett’s

positive relationship with an adult mentor, continued access to appropriate mental health

care, and a persistent and dedicated probation officer, set Garrett up for success in terms of

finding a job and becoming a productive adult.

Garrett is another example of a youth facing serious roadblocks to a successful

transition to adulthood, including a long history of justice involvement and significant mental

health problems. For youth such as Garrett, multiple factors need to be addressed, including

housing, mental health care, and education. In his case, Garrett was lucky to have mental

health and juvenile justice providers who had knowledge about community resources,

experience with transition age youth, and the resources to work together to meet his needs.

The majority of justice-involved youth are not as fortunate. Even under the best

circumstances, this fragmented system of services can fail transition age youth, and such

youth have the capacity to fall through the cracks because of inappropriate services (in

Garrett’s case, traditional high school and adult education), failure to qualify for services

(unwillingness to disclose mental health condition), and lack of family support, among other

barriers. There have been some recent efforts to improve coordination of services, but much

more needs to be done. In the next sections of this paper, we review what is known about

best practices for justice-involved transition age youth with mental health problems and

provide suggestions for further development. Although there are few specific policies

focused on transition needs of youth in the juvenile justice system with or without mental

health problems (Hoffman, Heflinger, Athay, & Davis, 2009), policies that may impact this

group are highlighted.

Evidence-Based and Promising Practices and Policies

Unfortunately, there is very little information on evidence-based practices specifically

for justice-involved transition age youth with mental health problems. Most of what we

know is extrapolated from studies with adult or adolescent justice-involved populations or

from studies of mental health treatments in the general population. These approaches may

work differently for justice-involved transition age youth with mental health problems, given

Transition Age Youth 19

the multiple complicating factors that must be addressed. Further, more research attention

is needed on treatment of mental health problems in justice-involved populations of all ages.

For example, a variety of treatments have been well validated to target delinquency among

justice-involved adolescents (e.g., Multisystemic Therapy, Functional Family Therapy; for

review, see Henggeler & Sheidow, 2012), but far fewer treatments are specifically designed

for transition age youth or to address mental health problems among justice-involved youth

from either age group. Thus, we will summarize what is known that may be applicable to

transition age youth while identifying areas in need of further investigation and

development.

Multisystemic Therapy

Multisystemic Therapy (MST) is a well-established, intensive, community-based

treatment for delinquent behavior among justice-involved adolescents (Henggeler,

Schoenwald, Borduin, Rowland, & Cunningham, 2009). Two adaptations of MST are relevant

to this review. First, MST was adapted for justice-involved transition age youth with serious

mental health concerns (i.e., Multisystemic Therapy for Emerging Adults [MST-EA]). MST-EA

integrates MST principles, evidence-based mental health treatments, and an on-staff

psychiatrist for medication monitoring. In addition, MST-EA therapists target concerns

relevant to transition age youth (e.g., educational/vocational goals, independent housing). A

pilot study found reduced recidivism and mental health symptoms and effective engagement

in school, work, or both (Sheidow, McCart, & Davis, 2012), but additional research is needed.

Second, Family Integrated Transitions (FIT) is a MST adaptation for youth with co-occurring

mental health and substance use disorders transitioning back home from incarceration

(Trupin, Kerns, Walker, DeRoberts, & Stewart, 2011). FIT combines MST, dialectical behavior

therapy, parent training, and motivational enhancement implemented two to three months

prior to release through four to six months after release. A pilot study found reductions in

felony (but not overall) recidivism among 12- to 19-year-old youth (Trupin et al., 2011).

However, FIT was not designed for transition age youth, rather for justice-involved

adolescents with mental health problems who are living with their parents.

Foster Care

Transition Age Youth 20

Several policies and programs related to foster care are relevant for justice-involved

transition age youth. The first is the John H. Chafee Foster Care Independent Living Program,

which was expanded under the Foster Care Independence Act (FCIA) of 1999 to provide aid

to youth up to age 21 to promote successful transition to independent living. Funds can be

used for support services, including housing; educational, vocational training; and mental

health treatment (Foster & Gifford, 2005). Thus, youth-serving professionals should be aware

of how to access these funds in their states. It should be noted, however, that states have

had difficulty providing comprehensive and well-coordinated services under this program

because of limitations in available federal funds (Collins, 2004). Second, Multidimensional

Treatment Foster Care (MTFC) is home-based family treatment developed for youth involved

with child welfare as an alternative to group homes and residential settings (Chamberlain,

2003). MTFC utilizes specialized foster homes where caregivers are well trained and

supported to handle delinquent behaviors, as well as coordination of care for individual and

family therapy, educational programming, skills training for youth, and psychiatric care if

needed. MTFC has shown effectiveness in reducing delinquent behaviors, justice system

contacts, substance use, and teen pregnancy with adolescent populations (up to age 17)

(Chamberlain, Leve, & DeGarmo, 2007; Leve, Chamberlain, Smith, & Harold, 2012; Smith,

Chamberlain, & Eddy, 2010). MTFC has not been evaluated with transition age youth.

However, given the extension of foster care services through the transition age, MTFC may

prove to be useful for this group.

Wraparound Services

Wraparound services use a system of care philosophy, emphasizing the importance

of maintaining youth in the least restrictive environment through intensive coordination of

multiple services (Bruns et al., 2004). The Connections program in Washington state is one of

the most rigorously studied wraparound programs for youth with mental health problems

(Pullman et al., 2006). Each family is assigned to a team of professionals, including a mental

health care coordinator, probation counselor, family assistance specialist (for emotional

support, practical assistance), and a juvenile services associate (for mentoring, aiding with

completion of the treatment plan). Youth in this program were less likely to recidivate in

general and have a felony offense in particular, and they served less detention time than

Transition Age Youth 21

comparison youth (Pullman et al., 2006). Other similar programs also have shown promising

findings for reducing recidivism (Anderson, Wright, Kooreman, Mohr, & Russell, 2003;

Kamradt, 2000), though one program produced positive effects on educational outcomes

and police contacts but not on arrests or incarceration (Carney & Buttell, 2003). Interestingly,

evaluations of these programs have not focused on mental health outcomes. Further, there

have not been evaluations of wraparound services specifically for transition age youth.

Diversion Programs

Similarly, there has been research on a multitude of diversion programs for juvenile

offenders, though not specifically for transition age youth (for a review, see Chapin & Griffin,

2005). Diversion programs provide alternatives to formal justice system sanctions, typically

for first-time offenders, and often provide treatment in lieu of punishment. A recent meta-

analysis failed to find a link between these programs for general juvenile justice system

populations and a significant reduction in recidivism, even among diversion programs

specifically for mental health needs (Schwalbe, Gearing, MacKenzie, Brewer, & Ibrahim,

2012). However, evidence-based interventions for adolescent delinquent behaviors, such as

MST and Functional Family Therapy, were rarely included as part of the programs’ diversion

plans; when they were included, results were promising. Thus, diversion programs may be an

effective tool when evidence-based treatments are available in the surrounding

communities. These findings highlight the need to develop and disseminate effective

treatments that can serve as viable diversion options specifically for transition age youth.

Furthermore, diversion programs can effectively reduce the amount of time spent in locked

settings, a known contributor to developmental delays in this age group (Chung et al., 2005).

For these reasons, diversion programs tailored to meet the needs of transition age youth

with mental health problems should be developed and examined as alternatives to formal

sanctions.

Reentry and Aftercare Programs

A variety of reentry and aftercare programs have been developed for justice-involved

youth, with a few designed specifically for transition age youth. Such programs are initiated

either during the transition from incarceration to the community or soon after reentry, and

Transition Age Youth 22

they aim to reduce recidivism through provision and coordination of services. In a meta-

analysis of such programs for justice-involved adolescents and young adults (but not

specifically youth with mental health needs), a small but positive effect on recidivism was

identified (James, Stams, Asscher, De Roo, & van der Laan, 2013). Interestingly, results

suggested a particular benefit for older youth compared with younger youth. Two of the

reviewed programs were designed specifically for transition age youth. The Boston Reentry

Initiative (BRI) involved individualized transition plans (e.g., acquisition of housing and

employment, continuation of mental health treatment) as well as frequent contact with a

mentor for ensuring program success (Braga, Piehl, & Hureau, 2009). BRI lowered re-arrest

rates among young adults (18 to 32) with violent criminal histories. The second program,

Lifeskills’95, also incorporated developmentally appropriate services, including job training

and educational resources, skills training, and substance use services delivered through

weekly meetings (Josi & Sechrest, 1999). Lifeskills’95 was superior to usual services on

measures of recidivism, employment, substance abuse, and family relationships among

youth aged 16 to more than 22. Although promising, these programs have not been tested

within the juvenile justice system or specifically with youth with mental health needs.

A promising reintegration program that has been evaluated for adolescents is

Multidimensional Family Therapy–Detention to Community (MDFT-DTC) (Liddle, Dakof,

Henderson, & Rowe, 2011). MDFT is a family-based intervention originally designed for

treatment of adolescent substance use (Little, Dakof, & Diamond, 1992). The DTC adaptation

extended the MDFT model to justice-involved youth with substance abuse and related

emotional or behavioral disorders. In a pilot study, MDFT-DTC showed promising results in

terms of feasibility, implementation, and treatment engagement and retention (Little et al.,

2011). It should be noted, however, that MDFT-DTC’s family focus may preclude it from

being effective for transition age youth, particularly those with strained or nonexistent

relationships with parents.

Coordination of Care Programs

Given the wide array of services that youth must navigate, improving coordination of

care and linkage to services is important. Although coordination of care is often included as