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July/August 2016 Issue

Children and Families Forum: Treatment Instead of Serving Time
By Jeff Kretschmar, PhD
Social Work Today
Vol. 16 No. 4 P. 30

At an increasing rate, our nation's jails and prisons have become de facto mental health facilities. For example, the largest provider of mental health services in Chicago is the Cook County Department of Corrections. Unfortunately, this is not unique to Chicago or adult offenders. A significant proportion of both adults and juveniles who enter the justice system experience behavioral health issues. Recently, leadership at many justice facilities has reevaluated the role their agencies play in the identification and treatment of these issues.

The Scope of the Problem
Research studies report that between 65% and 75% of youths who enter the juvenile justice system experience behavioral health issues (Cocozza & Skowyra, 2000; Teplin, Abram, McClelland, Dulcan, & Mericle, 2002). The Ohio Department of Youth Services (ODYS), the entity responsible for operating Ohio's youth prisons, reports that approximately one-half of the youths committed to their facilities have documented behavioral health issues and are receiving at some type of related services while incarcerated. Among girls, that number approaches 100%.

While the origins of these issues are diverse, one aspect is clear: Juvenile justice-involved youth report significantly elevated levels of exposure to violence and trauma. While exposure to violence is common among all youths, it is particularly prevalent in juvenile justice-involved youths. For example, Finkelhor, Turner, Shattuck, & Hamby (2013) found that in a national sample, approximately 60% of youths reported childhood exposure to violence or trauma. However, a study that examined justice-involved youths found that more than 90% experienced at least one traumatic event (Abram, Teplin, Charles, Longworth, McClelland, & Dulcan, 2004).

On any given day in the late 1990s, more than 2,000 Ohio youths were serving time in a juvenile prison. Around the same time, juvenile court judges and magistrates in Ohio met with leaders from the Ohio Department of Mental Health & Addiction Services and ODYS to discuss a growing concern: the increasing number of youths with behavioral health issues appearing in local courtrooms. At the time, there were few alternatives to incarceration available—even when a jurist knew a youth needed behavioral health treatment.

One recommendation from this meeting: Develop alternatives to detention for juvenile justice-involved youths with behavioral health issues. Instead of incarceration, youths would be diverted into comprehensive community and evidence-based behavioral health treatment that juvenile justice facilities were unable to provide, including family-based treatment that is nearly impossible to offer in a correctional facility. The central tenet of the project—known as the Behavioral Health Juvenile Justice (BHJJ) Initiative—aimed to transform local systems' ability to identify, asses, evaluate, and treat youths and their families.

Ohio's BHJJ Initiative
The state identified criteria counties could use to determine who could participate: eligible youth, between 10 and 18 years of age, with at least one DSM Axis I diagnosis and current juvenile justice involvement. Counties were required to use evidence-based or promising treatment models, and the state began accepting proposals from prospective BHJJ counties in 2005. Six projects were funded in the first cohort, and the first youth was enrolled in January 2006. The state also funded researchers from Case Western Reserve University to conduct an ongoing outcome evaluation.

How Does BHJJ Work?
Youths are identified for BHJJ by local juvenile courts after being charged with a crime. Youths deemed eligible by court personnel typically receive a diagnostic assessment from a local treatment provider to determine their behavioral health needs. If the youth qualifies and agrees to participate, a recommendation to BHJJ is made to the jurist. In most cases, the recommendation is accepted and the family is enrolled in the program. At that point, the court makes a referral to the identified treatment provider, and services begin. Services are typically provided in the home by licensed social workers or other clinical staff. The court remains involved throughout treatment, as most BHJJ youths are on probation during their participation.

Who's Enrolled in BHJJ?
Since 2005, more than 3,500 youths have received BHJJ services in 17 counties. A BHJJ youth is more likely to be male (60%), nonwhite (52%), around 15.6 years old, and averages 2.5 DSM diagnoses. Common diagnoses include ADHD, cannabis-related disorders, and oppositional defiant disorder. More than one-half of the youths have problems with alcohol or drugs, and 40% have documented co-occurring mental health and substance use disorders. Commonly used drugs include alcohol, marijuana, and pain medications, and the majority of youths start drug use around age 13.

Overall, 89% of BHJJ youths report at least one past-year victimization or traumatic event—including being physically hit or attacked (46%), witnessing an attack (46%), being threatened with physical harm (42%), and being emotionally abused by an adult (30%)—in the past year. Girls generally report higher levels of violence exposure. For example, 27% of girls and 7% of boys have a history of sexual abuse. Girls are more likely than boys to talk about suicide (50% vs. 30%) and attempt suicide (24% vs. 9%). BHJJ youths, especially girls, report significant issues with anger and aggression; the author has been published on this subject (Kretschmar, Butcher, Flannery, & Singer, 2016).

The Role of the Local Treatment Agency
Social workers and other clinical staff are essential to BHJJ's success. They provide behavioral health assessments used in establishing a youth's eligibility. Once a youth is enrolled, treatment begins; depending on the model chosen, this can be individual or family-based therapy. While models vary by county, commonly used models include multisystemic therapy, functional family therapy, trauma-focused cognitive behavioral therapy, and integrated co-occurring treatment.

Clinical staff works closely with courts, providing updates on progress, attending team meetings, and providing updates on a youth's behavioral health improvements to jurists. The relationships built between court staff and treatment agencies have fostered an unprecedented level of cooperation, collaboration, and understanding of each other's roles in the treatment and care of these youths.

For many treatment agencies, working with a juvenile justice population was new. Youths enrolled in BHJJ often looked very different than the population they traditionally served. BHJJ youths experienced so much trauma that treatment agencies had no other choice than to fully embrace what it means to be trauma informed. To better serve BHJJ youths, the state provided funding to train local treatment staffs on how trauma impacts the adolescent brain, behavior, and how best to incorporate trauma-informed practices and techniques into treatment.

Treatment Works
As an older, multisystem involved group with histories of mental health and substance use issues, juvenile justice-involved youths represent a challenging population to serve. Youths with co-occurring disorders are among the most difficult to treat (Hawkins, 2009). Family engagement can often be low. Treatment staff faces a significant uphill battle to enroll and maintain youths and family in treatment.

Still, BHJJ is working. Two of three youths successfully complete treatment. Youths experience significant improvements in functioning and problem severity—and reductions in substance use and trauma symptomatology. Academic performance improved, and suspensions and expulsions greatly dropped. Risk for out of home placement was cut in half.

While behavioral health improvements are certainly a priority, a central question is whether youths go on to be committed to an ODYS facility. Less than 4% of BHJJ youth were eventually committed to an ODYS facility any time after their enrollment—translating into a significant financial savings for Ohio. It costs about $200,000 to commit a youth to an ODYS facility for the average stay (12 months). Alternatively, the cost of BHJJ is about $5,000 per youth.

When BHJJ was conceived, the average daily population in the 10 ODYS facilities topped 2,000. In 2015, the average daily population was 470. The reduction in population allowed ODYS to shutter several of its facilities, leaving only three in operation and saving the state millions of dollars. Ohio has committed to reinvesting a portion of the savings back into communities so they can continue to provide these critical behavioral health services to justice-involved youths.

During the past 15 years, Ohio's juvenile justice reform efforts have been among the most progressive in the nation. The juvenile justice system had to acknowledge they had become a warehouse for youths with behavioral health issues. To their credit, state-level leadership and local jurists recognized incarceration was not the answer—and they had a real opportunity to change the way juvenile justice-involved youths with behavioral health issues were assessed and treated. This meant utilizing social workers and other clinical staff at the local level to provide the comprehensive behavioral health care that juvenile justice facilities simply cannot provide. Ohio's juvenile justice reform efforts have produced both short- and long-term positive outcomes for a vulnerable and at-risk population.

— Jeff Kretschmar, PhD, is a research assistant professor and senior research associate with the Begun Center for Violence Prevention Research and Education at Case Western Reserve University's Jack, Joseph, and Morton Mandel School of Applied Social Sciences.

Abram, K. M., Teplin, L. A., Charles, D. R., Longworth, S. L., McClelland, G. M., & Dulcan, M. K. (2004). Posttraumatic stress disorder and trauma in youth in juvenile detention. Archives of General Psychiatry, 61(4), 403-410.

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

Finkelhor, D., Turner, H. A., Shattuck, A., & Hamby, S. L. (2013). Violence, crime, and abuse exposure in a national sample of children and youth: An update. JAMA Pediatrics, 167(7), 614-621.

Hawkins, E. H. (2009). A tale of two systems: Co-occurring mental health and substance abuse disorders treatment for adolescents. Annual Review of Psychology, 60, 197-227.

Kretschmar, J.M., Butcher, F., Flannery, D.J., & Singer, M.I. (2016). Diverting juvenile justice-involved youth with behavioral health issues from detention: Preliminary findings from Ohio's Behavioral Health Juvenile Justice (BHJJ) Initiative. Criminal Justice Policy Review, 27(3), 302-325.

Teplin, L. A., Abram, K. M., McClelland, G. M., Dulcan, M. K., & Mericle, A. A. (2002). Psychiatric disorders in youth in juvenile detention. Archives of General Psychiatry, 59(12), 1133-1143.