Juvenile Justice Reform and Best Practices in Juvenile Systems

1. Juvenile Justice Reform and Best Practices in Juvenile Systems NAMI 2005 Annual Convention Austin, Texas Eric W. Trupin, Ph.D. Department of Psychiatry and Behavioral Sciences University of Washington School of Medicine

2. Status of Mental Health System and Evidence-Based Treatments • President’s Commission reports public mental health system is “in a shambles” (President’s New Freedom Commission Report, 2004) • 90% of public mental health services do not deliver treatments programs or services that have empirical support (Elliot, 1999; Henggeler et al., 2003)

3. Status of Mental Health System and Evidence-Based Treatments • More than 550 different psychotherapies exist as well as an increasing number of empirically supported programs for multi-problem youth (Kazdin, 2003) • Many of the above treatments, services and programs are “evidence-based practices” (Hoagwood, Burns, et.al. 2001) • Startling discrepancies between high quality clinical promise and poor clinical practice (Hoagwood, et. al. in press)

4. Evidence-Based Treatments Poorly Disseminated • Simplistic strategies for understanding process of implementation • Lack of attention to theories and methods from other fields (Marketing, anthropology, organizational behavior) that could enhance methods for adopting new approaches

5. Characteristics of Empirically Supported Treatments with Children • Focus on the development of skills, not on catharsis or insight • Utilization of manuals emphasizing adherence and fidelity • Consistent supervision of clinicians • Homework or out-of-session work • Focus on problems and solutions, rather than changing personality • Active engagement and empowerment of family or caregiver

6. Facts • Seventy percent of the nation’s mental health dollars for children and adolescents are spent on out-of-home placements. (Burns & Friedman, 1990) • No scientific evidence indicates that the most restrictive and expensive out-of-home placements (psychiatric hospitalization, criminal justice detentions) bring out desired clinical outcomes. (Sondheimer et al., 1994)

7. Facts • Traditional office-based outpatient mental health care shows little evidence of effectiveness with children with serious emotional disorders. (Weisz, Weiss, and Donenberg, 1992) • Emerging community-based services are being disseminated without the necessary support and consistent supervision needed by community-based clinicians.

9. Increased Focus • Numbers of detained youth have tripled in last 2 decades • 50-80% have Psychiatric or Substance Use Disorders, or both • 1 in 3 African American males, ages 16-27, are in jail, correctional facilities, on probation or parole

10. Increased Focus • Over 70% recidivism rates common for juvenile offenders • Costs to keep youth in secure facilities: New York: $85,000. Louisiana: $50,000. • 6 states spend more on prisons and detention facilities than on public colleges and universities

11. Recidivism Rates • 58% of youth released from Washington’s Juvenile Rehabilitation Administration in 1999-2000 were convicted of new felonies or misdemeanors within 18 months. (Source: Washington State Institute for Public Policy) • 45% were convicted of a new felony

12. Legal Mandates • Results of case law: • The right of access to care • The right to receive care that is ordered • The right to a professional medical judgment • Federal Individuals with Disabilities Education Act (IDEA) • Conditions of Confinement Litigation

13. Legal Mandates • Civil Rights of Institutionalized Persons Act (CRIPA) – 1997 • US Attorney General can investigate and litigate on conditions of confinement in state operated institutions • Special Litigation Section investigates for patterns or practices of violations of residents’ federal rights (not specific cases) • Methods include settlements, consent decrees

14. Standards Utilized in Department of Justice Investigations • Screening/Initial Assessment • Specialized Mental Health Assessment • Treatment Planning • Case Management • Mental Health Counseling

15. Standards Utilized in Department of Justice Investigations • Management of Psychotropic Medications • Crisis Management • Suicide Prevention • Physical Restraint • Chemical Restraint • Youth Development/Treatment Programs • Institutional Practices Raising Mental Health Concerns

16. Difficulties estimating prevalence of mental health disorders among youth in the juvenile justice system • Regional variation • Use of standardized assessment tools limited • Under-sampling of certain populations • Youths’ report of mental health status may vary as a function of how long and in what environment they have been incarcerated • Youth, families, and institutional staff may be suspicious of research • Inconsistent scope and quality of records to provide historical information supporting diagnoses

17. “Mental Health and Juvenile Justice: Building a Model for Effective Service Delivery” • Coordinated by Policy Research Associates • Focus on determining the mental health status of youth, extent to which services are available and meeting needs, and level of satisfaction • Multiple sites (Texas, Louisiana, and Washington) • Sampled from different “levels” of juvenile justice system (Detention, Secure, Group Homes) • Used standardized data collection instruments

18. Preliminary Results • 76.7% of participants met screening criteria for a mental health or substance use disorder • Of those that met screening criteria, 85.8% met criteria for at least 1 diagnosis • 64.5% met criteria for a substance use disorder

19. Characteristics of Empirically Supported Treatments • Focus on the development of skills, not on catharsis or insight • Continuous assessment of progress • Homework or out-of-session work • Focus on problems and solutions, rather than changing personality • Recognition of the importance of therapeutic relationship

20. Stages of Intervention with Youth Engaging in Criminal Behavior • Prevention of escalation of criminal behavior • Diversion • Mentoring • Community-Based Treatment Programs • Transition • Dialectical Behavior Therapy • Families In Transition

21. Early Intervention • Targets youth who are beginning to engage in antisocial behavior and are at a high risk of having that behavior continue and escalate into more serious criminal activity • Focus is on identifying and intervening with negative influences in youths’ lives that contribute to antisocial behavior.

22. Diversion Programs • Designed to minimize negative impacts of incarceration • Divert youth involved in first-time or minor offenses into treatment, rather than secure facilities • Target risk factors for recidivism, such as parent-child conflict and poor problem solving skills • Can include assessment, counseling, tutoring, job training, substance abuse treatment, community service, restitution, psychoeducation

23. Examples of Diversion Programs in King County, Washington • Prime Time Project • Community Juvenile Accountability Act (CJAA) • Chemical Dependency Diversion Alternative (CDAA)/Juvenile Drug Courts • Mental Health Disposition Alternative (MHDA) • Treatment Court

24. Community Based Treatment • Provide rehabilitation services to youth and families in their homes and communities. • Views families as partners in creating an environment that supports change.

25. Functional Family Therapy (FFT) • A program designed to prevent the escalation or continuation of violent or serious externalizing behavior. • Targets youth at risk of incarceration or other out-of-home placement due to behavior. • Family behavioral intervention.

26. Phases of FFT • 1. Motivation and Engagement • Goals: develop alliance, reduce negativity, minimize hopelessness, reduce dropout, increase motivation for change • 2. Behavior Change • Goals: develop and implement individualized change plans, change presenting delinquency behavior, build relational skills • 3. Generalization • Goals: maintain and generalize change, relapse prevention, engage community supports

27. FFT Outcomes • FFT significantly reduces recidivism for juvenile offenders • In Washington State, youth treated by competent FFT therapists had a 38% reduction in felony recidivism at 18-months post-release

28. Multisystemic Therapy (MST) • Targets youth engaged in serious antisocial behavior and their families • Based on of the idea that behavior is determined by the various systems that affect and individual, including the family, school, peer group, and community.

29. MST Continued • Goal is to change the systems that create and sustain high-risk behavior. • Therapist works with family to identify function of problematic behavior and the factors that contribute to it. • Therapist works to change factors that contribute to and reinforce problematic behavior • Therapy takes place in the youth’s natural environment.

30. MST: Parents are seen as key agents of change • A major goal is to enhance parents’ ability to monitor manage youth’s behavior, and give effective rewards and consequences.

31. MST Outcomes • Randomized controlled trials with youth post-incarceration indicate that MST is effective at reducing number of re-arrests, number of days incarcerated, peer-directed violence, and increasing family cohesion and the number of youth who did not recidivate at all.

32. MST Outcomes: Recidivism • In a randomized study of 200 juvenile offenders, youth who participated in MST had a lower (22.1%) rate of recidivism than did youth who participated in individual therapy (71.4%) at 4-year follow-up. (Borduin, Mann, Cone, Henggeler, Fucci, Blaske, & Williams, 1995)

33. Treatment Within Juvenile Justice Settings

34. Juvenile Rehabilitation Administration’s Integrated Treatment Model • Used in JRA’s residential programs • Framework for treatment planning across continuum of care

35. Parameters of the Integrated Treatment Model (ITM) • Cognitive-behavioral basis • Family-focused • Evidence-based approaches implemented • Skill-based

36. Integrated Treatment Model: Assessment • Identification and prioritization of treatment needs is a major goal • Use of standardized, valid diagnostic measures (Diagnostic Interview Schedule for Children) • Treatment heirarchy is established, targeting • Threats of harm to self or others • Physical or sexual aggression • Escape ideation or attempts • Treatment-interfering behaviors • Motivation and engagement • Quality-of-life interfering behaviors • Significant treatment considerations

37. Integrated Treatment Model: Methods of Change • Behavior Modification: Reinforcement, punishment, shaping, extinction, contingency management, cue removal and exposure • Coaching and role playing • Motivation enhancement • Validation • Cognitive restructuring • Skills training (Dialectical Behavior Therapy)

38. Components of Integrated Treatment Model • Dialectical Behavior Therapy • Substance abuse treatment • Relapse prevention • Sex-offender treatment • Aggression-replacement therapy • Functional family therapy • Family Integrated Treatment

39. Dialectical Behavior Therapy • Developed by Marsha Linehan for the treatment of Borderline Personality Disorder (BPD) • Goal is to reduce problems associated with emotional dysregulation

40. Emotional Dysregulation • The inability to monitor, evaluate, and change emotional responses • Impulsivity • Intense emotional responses • Slow return to normal after emotional arousal

41. Emotional Dysregulation • A hallmark symptom of Borderline Personality Disorder • Also related to a range of problems commonly seen in the Juvenile Justice Population • Substance abuse, depression, anxiety, poor impulse control, poor anger management • DBT: a promising treatment for juvenile offenders?

42. What is DBT? • Emphasis on mindfulness • Behavioral therapy components • Goal-focused interventions • Behavior chain analysis is used to identify antecedents and consequences of behavior, and to prompt consideration of alternative courses of action • Recognition that one needs to change one’s behavior in order to change one’s feelings

43. DBT Skills • Core Mindfulness • Emotion Regulation • Distress Tolerance • Interpersonal Effectiveness

44. Dialectics: Acceptance vs. Change • Validation • Patients’ emotional, cognitive, and behavioral responses are understandable in the context of the environment and the patient’s skill level • Patient may not have created his/her problems, but he/she is responsible for solving them • Therapist coaches patient on more effective behavioral responses

45. DBT in Juvenile Justice Settings • Delivered through groups, individual therapy, and daily interactions with staff • Teaches behavioral analysis, cognitive restructuring, skills coaching • Integrated into the culture of the institution

46. Is DBT effective in juvenile justice settings? • Outcome research is limited • Girls in mental health cottage who received DBT had significantly lower 12 month felony recidivism rate than those who were residents of the cottage before the DBT program began(10% vs. 24%). (WSIPP, 2002) • Punitive actions by staff in mental health cottage decreased when cottage began implementing DBT. (Trupin, Stewart, Beach & Boesky, 2002)

47. Transitioning Youth From Incarceration to the Community • How can we give youth with co-occurring disorders the skills they will need to avoid recidivating?

48. Family Integrated Transitions (FIT) • A family- and community-based treatment for youth with co-occurring mental health and substance abuse diagnoses who are being released from secure institutions in Washington State’s Juvenile Rehabilitation Administration

49. FIT targets the multiple determinants of antisocial behavior • Multisystemic Therapy framework to change the systems that create the reinforcement contingencies for behavior • Dialectical Behavior Therapy to promote emotional and behavioral regulation • Motivational Enhancement Therapy to promote engagement in treatment • Relapse Prevention to give youth skills to promote sustained abstinence

50. Family Integrated Transition (FIT): Target Population • Ages 11 to 17 at intake • Substance abuse or dependence disorder AND • Axis I Disorder OR currently prescribed psychotropic medication OR demonstrated suicidal behavior in past 6 months • At least 4 months left on sentence • Residing in service area