Current Status of Youth with Co-Occurring Disorders in the Juvenile Justice System

1. Current Status of Youth with Co-Occurring Disorders in the Juvenile Justice System Eric W. Trupin, Ph.D. Department of Psychiatry and Behavioral Sciences University of Washington School of Medicine Birmingham, Alabama April 20, 2006

2. Scope of the Problem

3. Scope of the Problem • Over 125,000 youth detained in Juvenile Justice Facilities nationwide • Over 60% have Psychiatric or Substance Use Disorder, or both • Disproportionality – over representation of minorities • Increasing numbers of youth adjudicated as adults

4. Scope of the Problem • Over 50% recidivism rates common for juvenile offenders • Costs to keep youth in secure facilities. California: $125,000. New York: $85,000. Louisiana: $55,000. Washington State: $57,000. • 6 states spend more on prisons and detention facilities than on colleges and universities

5. Unmet Need • Unmet need for mental health care is as high now as it was before the expansion of the knowledge base on effective interventions (Sturm, 2000) • Unmet need highest among minority youth

6. Mental Disorders Among Youthin the General Population • 20% of children and adolescents experience a mental disorder • 10% suffer illness severe enough to cause impairment • Less than half receive treatment Surgeon General’s Report on Children’s Mental Health

7. Critical Issue: Selected Findings • Congressional Survey: Over a 6-month period,15,000 youth with mental health needs unnecessarily incarcerated awaiting services (each day, 2,000 youth wait in detention for services ~7% of all youth in detention) (Waxman/Collins, 2004)

8. System Failure…

9. Disparities • Youth of Color: • Are 1/3 of adolescent population; yet 2/3 of juveniles in detention and state correctional systems(Snyder & Sickmund, 1999) • Experience disparities at all stages of juvenile justice involvement (arrest, detention, processing, disposition) – leads to “cumulative disadvantage” and disproportionate minority confinement(Males & Macallair, 2000) • Youth of color more likely than white youth to receive out-of-home placement; white youth more likely placed on probation(Snyder and Sickmund, 1999) • African American and Latino youth receive more punitive treatment than white peers charged with same types of offenses(Villarruel and Walker, 2002)

10. Disparities • Youth of color: • Tend to receive mental health services through juvenile justice and child welfaresystems more often than through schools or mental health settings(Alegria, 2000) • In juvenile and adult corrections less likely than white youth to undergo psychological assessment or receive therapeutic treatment(Huang & Arganza, 2003) • Are more likely to receive diagnosis of conduct disorder, antisocial personality disorder or substance abuse disorder than an anxiety or depressive disorder(Dembo, 1988, etc.) • Dual Pathway: • White youth more likely to be diverted from jj system to mental health system for “treatment;” whereas minority youth processed in jj system for “punishment” (Krisberg etc., Mason and Gibbs, 1992; Kotler, 2001)

11. Growing Sense of Crisis • Increasing number of youth with mental disorders entering the juvenile justice system • 27% increase between 1995 to 2001 in Texas. • Juvenile justice is becoming the system of last resort • NAMI survey found 36% of youth placed in justice in order to access services

12. Growing Sense of Crisis (cont.) • Documented failure to adequately address mental health needs of justice youth • Uncoordinated systems and unclear policies • DOJ investigations highlight inadequate services, inappropriate use of medication, etc. • Increasing sense of urgency surrounding these youth, their care, and system responsibility issues

13. 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)

14. 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)

15. 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

16. 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

17. 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)

18. 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.

20. Kids speak for themselves…

21. Legal and Constitutional Context

22. Examples of Investigatory Findings • Staff placed a minor in handcuffs and she began sobbing and screaming that she would kill herself. Staff warned her, that if she did not stop sobbing, she would be “OC sprayed” (Oleoresin Capsicum). Staff tried to spray youth when she tried to push a staff member, after which 2 staff members held the girl while the other staff member sprayed her.

23. Examples of Investigatory Findings • 13-year old boy reportedly placed in restraint chair to prevent self-mutilation. No staff approached him and he was not allowed to attend school or receive programming, counseling or medication. Hours before he had been locked naked in his empty cell which smelled of urine and had torn pieces of toilet paper on the concrete floor which he had been using as a pillow.

24. Examples of Investigatory Findings • Girls punished for acting out or being suicidal by being placed in a cell called the “dark room” – a locked, windowless isolation cell. With lights turned out (as girls reported they are when room is in use) the room is completely dark. One girl reported being placed naked in the dark room from Friday thru Monday morning. The room is stripped of everything but a drain in the room which serves as a toilet.

25. Civil Rights of Institutionalized Persons Act (CRIPA) • Congress enacted CRIPA in 1980 to provide the DOJ with the statutory authority to protect institutionalized persons • CRIPA authorizes the Attorney General to investigate conditions in juvenile institutions and bring litigation when necessary, to realize systemic “fixes” (individuals not represented and monetary damages not sought) • Congress has called CRIPA, “the single most effective method for redressing systemic deprivations of institutionalized persons’ Constitutional and Federal Statutory rights.”

26. Civil Rights of Institutionalized Persons Act (CRIPA) • Since inception, DOJ Special Litigation Section of Civil Rights Division has investigated over 100 juvenile correction facilities in 20 states (most initiated in last 10 yrs) • Investigate, monitor implementation of consent decrees, settlement agreements, memoranda of understanding and court orders

27. Civil Rights of Institutionalized Persons Act (CRIPA) • To date, most investigations have been resolved without contested litigation • DOJ has focused on 3 sources of Federal rights: • The Constitution • Americans with Disabilities Act (ADA) • Individuals with Disabilities Education Act (IDEA)

28. Areas of Concern in Recent DOJ Investigations • Protection from Harm • Suicide Prevention • Inadequate Mental Health & Substance Abuse Services • Inadequate Medical Care • Inadequate Education Instruction of Youth with Disabilities

29. Protection from Harm • Prevalence of Adult Corrections Model • Staff violence • Unsafe restraint practices • Youth violence • Excessive use of disciplinary isolation/lack of procedural protections

30. Protection from Harm • Impact of crowding • Mix of young offenders with older juveniles • Mix of juveniles w/ minor offenses w/ those committing serious offenses • Other abusive practices • Inappropriate staff-youth relationship • Denial of access to bathrooms

31. Suicide Prevention • Insufficient assessment of suicidal youth • Inadequate MH services for youth on suicidal precautions • Unsafe housing of youth at risk of self-harm • Inadequate supervision of youth on suicide precautions and in seclusion • Lack of preparedness for suicide attempts and other self-harm

32. Inadequate Mental Health & Substance Abuse Services • Inadequate screening, identification and assessment • Inadequate clinical assessment, treatment planning and case management • Inadequate psychotropic medication management • Inadequate mental health and substance abuse counseling (i.e., evidence-based practices) • Lack of family involvement • Failure to place youth in court-ordered treatment • Inadequate staff training in behavior management principles

33. Inadequate Medical Care • Inadequate access to medical treatment • Inadequate health assessment • Inadequate medical treatment of chronic conditions & physical injuries • Inadequate medication administrative practices • Inadequate dental care

34. Inadequate Education Instruction of Youth with Disabilities • Inadequate assessment • Inadequate individualized education programs (IEPs) • Lack of related services • Lack of adequate instruction for youth with disabilities • Inadequate vocational education for youth with disabilities

35. Inadequate Transition Planning • Rehabilitative needs/achievements inadequately communicated to parole counselors, families and community providers • Inadequate transition of youth to community mental health and substance abuse services

36. Focused Behavioral Health Concerns of DOJ Investigations

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

38. 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

39. An Example: Louisiana

40. Political Context • Increase in juveniles detained in State – “Tough on Crime” approach • State wants to control costs – movement to privatize juvenile prison management • Governor makes deals for private interests of “friends” • Managing contracts emphasized profit, not provision of services to youth

41. Political Context • State obligated to maintain census at facilities, or pay management company • Juvenile Justice Project of Louisiana becomes aware of abuses in facilities, initiates class-action suit against State, brings media light to allegations • Civil Rights of Institutionalized Persons (CRIPA) investigation begun by Department of Justice (DOJ)

42. Louisiana: The Situation • Among the highest rate of juveniles in jails/groups homes in US: 582 juveniles per 100,000 residents • $62 m. spent on youth prisons/yr: 45% on security, 16% on rehab and education • 4 large juvenile prisons, fostering unsafe, inhumane conditions • 73% of youth incarcerated for non-violent offenses

43. Louisiana: The Situation • 73% of youth incarcerated for non-violent offenses • Almost 60% with sentences of 3 yrs or more, 16% with 5 yrs or more. One-third sentenced to 3 or more years for non-violent offenses

44. DOJ Allegations • Every child interviewed reported being hit or kicked by officers • Minor offenses – talking back, looking the wrong way, walking out of line – elicited assaults from officers • Children reported being assaulted while sleeping • Staff confirmed that children are afraid to report abuse, for fear of more abuse

45. DOJ Allegations • Juveniles & staff report that officers “paid” children (w/ cigarettes, food, soap, special protection) to beat up other children. • Practice of “Take Five” sanctioned, where guards agree to ignore situation when a child is beaten by other children.

46. DOJ Allegations • In 5-mo. period at one facility for 178 children, 40 children required treatment in ER for orthopedic injuries or lacerations requiring stitches • Reports of physical/sexual assaults at night in dormitories. Report of coercion for oral sex between 2 boys in classroom, while officer slept. Younger children & those w/ low IQ frequent targets. Suspicions of sexual abuse by female officers

47. Key Components of Complaint Filed by DOJ • Failure to provide: • Adequate medical, dental, mental health care • Reasonably safe conditions • Adequate rehabilitative services • Adequate general/vocational educational svcs • Adequate educational accommodations and assessment of those requiring special accommodations

48. Key Components of Complaint Filed by DOJ • Subjecting juveniles to unreasonable isolation and restraints • Denying qualified, disabled juveniles to facility services, programs and activities • Failure to comply with 14th Amendment, Americans with Disabilities Act & Individuals with Disabilities Education Act

49. Response to Complaint • Federal judge agrees with content of complaint, requires State to initiate remedies, which may avoid trial • Judge recommends involvement of LSU in providing remedies to charges, and improving services

50. The Negotiated Settlement • September 2000: “Over 100 pages of detailed obligations and responsibilities that the State of Louisiana agreed to, with time tables and monitoring mechanisms…” (Bill Lann Lee, Acting Assistant Attorney General for Civil Rights, NY Times, 9/8/00) • If State has not fulfilled obligations after 2 and a half years, DOJ can re-file • March 2006: State in full compliance with Settlement