Detained on a misdemeanor, a youth in New Jersey attempts suicide five times in eight weeks. In custody for five weeks, a juvenile in need of mental health services is beaten over and over again.

These are real stories and real issues for this country's juvenile justice system. Like it or not, juvenile justice facilities are receiving youth with serious mental health problems that require treatment and observation.

"It's not the function of juvenile justice to be mental health and psychiatric centers, but their feeling is they are stuck. They have the kids right now. It's being sold as the place to go. There's no alternative. [And] all over the country people are coming in and finding horrible circumstances for the kids of our country," said Joseph Cocozza, Director of the National Center for Mental Health and Juvenile Justice.

According to Cocozza, juvenile justice systems are becoming de-facto mental health service centers to this group because no one else is picking up the ball.

"More and more it is seen as the system of last resort in receiving services. We hear it over and over again from program administrators to family members," Cocozza said.

A recent NAMI (National Alliance for the Mentally Ill) study found that families were increasingly turning to juvenile justice centers or facilities for mental health services for youth because there were no alternatives in the community.

The rising number of youth with mental health problems in the juvenile detention setting seems to back up that trend. According to Cocozza, recent research indicates that a majority of youth in the system have a mental health disorder and as many as 20 percent of these juveniles have a serious mental health need that requires immediate attention.

And, if they don't receive that attention, a facility can be held liable.

A June 2004 ruling by the Third Circuit Court of Appeals, J.M.K. v. Luzerne County Juvenile Detention Center et al., indicated that a juvenile justice facility has the obligation to screen youth who come through the door for potential mental health problems and to provide services and monitoring when needed. Interestingly, in this case, the youth, who had 11 prior psychiatric inpatient hospitalizations, was beaten by other juveniles in the facility, but suffered no physical injury from the attacks.

According to Lourdes Rosado, a senior attorney for the Juvenile Law Center, because the court spoke out strongly (despite the lack of injury), it indicates the importance that the federal court is placing on assessment and care of these youth.

"There really is an obligation to identify kids with mental disorders when they enter and try to flag them and the potential problems and dangers to themselves and others. It really requires agencies and facilities to think in advance how they are going to assess them, what instruments they are going to use and they relationships they have with treatment providers," said Rosado.

Agencies across the country have come a long way in terms of learning about the youth who are detained there. Many are using nationally recognized assessment instruments to discover whether there are mental health problems in the juvenile population and those tools are becoming more adept at flagging serious problems.

Tools for Assessment

According to Cocozza, as assessment tools have improved, agencies and researchers have been better able to document the rising number of youth in need of mental health services. Once those numbers are down on paper, it's hard to ignore them.

"What's happening at this point is we are beginning to understand and document. Probation departments [and] corrections departments now have something in front of them. These are real kids with real names and need serious help to deal with their mental health issues," he said.

One well-known assessment instrument, the MAYSI, has recently undergone a revision and agencies are able to access technical assistance to implement it. Another, computer-based assessment tool has also been tested in several states and can complement the MAYSI.

This relatively new assessment, Voice DISC (Diagnostic Interview Schedule for Children), was created by researchers at Columbia University's Department of Child Psychiatry and is designed to help agencies determine quickly what a youth's problems are and respond to those who need immediate services.

The V-DISC is a self-administered test by computer that uses the responses to six sets of questions to assess impairment in relation to the youth's relationships with caretakers, family, peers and at school.

The V-DISC differs from other assessment tools in that it also provides a provisional diagnosis for the youth taking the test.

"It's computerized and it's oral and it doesn't require an enormous staff investment. The [youth] self-administers [the test] and for those who don't have good reading skills, the information can be presented over headphones," said Gail Wasserman, Director of the Center for the Promotion of Mental Health in Juvenile Justice at Columbia University/New York State Psychiatric Institute.

Since the V-DISC does not require a lot of manpower to implement, agencies with few resources could begin to assess the need of their population and improve the delivery of services they need.

With the diagnostic information derived from the V-DISC, agencies can have a greater capacity to help those youth who need it.

"They get some idea of the mental health burden they have to deal with. Then, they can use it to create a Plan B [such as] we need more staff who can deal with these disorders," said Wasserman.

The V-DISC and other assessments can help practitioners comprehensively and systematically determine which kids need further evaluation.

According to Wasserman's research, juvenile justice agencies need all the help they can get. In her research she has found that agencies differ greatly in terms of protocols for assessing the mental health needs of youth as they enter the system.

Some agencies contract out for services, some utilize state public health and mental health resources, some are rarely doing what they should, Wasserman said.

This is why it is so important for agencies to get a true picture of the needs of the youth entering the system.

"As you get deeper [in to the system] there's a deeper prevalence of disorder. Most of our analysis shows that 65 percent have some needs," she said.

Wasserman said in many jurisdictions, the services a youth receives depends largely on how astute a judge is at analyzing psychiatric problems.

"Currently, before trial or probation they can request an evaluation but it is subjective," she said.

But mental health experts have begun to make some recommendations about how the juvenile justice system should respond to this issue.

A consensus conference of national mental health experts and juvenile justice practitioners held in 2002 resulted in the publication of six recommendations for the management of juveniles with mental health disorders.

The recommendations range from assessment to the services rendered.

They include,
*Provide an evidence-based, scientifically sound mental health screen within the first 24 hours of a youth's arrival at a facility as part of a general health screen,
*Provide an evidence-based, scientifically sound mental health assessment for all youths as early as possible in order to determine need for mental health services prior to disposition to inform judicial and probation planning,
*Mental health assessment must be comprehensive and based on a careful review of information from multiple sources and measure a range of mental health concerns, including disorders, suicidality as well as functioning at home or in school,
*Provide an evidence-based, scientifically sound screening or assessment for all youths preparing to leave a post-adjudicatory secure facility and return to their communities,
*Provide evidence-based, scientifically sound screening/assessment on a regular basis for all youths as part of a routine medical screening, and
*Ensure that mental health staff are professionally credentialed or are directly supervised by credentialed staff. Provide training for staff appropriate to their role for assessment in evidence-based, scientifically sound mental health screening/assessment procedures.

As recommendations and best practices emerge, mental health experts are hopeful that juvenile justice agencies will begin to adopt them.

"In the past one could say we don't know [how many youth need mental health services.] Now we have good scientifically based instruments that [tell us that information,]" said Cocozza.

Enhancing Efforts in Arizona

While Arizona currently screens all juveniles coming into the system for mental health problems, in early 2005 the Department of Juvenile Corrections (ADJC) plans to improve its screening and assessment methods to ensure that juveniles are getting services targeted to their exact mental health needs.

"One of the things that I am committed to is making sure that we do a good job of screening and assessing our kids," said Kellie Warren, Director of Medical and Behavioral Health Services for the ADJC.  "[Our goal is to] look at who we have coming into our facilities and how we need to plan to deal with them and treat them more appropriately."

Currently, juvenile inmates in Arizona go through a 21-day intake process.  On the first day of their incarceration, they take a MAYSI and within the first two weeks, they receive a V-DISC and a clinical interview.

"We are looking to see really quickly if we need to jump in and put the kid on the kind of status that would protect him or her from harm," Warren said.

While these screening tools help the ADJC to identify juveniles who are in need of immediate specialized mental health care or further assessment, Warren said that the agency's new initiative calls for more intensive screening of these kids when they first enter the system.

"We are trying to look more at incorporating mental health specific screening assessment tools so that we are making sure we are meeting the needs of those populations who are coming through our door," said Warren.

Although the agency has not yet decided which additional screening instruments it will administer to juveniles, the goal is to get a better understanding of what the kids' mental health needs are so that they can be placed in proper housing units, where their treatment needs will be met, according to Warren.

The ADJC has substance abuse units and mental health units, where juveniles with extensive mental health needs are placed.  Staff members on those units are all trained to deal with the juveniles' mental health needs.  Additionally, ADJC has units for juvenile sex offenders where they receive specialized treatment, as well

While the agency's initiative aims to better identify juveniles for mental health services, it is also focused on ensuring that kids continue to receive services even beyond their incarceration.

"Right now, my goal is not to just identify who the kids are, but to actually wrap around services for those kids that would help address their issues on an ongoing basis," Warren said.  "We're out visiting sites and establishing relationships with community providers so that once the kid leaves here, we can continue to [meet] their needs - that is very important."

Warren said that transitional planning for these young offenders is ongoing and begins when they are first incarcerated.  But as the agency's screening and assessment processes are improved, planning for what these juveniles will need in the community is going to be enhanced, too.

According to Warren, each child will have an individual case plan, which is created within the first 45 days of his or her incarceration and reviewed every 30 days after.  Every 90 days, she said, the juvenile's family and other key figures in their life, like parole officers or community treatment providers, will be invited in to discuss that treatment plan.

Incorporating family into the juveniles' treatment is vital, Warren said.

"We [want to] make sure that we are actually giving the kids and their parents what they need," said Warren.  "We are receptive to family being active participants in the treatment planning for these kids.  [We] invite them in to educate them as far as what their kids needs are so that families are better prepared to deal with them," she said.  "A lot of systems often see the family as the problem, but we want to see them as the solution and just give them as much resources as we can."

Warren expects that by March, the ADJC initiative will be off the ground and the agency will be equipped to provide more targeted and comprehensive mental health services to juvenile offenders.

"[We] are just finding that our kids are a lot more damaged psychologically and emotionally," Warren said.  "I am looking forward to where we are going to take this initiative in providing more continuous care for our kids before they get here, while they are here and even when they get into the community."

Mental health experts believe that improvements will soon occur on a grander scale thanks to national efforts to heighten awareness of the issue and to highlight proper procedures and policy.

According to Cocozza, a congressional report released in August by the U.S. House of Representatives shows that lawmakers are paying attention to the problem as well.

According to the report, which was commissioned by House Government Reform Committee member Henry Waxman (D-Calif.) and Senate Governmental Affairs Committee Chair Susan Collins (R-Maine), two-thirds of juvenile detention facilities in 47 states hold youth who are waiting for mental health services in the community.

Reports such as these, combined with funding for diversion programs from such government agencies as SAMSHA and OJJDP, indicate that there is a growing understanding of the scope of the problem and that it goes well beyond the juvenile justice system.

"It's not the juvenile justice piece alone, we need all the services to step up. We need to develop and put money in to divert these youth in a way that is effective," said Cocozza, whose organization is pushing this idea for reform.

But there are still some obstacles to overcome.

"One of the battles that always goes on is youth tend to not have the same priority [so] it takes extra emphasis and an extra push," he added.

Resources:

National Center for Mental Health and Juvenile Justice, www.ncmhjj.com

NCMHJJ Resource Kit:
http://www.ncmhjj.com/resource_kit/Default.htm

Center for the Promotion of Mental Health in Juvenile Justice: www.promotementalhealth.org/centerresearch.htm

Juvenile Law Center 2004 Cases: www.jlc.org/home/legaldevelopements/others2004.htm

The U.S. House of Representatives Report Incarceration of Youth Who Are Waiting for Community Mental Health Services in the United States, is posted online at www.reform.house.gov/min