It's on the lips of many working in the juvenile justice field: "mental health."  With more kids entering juvenile correctional facilities with mental health disorders than ever before, the system is being called on to find better ways to identify which juveniles are in need of treatment for mental health disorders, and beyond that, what type of treatment to provide.

Today, many agencies rely on the Massachusetts Youth Screening Instrument (MAYSI) to red flag juveniles who may have some mental health problems and require further evaluation to determine what their mental health needs are.  This is an important step towards targeting services to the young offenders who need them, said Tom Grisso, a professor of psychiatry at the University of Massachusetts Medical School and the author of both the MAYSI and its most recent version, the MAYSI-2.

Author of Double Jeopardy: Adolescent Offenders with Mental Disorders, Grisso talked recently with The Corrections Connection about the importance of screening and assessing juveniles for mental health problems when they enter the juvenile justice system.  He also talked about screening instruments, including the MAYSI and connecting juveniles to services in the community to satisfy their mental health needs.

Q:  How far has the juvenile justice system come in terms of addressing the mental health needs of juvenile offenders?

Grisso: I think it was around the late 1990s [to the] early 2000s that the issue really began to move to the front burner in juvenile justice.  A number of national organizations, like OJJDP and others, began to really encourage and [pay more] attention to kids' mental health needs in the juvenile justice system and there were other federal activities that greatly encouraged juvenile justice systems in all states to begin to attend to the issue.

Another thing that happened in the late 90s [was] we began to get actual data [about] the proportion of kids in juvenile justice facilities who met criteria for mental health disorders.  Some of those studies were indicating around 70 percent of kids in, for instance, the average pretrial detention center, met criteria for one or more mental health disorders.  The research and the federal attention began to have an impact and, actually, in the last three to four years within juvenile justice systems around the country there has been a lot of attention [paid] to the issue, especially how [to] identify kids [with mental health disorders] as they are coming into a juvenile facility.

Number one - [attention has been paid to identifying] kids who might have very immediate, urgent mental health needs, as in suicide potential or [kids who are] so depressed that there are risks not only of suicide, but also of aggression to other in adolescents.  Depression and anger go together and anger, of course, is a stimulus to aggression.  It's also an issue of protection of other kids, as well as protection of [kids] from suicide.

Also, screening helps to get an idea of what the youths' longer range needs may be.  Usually, screening tools don't provide a really good, stable diagnosis.  They raise a flag that a kid needs further assessment to determine [what a juvenile's mental health needs may be or whether] mental health treatment may have to be part of a longer range plan in working with a kid.  Juvenile justice systems across the country have become highly aware of [the importance of screening] and almost all of them are doing something about it, whereas there was no activity of this type six or seven years ago.

I went to a meeting of juvenile justice administrators nationwide and the person who was leading this meeting asked [the audience], What do you think are the three most important issues facing juvenile programs right now?  One [administrator] stood up and said, "Mental health.  Mental health.  And mental health. 

It really is on the front burner for everybody.  The few places in the country where it is not on the front burner are far behind the rest.  That creates, of course, a need for the juvenile justice system to have some kind of reliable, valid way to screen every kid coming through the front door. 

In the 90s, there really was no such instrument available.  We were developing the Massachusetts Youth Screening Instrument (MAYSI) at that time and we were ready to turn it loose [to practitioners] just about the time that the issue really became [a national focus].  And that has been part of the reason why the MAYSI has become so widely used by a range of facilities across the country.

Q: Can you describe the MAYSI?

Grisso: When we developed the MAYSI, we knew the niche that it needed to fit.  It needed to be very short.  It needed to take no longer than 10 or 15 minutes because it was going to be used with every kid coming through the door.  It had to be simple to administer and score.  It had to [be able to be] used by people who are not clinicians because detention centers do not have PhD psychologists sitting around 24 hours a day.  It had to identify some of the key things that anybody working in those facilities would be interested in, for instance, suicide, depression [or] anger.  [Also], if the youth has been very heavily using alcohol and drugs recently, [they] might be ready to go into withdrawal.  There were actually seven things that we built in the MAYSI along those lines:

 [-Alcohol/Drug Use
 -Angry-Irritable
 -Depressed-Anxious
 -Somatic Complaints
 -Suicide Ideation
 -Thought Disturbance
 -Traumatic Experiences]
 

We have to educate people, not just to the value of screening, but to the importance of not misusing it.  Many people want to begin to treat the [test] scores as though they were diagnoses - as though [they are] enough to build a treatment plan on.  [Screening scores are] definitely not for that purpose, [though].  They are for the purpose of triage - raising a red flag for a certain number of kids.  [It helps to determine] how immediate [the] needs are for some kind of mental health response.  [It is also used] for flagging kids for whom further assessment seems warranted.

So many places that are using the MAYSI use it in that emergency sense - Is there something that we need to do with the youth right now, like use local community mental health services to [provide] inpatient services [for them]?  Is it a suicide issue or is it a kid that we might need to put on suicide watch while in the detention center?  They are using it to determine how to use the results that they have for clinical consultation.  Many have an arrangement with clinicians to be at the detention center a couple of times a week to do more careful evaluations for those kids who may have a longer range need.  This helps them to sort out which kids to schedule for those assessments.

Q: How does the MAYSI-2 differ from the original MAYSI?

Grisso: There was a MAYSI in the 90s that was based on our initial research and it really wasn't promoted.  We used it in Massachusetts and the California Youth Authority used it.  During the period that it was being used in the late 90s, we decided to do some further research.  We did an analysis of the items and we cleaned up the scale in the MAYSI and when we did that, we thought we'd better call it the MAYSI-2.  That came out in 2000.  Virtually everyone [who is using the tool] is using the MAYSI-2.  The original MAYSI had a very limited distribution.

Q: What kinds of efforts have you made to make the MAYSI-2 available to juvenile justice agencies?  How has the National Youth Screening Assistance Project helped?

Grisso: The National Youth Screening Assistance Project (NYSAP) started in 2000 [and] is funded by the MacArthur Foundation.  That allows us to set up this distribution center and a technical assistance service so that any place that was using the MAYSI could call us for problems they were having - either tech problems, like scoring problems or bigger problems, like, for instance, we've put the MAYSI in place and now the prosecutors in our juvenile court are asking us to routinely send over the results for every kid.  Well, that is not a MAYSI problem, per se.  It is a systems problem and a lot of what we ended up dealing with across the years [were] not what are technical things about the MAYSI because it's pretty simple.  The difficult things are how does the system adapt to having such a thing in place.  The problem with prosecutors getting [the results] is that there are items on there about [things like] alcohol and drug use [and] fighting that could be damaging to kids' legal cases.  When they take this screening instrument, they are not being asked [if they want to].  In fact, the detention centers, in most cases, are required to be doing such screening, therefore kids are in danger of providing information that might not be in their best legal interest.  In most places, it has not been difficult to deal with [that issue].  Mostly, the judge orders that the screening data cannot be used.  We've helped places think through this [problem] so that before they put the MAYSI into place, they've [dealt with it already].

The other thing was that we wanted, across the first few years, to assist whole states in putting the MAYSI into place.  So, for instance, if a state had a coalition of detention centers or if they were all run by the state, we would actually come to them and sit with the state administrators for juvenile justice and help them think through how [they are] going to use the MAYSI. For instance, each of the scales has a cutoff score.  [If an agency were to perform] special evaluations on every youth above [the] cutoff, it would be too many kids [to evaluate].  Generally, [the states] have to pick and choose among the sacles [based on] what is important to them.  Some states ended up saying suicide [is the most important thing].  These are decisions they have to make.  The MAYSI doesn't come with a package of prescriptions like that.  Then they have to decide how they are going to respond.  Do they have the resources to bring in a clinician?  [We are there] to help them think through those things while they are putting the MAYSI in place. 

[We are] doing that on a statewide basis.  Then we also will come and [provide] some training [to] some [staff] from each of the detention centers.  [They will] come to particular place in the state during a given day and we have our trainers there.  We can't do this for each individual detention center around the country, but when a whole state is going up on the MAYSI, we do it.

That has resulted in 36 states using the MAYSI statewide in some part of their system (like probation or juvenile detention).  It's used in 48 states altogether.  Right now it's pretty clearly the most widely used mental health screening instrument at the front door of juvenile justice facilities.

[In] many of those places, now, when you take the MAYSI, they save those MAYSI scores. We have a CD that they can use to give it to the youth on a computer that makes it easy to dump those scores into a database.  Eighteen states were able to send us large databases.  Under another research grant, we developed our own database of over 70,000 MAYSI cases and we are now able to develop national norms.

That is the next thing that we are going to come out with - [national norms] - and [we are going to] adjust [our] cutoffs based on that.  Also we are producing a new version of the CD that will be a lot fancier than the one that is out there now.  We've had a Spanish version of the MAYSI for some years, but it always got complaints [because] there are so many different Spanish dialects around the country.  [But] we have finally arrived at a Spanish version that wherever we send it in the country, they seem to be happy with it.

The new CD will have [that] new Spanish version.  That is supposed to be [released in] April or May of 2005.  We are [also] coming out with some supplements to the manual that will have the national norms data in it then.  [We are] doing it all at once.

Q: Can you discuss the V-DISC and its relationship to the MAYSI?

Grisso: The Voice DISC (Diagnostic Interview Schedule for Children), or V-DISC, is far more oriented toward providing a diagnosis for youth, whereas the MAYSI just focuses on different kinds of symptoms.  For instance, on the MAYSI, [if a juvenile is] high on the depressed and anxious scale, it doesn't necessarily mean they meet Diagnostic & Statistical Manual (DSM) criteria for a depression disorder. Something like the V-DISC, which does focus on diagnosis is a logical second step.  Once you've found kids high on the MAYSI, the V-DISC can be a second way to sort [out] kids who do meet diagnostic criteria.

[The V-DISC] takes longer so it would be pretty hard for many places to be able to give [it] as their screening tool to every kid as they come in.  It's got some really nice features because, like the MAYSI, it can be used on the computer.  It speaks the items to the [juvenile] - both the MAYSI and the V-DISC do that.  Many [agencies] use the MAYSI as the first screen and then use that to determine what kids may need a more formal diagnosis such as the V-DISC will give.

Q: What kind of progress do you think the juvenile justice system will be able to make with these kinds of tools in place?

Grisso: The good news is that, obviously, if you are going to do anything down the road in terms of improving services, you've got to be able to identify who needs them.  All this act about identifying, screening and V-DISCing and so forth - it's happening.  It's happening very encouragingly and the system is far better able than it used to be to identify those kids.  It's also able to identify them in ways that indicate what needs to be done with them.  The hard part now is finding the services to actually respond.  Things like the MAYSI and the V-DISC are pushing the issue.  [They] are showing people - administrators and juvenile justice systems - what the level of need is and what the type of need is.  In that sense, by the fact that they are in place, they put pressure on the system.  The hard part comes when you actually look at where the dollars are going to come from to provide the services.  Child community services deteriorated substantially in the 90s that is part of the reason, I think, that the proportion of kids in the juvenile justice system with mental health disorders are high. 

The encouraging thing that I see happening is that this is causing the juvenile justice system and community mental heath systems to begin to move closer together than they have in the past.  They have almost perceived themselves as totally separate entities in the past.  The connections between the two agencies have been rare.  What we are seeing now is a great recognition on the part of both of those agencies that they are sharing the same kids and that any kind of improvement in services is going to have to involve juvenile justice and community mental health working in tandem.

There are various places in the country where you do see that happening.  At some point or other, somebody is going to have to commit the money to it, but trends are in the right direction in most places.