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Journal Issue: Juvenile Justice Volume 18 Number 2 Fall 2008

Adolescent Offenders with Mental Disorders
Thomas Grisso

The Role of Juvenile Justice

Given the involvement of a community's juvenile justice system in a community system of care, what would be its responsibility for responding to delinquent youth with mental disorders? Logic and research suggest that its role would still be considerable, but much more focused and limited than if it were the sole provider of mental health services for youth in its custody.52 Moreover, its primary roles would be somewhat different at various stages in juvenile justice processing.

Identification and Diversion to Community Mental Health Services
The first stage in juvenile justice processing is the youth's arrest and referral to the juvenile court. Once arrested, some youth are immediately placed in a secure pretrial detention facility. Others remain at home but are ordered to appear for intake interviewing. In either case, intake probation officers must decide whether a youth should proceed to trial or whether the case should be handled more informally. In addition, some youth will await trial in pretrial detention, while others will not.

A primary role of the juvenile justice system at this stage should be to identify youth with mental disorders who can be diverted from juvenile justice processing, so that they can continue to be in the community where treatment services are based rather than remaining in pretrial detention or proceeding to full juvenile justice processing. Often this diversion is feasible because some youth are initially referred to juvenile detention centers for minor offenses or present no danger to others that requires secure containment. If their mental health problems were identified at this early stage, and if policies and system-of-care options (including foster and shelter care services if they cannot return home) were in place, then many youth with mental disorders could be diverted from formal juvenile justice processing. Substantial evidence suggests that systematic, well-functioning diversion programs have reduced the census of juvenile pretrial detention centers in many communities, often by half.53

Diversion first requires identifying youth with mental health problems. That, in turn, requires a procedure called screening soon after youth are apprehended by police or are otherwise referred to juvenile court. Screening has two purposes. One is to determine the imminent risk of harm to self or others. Some youth truly need the structure of pretrial detention to provide temporary protection for themselves and the community, and diverting youth at high risk may jeopardize them, the community, and the effectiveness of the system-of-care collaborative model. The other purpose of screening is to identify youth who have current mental health needs—such as serious depression or anxiety, suicidal thoughts, or risk of substance use withdrawal —that might require immediate attention.

Youth may be screened at a special "juvenile assessment center" where all youth are taken when they are apprehended by law enforcement, immediately upon entry to a pretrial detention center (where appropriate diversion can occur within a few hours), or by intake probation officers at first contact with youth. Research suggests that until recent years mental health screening was conducted in about two-thirds of detention centers but typically involved a few informal questions, rather than standardized tools.54 In recent years, however, policymakers have urged juvenile justice intake programs to employ "evidence-based" screening tools—standardized methods for which research has demonstrated their validity.

In the past few years, procedures and technology for mental health and aggression risk screening in juvenile justice intake have been highly refined, and several well-validated screening tools (requiring no clinical expertise) designed specifically for use in juvenile justice settings have been made available.55 Typically this type of screening is brief—usually requiring ten to fifteen minutes—and can be performed by specialized detention staff rather than mental health professionals. The purpose is neither to diagnose nor to develop treatment plans, but rather to classify youth simply as high or low risk (to assess whether they should remain in the community) and as highly likely or not likely to have mental health needs that require clinical attention as soon as possible.

Although the validity of screening methods has been well researched, less is known about whether screening helps improve outcomes for youth with mental disorders. For example, little is known about whether mental health screening disproportionately diverts youth of various races or ethnicities to mental health services instead of juvenile justice processing. Screening might reduce such disparities if it decreases errors related to discretionary decisions of juvenile justice personnel, or it might increase such disparities if the prevalence of mental disorders differs for various racial and ethnic groups of youth referred to the juvenile justice system.56

Nor has research shown that mental health screening reduces mental health problems for youth diverted from the juvenile justice system. In fact, mental health screening by itself will not lead to better outcomes unless there are effective community mental health services to which screened youth can be diverted. Again, the emphasis must be on "evidence-based" services. It does no good to divert youth to community programs that can show no evidence of their value. Fortunately, evidence-based treatment programs do exist, as does some evidence that the best community-based programs for preventing delinquency recidivism also work well for youth with mental disorders.57

Emergency Mental Health Services in Pretrial Detention
During the pretrial stage of juvenile justice processing, juvenile detention centers have special obligations regarding youth in their custody awaiting trial. Their treatment obligations, however, should be limited. They cannot provide long-term treatment for youth (for example, treatments designed to reduce delinquency), because the juvenile justice system is limited in its authority to exercise such interventions until it has established its jurisdiction over the youth—that is, has found the youth delinquent after a hearing on the evidence. Detention centers are obligated to meet the immediate needs of youth in temporary custody, including their mental health needs that present as conditions that would pose harm to the youth if they were not addressed immediately.

Thus all detention centers should have the capacity to respond to mental health emergencies, such as suicide risks and escalation of symptoms to an extent that creates a threat to youth or others. Having that capacity does not mean that mental health professionals would always need to be on staff (although in large detention centers they often are). But facilities would need clear staff procedures for responding to youths' emergency mental health needs, as well as access to outside clinical consultants and arrangements for rapid transfer to psychiatric facilities when necessary.

Some research suggests that despite the high prevalence of mental disorders among youth in pretrial detention centers, only about 15 to 30 percent of detention youth who meet criteria for a mental disorder receive treatment while in detention.58 It is difficult to apply these findings to policy or planning, however. The shortfall is great if one presumes that every youth with a diagnosed mental disorder needs immediate treatment. But that presumption may be faulty, given that many youth with mental disorders might not need immediate treatment or might need effective treatment that could only be provided outside of detention, such as family-based treatments. Much more research is required to determine the level of need in detention centers based on symptom levels of youths' mental conditions rather than on a diagnosis alone.

Assessment for Dispositional Treatment Planning
When youth are adjudicated delinquent, courts then determine the placement most appropriate for managing their rehabilitation. As it does in detention settings, screening at this point requires identifying mental health needs, but at this stage the purpose is not to identify youth who need emergency intervention but rather those whose rehabilitation plans should include specific types of longer-term mental health treatment. Such screening requires comprehensive and individualized assessment methods.

The information produced by that screening is typically provided to judges by specially trained probation officers, who should be using standardized tools that have recently been made available to assist them in collecting data on youths' needs, including mental health problems.59 Some youth, however, need assessments by clinical professionals as a follow-up to probation assessments. Models for clinical evaluation services in juvenile courts are available, but little research has examined their efficiency and effectiveness in providing relevant information for the courts.60 Assessments at this stage should help the juvenile court identify youth with mental disorders who, although adjudicated, might best be rehabilitated in non-secure community placements where they can benefit from a range of mental health services that typically are not available in secure correctional facilities.

Secure Care Mental Health Services and Aftercare
Different mental health service issues arise when certain youth, after having been adjudicated delinquent, must be sent to secure correctional facilities outside the community for reasons of public safety. In these cases, mental health services should be made available within the secure facility itself. For some youth, the system can meet this need by buying psychiatric consultation services from outside the facility and by hiring mental health professionals to provide psychosocial interventions, such as individual psychotherapy. But a small percentage of delinquent youth—those with serious, chronic, and persistent mental disorders—will be too disturbed to be able to function within the routine programming of most correctional programs for youth.

There is as yet little research to guide the development of appropriate services for these youth. Some juvenile justice systems have identified certain secure facilities as "clinical units" where youth with serious, disruptive mental disorders are separated from the general youth correctional population and where they receive specialized clinical services from full-time mental health professionals on staff. A model that blends the resources of the juvenile justice system and the child mental health system to operate and staff such facilities would seem to offer various advantages. Such facilities exist in some states, but they have not been "modeled" or studied in a way that would allow for their systematic development nationwide.

Finally, new issues may arise when youth are released from secure residential programs back into the community. Typical "aftercare" programs involve close monitoring by probation officers when youth re-enter the community and often include educational and social plans for their re-integration. For youth with serious mental disorders, the most effective way to deliver those services is likely to involve the juvenile justice system's continuing jurisdiction over youth during aftercare, but with primary interventions based in a community system of care.61