A national survey of U.S. juvenile mental health courts.

OBJECTIVE: The authors surveyed U.S. juvenile mental health courts (JMHCs). METHODS: Forty-one were identified in 15 states, and 34 returned surveys; one was completed on the basis of published information. Topics included the court's history, youths served, inclusion and exclusion criteria, the court process, and services provided. RESULTS: Half (51%) reported that the juvenile court was responsible for the program; for 11% the probation agency had the responsibility, and 17% reported shared responsibility by these entities. Fifty-one percent reported that all youths with any mental disorder diagnosis are eligible. The most commonly reported participant diagnoses are bipolar disorder (27%), depression (23%), and attention-deficit hyperactivity disorder (16%). Seventy percent currently include participants with felony offenses, and 91% with misdemeanors; 67% exclude status offenses, and 21% exclude violent offenses. A guilty plea was required by 63%. Incentives to participate included dismissal of charges (40%), reduction in court hearings (43%), praise by the judge and probation officer (60%), reduction in curfew restrictions (23%), and gift cards or gifts (71%). Sanctions for not participating included increased supervision or hearings (60%), performing community service (54%), and placement in residential detention (60%). Most JMHCs reported use of a multidisciplinary team to coordinate community-based services to prevent protracted justice system involvement. CONCLUSIONS: JMHCs are being developed in the absence of systematically collected outcome data. Although they resemble adult mental health courts, they have unique features that are specific to addressing the complex needs of youths with mental disorders involved in the justice system. These include diagnostic and treatment challenges and issues related to involving families and schools.

Incarceration and psychotropic drug use by youth.

OBJECTIVE: To determine changes in psychotropic medication use before and after juvenile justice incarceration, contrasting stays in long-stay commitment facilities and short-stay detention facilities. DESIGN: Statewide administrative data (July 1, 1998, through June 30, 2003) from the Florida Department of Juvenile Justice and Florida Medicaid. Medication prescriptions filled before entry and after release from facilities were determined based on paid claims. Psychotropic medication was categorized by drug class based on the National Drug Code. SETTING: General community services. PARTICIPANTS: All of the Medicaid-enrolled youth aged 11 to 17 years identified as having a stay in a juvenile justice facility. The total sample included 67 819 detention stays and 59 918 commitment stays. Main Exposure Incarceration in juvenile commitment and detention facilities. Main Outcome Measure Filled prescriptions for psychotropic medication by class 30 and 90 days before and after incarceration. RESULTS: Ninety days prior to detention, 3666 youth (5.4%) had psychotropic drug claims. Among these, 2296 (62.6%) had any psychotropic medication claims in the 30 days after release. Among commitment cases, 29.6% continued medication use after release. Onset of medication use after release from detention and commitment facilities was relatively uncommon (1.7% and 1.9%, respectively). Youth in commitment facilities were less likely than youth in detention facilities to resume their medication use across drug classes after 30 days (chi(2)(3) = 6.28; P = .04) and after 90 days (chi(2)(2) = 7.62; P = .02). CONCLUSIONS: The results find greater support for a disruption effect than a discovery effect from incarceration. The findings suggest several areas for further investigation and improvement of services for incarcerated youth.

Diversion from the juvenile justice system: the Miami-Dade Juvenile Assessment Center Post-Arrest Diversion Program.

Many arrested youth present with multiple problems, including substance use and mental health problems, poor academic performance, and often come from violent homes and neighborhoods. These problems are directly associated with delinquent behavior and status offenses, presenting challenges to justice agencies, which must respond to these factors to support youths' resources and resiliencies and to reduce the probability of recidivism. The Miami-Dade Juvenile Assessment Center implemented a diversion program for first-time, nonviolent youth. The Post-Arrest Diversion (PAD) program provides systematic, standardized screening and assessment, individualized case planning, an extensive referral service, and case management and follow-up.

Outcomes for women with co-occurring disorders and trauma: program-level effects.

Program-level effects at 6 months are reported from meta-analysis of a nine-site quasi-experimental study of comprehensive, integrated, trauma-informed, and consumer-involved services for women who have mental health problems, substance use disorders, and who have experienced interpersonal violence. The average weighted effect size is significant for the treatment condition for improved post-traumatic symptoms (p < 0.02), drug use problem severity (p < 0.02), and nearly significant for mental health symptoms (p < 0.06). There is significant heterogeneity in effect sizes across sites. Program-level variables were examined in an effort to explain this heterogeneity. The findings indicate that sites which provided significantly more integrated counseling produced more favorable results in mental health symptoms (p < 0.01) and both alcohol (p < 0.001) and drug use problem severity (p < 0.001). The same trend is observable for reductions in post-traumatic stress symptoms, although the difference does not attain statistical significance.

Mental health assessments in juvenile justice: report on the consensus conference.

OBJECTIVE: At national, state, and local levels, there is increasing recognition of the importance of identifying and responding to the mental health needs of youths in the juvenile justice system, as policymakers and practitioners struggle to find ways to address causes and correlates of juvenile crime and delinquency. The proposed guidelines for mental health assessment provide explicit information about how, why, and when to obtain mental health information on justice youths at each important juncture in processing. METHOD: A national group of expert researchers and practitioners convened in April 2002. Experts derived six recommendations, following the expert consensus method, for conducting mental health assessments in juvenile justice settings. Experts had broad experience creating collaborations between juvenile justice, mental health, and child welfare systems and understood the policy and health implications of conducting such assessments in juvenile justice settings. RESULTS: Consensus Conference recommendations regarding screening for emergent risk, screening and assessment of mental health service needs, comprehensive mental health assessment components, assessment before community re-entry, need for periodic reassessment, and staff training are presented. CONCLUSION: Deriving specific recommendations that can be implemented systematically is a necessary first step toward policy changes that will optimize the standard of care for this vulnerable population.

Successful program maintenance when federal demonstration dollars stop: the ACCESS program for homeless mentally ill persons.

A major issue that has long dogged federal human services demonstration programs is the perception that when federal dollars end, the programs end-regardless of any proven successes. Access to Community Care and Effective Services and Supports (ACCESS) was a 5-year federal demonstration project to foster partnerships between service providers for homeless people with serious mental illness and co-occurring substance abuse disorders; and to identify effective, replicable systems integration strategies. After federal funding ended, research teams visited the ACCESS sites to determine which project elements remained and which strategies were used by the sites to continue ACCESS. This article describes ACCESS services and systems integration activities retained by the sites, new funding streams, and strategies used to obtain continued funding.

Overview of the ACCESS Program. Access to Community Care and Effective Services and Supports.

The authors provide an overview of the ACCESS program (Access to Community Care and Effective Services and Supports), which evaluated the integration of service systems and its impact on outcomes for homeless persons with severe mental illness. The ACCESS program provided funds and technical assistance to nine community sites to implement strategies for system change that would promote systems integration. These experimental sites, along with nine comparison sites, also received funds to support outreach and assertive community treatment for 100 clients a year for four years at each site. Data on the implementation of system change strategies were collected from 1994 to 1998 during annual visits to the sites. Data on changes in systems integration were obtained from interviews with key informants from relevant organizations in each community. Client outcome data were obtained at program entry and three and 12 months later from 7,055 program participants across the four annual client cohorts at all sites. Detailed findings from the ACCESS evaluation are presented in two accompanying articles, and overall conclusions are offered in a fourth article.

Integration of service systems for homeless persons with serious mental illness through the ACCESS program. Access to Community Care and Effective Services and Supports.

OBJECTIVE: The aim of this study was to evaluate the first of the two core questions around which the ACCESS (Access to Community Care and Effective Services and Supports) evaluation was designed: Does implementation of system-change strategies lead to better integration of service systems? METHODS: The study was part of the five-year federal ACCESS service demonstration program, which sought to enhance integration of service delivery systems for homeless persons with serious mental illness. Data were gathered from nine randomly selected experimental sites and nine comparison sites in 15 of the nation's largest cities on the degree to which each site implemented a set of systems integration strategies and the degree of systems integration that ensued among community agencies across five service sectors: mental health, substance abuse, primary care, housing, and social welfare and entitlement services. Integration was measured across all interorganizational relationships in the local service networks (overall systems integration) and across relationships involving only the primary ACCESS grantee organization (project-centered integration). RESULTS: Contrary to expectations, the nine experimental sites did not demonstrate significantly greater overall systems integration than the nine comparison sites. However, the experimental sites demonstrated better project-centered integration than the comparison sites. Moreover, more extensive implementation of strategies for system change was associated with higher levels of overall systems integration as well as project-centered integration at both the experimental sites and the comparison sites. CONCLUSIONS: The ACCESS demonstration was successful in terms of project-centered integration but not overall system integration.

Lessons from the evaluation of the ACCESS program. Access to Community Care and Effective Services.

The authors summarize the main findings of the ACCESS (Access to Community Care and Effective Services) program and offer lessons for policy makers. Data from studies at the site level and the client level, which were presented in the two previous articles in this issue of Psychiatric Services, are summarized and synthesized with the authors' collective experience with the ACCESS program. The results of the evaluation suggest that although service systems integration can be improved, targeted efforts to implement strategies for integration do not produce better client outcomes. Efforts to integrate service systems can be supported by their effects on some organizational relationships within the mental health service system but not by their widespread effects across human services or their direct effects on clients.