This Web site is a component of the SAMHSA Health Information Network
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Section 4: Key Elements of the National Statistical PictureChapter 18. The Availability of Mental Health Services to Young People in Juvenile Justice Facilities: A National SurveyIngrid Goldstrom, M.Sc.,* Fan Jaiquan,† Marilyn Henderson, M.P.A.,* Alisa Male, M.A.,† and Ronald W. Manderscheid, Ph.D.* *Center for Mental Health Services, Substance Abuse and Mental Health Services Administration;† Synectics for Management Decisions, Inc. In addition to its nationwide surveys of mental health organizations and the people they serve, the National Reporting Program of the Center for Mental Health Services (CMHS) continues to fill the gaps in information about the availability of mental health services outside of the traditional mental health sector. The survey discussed in this chapter builds upon earlier successful inventories of mental health services availability in State prisons (Goldstrom, Rudolph, & Manderscheid, 1992) and in local jails (Goldstrom, Henderson, Male, & Manderscheid, 1998) and represents another step toward the completion of the picture of the "de facto mental health system." The 1998 Inventory of Mental Health Services in Juvenile Justice Facilities is the first national survey of the availability of mental health services to young people in juvenile justice facilities. As such, it can contribute to the momentum building to better address the needs of children and adolescents with mental, emotional, or behavioral health problems. A 1999 Amnesty International report discussed the lack of mental health services for children both in the community and within the juvenile justice system. In October 2000, the American Academy of Pediatrics (2000) issued a consensus statement signed by 14 organizations recognizing the shortage of community mental health services for young people, the effectiveness of specific mental health services, and the potential impact of early intervention to reduce the number of young people involved in the juvenile justice system. Even more recently, the Coalition for Juvenile Justice's annual report to the White House and Congress summed up its sentiments by citing a juvenile justice superintendent's words that "finding a suitable placement for a youth with mental health problems is the 'single, greatest problem we face'" (Coalition for Juvenile Justice, 2000). These concerns are now at the forefront of public policy discussion and action. Of late, much has been accomplished with regard to establishing promising partnerships and collaboration between the various, often intersecting, sectors caring for young people— mental health, juvenile justice, educational, child welfare, and social services; general health care; substance abuse systems; and families— to form the basis for solutions. However, the collection of empirical data to examine trends and support policy decisions lags far behind. In an effort to look at the relationship between at least two of the partners— the mental health system and the juvenile justice system— the present survey provides a snapshot of mental health services available in juvenile justice facilities in 1998. It establishes a baseline about the availability of mental health services in these settings so that we can begin to objectively measure the impact of policy changes over time. This survey also examines the disciplines of the mental health providers working within the juvenile justice system and which other sectors of care are interacting with the juvenile justice system to provide access to mental health services for the children and adolescents within the system.
The Juvenile Justice System Like the mental health system, the juvenile justice system evolved out of society's attempt to break away from using jails and prisons to house its most vulnerable citizens. Prior to the development of the juvenile court 100 years ago, children were housed with adults. Despite this, the roots of the juvenile justice system were in civil and not criminal law; hence the juvenile justice system was created as distinct from the adult criminal justice system in both intent and practice. The juvenile justice system in the United States was modeled after the English doctrine which allowed the court, on behalf of the state, to become parent to children whose biological parents were unwilling or unable to raise them. The court was deemed to be benevolent; its number one concern was the welfare of the child. These ideals applied equally to young offenders, as well as to those who were dependent, neglected, and abused. Treatment, rehabilitation, protection, and guidance were the watchwords of the juvenile court (Greenwood, 1984). The Contemporary Juvenile Justice System Developments in the juvenile justice system in the 1960's and 1970's paralleled some of those in the mental health movement. Policies of deinstitutionalization, diversion, and community care in the least restrictive setting were implemented. However, as the policy pendulum inevitably swings, by the 1990's the prevailing public attitude, which has followed us into the new millennium, has been to "get tough on crime" (Kresnak, 1999; National Governors' Association, 1991). In 1996, for example, 10,000 delinquency cases were waived to the adult criminal justice system (Snyder & Sickmund, 1999). Today, there is a contradiction between the original intent of the juvenile justice system, based on treatment and rehabilitation on the one hand, and the public urge to punish, on the other. The notion persists that juvenile crime is pervasive and worsening, despite the fact that the rate of serious violent crimes committed by young people in 1998 was the lowest recorded since these data were first collected in 1973, representing a drop of more than one-half from the 1993 high (Earl Appleby, July 13, 2000, personal communication). Many contemporary challenges exist to providing mental health services to young people in the juvenile justice system. The move by States and local political entities to contract with "for-profit" corporations to operate juvenile justice facilities historically operated under contract by not-for-profit agencies has raised concerns that business motives may conflict with professional standards of staff safety, public safety, and quality of life for residents (NJDA, 2000). As the operation of public systems has been privatized (as was the case with the mental health system in the 1980's), there is concern that government is abandoning its role as service provider and regulator (Privatization, 1998; remarks by John Petrila). Financing issues abound. State budgets tend to favor institutional-over community-based services for public sector spending on juvenile justice. Categorical funding at the Federal, State, and local level impedes interagency collaboration. Since 1984 changes in Federal regulations regarding Medicaid, responsibility for financing health services to youth in juvenile justice facilities has shifted from Federal to State or local governments, creating health disparities. Youth in facilities that are largely private, such as group homes and halfway houses, remain eligible for Medicaid, thereby ensuring that the Federal and local governments share in their health care costs (NCCHC, 2000). Youth in largely public facilities, such as detention centers and training schools, don't have this same assurance. Overcrowding, particularly affecting public facilities such as detention centers and training schools, is increasing and is associated with suicide, physical assaults, and accidental injuries (NJDA, 2000), as well as reduced services and programs and the inability to train staff. Rates of suicide in juvenile justice facilities are higher than in the community (Hayes, 2000). Because no one system operates in a vacuum, trends within the mental health system have affected the juvenile justice system. For example, deinstitutionalization of State mental hospitals has resulted in shifts between inpatient mental health care and the juvenile justice system (American Psychiatric Association, 1995). To the extent that children and adolescents cannot get mental health benefits, or have inadequate benefits, there are fears that the juvenile justice system will become the default system for the provision of mental health services (Bilchik, 1997). This fear is accompanied by the reluctance of the mental health system to treat children and adolescents who are poor and may be violent (Hunzeker, 1993) and by doctor and therapist shortages and long waiting lists at local mental health clinics (Coalition for Juvenile Justice, 2000). There is an overrepresentation of young people of color in the juvenile justice system; these same children and adolescents are underserved in the mental health system (GAINS Center, 1999). Juvenile justice facilities, like mental health facilities, often lack culturally appropriate and competent tools, staff, and programs. Both the mental health and juvenile justice systems share the problem of a lack of available and appropriate services and residential placements. The success of both systems relies on providing a full continuum of care and treatment in the least restrictive setting possible. Because nonsecure placements have declined at least 25 percent over the past 10 years, fewer mental health, group home, and foster care placements exist, and children and adolescents are forced into more stressful institutionally based placements (Prescott, 1998). Lingering questions remain about who is responsible and who pays for mental health services to youth in the juvenile justice system. Different systems may recognize their joint responsibility to young people, but tight budgets at the local levels, where pooled or blended funding does not exist, reinforce turf wars. Young People With Mental, Emotional, or Behavioral Health Problems and the Juvenile Justice System "Children who live in poverty and children of the working poor are dependent on fragmented and under funded public systems that typically fail to provide them with safety nets" (Coalition for Juvenile Justice, 2000). Risk of Involvement in the Juvenile Justice System Children and youth with mental, emotional, or behavioral health problems are at high risk for having additional disabilities, such as learning disabilities, and are also at risk for falling through safety nets, particularly if they drop out of school. Among those identified with a serious emotional disorder who have dropped out of school, 73 percent were arrested within 5 years (Garfinkle, 1997). There is considerable consensus that age, race, ethnicity, gender, and socioeconomic status, more than diagnosis, determine whether a child or adolescent with mental, emotional, or behavioral health problems has contact with the juvenile justice system. It has been found that young people in the juvenile justice system with these problems are similar to those in the community mental health or other public sector service systems in terms of their behavior and service needs, and are much more alike than either is to other children and adolescents in their community (Hunzeker, 1993; Melton & Pagliocca, 1992; National Conference of State Legislatures, 1989). Whether a child with mental, emotional, or behavioral health problems with a status offense such as running away, for example, becomes involved in the juvenile justice system has a lot to do with factors beyond his or her control, such as the following:
Characteristics of Young People With Mental, Emotional, or Behavioral Health Problems Within the Juvenile Justice System Poor children and adolescents are overrepresented within the juvenile justice system and experience higher rates of mental, emotional, or behavioral health problems (GAINS Center, 1999). Once within the juvenile justice system, there is some evidence that young people with mental, emotional, or behavioral health problems fare less well than youth without these problems. In one State study, children and adolescents with mental, emotional, or behavioral health problems stayed an average of 5.7 times longer than others in the juvenile justice system (Privatization, 1998; remarks by Chris Siegfried). Like adults in the criminal justice system, youth in the juvenile justice system are more likely to have histories of child abuse and neglect. It is estimated that between 25 percent and 31 percent have been abused and that between 6 percent and 28 percent have previously attempted suicide (Edens & Otto, 1997). Girls experience higher rates of depression, attempt suicide more often, frequently self-mutilate, demonstrate a high prevalence of physical, sexual, and emotional abuse and victimization, and are more likely to be at risk for over-medication without psychotherapy (Prescott, 1998). Further, dealing with fragmented systems can enhance the problems faced by many young people with mental, emotional, or behavioral health problems who become involved in the juvenile justice system. Many may have lived in shelters because of abuse or neglect in the home or in therapeutic foster care (child welfare system). Concurrently, they may be in special education classes at school (educational system). Perhaps they have resided for a period in a residential treatment center or psychiatric hospital (mental health system). If they are arrested, even for something relatively minor such as trespassing, they come under the auspice of yet another agency and cast of characters, and their problems are likely to be exacerbated by the multiplicity of bureaucracies trying to help them. It is also important to note that young people may enter the juvenile justice system without mental, emotional, or behavioral health problems; however, these problems may be triggered by a host of environmental stressors once they are there. Epidemiology of Mental, Emotional, and Behavioral Health Problems Within the Juvenile Justice System Generally, what we do know about the extent of mental, emotional, or behavioral health problems in juvenile justice settings is, as Edens and Otto (1997) point out, the following: the prevalence of mental disorders is considerably higher than it is in the general population; the prevalence is higher than in community settings; conduct disorders are the most common diagnosis; the cooccurrence of more than one mental health problem, such as conduct disorder with attention deficit or attention deficit hyperactivity disorder, post-traumatic stress syndrome, or affective disorder, is high; and the co-occurrence of any mental, emotional, or behavioral health problems with substance use is higher than in the general population. Because national epidemiologic studies of children and youth are so costly, they are rarely undertaken. None have been done in the juvenile justice system. Estimates of the number of children and adolescents with mental, emotional, or behavioral health problems in juvenile residential placements come from various sources, such as extrapolations from general prevalence studies, and State and local studies in particular juvenile justice settings, such as detention centers. Many studies do not have generalizability because of the limitations of the research (Cocozza, 1992), such as the way they define mental, emotional, or behavioral health problems in the first place. For the purpose of estimating incidence and prevalence, CMHS recognizes three levels of mental, emotional, and behavioral health problems for children ages 9 to 17, based on degree of functional impairment. In the general youth population, 20 percent have a diagnosable disorder. Within this 20 percent are young people with serious emotional disturbances that interfere with school, family, community activities and other aspects of their daily lives; an estimated 9 percent to 13 percent of them have substantial functional impairment, and within that group, 5 percent to 9 percent have extreme functional impairment (Friedman, Katz-Leavy, Manderscheid, & Sondheimer, 1996, 1998). On the basis of these general population estimates and other methodologically sound studies, experts expect that the prevalence of young people with serious mental disorders in juvenile justice settings is at least 20 percent (Open Society, 2000). A National Mental Health Association (2000) analysis of multiple well-designed studies estimates that up to 75 percent have some mental, emotional, or behavioral health problem. Edens and Otto (1997) have produced "tentative" estimates for specific disorders and common experiences of children and adolescents in juvenile justice settings as follows: 50 to 90 percent with conduct disorder; up to 46 percent with attention deficit disorder; 6 to 41 percent with anxiety disorders; 25 to 50 percent with substance abuse or dependence; 32 to 78 percent with affective disorders; and 1 to 6 percent with psychotic disorders. Further, they estimate that between 12 percent and 26 percent have experienced psychiatric hospitalization, and 38 percent to 66 percent, outpatient treatment. More than 50 percent have co-occurring disorders. In addition to estimates of incidence and prevalence of mental, emotional, or behavioral health problems in the system as a whole, there are some data about the mental health needs and prevalence of specific mental disorders in one facility type: detention centers. A 1994 study in Virginia detention centers during 1 day revealed that nearly one-half (49 percent) of the children and adolescents required mental health services and 20 percent had been hospitalized in a psychiatric facility (Virginia Department of Criminal Justice Services, 1994). In a more recent study funded by CMHS, Teplin (unpublished data) found that on 1 day, 68 percent of youth in detention had at least one DSM-III-R disorder (American Psychiatric Association, 1987); 19 percent had a DSM-III-R diagnosis of any affective disorder; 22 percent, any anxiety disorder; 42 percent, any disruptive behavior disorder; and 49 percent, substance abuse or dependence. The presence of substance abuse or dependence confounds residential placement decisions because there may be separate facilities for these youth. [These separate placements are not included in the CMHS survey. However, the Office of Applied Studies, Substance Abuse and Mental Health Services Administration recently completed a survey of substance abuse treatment in juvenile justice facilities, using essentially the same universe as the CMHS survey, and found that approximately 37 percent of these facilities provide substance abuse treatment (SAMHSA, 2000).] CMHS Survey Background and Definitions Figure 1 provides an orientation to the juvenile justice system. It portrays selected portions of a chart designed to illustrate how cases flow through the juvenile justice system (Snyder & Sickmund, 1999). (Note: State and local systems differ; therefore, this schematic should be viewed as illustrative only.) Of relevance to the CMHS survey and the mental health field in general are the following points: First, note the arrows pointing toward diversion from the various boxes. The intention of the juvenile justice system (probation officers, intake officers, and/ or prosecutors) during these early stages is to evaluate young people's needs, assess their amenability to treatment, and decide whether to divert the youth outside of the juvenile justice system or to move the case forward to adjudication (judgment). It is important to keep in mind that there are numerous opportunities for diversion out of the juvenile justice system to appropriate mental health services, if the latter are available. Second, like the mental health system, the aim is to place youth in the least restrictive setting possible, which often depends on the local availability of a continuum of facility types. Facilities differ with regard to the degree of security they provide, their proximity to the local community in which family resides, whether the facility is public or private, and their usefulness for short-or long-term placement. Last, at some point between initial referral to the court and a disposition by the judge, young people may be held in secure detention centers, sometimes called "youth jails." In 1996, 320, 400 delinquency cases in the United States involved detention (Snyder & Sickmund, 1999). Detention centers hold children and adolescents when it is believed the youth is a threat to the community, will be at risk if returned to the community, or may fail to appear at an upcoming hearing, as well as for di-agnostic evaluation purposes (Snyder & Sickmund, 1999). They also serve as temporary placements until beds open up in more appropriate residential placements; in this regard, some young people may have to wait a long time. The focus of the 1998 Inventory of Mental Health Services in Juvenile Justice Facilities is on mental health services availability in detention centers, shelters, reception/diagnostic centers, group homes and halfway houses, ranches/camps/farms, residential treatment facilities, and training schools. Figure 2 defines these facility types. Generally, facility type is ordered on this figure and subsequent tables ranging from the shortest term facilities to the most secure, longest term institutions. As Figure 2 demonstrates, facility types have different placement purposes that may impact on their provision of mental health services. Detention centers and shelters tend to accommodate young people who stay for a short time, usually prior to adjudication; the remaining facilities are for those who stay for a longer term, postadjudication. Shelters, group homes, and halfway houses tend to be in local communities. Training schools are typically the most secure placement for children and adolescents, with the longest stays. It is important to keep these differences in mind when examining the data. Table 1 displays the number and percentage of juvenile justice facilities in the survey and the number and percentage of youth in these facilities on 1 day, by type of facility. Group homes and halfway houses constituted the most numerous facility type; over one-third (36 percent) of all facilities were of this type, yet only 13 percent of youth resided in them on 1 day. After group homes and halfway houses, the most common types of facilities were residential treatment facilities (RTFs) (24 percent) and detention centers (18 percent). Youth were fairly evenly distributed among detention centers (26 percent of youth), RTFs (22 percent of youth), and training schools (25 percent of youth). The plurality of juvenile justice facilities in the survey, group homes and halfway houses, are less likely to formally provide on-site access to mental health services and to have staff available to answer a long survey form. In order to accommodate their uniqueness and not overwhelm them with a lengthy questionnaire, a short version of the survey questionnaire was designed. Please see appendix C for details about the methodology, the survey forms used, and the impact of the different questionnaires on analyses. Mental Health Services Figure 3 provides the definitions of seven mental health services used for the survey. Recent policy statements (Surgeon General, 2000) and literature highlight the importance of early identification of youth with mental health problems in the juvenile justice system. Therefore, intake screening of each child and adolescent, and subsequent evaluation by a mental health professional for those suspected as having a mental health problem, are essential services (Open Society, 2000). Screening should occur at the earliest point of contact and be available at all stages of juvenile processing (Cocozza & Skowyra, 2000), including upon entry to a juvenile justice facility. (Note that with the exception of detention centers, this survey does not capture screening and evaluation services that may take place prior to adjudication.) It bears repeating that it is not only youth with preexisting conditions who are of concern, but also those who may develop mental, emotional, and behavioral health problems while in the custody of the juvenile court. In addition to screening and evaluation, 24-hour availability of emergency mental health services is important, especially in overcrowded settings. Emergency services, as well as screening, are helpful to identify youth with mental, emotional, or behavioral health problems and to reduce the potential for suicides. Once a youth is recognized as having a mental health problem, treatments, such as therapy and medication, are important. It may not be appropriate for short-term facilities to provide therapy/counseling if the children and adolescents are not there long enough to benefit; however, if treatment is one of the pillars of the juvenile justice system's ideals, therapy would be expected to be widely available in long-term facilities. Although there is controversy about the use of medication as a restraint in juvenile justice settings, its availability is sometimes essential for treatment purposes. Ideally, medications are given in conjunction with therapy, not in lieu of therapy. Findings Table 2 provides the national picture of mental health services availability to youth in juvenile justice facilities at the time of the survey. Ninety-four percent of all facilities provided access to any one mental health service, with a range of 81 percent of shelters to all reception/diagnostic centers (100 percent), and nearly all residential treatment facilities (99 percent). Note that aggregate data obscure the wide discrepancies in service availability by facility type. Although screening and evaluation are considered the most essential services, in general, more facilities provided access to medication and emergency mental health services. Note that medication was either the first or second most commonly provided service within each facility type. Across the board, the largely private community-based group homes and halfway houses were doing comparatively better in making the basic services available. Screening, considered by many to be the most critical mental health service, was routinely available for youth in 85 percent of the group homes and halfway houses. These settings were also very likely to provide access to evaluation (82 percent), emergency services (82 percent), medication (87 percent), and therapy (83 percent). The issue of whether a youth should be screened each time he or she is moved to a different placement within the juvenile justice system may account for the low proportion (29 percent) of RTFs that provided access to screening; presumably youth were screened prior to these placements, which clearly focused on evaluation services. RTFs were the most likely facility type (87 percent) to provide access to evaluations by mental health professionals. It appears that the facilities largely used for preadjudication purposes, detention centers, and shelters were less likely than other facility types to provide access to screening, evaluation, and therapy, perhaps reflecting their role as short-term facilities. However, detention centers stand out as doing comparatively better in providing access to emergency services; 85 percent of detention centers, known to have high rates of overcrowding and suicide, did make emergency mental health services available. The longer term placements (RTFs, group homes and halfway houses, and training schools), where treatment is seen as a goal, were most likely to provide access to medication and therapy services. Mental Health Services Availability in Facilities Where Youth Are From Different Service Sectors The data base used to conduct this survey contained facilities housing youthful offenders, and children and adolescents placed by the mental health and/or social services/child welfare sectors. The placement of youth by different service sectors under one roof is attributable, among other factors, to the historical role of the juvenile justice system to help abused and neglected children and adolescents, and the contemporary trend toward privatization and its financial incentives to keep beds filled. In addition to RTFs, facility types likely to house young people placed by multiple sectors are shelters, group homes, and halfway houses. Table 3 contains the results of services availability in these three settings, by the proportion of young offenders housed (less than 25 percent, 25 to 75 percent, and greater than 75 percent). It is presumed that facilities with fewer offenders may also house children and adolescents with mental, emotional, or behavioral health problems and/or those who have been abused and neglected and are at high risk for having these problems. Overall, across the three facility types, it appears that facilities in the middle range (between 25 percent and 75 percent young offenders) were more likely to make mental health services available to the young people housed there. Regardless of the proportion of offenders, the large percentage of facilities providing access to medication services across all facility types, particularly in group homes and halfway houses and RTFs, was noteworthy. Most RTFs in the survey (65 percent) largely housed young offenders. Although these RTFs were comparatively less likely than other RTFs to provide access to mental health services, over three-quarters of the RTFs with largely offender populations did provide access to evaluation (85 percent), emergency services (83 percent), medication (88 percent), and therapy (77 percent). Note that facilities with the fewest offenders, perhaps what the mental health system calls residential treatment centers (RTCs) for emotionally disturbed children, were the most likely to provide medication (97 percent of facilities with fewer than 25 percent offenders). RTCs have particular importance to the mental health system. According to the Surgeon General's Report on Mental Health (U.S. Department of Health and Human Services, 1999, page 171), youth who are placed in RTCs "clearly constitute a difficult population to treat effectively." After inpatient hospitalization, RTCs are the second most restrictive form of care for children with severe mental disorders (U.S. Department of Health and Human Services, 1999). Although used by only about 8 percent of treated children, they represent nearly 25 percent of the national outlay on dren's mental health (U.S. Department of Health and Human Services, 1999). There was no clear pattern of differences in services availability based on the proportion of young offenders in group homes and halfway houses. Among facilities serving mainly offenders, more than four out of five did provide access to the essen-tial services of screening (87 percent) and evaluation (83 percent), emergency services (84 percent), and the treatments of medication (87 percent) and therapy (81 percent). Although the majority of RTFs and group homes and halfway houses in the survey housed largely of-257 Table 2. Number and percent distribution of juvenile justice facilities providing access to mental health services, by type of facility and type of service fenders (75 percent or more offenders), shelters were more diverse at the time of the survey, possibly reflecting their preadjudication role. Slightly more than one-third of the shelters in the universe (36 percent) held mainly offenders. Across shelter types, those with the greatest proportion of offenders were the least likely to provide access to the essential services of screening and evaluation, or treatments (medication and therapy). Therapy was more likely to be available to youth in shelters with the fewest offenders; nearly half (49 percent) made it available. Mental Health Providers in Juvenile Justice Facilities Table 4 addresses the extent to which mental health professionals work within juvenile justice facilities and the disciplines of those who do. Note that group homes and halfway houses are excluded from this analysis because on-site staffing data were not collected for this facility type. Overall, in approximately two-thirds of faciliies, psychiatrists (61 percent of facilities), psychologists (69 percent of facilities), and/or providers with master's degrees in social work (M.S.W.) (61 percent of facilities) were available on site. With the exception of shelters, psychologists were the most commonly available discipline; Ph.D.s were more likely (56 percent of facilities) than those with master's degrees only (50 percent) to be represented. Shelters were the facility type least likely to provide on-site access to mental health professionals. M.S.W. social workers were more likely to be available than psychologists (54 percent of shelters had on-site M.S.W. social workers, 50 percent had psychologists, and 32 percent psychiatrists). The longest term, most remote and secure facilities, RTFs and training schools, were more likely than other facility types to have on-site psychiatrists and psychologists. Involvement of Other Sectors of Care in Making Mental Health Services Available to Young People in Juvenile Justice Facilities Often, multiple agencies, providers, and families share responsibility for young people with mental, emotional, and behavioral health problems, and collaboration among these partners is deemed ideal. Tables 5 through 7 begin to explore relationships between juvenile justice facilities and other sectors of care in mental health services provision. The involvement of different partners is analyzed both by type of facility and by type of mental health service. Table 5 examines the other sectors of care involved in paying for and/or providing mental health services to youth in juvenile justice facilities, by type of facility and type of source. Table 6 looks at these same facilities by type of mental health service. Group homes and halfway houses are excluded from tables 5 and 6. They were asked where off-site mental health services were located. Results are presented in table 7. Linkages Between Detention Centers, Shelters, Reception/Diagnostic Centers, Ranches/Camps/Farms, RTFs, and Training Schools and Other Sectors of Care Table 5 shows that overall, where outside sources worked with juvenile justice facilities to make mental health services available to young people, these sources were most likely to be other parts of the juvenile justice system (63 percent of facilities), such as juvenile courts or attorneys. As might be expected because of their role in housing youth prior to adjudication, detention centers were most likely (80 percent of detention centers) to engage with other parts of the juvenile justice system. Shelters were the least likely facility type (41 percent of shelters) to work with juvenile justice sources. Nearly one-half (47 percent) of juvenile justice facilities (excluding group homes and halfway houses) providing access to mental health services worked with mental health agencies or providers to make those services available. Overall, facilities were almost as likely to be involved with the local community (31 percent) as State mental health agencies and providers (29 percent). Note that RTFs and training schools, the most secure and remotely located facilities, were more likely to be involved with State than local mental health agencies, yet all other facility types were more likely to be involved with local community agencies or providers. Specifically, detention centers were the most likely facility type (58 percent of detention centers) and training schools the least likely facility type (29 percent of training schools) to work with the mental health system to provide mental health services. The overall role of social services/child welfare agencies in paying for and/or providing mental health services was almost as great as that of the mental health system; 40 percent of juvenile justice facilities worked with social service/child welfare agencies. Approximately one-half of shelters (52 percent) and RTFs (51 percent) interacted with the social service/child welfare system. Families also played a relatively significant role in mental health services provision, particularly in the preadjudication settings of detention centers and shelters. Over one-third (34 percent) of facilities overall interfaced with families to make mental health services available. Nearly one-half (49 percent) of detention centers and over one-third (35 percent) of shelters reported that families were engaged in paying for or providing mental health services. Table 6 presents the percentage of facilities (excluding group homes and halfway houses) that worked with sources outside of their facility to pay for and/or provide mental health services, by type of mental health service. As presented previously in table 5, juvenile justice facilities were more likely to work with other parts of the juvenile justice system than with other sources; the exception to this, highlighted in table 6, was the relatively larger role of the mental health system in providing and/or paying for 24-hour inpatient mental health care, the most intensive mental health service available. Nearly one-half of all facilities providing 24-hour inpatient care (45 percent) did so with the help of the mental health system. In providing this service, facilities were more likely to work with the State (26 percent of facilities) than the local community mental health agencies (17 percent). Approximately one-third of the facilities worked with mental health agencies to provide evaluation (33 percent) and emergency services (35 percent). These facilities are only slightly more likely to interact with the local community than State mental health agencies. Also as noted in table 5, the overall role of the social service/child welfare system in providing and/or paying for mental health services was nearly as great as that of the mental health system. In the case of medication services, the social service/child welfare agencies played a larger role (28 percent of facilities) than mental health agencies (17 percent). Further, in nearly one-third of facilities (29 percent) that provided access to mental health services, families played a role in paying for or providing medication services. Linkages Between Group Homes and Halfway Houses and Other Sectors of Care Table 7 displays the responses to the question of where off-site mental health services were located for youth residing in group homes and halfway houses. The mental health system, particularly local community mental health agencies, played a large role in providing off-site mental health services, greater than any other source, including other parts of the juvenile justice system. In over three-quarters (77 percent) of these facilities, mental health services were available through the mental health system. Local community mental health agencies were by far the most likely source to be working with youth, with one exception. This exception was the role of State mental health agencies and particularly private psychiatric hospitals in providing the most intensive service, 24-hour inpatient mental health care. Twenty-three percent of group homes and halfway houses worked with the State and 36 percent worked with the private sector in providing hospitalization. Social services agencies, on the other hand, played a relatively small role in the provision of off-site mental health services, and families an even smaller role. Only 20 percent of facilities interacted with the former, and 8 percent worked with the latter. Although findings from table 7 cannot be directly compared with findings from table 6 because of differences in questions, in general, interfaces between the juvenile justice system and the mental health system around providing mental health services for youth appeared to be more common in group homes and halfway houses than in other types of facilities. Summary of Findings On 1 day in 1998, nearly 75 percent of young people in juvenile justice facilities were fairly evenly distributed among three facility types— detention centers (approximately 29,000 youth), RTFs (approximately 25, 000), and training schools (28,000). If one is seeking to develop or enhance mental health services that affect the greatest number of youth, these would appear to be the settings to focus interventions. Detention centers were more likely to provide access to emergency mental health services (85 percent of detention centers) than screening (71 percent), evaluation (56 percent), or therapy (43 percent). Emergency mental health services can help to identify youth with mental health problems and prevent suicide, a problem in these overcrowded facilities; however, they are not a substitute for screening and evaluation services. Roughly compa-rable to jails for adults, detention centers appeared to be much less likely than jails to make mental health services available. A 1993 survey of local jail mental health services found that, nationwide, 84 percent of facilities provided access to screening, 73 percent to evaluation, 85 percent to medication services, and 66 percent to therapy (Goldstrom, Henderson, Male, & Manderscheid, 1998). Young people were placed within some facility types, particularly shelters, group homes, halfway houses, and RTFs, from different service sectors. Mental health services appeared to be more widely available where there were not "too few" (25 percent or fewer) or "too many" (greater than 75 percent) young offenders housed under one roof. Providing prevention services in facilities housing youth with diverse problems might be considered. Overall, RTFs and training schools, facilities geared toward long-term treatment, were indeed more likely to provide access to medication and therapy than other facility types. RTFs principally serving youth in the juvenile justice system (facilities with greater than 75 percent offenders) were more likely than other RTFs to provide evaluations by mental health professionals (85 percent of RTFs) and medication services (88 percent). Approximately three-quarters (77 percent) of these RTFs also provided therapy. In comparison with RTFs serving mostly youthful offenders, training schools, or "youth prisons," were more likely to provide screening (76 percent of training schools), yet a little less likely to make evaluation services available. Access to a psychiatrist is deemed by some to be a measure of access to mental health services (Torrey et al., 1992) and is certainly important when a new prescription or continuation of psychotropic medication is indicated. Excluding group homes and halfway houses, of the 954 facilities that provided access to medication services and were asked the question about who prescribed the psychotropic and/or psychopharmacological medication, 83 percent reported that psychiatrists prescribed the medication. This finding may suggest that juvenile justice facilities were more likely to utilize psychiatrists to prescribe and/or monitor medication than is the practice in the general community, where pediatricians and other physicians do the same. Over two-thirds of juvenile justice facilities, again excluding group homes and halfway houses, provided on-site access to psychiatrists, psychologists, and/or M.S.W. social workers. The most remote settings, RTFs and training schools, were the most likely to provide on-site staff. Shelters were more likely to make M.S.W. social workers than other mental health professionals available. A key to serving youth with mental, emotional, or behavioral health problems is collaboration among the various agencies, providers, and families who share responsibility for their well-being. While willing collaboration is the ideal, in reality State or local laws might compel agencies, providers, or families to make contributions or provide services. The extent to which juvenile justice facilities work with other sectors of care to pay for and/or provide mental health services to youth in facilities may not be an accurate measure of collaboration; however, it is a measure of some linkage, ranging between a statutory requirement and true collaboration among partners. Nearly one-half of juvenile justice facilities (47 percent of facilities, excluding group homes and halfway houses) worked with the mental health system to provide access to mental health services. Detention centers were the facility type most likely (58 percent) to work with the mental health system and with families (49 percent). Detention centers more commonly interfaced with local (44 percent) than State mental health agencies (34 percent). RTFs and training schools were less likely than detention centers to work with the mental health system (40 percent and 29 percent, respectively), and when they did, it was more common for them to work with State rather than local mental health agencies. This finding could be related to these facilities' geographic locations, closer to State than local agencies, and/or to the more serious nature of the offenses for which youth are housed in these settings, accompanied by community providers' reluctance to work with them. It could also reflect the presence of mental health services within and under the auspices of the juvenile justice facility, obviating the need to rely on outside sources of care. Overall, more RTFs (51 percent) interfaced with social services/child welfare agencies than with mental health agencies to provide/pay for on-site mental health services. Interface with the mental health system was most likely to occur around providing 24-hour inpatient mental health care. Forty-five percent of facilities providing this service worked with mental health agencies, most commonly the State (26 percent). About one-third of facilities linked in providing/paying for evaluation (33 percent) and emergency services (35 percent); these facilities were more likely to work with local than State mental health agencies. Medication services more commonly involved social services/child welfare agencies (28 percent of facilities) and families (29 percent) than mental health agencies. In over three-quarters (77 percent) of group homes and halfway houses providing access to mental health services, mental health agencies and providers were involved. With the exception of the most intensive services (24-hour inpatient mental health care and separate residential settings for youth with these problems), youth in group homes and halfway houses received services through local, rather than State, mental health agencies. The private sector was more likely than the State to be involved in providing emergency services and 24-hour inpatient care. Group homes and halfway houses housing largely juvenile offenders (more than 75 percent) were the facility type most likely to provide the essential mental health services of screening (87 percent of facilities), evaluation (83 percent), emergency services (84 percent), medication (87 percent), and therapy (81 percent). Among other factors, the greater availability of mental health services to youth in these largely offender facilities could reflect local availability of community-based mental health services, the juvenile justice system's responsiveness to local communities' demands for safety in their neighborhoods, and/or the option available to many of these largely private facilities to refuse to take all youth who have been referred. In any event, it appears that mental health services were more likely to be available to young offenders in the most homelike, community-based, rather than institutional, settings. Shelters, particularly those housing more than 75 percent offenders, were the least likely type to provide mental health services, were the least likely type to provide on-site access to a psychiatrist or psychologist, and were more closely linked with social service agencies (52 percent) than mental health agencies (44 percent) in providing/paying for mental health services. Limitations Several caveats are associated with interpreting these data on the availability of mental health services to youth in juvenile justice facilities. First, while analyzing data by facility type makes good sense from a mental health policy perspective, problems are inherent in any self-classification system where there are no clearly agreed-upon definitions for facility types. Second, a short version of the form was specifically designed for group homes and half-way houses. Although this facility type represents over one-third of all juvenile justice facilities, their residents represent only about 13 percent of the entire population of children and adolescents in facilities. Because there were fewer items on the group home and halfway house form, some of the tables encompass only responses from the six other facility types. Therefore, the reader should refer appendix tables C1 and C2 to interpret results. Third, response rates vary across facility types. Appendix table C3 provides needed detail. Fourth, note that statistical tests have not been performed on differences contained in the tables. Therefore, differences may not be statistically significant. Fifth, this is the first time these data have been collected and analyzed, and, as such, they represent only a baseline from which to look at future trends. Although it may be tempting to compare these findings with local or State surveys, surveys of a particular facility type, or subsequent surveys, the reader is cautioned to use the same definitions of services and facility types when making comparisons across surveys. Sixth, because these data have not been collected before, it is difficult to attach any judgments to them. The availability of mental health services tells us little about whether they are used. Nor do the data tell us what should be available in facilities and how services are best provided. These data sim-ply present a snapshot of the juvenile justice facilities at one point in time. Last, the availability of a service says nothing about its quality or outcomes for particular children and adolescents. Therefore, it does not respond to the question of adequacy of services raised by Amnesty International (1999). In order to examine that, longitudinal studies of individual children and adolescents (see Teplin, 2000) are also required. Conclusions The CMHS survey estimated that about 113,000 children and adolescents were in juvenile justice facilities on 1 day during the study period. Experts agree that about 20 percent of young people in the juvenile justice system experience serious emotional disturbances (Open Society, 2000), with perhaps up to 75 percent experiencing some mental, emotional, or behavioral health problem (National Mental Health Association, 1999, 2000). On the basis of these estimates, on a given day approximately 22,600 young people placed in juvenile justice facilities could have serious emotional disturbances and up to 84,750 may have some problem. Whenever possible, youth with mental, emotional, or behavioral health problems should be diverted from the juvenile justice system (Cocozza & Skowyra, 2000). Of course it must also be acknowledged that there may be youth whose offenses are too serious to allow them to be diverted out into the community. Probation officers, court intake staff, and judges possess wide discretion about diverting children and adolescents out of the system or moving a case forward (Greenwood, 1984). Young people will be well served to the extent that these professionals have access to the most appropriate objective and gender-, race-, and culturally sensitive tools to screen each of them for mental, emotional, and behavioral health problems, places to refer them for mental health evaluations, if necessary, and appropriate and available treatment programs in the local community. The reality is, however, that although effective treatments such as Multisystemic Therapy (Henggler, 1997; Melton & Pagliocca, 1992) and Functional Family Therapy (Coalition for Juvenile Justice, 2000) exist, and the intentions of the juvenile justice, mental health system, and other sectors of care are good, many communities simply lack a range of available community-based mental health resources or appropriate residential placements for young people with mental, emotional, or behavioral health problems. Except for detention, this survey did not examine mental health services availability during the early stages of court processing, prior to adjudication, where youth can be diverted out of the system. CMHS is currently funding a major program on diversion from the criminal justice system; perhaps a similar survey on juvenile justice system diversion activities would be helpful. If youth are adjudicated delinquent and are placed in correctional facilities, the experts agree that the key for helping those with mental, emotional, or behavioral health problems is early identification, with mental health professionals rather than corrections staff as treatment providers (Coalition for Juvenile Justice, 2000). The National Commission on Correctional Health Care (NCCHC), as well as a host of other organizations (Woolard, Gross, Mulvey, & Reppucci, 1992), has developed voluntary standards for the juvenile justice system. These standards include minimum requirements for immediate screening on admission and immediate referral for evaluation by a qualified mental health professional for youth thought to be "suffering from serious mental illness" (NCCHC, 1999). Once youth are identified, if they are in relatively open community residential placements, such as shelters or group homes and halfway houses, hypothetically they could be linked to mental health services in the community. If they are in secure settings outside of their local communities, service needs might necessitate on-site staff and programs. At least since the 1984 inception of the Child and Adolescent Service System Program (CASSP) system-of-care model of family-centered and community-based services for children and adolescents with mental, emotional, and behavioral health prob-lems (Sondheimer & Evans, 1995), it has been clear that cross-system collaboration must form the basis of all solutions to helping young people; their needs cannot be placed at the doorstep of any one agency or system (Cocozza & Skowyra, 2000). Partnerships among all child-serving systems, providers, families, and youth are critical, whether efforts are geared toward prevention, diversion, services during juvenile court processing or in facilities, individualized discharge planning to ensure reintegration into the community with appropriate support services and treatment, or services designed to help youth make the transition to adulthood. Indeed, significant strides have been made in collaboration among mental health, educational, child welfare and social services, juvenile justice, general health care, and substance abuse agencies at the Federal level in facilitating the delivery of integrated services to children and their families at the local level. Just a few recent examples are the Safe School/Healthy Student Program, Circles of Care Program, and the Comprehensive Community Based Mental Health Services Program for Children with Serious Emotional Disturbances and Their Families. A national youth policy, such as exists in England, would go even further toward fostering collaboration, currently impeded by short-term funding for problem-focused, categorical programs (Erickson, 2000). However, in the United States, where States and localities make their own policies about the young people they serve, it is ultimately at the local level where collaboration must be implemented (Privatization, 1998, remarks by John Petrila). Local-level collaborative efforts are also becoming more evident. One excellent model, Milwaukee Wrap Around, pools local dollars across service sectors to "wrap" services, support, and supervision around children and their families through the implementation of an integrated multiservice approach to meeting needs in an individualized way (Kamradt, 2000). In addition to pooling funds, local communities are experimenting with community assessment cen-ters, joint teams of key service providers from the different sectors who conduct assessments and develop treatment plans, collaborative case management, and a host of other solutions. Case management can be seen as the glue to developing and holding together truly integrated services for individual young people. The present survey found that, excluding group homes and halfway houses, 78 percent of juvenile justice facilities report that they provide someone to work with the juvenile justice system to attempt to get charges modified or dropped for juveniles with mental health problems. Eighty-one percent of detention facilities report having this function. However, when respondents were asked whether youth with special mental health needs were assigned a different case manager or case management team from those without special needs, overall only 4 percent report that they "always" provide a different case manager or case management team and 2 percent "sometimes" provide this as a separate function. Detention centers and training schools, largely public facilities, are the mostly likely to either "always" or "sometimes" provide separate case management; 27 percent of the former and 41 percent of the latter report the availability of this service. When asked about who provides this case management service, in only about one-fourth or fewer facilities are mental health providers, either on-or off-site, involved. This function is largely within the realm of probation staff, juvenile corrections agency staff, or attorneys. While collaboration does not require the creation of a single system, it does demand an interconnected network of organizations that can complement each other through the transfer of appropriate information, resources, and clients among components (GAINS Center, 1999). Currently, the transfer of appropriate information has not been broadly accomplished. The "transinstitutionalization" of "youth in trouble" (Lerman, 1991)— in juvenile justice facilities, residential treatment centers, psychiatric hospitals, or residential schools— makes it difficult to count or follow the many youth who spend their lives bouncing from system to system. The inability of our data systems to determine the extent of overlap in counts conducted in residential facilities within the different systems (Lerman, 1991) hampers our ability to examine trends and formulate rational policy for youth with mental, emotional, and behavioral health problems in each system. The Coalition for Juvenile Justice (2000) goes so far as to recommend building integrated (cross-agency) information systems. Certainly, the need for privacy and confidentiality in data systems and the avoidance of stigmatization toward young people using services are challenges to creating col-laborative data systems. 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