Handle with Care
by Jill Wolfson
Coalition for Juvenile Justice 2000 Annual Report
Serving the mental health needs of young offenders

Having grown steadily despondent, Thomas, a 15-year-old boy in a juvenile detention facility, is unusually playful, talkative and seems happy one day. Unit supervisors and a counselor notice the boy's change in behavior and are relieved. Because of his erratic mood swings and tantrums, Thomas was becoming a serious problem.

A counselor, before leaving to perform a few tasks, promises to bring the boy candy when he returns. Thomas appears to be having one of his best days in months. Yet, seven minutes later the boy hangs himself in his cell.

Thomas—diagnosed with Bipolar Disorder—lived with a mental health problem, as do 20 percent of youth to varying degrees during childhood. For many years, unfortunately, Thomas was among the two-thirds of all youth who need mental health treatment, but do not receive any. While growing up, his teachers and mother were troubled by his actions, but lacked the knowledge to identify the causes of his behavior. Thomas, in fact, did not gain access to mental health services until he broke the law.

The juvenile justice system has largely become a warehouse for children suffering from mental illness. Fifty to 75 percent of incarcerated youth nationwide are estimated to have a diagnosable mental health disorder. At least half of these youth also have substance abuse problems, often a result of crude attempts at selfmedication. Moreover, nine to 13 percent of the approximately 120,000 youth confined in juvenile facilities nationwide suffer serious emotional disturbances.

Eleven thousand boys and 17,000 girls demonstrate suicidal behavior in juvenile facilities each year. In general, the U.S. juvenile justice system is unprepared to adequately treat or manage youth with mental health problems. Seventy-five percent of juvenile facilities do not meet basic suicide prevention guidelines, according to the Office of Juvenile Justice and Delinquency Prevention (a division of the U.S. Department of Justice). Many detention facility staff are never trained to recognize and respond appropriately to symptoms of mental health distress. Some young inmates, consequently, have been overmedicated, too frequently isolated, beaten or killed when "acting out."

The juvenile justice system's difficulties in addressing mental illness among youth is but one reflection of wider shortcomings. Schools, family and social service organizations, law enforcement agencies and medical institutions—whole communities—lack integrated plans and programs designed to handle mental health problems with care. Efforts are generally piecemeal; those directed toward youth tend to be cookie-cutter rigid, offering a single framework regardless of patient needs. In addition, a pervasive, negative, social stigma is still attached to mental illness.

Mental health, therefore, is not commonly listed among national concerns. Yet, mental health disorders cost the United States more than $150 billion annually for treatment, social services, disability payments, lost productivity and premature death. Mental health services are so lacking throughout the United States that many families believe that their best course of action for a troubled son or daughter is to surrender their child to the courts in order to receive help. Thirty-six percent of respondents to a national survey of parents with court-involved children said their children were in the juvenile justice system because mental health services outside of the system were unavailable to them. Twenty-three percent of parents had been told they would have to relinquish custody of their children to get needed services. Twenty percent actually relinquished custody to get services.

Vulnerable Populations

The youth most vulnerable to mistreatment and mismanagement among those suffering from mental health problems are children of color, females and sexual minority youth. Children of color often face issues that make them prone to develop mental illnesses and less likely to receive treatment. Poverty, prenatal drug/alcohol exposure, discrimination, and domestic and community violence disproportionately confront youth of color. All are risk factors that trigger mental health disorders. Youth of color, particularly males, are misdiagnosed or not diagnosed at all.

Girls experience gender-specific risk factors that may derail their mental health and lead them into delinquency. In general, girls are more likely to experience Depression, Anorexia Nervosa and Bulimia Nervosa, and are more likely to practice self-mutilation and attempt suicide than boys. For example, girls are three times more likely than boys to be sexually abused, and sexual abuse has been recognized as a cause of mental health disorders and related to increased truancy, prostitution and violence, among other destructive behaviors. There is, however, a dearth of gender-specific research focused on girls with mental health problems, as well as gender sensitive intervention/aftercare programs, in communities at-large and the juvenile justice system in particular.

Eighty percent of gay, lesbian, bisexual and transgender youth in the general population report a high level of social and emotional isolation, because of societal perceptions and rejection of their sexual orientation. Half report parental rejection because of their sexual orientation. In the juvenile justice system, such youth routinely complain of physical and verbal abuse from other youth and even staff. Services designed specifically for troubled gay, lesbian, bisexual and transgender youth are scarce.

Promising Approaches

There are, however, promising trends in mental health services and the juvenile justice system. Heightened awareness of mental health disorders has led to increased research and new treatment practices. Among delinquent youth who receive structured, meaningful and sensitive treatment, recidivism rates are 25 percent lower than those in untreated, control groups. Highly successful programs reduce reoffense by as much as 80 percent.

Several successful programs for effective mental health service provision are featured in the report. Youth Villages, a private, nonprofit organization based in Tennessee, provides a wide range of services tailored to the individual needs of youth and families, including residential treatment centers, group homes, outpatient psychiatry, alternative education and therapeutic foster care. Youth Villages employs the tenets of Multisystemic Therapy (MST), an intensive family-and-community based treatment that addresses the numerous factors of serious antisocial behavior in juvenile delinquency. Patrick Lawler, Director of Youth Villages, reports that the organization effectively serves more than 2,000 youth each year in Tennessee, Mississippi and Arkansas.

Wraparound Milwaukee provides a coordinated package of services across a broad continuum of care from prevention and early detection to crisis management and intensive rehabilitative counseling. The approach employs that idea of "no wrong door"—allowing a troubled youth and his family to receive supportive mental health services from any point of contact including schools, religious institutions, recreation programs, public health facilities and law enforcement agencies. Like Youth Villages, Wraparound Milwaukee improves public safety while keeping youth in their family systems, close to home and community.

Recommendations for Change

In view of the current state of mental health services available for troubled youth, the Coalition for Juvenile Justice (CJJ) offers targeted recommendations to the President, the U.S. Congress, community leaders, juvenile justice facilities, youth and the general public. CJJ believes that youth and families should have access to high quality, integrated mental health and juvenile justice services. Among CJJ recommendations promoting such a continuum of care are the following:

• Urging Congress to authorize and appropriate $100 million to further assist states in moving juvenile justice/mental health programming to more cost-effective family and community-based settings;
• Mental health professionals and advocates should recognize that youth of color and girls often do not benefit from current mental health treatment practices and should, therefore, advocate for more research, as well as culturally relevant assessment and treatment;
• Asking policy makers to mandate that no parent be forced to yield legal custody of their child solely for the purpose of acquiring mental health treatment; and
• Establishing regular training programs for juvenile detention facility staff on mental health issues, as well as cultural, racial, gender, sexual orientation and developmental issues.

Key Facts

• Between 50 to 75 percent of incarcerated youth have diagnosable mental health disorders.
• Every day, only 1/3 of youth who need mental health interventions receive them.
• Thirty-six percent of respondents from a national survey said their children were in the juvenile justice system because mental health services outside of the system were unavailable to them.
• Highly successful mental health treatment programs for court-involved youth have been shown to reduce reoffense rates by as much as 80 percent.
• Seventy-five percent of our nation's confined juveniles are in facilities that fail to conform to even the most basic suicide prevention guidelines.
• Roughly 2/3 of all dollars now spent on juvenile justice go to housing delinquent and mentally ill youth in costly lockups that provide little more than warehousing.
• Seventy-five percent of youth treated in costly traditional residential mental health treatment centers were either readmitted to a mental health facility or incarcerated within seven years of release.
• Every year, mental health disorders cost this country more than $150 billion for treatment, social services, disability payments, lost productivity and premature mortality.
• Incarcerated African American adolescents are less likely than their white counterparts to have previously received mental health services.
• Youth of color in the juvenile justice system who are suffering from mental illness are frequently misdiagnosed or not diagnosed at all.
• Among girls in the court system, more than 75 percent have been sexually abused.
• More than half of young women in training schools [large scale juvenile corrections facilities] have reported attempting suicide.

Effective Mental Health Treatment Programs for Youth

• Highly structured, intensive programs that focus on changing specific behaviors;
• Development of basic social skills;
• Individual counseling that directly addresses behavior, attitudes, and perceptions;
• Sensitivity to a youth's race, culture, gender and sexual orientation;
• Family member involvement in the treatment and rehabilitation of their children;
• Community-based, rather than institution-based, treatment;
• Services, support and supervision that "wrap around" a child and family in an individualized way;
• Recognition that youth think and feel differently than adults, especially under stress;
• Strong aftercare services.

Bipolar Disorder (also known as Manic-Depressive Disorder): a disorder where a person's moods swing from depression to mania, generally with periods of normal moods between the two extremes.