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JJIE Hub: Key Issues — Mental Health & Substance Use Disorders

Juvenile justice systems across the country are filled with youth that have mental and substance use disorders (“behavioral health disorders”).  A 2003 report found that the use of juvenile detention facilities to house youth with mental health problems was “widespread and a serious national problem.”[1] Recent research provides us with a more accurate picture of these youth.

  • The number of youth with behavioral health disorders at all points in the juvenile justice system is higher than that of youth in the general population.[2]
  • The percentage of youth with disorders is largest in the deeper end of the system--secure confinement after trial.
  • In a study by Dr. Gail A.Wasserman and colleagues published in 2010, they found that more than half (51.9 percent) of youth in the juvenile justice system overall had at least one mental health or substance use disorder. Of those youth just entering the system, 35 percent were found to have a mental health disorder; of those committed to a secure facility, 64 percent were found to have a mental health disorder.[3]

  • Youth in the juvenile justice system have been found to have high rates of substance use disorders, disruptive disorders (including conduct disorder, attention deficit hyperactivity disorder [ADHD], and oppositional defiant disorder), anxiety disorders (including post-traumatic stress, panic, obsessive-compulsive, and phobia disorders), and mood disorders (including manic episodes and depression).[4]
  • The odds that youth will suffer from a major disorder go up significantly if they have a substance use disorder.[5]
  • Large numbers of youth also have multiple mental health disorders, or co-occuring mental and substance use disorders.[6]
  • Girls are significantly more likely to suffer from disorders related to anxiety and depression, and to have more  co-occurring disorders.[7]
  • Most youth detained in juvenile detention centers have been exposed to trauma in the form of community and family violence.[8]
    • These youth are at higher risk for mental and substance use disorders.[9]
    • These youth often receive diagnoses of attention deficit disorder, oppositional defiant disorder, conduct disorder, or post-traumatic stress disorder.
    • To treat these youth effectively, they require evidence-based trauma-informed care.
    • Some research estimates that 75 to 93 percent of youth entering the justice system each year have experienced some degree of trauma.[10]
    • Youth involved in the juvenile justice system have an increased risk of suicide and the risk is further increased for youth with a mental illness or substance use disorder.[11] Youth in residential facilities have nearly three times the suicide rate of youth in the general population, and suicide is the leading cause of death for youth in confinement.[12]
    • In adult facilities, youth under 18 are two times more likely to commit suicide than adult inmates.[13]

They Have Limited Access to Treatment in the Community

  • Many youth with disorders go untreated simply because of a lack of mental health services available to them in the community. This can result in disruptive behavior leading to an arrest and sometimes confinement in a juvenile facility --even though most have committed minor, non-violent offenses.

  • Even if treatment is available in the community, families often have difficulty accessing care because their insurance coverage is inadequate and it is not always clear whether public sources of funding will cover these services.

Systems of Care Don’t Work Together Well

  • Many mental health and juvenile justice systems fail to work together to effectively address youth with mental and substance abuse disorders. Effective models indicate these two systems should also work with education, child welfare, and substance abuse treatment providers.
  • Better coordination can help to identify youth with mental health needs earlier to prevent their entry into the juvenile justice system, ease their reentry into the community if they have been in the system, and assist in securing funding for mental health services.

Youth Disorders Are Not Identified

When youth with mental and substance use disorders are identified early, they can get the treatment they need to avoid going deeper into the system. Not all intake staff or other juvenile justice personnel screen youth for mental and substance use disorders.[14]

Law Enforcement and School Staff Lack the Training to Identify Disorders in Youth

    • Schools and law enforcement are often the first responders to situations where youth with mental health and/or substance use disorders may be acting out.
    • Training these professionals to recognize symptoms, how to defuse situations, and giving them treatment alternatives to the juvenile justice system can significantly reduce the number of youth unnecessarily arrested and processed through juvenile court. [15]

Given the large number of youth with mental and substance use disorders in the juvenile justice system, it is not feasible to conduct extensive evaluations of each child. Instead, these youth can be identified by systematically screening and assessing them using evidence-based tools at key decision points in the juvenile justice system.

  • Screening is used to identify which youth may have mental health and/or substance use disorders.
  • Screening should identify which youth need immediate help as well as those youth more likely to have a disorder that requires special attention.
  • Screening does not provide a valid mental health diagnosis.
  • A screening instrument identifies current symptoms and its results are useful only for the short term.
  • Click to see examples of evidence-based screening tools commonly used in juvenile justice settings.

  • Assessment is a more comprehensive and individualized identification of the mental health and/or substance use disorders and needs of the youth.
  • An assessment generally identifies whether the youth has mental health and/or substance use disorders, the type and extent of any disorders, behavior resulting from these issues, and may make psychiatric diagnoses and recommendations for treatment.
  • Note that an assessment for mental health purposes is a different tool than a risk assessment.
  • Click for a list of evidence-based assessment instruments commonly used in juvenile justice settings.

Experts recommend that screening occur as soon as a young person gets to probation or intake and at all critical stages of juvenile justice processing, such as admission to facilities or community programs.[16]  An assessment may then be needed for certain youth based on the results of the initial screening. The initial screening may be done in two parts, with the first part done immediately as an “emergency” screen to identify any mental health crises.

One size does not fit all. Many factors impact the screening and assessment tool that a juvenile justice system uses. Some major considerations are:

  • Evidence of scientific rigor – best practices call for using only tools that are “evidence-based,” meaning that there is research evidence of their reliability and validity with youth in the juvenile justice system.
  • Instruments should take into account gender, age, various ethnic backgrounds, and learning disabilities.
  • Financial costs for different screening and assessment tools vary. These costs can include training of staff, level of staff qualification required to administer the tool and additional information gathering required to complete the assessment.
  • The “decision point” in the juvenile justice process at which the screening or assessment tool is being used matters. For example, there may be different concerns regarding a youth’s disorder and behaviors depending on whether they have just been arrested and are at probation intake, or if they have just been adjudicated and sent to an institution.

Absolutely. When they are screened or assessed, youth must share confidential information. Young people evaluated before trial may be asked, for example, about illegal behavior or substance abuse, and if this information is provided to the court it could end up being used against them, thereby violating their right to protect themselves from self-incrimination. These instruments can also uncover information about young people’s competency to stand trial, which may directly affect their legal options and what happens to their cases. Finally, while the information collected is supposed to be kept confidential, lack of clarity about the law can mean that it is often shared inappropriately between professionals and agencies. Safeguards can be put in place to address many of these concerns.

More and more communities are diverting these youth from the juvenile justice system to other systems of care. Improving services to the youth who remain in the juvenile justice system can prevent them from reoffending. Ways to do this include educating and training juvenile justice personnel in best practices in handling youth with disorders; engaging youths’ families; and providing mental health and substance abuse treatment after they leave the justice system.

While no treatment approach is 100 percent effective with all youth, many effective evidence-based practices have been developed to provide treatment for youth with mental health and substance use disorders in the juvenile justice system. These interventions include psychosocial interventions, community-based programs, and medication therapies.

Funding is a critical issue. A 2003 study found that 12,000 families in 19 states had relinquished custody of their children for the sole purpose of trying to get them the mental health services they needed; about 9,000 were sent to the juvenile justice system.[17]

  • Private health insurance[18]
  • Medicaid and the Children’s Health Insurance Program (CHIP)[19]
    • While these federal funds underwrite treatment for young people in many states, access to benefits varies state by state, and there are numerous barriers to using Medicaid or CHIP to meet the mental health needs of youth in the justice system.
  • Federal Grant Programs[20]
    • Federal grant programs make up a smaller percentage of mental health financing than the private and public insurance programs listed above.

Mental Health & Substance Use Disorders Sections

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Notes

[1] U.S. House of Representatives, Committee on Government Reform – Minority Staff, Special Investigations Division, “Incarceration of Youth Who Are Waiting for Community Mental Health Services in the United States” (July 2004). This investigation of detention facilities across the country found that two-thirds of juvenile detention facilities hold youth who are waiting for community mental health treatment.

[2] Joseph J. Cocozza and Kathy Skowyra, “Youth with Mental Health Disorders: Issues and Emerging Responses,” Office of Juvenile Justice and Delinquency Prevention Journal 7, no. 1, (2000): 3-13, ; Jennie L. Shufelt and Joseph J. Cocozza, "Youth with Mental Health Disorders in the Juvenile Justice System: Results from a Multi-State Prevalence Study" (Delmar, NY: National Center for Mental Health and Juvenile Justice, June 2006), accessed January 29, 2014 at ; Linda Teplin, et al., “Psychiatric Disorders in Youth in Juvenile Detention, Archives of General Psychiatry 59, (2002): 1133-1143, ; Gail Wasserman et al., “The Voice DISC-IV with Incarcerated Male Youths: Prevalence of Disorder,” Journal of American Academy of Child and Adolescent Psychiatry 41, no. 3, (March 2002): 314-21, ; Gail Wasserman et al.,  “Gender Differences in Psychiatric Disorders at Juvenile Probation Intake,” American Journal of Public Health 95, no. 1, (January 2005): 131–137, accessed March 16, 2013, ; Gail Wasserman et al., “Psychiatric Disorder, Comorbidity, and Suicidal Behavior in Juvenile Justice Youth,”  Criminal Justice and Behavior 37, no. 12, (December 2010), 1361-1376, accessed March 16, 2013.

[3] Gail A. Wasserman, Larkin S. McReynolds, Craig S. Schwalbe, Joseph M. Keating, and Shane A. Jones, “Psychiatric Disorder, Comorbidity, and Suicidal Behavior in Juvenile Justice Youth,” Criminal Justice and Behavior, Vol. 37, No. 12 (December 2010): 1361-1376, 1366.

[4] Actual rates of incidence can vary, in part because researchers use different criteria for which disorders to include.

[5] Karen M. Abram et al., “Comorbid Psychiatric Disorders in Youth in Juvenile Detention,” Archives of General Psychiatry 60, no. 11 (2003): 1102.

[6] Abram et al., “Comorbid Psychiatric Disorders,” 1099.

[7] Abram et al., “Comorbid Psychiatric Disorders,” 1099.

[8] Kristine Buffington, Carly B. Dierkhising, and Shawn C. Marsh, “Ten Things Every Juvenile Court Judge Should Know About Trauma and Delinquency,” (Reno, NV: National Council of Juvenile and Family Court Judges, 2010), 2.

[9] Buffington, Dierkhising, and Marsh, “Ten Things,” 2.

[10] Erica J. Adams, “Healing Invisible Wounds: Why Investing in Trauma-Informed Care for Children Makes Sense,” (Washington, DC: Justice Policy Institute, July 2010).

[11] Youth in Contact with the Juvenile Justice System Task Force of the National Action Alliance for Suicide Prevention, “Need to Know: A Fact Sheet Series on Juvenile Suicide,” (September 2013): 1.

[12]National Action Alliance for Suicide Prevention, “Need to Know: A Fact Sheet Series on Juvenile Suicide,” 1.

[13] Antoinette Davis, Andrea Gentile, Caroline Glesmann, "No Place for Youth: Girls in the Adult Justice System," (Washington D.C.: National Institute of Corrections, 2016.)

[14] Kathy Skowyra and Joseph J. Cocozza, Blueprint for Change: A Comprehensive Model for the Identification and Treatment of Youth with Mental Health Needs in Contact with the Juvenile Justice System (Delmar, NY: National Center for Mental Health and Juvenile Justice, 2007), 25-30

[15] Jacquelyn Greene, Esq. and Olivia Allen, Disrupting School-Justice Pathways For Youth With Behavioral Health Needs (Reno, NV: National Council of Juvenile and Family Court Judges, 2017), 12-13. See also, Lisa H. Thurau, “Survey of Police Chiefs Shows Need for Police Training to Work with Youth” (Reclaiming Futures blog, September 15, 2011), for evidence that police chiefs surveyed by the International Association of Chiefs of Police (IACP) want more training on the best practices for working with youth but lack funding and agency resources to provide it. See full report here.

[16] Skowyra and Cocozza, Blueprint for Change, 25; Thomas Grisso and Lee A. Underwood, Screening and Assessing Mental Health and Substance Use Disorders Among Youth in the Juvenile Justice System: a Resource Guide for Practitioners (Washington, DC: Office of Juvenile Justice and Delinquency Prevention, December 2004), 3.

[17] Sonya Schwartz and Melanie Glascock, “Improving Access to Health Coverage for Transitional Youth” (Washington, DC: National Academy of State Health Policy, 2008), 4.

[18] More than half (58 percent) of all children are covered by private health insurance, but private coverage is often limited for mental health treatment, and families often face caps for this coverage, so they often end up paying for a significant portion of care with their own funds. The Patient Protection and Affordable Care Act (ACA) of 2010 places a strong emphasis on private care, which is likely to increase the role of primary care doctors, such as family practitioners and pediatricians, in the delivery of mental health services to youth. See Models for Change, “Knowledge Brief – Mental Health Services in Juvenile Justice: Who Pays? What Gets Paid for? And Who Gets to Decide?” (Chicago, IL: John D. and Catherine T. MacArthur Foundation, December 2011); and Josette Saxton, “Treatment, Not Punishment: Untangling the Mental Health – Juvenile Justice Knot,” (Austin, TX: Texans Care for Children, May 6, 2010).

[19] Models for Change, “Knowledge Brief – Mental Health Services in Juvenile Justice,”; Saxton, “Treatment, Not Punishment"; and Carrie Hanlon, Jennifer May, and Neva Kaye, “A Multi-Agency Approach to Using Medicaid to Meet the Health Needs of Juvenile Justice-Involved Youth,” (Chicago, IL: John D. and Catherine T. MacArthur Foundation Models for Change initiative, December 2008), 6.

[20] Models for Change, “Knowledge Brief – Mental Health Services in Juvenile Justice.”