Ohio Department of Mental Health Task Force on Juvenile Offenders

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Final Report and Recommendations: Ohio Task Force on Mental Health Services to Juvenile Offenders

February, 1998

Prepared for:

Michael F. Hogan, Ph.D., Director ODMH
through Judy Wortham, Deputy Director, Program & Policy, ODMH

Geno Natalucci-Persichetti, Director ODYS
through Cheri L. Walter, Deputy Director, Program Services, ODYS

1. INTRODUCTION

The Task Force on Mental Health Services to Juvenile Offenders was convened after a Joint meeting presented by the Ohio Department of Youth Services (ODYS), Ohio Department of Mental Health(ODMH) and Ohio Association of Juvenile and Family Court Judges at the Reclaim, Ohio, Conference held in Columbus in June, 1997. As a result of this meeting, the three systems agreed to collaborate on developing recommendations to the State Department Directors of ODYS and ODMH regarding services to youth who are mentally ill and involved in the juvenile justice system.

Several changes at the local, state and societal levels over the past decade set the context for the work of the Task Force. The impact of managed care and tightening resources, the desire for increased effectiveness and efficiency of services, increasing concerns for juvenile violence and public safety, limitations by correctional facilities on responding to the increasing complex mental health needs of offenders, and pushes toward local management of community problems all contributed to a high level of energy available to complete the Task Force's charge. A clear point of agreement from the beginning was that compartmentalized services and unlinked treatment philosophies are not working to meet the needs of youth with mental illnesses presenting to the juvenile justice system today.

The primary need identified is for coordination of mental health treatment and service to youth who are mentally ill and continuing crimes. The Task Force more specifically defined the target population of severely mentally ill youth as under the age of 18, who exhibit aggressive or violent behaviors to self and/or others, and who require mental health treatment to occur in a secured facility.

2. TASK FORCE PROCESS

Initiation
It was determined that a formalized mechanism needed to be enacted that would allow for a full discussion of the issues and a deep exploration of the complexities involved. The Task Force was convened at the call of the two Department Directors, with particular attention given to ensuring that the multiple constituents were represented, including Mental Health Board staff, community providers, and Juvenile Court Judges and staff, as well as a cross section of Youth Corrections staff. The total group's size was forty-two (42) and most committee meetings, including sub-committee, had greater than 75% participation by members of the Task Force. The Office of Quality provided an expert facilitator for the first meeting, but then the group quickly moved into self-facilitation.

The Work
A total of six Task Force Meetings were scheduled over a six-month period of time. Between the larger Task Force meetings, numerous sub-committee meetings were held, often using telephone conferencing and, in some instances, visiting treatment sites in order to demonstrate in a real way the collaborative nature of the Task Force work.

The three sub-committee groupings evolved from the original goals set out by the Task Force at its initial meeting in July. The areas of interest fell into the following categories: 1) Clinical Treatment; 2) Collaboration; and 3) Legislative and Funding issues. Naturally, there were several areas of overlap between the groups. All of the meeting minutes and reports of the sub-committees are included as attachments to this report.

Near the end of the year, it was necessary to begin consolidating the copious amount of work generated into a concise set of recommendations to the Directors of the respective Departments. Several revisions of the recommendations and final report were necessary in order to satisfy all constituents.

It is believed that this report represents a significant achievement in beginning to reconcile the divergent philosophies and goals of the various state and local systems and sets forth clear recommendations to the Directors of ODMH and ODYS on how to best respond to youth who are mentally ill and committing violent crimes.

3. THEMES, GUIDING PRINCIPLES AND CHALLENGES

In order to ground the work of the Task Force and provide direction to the various subcommittees, the following themes, guiding principles and challenges were delineated:

Themes
The main focus of the Task Force was to develop an innovative approach to meet the needs of the targeted population by utilizing the best practices from both Mental Health and Juvenile Corrections. A convergence between research-supported mental health treatment practices (including psycho-pharmacology and behavioral management strategies) with principles of correctional medicine is needed to develop a continuum of care with the intent of alleviating or managing severe mental/emotional disturbance, and hopefully reducing recidivism in this population.

A compelling, underlying theme to the Task Force's work is that the needs of youth are different from those of adults. While it is not feasible to superimpose the solutions reached by the adult systems of Corrections and Mental Health through the settlement process of Dunn v. Voinovich, some of the same guiding principles could be applied.

Guiding Principles
A Task Force motivator was to concentrate on collaboration and building bridges to all systems. It was clear that stewardship of limited resources was critical to a successful partnership across systems, with pooled funding being the most often suggested strategy. The principle of dollars following youth across counties has proven to be successful in other areas and also might be applied here. It is also believed that expanded dispositional options made available to judges at the time a youth is presented to the juvenile justice system will greatly enhance our collaborative efforts to effectively meet the needs of these most challenging youth.

The guiding principle of safety for the community, for the youth, for the staff, and for the systems involved with mentally ill juveniles who are committing crimes is primary. In addition, a sense that early intervention leads to better outcomes indicates the need for good screening and multi-disciplinary assessment in all three fields. It was further strongly agreed by all Task Force members that the families of these children be required to be included in the established continuum of care, as the local community, state, and region have responsibility to the child, while the parents/guardians continue to have responsibility for the child. The integrity and effectiveness of this continuum of care is believed to be dependent on the development of culturally competent and gender specific services. Finally, the development of meaningful data using the latest technology available became an aspiration for the entire Task Force. This issue is explored further in the Data and Analysis sections below.

Challenges
The basic challenge and opportunity presented to the Task Force was that of balancing the divergent basic philosophies of the various systems. Mental health delivery systems have the primary goal of providing individualized treatment in the least restrictive environment. Correctional facilities are primarily focused on providing community safety, restitution to victims, and sanction for illegal behavior. An exciting challenge in the endeavor of the Task Force is that of balancing the need to provide effective mental health intervention while providing safety to the community, restitution to victims, and appropriate sanctions for wrongful behaviors.

4. DATA AND ANALYSIS

Due to the absence of a coordinated inter-departmental management information system, the types of data needed to do a thorough analysis of current population trends were not possible.

In the interim, the Task Force had to rely on two relatively prescripted sets of data. One set was qualitative data, i.e. oral reports of case stories and their antecedent situations. The other set was research and survey data of youth who were already incarcerated for serious crimes in ODYS facilities.

Following is a summary analysis of the second set of information:

Timmons-Mitchell, et al (1997) surveyed the prevalence of mental health issues of incarcerated males and females in Ohio. Based on a sampling of incarcerated youth assessed during the years of 1995-1996 (n-165), a high percentage of youth evidenced remarkable mental health disorders. Eighty-six percent (86%) of females and twenty-seven percent (27%) of males were identified as having significant mental health symptomatology. In addition to Conduct Disorder, other primary diagnoses were ADHD, Substance Abuse, Mood Disorders, Sleep Disorders, Anxiety Disorders, and Psychotic Disorders, with a surprising over-representation of youth in the study sample having serious psychotic disorders. Current felony level for this sample was 2.89 for males and 2.62 for females.

In a 1997 sampling (June 1997) of 111 male youth at Scioto Juvenile Correctional Center, the ODYS facility housing youth with the most serious mental illnesses, 26% of the youth were diagnosed with a mood disorder, 27% with PTSD, 19% with primary diagnosis of substance abuse (not including dual diagnosis with substance abuse as a secondary diagnosis), 8% with severe ADHD, 6% with Schizophrenia spectrum and other Psychotic Disorders, and 6% with other disorders. Eight percent of these females were on psychotropic medications.

Although valid interpretations from this data may be difficult, a beginning analysis shows that a significant percentage of youth involved in the juvenile justice system have very serious mental health issues. Juvenile Courts report that often youth are sent to ODYS facilities because appropriate secure resources are not available in many local communities. Alternatives to corrections-based sanctions have not been fully tested for mentally ill youth who are also committing violent crimes, primarily because such resources have not been made available to the juvenile justice system.

The Task Force also recognizes that major data gaps exist, especially for very young children (under 12 years of age). Further exploration of the data representing the many different perspectives of the Task Force constituents was recommended.

5. RECOMMENDATIONS

In order to respond to the primary goal of identifying mental health treatment and services to youth who are mentally ill and committing violent crimes, while at the same time emphasizing secure placement options, the following recommendations are outlined:

Recommendation Set A: Continuum of Care
#1. Mobilize an Advisory Board to identify secure treatment beds (*) as an additional dispositional option for Juvenile Courts in the treatment of the population identified in this report. This Advisory Board shall be charged with identifying how secured beds will be identified, the location of these beds, and recommended treatment modalities. The Advisory Board shall involve the collaborative efforts of ODMH, ODYS, representatives from the Ohio Association of Juvenile and Family Court Judges, representatives of ADAMH Boards, community providers, and consists of some members from the current Task Force on Mental Health Services to Juvenile Offenders. (*) For the purposes of this report and the recommendations contained herein, a secured facility is defined to have the following characteristics:

  • Facility is locked and designed appropriately for the population
  • No eject, no reject policy
  • Staff is trained in appropriate mental health and behavior management strategies
  • Staff is trained in crisis prevention, intervention, and management
  • Staff is trained in suicide prevention and monitoring
  • If a youth leaves (AWOL) it is treated as an escape
  • Facility is located as close as possible to home, family and community
  • Individualized treatment planning based on youth needs with required family involvement identified
  • Required coordination between the facility, court, mental health and appropriate others
  • Education/PCSA to be focused on transition and aftercare

One strongly recommended method of exploring alternatives is the development of a gender specific and culturally competent pilot project which addresses the following issues:

  • Co-Occurring mental health and substance abuse disorders
  • Identification of funding streams that support secure treatment; regulatory barriers to the efficient and maximum use of these funds; and the ability for funds to support these alternatives
  • Parallel development of best practices in treatment within secure treatment and the refinement of continuum of care options
  • Development of protocols that support alternative uses of funding streams
  • Development of admission, continued stay, transfer, and discharge criteria for youth in a secure setting
  • Development of hybrid licensing protocols that support secure treatment modalities

Guidelines for a pilot project shall be developed by an interagency Advisory Board within 90 days of acceptance of this report and its recommendations by the Directors of the Ohio Departments of Mental Health and Youth Services. Following acceptance of the guidelines for a pilot project, an R.F.P. shall be developed with scheduled implementation of the project to begin with FY2000, July 1, 1999.

It is recommended that the Advisory Board consist of members from the current Task Force on community mental health and other community services to Juvenile Offenders. The Advisory Board shall monitor the pilot project and shall develop the guidelines for the evaluation of the pilot project to determine project replication and system reform. Local evaluation of the pilot project shall be conducted in conjunction with the local Family and Children First Council.

ODMH and ODYS shall provide adequate fiscal resources to support the exploration of alternative placements.

In developing the R.F.P. the Advisory Board should seek consultation from individuals in state government with specific expertise regarding funding sources that include but are not limited to Medicaid and Title IV-E. Regardless of source, funding must support treatment in the clinical setting most appropriate to the needs of the youth and as close to his/her home and family as possible.

#2. The Ohio Departments of Mental Health and Youth Services in conjunction with the Ohio Association of Juvenile and Family Court Judges and community mental health providers shall collaboratively develop/adopt a culturally competent and gender specific multi-disciplinary assessment process which determines levels of risk, levels of care and treatment modalities. It is recommended that consideration be given to identifying existing assessment tools capable of being used across systems in determining levels of care and that can recommend treatment modalities. The assessment process, which shall be gender specific and culturally competent, shall be developed within 90 days of acceptance of this report and its recommendations. The fiscal support to the development/adoption of this assessment process will be provided by the Ohio Departments of Mental Health and Youth Services.

#3. The interagency Advisory Board shall identify, recommend and communicate "best practices" for secure treatment for children with mental illness and who are involved with the justice system. The best practices shall be aimed at youth who are violent offenders, who have severe mental illness and who are under the age of 18. Local Family and Children First Councils shall be encouraged to serve as the catalyst for implementing cross system training. Funding for the development of a best practice resource guide shall be provided by the Ohio Family and Children First Cabinet Council. (Through ODHS Title IV-B funds).

Recommendation Set B: Collaboration
#4. Develop and implement a collaborative cross system training curriculum which is systemic in nature, gender specific and culturally competent, and which is policy driven at both the local and state levels. At a minimum the training content will:

  1. Be family centered, and promote strength-based service practice
  2. Develop cross system knowledge and skill building
  3. Identify basic cross-system service responsibilities and resources
    1. develop and distribute a directory of cross system service resources
    2. cross system definitions and common vocabulary tied to cross system management information system
    3. best practices which would include any anecdotal case materials to use as examples
  4. Be gender and cultural specific

The cross system training curriculum shall be developed in parallel with all other efforts and work groups that are focusing on children in out-of-home placements. The curriculum shall be developed within 90 days of acceptance of this report and its recommendations. The OFCF Cabinet Council shall insure adequate funding to insure the development and implementation of a cross system training curriculum.

#5. Mandate ongoing community linkages and appropriate family involvement for all youth as targeted in this report throughout the course of their secure placement.

Recommendation Set C: Quality Management
#6. Incorporate evaluation and research into collaborative activities. ODMH and ODYS shall write a grant for the 1999 fiscal grant cycle to the Office of Criminal Justice Services to support state and local evaluation and research efforts.

#7. Initiate systematized data collection on the targeted population identified in this report across three areas: Mental Health, Juvenile Justice and Youth Services; the Task Force will support state and local efforts in the initiation of "profiling" methods for more rapid identification, treatment modalities and better outcomes for the target population. This interagency effort will explore collaborative MIS projects to support the treatment, tracking and analysis of multi-system needs and youth and families who access services from multiple systems. Consideration may be given to the current OFCF Interagency Research and Evaluation team.

ODYS is encouraged to apply for the funding of a collaborative data collection and information management system through the Youth Accountability Grant.

Recommendation Set D: Legislation/Funding
#8. Refer the "Competency To Stand Trial" issue for juveniles to the Juvenile Sentencing Commission. The Task Force identified juvenile competency as a very important issue that needs to be further addressed. The issues of whether juveniles understand the charges against them, can assist their attorney in their defense, and understand court procedures are complex, requiring further legal investigation and research. The Juvenile Sentencing Commission is currently working on the issue of competency of juveniles and the Task Force sees this body as appropriate to adequately determine the legal course needed to address this issue.

#9. Engage the Ohio Family and Children First (OFCF) Cabinet Council and local Ohio Family and Children Councils in identifying pooled funding strategies for youth. Specific consideration shall be given to multi-need youth. Attention should be given to other task forces/work groups addressing pooled funding strategies.

6. NEXT STEPS

The Task Force realizes that many other systems experience the impact of these issues other than those involved in this committee. As a next step, it is suggested that a similar process to the one used by this Task Force be used to engage the following systems in a process that moves all systems forward:

  • the MR/DD community: state and local level
  • the substance abuse treatment and prevention communities
  • the health community: state, county, and local level
  • groups involved in Ohio Works First, welfare reform (particularly IV-E)
  • the education community: state and local level
  • the Reciprocal Interagency Licensing Work Group

Using the process that this Task Force went through as a template (outside facilitation, multiple constituents, large group of representatives at the table, getting grounded in values first, making collaboration the key) may help many systems deal more effectively with children and families who have multiple needs.

The Task Force further recommends as a next step, the expansion of data collection efforts to include substance abuse, child welfare, education, health and case management. To accomplish this step, the Task Force recommends that attention be given to all current and proposed efforts aimed at shared consumer record information and integrated case management, e.g. MACSIS.

Finally, the Task Force realizes that there are many efforts currently addressing numerous issues related to particular needs of youth in Ohio. Where possible and appropriate, the work of the Advisory Board should be closely linked with other efforts aimed at meeting the needs of Ohio's youth in out-of-home placements, e.g. cross system training, pooled funding strategies, consolidated individual case planning, information exchange and confidentiality.

LEGISLATION FUNDING SUB-COMMITTEE

Recommendations regarding funding of Secure Residential Treatment Services

  1. Medicaid and Title IV-E can both potentially serve to finance portions of residential treatment services for offending youth with MH treatment needs. However, pursing this course will require great care and understanding of the rigors of both programs. Significant consultation will be necessary with state staff possessing expertise in these areas.
  2. Both funding sources require non-federal match from some source of public resources Medicaid = 40%; Title IV-E=50%. Debate must occur at the local community level about how to provide the non-federal match. Realistically, these funds must come from multiple public sources since no ONE system has the funds or the full responsibility for these youth. Funds pooling and/or risk pooling across multiple counties may also be an option worth considering.
  3. Pursuing either Medicaid or Title IV-E will also require some significant start up administrative costs in personnel time, paperwork, contract negotiation, etc. These costs may not be reimbursable under either program and will not be insignificant.
  4. The most efficient way to pursue the provision of these services would be to utilize existing residential agencies who are certified as IV-E child care institutions and Medicaid providers.
  5. Before proceeding any further with implementing new residential treatment services, we MUST have better data regarding the number of youth for whom these services arc needed. Other demographic data should also include home county, age, gender, ethnic and racial compositions diagnosis, and type of offense.
  6. Task Force members should continue to work with ODHS on the issue of temporary custody vs. voluntary placements for youth eligible for Title IV-E. Some external encouragement from the Task Force may be needed to advance this issue. Ultimately, also, statutory change will be needed.
  7. An additional non-funding recommendation made at earlier meetings included the issue of youth who are not competent to assist in their own defense or were incompetent at the time that an offense was committed. Juvenile courts currently lack statutory authority to mandate these youth into treatment which would be beneficial for them. There may be a need to amend the ORC to provide such authority. Some other states have already done so. The Sub-Committee recommends that this matter be referred for debate and action by the Judicial Sentencing Commission.

COLLABORATION SUB-COMMITTEE

I. Building a common understanding regarding children with neuro-biological disorders who have committed violent acts

  1. Acknowledge primary tensions with system:
    1. Individualized treatment in least restrictive environments and community safety
    2. Treatment vs. punishment/sanctions
    3. Stabilization vs. cure
    4. Security vs. supervision
  2. Define primary concepts (see attached) relevant to this population

  3. Articulate needs/issues of MH and CT systems

    4. MH Needs/Issues:

    1. Clarity about knowledge (researched) regarding what clinically works with violent, mentally ill youth
    2. Expectations around curing these children (including court's expectations around community safety)
    3. Expectations around funding available to address the unmet needs of children appearing before the court
    4. Involvement as early as possible in the assessment/treatment process

    COURT Needs/Issues:

    1. Thorough and holistic assessments of the child/family (MH, substance, abuse, MR/DD, etc.)
    2. Treatment planning that takes into account individual treatment and community safety
    3. What services/supports are available within the system of care (including the Family and Children First Council)
    4. Access to mental health services in a timely, easy manner
    5. Also need to know what works clinically with these youth
    6. Expectations around funding available to address the unmet needs of children appearing before the court
  4. Identify basic elements cross training and community practices which develop greater awareness of the needs of these youth (Stark County's "Walk-a-mile" initiative)

  • Summarize existing research regarding prevention and treatment in brief, usable ways

    • COLLABORATION SUB-COMMITTEE

    II. Systems collaboration regarding children with neuro-biological disorders who have committed violent acts

    1. Develop profile of youth appearing before the courts that challenge the local system the most (this already exists?)

    2. Use the juvenile court hearings (Charge-Plea-Trial-Adjudication etc.) process to focus recommendations around collaboration and early assessment.

    3. Integrate the 3 principles of service coordination identified in the OFCF statute.

    4. Build on family driven, child centered practices (see attached for example).

    5. Identify best practices in communities regarding collaboration to include:
      • Thorough, holistic assessments
      • Access to services
      • Individual risk and community risk screening tools
      • Shared funding practices
    6. Coordinate work with the other two committees

    PRIMARY CONCEPTS

    1. Mental illness/serious emotional disturbance/neuro-biological disorders
    2. Court order
    3. Probation/parole
    4. Define the steps in the hearing process(Charge-Plea-Trial-Adjudication- etc.)
    5. System of care
    6. Secure treatment facility
    7. CASSP principles

    CLINICAL SERVICES/CONTINUITY OF CARE SUB-COMMITTEE

    ...Recommendation from the clinical Sub-Group of the DYS/Juvenile Justice/Mental Health Task Force

    Recommendation #1
    Launch an ongoing initiative ("Learning Institute") of system wide cross training for the specific needs and treatment approaches for youth who are mentally ill and criminally offending. The initiative should focus on using:

    • Multiple technologies (ex: video-conferencing, CD-ROM)
    • Collaborative partners (ex: universities, OFCF Councils)

    This initiative begins to develop the forum for disseminating the learnings achieved by implementation of Pilot Projects of Recommendation #2.

    Recommendation #2
    Initiate a pilot project strategy to explore various treatment alternatives for youth who are mentally ill and criminally offending. Elements of the pilot project strategy should include:

    • At least four pilot projects regionally located throughout the state
    • An RFP selection process
    • Cross system collaboration that represents an array of acceptable alternative services
    • Existing funding streams supplemented by minimal start-up dollars
    • Clear criteria for success of the projects measured by outcome data
    • Over-riding principle of community safety balanced with family stability and individual need

    Recommendation #3
    Development and adoption of a multi-system Risk Assessment and Clinical Screening Tool for youth who are mentally ill and criminally offending that provides a baseline functional index for decision making. The tool must demonstrate:

    • Consensus and utility across systems
    • Research validity and reliability
    • Clear criteria and specific guidelines for movement in and out of levels of care across systems
    • Consistency with implied values and principles of the Task Force