The Missing Link(age): Multilevel Contributors to Service Uptake Failure Among Youths on Community Justice Supervision

Juvenile probation staff perceptions of engaging families in substance use services

Objectives

Study objectives were to (a) understand juvenile justice staff members' experiences with engaging families in youth substance use services and (b) identify staff-perceived barriers to family engagement across steps of substance use service provision.

Background

Lack of family involvement in juvenile justice system substance use (SU) services is a key barrier to successful treatment of justice-involved youth.

Method

From June through November 2015, 33 focus groups were conducted at juvenile justice system probation sites across seven states. There were 263 participants, which included juvenile justice probation and behavioral health staff.

Results

Strategies to engage families in services were highly variable across the 33 juvenile justice sites. Juvenile justice staff members identified barriers to family engagement in SU services including family discomfort, distrust of juvenile justice staff, lack of family service compliance, difficulties accessing SU services, lack of transportation, insurance and cost barriers, low perceived need for treatment, lack of SU education, and SU treatment stigma.

Conclusion and Implications

Barriers to family engagement directly impact the success of SU service provision in juvenile justice settings. Implementation of strategies to engage families of justice-involved youth (e.g., providing tangible, informational, and emotional support to families, and involving families in juvenile justice policy and care decisions) are critical to improving SU outcomes among this vulnerable population.

The impact of co-occurring mental health problems on referral to and initiation of treatment among youth under probation supervision: Findings from a cluster randomized trial

INTRODUCTION

Many youth under community supervision have substance use and co-occurring mental health issues. Yet, access to treatment is limited, and many programs cannot address co-occurring disorders. This study examines how co-occurring symptoms among youth on probation affect referral to and initiation of treatment. We hypothesize that both referral and initiation rates will be lower for youth with any co-occurring indicators.

METHODS

This study collected administrative data from 14 sites in three states between March 2014 and November 2017 using JJ-TRIALS, a cluster randomized trial. Among 8552 youth in need of treatment (screened as having a substance use problem, drug possession arrest, positive drug test, etc.), 2069 received a referral to treatment and 1630 initiated treatment among those referred. A co-occurring indicator (n = 2828) was based on symptoms of an internalizing and/or externalizing issue. Descriptive analyses compared referral and initiation by behavioral health status. Two-level mixed effects logistic regression models estimated effects of site-level variables.

RESULTS

Among youth in need with co-occurring internal, external, or both indicators, only 16 %, 18 %, and 20 % were referred to treatment and of those referred, 63 %, 69 %, and 57 % initiated treatment, respectively. Comparatively, 27 % and 83 % of youth with a substance use only indicator were referred and initiated treatment respectively. Multi-level multivariate models found that, contrary to our hypothesis, co-occurring-both (p = 0.00, OR 1.44) and co-occurring-internal indicators (p = 0.06, OR 1.25) predicted higher referral but there were no differences in initiation rates. However, there was substantial site-level variation.

CONCLUSIONS

Youth on probation in need of substance use treatment with co-occurring issues have low referral rates. Behavioral health status may influence youth referral to treatment depending on where a youth is located. Depending on the site, there may be a lack of community programs that can adequately treat youth with co-occurring issues and reduce unmet service needs.

Who gets screened and who tests positive? Drug screening among justice-involved youth in a midwestern urban county

BACKGROUND

Given high rates of substance use among justice-involved youth, justice systems have attempted to monitor use through drug screening (DS) procedures. However, there is discretion in deciding who is screened for substance use, as not every youth who encounters the system is screened. The aim of the current study was to examine factors associated with selection for and results of oral DS among justice-involved youth assigned to probation to better inform potential DS policy. Electronic court records from 4,668 youth with first-incident records assigned to probation in a midwestern urban county's juvenile justice system between 2011 and 2016 were included in the analytical sample. Race/ethnicity, gender, age, number of charges and charge type for the current incident were included as independent variables.

RESULTS

Multivariable hierarchical logistic regression analyses indicated that males were more likely to be assigned to DS (aOR = 0.40, 95%CI [0.34, 0.46]), and more likely to test positive for use (aOR = 0.43, 95% CI [0.34, 0.54]) than females. As age increased, youth were less likely to be assigned to DS (aOR = 0.91, 95% CI [0.87, 0.94]), with non-significant differences in DS results. Greater number of charges were associated with a higher likelihood of being assigned to DS (aOR = 1.55, 95% CI [1.43, 1.68]). Youth with violent offenses were more likely to be assigned to DS than those with other offense types (property offenses, drug offenses, statutory offenses, disorderly conduct, and all other offenses), but less likely to test positive for use.

CONCLUSIONS

Many factors were associated with differences in DS, but these factors were not always associated with differential DS results. Demographic or charge-based decisions may not be appropriate for DS assignment.

A mixed methods evaluation of family-driven care implementation in juvenile justice agencies in Georgia

BACKGROUND

Improving family engagement in juvenile justice (JJ) system behavioral health services is a high priority for JJ systems, reform organizations, and family advocacy groups across the United States. Family-driven care (FDC) is a family engagement framework used by youth-serving systems to elevate family voice and decision-making power at all levels of the organization. Key domains of a family-driven system of care include: 1) identifying and involving families in all processes, 2) informing families with accurate, understandable, and transparent information, 3) collaborating with families to make decisions and plan treatments, 4) responding to family diversity and inclusion, 5) partnering with families to make organizational decisions and policy changes, 6) providing opportunities for family peer support, 7) providing logistical support to help families overcome barriers to participation, and 8) addressing family health and functioning. FDC enhances family participation, empowerment, and decision-making power in youth services; ultimately, improving youth and family behavioral health outcomes, enhancing family-child connectedness, and reducing youth recidivism in the JJ setting.

METHODS

We evaluated staff-perceived adoption of the eight domains of FDC across detention and community services agencies in the state of Georgia. We collected mixed methods data involving surveys and in-depth qualitative interviews with JJ system administrators, staff, and practitioners between November 2021- July 2022. In total, 140 individuals from 61 unique JJ agencies participated in surveys; and 16 JJ key informants participated in qualitative interviews.

RESULTS

FDC domains with the highest perceived adoption across agencies included identifying and involving families, informing families, collaborative decision-making and treatment planning, and family diversity and inclusion. Other domains that had mixed or lower perceived adoption included involving families in organizational feedback and policy making, family peer support, logistical support, and family health and functioning. Adoption of FDC domains differed across staff and organizational characteristics.

CONCLUSIONS

Findings from this mixed methods assessment will inform strategic planning for the scale-up of FDC strategies across JJ agencies in the state, and serve as a template for assessing strengths and weaknesses in the application of family engagement practices in systems nationally.

Evaluating e-Connect: Mitigating Race by Gender Disparities in Behavioral Health Referral Among Youths on Probation, Northeast United States, 2019

Addressing the behavioral health needs of youths involved in the justice system is key to reducing recidivism risk and preventing long-term system involvement. However, rates of treatment referral and initiation remain low, especially among minoritized youths and boys. The e-Connect System, a digital, clinical decision support system, addresses this problem by increasing rates of behavioral health treatment referral and initiation rates among youths on probation. In this study, we examine whether e-Connect helps improve equity in referral and treatment initiation outcomes. (Am J Public Health. 2023;113(12):1267-1270. https://doi.org/10.2105/AJPH.2023.307417).

Results of a national survey of substance use treatment services for youth under community supervision

BACKGROUND

Despite the heightened risk for substance use (SU) among youth in the juvenile justice system, many do not receive the treatment that they need.

OBJECTIVES

The purpose of this study is to examine the extent to which youth under community supervision by juvenile justice agencies receive community-based SU services and the factors associated with access to such services.

METHODS

Data are from a nationally representative sample of Community Supervision (CS) agencies and their primary behavioral health (BH) partners. Surveys were completed by 192 CS and 271 BH agencies.

RESULTS

SU services are more often available through BH than CS for all treatment modalities. EBPs are more likely to be used by BH than by CS. Co-location of services occurs most often in communities with fewer treatment options and is associated with higher interagency collaboration. Youth are more likely to receive services in communities with higher EBP use, which mediates the relationship between the availability of SU treatment modalities and the proportion of youth served.

CONCLUSION

Findings identify opportunities to strengthen community systems and improve linkage to care.

Impact of implementation interventions to improve substance use service delivery on recidivism among justice-involved youth

Substance use disorders (SUD) are prevalent among justice-involved youth (JIY) and are a robust predictor of re-offending. Only a fraction of JIY with substance use problems receive treatment. This paper describes the impacts of system-level efforts to improve identification and referral to treatment on recidivism of JIY. A cluster randomized trial involving 20 county juvenile justice agency sites across 5 states was used to implement an organizational intervention (Core vs Enhanced) to juvenile justice staff and community-based treatment providers, working with 18,698 JIY from March 2014 to August 2017. Recidivism rates over four study time periods were examined. Logistic regression was used to predict recidivism as a function of site, need for SUD services, level of supervision, time, organizational intervention, and time x intervention interaction terms. Results indicated that Enhanced sites showed decreased levels of recidivism compared to Core-only sites, where it increased over time. Additionally, need for SU services, level of supervision, and site were significant predictors of reoffending. Findings suggest the potential value of facilitation of juvenile justice agency efforts to increasing identification of and referral to SUD services of JIY in need of such services for reducing further contact with the legal system.

JUVENILE PROBATION OFFICER PERCEPTIONS OF PARENTAL INVOLVEMENT IN JUVENILE PROBATION AND WITH CONTINGENCY MANAGEMENT

Probation is a common sanction for youth substance users, and as such, juvenile probation officers (JPOs) shoulder much of the burden for treatment and rehabilitation. To improve youth outcomes and alleviate some of the burden, JPOs may seek parental involvement in the probation and substance use desistance processes. Using focus group data, we analyzed JPO perceptions of the role parents play in contingency management (CM)-an incentive system designed to produce and reward decreased substance use-and whether they perceived any value in CM. We found that most JPOs perceived parental involvement as critical to the success of both substance use treatment and CM for youth. Our findings also suggest JPOs found parental involvement in CM valuable given that CM was employed on nonstudy clients and future clients. This has implications for the practicality and sustainability of CM as a youth probation intervention.

The comparative effectiveness of Core versus Core+Enhanced implementation strategies in a randomized controlled trial to improve substance use treatment receipt among justice-involved youth

BACKGROUND

Most justice-involved youth are supervised in community settings, where assessment and linkage to substance use (SU) treatment services are inconsistent and fragmented. Only 1/3 of youth with an identified SU need receive a treatment referral and even fewer initiate services. Thus, improving identification and linkage to treatment requires coordination across juvenile justice (JJ) and behavioral health (BH) agencies. The current study examines the comparative effectiveness of two bundled implementation intervention strategies for improving SU treatment initiation, engagement, and continuing care among justice-involved youth supervised in community settings. Exploration, Preparation, Implementation, Sustainment (EPIS) served as the conceptual framework for study design and selection/timing of implementation intervention components, and the BH Services Cascade served as the conceptual and measurement framework for identifying and addressing gaps in service receipt.

METHODS

Part of a larger Juvenile-Justice Translational Research on Interventions for Adolescents in the Legal System (JJ-TRIALS) Cooperative, this study involved a multisite, cluster-randomized control trial where sites were paired then randomly assigned to receive Core (training teams on the BH Services Cascade and data-driven decision making; supporting goal selection) or Core+Enhanced (external facilitation of implementation teams) intervention components. Youth service records were collected from 20 JJ community supervision agencies (in five states) across five study phases (baseline, pre-randomization, early experiment, late experiment, maintenance). Implementation teams comprised of JJ and BH staff collaboratively identified goals along the BH Cascade and used data-driven decision-making to implement change.

RESULTS

Results suggest that Core intervention components were effective at increasing service receipt over time relative to baseline, but differences between Core and Core+Enhanced conditions were non-significant. Time to service initiation was shorter among Core+Enhanced sites, and deeper Cascade penetration occurred when external facilitation (of implementation teams) was provided. Wide variation existed in the degree and nature of change across service systems.

CONCLUSIONS

Findings demonstrate the criticality of early EPIS phases, demonstrating that strategies provided during the formative exploration and preparation phases produced some improvement in service receipt, whereas implementation-focused activities produced incremental improvement in moving youth farther along the Cascade.

The nexus between gender, parental supervision, and opioid misuse among justice-involved adolescents

Justice-involved adolescents (JIA) are at higher risk for opioid misuse (OM) and opioid-related overdose than nonoffending adolescents. Untreated OM can lead to severe consequences (e.g., trauma), which may be harsher for female JIA. Therefore, examining risk and protective factors, such as parental supervision, is essential to identify factors that may impact OM. The current study used a statewide, cross-sectional dataset including 79,960 JIA from the Florida Department of Juvenile Justice. Stratified logistic regression analyses were conducted. Results indicated that JIA who experienced sporadic or inadequate supervision had 2.14 and 3.54 higher odds, respectively, of misusing opioids compared to JIA who experienced consistent supervision. Female JIA who experienced sporadic or inadequate supervision had 2.23 and 3.70 higher odds, respectively, of misusing opioids. Results suggest parental supervision is an important protective factor that should be considered in developing prevention and treatment efforts that serve JIA who misuse opioids, especially females.

Using structured implementation interventions to improve referral to substance use treatment among justice-involved youth: Findings from a multisite cluster randomized trial

INTRODUCTION

Youth involved in the justice system have high rates of alcohol and other drug use, but limited treatment engagement. JJ-TRIALS tested implementation activities with community supervision (CS) and behavioral health (BH) agencies to improve screening, identification of substance use service need, referral, and treatment initiation and engagement, guided by the BH Services Cascade and EPIS frameworks. This paper summarizes intervention impacts on referrals to treatment among youth on CS.

METHODS

This multisite cluster-randomized trial involved 18 matched pairs of sites in 36 counties in seven states randomly assigned to core or enhanced conditions after implementing the core intervention at all sites for six months. Enhanced sites received external facilitation for local change team activities to reduce unmet treatment needs; Core sites were encouraged to form interagency workgroups. The dependent variable was percentage referred to treatment among youth in need (N = 14,012). Two-level Bayesian regression assessed factors predicting referral across all sites and time periods. Generalized linear mixed models using logit transformation tested two hypotheses: (H1) referrals will increase from baseline to the experimental period, (H2) referral increases will be larger in enhanced sites than in core sites.

RESULTS

Although the intervention significantly increased referral, condition did not significantly predict referral across all time periods. Youth who tested drug positive, had an alcohol/other drug-related or felony charge, were placed in secure detention or assigned more intensive supervision, or who were White were more likely to be referred. H1 (p < .05) and H2 (p < .0001) were both significant in the hypothesized direction. Interaction analyses comparing site pair differences showed that findings were not consistent across sites.

CONCLUSIONS

The percentage of youth referred to treatment increased compared with baseline overall, and enhanced sites showed larger increases in referrals over time. However, variations in effects suggest that site-level differences were important. Researchers should carry out mixed methods studies to further understand reasons for the inconsistent findings within randomized site pairs, and how to further improve treatment referrals across CS and BH systems. Findings also highlight that even when CS agencies work collaboratively with BH providers to improve referrals, most justice-involved youth who need SU services are not referred.

Predicting initiation to treatment for youth on probation: A multi-level approach

BACKGROUND

Previous research on youth involved in the juvenile legal system (JLS), who have higher substance use prevalence than other adolescents, has focused on treatment outcomes post-initiation. Scant research has examined factors affecting treatment initiation following JLS referral. The current work addresses this gap by estimating net impacts of state, site, and client attributes on initiating treatment.

METHODS

Mixed effects logistic regression models analyzed data from the Behavioral Health Services Cascade framework of the JJ-TRIALS project for 5325 youth records from 22 sites across six states, using weighted hot deck imputation to address missing data. The analysis permitted estimating net impacts of individual factors while controlling for state variation factors and separating out within-state site variation.

RESULTS

Rates of treatment initiation varied significantly across sites. About 63% of outcome variation arose from site and state disparities. The odds of initiating treatment were 127% higher for youth under a higher supervision level compared to youth under low supervision. Race and ethnicity were significantly associated with initiation, with Black and Hispanic youth having 44% and 42% lower odds of initiating treatment, respectively.

CONCLUSION

Individual factors, including race, ethnicity, and level of supervision, significantly differed in treatment initiation, controlling for between-state variation and allowing between-site-within-state effects to operate separately. A deeper understanding of factors shaping initiation may help behavioral health and JLS agencies to develop strategies to increase initiation for referred youth. This is the first study delineating individual, cross-program, and between-state variation in treatment initiation among referred youth.

Sexual Trauma Informed Understanding of Longitudinal Depression among Repeat Juvenile Offenders

Childhood sexual assault (CSA) victimization and depression are global public health concerns that disproportionately affect youths involved in the juvenile justice system. Little research has examined the influence of CSA on the stability of depressive symptoms among repeat juvenile offenders. The present study tested a gendered model of the association between lifetime CSA victimization and depression for three time points: baseline juvenile assessment entry; second reentry; and third reentry. Further, covariate analyses were conducted to explore the impact of socio-demographics on CSA victimization and depression. Results indicate that CSA victimization was associated directly with baseline depression and indirectly with depression at second reentry for both male and female justice-involved youths. For white, male youth, there were significantly higher rates of depression over time, than other males. However, age, African American or Hispanic race/ethnicity, living situation, and urbanity were not significantly associated with CSA victimization at baseline or depression over time. These findings underscore the need for juvenile justice services that address exposure to childhood trauma and mental illness more effectively.

Bridging juvenile justice and behavioral health systems: development of a clinical pathways approach to connect youth at risk for suicidal behavior to care

BACKGROUND

Justice-involved youth have high rates of suicidal behavior and co-morbid psychiatric disorders, yet low rates of service use. Implementation efforts aimed at supporting cross-agency linkage protocols may be useful components of interventions promoting behavioral healthcare service access for youths on probation. The purpose of this study was to develop clear referral Pathways for three suicide risk classifications of youth, across 10 counties in a single state through a community-academic partnership in New York state, a strategic planning process between county Probation departments and community Behavioral Health.

RESULTS

We sought to clarify service destinations for youth in three classes of risk for suicidal behavior: Class I (Crisis, Imminent Risk); Class II (Crisis, Non-Imminent Risk); and Class III (Non-Crisis but in Need of Service). Prior to Pathway Meetings, there was a low degree of agreement between Probation and Behavioral Health leadership for the appropriate service destination for youths in crisis, whether at imminent risk (Class I: 57.8% overlap) or at lower than imminent risk (Class II: 45.6% overlap). Options for referral destinations for Classes I and II decreased significantly (indicating greater overlap) as a result of Pathway Meetings [(Class I: from 2.5 to 1.1 (t₍₉₎ = 3.28, p < 0.01); Class II: from 2.8 to 1.3 (t₍₉₎ = 4.025, p < 0.003)]. Pathway Meetings allowed Behavioral Health and Juvenile Justice systems to make joint decisions regarding referral pathways, resulting in innovative solutions, such as the use of mobile crisis.

CONCLUSIONS

The community-academic partnership served to bring internal (Juvenile Justice) and external (Behavioral Health) contexts together to successfully generate agreed upon Pathways to care for youths demonstrating risk for suicidal behavior. Bridging Behavioral Health and Juvenile Justice systems together to agree to referral Pathways for each risk class can increase appropriate service use.

TRIAL REGISTRATION

ClinicalTrials.gov , NCT03586895 . Registered 21 June 2018, https://register.clinicaltrials.gov/prs/app/template/EditRecord.vm?epmode=Edit&listmode=Edit&uid=U0003B7I&ts=4&sid=S00080NN&cx=-n4kinh.