Patterns of Treatment Services and Costs for Young Offenders with Mental Disorders

JCAPN Volume 18, Number 3, July-September, 2005 103

Journal of Child and Adolescent Psychiatric Nursing, Volume 18,Number 3, pp. 103–112

Blackwell Publishing, Ltd.Oxford, UKJCAPJournal of Child and Adolescent Psychiatric Nursing1073-6077© 2005 by Nursecom, Inc.if know 2005182

ORIGINAL ARTICLE

Patterns of Treatment Services and Costs for Young Offenders with Mental Disorders


Deborah Shelton, PhD, RN, CNA

PROBLEM:

This study describes mental health

treatment service delivery patterns and costs for

youth in a juvenile justice system.

METHODS:

A secondary data analysis on a

random sample of juvenile offenders (N = 312)

was completed. Service patterns and costs were

described. Selected variables were examined for

their ability to predict who received treatment.

FINDINGS:

Only 23% of youth diagnosed with a

mental disorder received any treatment. Older

youth and African American youth received fewer

services, and race was the only significant

predictor for receiving treatment (p = .001).

CONCLUSIONS:

Mental health treatment services

were scarce, and the data reflects a race bias in the

provision of services. Although the law protects

the right to treatment for these individuals,

provision of services remains a challenge.

Search terms:

Juvenile justice, treatment

services and costs, young offenders

Deborah Shelton, PhD, RN, CNA, is a program manager and adjunct associate professor at the University of Connecticut, School of Nursing in Storrs, CT.

Introduction

There is a growing recognition that the mentalhealth needs of youth in juvenile justice systems havenot received the attention they deserve (Burns, How-ell, Wiig, Augimeri, Welsh, Loeber & Peterchuk, 2003;Herz, 2001). The difficulties in serving the complexemotional problems experienced by these youth, com-bined with their serious behavioral problems, andhigh costs and questionable effectiveness associatedwith these services result in a shifting of responsibilitybetween child service systems (Shelton 2001a, Teplin,1991). Research studies indicate that youth in juvenilejustice systems experience substantially higher ratesof mental health disorders than youth in the generalpopulation (Cocozza & Skowyra, 2000; Shelton, 2001b).Many of the youth in juvenile justice systems withmental health disorders also have a co-occurring sub-stance abuse disorder (Huizinga, Loeber, Thornberry& Cothern, 2000), a disorder that brings these youth tothe attention of the juvenile justice system.

In spite of the limited research, a set of strategiesthat appear to be critical to assuring treatment foryoung offenders includes collaboration across sys-tems, diverting status offenders from the juvenile jus-tice system, mental health screening and detailedmultimodal assessments, and effective community-based alternatives (Office of Juvenile Justice andDelinquency Prevention, 2001). But for those who areplaced in juvenile detention and correctional facilities,access to appropriate treatment services crucial to theirrehabilitation (stated as within the mission of juvenilejustice systems), and their right by law continues to belimited (Chinn & Babics, 1995). With the examples ofthe difficulties to manage mental health care costsacross all child service system components, it seemslikely that the additional cost of providing these

104 JCAPN Volume 18, Number 3, July-September, 2005


services within juvenile justice systems presents thelargest barrier for meeting the mental health needs ofdetained and incarcerated young offenders.

This retrospective study aims to contribute to theunderstanding of those treatment services available toyoung offenders with mental health disorders placedin juvenile detention and correctional facilities, bydescribing treatment service characteristics over a 20-year time period (1978–1998) and estimated costs ofthe Maryland Juvenile Justice system. The findingsof this study can guide planning and policy effortsby addressing gaps in information with regard totreatment services provided by this state agency.

Literature Review

The prevalence of different types of mental disor-ders, as well as where people get treatment is influ-enced by individual and family characteristics,characteristics of providers, and organizational factors.Substance abuse and antisocial personality disordersare more prevalent among males, and are more likelyto come to the attention of criminal justice systemsbecause of their presenting behaviors and difficulty totreat (Nauth, 1998). Females offenders are more likelyto report substance dependency, and once in treat-ment remain in treatment longer, but do not vary fromtheir male counterparts in their perceived need fortreatment (Kim & Fendrich, 2002). Gender furtherinfluences access to and type of service provided, andseverity of psychopathology or criminality influencesthe restrictiveness of the placement setting (McDer-mott, McKelvey, Roberts & Davies, 2002). Nonwhitesare less likely to utilize formalized healthcare servicesthan their white counterparts (Walker, 1996), butwhen they do receive psychiatric care, it is throughpublic rather than private service systems, includingjustice systems (Shelton, 2001b; Smith, 1998).

Where individuals are served is also influenced byprovider characteristics. Factors such as educationaltraining (Thyer, 1995), perceptions of client problemsand family support (McDermott et al., 2002), precon-

ceived ideas about treatment effectiveness (Solomon,Draine & Marcus, 2002) and cultural biases (Pope &Feyerherm, 1992) clearly influence access to services aswell as detention, outcomes of case processing, andincarceration. In addition, organizational influencessuch as hierarchical structure, top-down managementstyles, court jurisdictions, age limitations, sentencingoptions, distribution of correctional beds, as well asuse of local and private beds dramatically variesbetween states, and impacts the system capabilitiesand resources (Dedel, 1998).

The cumulative effect of these factors has resultedin the shifting of many people back and forth betweenmental health and justice systems. Toch (1982) coinedthe phrase “bus therapy,” to describe the “off-loading”of difficult individuals between mental health and cor-rectional facilities in such rapid cycles that the busrides between facilities seem to be the only “therapy”provided. Depending on whether the young offenderis attached to the mental health system or to the crim-inal justice system, the priority for treatment changes.In the mental health system, common outcome meas-ures focus on symptom reduction, reduced length ofstay, readmission to the hospital, and quality of life(Test, 1992). In the criminal justice system, reducingrisk of recidivism has generally been the outcome ofinterest (Lipsey, 1992). It can be argued that bothshould be targeted regardless of the system in whichthe individual happens to be placed. Rice and Harris(1997) suggest that treatment for what are commonlythought of as major mental disorders cannot usuallybe expected on its own to reduce the likelihood ofcriminal or violent recidivism. Thus, a comprehensivetreatment program for offenders with mental disorderwill have to include both treatments for psychiatricsymptoms, and treatments that address criminal andviolent behavior directly. Various states have begun toexperiment with different models for dealing with theissue of provision of mental health services to youthwith serious/criminal behavioral problems. The impli-cations of providing mental health services to youthfuloffenders under the auspices of the justice system, as


compared to the mental health system, versus a hybridor blended system, warrant a careful examination.

Young Offender Treatment

The most comprehensive examination of theoffender treatment literature was completed by Lipsey(1992). In this meta-analysis, 443 studies of offendersbetween the ages of 12 and 21 years who met the follow-ing criteria were included: some intervention aimedat reducing delinquency or antisocial behavior; hadat least one quantitative measure of delinquencyoutcome; and included a randomly selected group orcontrol group that was sufficiently described so as todetermine pretreatment similarities between groups.Lipsey (1992) was able to reject the hypothesis thatnothing works, noting that specific and structuredtreatment (such as behavior and skills training) andmultimodal treatments were more effective. Otherfindings of importance were that best treatmentscut recidivism rates between 20 and 40%, treatment ininstitutions were less effective than treatment innoninstitutional settings, and among community-basedtreatments, the more intensive treatment in terms ofduration and frequency of treatment contacts weremore effective.

A meta-analysis by Andrews, Zinger, Hoge, Bonta,Gendreau, and Cullen (1990) utilized different criteria.For this analysis, four categories were used. Thesewere criminal sanctions without treatment; inappro-priate correctional service (defined as service targetedto low-risk offenders, nondirective group approaches,“scared straight” therapy); appropriate correctionalservices (behavior programming for high-risk cases,structured techniques targeting criminal behavior);and unspecified service (those lacking sufficient infor-mation to be classified). It was concluded that thosestudies classified as “appropriate correctional services”cut recidivism rates by over 50%. In summary, thereis evidence to conclude that programs with highlystructured, and behavioral or cognitive-behavioraltreatment that are run in the community with integrity

and enthusiasm target higher rather than lower riskoffenders, and are intensive in terms of numbers ofhours, and overall length of the program have beenconsiderably more effective than others (Rice & Harris,1997). Programs founded on a deterrence philosophy,and that use traditional psychotherapy or casework,are considered less effective and in some instancesharmful for certain offenders (Rice, Harris & Cormier,1992).

The implications of providing mental health

services to youthful offenders under the

auspices of the justice system, as compared

to the mental health system, versus a hybrid

or blended system, warrant a careful

examination.

Patterns of “benign neglect” are clear as mentalhealth assessment and treatment are not as a rule inte-grated into juvenile justice systems, despite growingdocumentation of the high rates of mental health prob-lems among young offender populations (Herz, 2001).Yet, few studies actually document the services thatare available or utilization patterns and descriptors ofwhich young offenders actually receive mental healthservices. This study begins to address this issue bydescribing those services available through the Mary-land State system, utilization patterns, and estimatedcosts of providing these services to these youngoffenders with mental disorders. Findings contributeto the identification of service need and gaps, and dis-cuss programmatic design elements to be considered.



Methods

The aims of this study were to: (a) describe mentalhealth treatment patterns by type of service and costsby age, gender, race, level of crime seriousness, andnumber of juvenile justice episodes of incarceration;(b) describe mental health treatment patterns and costsfor youth by psychiatric diagnostic classification; (c)compare differences in treatment services provided toyoung offenders who met the criteria for psychiatricdiagnoses versus those who did not meet criteria; and,(d) determine if age, gender, race, level of crime seri-ousness, or number of incarceration episodes werepredictors for the provision of mental health servicesby this juvenile justice system; and which, if any ofthese selected variables influenced cost to the system.

A secondary analysis of a random sample of 312youth in detention and committed facilities in thestate of Maryland (Shelton, 2001b) was conducted. Theinitial study was designed to estimate the rate ofemotional disorder in the juvenile justice system.Diagnostic interviews and level of functioning andhealth status were determined utilizing standardizeddiagnostic instruments, self-report surveys and crimi-nal database and field record reviews. The accuracy ofthe data was validated across the multiple sources.Detail regarding the reliability and validity of theseinstruments can be found elsewhere (Shelton, 20001b).For this study, the historical records were of particularinterest as they held the information regarding type ofservice, length of services provided, and reasons forrelease from treatment services. No data were avail-able regarding the quality of the treatment service orthe type of practitioner. At the time that the originalstudy was conducted, youth in the sample had beeninvolved in this juvenile justice system for a 20-yearperiod (1978–1998). These data were included in thisstudy. Descriptive statistics, analysis of variance, andlogistic regression analyses were used to address theaims of the study.

Computation of levels of crime seriousness derivedfrom the Uniform Crime Index (UCI) were collapsed

(ranging from “most serious” to “least serious”) basedupon previous work by the Maryland Departmentof Juvenile Justice (1995). Offenses categorized as“most serious” included violent person to personcrimes, serious drug offenses, use of weapons, andmajor property felonies (>$300.00). Minor drugoffenses, felonies (<$300.00), malicious destruction/vandalism, and status offenses were categorized as“least serious.”

Cost data were obtained from the fiscal departmentof the Maryland Department of Juvenile Justice. Thesecosts were available as “unit costs” defined as the totalcost per day. Data regarding the actual numbers ofhours of treatment provided to each person were notcollected. This limitation of the data is in part becauseof the structure of the juvenile justice system in Mary-land. Like many other states, Maryland utilizes manyprivate vendors (Dedel, 1998), who were not requiredand (upon contact) unwilling to share detailed utiliza-tion and cost data associated with treatment servicesversus bed and board services. Length of stay (numberof days) in a treatment service was available, as well asall vendors and types of services they report to pro-vide for each youth. Distributions on total costs wereexamined, as well as cost per episode. Cost distribu-tions were collapsed into high, medium, and low cate-gories for some of the analyses.

Sample Demographics

Eighty-one percent of the randomly selected samplewas male, 57% African American, followed by 26%Caucasian, 6% Hispanic, and 11% other ethnic andracial minorities. Eighty-two percent of youth were intheir late adolescence (range = 12–20 yrs,

x

= 16 yrs.).Thirty-six percent of these youth were expelled or sus-pended from school at the time of arrest, and 14% didnot attend school. Eleven percent of youth were iden-tified as having a learning disability, and 37% in needof special education services. Most youth were fromfamilies with an income below the poverty level (84%),and 24% reported to have no insurance. These 312


youth were arrested 2,629 times (range 2–26 times perperson) and adjudicated for fewer than half of thesearrests. Thirty-nine percent of these youth were identi-fied by the courts to be children in need of assistance(CINA) or children in need of services (CINS). Fifty-four percent of these arrests were categorized as “mostserious” offenses. The number of placement episodesin the juvenile justice system ranged from 1 to 17events, with the majority of youth having six out-ofhome placements or less. Eighty-six percent of theyouth sampled had some mental health problem, but53% met the more stringent criteria for diagnosticclassification based on the

Diagnostic and StatisticalManual of Mental Disorders

(4th ed.) (DSM-IV) andGlobal Assessment of Functioning (GAF). Of these, 57%had more than one AXIS I diagnosis, and 74% werealso diagnosed with a substance abuse disorder. Four-teen percent of those diagnostically classified werethought to be in need of a

very

restrictive setting as aresult of the nature of their offense.

Findings

Mental Health Treatment Utilization

Cost and service patterns for all youth sampledwere examined per juvenile justice episode. For allyouth sampled, the range of juvenile justice episodeswas between 1 and 17, with most youth having six orfewer interactions with the system. The average lengthof stay (LOS) was 447 days (SD = 417) or 1.2 years withwide variation in a single episode from 7 days tonearly 10 years (3,577 days). For the three “deep end”youth who spent over 9 years in one episode, theywere older than 16 years of age, and incarcerated for asex offense (

n

= 1) and for first-degree murder (

n

= 2).Total cost per episode, determined by the “daily unitcost” multiplied by the number of days of incarcera-tion found the average cost per youth to be $46,451 witha wide range of costs per episode ($663 to $356,262).The median cost (most frequently incurred per episode)was $20,000. The descriptive analyses of total costs

by age, race, gender, crime severity, and number ofepisodes can be found in Table 1.

Total cost per episode, determined by the

“daily unit cost” multiplied by the number

of days of incarceration found the average

cost per youth to be $46,451 with a wide

range of costs per episode ($663 to $356,262).

A Pearson correction coefficient was used to explorethe variations in costs associated with juvenile justicesystem utilization. Number of arrests (

r

= .161,

p

= .01)and episodes of incarceration (

r

= .354,

p

= .01) wereassociated with total costs. Not surprisingly, thenumber of arrests was significantly associated withnumber of adjudications, and the more frequent occur-rence of these was associated with out-of-home place-ments (episodes). The negative and significantcorrelation of crime seriousness with number ofarrests, number of adjudications, and number ofepisodes was expected, as youth who commit moreserious crimes are incarcerated for longer periods oftime. This analysis is presented in Table 2.

Treatment Patterns for Youth with a Disorder

Fifty-three percent (

n

= 166) of the total sample metcriteria for a diagnosed mental disorder. Only 26%(

n

= 43) of these youth received any treatment whileunder the care of this juvenile justice system, and 2%without a diagnosis received treatment. Youth diagnosedwith tics, mania, depression, or obsessive-compulsivedisorders most frequently received some form of treat-ment. Youth diagnosed with schizophrenia and related



disorders were the least treated diagnostic group. Forthose youth with mental disorders who did receivetreatment, the types of treatment most frequently utilizedwere family therapy (11.5%), group therapy (1.4%),individual therapy (.5%), and rarely medication (0.09%).

Pattern of Treatment Services Over Number of Episodes

Cost and service patterns for youth with mental dis-orders were examined per juvenile justice episode.

Findings noted in the original study (Shelton, 2001b)showed that for a given youth, crime seriousness andnumber of juvenile justice episodes increased overtime. As would be expected, the total costs increasedas well. Given that the offenses of these youth wereless serious, the costs appear to be related to an over-reliance on institutional care (81%) than community-based treatment services (19%). Over all episodes, 75%of youth were placed in a juvenile justice residentialfacility, 6% in a mental health treatment facility,and 19% were placed in community juvenile justice

Table 1. Total Cost by Demographic and Juvenile Justice Factors

Factor Mean ($) SD ($) Minimum ($) Maximum ($)

Total cost (dollars) 46,451 45,935 663 356,232Gender

Males 47,501 47,555 663 356,232Females 43,461 41,208 1,612 168,529

RaceCaucasian 58,226 55,857 2,004 297,973African American 43,274 41,263 663 356,262Other 39,031 43,997 948 191,836

Age12–14 35,463 31,686 1,889 104,08315–17 46,275 44,364 663 356,26218–20 63,423 70,925 7,243 297,973

Level of crime severityLeast serious 49,236 44,915 19,982 139,919Less serious 31,967 35,593 1,612 168,529More serious 42,414 43,959 948 297,973Most serious 52,886 48,963 4,646 356,262

Table 2. Correlation of Total Costs with Juvenile Justice Factors

Total costNumber of arrests

Number of adjudications

Episodes of incarceration

Mean seriousness of crime

Total cost 1.00Number of arrests .161** 1.00Number of adjudications .110 .717** 1.00Episodes of incarceration .354** .258** .257** 1.00Mean seriousness of crime .008 −1.50** −1.97** −1.35** 1.00


program. Figure 1 compares the percent of youth whowere diagnosed and received treatment, with thosediagnosed who did not receive treatment throughjuvenile justice system. As reflected in Fig. 2, asepisodes of juvenile placements increased, provisionof mental health services decreased.

Treated Youth

In comparing age, gender, race, and crime serious-ness of young offenders who met the criteria for psy-chiatric diagnoses, a racial bias in provision of serviceswas noted. African Americans comprised 63.1% ofthose who met the diagnostic criteria, but only 11.9%of these received treatment. Caucasians made up24.4% of those diagnosed, yet 42.6% of these receivedtreatment. Although Caucasian youth made up asmall proportion of the total sample (12.5%), theyreceived the majority of treatment made available(

χ

2

= 29.23, d.f. = 2,

p

= .001). Age and gender were notsignificantly different among those diagnosed andtreated. Given repeated episodes within the juvenilejustice system, youth were more likely to receive treat-ment through this system (

χ

2

= 18.66, d.f. = 1,

p

< .001),but this was not related to crime seriousness.

Predictors of Treatment in the Juvenile Justice System

It was of interest to determine which selected char-acteristics (presence of a mental disorder, age, race,level of crime seriousness, or number of incarcerationepisodes of the youth) sampled predicted provision ofmental health services by this juvenile justice system.A logistic analysis was performed with provision oftreatment as an outcome. A test of the full model withall five predictors against a constant-only model wassignificant (

χ

2

= 39.53, d.f. = 8,

p

< .001) indicating thatas a set, these variables reliably distinguished betweenthose who received treatment and those who did not.The prediction rate was 25.9% for treatment, and 94.4%for no treatment, yielding an overall success rate of

78.4%. An examination of the parameters of the modelrevealed that only number of episodes (

χ

2

= 12.89, d.f. = 1,

p

< .0003) and Caucasian race (

χ

2

= 6.51, d.f. = 1,

p

< .01)were significant predictors in the model. A similaranalysis using mean crime seriousness rather thanmaximum crime seriousness produced similar results.

. . . a racial bias in provision of services was

noted. African Americans comprised 63.1%

of those who met the diagnostic criteria, but

only 11.9% of these received treatment.

Predictors of Cost for Treated Youth

A sequential regression analysis was employed todetermine if addition of information regarding thetype of disorder, and receipt of treatment to theselected demographic and juvenile justice utilizationvariables to would improve prediction of costs inthis system. For the total model with all variablesentered, the model was significant (

F

= 8.201, d.f. = 14,

p

< .001), predicting 32.5% of the variance in total cost(adjusted

R

2

= .285). Adding type of disorder or provi-sion of treatment made a slight but nonsignificantimprovement in the model. The final model was ableto account for 32.5% of the variance in total cost(adjusted

R

2

= .285) with significant coefficients fornumber of episodes (

B

= .144,

t

= 7.27,

p

< .001), severityof crime (

B

= .509,

t

= 3.23,

p

= .001), age (

B

= .138,

t

= 3.04,

p

= .003), and treatment (

B

= .284,

t

= 2.00,

p

= .046).For this sample, the most costly youth were older, hadcommitted a more serious crime, had multiple incar-cerations, and received some treatment over the courseof their involvement in the juvenile justice system.



Discussion

Provision of treatment services by this juvenile justicesystem was extremely limited. In this study, high coststo the juvenile justice system are not associated withthe provision of services, but more likely tied to over-reliance on residential programming. Bias in provisionof services was noted. Younger Caucasian youth weremore likely to receive some form of treatment. Whenprovided, services were initiated in the second episodein the juvenile system, and were nonexistent by the12th episode. It is as if the system wanted to see if thechild would return after the first episode, and then hadgiven up on youth who keep returning to the system.

The presence of a mental disorder had no predictiveability for receipt of treatment. Only by repeatedepisodes of involvement with the system wereyouth more likely to receive some form of treatment.However, if crime severity increased, the likelihood ofreceiving treatment would decrease. The focus onfamily therapy over other treatment options alludes tothe perception of where the problem lies—with thefamily. While unresolved family issues are likely toinfluence involvement with the juvenile justice system(Preski & Shelton, 2001), a multimethod approachaddressing individual needs in combination withfamily therapy are likely to be more effective.

While the total responsibility for the well-being ofchildren does not lie solely with this juvenile justicesystem, the decision not to provide treatment servicesto youth in need and under their care implies neglect.For this sample, there was no indication of treatmentupon the first episode, indicating a lack of understand-ing about childhood mental disorders. It implies a per-ception that these youth will go away, be treatedelsewhere, or grow out of their problems. Like youthin other juvenile justice systems across the country,high numbers of this sample were youth who hadbeen abused (58%), neglected or exposed to violence(67%). The literature clearly demonstrates a trendtoward criminal and violent behaviors for those whoare not treated (Burns et al., 2003).

If juvenile justice systems have not

traditionally provided mental health

treatment, and mental health programs are

not designed for youth with criminal

behaviors, what is there?

Although there is evidence that intensive cognitiveand behavioral skills training programs can help someyoung offenders, programs that incorporate thesetreatment options are not the norm in most jurisdic-tions. Instead, young offenders are frequently placedin programs modeled after those designed for adults.Intensive supervision, probation, and parole (ISP)procedures (Petersilia, 1997) are an example of adultprogramming applied to the juvenile justice system asless expensive community alternatives to incarceration.Although cost data for juvenile intensive supervisionprograms is unavailable, a study of adult ISP programswas found to be more expensive and more likely todetect technical conditions of probation and parole,resulting in more frequent incarceration (Turner,Petersilia & Deschenes, 1992). Of the few cost–benefitstudies of juvenile interventions published, a community-based cognitive behavioral treatment with intensiveoutpatient counseling at a local mental health centerand intensive case management where caseloads wereno more than 10–12 youth were found to be mostbeneficial (Robertson, Grimes & Rogers, 2001). This inter-vention, when compared to a regular probation group,and an intensive supervision and monitoring groupwas found to significantly reduce juvenile justiceexpenditures on court referrals and days of detention.Even with the use of additional and professionalpersonnel, the approximated $2,928 price tag per


participant represented a cost saving. For every dollarspent on the program, $2 was saved.

Conclusion

The biases evidenced in this exploratory study raiseadditional questions, and point to the need for contin-ued detailed study. Continued reliance on parallel sys-tems clearly decreases the likelihood that a youngoffender with a mental health problem will receivetreatment. If juvenile justice systems have not tradi-tionally provided mental health treatment, and mentalhealth programs are not designed for youth with crim-inal behaviors, what is there? And, for the individualwho is involved in both systems, the lack of coordina-tion between the two increases the probability thattransfers between systems will be driven by availableresources. This historical pattern of “transinstitution-alization” has been well documented (Herz, 2001;Federle & Chesney-Lind, 1992; Shelton & Merick, 1996,Szasz, 1977). Even with advances in access to care formentally ill in recent years under the American Dis-abilities Act (Honberg, 2000), how the rights of theseyouth are interpreted in a system where liberties arerestricted is not known. It would be wise to enhancethe system’s credibility by addressing young offendermental health needs accurately and effectively.

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Patterns of Treatment Services and Costs for Young Offenders with Mental Disorders

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