THE LAW REVIEW AT JOHNS HOPKINS
A student-run publication by the Law and International Organizations Society at the Johns Hopkins
School of Advanced International Studies
Mental Health Policies and Programs as a Tool to Reduce Recidivism in Juvenile Justice Facilities
by Allyn Rosenberger Spring 2019
The majority of youth in American juvenile justice facilities currently suffer from, at least, one mental health condition. The implementation of mental health policies and programs within the system can mitigate these problems and reduce recidivism among this vulnerable population. Presently, the juvenile justice system underprovides sufficient mental health services, contributing to escalating rates of recidivism. Addressing the mental health needs of this vulnerable population will ultimately require the implementation of policies and programs in the community and at each point of interaction with the juvenile justice system. Because of the high prevalence of mental health problems among youth currently in the system, this paper will focus on policies and programs that address the needs of juvenile offenders when they arrive at a facility, during their incarceration, and during their transition back into the community.
Youth in the juvenile justice system disproportionately suffer from mental health problems, but the implementation of mental health policies and programs within the system can mitigate these problems and reduce recidivism among this vulnerable population. Two-thirds to three-fourths of youth in U.S. juvenile justice facilities suffer from at least one mental health condition1. One-fifth of these youth experience severe mental health symptoms, limiting their ability to perform daily tasks, follow rules, and avoid serious behavioral problems2. Despite the high prevalence of mental health conditions among their charges, the juvenile justice system currently underprovides sufficient mental health services, contributing to high rates of recidivism3. Considerable evidence demonstrates that “mental health difficulties are linked directly and indirectly to later offending behavior and delinquency” 4. Youth with mental health problems “have a greater risk of offending and re-offending than youth on average”5.
Addressing the mental health needs of this vulnerable population will ultimately require the implementation of policies and programs in the community and at each point of interaction with the juvenile justice system (Figure 1). Advocates and policy-makers may consider preventative, community-based measures like ensuring access to counseling and behavioral health services among high-risk youth or implementing constructive discipline in schools6. Furthermore, training decision-makers to know when community-based support, rather than detention, can address non-violent offenses and expanding basic incarceration options to include treatment-centered services represent important strategies7. Due to the high prevalence of mental health problems among youth currently in the system, this essay will focus on policies and programs that address the needs of juvenile offenders when they arrive at a facility, during their incarceration, and during their transition back into the community. This is not to suggest, however, that policies addressing the other factors listed in Figure 1 are not important; such policies simply lie beyond the scope of this analysis. Based upon the policies and programs this essay has analyzed, this essay asserts three things. First, jurisdictions should require juvenile justice facilities to adopt behavioral health screening and assessment tools to match youth with the most effective treatment options8. Second, policy reform should ensure the provision of these treatment services while youth are detained9. Finally, jurisdictions should require the juvenile justice system to support youth as they transition out of detention by connecting them with community resources and assisting them with Medicaid re-enrollment10.
Overview of Mental Health Needs Among this Population
The prevalence of mental health problems among youth in the juvenile justice system is more than three times higher than youth in the general population11. Up to 75 percent of the 2 million youth involved in the juvenile justice system meet the criteria for a mental health disorder12. Youth offenders often struggle with “affective disorders (major depression, persistent depression, and manic episodes), psychotic disorders, anxiety disorders (panic, separation anxiety, generalized anxiety, obsessive-compulsive disorder, and post-traumatic stress disorder), disruptive behavior disorders (conduct, oppositional defiant disorder, and attention-deficit hyperactivity disorder), and substance use disorders”13.
Despite these problems, few youth receive proper screening for mental health problems when they enter the juvenile justice system. The Berkeley Center for Criminal Justice found many jurisdictions fail to utilize validated screening and assessment instruments consistently14. Moreover, many detained juveniles do not receive the care they need or receive inadequate treatment15. Only 30 percent of juvenile offenders receive counseling services and less than 5 percent currently participate in evidence-based treatment strategies16. Twenty-five percent of all juvenile justice facilities report providing no or very poor mental health treatment for youth in their care17. Compounding these problems within juvenile justice facilities, few youth are connected to necessary mental health services when they leave detention. This can cause a “gap in services that negatively impacts” reentry into their home communities18.
Screening and Assessment
Systematically identifying the mental health needs of youth in the juvenile justice system is one of the most important steps to responding to these needs19. Many evidence-based screening and assessment tools exist, but juvenile justice facilities fail to utilize them consistently or do not use them at all20. Policy change can address this shortcoming by mandating the utilization of evidence-based screening and assessment within the juvenile justice system. Texas has paved the way for this by first, in 2001, mandating the use of the Massachusetts Youth Screening Instrument for all youth referred to local probation departments21. Then, in 2010, Texas required its juvenile facilities to utilize an approved, validated assessment tool like the Child and Adolescent Functional Assessment Scale22 .
Incarceration provides an opportunity to engage with youth who typically have very little access to mental health treatment23. Extensive evidence “shows that mental health treatment can, if designed well and delivered effectively, substantially reduce offending by delinquent and high-risk youth24”. Estelle v. Gamble (1976) held that access to health care is a constitutional right for incarcerated individuals, yet the juvenile justice system lacks sufficient mental health care25. This essay will discuss three potential treatment strategies.
A. Cognitive Behavioral Therapy
Cognitive Behavioral Therapy (CBT) teaches youth “awareness of social cues and promotes delaying, problem solving, and nonaggressive responding strategies26”. This approach is particularly effective with juvenile offenders because of its focus on triggers of disruptive and aggressive behavior27. CBT is typically administered to youth struggling with depressive, anxiety, affective, personality, substance, and post-traumatic stress disorders28. Research has demonstrated reductions in recidivism of up to 50 percent following CBT treatment29.
Thinking For a Change (T4C) is a common CBT intervention that aims to restructure the thinking of juvenile offenders and teach them pro-social cognitive skills30. Jack Bush, Ph.D., Barry Glick, Ph.D., and Juliana Taymans, Ph.D. developed the program with the National Institute of Corrections (NIC)31. T4C is administered in weekly small groups for one to two hours32. The curriculum consists of 25 lessons with a heavy focus on problem-solving33. T4C also stresses interpersonal communication skills development and cognitive self-change34. The NIC trains corrections professionals to administer the program in juvenile justice facilities, among other locations35. A study in 2009 found a statistically significant difference in the proportion of offenders who recidivated between a group receiving T4C and a group who did not36.
B. Wraparound Approach
Wraparound services link a youth’s needs with support within her or his community. A counselor works directly with youth and their families to address their unique needs with an emphasis on building healthy, safe, and adaptive coping skills through culturally competent individual and family therapy sessions37. This strategy is effective for most serious emotional and mental health needs38. A wraparound program for juvenile offenders in Orange County, California reduced recidivism by 75 percent on average39.
Wraparound Milwaukee has successfully integrated the juvenile justice system with mental health services to provide mental health care to juvenile offenders40. This program contracts with six community agencies for the over 100 coordinators who facilitate the delivery of services41. Wraparound Milwaukee has also organized a provider network of over 400 providers to offer services to youth and their families; a Mobile Urgent Treatment team provides crisis intervention services42. The program serves over 1,600 youth annually, over 750 of whom are juvenile offenders in the juvenile justice system43. Wraparound Milwaukee serves an average of 425 juvenile offenders each day, accounting for nearly 40 percent of youth on probation in the county44. Five studies of the program demonstrate that rates of recidivism for participating youth are low and stable; participating youth do not re-offend at as high a rate as the general population of juvenile offenders45.
C. Yoga and Mindfulness Training
The Georgetown Law Center on Poverty and Inequality released a report suggesting yoga and mindfulness programs might be an effective way to help girls in juvenile justice facilities manage the impact of trauma46. Among incarcerated girls, this intervention strategy leads to improvements in self-regulation, emotional development, neurological and physical health, and interpersonal relationships47. A study at Alameda County Juvenile Justice Center demonstrated yoga and mindfulness programming for incarcerated youth can reduce perceived stress and increase self-control, self-awareness, and resilience48 Trauma-informed yoga and mindfulness training can also reduce recidivism49.
The Art of Yoga Project combines trauma-sensitive yoga, meditation, creative arts and writing to address the mental health needs of girls in the juvenile justice system50 Each class mirrors “bottom-up” brain development by first regulating the brainstem through sensory integration and self-regulation, then the limbic system through relational activities, and finally the prefrontal cortex through cognitive activities51. At least 80 percent of participating girls consistently report improvements in interpersonal skills, pro-social behavior, and emotional regulation52 Participants also show a statistically significant increase in self-awareness, self-respect, and self-control53 The Georgetown Law Center on Poverty and Inequality recommends The Art of Yoga Project be brought to scale54. The leaders of the project do not measure the effect of their program on rates of recidivism, as they consider it too complicated to measure effectively55. The founder, Mary Lynn Fitton, however, expresses confidence that the dramatic benefits of the program help prevent participants from re-offending 56.
Juveniles who do not receive appropriate mental health treatment after their release are more likely to return to detention57. Because any discontinuity in the care they receive while detained puts youth at risk for relapse, discharge planning to establish care in the community is essential58. The lack of immediate re-connection to Medicaid upon release from juvenile justice facilities makes it more difficult for juveniles to access the services that they need59.
In 2009, Texas reformed its reentry practices60. Prior to release, juvenile justice facilities must refer youth with special needs to the local Community Resource Coordination Groups and the Texas Correctional Office on Offenders with Medical or Mental Impairment61. Furthermore, the Texas Juvenile Justice Department entered into a Memorandum of Understanding with the Texas Health and Human Services Commission to help youth reestablish Medicaid eligibility before release from detention62. This process begins 30 days before a youth’s release so that the released youth may receive Medicaid benefits the day she or he reenters the community63. Kansas recently implemented the No Place Like Home project to facilitate Medicaid enrollment of youth discharged from the juvenile justice system64. Professionally trained mentors help youth with the enrollment process65. Both of these strategies are still being monitored for effectiveness.
A. Screening and Assessment
Jurisdictions should adopt policies that require facilities to use evidence-based screening and assessment instruments. In addition, they should include measures of accountability in this legislation to ensure facilities actually administer their screening and assessment tools.
Juvenile justice facilities may oppose this approach because it would require them to train existing staff to implement the screening and assessment tools or hire new staff to do so, both of which may prove costly66. In addition, the tools themselves and the software they require may force the facility to incur significant costs67. However, identifying mental health needs early and connecting youth with the appropriate treatment will improve the mental health of youth and reduce recidivism, thereby saving facilities money and improving the outcomes of their charges.
Most children moving through juvenile justice facilities are eligible for Medicaid68. However, the inmate exclusion policy, otherwise called the inmate payment exception, limits federal Medicaid funding for health or mental health services for the youth detained in juvenile justice facilities69.
There are two major ways to ensure juvenile offenders have access to the treatments delineated above. First, jurisdictions can keep most placement facilities residential, or work to send most juvenile offenders to residential facilities, so youth can avoid inmate exclusion and maintain Medicaid coverage. Second, lawmakers could end the inmate exclusion. This approach could also save states and counties millions of dollars because currently, they must pay for all health care services provided70.
The most salient challenge to this approach is that opponents will criticize sending “dangerous” youth to therapeutic facilities. Advocates and policymakers, however, can return to the historical mission of the juvenile justice system to counter this criticism; namely, that the juvenile justice system was designed to rehabilitate children and address their needs. Currently, those needs overwhelmingly relate to mental health problems and require interventions that enable youth to receive treatment, like sending them to residential facilities.
C. Reentry Procedures
Finally, advocates and policymakers must make sure every youth leaving the system has health coverage and is connected to community supports. In many states, youth are terminated from Medicaid coverage when they enter custody, even though the inmate exclusion policy only requires states to suspend coverage71. Consequently, mandating that youth are only suspended from coverage upon detention could help ensure that youth are more easily re-enrolled upon release. Furthermore, requiring facilities to train and/or hire staff to help youth restore their benefits upon reentry and connect youth with community resources would prevent juvenile offenders from facing a lapse in support upon release.
Policymakers may receive political pushback for requiring suspension, rather than termination of Medicaid coverage, particularly among people who believe these children are undeserving of benefits. In addition, juvenile justice facilities may be reluctant to spend their limited resources on training and/or hiring staff to facilitate the reentry process as it relates to mental health. However, “when high-quality reentry and aftercare services are available, youth need to spend less time in secure placement, and the overall cost of juvenile corrections can be reduced”72.
When two-thirds to three-fourths of youth in juvenile justice facilities suffer from at least one mental health condition, it is imperative that the juvenile justice system improve its mental health interventions. Although community-based interventions to prevent mental health problems and address them early are also critical, this essay has focused on addressing mental health needs once youth are within the juvenile justice system. First, jurisdictions should mandate the utilization of evidence-based screening and assessment tools so that the mental health needs of juvenile offenders are identified immediately upon entry. Second, reforms should be made to circumvent or eliminate the inmate exclusion policy so that facilities can receive federal Medicaid funding for mental health treatment services. Finally, jurisdictions should require facilities to assist exiting youth with Medicaid reenrollment and help connect them with community resources. Each of these strategies can improve the mental health of juvenile offenders and help reduce recidivism.
Although addressing the mental health needs of juvenile offenders is complex, and consequently requires myriad policy and program interventions, these three approaches represent an important component of any strategy. Without policy change, these vulnerable youth will continue to struggle with mental health problems and recidivate, and the juvenile justice system and society will bear the burden of the associated costs.
1. L. Acoca, J. Stephens & A. Van Vleet, Health coverage and care for youth in the juvenile justice system:
The role of Medicaid and CHIP, (2014), https://kaiserfamilyfoundation.files.wordpress.com/2014/05/8591-health-
2. American Academy of Child and Adolescent Psychiatry, Mental illness in families,
3. American Institutes for Research (n.d.), No Place Like Home., https://www.air.org/project/no-place-home.
4. Center on Juvenile and Criminal Justice. (n.d.). , Wraparound Program, http://www.cjcj.org/Direct-services/Wraparound-
5. K. Clark & S. Gehshan, Meeting the health needs of youth involved in the juvenile justice system, (2007),
http://jointcenter.org/docs/pdfs/Meeting the Health Needs of YMOC in JJ System.pdf.
6. R. D. Crutchfield, Current criminal justice system policy reform movements: The problem of unintended consequences., 5
Indiana Journal of Law and Social Equality 329–354
7. R. Epstein & T. Gonzalez, Gender & trauma somatic interventions for girls in juvenile justice: Implications for policy and
practice, (2017), http://theartofyogaproject.org/wp-content/uploads/2012/05/gender-and-trauma.pdf
8. D. Reilly, Improving Youth Outcomes in theTexas Juvenile Justice System, (2015),
9. N. Fisher, 4 things to understand about youth, mental health, juvenile justice in the US, (2015),
10. Fitton, M. L. (2018, March 28). [Personal interview by A. Rosenberger].
11. S. Gonsoulin & N. Read, Providing behavioral health care services for juveniles leaving the justice system., (2011),
12. J. Hyde, The mental health crisis in our juvenile detention centers, (2016), http://www.sharedjustice.org/domestic-
13. B. Kamradt & P. Goldfarb, Demonstrating effectiveness of the wraparound model with juvenile justice youth through
measuring and achieving lower recidivism (2015), https://nwi.pdx.edu/pdf/Wraparound-model-with-jj.pdf.
14. P. S. Landau & J.B. J. Gross, Low reincarceration rate associated with ananda marga yoga and meditation, 18 International
Journal of Yoga Therapy 43–48 (2008), http://iaytjournals.org/doi/abs/10.17761/ijyt.18.1.a41504h5w240v3u4.
15. R. A. Mendel, Bernalillo County mental health clinic case study (2013), http://www.aecf.org/m/resourcedoc/aecf-
16. National Center for Youth Law, Improving outcomes for youth in the juvenile justice system (2011),
17. National Conference of State Legislatures. (n.d.), Medicaid for juvenile justice-involved children,
18. National Institute of Corrections. (n.d.), Thinking for a change, https://nicic.gov/thinking-for-a-change.
19. National Institute of Justice. (n.d.), Program profile: Thinking for a change,
20. R. Ramadoss & B. K. Bose, Transformative life skills: Pilot studies of a yoga model for reducing perceived stress and
improving self-control in vulnerable youth, 20 International Journal of Yoga Therapy 75–80 (2010),
21. State criminal justice advocacy in a conservative environment, (2015), Retrieved from http://sentencingproject.org/wp-
22. SHIELDS For Families (n.d.), Juvenile justice mental health services, https://www.shieldsforfamilies.org/juvenile-justice-
23. SHIELDS For Families (n.d.), Mission Statement, https://www.shieldsforfamilies.org/mission-statement/.
Texas Juvenile Justice Department, Youth reentry and reintegration, (2012),
24.The Art of Yoga Project (n.d.), The Impact, http://theartofyogaproject.org/what-we-do/the-impact/.
25. The Art of Yoga Project (n.d.), Our Model, http://theartofyogaproject.org/what-we-do/our-model/.
26. The Berkeley Center for Criminal Justice, Mental health issues in California’s juvenile justice system,(2010),
27. S. Tiano, California wraparound program reduces juvenile recidivism by focusing on mental health
Juvenile Justice Information Exchange (2016), https://jjie.org/2016/12/05/california-wraparound-program-
28. L. A. Underwood & A. Washington, Mental illness and juvenile offenders, 13 International Journal of Environmental
Research and Public Health 228–241 (2016),https://doi.org/10.3390/ijerph13020228.
29. UNICEF, Advocacy toolkit (2010), https://www.unicef.org/evaluation/files/Advocacy_Toolkit.pdf
G. Vincent, Screening and assessment in juvenile justice systems: Identifying mental health needs and risk of
reoffending Substance Abuse and Mental Health Services Administration
30. T. Winkelman, A. Young & M. Zakerski, Inmates are excluded from Medicaid and it makes sense to change that,
31. Wraparound Milwaukee (n.d.), Wraparound Milwaukee, http://wraparoundmke.com/.
33. Young Minds Advocacy, Fulfilling Medi-Cal's promise: Extending home and community-based mental health services to
juvenile justice-involved youth in California (2015), http://zff.org/knowledge-center/publications/Fulfilling-Medi-
34. Youth.gov. (n.d.), Reentry, https://youth.gov/youth-topics/juvenile-justice/reentry.
© 2019 by The Law Review at Johns Hopkins.
All rights reserved.
4 Underwood & Washington (2016).
6 Hyde (2016).
10 National Conference of State Legislatures, n.d.
16 Mendel (2013).
17 Gonsoulin & Read (2011).
19 SHIELDS For Families, n.d.
21 SHIELDS For Families, n.d.
23 Clark & Gehshan (2007).
28 The Berkeley Center for Criminal Justice (2010); Underwood & Washington (2016).
29 Underwood & Washington (2016).
31 NIC, n.d.
33 NIC, n.d.
34 National Instiute of Justice, n.d.
36 National Institute of Justice, n.d.
37 Center on Juvenile and Criminal Justice, n.d.
39 Tiano (2016).
46 Epstein & Gonzalez (2017).
48 Ramados & Bose (2010).
55 M.L. Fitton, personal communication, March 28, 2018.
57 Gonsoulin & Read (2011).
64 American Institute for Research, n.d.
66 Vincent (2012).
71 Mendel (2013).
1 Mendell (2013).
3 Fisher (2015).
7 Gonsoulin & Read (2011); Hyde (2016)
8 Hyde (2016).
9 Gonsoulin & Read (2011)
11 Fisher (2015).
12 Underwood & Washington (2016).
14 The Berkeley Center for Criminal Justice (2010).
15 Acoca, Stephens, & Van Vleet (2104).
18 Youth.gov, n.d.
20 The Berkeley Center for Criminal Justice (2010).
22 Reilly (2015); Vincent (2012).
24 Mendel (2013).
25 Winkelman, Young, & Zakerski (2017).
26 Underwood & Washington (2016).
32 Underwood & Washington (2016).
35 NIC, n.d.
38 Kamradt & Goldfarb (2015).
40 Underwood & Washington (2016).
41 Wraparound Milwaukee, n.d.
43 Kamradt & Goldfarb (2015).
47 Epstein & Gonzalez (2017).
49 Epstein & Gonzalez (2017); Landau & Gross (2008).
50 The Art of Yoga Project, n.d.
54 Epstein & Gonzalez (2017).
61 Texas Juvenile Justice Department (2012).
68 Acoca, Stephens, & Van Vleet (2014).
69 Acoca, Stephens, & Van Vleet (2015).
70 Winkelman, Young, & Zakerski (2017).
72 Texas Juvenile Justice Department (2012).
The editorial staff of The Law Review at Johns Hopkins does not endorse the opinions expressed in individually published articles.