Kentucky's juvenile mental health services evolve.
In 1997, most services were provided in a residential setting with very little effort made to develop aftercare services or to provide continuity of care. Only two of the 11 residential programs had a mental health clinician on staff. Psychiatric services were provided by private practitioners who contracted their services but could not spend much time at the facilities. Community services, group homes and day treatment programs would send youths to the local community mental health centers. Detention centers, which were under county administration at that time, also contracted with community mental health centers. By 2008, though, all detention centers except Louisville were state operated.
The mental health administrators met frequently to work on a variety of issues. They developed a standard format for mental health evaluations, refined the treatment planning process, created a process for making mental health referrals both in the department and to outside agencies, and began to design policies on mental health issues. Of particular concern from the consent decree was the development of processes to deal with suicidal youths and youths who required restraints or isolation.
To upgrade mental health services, the department began hiring clinicians with master's degrees (primarily in psychology) to be treatment directors at the residential programs. This process took about two years. In addition, the psychiatric services at facilities were slowly turned over to the psychiatry departments at the University of Kentucky and the University of Louisville. All the psychiatrists providing services now are child psychiatrists or child psychiatry residents. That change was completed in 2009 as existing providers retired or chose to leave.
The facility treatment directors conduct a mental health evaluation on every youth entering the residential programs. They review intake screenings. All youths entering residential programs are given the MAYSI-2 (Massachusetts Youth Screening Instrument), which was developed to identify potential mental health and substance abuse problems in youths involved in the justice system. (1) They also run treatment team meetings and provide overall direction on how to approach youths with mental health or behavioral issues. The treatment directors all review the quality of treatment plans and perform quality checks on counselor notes. They also conduct individual and group therapy on occasion. They hold staff trainings on a variety of issues ranging from various mental health disorders to dealing with youth management issues.
By the end of 2000, the department met the requirements of the consent decree, and it was terminated. It had been apparent for some time that mental health practitioners in the community were, for the most part, not interested in providing sex offender services, and others who were providing services were not working well with the department's community staff. Department staff decided to create a mental health branch that would primarily provide sex offender counseling but also some substance abuse treatment and mental health services in areas that lacked sufficient providers. In addition, the department was mandated by the Legislature to conduct sex offender risk assessments and help evaluators perform timely evaluations. During the next two years, employees were hired and the private contractors were phased out; all state-funded outpatient sex offender treatment was provided by the department. In 2002, the department chose the J-SOAP-II (Juvenile Sex Offender Assessment Protocol II) developed by Prentky and Righthand in 2003 (2) (available through CSOM-Center for Sex Offender Management) and ERASOR Version 2.0 (3) as the guided instruments to be used for sex offender assessments. In addition, the department participated in a study to evaluate the MEGA (Multiplex Empirically Guided Inventory of Ecological Aggregates for Assessing Sexually Abusive Adolescents and Children) and continues to participate in a cross-validation study of the inventory. (4)
As psychiatric services provided by the universities expanded, it became apparent that travel was a major problem. Teleconferencing began with one site toward the end of the consent decree process, and after most of the technical problems were ironed out, a second facility was added in 2002. As the state opened more detention centers, the need for psychiatric consultations became clear. The detention centers at first tried working with local providers but were generally not satisfied with the service and gradually asked the University of Kentucky to provide consultations. At the time of this report, the Psychiatry Department provides services to all but two state-run facilities. Three facilities are involved through teleconferencing. If emergency consultations are needed, the regional psychologists are also available to the detention center staff to give direction on what steps to follow or to facilitate referrals for emergency hospitalizations.
As the mental health branch became established, several factors coincided to heighten awareness of substance abuse problems. The Reclaiming Futures Project, sponsored by the Robert Wood Johnson Foundation, had picked one site in Southeastern Kentucky and had asked the department to provide a juvenile justice fellow in 2004. Reclaiming Futures requested that the chief of mental health services fill the slot. In addition, the governor's office encouraged the department to develop a substance abuse treatment program. During the next three years, an overall structure was developed and tested in pilot programs. All counselors, community staff and mental health staff were trained on strength-based treatment approaches, motivational interviewing, cognitive self-change and treatment planning. In addition, some community staff, counselors and mental health staff were trained to use the GAIN-Q (Global Appraisal of Individual Needs) instrument to determine what approach should be taken. (5) Those with low risk for substance abuse would receive a prevention program Prime for Life-Under 21 tested by the Prevention Research Institute. (6) Prime for Life has individuals look at their risk factors for substance abuse and gives them help on how to manage these factors. It also gives them an idea about how substance abuse influences their thinking and behavior. Those with a moderate risk for substance abuse received the Cannabis Youth Treatment Series (CYT Modules 1 and 2). (7) CYT provides substance abuse information and a set of social skill-building exercises that include drug refusal techniques. Those with a high risk for substance abuse started Seven Challenges. (8) Seven Challenges has individuals work on self honesty. They review their drug use history, and then examine the positives and negatives of using drugs. They look at what they and their environment do to cause them problems. They look at their life goals and what has to happen in order for them to be achieved. Once they decide to stop using drugs, they examine relapse prevention. Prime for Life and CYT were provided by facility counselors or community staff. Seven Challenges was provided by facility counselors or the mental health branch.
Over time, it became clear that, although this approach looked good on paper, the time requirements were huge. This became even more critical as state budget revenues declined and staff positions were not replaced. In 2009, the decision was made to use a substance abuse screen developed at Children's Hospital in Boston called the CRAFFT. (9) The GAIN-Q was then only used for youths who scored above the cut-off on the screen. Youths who did not meet the actual cut-off score also were not placed in the prevention program. The time savings were tremendous. Individuals without a substance abuse problem were not subjected to an unnecessary intervention. Community workers could also spend more time providing services instead of doing evaluations that did not result in interventions. In addition, if a youth developed a substance abuse problem later, the GAIN-Q could be given at that time. The prevention program then became the first graduated response in that case. CYT and Seven Challenges could be applied later if necessary. Incidentally, Chestnut Health Systems had also developed the GAIN-SS (10) or short screener, which has been used by several agencies in the state, including the Office of the Courts and the Family and Youth Resource Centers in the public schools. Both those agencies found the screening instrument to be helpful as well.
The Classification Branch, based in the Central Office and responsible for all out-of-home placements, had always been aware that a large number of youths had mental health problems, but it generally relied on the mental health staff for consultation on where youths might go if out-of-home placement was required. One facility had a unit for youths with mental health problems but could not meet the total demand in the juvenile justice system. In 2005, the department started using the Child and Adolescent Service Intensity Instrument (CASH) developed by the American Academy of Child and Adolescent Psychiatry. (11) The instrument was used to review the records of any youth referred for out-of-home placement who had identified mental health needs. The instrument identified the intensity and type of service needs and helped the Classification Branch with placement issues. The author worked on the development of the instrument and trained the classification staff on its use. The instrument helped classification staff make more appropriate placements within and outside of the department.
Another big issue for the department was the number of psychiatric hospital admissions coming from both community and residential settings. As the number of mental health clinicians increased, hospitalizations did gradually decrease, but starting in 1997, the idea of creating a unit that dealt with more intensive psychiatric issues came under discussion. In the next five years actual procedures for such a unit were developed, but a unit was not actually started until 2006. To be eligible for transfer to this unit, youths can be in any out-of-home placement: residential, group home, private child care facility or foster care. Admissions are referred to a committee that includes the classification branch manager, the regional director (where the unit is located), the superintendent of the facility, the facility psychologist, the regional psychologist (where the unit is located) and the chief of mental health services. The decision on admission is made that day. Because that unit is more intensively staffed with both counselors and youth workers, the youths get more individual attention and are observed better. The unit is able to see what interventions are effective. The facility psychologist makes a report to the admission committee on what type of setting and interventions should work, and the youth is sent to the recommended setting. The average stay on the unit runs from six to eight weeks. Hospital admissions were cut further because of the unit's formation.
During the past year, the department focused more on improving quality and consistency. A format for sex offender evaluations is being developed, along with a series of standard questions that need to be addressed. Training for sex offender treatment providers has been updated and skill-building is being emphasized. Informational updates will be provided online. Regional psychologists have started meeting with group home counselors, facility psychologists and detention center counselors on an ongoing basis to provide consultation and support. There is also an initiative to simplify the treatment planning process and tie it into to YLS/CMI (Youth Level of Service/Case Management Inventory), which is the risk/needs assessment inventory of the department. (12) Achieving these changes will be necessary in order to improve departmental efficiency in a time of budget shortfalls.
(1) Grisso, T. and J.C. Quinlan. 2005. Massachusetts youth screening instrument - Version 2. In Mental health screening and assessment in juvenile justice, eds. T. Grisso, G. Vincent and D. Seagrave, 99-111. New York: The Guilford Press.
(2) Prentky, R. and S. Righthand. 2003. Juvenile sex offender assessment protocol II (J-SOAP-II) manual. Silver Spring, Md.: Center for Sex Offender Management. Available at www.csom.org/pubs/jsoap.pdf.
(3) Worling, J.R. and T. Curwen. 2001. The ERASOR: Estimate of risk of adolescent sexual offense recidivism, version 2.0. Toronto: Thistle-town Regional Centre.
(4) Miccio-Fonseca, L.C. 2009. MEGA: A new paradigm in protocol assessing sexually abusive children and adolescents. Journal of Child and Adolescent Trauma, 2(2): 124-141.
(5) Chestnut Health Systems. 2009. Global appraisal of individual needs (GAIN). Normal, Ill.: Chestnut Health Systems. Available at www.chestnut.org/LI/gain/index.html#instruments.
(6) Prime for Life. Homepage. Lexington, Ky.: Prime for Life. Available at www.primeforlife.org/homepage.cfm?CFID-112404&CFTO KEN=26052899.
(7) Idaho RADAR Network Center. Cannabis Youth Treatment Series modules. Boise: Boise State University, Idaho RADAR Network Center. Available at http://hs.boisestate.edu/radar/materials/cytmanuals.html.
(8) Schwebel, R. The Seven Challenges homepage. Tucson, Ariz.: The Seven Challenges. Available at www.sevenchallenges.com/default.aspx.
(9) Center for Adolescent Substance Abuse Research. The CRAFFT Screening Tool. Boston: CeASAR. Available at www.ceasarboston.org/clinicians/crafft.php.
(10) Chestnut Health Systems. 2009.
(11) American Academy of Child & Adolescent Psychiatry. CASH. Washington, D.C.: AACAP. Available at www.aacap.org.
(12) Hoge, R.D. 2005. Youth level of service/case management inventory. In Mental health screening and assessment in juvenile justice, eds. T. Grisso, G. Vincent and D. Seagrave, 283-294. New York: The Guilford Press.
William M. Heffron, M.D., is chief of mental health services for the Kentucky Department of Juvenile Justice.
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|Author:||Heffron, William M.|
|Date:||Jun 1, 2010|
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