Mental Health: How the Juvenile Justice System Addresses Youths' Mental Health

Definitions

Mental health includes a person's psychological, emotional, and social well-being (CDC, 2023; SAMHSA, 2023c; Westerhof and Keyes, 2010).

• Psychological well-being refers to positive individual functioning that promotes self-realization (Westerhof and Keyes, 2010).
• Emotional well-being refers to feelings of happiness and satisfaction with life (Westerhof and Keyes, 2010). Emotional health (or emotional wellness) is an individual’s ability to cope with both positive and negative emotions (National Institutes of Health, 2022; WebMD, 2024).
• Social well-being refers to positive societal functioning and value, such as building and maintaining healthy relationships and having meaningful, authentic interactions with others (Boston University, n.d.; CDC, 2022; Westerhof and Keyes, 2010).

Mental health affects how a person feels, thinks, and acts (CDC, 2023; SAMHSA, 2023d; Westerhof and Keyes, 2010) and is more than just the absence of mental illness (Fusar–Poli et al., 2020). However, the definition of mental health varies depending on the source (Galderisi et al., 2015; Stein et al., 2010; Stein, Palk, and Kendler, 2021). For example, the World Health Organization defines mental health as a state of well-being in which the individual realizes his or her own abilities, can cope with the normal stresses of life, and can work productively and fruitfully (Fusar-Poli et al., 2020). The American Psychological Association (2018a) defines mental health as a state of mind characterized by emotional well-being, good behavioral adjustment, relative freedom from anxiety and disabling symptoms, and a capacity to establish constructive relationships and cope with the ordinary demands and stresses of life.

Behavioral health is a general term that encompasses the promotion of emotional health; the prevention of mental illnesses and substance use disorders; and treatments and services for mental and/or substance use disorders (SAMHSA, 2023a).

Mental disorders relate to issues or difficulties a person may experience with his or her psychological, emotional, and social well-being. Mental illnesses are disorders that affect a person’s thoughts, moods, and/or behaviors. Mental illnesses can range from mild to severe (SAMHSA, 2023d).

The Diagnostic and Statistical Manual of Mental Disorders (DSM) is a standard classification tool for mental disorders used by many mental health professionals in the United States. The most recent DSM is the fifth edition with text revision (DSM–5–TR) [First et al., 2023].

Mental health problems can be categorized in different ways. For example, they can be viewed as either internalizing or externalizing disorders. Internalizing disorders are negative behaviors focused inward, such as depression, anxiety, and dissociative disorders. Externalizing disorders are characterized by behaviors directed externally toward a youth's environment, such as conduct disorders, oppositional defiant disorder, and antisocial behaviors (Cosgrove et al., 2011; Eisenberg et al., 2001; Kimonis, Frick, and Fleming, 2019; Loyd et al., 2019). Mental health disorders can also be organized into five types: 1) mood disorder (e.g., depression, bipolar), 2) anxiety disorder (e.g., generalized anxiety disorder, panic disorder), 3) behavior disorder (e.g., attention-deficit/hyperactivity disorder (ADHD), conduct disorder, oppositional defiant disorder), 4) substance use disorder, and 5) other (e.g., eating disorder, psychosis) [Center for Behavioral Health Statistics and Quality, 2016].

Neuropsychiatric disorder is a medical term that encompasses a broad range of complex conditions with both neurologic and psychiatric symptoms (Bray and O'Donovan, 2018). These disorders are characterized by behavioral, cognitive, and emotional disturbances rooted in brain malfunction. Neuropsychiatric disorders include schizophrenia, bipolar disorders, major depressive disorder, psychopathy, autism spectrum disorder, and ADHD. Their underlying biological mechanisms are largely unknown (Bray and O'Donovan, 2018; Mathee et al., 2020).

Psychopathology is the scientific study of mental disorders, including their theoretical underpinnings, etiology, symptomatology, progression, diagnosis, and treatment (American Psychological Association, 2018b). Psychopathology is a broad discipline that draws on research from fields such as psychology, psychiatry, biochemistry, pharmacology, neurology, and endocrinology.

Serious emotional disturbance (SED) refers to diagnosable emotional, mental, or behavioral disorders resulting in functional impairment that substantially limits a child's functioning in school, family, or community activities (Center for Behavioral Health Statistics and Quality, 2016; Mayhew, 2018; SAMHSA, 1993). This term was defined by the Substance Abuse and Mental Health Services Administration (SAMHSA) in 1993 to assist states in measuring the prevalence of children with SED for their applications for Community Mental Health Block Grant funding (SAMHSA, 1993; SAMHSA, 1998). Although the DSM–5–TR does not employ the term SED, it provides criteria for diagnosing disorders that can constitute SED (e.g., posttraumatic stress disorder, bipolar disorder, conduct disorder). Substance use disorders and developmental disorders are not considered a SED unless they co-occur with another diagnosable SED (Center for Behavioral Health Statistics and Quality, 2016; SAMHSA, 1993).

Medicaid is the primary source of public funding for mental health treatment in the United States (Cummings et al., 2013; Deck and Vander Ley, 2007). Under Medicaid's Early and Periodic Screening, Diagnosis, and Treatment program, children can access any service needed to treat a condition if deemed medically necessary (Koppelman, 2005). Also, the federal Children's Health Insurance Program (CHIP) covers essential mental and behavioral health services for children and teens (Centers for Medicare & Medicaid Services, n.d.).

Medicaid waiver. To be eligible for Medicaid and CHIP, families generally must meet income requirements. However, there are exceptions. Some states provide Medicaid waivers to families of youth with SEDs, which remove or relax income eligibility requirements to provide insurance coverage for expensive treatment to otherwise ineligible families (Graaf and Snowden, 2018).

Given the various ways that mental health is defined in research (McCormick, Peterson-Badali, and Skilling, 2017), it is sometimes difficult to compare results across studies. Studies may use different diagnostic tools for identifying mental health needs. Also, some conditions may be categorized differently depending on the study. Additionally, there is more empirical research on preventing poor mental health than on strengthening mental health (Fusar-Poli et al., 2020).

Tools for Identifying Mental Health Needs

Juvenile justice systems use a variety of tools to identify mental health needs, although most fall into one of two categories: 1) screening and 2) assessment (Hoge, 2012; Morgan-D'Atrio, 2012). Some of these tools were developed specifically for juvenile justice populations while others are implemented in the juvenile justice system but were developed for more general use. Tools can be multidimensional, screening for more than one mental health or substance use problem, or unidimensional, screening for just one problem.

• The purpose of screening is to identify youth who may require an immediate response to their mental health needs and to identify those with a higher likelihood of requiring special attention (APA Services, Inc., 2014; Vincent, 2012a; Soulier and McBride, 2016), similar to triage in an emergency room. Nonclinical staff can administer these tools.
• The purpose of assessment is to gather more comprehensive and individualized profiles of youth. Assessment is performed selectively, for youth with higher needs who often are identified through screening. Mental health assessments tend to involve specialized clinicians and generally take longer to administer than screenings (APA Services, Inc., 2014; Vincent, 2012a).

Researchers have found that standardized tools and instruments are more useful than other methods of identifying mental health needs, such as unstructured or clinical procedures. Standardized tools demonstrate higher levels of validity and ensure some consistency in the decision-making process (Hoge, 2012). It is also easier to evaluate the reliability of standardized tools (Hoge, 2012) than unstructured or clinical procedures. Some of the screening and assessment tools used in juvenile justice practice and research are listed in Table 1 and described below.

Screening Tools. The most widely used mental health screening tool in juvenile justice settings is the Massachusetts Youth Screening Instrument–Version 2 (MAYSI–2 [Christian, 2023; Wachter, 2015]. The MAYSI–2 is a 52-item, multidimensional instrument designed specifically for justice system-involved youth (NYSAP, n.d.). It includes seven subscales: 1) alcohol/drug use, 2) angry/irritable, 3) depressed/anxious, 4) somatic complaints, 5) suicidal ideation, 6) thought disturbance, and 7) traumatic experiences. MAYSI–2 scores are used in much of the research on mental health and juvenile justice (e.g., Gilbert et al., 2015; Jaggers et al., 2023; Vincent et al., 2008).

Unidimensional tools employed in the juvenile justice system tend to screen for depression, suicidal tendencies, substance use problems, or exposure to adversity or trauma. Examples include the Children's Depression Inventory (Kovacs, 1985) and the Suicidal Ideation Questionnaire (Reynolds, 1988), which can help determine whether a youth should be monitored for suicide risk on admission to a detention or residential facility (see Table 1). Screening tools for substance use problems include CRAFFT (representing the key words Car, Relax, Alone, Forget, Friends, and Trouble), which is a six-item tool designed to screen children for the likelihood of alcohol and other drug use disorders (Mitchell et al., 2014; Yurasek et al., 2021), and the Personal Experience Screening Questionnaire (PESQ) [Winters, 1992].

Table 1. Screening and Assessment Tools

_{Sources: Achenbach and Rescoral, 2001; Andershed et al., 2002; Baskin-Sommers and Baskin, 2016; Corrado et al., 2004; Grisso and Barnum, 2006; Colins et al., 2015; Gilbert et al., 2015; Elhai et al., 2005; Grasso et al., 2015; Hodges, 2000; Kaplow et al., 2020; Knight et al., 2002; Kovacs, 1985; Lang et al., 2023; Lang and Connell, 2017; Lang and Connell, 2018; NIDA, n.d.; Powell, 2022; Reich, 2014; Reynolds, 1988; Teplin et al., 2021; Turner et al., 2022; Wachter, 2015; Wasserman et al., 2005; Weathers et al., 2018; Winters, 1992.}

Assessment Tools. Numerous mental health assessments are employed in juvenile justice settings to identify mental health and substance misuse needs. One widely studied assessment is the Achenbach System of Empirically Based Assessment (ASEBA) [Achenbach and Rescorla 2001], which includes three instruments completed by youth (Youth Self-Report), parents (Child Behavior Checklist), and teachers (Teachers Report Form). The ASEBA instruments are standardized forms that include items describing a broad spectrum of problems, and they have been translated into more than 100 languages (Achenbach, 2019).

Other Screening and Assessment Tools. Juvenile justice systems also use screening and assessment tools to determine if they should place a youth in secure juvenile detention while awaiting the resolution of their case (Viljoen et al., 2019) and to identify other risks, such as risk of future violence or recidivism (e.g., Barnes-Lee and Petkus, 2023; Vincent et al., 2012a; Vincent, Chapman, and Cook, 2011). These tools include the Structured Assessment of Violence in Youth (SAVRY), the Youth Level of Service/Case Management Inventory (YLS/CMI), the Youth Assessment and Screening Instrument (YASI), Positive Achievement Change Tool (PACT), and the Risk & Resiliency Checklist (RRC) [Baglivio, 2017; Barnes-Lee and Petkus, 2023; Hamilton et al., 2019; Jones et al., 2016; Vincent et al., 2012b; Vincent, Chapman, and Cook, 2011). For more information, see the Model Programs Guide literature review Risk/Needs Assessments for Youth.

Types of Mental Health Interventions

Interventions to improve mental health outcomes generally fall somewhere on the continuum of prevention, treatment, and recovery (SAMHSA, 2016; Perlman and Jordan, 2017; Stanojlović and Davidson, 2021). Two broad categories of mental health and substance misuse interventions are psychosocial and psychotropic.

• Psychosocial interventions are interpersonal or informational activities, techniques, or strategies that address biological, behavioral, cognitive, emotional, interpersonal, social, or environmental factors to improve health functioning and well-being (Institute of Medicine, 2015). The two primary categories of psychosocial interventions are therapeutic and preventative. Therapeutic interventions typically are for individuals or smaller social systems (such as families and peers). These interventions generally seek to address diagnosable mental health problems (Borduin, Schaeffer, and Heiblum, 2009). Psychosocial prevention programs tend to be broad efforts for large groups (such as schools or neighborhoods), and they generally are designed for specific subgroups of high-risk children and youth (Sawyer, Borduin, and Dopp, 2015).
• Psychotropic interventions use medications to treat mental health disorders (Lyons et al., 2013; Shahidullah et al., 2023; TSMHSAS, 2013). The five main types of psychotropic medications are: 1) antidepressants, to treat depression; 2) anti-anxiety medications; 3) stimulants, to manage ADHD and certain other conditions; 4) antipsychotics, to manage psychosis; and 5) mood stabilizers, to help regulate extreme emotions (Ghaemi, 2015; Shahidullah et al., 2023; WebMD, 2023). The use of psychotropic interventions is sometimes called pharmacological treatment or pharmacotherapy, which is the treatment of a disorder by the administration of drugs (American Psychological Association, 2018; Shahidullah et al., 2023).

There is no regular census measuring levels of mental health disorders in the juvenile justice population nationally. However, an abundance of research has found that a large proportion of youth in the juvenile justice system have a diagnosable mental health disorder, and that they experience higher rates of mental health concerns (including substance misuse) than youth who are not system-involved (e.g., Fazel, Doll, and Langstrom, 2008; Gordon and Moore, 2005; Romaine et al., 2011; Rosenberg et al., 2014; Shufelt and Cocozza, 2006; Schauss et al., 2020; Schubert and Mulvey, 2014; Tolou-Shams et al., 2019; Vitopoulos et al., 2019;  Wasserman et al., 2010; Yurasek et al., 2021). Many youth in the juvenile justice system are also diagnosed with multiple disorders (e.g., Beaudry et al., 2021; Shufelt and Cocozza, 2006; Sibley et al., 2011; Teplin et al., 2013). This section summarizes findings from studies examining the prevalence of mental health issues among juvenile justice system-involved youth in various jurisdictions in the United States and in other countries. The data are not nationally representative, but they provide helpful information for understanding the scope of the problem.

Studies using data from the Pathways to Desistance Study, which is a longitudinal study of youth from Phoenix, AZ, and Philadelphia, PA, who had been involved in serious offenses, suggest that about two thirds of youth in detention or correctional settings have at least one diagnosable mental health disorder, compared with an estimated 9 to 22 percent of the general youth population (Schubert and Mulvey, 2014; Schubert, Mulvey, and Glasheen, 2011). Beginning in 2000, this study recruited 1,354 participants (654 in Philadelphia and 700 in Phoenix).

A systematic review of 47 studies of youth in juvenile detention from 19 different countries published in 1966–2019 found high levels of mental disorders in detained youth (Beaudry et al., 2021). This review, which included analyses of more than 32,000 youth (85 percent from the United States), concluded that mental health disorders were "substantially more common" in detained youth than in the general population. Findings regarding the prevalence of mental health problems are summarized below.

• Current major depression episode: 10.1 percent of males, 25.8 percent of females
• Attention-deficit/hyperactivity disorder (ADHD): 17.3 percent of males, 17.5 percent of females
• Conduct disorder: 61.7 percent of males, 59.0 percent of females
• Posttraumatic stress disorder (PTSD): 8.6 percent of males, 18.2 percent of females
• Psychotic illness: 2.7 percent of males, 2.9 percent of females

A small study of 423 first-time offending, nonincarcerated youth, whose cases were handled by a large family court in the northeast United States, found that 30 percent had been previously diagnosed with a psychiatric condition, 31 percent had been prescribed psychiatric medication, and 17 percent had been hospitalized in a psychiatric in-patient unit (Tolou-Shams et al., 2019). Another small study found that the most common diagnoses among youth in detention and treatment facilities in Maryland were insomnia (39 percent of the youth) and ADHD (39 percent), followed by anxiety (18 percent), with 72 percent of the youth having more than one disorder diagnosis (McGee et al., 2022). A small study of 92 youth who were waived into the adult criminal justice system in New Jersey found that about 71 percent of the youth reported being diagnosed with a mental health illness (Valentine, Restivo, and Wright, 2019). The number of self-reported mental illnesses per youth ranged from 0 to 7; the illnesses included attention-deficit/hyperactivity disorder [ADHD] (45 percent of the youth), depressive disorder (28 percent), bipolar disorder (15 percent), anxiety disorder (9 percent), conduct disorder (8 percent), oppositional defiant disorder (8 percent), PTSD (6 percent), and schizophrenia (3 percent). Additionally, 15 percent of respondents indicated "other," which included behavior disorders, emotionally disturbed, emotional behavior disorder, antisocial disorder with severe stress, and borderline personality disorder.

Some studies examine only one mental health disorder.

• Attention-deficit/hyperactivity disorder. A meta-analysis of 102 studies involving about 70,000 individuals from around the globe, but primarily in Europe and North America, examined prevalence rates of ADHD in detention facilities (Baggio et al., 2018). The authors found that the prevalence of ADHD among people living in detention (both adults and youth) was high, corresponding to a fivefold increase compared with the general population. Another meta-analysis of individuals in prison (which included 9 studies of youth samples), found that 30.1 percent of the incarcerated youth were diagnosed with ADHD (Young et al., 2015). This figure corresponded to a fivefold increase in the prevalence of ADHD compared with the general population.
• Autism spectrum disorder. A systematic review of studies conducted within and outside the United States published between 1990 and 2016 examined the co-occurrence of autism spectrum disorder (ASD) and delinquency. The authors found that the reported prevalence of ASD ranged from 2 to 18 percent in both juvenile justice populations and in populations of youth who self-reported engaging in delinquent behaviors (Rutten, Vermeiren, and Van Nieuwenhuizen, 2017). The authors could not conclude that people with ASD were more or less likely to offend than the general population, owing to conflicting study results.
• Suicidal thoughts and behaviors. Youth who are incarcerated die by suicide at a rate two to three times higher than that of youth in the general population (Abram et al., 2014). A study from the Northwest Juvenile Project, which examined data for 1,829 adolescents who were securely detained in a juvenile detention center in Chicago, Illinois, between 1995 and 1998, found that about 10 percent of the youth had thought about suicide in the past 6 months and 11 percent had attempted suicide (Abram et al., 2014). More than one third of the boys and nearly half the girls reported that they felt hopeless or thought a lot about death or dying in the 6 months prior to detention. The researchers also found that suicide attempts were most prevalent in girls and in youth with anxiety disorders and that fewer than half the youth with thoughts of suicide had told anyone.
• Psychosis. A systematic review and meta-analysis involving more than 13,000 boys and almost 3,000 girls in juvenile detention and correctional facilities found that the youth were almost 10 times as likely to suffer from psychosis than youth in the general population (Fazel, Doll, and Langstrom, 2008). This meta-analysis included 25 studies, 60 percent of which were conducted in the United States; 93 percent of the youth from the 25 studies were from the United States.

For many youth, mental health problems persist after juvenile justice system involvement (Kemp et al., 2021a; Teplin et al., 2021). A cohort study of 1,829 youth detained in a juvenile detention facility in Chicago, Illinois (mentioned above), found that 64 percent of males and 35 percent of females with a psychiatric disorder during detention also had a disorder 15 years later (Teplin et al., 2021).

Differences by Sex

There are some well-documented differences in youth mental health needs by sex (e.g., Campbell, Bann, and Patalay, 2021; Gaylor et al., 2023; Lu, 2019), which are also seen in juvenile justice populations (e.g., Beaudry et al., 2021; Duron et al., 2022). For example, a study collected data from more than 1,400 youth in three U.S. states in juvenile justice settings, such as detention centers, secure residential facilities, and community-based programs. The study found that more than 80 percent of the girls met the criteria for at least one disorder, compared with 67 percent of boys (Shufelt and Cocozza, 2006). The authors found that much of the difference between girls' and boys' mental health needs was attributable to girls' higher rates of internalizing disorders, such as anxiety disorder (56 percent of girls, compared with 26 percent of boys) and mood disorders (29 percent of girls, compared with 14 percent of boys). This study found that girls and boys experience comparable rates of disruptive disorders, such as conduct disorders. This finding is notable because studies of general youth populations tend to find that girls are less likely than boys to have disruptive disorders (also called externalizing disorders) [e.g., Fairchild et al., 2019].

More recent studies continue to identify sex differences, finding that girls in the juvenile justice system are more likely to experience major depression, anxiety, PTSD, and emotion dysregulation, compared with boys in the juvenile justice system (Beaudry et al., 2021; Holzer et al., 2018; Loyd et al., 2019; Kerig and Becker, 2010; Villodas et al., 2023). Analysis of data from the National Survey on Drug Use and Health found that between 2005 and 2014 the prevalence of major depressive episodes among girls increased for both system-involved and nonsystem–involved groups, from 24.4 percent to 33.0 percent for the system-involved girls and from 12.4 percent to 16.7 percent for the nonsystem–involved girls (Holzer et al., 2018). There were no significant trend changes among boys.

Research suggests some mental health needs may be more common in justice system–involved boys. Compared with justice system-involved girls, researchers have found that justice system-involved boys demonstrate more callous-unemotional traits, which is a dimension of psychopathy (Gómez and Durán, 2024; Pechorro et al., 2013); are more likely to be diagnosed with ASD (Slaughter et al., 2019); and have higher levels of moral disengagement (Gómez and Durán, 2024). They also appear to be more impaired in prosocial behaviors (Pechorro et al., 2013). However, compared with the abundance of research identifying higher mental health needs among girls, there is much less research identifying mental disorders that are more prevalent among boys.

Some studies have found that differences by sex remain after discharge. A cohort study of 1,829 detained youth determined that, compared with females with an identified mental health disorder during detention, males with an identified mental health disorder during detention had 3.37 times the odds of experiencing a persistent psychiatric disorder 15 years after being detained (Teplin et al., 2021). Studies also demonstrate that, after discharge, girls use mental health services more than boys do. An examination of data from more than 6,000 youth ages 13–18, who were securely detained in a large midwestern detention center, found that girls were more likely than boys to have a mental health visit within 30 days of release (Aalsma et al., 2012).

Differences by Race/Ethnicity

Researchers have identified several differences by race/ethnicity in mental health indicators of youth in the juvenile justice system (Gilbert et al., 2015; Jaggers et al., 2023). For example, a cohort study of 1,829 youth detained in a juvenile justice facility found that substance use and behavioral disorders were more common among non-Hispanic white youth than among Hispanic and Black youth (Teplin et al., 2021). Analysis of data from detained youth in Indiana determined that white and Hispanic youth scored higher on the alcohol and drug use subscale of the MAYSI–2 than African American youth; Hispanic youth scored lower than African American and white youth on the angry or irritable scale, suicidal ideation scale, and traumatic experiences scale; and African American girls scored lower on the somatic complaints subscale than other girls (Aalsma et al., 2014b).

Also, a study of more than 4,000 youth in a secure state-operated program in the southwest examined seven subscales of the MAYSI–2 by race/ethnicity (Gilbert et al., 2015). They found differences between racial and ethnic groups on three of the seven subscales: 1) alcohol/drug use, 2) angry/irritable, and 3) suicide ideation. Native American youth had the highest average score on the alcohol/drug subscale (compared with white, Black, Hispanic, and Mexican/Mexican American youth), and Black youth had the highest score on the angry/irritable subscales. Also, Black, white, and Native American youth scored much higher on suicide ideation than Asian, Hispanic, and Mexican/Mexican American youth. There were no differences by race or ethnicity in the other four examined areas: 1) depressed/anxious, 2) somatic complaints, 3) thought disturbance, and 4) traumatic experiences.

Emerging research examines the effects of discrimination on youth mental health. One study of 173 recently arrested adolescents in a large midwestern city found that experiencing interpersonal ethnic/racial discrimination was associated with increased internalizing symptoms and externalizing behaviors (Loyd et al., 2019). The study authors also determined that the relationship between discrimination and internalizing symptoms was stronger for girls than for boys.

In the early 2000s, news articles in more than 30 U.S. states described the difficulty many parents had in accessing mental health services for their children, and they reported that some parents were choosing to place their children in the child welfare or juvenile justice system to obtain the services. In response to these articles, the United States Government Accountability Office (GAO) was asked to determine: 1) the number and characteristics of children voluntarily placed in the child welfare and juvenile justice systems to receive mental health services, 2) the factors that influence such placements, and 3) promising state and local practices that may reduce the need for child welfare and juvenile justice placements. According to the GAO report (2003a; 2003b), child welfare directors in 19 states and juvenile justice officials in 30 counties estimated that, in fiscal year 2001, parents placed more than 12,700 children into the child welfare or juvenile justice systems so these children could receive mental health services. They also estimated that nationwide, the number was likely higher because many state child welfare directors and county juvenile justice officials did not provide data to the GAO on this issue.

Following the completion of the 2003 GAO report, the Special Investigation Division of the Committee on Government Reform in the United States House of Representatives prepared a report describing the incarceration of youth waiting for community mental health services (U.S. Waxman and Collins, 2004). To gather information, the Special Investigations Division surveyed every juvenile detention facility in the United States to assess what happens to youth when community mental health services are not readily available. More than 500 juvenile detention administrators in 49 states responded. This report was the first national study of its kind, covering the period from January 1 to June 30, 2003. The authors explained that without access to treatment, some youth with serious mental health disorders were placed in secure detention without any criminal charges pending against them. In other cases, youth who were charged with crimes but were eligible for release remained incarcerated for extended periods because no inpatient bed, residential placement, or outpatient appointment was available. The report concluded that this misuse of detention centers as holding areas for youth needing mental health treatment was unfair to the youth and undermined their health, disrupted the function of detention centers, and was costly to society.

Reliance on the juvenile justice system to meet the needs of youth with both mental health needs and status, delinquent, or criminal offenses has been increasing since the late 1990s (Grisso, 2007; Mendel, 2023; Underwood and Washington, 2016). Today, behavioral health service delivery is typically done through collaborative partnerships with behavioral health agencies. As youth move deeper into the juvenile justice system, they tend to have more screenings, assessments, and service referrals (Bowser et al., 2018; Chan and Dierkhising, 2023). Although there are still gaps, juvenile justice systems appear to have made considerable efforts to identify and address the needs of the youth in their care during the past few decades.

This section describes several ways the juvenile justice system addresses the mental health of the youth in their care, using mental health courts, community-based programming, and residential care. The section ends with findings from studies of young people's perceptions regarding the care they receive.

Juvenile Mental Health Courts

Mental health courts are specialized, treatment-oriented, problem-solving courts, similar to drug courts. They provide rehabilitation, services, and treatment to reduce recidivism and other negative outcomes for individuals with mental health disorders (Fox et al., 2021). Meta-analytic research has found that adult mental health courts are associated with significant reductions in recidivism (Cross et al., 2011; Lee et al., 2012; Lowder, Rade, and Desmarais, 2018; Sarteschi, Vaughn, and Kim, 2011).

The first juvenile mental health court (JMHC) in the United States was established in 2001 (Arrredondo et al., 2001). The main purpose of JMHCs is to treat and rehabilitate youth (e.g., by treating mental health issues, reducing recidivism). They use a multidisciplinary team approach to develop and monitor treatment plans and compliance and provide necessary treatment. Team members can include district attorneys, public defenders, mental health providers, and case managers or probation officers (Cocozza and Shufelt, 2006; Arredondo et al., 2001). JMHCs follow the principles of therapeutic jurisprudence. These principles promote a nonadversarial, treatment-oriented approach when adjudicating adolescents in court for delinquency offenses, while upholding their due process rights (Winick and Wexler, 2003; Porter, Rempel, and Mansky, 2010). By 2009, there were 41 juvenile mental health courts in 15 states (Callahan et al., 2012). In April 2024, SAMHSA's Juvenile Mental Health Treatment Court Locator indicated that 56 juvenile mental health courts were operating in 17 states (SAMHSA, 2024).

A small evaluation of a JMHC in Colorado found that youth who completed all court requirements were less likely to recidivate than comparable youth who did not participate in the JMHC (Heretick and Rus, 2013). An evaluation of a JMHC in Santa Clara County, California, involving 63 youth determined that recidivism was reduced among JMHC participants, regardless of sex and ethno-racial background (Behnken, Bort, and Borbon, 2017). Additionally, a meta-analysis of 30 evaluations of mental health courts conducted from 1997 through 2020 found that mental health court participation corresponded to a 74 percent decrease in recidivism and that these effects were similar for both adults and youth (Fox et al., 2021). Evaluations from other countries have also identified potential benefits from JMHCs, especially in terms of reducing recidivism (e.g., Marr et al., 2023).

Community-Based Programming

There is near consensus among researchers and practitioners that, whenever reasonably possible, youth should be served in their own communities while living at home with their families, instead of being sent to a residential placement (e.g., Cullen and Johnson, 2014; Hildebrand, 2020; Mental Health Initiatives, 2022; Ryan, 2022; Underwood and Washington, 2016; Whitley et al., 2022). Some research has been conducted on approaches to increase youth engagement in community-based mental health care. Many of the referrals to these services come from juvenile court or juvenile probation departments.

For example, the Family Connect program for court-involved youth uses linkage specialists to address multilevel barriers to engaging in mental health care. This intervention draws from motivational interviewing and motivational enhancement techniques. The program's four goals are to: 1) engage the family through active listening and validation of the families' experiences and current needs, 2) promote the idea that treatment is necessary for the youth and that it could provide an opportunity for positive change, 3) promote reengagement of the caregiver or youth, and 4) remove barriers to achieving treatment enrollment. An evaluation with a small number of youth provided preliminary support for the program's approach, although the small number of participants made it difficult to form significant conclusions (Elkington et al., 2023).

Because almost all youth involved in the juvenile justice system have contact with juvenile probation staff (Myers and Orts, 2024), there has been some research on how to best use the youth-probation officer relationship to improve mental health care access and quality. For example, a study examined the effect of a training program for juvenile probation officers to learn and deliver contingency management for youth with substance use treatment needs (Sheidow et al., 2020). The evaluators found that probation officers were able to incorporate contingency management into their services and that they delivered significantly more cognitive-behavioral components and similar levels of behavior modification components, compared with clinicians.

Another study examined the extent to which youth under community supervision (which generally indicates probation supervision) receive community-based substance use services, in a large national sample of 192 community supervision agencies and 271 behavioral health partners (Knight et al., 2023). The authors found that substance use services were more often available through behavioral health partners than through community supervision agencies. They also determined that behavioral health partners were more likely to use evidence-based practices than community supervision agencies and that youth were more likely to receive services in communities with higher rates of using evidence-based practices.

An earlier study of the same dataset examined behavioral health services more broadly (Scott et al., 2019). This study found that there were established cross-system relationships to assess and refer for substance use and mental health treatment, but less so for prevention services. Also, youth referred from community supervision to behavioral health programs represented a more "severe sub-group" of youth under supervision, indicating that screenings and assessments used by supervision agencies appropriately identified the youth with the highest needs for referral to more highly trained staff. Almost one fourth of the community supervision agencies employed master's level clinicians and one fifth employed bachelor's level clinicians to serve their youth. Ninety-three percent of the behavioral health providers employed master's-level clinicians, more than one third employed doctoral-level clinicians, and more than half employed bachelor's-level clinicians. The authors also determined that more intensive substance use and mental health treatment, aftercare, and recovery support services were limited in availability.

Researchers have identified some best practices that help probation officers address youth mental health: a) use specialized intake/probation officers trained in working with youth with mental health disorders; b) conduct evidence-based screening and assessment to ensure referral to appropriate treatment and programming; c) collaborate with partner agencies and understand available resources; d) actively and meaningfully engage with youth and their families in developing case plans; and e) ensure that case plans are informed by screenings, assessments, and input from youth and their families (Mental Health Initiative, 2022; Vincent et al., 2012a). For more information about probation, see the Model Programs Guide (MPG) literature review Alternatives to Secure Detention and Confinement.

Screening for Mental Health Needs in Residential Programs

In 2022, more than 130,000 youth with delinquency cases and an estimated 2,000 youth with status offenses in juvenile court were sent to secure detention while awaiting the result of their cases; also, 38,200 youth with delinquency cases and 1,800 youth with status offense cases were sent to out-of-home placement as a disposition (Hockenberry and Puzzanchera, 2024).

The Juvenile Residential Facility Census (JRFC) surveys juvenile residential facilities in the United States about procedures for mental health screening. In 2022, more than 1,200 facilities responded to JRFC questions about screening youth for mental health and substance use treatment needs. The proportion of facilities reporting that they screen youth for mental health service needs increased between 2000 and 2022, when nearly all facilities (98 percent) reported that they screened at least some youth for mental health needs (Hockenberry, 2024). In 2000, 47 percent of facilities screened all youth for mental health needs, 33 percent screened some youth, and 20 percent did not screen for mental health needs. By 2022, 69 percent screened all youth, 29 percent screened some youth, and only 2 percent did not screen.

Also, in 2000, 59 percent of facilities screened all youth for substance use needs, 24 percent screened some youth, and 18 percent did not screen for mental health needs. By 2022, 74 percent screened all youth for substance use needs, 10 percent screened some youth, and 16 percent did not screen (Hockenberry, 2024).

Residential Treatment Centers

In 2021, about one third of committed youth and 3 percent of detained youth were in a residential treatment center (RTC) [Puzzanchera, Sladky, and Kang, 2023b]. RTCs are designed to provide individually planned treatment programs for youth referred to treatment because of an offense, in conjunction with residential care. Treatment programs can address issues such as substance misuse, sex offending, and mental health challenges. Such facilities generally require specific licensing by the state, which may mandate that the treatment provided be reimbursable by Medicaid (Dmitrieva et al., 2012; Puzzanchera, Sladky, and Kang, 2023a). RTCs vary with respect to their level of security (Puzzanchera, Sladky, and Kang, 2023b), but generally differ from other secure placements because they have a stronger focus on rehabilitation and typically provide a range of services centered on a specific intervention model (Dmitrieva et al., 2012; Puzzanchera, Sladky, and Kang, 2023b).

The number of youth held in RTCs declined substantially in the United States, from 20,355 in 2006 to 4,802 in 2021, a decrease of 76 percent (Puzzanchera, Sladky, and Kang, 2023b). This reduction is a result of an overall decline in the use of all types of residential placements.

Some research has examined the effects of RTCs, compared with traditional juvenile institutions (e.g., Caldwell et al., 2006; Dmitrieva et al., 2012; Gordon, Moriarty, and Grant, 2000). A study of 141 boys with juvenile offenses and high psychopathy scores compared the boys placed in an RTC with the boys placed in a conventional juvenile correctional institution (JCI) [Caldwell et al., 2006]. The researchers found that the boys in the JCI group were more than twice as likely to violently recidivate in the community after 2 years, compared with the boys in the RTC group. Placement in the RTC also was associated with relatively slower and lower rates of serious recidivism.

Another study compared differences in psychosocial maturity outcomes of more than 1,000 male adolescents adjudicated with serious charges in three different situations: 1) confinement in a secure facility, 2) confinement in a residential treatment facility (which may or may not be secure), and 3) not in a facility (Dmitrieva et al., 2012). The study authors found that placement in a residential treatment facility was not associated with a short-term decline in temperance and responsibility (as placement in secure confinement was). However, they also determined that youth who spent more time in a residential treatment facility showed slower net growth in psychosocial maturity, perspective, and responsibility (i.e., a negative effect on the developmental trajectory of psychosocial maturity), compared with youth who were not incarcerated. This finding was contrary to their expectations.

For more information about RTCs, see the MPG literature review Alternatives to Secure Detention and Confinement.

Young People's Perceptions of Mental Health Care

There is limited research on the extent to which youth in the juvenile justice system and their families are satisfied with mental health services. A study involving 201 individuals, who were incarcerated in juvenile or adult facilities when they were younger than 24, examined their perceptions of the mental health care they received while incarcerated (Miodus, 2023). Slightly fewer than half of the participants (46 percent) reported receipt of a full mental health assessment in the facility, and 39 percent indicated receipt of a screening assessment. Thirty-six percent reported that they had received psychiatric medication management, and the same percent shared that they had received individual therapy. Twenty-one percent said that they received case management, 18 percent participated in family therapy, and 18 percent participated in group therapy.

Overall, participants indicated slightly greater than average satisfaction with the mental health care they received, although there were significant differences in satisfaction among racial groups, mental health diagnoses, and facility types. Black participants indicated a higher satisfaction with mental health care than white participants, participants placed in juvenile detention centers or residential treatment centers were more satisfied than participants  sent to prisons, and participants diagnosed with posttraumatic stress disorder, schizophrenia/psychotic disorder, or a substance use disorder were more satisfied with the care received than those diagnosed with depression, anxiety, obsessive–compulsive disorder, traumatic brain injury, attention-deficit/hyperactivity disorder, or a personality disorder (Miodus, 2023).

In open-ended survey responses and interviews, participants indicated that the mental health services received while they were incarcerated led to symptom improvement and better life outcomes. Also, participants valued the connections with others and opportunities to share about themselves and be listened to. Participants identified areas for improvement including reducing delays in accessing services, increasing the amount of treatment, improving service quality, and addressing discrimination and racism in service delivery (Miodus, 2023).

An earlier study of 369 youth who received child welfare, juvenile justice, mental health, special education, or substance misuse public services in San Diego, CA, found that youth-reported satisfaction with services was "generally positive" (Garland et al., 2003). However, the study authors suggested that consumer satisfaction not be used as an indicator of effectiveness in reducing symptoms or improving functioning.

Pharmacotherapy is the treatment of a disorder by the administration of a drug. The use of psychotropic medication to manage disruptive, aggressive, and delinquent behaviors in youth has increased over time (Armstrong-Hoskowitz et al., 2020; Cohen, Pfeifer, and Wallace, 2014; Davis et al., 2021; Finkelhor and Johnson, 2017; Thackeray et al., 2018). Certain subgroups of young people—such as justice system-involved youth—are particularly affected. Some studies have examined the prevalence of psychotropic medications in juvenile justice system populations and the effect of psychotropic medications on recidivism (e.g., Anderson, Rapp, and Kierce, 2022; Engel, Abulu, and Nikolov, 2012; McGee et al., 2022; Tamburello et al., 2023). However, no source regularly tracks prevalence and changes over time nationally.

Highlighted below are individual studies measuring the prevalence of psychotropic drug prescriptions for youth in the juvenile justice system.

• Anderson, Rapp, and Kierce (2022) examined medical files for 135 adolescents adjudicated for sexual offenses and found that 42 percent received one or more psychotropic medications during their stay in the juvenile residential facility. The most frequently prescribed psychotropic medications were stimulants (54 percent), antidepressants (51 percent), and antipsychotics (19 percent). Slightly more than a quarter of the residents simultaneously received two or more psychotropic medications. Slightly fewer than 40 percent of the youth who received psychotropic medications experienced discontinuation of all psychotropic medication prior to discharge. Another finding was that residents who entered the facility with psychotropic medication were less likely to experience discontinuation than those who received psychotropic medication after intake.
• A study analyzing 668 consecutive new admissions to three post-adjudicatory secure facilities in one state determined that 10 percent of the youth had a psychotropic medication dispensed within a month of intake (Lyons et al., 2013). Of the youth receiving medication, half received an antidepressant, 38 percent received an antipsychotic, and 19 percent received an anticonvulsant mood stabilizer.
• A newer study of youth in detention and treatment facilities in Maryland found that 34 percent of the youth were prescribed melatonin, 18 percent trazadone, and 10 percent quetiapine (McGee et al., 2022). Fifty-eight percent of the youth took more than one sleep/psychotropic medication.
• Analysis of 8 years of data from detained youth in Alameda County, CA, determined that a monthly average of 17 percent of youth were prescribed psychotropic medications (Cohen, Pfeifer, and Wallace, 2014).
• A small study of 92 youth, who were waived into the adult criminal justice system in New Jersey, found that 47 percent of the youth self-reported being on medication during or prior to their system involvement (Valentine, Restivo, and Wright, 2019).

Research has sought to understand the relationship between juvenile justice system involvement and psychotropic drug use to treat mental health disorders. A study examined statewide administrative data from the Florida Department of Juvenile Justice and the Florida Medicaid program to determine changes in psychotropic medication use before and after incarceration (Cuellar et al., 2008). Examination of more than 125,000 stays (67,819 short-term detention stays and 59,918 long-term commitment stays) revealed that 90 days prior to intake, 5.4 percent of the detained youth and 4.4 percent of the committed youth had psychotropic drug claims. Among the youth with drug claims, in the 30 days after release, 62.6 percent of the detained youth and 29.6 percent of the committed youth still had psychotropic medication claims. Also, they found that the onset of medication use after release from residential facilities was relatively uncommon (1.7 percent for detained youth and 1.9 percent for committed youth). The authors concluded that their results supported the argument that youth incarceration disrupts medication use and does not act as an opportunity to discover and address mental health needs. They provided several potential reasons for this finding, including that the juvenile justice system’s emphasis for mental health assessment remains on emergent conditions (e.g., to prevent suicide) rather than ongoing treatment.

Researchers have also examined factors associated with psychotropic medication use. For example, a study of youth leaving juvenile justice residential placement in Florida during a 3-year period found that males (compared with females), and Black and Hispanic youth (compared with white youth), were less likely to be prescribed medication during placement (Wolff, Baglivio, and Intravia, 2022). The study determined that each additional adverse childhood experience was associated with about a 9 percent greater chance of having medication prescribed. The authors suggested that adverse childhood experiences increased a youth's mental health needs, which led to prescription of psychotropic medication. Also, the Cohen, Pfeifer, and Wallace (2014) study mentioned above found that detention centers in rural counties had lower levels of medication use than detention centers in urban counties.

Additionally, some studies consider whether psychotropic medications influence initial entry into the juvenile justice system and recidivism after initial contact. A study examining data from 2,065 at-risk youth from the National Study of Child and Adolescent Well-Being (NSCAW) explored whether psychotropic medication influenced delinquent behaviors and involvement in the juvenile justice system over a 7-year period (Armstrong-Hoskowitz et al., 2020). The authors found that treatment with psychotropic medications did not significantly decrease delinquent behaviors among youth or prevent entry into the juvenile justice system. Also, the Wolff, Baglivio, and Intravia (2022) study of youth in the Florida juvenile justice system (mentioned above) determined that psychotropic medication use was unrelated to recidivism. This finding was consistent across sex and race/ethnicity.

However, researchers, practitioners, and policymakers disagree as to whether psychotropic medications are overused or underused for juvenile justice populations and youth at risk of systems involvement (e.g., Britton, 2016; Finkelhor and Johnson, 2017; Penn, 2008; Tran, 2022).

There are three primary types of models for working with youth in the juvenile justice system: 1) the mental health model, 2) trauma-informed models, and 3) the risk-need-responsivity model. Each addresses the mental health needs of youth using different strategies.

Mental Health Model

Mental health models concentrate on treating targeted symptoms and behaviors, which are identified through comprehensive assessments and diagnoses (Griffin, Germain, and Wilkerson, 2012). Negative behaviors are seen as possible symptoms of a mental illness. This approach differs from the conventional punishment model, which is based primarily on deterrence theory and views youth as rational actors who can learn to stop inappropriate behaviors through graduated systems of punishments and rewards. Mental health models also differ from trauma-informed models (see below), although they are more like trauma-informed models than punishment models. A juvenile justice program that uses a mental health model tends to rely on clinicians, counselors, and psychiatrists. Services typically include individual counseling, group therapy, and medication (Griffin, Germain, and Wilkerson, 2012).

Trauma-Informed Model

Trauma-informed models of juvenile justice differ from the conventional  punishment model and the mental health model, and several models of trauma-informed care have been proposed (Baglivio et al., 2014; Branson et al., 2017; Griffin, Germain, and Wilkerson, 2012; Skinner-Osei et al., 2019). Compared with a mental health model, a trauma-informed model is based on the understanding that the youth is reacting to external events rather than battling an inherent mental illness. Second, a trauma-informed model takes more of a strengths-based approach, focusing on self-regulation skills and safety (as opposed to concentrating solely on removing mental health symptoms or negative behaviors). Third, the line staff plays a larger role, which results in children being treated in the context of a 24-hours-a-day milieu when in residential placement, instead of just during sessions with clinicians (Griffin, Germain, and Wilkerson, 2012). Because of these additional responsibilities, the staff must be able to: accurately identify and respond to the young people's needs; recognize and enhance youth strengths; support a system-wide approach that is responsive to different demographic characteristics (e.g., age); create transparent communication and coordination between youth-serving systems; and recognize and manage their own stress reactions effectively (Fehrenback et al., 2022). Trauma-informed care can help youth recognize, understand, and cope effectively with their trauma-related reactions so that they can make developmentally appropriate, healthy choices and achieve prosocial goals (Fehrenback et al., 2022).

A systematic review of the published literature on trauma-informed care found that there is relative consensus about a trauma-informed juvenile justice system's core domains related to clinical services, agency context, and overall systems (Branson et al., 2017). The core domains are 1) screening and assessment; 2) services and interventions; 3) cultural competence; 4) youth and family engagement; 5) staff training and support; 6) promoting a safe agency environment; 7) agency-level policies, procedures, and leadership; 8) cross-system collaboration; 9) system-level policies and procedures; and 10) quality assurance and evaluation. Although there is relative consensus about these 10 domains, there appears to be much less agreement on specific policies and practices (Branson et al., 2017).

Evaluations of trauma-informed programs for justice system-involved youth indicate that the programs show promise in reducing trauma symptoms and behavioral problems. An evaluation of a trauma-informed milieu invention in two detention centers, in a large northeastern city, found that the intervention was significantly related to a reduction in violent incidents in one of the facilities (Baetz et al., 2021). However, no research to date has examined the effectiveness of trauma-informed programs in reducing youth violence or recidivism in community samples (Zettler, 2021). For more information about tools to measure adversity and trauma and a more detailed description of trauma-informed approaches, see the MPG literature review Children Exposed to Violence.

The Risk–Need–Responsivity Model 

The risk-need-responsivity (RNR) model was designed to guide effective intervention strategies to prevent recidivism (Andrews and Bonta, 2010; Latessa, Listwan, and Koetzle, 2015). The risk principle refers to matching the type and level of intervention to the dynamic (i.e., changeable) risk factors for reoffending. These risk factors include antisocial values, beliefs, and attitudes; antisocial friends; isolation from prosocial others; family dysfunction; low levels of personal or educational achievement; low levels of involvement in prosocial activities; substance misuse; and several temperamental, personality, and mental health factors such as impulsivity, anger and rage, restlessness/aggressive energy, psychopathy, egocentrism, a taste for risk, weak problem solving skills, weak self-regulation skills, and lack of empathy. Some of these risk factors are also considered mental health needs (Van Deinse et al., 2021).

The need principle refers to using screening and assessment to identify the needs that should be addressed and the intensity of services. The responsivity principle refers to efforts to maximize the youth's ability to learn from an intervention by providing cognitive-behavioral treatment and tailoring the intervention to the youth's learning style, motivation, and strengths (Andrews and Bonta, 2010; Latessa, Listwan, and Koetzle, 2015; McCormick, Peterson–Badali, and Skilling, 2017; National Institute of Corrections, n.d.; Skeem, Steadman, and Manchak, 2015). 

Justice systems that use the RNR model have begun to deemphasize mainstream mental health practices focused on overall mental health or noncriminogenic mental health needs (e.g., depression and anxiety) in favor of shorter interventions that address the specific risk factors related to offending (e.g., criminogenic needs such as substance misuse and aggression) [Development Services Group, 2023; Skeem, Steadman, and Manchak, 2015]. According to the RNR model, when the primary goal of intervention is preventing recidivism, mental health needs that fall outside of the RNR criminogenic need domains should only be addressed in addition to the criminogenic needs (McCormick, Peterson-Badali, and Skilling, 2017). These noncriminogenic mental health needs include problems with mood, anxiety, personality functioning, reality testing, and trauma; they are considered responsivity factors (Andrews and Bonta, 2010; McCormick, Peterson-Badali, and Skilling, 2017). For example, a program working with a youth who has both antisocial behaviors and depression may be able to reduce the youth’s offending behaviors by reducing his antisocial values, attitudes, and beliefs but not by reducing his depression. However, if the youth is very depressed, he may not be able to fully participate in the intervention to decrease his antisocial behaviors; thus, his depression is still important to address.

A study examining the RNR model in a Canadian juvenile court found that youth with mood, anxiety, personality functioning, reality-testing, and/or trauma diagnoses were not more likely to reoffend than youth without such diagnoses, regardless of whether those mental health needs were treated (McCormick, Peterson-Badali, and Skilling, 2017). Diagnoses of ADHD, substance misuse, conduct disorder, and oppositional defiant disorder were not coded as mental health needs but as RNR risks, given that the diagnostic criteria overlap significantly with, and are captured within, the criminogenic need assessment. Considering noncriminogenic diagnoses (like depression) as responsivity factors, the study also found that youth who received appropriate mental health intervention were more likely to have their criminogenic needs addressed compared with youth whose mental health needs were not treated.

Out-of-home placements can cause iatrogenic effects (i.e., unintended negative consequences) for young people. As a result, youth who exhibit delinquent behaviors and become part of the juvenile justice system face greater risks to their mental health. For example, a study compared psychosocial maturity indicators of boys confined in a secure facility with boys who were not placed in a residential facility (Dmitrieva et al., 2012). The 1,000 boys in the sample were adjudicated with serious charges. The study authors found that incarceration in a secure setting was associated with a short-term decline in temperance and responsibility.

Another study, which examined individuals who had experienced at least one police contact in adolescence, compared those who were incarcerated with those who were never incarcerated. This study, which occurred in Seattle, WA, determined that those who were incarcerated as juveniles were more likely to experience several negative outcomes as adults, including alcohol misuse or dependence, compared with youth who were not incarcerated (Gilman, Hill, and Hawkins, 2015). Similarly, a researcher who analyzed data from the National Longitudinal Survey of Youth found significant harms to mental health following confinement in late adolescence (ages 16–17) and in emerging adulthood (18–24) [Powell, 2022].

Studies conducted with adult criminal justice populations find significant relationships between mental health and solitary confinement (Dellazizzo et al., 2020). Some studies show that being placed in solitary confinement while incarcerated can worsen mental health problems (Clark, 2017; Haney, 2008; National Institute of Justice, 2016; Shalev, 2017) although solitary confinement has not been found to reliably cause mental illness (Astor et al., 2018; Gendreau and Labrecque, 2018; Haney, 2003). However, there is very little research on the use of solitary confinement with youth (National Institute of Justice, 2016). The limited research conducted with youth populations suggests that the use of isolation may cause a more severe impact on adolescents, compared with their adult counterparts, because of developmental differences (Valentine, Restivo, and Wright, 2019). A study that examined the relationship between mental health and segregation among 92 youth who were waived to adult criminal court in, or released from, the New Jersey Department of Corrections found a statistically significant, positive relationship between amount of time in segregation and number of mental health diagnoses (Valentine, Restivo, and Wright, 2019). In other words, youth who spent more time in segregation had a greater number of mental health diagnoses.

For more information, see the MPG literature review Alternatives to Secure Detention and Confinement.

Researchers have found differences—particularly by race/ethnicity, sex, and age—in who is referred for mental health treatment in the juvenile justice system.

Race/Ethnicity

According to a 2016 systematic review of studies investigating racial differences among referrals to mental health and substance misuse services from within the juvenile justice system, most studies published from 1995 to 2014 found at least some racial differences in determinations of which youth received services, even when including statistical controls for mental health or substance use diagnosis or treatment need (Spinney et al., 2016). For example, a study of more than 12,000 youth in the Florida juvenile justice system, who reported substance use in the past 6 months, examined the factors related to whether a referral had been made for substance use treatment services (Johnson et al., 2022). The authors found no significant differences in referrals rates among white girls, white boys, and Latina girls. However, Black girls, Latino boys, and Black boys were significantly less likely to be referred to services than white boys. Similarly, an examination of data from 3,779 youth on probation in Maricopa County found that Black and Latino youth were less likely to receive mental health treatment services than white youth, after controlling for many other factors (White, 2019). For more information, see the Model Programs Guide (MPG) literature review Racial and Ethnic Disparity in Juvenile Justice Processing.

Sex

Some studies have found that juvenile justice processing differs by sex. A study of juvenile offenders in Texas found that girls were more likely than boys to receive mental health placements than incarceration, as a disposition outcome (Daurio, 2009). Also, Gunter-Justice and Ott (1997) found that family court judges recommended mental health placements more frequently for girls, compared with boys. Once within the system, girls are more likely than boys to be referred for treatment by facility staff, which, as Rogers and colleagues (2001) suggested, may have to do with the staff members themselves being female. For more information, see the MPG literature review Girls in the Juvenile Justice System.

Age

Age is often a determinant for who receives mental health services within the juvenile justice system. Various studies have indicated that younger juveniles (usually younger than age 15) are more likely to be referred for mental health placements (Herz, 2001; Daurio, 2009; White, 2019). For example, the study of youth on probation in Maricopa County mentioned above (White, 2019) found that as the age of youth on probation increased, the likelihood of receiving treatment services decreased. Also, Rogers and colleagues (2001) found that of the youth in a Southern California juvenile correctional facility, those who had been arrested before age 14 were more likely to have been referred for treatment than youth arrested after age 14. Herz (2001) posited that this referral disparity indicates evidence of a "two-tiered system," in which older adolescents receive a more punitive than rehabilitative approach compared with younger adolescents. Also, some studies have found that older youth are less likely than younger ones to access mental health services in the community after leaving secure detention (Aalsma et al., 2012).

There are many challenges in meeting the mental health needs of youth in the juvenile justice system, which often lead to service gaps in both the community and in residential programs. These challenges vary by jurisdiction but may include the following: insufficient capacity to meet youth mental health needs; inconsistent implementation of evidence-based practices; logistical challenges; difficulty providing qualified staff; and rules regarding the use of federal Medicaid and CHIP funds, making service access more difficult.

Insufficient Community Capacity

To access mental health care in the community, many steps must be successfully taken: 1) youth must be screened and assessed to identify service needs; 2) referrals must be made to community-based providers; 3) youth must initiate treatment; and 4) youth must continue to stay engaged in treatment (Sichel and Elkington, 2023). Often, there are obstacles that may result in youth "falling off" at any of these steps, sometimes referred to as the "behavioral health cascade" (Sichel and Elkington, 2023).

Several studies have attempted to examine the extent to which juvenile justice systems identify and meet young people's mental health needs when they are living in the community. For example, a study examined rates of substance use screening, identification of treatment needs, and referral to and initiation of treatment for more than 8,000 youth undergoing juvenile justice system intake in 33 community justice agencies in seven states (Wasserman et al., 2021). The authors found that more than 70 percent of the youth were screened for substance use problems, and more than half needed treatment. However, only about one fifth of those in need were referred to treatment, and only two thirds of the referred youth began treatment, resulting in only 10 percent of the youth with identified needs beginning services. Similarly, a small study of 348 justice system-involved youth in a northeastern state found that about 20 percent of the youth identified as having a substance use treatment need were not referred to any treatment (Yurasek et al., 2021).

Many studies find that the need for community-based mental health programming does not meet the demand, resulting in long waitlists or a complete lack of services (e.g., Abrams, 2023; Elkington et al., 2020; Meng and Wiznitzer, 2024). Juvenile justice stakeholders consistently point to the lack of community-based mental health and substance use services as their most significant challenge to improving outcomes for youth, especially in rural communities (The Council of State Governments, 2023).

Youth leaving secure placement and returning to their communities also face challenges. A recent study examined the availability of community-based services for youth who had previously received mental health services while in secure detention in New York (Martin et al., 2024). The researchers reached out to child and adolescent outpatient clinics across the state and found that while 88.5 percent accepted youth who had been involved in the juvenile justice system, 43.5 accepted them on a conditional basis and only 62 percent offered trauma-informed or evidence-based care. Also, there were few clinics near where most of the youth lived, and wait times were as high as six months or more. An older, qualitative study of detained youth residing in the Midwest and their caregivers determined that there were long wait periods between detention release and initial contact with court or probation officers, which decreased young people’s motivation to seek mental health care. However, coordination between the family, court, and mental health system facilitated connecting with mental health care (Aalsma et al., 2014a).

In addition to the challenge of too few community-based services, there are challenges associated with engaging youth in the programming that does exist. A qualitative study examined the perspectives of youth on probation with substance use disorders, their families, probation officers, and treatment providers (Elkington et al., 2020). The authors found that, although caregiver involvement is essential for youth engagement in community-based treatment, distrust of both the juvenile justice and substance use systems and minimization of the young people's substance use problems hindered family buy-in and engagement. An earlier qualitative study of youth leaving secure detention found that caregivers received insufficient information regarding their child during detention and felt "out of the loop," which resulted in difficulty using mental health care (Johnson-Kwochka et al., 2020). Also, a parent's history of poor experiences with healthcare providers may result in a reluctance to bring their children to receive mental health services (Meng and Wiznitzer, 2024). Finally, poor relationships between formal system providers and the communities they serve frequently result in the implementation of programs that the community perceives as unaligned with their needs, resulting in families unwilling to send their children to them (Burns Institute, 2021).

Most recommendations for improving access to mental health services include improving interagency communication and collaboration (e.g., Aalsma et al., 2014a; Ducharme et al., 2021; Nelson et al., 2024; Seiter, 2017; The Council of State Governments Justice Center, 2023b; Wasserman et al., 2021). Trust and communication between youth, their caregivers, juvenile justice staff, and treatment providers is essential (Sichel and Elkington, 2023). However, a lack of collaboration between juvenile justice agencies and community healthcare providers often disrupts care coordination and creates gaps in treatment and health services (Camhi, Mistak, and Wachino, 2020; Elkington et al., 2020; Sichel and Elkington, 2023).

For more information about barriers to community-based mental health care, see the MPG literature review The Influence of Mental Health on Juvenile Justice System Involvement.

Inconsistent Implementation of Evidence-Based Treatments

Evidence-based programs and practices generally have one or more rigorous outcome evaluations demonstrating their effectiveness (OJJDP, n.d.). Research studies have identified effective screening and assessment tools (Christian, 2023; Heilbrun and DeMatteo, 2012; Hoge, 2012; Shulman et al., 2018) as well as effective programs and approaches for treating youth with mental health needs (see Outcome Evidence). However, several areas of the juvenile justice system do not consistently implement evidence-based practices.

Some researchers have found that incarcerated youth are only rarely able to access evidence-based psychiatric care (Modrowski et al., 2023). For example, an examination of administrative records of 33 community justice agencies in seven states found that only about 43 percent of the youth were screened for psychiatric care with an evidence-based instrument (Wasserman et al., 2021).

Also, youth with substance use disorders in the juvenile justice system rarely receive pharmacotherapy (Goldman, Hull, and Wilson, 2023), although the use of psychotropic medication in combination with behavioral interventions has the potential to increase the likelihood of successful treatment (Hadland et al., 2018; Squeglia et al., 2019). A qualitative study gathered information from 14 medical and behavioral health providers employed in juvenile justice settings from 12 institutions in 9 states (Goldman, Hull, and Wilson, 2023). The majority of providers stated that they screened youth, but they described uneven implementation of behavioral health interventions and limited provision of onsite withdrawal management and treatment using medications for substance use disorder.

A qualitative study examining barriers to effective implementation of evidence-based practices found that, although both community mental health and juvenile justice staff members express commitment to implementing evidence-based practices, systems-level changes are needed to increase the capacity for providing evidence-based services (Johnson-Kwochka et al., 2020). Also, even when evidence-based practices are adopted, often they are not implemented properly (e.g., Ingel et al., 2022).

Logistical Challenges in Secure Facilities

There are several logistical challenges to implementing effective mental health programs in secure facilities, especially secure detention centers. When youth are detained, their daily schedules are usually strict and structured. Mental health treatment and programming must be scheduled along with school, court appearances, visits with attorneys or family members, and other services. Staff are often needed to transport youth to these services, which can limit offerings. Also, state and local jurisdictions have unique statutory codes governing the level of parental consent required for youth to receive treatment, which may delay treatment (Boesky, 2014; Perry and Morris, 2014).

Difficulty Hiring, Retaining, and Training Qualified Staff

Insufficient staffing has been a challenge for juvenile justice residential programs since the onset of the COVID–19 pandemic (e.g., Beard, 2023; Lyons, 2022; Miller, 2022; Person, 2023; Tab, 2022; The Council of State Governments Justice Center, 2023a). In addition to the lack of qualified behavioral health providers and clinicians willing to work with youth in the juvenile justice system, programs suffer from a shortage of line staff (The Council of State Governments Justice Center, 2023b). When a facility is understaffed, it is difficult to implement therapeutic programming, even when clinicians are available (Perry and Morris, 2014). In extreme cases, insufficient staffing may contribute to worsening safety and security (Bischoff, 2023; Burton, 2023; Kentucky Tonight, 2023; Swift, 2022). Along with making the delivery of mental health services difficult, the lack of qualified providers and sufficient line staff can exacerbate young people's mental health symptoms (Boesky, 2014).

Community-based programs also have been affected by staffing challenges since the start of the COVID–19 pandemic. Some providers have had to restrict the number of youth they serve or permanently close. Many public agencies report a lack of responses to service procurements, an inability to expend appropriated resources, or having to contract with providers lacking  sufficient juvenile justice expertise (The Council of State Governments Justice Center, 2023b). Hiring unqualified mental health professionals can result in a pattern of misdiagnoses and inappropriate treatments (Boesky, 2014). These challenges may inadvertently result in increased stays for youth on probation or more youth placed out of home, not because they are a public safety risk, but because they have unmet needs (The Council of State Governments Justice Center, 2023b).

Conditions of the Federal Medicaid Inmate Exclusion Policy

Researchers have found that individuals with public insurance, such as Medicaid and CHIP, are more likely to access mental health and behavioral health services than those with private insurance or no insurance (Graaf and Snowden, 2018; Deck and Vander Ley, 2007; Koppelman, 2005). Although many youth in juvenile justice residential facilities are eligible for Medicaid and CHIP, federal law has prohibited the use of these funds for inmates in public institutions. This law is often referred to as the "Medicaid inmate exclusion policy (MIEP)" or the "inmate exclusion policy" (Acoca, Stephens, and Van Vleet, 2014; Camhi, Mistak, and Wachino, 2020; Edmonds, 2021; Graaf and Snowden, 2020; Mistak and Sax, 2023). Because of this federal statutory limitation, justice system-involved youth historically have been at risk of losing access to Medicaid and CHIP benefits during placement in public facilities, which can result in discontinued coverage of mental health and behavioral health services (Mistak, 2023; HHS and DOJ, 2024).

Experts on Medicaid and the justice system have identified healthcare coverage gaps during reentry as a significant public health problem to which justice system-involved youth are particularly vulnerable (Scannell et al., 2022). In some jurisdictions, departments of corrections staff members help adult prisoners complete their Medicaid forms before they leave the facility (Albertson et al., 2020; National Conference of State Legislatures, 2023). However, unlike adults, youth depend on their parents or guardians to ensure that they have Medicaid coverage. As a result, reactivating Medicaid can be logistically challenging (Scannell et al., 2022), especially when there are communication gaps between parents, youth, and the juvenile justice system. Given young people's developmental immaturity and malleability, timely access to healthcare and to interventions that can improve health and justice outcomes during the reentry period is particularly important (Scannell et al., 2022).

There have been many calls to change or eliminate the MIEP (e.g., Edmonds, 2021; National Association of Counties, 2023; National Conference of State Legislators, 2023; Scannell et al., 2022; Widra, 2022). A qualitative study analyzing information gathered through interviews with 28 experts on Medicaid and the justice system identified the following recommendations for reducing healthcare coverage gaps: a) leaving Medicaid activated while youth are incarcerated, b) reactivating Medicaid before or during reentry, c) enhancing interagency collaboration, and d) addressing other societal challenges ensure healthcare access for Medicaid-eligible youth (Scannell et al., 2022). The group of 28 experts included 9 health policy researchers or policymakers; 8 frontline providers with expertise in medicine, pediatrics, or care coordination; 4 Medicaid administrators; 4 representatives from juvenile justice advocacy organizations; and 3 judges or probation officers.

The federal government is in the process of changing its approach to Medicaid funding for justice-involved youth (Buck and Goyal-Carkeek, 2024; HHS and DOJ, 2024; Mann et al., 2024; Park et al., 2023), through the Consolidated Appropriations Act, 2023 (P.L. 117–328). A partial MIEP waiver for youth in correctional institutions is scheduled to begin in 2025 (Tsai, 2024). The Act includes two provisions affecting the availability of some services for incarcerated youth in Medicaid and CHIP. Also, state and local governments have begun to develop new approaches (HB 501 [Utah], 2024; Camhi, Mistak, and Wachino, 2020; National Conference of State Legislators, 2023).

Researchers have identified many programs and practices that can improve mental health- and delinquency-related outcomes. Much of the research on the effectiveness of juvenile justice interventions finds that, to be effective, the intensity of services should match the youth's level of risk; interventions should target the youth's specific needs; and interventions should use cognitive and social learning approaches that are responsive to the youth's specific characteristics (Andrews, Bonta, and Wormith, 2011; Andrews and Dowden, 2006; Andrews et al., 1990; Dowden and Andrews, 2004; Latessa, Listwan, and Koetzle, 2015; Miller and Maloney, 2020).

A meta-analysis of 66 studies involving more than 11,000 children found that youth who participated in psychosocial interventions, which were designed to reduce juvenile antisocial behaviors, exhibited statistically significant reductions in aggression, conduct disorder symptoms, and delinquency, compared with youth who did not participate in these interventions (Sawyer, Borduin, and Dopp, 2015). Most of the interventions described below are examples of psychosocial interventions, and many incorporate cognitive-behavioral therapy (CBT). They do not include prevention and diversion programs, which are covered in the MPG literature review The Influence of Mental Health on Juvenile Justice System Involvement. Also, most of the highlighted programs do not concentrate on substance use specifically. For more information about interventions addressing substance use, see the MPG practice profile on juvenile drug courts and the MPG literature reviews Substance Use Prevention Programs and  Substance Use Treatment Programs.

Community-Based Programs for Youth in the Juvenile Justice System

Many community-based programs for youth in the juvenile justice system are considered therapeutic interventions because they use clinician-based approaches and are for individuals or smaller social systems, such as families and peers (Sawyer, Borduin, and Dopp, 2015).

Multisystemic therapy (MST) is an intensive family- and home-based treatment to address multiple facets of antisocial and delinquent behaviors in youth. Generally, this program is used with adolescents who have serious antisocial, delinquent, or other problem behaviors. Therapists and facilitators work individually with youth and their families to address the unique factors influencing the antisocial behaviors. MST engages individuals in the youth's immediate circle to develop an individualized plan for risk reduction. Various therapies inform the specific treatment techniques used, including behavioral, cognitive-behavioral, and pragmatic family therapies. Researchers have found that youth who participate in MST have a statistically significant reduction in rearrests and number of days incarcerated, compared with nonparticipating youth (Borduin et al., 1995; Borduin, Schaeffer, and Heiblum, 2009; Henggeler, Melton, and Smith, 1992; Timmons-Mitchell et al., 2006).

Connections is a juvenile court-based program designed to help youth on probation with emotional and behavioral disorders and their families. The approach is meant to provide an integrated, seamless, coordinated system of care for children with mental health problems. An evaluation of this program concluded that participating youth were statistically significantly less likely to recidivate, commit a felony offense or serve time in detention, compared with youth in the control group who did not participate (Pullman et al., 2006).

The Special Needs Diversionary Program (SNDP) offers intensive supervision and treatment for youth on probation with mental illness. The program, based on typical wraparound strategies, involves collaboration between mental health professionals and juvenile justice officials. For each case, an assigned therapist and SNDP probation officer provide individualized treatment and case management. Services include individual and family therapy, rehabilitation services, skills training, and chemical dependency education. An evaluation of this program, conducted with 299 youth ages 13–16, found that youth in the treatment group had statistically significant reductions in the number of rearrests within 1 year of program completion, compared with youth in the control group. However, there was no statistically significant impact on time to rearrest (Cuellar, McReynolds, and Wasserman, 2006).

In addition to the programs mentioned above, which are included in OJJDP's Model Programs Guide, many programs have been evaluated that seek to improve the mental health of justice system-involved youth in the community. For example, researchers evaluated a brief intervention for 15 court-involved youth at risk of suicide (Kemp et al., 2021b). The intervention included the development of a coping plan and a follow-up call. The researchers determined that participating youth had a reduction in suicide ideation and psychiatric symptoms 3 months after the intervention. Also, youth and caregivers reported that they found the intervention useful.

Residential Programs for Youth in the Juvenile Justice System

The Mendota Juvenile Treatment Center (MJTC) is a juvenile residential facility providing mental health treatment to youth in secure correctional institutions who have committed serious and violent offenses. Typically, youth are transferred to MJTC when they are unresponsive to customary rehabilitation services provided in correctional institutions. The staff consists of experienced mental health professionals. The program combines the security consciousness of a correctional institution with the mental health orientation of a psychiatric facility. MJTC's overarching goal is to replace the antagonistic responses and feelings created by traditional correctional institutions with more conventional bonds and roles, which can encourage positive social development. Participating youth demonstrated a statistically significant lower likelihood of violent (but not general) recidivism and had a longer offense-free period in the community before committing felony, violent, or violent-felony (but not misdemeanor) offenses, compared with control group participants who were treated in conventional juvenile correctional institution settings (Caldwell et al., 2006; Caldwell and Van Rybroek, 2005).

PSYCHOPATHY.COMP is a compassion-focused, therapy-based intervention to reduce psychopathic traits in youth in correctional settings. The program is delivered in 20 individual sessions held weekly for 60 minutes each. Topics include understanding emotions and needs, building awareness of the functioning of the human mind and body, understanding emotion regulation systems, developing strategies to manage distress, creating motivation for recovery, and preventing relapse. An evaluation of the intervention's effectiveness was conducted in Portugal with detained 14- to 18-year-old male youth diagnosed with a conduct disorder and high levels of psychopathic traits. The evaluation found that PSYCHOPATHY.COMP statistically significantly decreased measures of psychopathic traits, grandiose manipulative, callous–unemotional, impulsive irresponsible, daring irresponsible, and conduct disorder traits (Ribeiro da Silva et al., 2021a; Ribeiro da Silva et al., 2021b).

Family-Based Interventions

Family-based interventions are designed to decrease adolescent problem behaviors by making positive changes in their familial and social environments (Dopp et al., 2017). Some family-based programs are designed for youth already in the juvenile justice system. These interventions focus on improving communication and reducing conflict between parents and adolescents, strengthening parenting skills, and helping adolescents better engage with their families and their school environment (Baldwin et al., 2012). Treatment techniques are informed by various therapies, including but not limited to, behavioral and cognitive-behavioral therapies. A meta-analysis of studies evaluating family-based treatments for youth with a history of serious offending found that these interventions reduced antisocial behaviors and substance misuse and improved psychological functioning (Dopp et al., 2017).

For example, Functional Family Therapy (FFT) is designed to help youth ages 11–18, who have exhibited dysfunctional behaviors and are system involved or are at risk for delinquency, violence, substance use, or other behavioral problems. The FFT model concentrates on decreasing risk factors and on increasing protective factors that directly affect the youth, with an emphasis on familial factors. The intervention consists of 8–12 one-hour sessions for mild cases and up to 30 sessions for cases that are more difficult, integrating several elements (clinical theory, empirically supported principles, and clinical experience) into a comprehensive clinical model. Researchers have found that FFT participants, compared with youth who did not participate, experienced reduced suicide ideation, self-mutilation, and aggression; reduced impulsivity, depression, substance use, and anxiety; and increased anger control (Celinska, Furrer, and Cheng, 2013; Gordon et al., 1988; Sexton and Turner, 2010).

For more information about family-based interventions and engagement, see the MPG literature reviews Family Engagement in Juvenile Justice and Family Therapy.

Systemwide Interventions and Staff Training

The Juvenile Justice Assessment Planning Referral Placement (JJAPRP) is a training program for juvenile justice probation/parole case managers (PCMs), to promote their use of evidence-based practices for identifying the mental health and substance use treatment needs of youth with delinquency charges and increase access to services. An evaluation of JJAPRP found statistically significant reductions in re-referral and placement rates for youth whose PCMs received the enhanced training, compared with youth whose PCMs received the standard training or no training (Young, Farrell, and Taxman, 2013).

Availability, Responsiveness, and Continuity (ARC) is designed to enhance system effectiveness and organization, and to improve client outcomes for child welfare and mental health agencies. Clients include youth and their families, who may participate in a variety of services, such as pharmacotherapy, individual psychotherapy, family therapy, skills training, and therapeutic groups. ARC is based on five organizational change priorities: 1) mission driven, not rule driven; 2) results oriented, not process oriented; 3) improvement directed, not status quo directed; 4) relationship centered, not individual centered; 5) participation based, not authority based. This approach includes strategies at both the organizational and inter-organizational levels. Evaluations of ARC have found statistically significant reductions in problem behaviors for youth who were served by agencies that received the intervention, compared with youth who were served by control agencies (Glisson et al., 2016; Glisson et al., 2013).

The juvenile justice system plays an important role in addressing young people's mental health conditions, regardless of whether they contribute to delinquent behavior. The system fulfills this role in many ways, including screening and assessment for mental health needs, diversion from the juvenile justice system with referrals to more appropriate mental health interventions, mental health courts, and treatment in residential or non-residential settings. However, there are many challenges to meeting young people's needs, including insufficient community-based capacity; lack of collaboration between healthcare and corrections agencies; difficulty hiring, retaining, and training qualified staff; and conditions of the federal Medicaid inmate exclusion policy, which has prohibited the use of federal funds for ambulatory care services and medications for incarcerated individuals.

Mental health problems that are predictors of delinquency include some externalizing disorders (e.g., conduct disorder, oppositional defiant disorder, antisocial personality disorder, aggressive disorder), ADHD, substance use disorders, and psychopathy. To reduce the likelihood of recidivism, it is important for interventions to treat these criminogenic risk factors specifically. Additionally, noncriminogenic mental health conditions, such as depression, anxiety, and sleep disorders, must be treated for youth—particularly those in residential placements—to fully benefit from interventions.

Many evaluations have been conducted of interventions that address the intersection of mental health and juvenile justice. Therapeutic interventions for adolescents already in the juvenile justice system include  multisystemic therapy (MST), an intensive, family- and home-based treatment led by therapists and facilitators. This multifaceted program works to decrease antisocial and delinquent behaviors, promote prosocial behaviors, strengthen family functioning, and develop natural support systems. Evaluations concluded that participation in MST reduced the likelihood of rearrest and the number of days incarcerated. Participation in Connections, a court-based program designed to address the needs of youth on probation who have emotional and behavioral disorders, is associated with reductions in recidivism and days spent in secure detention. Functional Family Therapy (FFT) is a program that concentrates on decreasing risk factors and increasing protective factors, with an emphasis on the family. Evaluations of FFT have found that it is associated with reductions in suicide ideation, self-mutilation, and aggression; decreases in impulsivity, depression, substance use, and anxiety; and increases in anger control (Celinska, Furrer, and Cheng, 2013; Gordon et al., 1988; Sexton and Turner, 2010).

There are also interventions designed for staff. For example, the Juvenile Justice Assessment Planning Referral Placement trains probation/parole case managers to identify young people's mental health and substance use treatment needs and increase their access to services. This program has been associated with reductions in re-referrals of youth to court and in out-of-home placements (Young, Farrell, and Taxman, 2013). Availability Responsiveness and Continuity (ARC) is designed to enhance system effectiveness and organization and improve client outcomes for child welfare and mental health agencies. Evaluations of ARC have found youth experience statistically significant reductions in problem behaviors (Glisson et al., 2016; Glisson et al., 2013).

Youth in the juvenile justice system are more likely to struggle with various types of mental health challenges than youth who are not system involved. Community-based interventions outside of the juvenile justice system are preferred whenever possible. When youth must enter the juvenile justice system, mental health disorders associated with offending should be addressed to reduce recidivism. Especially for youth in residential programs, the juvenile justice system is also tasked with addressing noncriminogenic mental health concerns, to promote overall well-being and improve young people's ability to fully benefit from interventions that focus on reducing delinquency.

Suggested Reference: Development Services Group, Inc. September 2025. Mental Health: How the Juvenile Justice System Addresses Youths' Mental Health. Model Programs Guide. Literature review. Washington, DC: U.S. Department of Justice, Office of Justice Programs, Office of Juvenile Justice and Delinquency Prevention. https://ojjdp.ojp.gov/model-programs-guide/literature-reviews/how-the-juvenile-justice-system-addresses-youths-mental-health

Prepared by Development Services Group, Inc., under Contract no. 47QRAA20D002V.