Only a few states enact evidence-based care for troubled youth

Introduction

In a pair of feature stories published this week, JJIE described two modes of intensive at-home treatment that show great promise to improve outcomes for emotionally disturbed youth in the delinquency system, both of which cost far less than incarceration or treatment in a residential treatment center.

As our stories documented, use of these models has been expanding slowly in Georgia and remains limited, despite a growing consensus among state leaders that Georgia’s current approach to juvenile justice is yielding poor returns due to over reliance on secure confinement and lack of investment in community-based treatment backed by research.

This dynamic is not limited to Georgia, however. Most states are also making only limited progress toward revamping their juvenile justice and adolescent mental health systems to take advantage of these promising new treatment approaches.

Evidence-Based Family Therapy

The first promising approach involves intensive and highly regimented family therapy delivered by carefully trained and closely supervised therapists. A variety of models — Multisystemic Therapy, Functional Family Therapy, Brief Strategic Family Therapy, Multidimensional Treatment Foster Care, Multidimensional Family Therapy — have all been tested in random trials and repeatedly proved more effective than traditional programs and services in improving outcomes for delinquent teens and those with serious substance abuse or mental health issues. Cost-benefit analyses suggest these programs save $7 to $10 for every dollar spent to deliver them.

Yet, a 2011 study co-authored by Scott Hengeller, the originator of Multisystemic Therapy (MST), estimated that only about 15,000 youth receive intensive evidence-based family therapy each year — about 5 percent of the population who could benefit.

Last year, a team led by former RAND Institute scholar Peter Greenwood examined states’ progress in implementing MST and two other prominent evidence-based treatment models. Their study found that “Although there are sufficient resources currently invested in juvenile justice programs to provide [an evidence-based treatment program] for every youth who could use one, less than 10 percent of youths in need actually receive these programs.” A few states are “taking explicit steps to facilitate the implementation of these proven programs,” the Greenwood study found, but “many others have not taken any but the most rudimentary steps.”

Despite the slow progress nationwide, a handful of states are realizing promising returns by aggressively implementing at-home family-focused treatment models.

Connecticut: Since 2000, Connecticut has expanded its annual investment in evidence-based, family-focused adolescent treatment programs from $300,000 to $39 million. According to a recent Justice Policy Institute report, the state provided evidence-based family therapy to 955 probation youth in 2012, plus thousands of other young people in the state’s child welfare and children’s mental health systems. These investments have helped Connecticut reduce the number of juvenile offenders committed to state custody by 70 percent since 2000.

Ohio: Since 2009, Ohio has launched two programs offering intensive at-home treatment in lieu of incarceration for serious youth offenders in the state’s six most populous counties. The Targeted RECLAIM program offers evidence-based at-home therapy programs, while the Behavioral Health Juvenile Justice program offers intensive at-home or community-based psychiatric and counseling services to delinquent youth with serious mental health problems. Together, these counties reduced commitments to state custody by 65 percent in just three years. A recent evaluation found that youth served in Targeted Reclaim were less than half as likely to be incarcerated for subsequent offenses as a matched comparison group of comparable youth committed to state correctional facilities.

Louisiana: In 2006, after a decade of litigation and federal supervision to address abusive conditions in its juvenile corrections facilities, Louisiana signed on as a pilot state in the John D. and Catherine T. MacArthur Foundation’s Models for Change initiative. By that time, the state had made significant progress improving conditions within its facilities and reducing facility populations. However, state leaders saw an unmet need to expand use of evidence-based community programs for justice-involved youth. Since then, Louisiana has expanded its evidence-based family programming from six treatment teams serving 199 youth in 2006 to 44 treatment teams serving 2,235 youth in 2011. (Editor’s note: The MacArthur Foundation is a funder of the JJIE.)

Florida: Through its $15 million per year Redirection Program, Florida diverts more than 1,000 youth every year into evidence-based at-home family therapy who would otherwise be incarcerated or placed into residential treatment facilities. Several evaluations have found that youth served in these programs are less likely than comparable youth placed in residential or correctional facilities to be arrested, adjudicated or incarcerated for subsequent offenses, and the program has saved Florida taxpayers an estimated $170 million since 2004 through lower treatment/confinement costs and reduced recidivism.

Wraparound Care

The second promising strategy, wraparound care, is targeted to youth with severe emotional disturbances at high risk for placement into residential treatment facilities or correctional institutions. Wraparound programs mobilize a team of caring adults in a troubled child’s life — including parents or guardians, other relatives, teachers, neighbors, coaches and clergy — and empower the team to choose from an array of Medicaid-funded services suited to the young person’s needs and goals. Several studies show that intensive programs adhering carefully to core wraparound principles are effective in reducing delinquent conduct and are at least as effective as residential treatment in improving the behavioral health of troubled youth, and at far lower cost.

Data is more limited on the utilization of intensive high-fidelity wraparound care for troubled and delinquent youth. The most recent national survey of wraparound programs, conducted in 2007 by the National Wraparound Initiative, found that 819 wraparound programs of varying quality and intensity across the country served roughly 100,000 children per year. Eric Bruns, coordinator of the National Wraparound Initiative, estimates that 30 to 40 percent of these programs served youth in the juvenile justice system, though no estimates are available on the number of youth referred to wraparound directly from juvenile justice.

As with evidence-based family treatment models, the scope of wraparound replication efforts are highly uneven across states. Programming remains quite limited throughout much of the country, particularly for delinquent teens. Yet a number of jurisdictions have built expansive wraparound care systems that serve large numbers of youth with severe emotional disturbances and achieve impressive outcomes.

Milwaukee County, Wisc.: Wraparound Milwaukee, which pools funding from child welfare, Medicaid, juvenile justice and mental health budgets, has long been one of the nation’s largest and most effective wraparound programs, serving 1,400 children and youth each year. With an annual budget of nearly $50 million, Wraparound Milwaukee has dramatically reduced the county’s use of psychiatric hospital and residential treatment centers. A recent study found that just 15 percent of delinquent teens participating in Wraparound Milwaukee — about half of the total program population — re-offended during their period of enrollment.

New Jersey: Since 2002, New Jersey has erected a statewide “system of care” providing integrated services for emotionally disturbed children and youth, including intensive wraparound care for more than 2,000 high-risk children and youth on any given day. A recent study calculated that the wraparound programs have saved the state $40 million since 2004 through reduced use of residential care.

Oklahoma: Since 2004, Oklahoma has created local systems of care — including intensive wraparound services for the highest-risk youth — in 55 of the state’s 70 counties. According to the state’s Department of Mental Health And Substance Abuse Treatment, a study of 800 program participants in 2012 showed substantial reductions in truancy (51 percent), school suspensions (64 percent), arrests (67 percent) and out of home placements (35 percent).

Massachusetts: In 2006, a federal court ruled that Massachusetts was not providing adequate care to children with serious emotional disturbances. Since then, the state has erected a statewide system of care — the Children’s Behavioral Health Initiative — that is overseen by six care management entities and delivered through 32 community service agencies across the state. Together, these agencies provide intensive wraparound care to roughly 4,000 children and youth in any given month — about half of them adolescents — giving Massachusetts’s the largest wraparound care system in the nation. In a recent survey, 98.6 percent of families with children participating in intensive wraparound care expressed satisfaction with the program.

As the Greenwood study explained, “There is a long history, stretching from Copernicus and Galileo in the 16th century to professional baseball managers in present day, of practitioners taking a very long time before accepting the practical implications of scientific discoveries. Juvenile justice fits right into this pattern.”

Fortunately, a handful of pioneering jurisdictions are beginning to act on the evidence and blaze a path out of the dark ages and into a more enlightened era.