Research at CBHYJ

Documenting the Prevalence of Mental Health and Substance Use Disorders and Uptake of Behavioral Health Services Among Youth Involved in the Juvenile Justice System
Prevalence of psychiatric disorders. When we began our work on prevalence, both researchers and clinicians were limited in their efforts by a lack of clarity regarding the rates of disorder in the juvenile justice population, the characteristics associated with disorder, and the consequences of disorder for these youths. As an innovative approach to addressing these questions, we implemented the use of the Voiced Version of the Diagnostic Interview Schedule for Children (V-DISC) across a wide range of state and local juvenile justice agencies: 57 juvenile justice sites in 17 states, documenting BH needs of 9,819 youths. This work found substantially higher rates of psychiatric disorders in justice-involved youth, with prevalence of disorder increasing with further justice involvement (e.g. detention or placement). Our work has also found high rates of comorbidity among justice involved youth, including high rates of polysubstance use disorder.  Taken together these findings  indicate that screening, treatment and intervention for mental health and substance use problems should be standard practice in settings where justice-involved youth are likely to be found (e.g. juvenile justice facilities, primary care settings, psychiatric clinics).  

• Wasserman, G.A., McReynolds, L., Lucas, C., Fisher, P., Santos, L.  (2002) The Voice DISC-IV with incarcerated male youths:  Prevalence of disorder.  The Journal of the American Academy of Child and Adolescent Psychiatry, 41, (3) 314-321.
• Wasserman, G.A., Jensen, P., Ko, S.J., Cocozza, J., Trupin, E., Angold, A., Cauffman, E., Grisso, T. (2003) Mental health assessments in juvenile justice: Report on the Consensus Conference, Journal of the American Academy of Child and Adolescent Psychiatry, 42 (7) 752-761.  
• Wasserman, G.A., McReynolds, L.S., Ko, S.K., Katz, L.M., Cauffman, E., Haxton, W., Lucas, C.P.  (2004) Screening for emergent risk and service needs among incarcerated youth: Comparing MAYSI-2 and Voice DISC-IV, Journal of the American Academy of Child and Adolescent Psychiatry,  43 (5), 629-639.  
• Wasserman, G.A., McReynolds, L.S., Ko, S., Katz, L., & Carpenter, J.  (2005)  Gender differences in psychiatric disorder for youths in juvenile probations, American Journal of Public Health, 95 (1) 131-137.  
• McClelland, G. M., Elkington, K. S., Teplin, L. A., & Abram, K. M. (2004). Multiple substance use disorders in juvenile detainees. Journal of the American Academy of Child and Adolescent Psychiatry, 43(10), 1215–1224

Psychiatric disorders, recidivism and violence. Our work also documents that mental health problems, substance use, and related risk behaviors (e.g. sexual risk) typically co-occur and increase the risk of multiple poor outcomes, particularly recidivism, highlighting the need to adopt innovative and comprehensive approaches to risk reduction for high risk and vulnerable youth. With respect to recidivism, our work has examined the degree to which the mental health disorder profiles of adolescents in the system predicted subsequent arrests as juveniles and later, as young adults. We found that baseline externalizing disorders in these youth were associated with increased recidivism risk for both genders, whereas anxiety disorders were not associated with recidivism.  Our work has also examined the risk of violent behavior among justice-involved with psychiatric disorders over time. We found that violence and psychiatric disorder co-occurred over five years, and that compared to youth with no disorder, those with any disorder had greater odds of any violence (with the exception of males with major depressive disorder). However, only substance use disorders predicted subsequent violence five years later.  These results support practice guidelines recommending comprehensive behavioral health assessment in juvenile justice settings for youths with certain mental health symptoms, who might be well-served by diversion programs. Our data also show that juveniles with a substance use disorder (with or without co-occurring disorders) were at greater risk for escalations in offense seriousness over time. Early in juvenile justice system contact, juveniles should get effective treatment for substance use to prevent offending and violence escalation. Finally, our work supports the premise that mental health diversion and treatment can be used effectively to delay or prevent youth recidivism.   

• Evans-Cuellar A., Wasserman, G.A., McReynolds L.S., Ko S.J., & Katz L.M. (2006)  Can mental health treatment diversion reduce crime among youth?, Journal of Policy Analysis and Management, 25 (1) 197-214.
• Elkington, K. S., Teplin, L. A., Mericle, A. A., Welty, L. J., Romero, E. G., & Abram, K. M. (2008). HIV/sexually transmitted infection risk behaviors in delinquent youth with psychiatric disorders: a longitudinal study. Journal of the American Academy of Child and Adolescent Psychiatry, 47(8), 901–911.
• McReynolds LS, Schwalbe C, Wasserman GA. (2010). Contribution of psychiatric disorder to juvenile recidivism. Criminal Justice and Behavior, 37(2); 204-216.
• Hoeve, M., McReynolds, L.S., McMillan, C., Wasserman, G.A. (2013).  The influence of mental health disorders on severity of re-offending in juveniles.  Criminal Justice and Behavior. 40(3): 289-301.
• Hoeve, M., McReynolds, L.S., Wasserman, G.A. (2013).  The influence of adolescent psychiatric disorder on young adult recidivism. Criminal Justice and Behavior. 40(12): 1368-1382.
• Elkington, K. S., Teplin, L. A., Abram, K., Jakubowski, J. A., Dulcan, M., & Welty, L. (2016).  Psychiatric disorders and violence:  A study of delinquent youth after detention. Journal of the American Academy of Child and Adolescent Psychiatry. 54(4), 302-312.

Prevalence of Suicide Behaviors
In concert with high rates of psychiatric disorder, particularly PTSD and related traumatic experiences, our work has also documented alarmingly elevated rates of suicidal behavior including non-suicidal self-injury, among justice-involved youth.  In particular, we found that mood, substance use, and behavior disorder each increased suicide behavior in females, and anxiety disorder only for males. These findings highlight the need for systematic screening of suicide behavior and related behavioral health problems among justice-involved youth in order to rapidly refer and link these high-risk youth to treatment and care.

• Wasserman, G.A. & McReynolds, L.S. (2006) Suicide risk in juvenile probation intake, Suicide and Life-Threatening Behavior, 36 (2) 239-249.
• Nolen, S., McReynolds, L.S., DeComo, R.E., John, R., Keating, J.M., & Wasserman, G.A.  (2008)   Lifetime suicide attempts among Juvenile Assessment Center Youth, Archives of Suicide Research, 12 (2) 1-13.
• Wasserman G.A., McReynolds L.S., Schwalbe C.S., Keating J.M., Jones S.A. (2010) Psychiatric  disorder, comorbidity and suicidal behavior in juvenile justice youth. Criminal Justice and Behavior, 37(12); 1361-1376.
• Wasserman, G.A. & McReynolds, L.S. (2011).  Contributors to traumatic exposure and posttraumatic stress disorder in juvenile justice youths. Journal of Traumatic Stress, 24(4), 422-429.

Uptake of Behavioral Health Services
Yet despite high rates of behavioral health problems among justice-involved youth, work conducted by Center investigators have documented the low rates of service use in these youth.  In a sample of n=8307 youth under community supervision, from 6 states, we used the Behavioral Health Services cascade to determine at what point youth fall through the cracks between justice and behavioral health systems. The Behavioral Health Services cascade is a framework  for measuring unmet treatment needs, illustrating at what point in the process (e.g. screen/identification, referral, initiate)  service access and delivery issues may occur.  We found that approximately 70% of these youth are screened for behavioral health problems (43% with an evidence-based screener), and of those 50% were identified as needing treatment.  However, of those who need services, only 1 out of every 5 youth are referred, and 1 in 10 initiate treatment.  Referral and initiation were predicted by youth supervision level and staff-level variables.  A higher level of youth supervision was associated with a five-fold greater likelihood of referral, and staff with more job experience and a greater caseload were least likely to refer. By examining outcomes at each step across the cascade, our investigation is the first to document where service gaps occurred in this process and has identified critical intervention targets to better facilitate cross-system linkage regardless of youths’ level of recidivism risk.

• Wasserman, G. A., McReynolds, L. S., Taxman, F. S., Belenko, S., Elkington, K. S., Robertson, A. A., Dennis, M. L., Knight, D. K., Knudsen, H. K., Dembo, R., Ciarleglio, A., & Wiley, T. (2021). The missing link(age): Multilevel contributors to service uptake failure in youths on community justice supervision. Psychiatric Services, 72(5), 546–554.
• Knight, D. K., Dembo, R. Elkington, K. S., Flynn, P., Harris P., Hogue, A., Palinka, L., Robertson, A., Scott, C. K, (Under Review). Results of a National Survey of Substance Use Treatment Services for Youth Under Community Supervision. Journal of Substance Abuse Treatment.
• Funk, R., Knudsen, H. K., McReynolds, L. S., Bartkowski, J. P., Elkington, K. S., Steele, E. H., Sales, J. M., Scott, C. K. (2020). Substance use prevention services in juvenile justice and behavioral health results from a national survey. Health & Justice, 8(1), 11.

Using Ecological Approaches to Understand Multi-Level Influences on Mental Health and Substance Use Disorders, and Disparities In Service Use Among Youth Involved in the Justice System

Our work has documented the importance of the family, peers, neighborhood, and justice system and their intersection, when understanding how risk and protective factors work to either offset or promote substance use, mental health problems, related risk behaviors and recidivism in justice-involved youth. In particular, this work has expanded use of an Ecodevelopmental model to include how the juvenile justice system, and features within that system such as organizational culture, both directly and indirectly influences risk behavior.   Given the tremendous disparity in service use among justice-involved youth,  we have utilized the same model to understand how risk and protective factors within peer, family and neighborhood systems work to either offset or promote access to and use of treatment services.  This work has identified critical junctures for intervention and prevention, influenced justice system policy, and directly informed the development of system-level and implementation interventions to address this service gap.   

• Sichel, C. E., Javdani, S., & Yi, J. (2021). Perceiving fairness in an unfair world: System justification and the mental health of girls in detention facilities. American journal of community psychology.
• Wasserman, G.A., McReynolds, L.S., Whited, A.L., Keating, J.M., Musabegovic, H., & Huo, Yanling (2008).   Juvenile probation officers’ mental health decision making, Administration and Policy in Mental Health, 35; 410-422.
• Elkington, K. S., Belmonte, K., Latack, J. A., Wasserman, G., Donenberg, G. R., Mellins, C. A., & Hirsch, J. S. (2015). An exploration of family and juvenile justice systems to reduce youth HIV/STI risk.  Journal of Research on Adolescence, 25(4), 700-716.
• Elkington, K.S., Peters, Z., Choi, C.J. Amelia Bucek, Cheng-Shiun Leu Elaine J. Abrams, Claude A. Mellins. (2018). Predicting Arrest in a Sample of Youth Perinatally Exposed to HIV: The Intersection of HIV and Key Contextual Factors. AIDS & Behavior, 22, 3234.  
• Elkington, K.S., Lee, J., Brooks, C., Watkins, J., Wasserman, G.A. (2020). Falling between two systems of care: Engaging families, behavioral health and the justice systems to increase uptake of substance use treatment in youth on probation. Journal of Substance Abuse Treatment, 12, 49-59.
• Sales, J.M., Wasserman, G.A., Elkington, K.S., Lehman, W., Gardner, S., McReynolds, L., Wiley, T. & Knudsen, H. (2018). Perceived importance of substance use prevention in juvenile justice: A multi-level analysis. Health & Justice, 6:12. 

Developing Multi-Level Interventions to Reduce Risk Behaviors, Promote Resilience and Increase Equity in Behavioral Health Service Access and Use

Findings from our work examining prevalence of psychiatric disorders and corresponding ecological factors that influence these disorders has led the development and testing of interventions to reduce risk behaviors, promote health and behavioral health, and increase access to health and behavioral health treatment services. Working with numerous longstanding collaborators, Center investigators have documented a process to develop and adapt interventions carefully tailored to the context and population via use of formative work and community based participatory research. In particular, recent work has focused on achieving system change and interagency collaboration between health/behavioral health and justice systems to address unmet service need for those involved in the justice system.

Project Connect (5-SM57433; PI: Wasserman)
To address difficulties faced by community juvenile justice agencies in identifying youth service needs (particularly behavioral health and suicidal behavior), and in linking identified youths to community care, Dr. Wasserman developed Project Connect, a service-system intervention. Supported by a Garrett Lee Smith Suicide Prevention grant from SAMHSA, we worked with four New York State counties from June 2006 to November 2007. Our efforts were aimed at reducing suicide risk for juvenile probationers. We found that the combined use of (1) systemic screening for suicidality, (2) cross-agency decision trees about service linkage, (3) cross-agency Memorandums of Understanding (MOUs), and (4) behavioral health training increased access to services for identified youth by a factor of three.

Elkington, K.S., Lee, J., Brooks, C., Watkins, J., Wasserman, G.A. (2020). Falling between two systems of care: Engaging families, behavioral health and the justice systems to increase uptake of substance use treatment in youth on probation. Journal of Substance Abuse Treatment, 12, 49-59.

Wasserman GA, McReynolds LS, Whited AL, Keating JM, Musabegovic H, & Huo Y. (2009). Evaluating Project Connect:  Improving juvenile probationers’ mental health and substance use service access.  Administration and Policy in Mental Health, 36, 393-405.

e-Connect (R01MH113599; PI: Elkington)
The Center is currently working on e-Connect. e-Connect (R01-MH113599, PI Wasserman/Elkington) builds upon our previous work on Project Connect and JJ-TRIALS. Compared to youth in the general population, those involved in the juvenile justice system are at increased risk for suicidal behavior. However, evidence-based screening for youth with suicidal behavior and behavioral health concerns does not happen frequently or systematically within probation settings. Consequently, youth with suicidal behavior and related behavioral health problems  are often not referred for treatment, and even fewer access care. e-Connect builds in Project Connect and was developed as a digital clinical decision-support system to assist probation officers (POs) to address SB in youth. e-Connect formalizes interagency collaboration and uses a web-based application to seamlessly combine: (a) screening for SB and related BH problems among probation youth using an evidence-based screen, (b) classification of clinical need, and (c) locally-derived streamlined referral plans for BH services. We are currently in the Sustainment phase for this project, working in 10 New York counties. Findings from the e-Connect Implementation phase efficacy trial found that compared to standard practice, e-Connect resulted in a 42% increase in targeted referrals (aOR=3.18, 1.93-5.28), and 229% increase in BH service initiation (aOR=21.54, 10.73-46.07) by probation youth137,138. Moreover, the implementation of this systematized screening, referral and linkage system mitigated prior race disparities in referral and initiation seen at baseline.  

• Wasserman, G. A., Elkington., K. S., Robson, G., Taxman, F. (In press). Bridging Juvenile Justice and Behavioral Health Systems: Development of a Clinical Pathways Approach to Connect Youth at risk for Suicidal Behavior to Care. Health and Justice.

Family Connect (R34 DA039316; PI: Elkington)
Despite high rates of substance use and co-morbid mental health disorders, our work has shown that justice-involved youth are unlikely to be linked to the behavioral health services they need. Family Connect is a flexible, family-focused, linkage intervention developed to address multi-level barriers and increase youths’ engagement in care through the introduction of a linkage specialist. Family Connect addresses issues related to lack of family engagement and follow-through as a barrier to youth service access. This innovative service delivery model targets families, integrating cross-system linkage protocols from Project Connect with adapted evidence-based family engagement strategies. This approach is delivered by a linkage specialist (patient navigator) to improve engagement, linkage, and retention of probation youth by behavioral health services. The intervention pilot-test, comparing n=18 youth to n=95 historical controls, on referral, attending intake and initiating treatment has found that Family Connect is a promising approach to increase cross-systems linkage and access to behavioral health care and suggested that justice-involved youth and their caregivers found the intervention to be acceptable.

• Elkington, K.S., Lee, J., Brooks, C., Watkins, J., Wasserman, G.A. (2020). Falling between two systems of care: Engaging families, behavioral health and the justice systems to increase uptake of substance use treatment in youth on probation. Journal of Substance Abuse Treatment, 12, 49-59. PMCID: PMC7187516
• Elkington, K. S., Robson, G., Sichel, C. E., Lee, J. & Wasserman, G. (Under Review). Family Connect: The Development and Pilot-test of a Cross-systems Behavioral Health Treatment Referral and Linkage Intervention for Youth on Probation. Criminal Justice and Behavior.

MoveUp (R01 DA043122-01; PI: Elkington)
Our Center recently completed a trial examining efficacy of an intervention to increase HIV/STI testing, decease substance use and HIV/STI risk behavior  and increase HIV and SU linkage to treatment as necessary.  Justice-involved youth aged 18-24 are at significant risk for HIV but are unlikely to know their HIV status. Rates of HIV in justice populations are 2-5 times higher than the general population, yet despite this risk, HIV testing in justice settings, particularly community supervision programs, is not universal. Even after identification, data also suggest that linkage to community HIV care in justice populations is much lower compared to general population rates, due to system/organization-, staff-, and individual-level factors, particularly youth substance use (SU). Overcoming barriers to SU screening and enrollment in SU care is, therefore, central to decreasing justice-involved youth's negative HIV-related outcomes. Intensive efforts to increase screening and improve linkage to HIV (including PrEP for HIV – youth who are behaviorally eligible) and SU services for justice-involved youth are needed that addresses youth as well as justice and health/behavioral health system-level barriers. This project embed HIV testing outreach workers from a youth focused medical and HIV treatment program into an alternative sentencing program to deliver a new service delivery model (#MoveUP) that integrates evidence-based protocols for justice-involved youth to a) promote HIV and STI testing, HIV and SU risk screening and b) provide onsite intervention and c) cross-system linkage to HIV, STI, and SU care. #MoveUp efficacy trial randomized n=307 youth to #MoveUp or standard of care.  Results are currently being analyzed.    

• Elkington, K.S., O’Grady, M.A., Tross, S., Wilson, P., Watkins, J., Lebron, L., Cohall, R., Cohall, A. (2020). A study protocol for a randomized controlled trial of a cross-systems service delivery model to improve identification and care for HIV, STIs and substance use among justice-involved young adults. PMC Health & Justice, 8(1), 20.

Drawing on implementation science to develop and evaluate sustainable, effective, and appropriate best practices to promote cross-system collaboration between justice and behavioral health to increase access and service uptake among youth involved in the justice system.

JJ-TRIALS (U01DA036226; PI: Wasserman)
Our center was part of a multi-site cooperative research initiative of the National Institute of Drug Abuse. Known as the Translational Research on Interventions for Adolescents in the Legal System Research Collaborative (JJ-TRIALS), the group’s primary objective is to promote the systematic use of evidence-based practices to address the challenges faced by justice professionals when linking juvenile probationers to behavioral health services.  The research consortium comprised investigators across 7 states and 36 counites. In New York, we worked with the Office of Probation and Correctional Alternatives in six counties. The JJ-TRIALS study design was a cluster-randomized trial involving CS agencies in 36 counties in 7 states. The Core condition included five interventions implemented at all sites during a 6-month, pre-randomization period: (1) staff orientation meetings, (2) needs assessment/system mapping, (3) behavioral health training, (4) site feedback reports, and (5) goal achievement training. Following these core activities, matched pairs of sites within states were randomly assigned into Core or Enhanced conditions. Enhanced sites received external facilitation for local change team activities, whereas Core sites were encouraged to form interagency workgroups to address their process improvement goals. Compared with the baseline period, the percentage of youth in need who were referred to treatment increased during the experimental period, and the increase was greater in sites receiving Enhanced support. Also, of note is that the percentage of youth screened for substance use declined over time in the Core sites while remaining stable in the Enhanced sites.    

• Knight DK, Belenko S, Wiley T, Robertson AA, Arrigona N, Dennis M, Bartkowski JP, McReynolds LS, Becan JE, Knudsen HK, Wasserman GA, Rose E, DiClemente R, Leukefeld C, & the JJ-TRIALS Cooperative.  (2016)  Juvenile Justice—Translational Research on Interventions for Adolescents in the Legal System (JJ-TRIALS):  A cluster randomized trial targeting system-wide improvement in substance use services. Implementation Science.  11(57).  
• Belenko S, Knight D, Wasserman G, Dennis M, Wiley T, Taxman F, Oser C, Dembo R, Robertson A, Sales J. (2017). The Juvenile Justice Behavioral Health Services Cascade: A New Framework for Measuring Unmet Substance Use Treatment Services Needs among Adolescent Offenders. Journal of Substance Abuse Treatment,74:80-91.
• Robertson, A. A., Dembo, R., Weiland, D., Gardner, S., Pankow, J., McReyholds, L. S., Dickson, M. F., Dennis, M. L., Joe, G., Elkington, K. S. (2020). Recidivism among justice-involved youth: findings from JJ-TRIALS. Criminal justice and behavior, 47. PubMed Central.
• Belenko S, Dembo, R, Knight, D. K.,  Elkington KS, Wasserman GA, Robertson AA, Welsh WN Schmeidler J, Joe GW, Wiley T. (In Press) Using Structured Implementation Interventions to Improve Referral to Substance Use Treatment among Justice-Involved Youth: Findings from a Multi-site Cluster Randomized Trial. Journal of Substance Abuse Treatment.

Project Opioid Court REACH (U01 DA050071; PI: Elkington)
Our center is part of a NIDA-funded research consortium, the Justice Community Innovation Network (JCOIN), the goal of which is to improve access to high-quality care for people with opioid misuse and opioid use disorder in justice settings, whether detained or residing in the community. The centerpiece of the JCOIN approach is establishing partnerships with local and state justice systems and community-based treatment providers to achieve this aim.

Project Opioid Court REACH - Rigorous and Evidence-based Approaches for Court-based Health Promotion -- is one of 12 projects (and growing) across 16 states/territories in the JCOIN network. This project seeks to create an implementation blueprint for scaling-up the novel opioid intervention court model within New York State and elsewhere in order to ultimately link court participants who use opioids and/or are at risk for overdose with treatment. The project team will work with members of local opioid court stakeholder groups across 10 counties in NYS to develop, deliver and test technical assistance strategies to support the roll-out of opioid courts. These strategies will adhere to the Ten Essential Elements of Opioid Intervention Courts while taking into consideration the specific needs and resources of each community. This trial is currently ongoing.

• Elkington, K.S., Nunes, E., Schachar, A., Garcia, A., Van DeVelde, K., Reilly, D., O’Grady, M.A., Williams, A. R., Tross, S., Wilson, P., Cohall, R., Cohall, A., & Wainberg, M. L.  (2021). Stepped-wedge randomized controlled trial of a novel opioid court to improve identification of need and linkage to medications for treatment to opioid use disorder treatment for court-involved adults. Journal of Substance Abuse Treatment, 8; 108277