The cost of implementing a jail diversion program for people with mental illness in San Antonio,Texas

Jail diversion programs for people with mental illness are designed to redirect offenders with mental illness into community treatment. Although much has been published about program models and their successes, little detail is available to policy makers and community stakeholders on the resources required to start and implement a jail diversion program and which agencies bear how much of the burden. The current study used data on a model jail diversion program in San Antonio, Texas, to address this research gap. Data on staff costs, client contacts, planning, and implementation were collected for three types of diversion: pre-booking police, post-booking bond, and post-booking docket. An activity-based costing algorithm was developed to which parameter values were applied. The start-up cost for the program was $556,638.69. Pre-booking diversion cost $370 per person; 90% of costs were incurred by community mental health agencies for short-term monitoring and screening (>80% of activities). Post-booking bond and docket diversion cost $238 and $205 per person, respectively; the majority of costs were incurred by the courts for court decisions. Developing a multiple-intercept jail diversion program requires significant up-front investment. The share of costs varies greatly depending on the type of diversion.     

Estimating the cost impact of three dual diagnosis treatment programs

Specialized intervention programs for people with concurrent severe mental illness and substance abuse reduce the total costs of care. Compared to baseline, cost savings of over 40% were achieved by 18 months, primarily due to significant reductions in the use of acute and subacute mental health services and despite an increase in outpatient mental health services. There also was an observable impact on cost reductions in medical and criminal justice services without an increase in family costs over the same time period.     

Racial/ethnic disparities in prior mental health service use among incarcerated adolescents

Research on racial and ethnic disparities in mental health and substance abuse service use among incarcerated youth in the U.S. is inconclusive. This cross-sectional study adds to our understanding of racial and ethnic disparities by examining the prior use of mental health and substance abuse services among incarcerated juveniles. Guided by Andersen's behavioral model of health service utilization, a series of logistic regression analyses were conducted on a non-probability sample of 13–19 year-old youth in two residential facilities for juvenile offenders in Western Pennsylvania (N = 181). Black and Hispanic youth were less likely than White youth to have used mental health and substance abuse services, even when controlling for predisposing, enabling, and need factors. Additional analyses revealed that these differences did not hold across all service types, specifically with regards to outpatient service use. Significant differences did exist, however, in the prior use of inpatient mental health and substance abuse services. This suggests that White youth are often funneled into the mental health system, while youth of color enter the justice system. Implications for racial/ethnic disproportionality in service use and justice system involvement are discussed.     

‘Reach Out,Rise Up’: The efficacy of text messaging in an intervention package for anxiety and depression severity in young people

BackgroundDepression and anxiety are among the most commonly experienced mental health issues faced by young people in Aotearoa, New Zealand. Considerable barriers exist that prevent young people from engaging with face-to-face mental health services. Young people's preference for technology-based counselling mediums such as text messaging opens up new pathways for intervention.ObjectiveA pilot text message-based intervention package was trialled for use by young people to evaluate the potential efficacy of the text package as an intervention for depression and anxiety symptoms.MethodThe text package was piloted using a 10-week longitudinal cohort pilot with 21 young participants (12–24 years) who demonstrated mild to moderate anxiety and/or depression symptoms.ResultsParticipants' post-package scores were significantly lower than their pre-package scores for both anxiety (Z = − 2.83, p = .005, r = − 0.65) and depression (Z = − 2.49, p = .013, r = −.056). ‘Feeling encouraged and supported’ increased as a result of receiving support from a trained supporter (Z = − 2.06, p = .039, r = − 0.45), but not from friends/family (Z = − 1.72, p = .130, r = − 0.37). Anxiety and depression scores did not change as a result of support from either trained supporters or friends/family.ConclusionsFindings support the potential efficacy of the text package, justify wider trials of the text package, and support the use of text message-based interventions as potentially effective therapies for young people.     

The individual in economic analysis: toward psychology of economic behavior

“… Economics is supposed to be concerned with real people. It is hard to believe that real people could be completely unaffected by the reach of the self-examination induced by the Socratic question, ‘How should one live?’—a question that is, also a central motivating one for ethics. Can people whom economics studies really be so unaffected by this resilient question and stick exclusively to the rudimentary hard-headedness attributed to them by modern economics?” Amartya Sen, On Ethics & Economics.“… Apart from a few exceptions, the international consensus view within sociology, anthropology, political science and psychology seems to be that agents are not irrational in the way that neoclassical economists presume. The orthodox economic canons of rationality are thus widely rejected elsewhere,” Geoffrey M. Hodgson, Economics and Institutions.“Once we realize that the human mind is everywhere active and imaginative, then we need to understand the routes of this activity if we are to grasp how the human mind works. This is true whether the mind is trying to come to grips with painful reality, reacting to trauma, coping with the everyday or just making things up. Freud called this imaginative activity phantasy, and he argued both that it functions unconsciously and that it plays a powerful role in the organization of a person’s experience. This surely, contains the seeds of a profound insight into the human condition; it is the central insight of psychoanalysis … a pervasive aspect of mental life …. Are we to see humans as having depth—as complex psychological organisms who generate layers of meaning which lie beneath the surface of their own understanding? Or are we to take ourselves as transparent to ourselves?” Jonathan Lear, Open Minded: Working Out the Logic of the Soul.     

Mental Illness and the Criminal Justice System

This is the second essay in a two‐part series exploring the relationships between mental illness, criminal behavior, and the criminal justice system. The number of mentally ill persons in prisons and jails has increased substantially over the last several decades, and there are currently more people with mental illness behind bars than there are in mental hospitals. In this essay, we place these trends within a broader historical context of the social control of mental illness in the United States. We identify how and why mentally ill persons have come to be overrepresented in the criminal justice system and highlight the unique challenges this population poses for police, courts, and correctional facilities. Finally, we review several recent innovations in policy and practice that may help alleviate that burden of criminal justice involvement on mentally ill offenders, as well as the burden of mentally ill offenders on the criminal justice system.     

Predicting program success for adult offenders with serious mental illness in a court ordered diversion program

ABSTRACT

Individuals with mental illnesses are disproportionately involved with the criminal justice system and are now being diverted from jails to community-based supervision. This study examines secondary data from a state hospital, mental health diversion program. Logistic regression was used to examine risk factors that best predicted successful program completion. Results indicate that non-whites are more likely to complete. Participants in supervised housing, ever been re-hospitalized, diagnosed with a depressive or psychotic disorder or who had their probation revoked were less likely to complete. Findings indicate practitioners should provide a holistic and individually oriented treatment approach for success.     

Criminal conduct subgroups of “aging out” foster youth

Subgroups of adolescents drawn from the Midwest Study of the Adult Functioning of Former Foster Youth were identified on the basis of cluster analysis of self-reported criminal behavior: Cluster 1: No Criminal Activity (n = 204), Cluster 2: Moderate Criminal Conduct (n = 300), Cluster 3: Extensive Criminal Involvement (n = 87), and Cluster 4: Group Fighting (n = 139). Logistic regression analysis revealed higher proportions of foster youth with alcohol and drug diagnoses, male gender, out of school status, and limited caregiver closeness in each of the groups in which there was evidence of significant criminal conduct (Clusters 2, 3, & 4) in comparison to the no criminal activity group (Cluster 1). The same variables contributed to discrimination between the cluster subgroup with the most serious and pervasive pattern of criminal conduct (Cluster 3) and the two with less extensive criminal involvement (Clusters 2 & 4). Current findings and those of G. R. Cusick, M. E. Courtney, J. Havlicek & N. Hess (2010), help in identifying the differing needs of youth aging out of the child welfare system and should be useful in informing development of targeted interventions.     

From foster care to juvenile justice: Exploring characteristics of youth in three cities

Children placed in foster care are at risk for becoming involved with the juvenile justice system. This study documents the rates at which children involved with foster care enter the juvenile justice system (crossover or dually involved), and the factors associated with this risk. We utilize multiple birth cohorts and prospective, longitudinal data from birth to maturity separately in three major American cities. Analyses consider integrated administrative records from multiple birth cohorts representing populations in Cook County (Chicago; N = 26,003), Cuyahoga County (Cleveland; N = 10,284), and New York City (N = 13,065). Crossover rates ranged from 7 to 24%. African American males, and children who experienced congregate care were at highest risk for juvenile justice involvement. Older age at first foster care placement signaled progressively greater risk, as did more foster care spells for those first placed as infants. We discuss findings in terms of developmental theory, and as actionable intelligence to inform prevention, practice, and policy.     

Mental health outcomes among child welfare investigated children: In-home versus out-of-home care

BackgroundChild welfare has increasingly focused on alternatives to out-of-home (OOH) placement. In-home services, such as parent training, have increased and more maltreated children remain in-home. Yet, little is known about the effect on mental health of maintaining vulnerable children in-home vs placement in stable OOH care.ObjectiveTo evaluate and compare difference in mental health among children investigated by child welfare and who remained in-home vs. those who were placed in stable OOH care.Design/methodsWe examined a cohort of children (aged 1.5–18 years) from a nationally representative sample of children investigated by child welfare using the National Survey of Child and Adolescent Well-Being II (NSCAW II). We compared changes in mental health functioning over 18 months for children who remained in-home with parent training versus those placed in stable OOH care.ResultsAmong the 749 children in our sample, baseline characteristics of children who remained in-home with parent training and those placed in stable OOH care were similar. Among school-aged children placed in stable OOH care, mental health problems decreased from 26% to 13% (p = .003). This differed significantly from school-aged children who remained in home, for whom mental health problems increased (50% decrease stable OOH care vs. 23% increase in home; p = .007). Among pre-school aged children, mental health problems increased in both settings, particularly stable out-of-home care (p = .008).ConclusionsFor school aged children with a history of maltreatment, mental health outcomes improve following stable OOH placement, yet worsen when remaining in-home with parents. Pediatricians should be watchful for mental health problems among children who remain home after maltreatment and should advocate for high-quality stable OOH care when it is necessary. Child welfare may need to monitor the outcomes of children remaining at home more closely and provide more intensive preventive and treatment services to families.     

Finish what you start: A study of Design Team change initiatives' impact on agency climate

This study employs a multi-site longitudinal design to examine the effect of a Design Team intervention on organizational climate. Thirteen private, not-for-profit child welfare agencies from one state participated in a Design Team intervention to address workforce needs. A total of 407 workers from those agencies responded pre and post intervention to a survey that measures worker perceptions of the psychological climate of their organization using the Parker Psychological Climate Survey. Workers in organizations that completed the Design Team intervention had statistically significant increases in three of the four dimensions of the Parker scale. On the role dimension, significant change was noted on all three subscales on the interaction between Time 1 and Time 2 (ambiguity: p = 0.012; conflict: p = 0.04; overload: p = 0.05). On the organization dimension, the justice and support subscales had significant differences in the desired direction (justice: p = 0.05; support: p = 0.03). On the supervisor dimension, significant change was observed in the desired direction for both the goal emphasis and work facilitation subscales (goal emphasis: p = 0.02; work facilitation: p = 0.00). Statistically significant improvements in the organizational climates of child welfare agencies suggest the benefit of future research to test the effectiveness of Design Team interventions in other service areas. These findings build on intervention research with organizations by linking the ability of an organization to fully implement a change initiative to their capacity to improve the workplace climate for employees.     

Examining implementation and preliminary performance indicators of veterans treatment courts: The Kentucky experience

Veterans’ Treatment Courts (VTCs) are posited as a solution to offer rehabilitation for veterans involved in the criminal justice system. Despite the pervasive implementation of VTCs, there is little research focused specifically on VTC implementation and outcomes, which are based on other problem-solving court models such as drug court. The current study presents qualitative process evaluation data from key stakeholders (n = 21) and veteran participants (n = 4) to show accomplishments, challenges, and lessons learned during first-year implementation at two VTC sites. Quantitative performance data is also presented on veteran participants (n = 19) served during the first year to show: types of services, monitoring, judicial interaction, sanctions/therapeutic responses, and rewards, as well as preliminary data on recidivism. Qualitative data, from both key stakeholders and veteran participants, suggests that offering rehabilitation via various program components, services/referrals, and accountability are critical to the success of the VTC. Data also provides valuable lessons learned for VTC implementation including communication, collaboration, information/protocols, and resources. Performance data shows that a variety of services are utilized and that frequent judicial interaction, drug testing, and sanctions are cornerstones of the VTC. Implications and future directions for research are discussed.     

A randomized controlled trial of the effectiveness of the youth crime prevention program ‘New Perspectives’ (NP): Post-treatment changes and moderator effects

ObjectivesNew Perspectives (NP) aims to prevent that youth at onset of a criminal career will develop a more persistent criminal behavior pattern. The study aim was to examine whether NP was effective relative to care as usual in preventing and reducing (persistent) delinquency. Moreover, we examined improvements in secondary outcomes (e.g., peer and parent relationships and cognitive distortions) and other outcomes (e.g., substance use and self-esteem).MethodsAt-risk youth (N = 101) aged 12 to 19 years were randomly assigned to the intervention group (NP, n = 47) or control group (‘care as usual’, n = 54). The effects of the NP intensive phase (3 months after program start) and aftercare phase (6 months after program start) were analyzed.ResultsNP and care as usual did not differ on any of the outcome measures at both post-test occasions. The effects of NP were the same for boys and girls, different age groups, and ethnic groups.ConclusionsThe overall null-effects are discussed, including implications for further research, policy, and practice.     

Social Return On Investment (SROI): Problems,solutions … and is SROI a good investment?

The conclusion of this special issue on Social Return On Investment (SROI) begins with a summary of both advantages and problems of SROI, many of which were identified in preceding articles. We also offer potential solutions for some of these problems that can be derived from standard evaluation practices and that are becoming expected in SROIs that follow guidances from international SROI networks. A remaining concern about SROI is that we do not yet know if SROI itself adds sufficient benefit to programs to justify its cost. Two frameworks for this proposed metaevaluation of SROI are suggested, the first comparing benefits to costs summatively (the resource → outcome model). The second framework evaluates costs and benefits according to how much they contribute to or are caused by the different activities of SROI. This resource → activity → outcome model could enable outcomes of SROI to be maximized within resource constraints (such as budget and time limits) on SROI. Alternatively, information from this model could help minimize the costs of achieving a specific level of return on investment from conducting SROI. Possible problems with this metaevaluation of SROI are discussed.     

Unmet legal and social advocacy needs of children with sickle cell disease: Implications for health care payer costs

Previous studies of advocacy needs faced by children and families have not differentiated needs that require attorney involvement (“legal advocacy needs”) from needs best addressed by social workers or lay advocates (“social advocacy needs”). Studies have also not examined the relationship between either type of need and health care costs. We developed a novel, replicable process to differentiate between legal advocacy needs and social advocacy needs. We then collected cross-sectional data from a sample of 52 children with sickle cell disease who were at least 1 year of age, a population with high advocacy needs and high health care costs. Mean annual health care costs to payers for children whose families had a least one legal advocacy need were $16,314, compared to $5552 for children in families with no legal advocacy needs (P = 0.007). After adjusting for covariates, the presence of a legal advocacy need was associated with $12,040 more in health care costs to payers (P = 0.02). Whether interventions to prevent and resolve legal advocacy needs can reduce health care costs by addressing the social determinants of health warrants future study.     

Expanding the conceptualization of re-entry: The inter-play between child welfare and juvenile services

Re-entry in child welfare is traditionally viewed as a child exiting to permanency and then reentering the child welfare system. Using this approach is effective for understanding child welfare practice from a single-system lens, but gives an incomplete picture of how children may move between related child serving systems. The present study expands the definition of re-entry by examining re-entry for 2259 children who either return to the child welfare system or move into the juvenile justice system after reunification from foster care. When measuring a broader concept of re-entry (into either system) the rate of re-entry went from 18% to 25% - a 33% increase. Regression analyses further suggested that many of the risk and protective factors associated with standard child welfare reentry were also predictive of multisystem re-entry such as having previous child welfare experience (OR = 1.79, p < 0.000), and child behavior as a factor at removal (OR = 1.75, p < 0.000). Findings of this study support the need to continue increasing the conceptualization of re-entry to be more inclusive of related systems as well as continuing to focus research efforts on understanding effective practices within child serving systems so that re-entry into either system is mitigated.     

Juvenile justice sentencing: Do gender and child welfare involvement matter?

For young people who come into contact with the juvenile justice system, how they are sentenced following an arrest may profoundly influence the course of their development and adjustment as adults. Much of the research to date has focused on racial and ethnic disparities in juvenile justice sentencing policies and practices, and less is known about sentencing disparities based on other youth characteristics. Using Los Angeles County administrative data, this study investigates the effects of gender and child welfare statuses on sentencing for young people who are arrested for the first time (N = 5061). Results indicate that both young men and women are sentenced more harshly dependent upon the disposition, such that girls were more likely to be sentenced to group homes compared to boys, but boys were more likely to be sentenced to correctional facilities compared to girls. Child welfare-involved youth with a recent placement history are prone to more punitive sentences compared to their non-child welfare counterparts. Further, child welfare young women were not more likely to be sentenced to a harsher disposition compared to child welfare young men or non-child welfare young women. Implications for practice and future research are discussed.     

Mental health services for children and caregivers remaining at home after suspected maltreatment

ObjectiveBehavioral problems are common among children remaining at home after suspected maltreatment, but the effectiveness of current mental health services to improve these behavioral problems is unknown. The objective was to determine whether receipt of child and caregiver mental health services was associated with improvements in behavioral problems in maltreated children remaining at home.MethodsWe retrospectively analyzed Second National Survey of Child and Adolescent Well-being data. We included 1117 children ages 2–17 remaining at home after a maltreatment investigation, excluding children with missing outcome, covariate, or survey weight data. We compared mean Child Behavioral Checklist (CBCL) change scores from baseline to 18 months between children who did and did not receive mental health services, before and after adjusting for child, caregiver, and child welfare agency factors using survey-weighted linear regression.ResultsNearly one-quarter (22.6%) of children and 16.0% of caregivers received mental health services. Children receiving services had worse unadjusted baseline and 18-month CBCL scores than children not receiving services (all P < 0.001). Adjusted CBCL change scores revealed behavioral worsening among children receiving services but improvement among children not receiving services (all P < 0.001). However, children had improved behavior, regardless of their own service receipt, if their caregivers received services and reported an absence of depression at 18 months.ConclusionsChildren receiving mental health services had worse behavioral changes than children not receiving services. Caregiver receipt of services was associated with improved child behavior, suggesting that a family-centered approach may be most influential in improving behavioral outcomes among this population.     

Factors associated with treatment attrition for Medicaid-enrolled youth with serious emotional disturbances

Premature discontinuation from treatment is a significant problem that undermines the delivery of effective mental health services and increases the risk for relapse and poor outcomes. However, factors associated with treatment attrition in children and adolescents are not well understood. This retrospective longitudinal cohort study examines factors associated with attrition for Medicaid-enrolled youth, aged 5 to 17 with “new episodes” of ICD-9-CM diagnosed serious emotional disturbance (N = 43,122). Information on individual-level (demographic and clinical characteristics) and contextual-level variables (county socio-demographic, economic, and health care resources) were abstracted from Medicaid claim files and the Area Resource File. Multilevel modeling was used to assess the association between individual and contextual-level variables and attrition. Of the 43,122 youth in the study sample, 4056 (9.4%) discontinued treatment. The odds of treatment attrition were significantly higher for youth who were male (OR = 1.16, p < 0.001), black compared to white (OR = 1.19, p < 0.001), had a co-occurring substance abuse disorder (OR = 1.35, p = 0.01), and lived in a county with a larger percentage of minorities (OR = 1.02, p = 0.01). In contrast, youth diagnosed with bipolar and depressive disorders compared to ADHD (OR = 0.78, p < 0.001 and OR = 0.87, p = 0.01, respectively), with comorbid psychiatric (OR = 0.74, p < 0.001) and medical disorders (OR = 0.82, p < 0.001), and a prior history of two or more psychotropic medications compared to no medications (OR = 0.76, p < 0.001) had lower odds of attrition. Residence in a county with a larger number of pediatricians and psychologists also reduced the odds of attrition (OR = 0.97, p = 0.05 and OR = 0.99, p = 0.03 respectively). Overall, this study suggests that a combination of individual factors, demographic and clinical, and contextual factors impact attrition in children's mental health outpatient treatment.     

Looking for sufficient change: Evaluation of counsellor training for STI syndromic management in India

In India, public health care of Sexually Transmitted Infections is delivered through Designated STI/RTI Clinics (DSRCs) using syndromic management. This paper describes efforts, over three years, to improve in-service training for counsellors positioned at DSRCs—using a data approach. The programme managers realised, through rigorous monitoring of initial induction training reports that, while knowledge and attitudes of most trainees had improved as evident from t-tests, at least one-quarter scored worse on post-training assessments (n = 859). Therefore, they undertook a survey using a competency approach to diagnose what critical competencies are influenced through training: counselling skills, risk reduction suggestions, labelling male and female anatomy, record-keeping and STI patient education (n = 132). Survey results demonstrated that trainees failed to pass a two-thirds cutoff score in most competencies. These findings led the programme managers to modify training and implement tighter quality measures. In the second round of training – refresher training – outcomes on competency assessments before and after training showed more acceptable performance (n = 833). The paper describes how programme managers, after an acceptance of such initial short-comings, developed customized assessments when literature provided limited guidance and how they worked to achieve change that was acceptable for programme needs.