Use of Psychiatric Medications in Juvenile Detention Facilities and the
Impact of State Placement Policy Edward Cohen, Ph.D.,
San José State University (Presenter)
Jane Pfeifer, M.P.A.,
Chief Probation Officers of California
Neal Wallace, Ph.D.,
Portland State University
26th Annual Children’s Mental Health Research and Policy
Conference, Tampa FL March 3 - 6, 2013
Introduction
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Aims of study
1. To understand the extent to which youth incarcerated in California’s juvenile detention facilities are taking psychotropic medications and using mental health services
2. To explore whether a 2007 policy change limiting court-ordered state placements resulted in change in the use of these services at the local level
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Review of Literature
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Prevalence of MH problems for youth in juvenile detention facilities
• Up to 66% of male and 73% of female youth in detention settings can be diagnosed with a mental disorder1
• Youth with mental disorders stay in detention longer than those without mental disorders2
– Detention settings have iatrogenic effects – longer stays result in lowered mental functioning
– Youth are often held in detention past legal limits due to inability to place3
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Use of psychotropic medications in detention facilities & out of home care • Very few studies of mental health services and
medications provided to youth in detention – Report from one Midwestern state: 17.5% of sampled
youth in detention had psychotropic Rx4
– Psychotropics can account for over 80% of the total budget of all healthcare medications in detention settings5
• Recent study in child welfare6
– Medications inappropriately given to children in out-of-home care without attention to psychosocial issues
– There are no such quality studies published for juvenile justice mental health services
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The costs and contexts of mental health services in detention facilities
• A Survey of California counties showed high levels of burden in caring for detained youth with mental health problems7 – High costs for medications – High rate of worker injuries & disruption of daily programming – Behavioral problems are most difficult to manage – Youth with serious psychoses or suicidal intent require
extraordinary resources such as 1:1 staffing – Informal counseling and behavioral management a large part of
facility staff’s job – Concerns about both over- and under-medication – Gaps include inadequate residential treatment alternatives and
poor continuity of care after release (including medications)
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Dept. of Juvenile Justice Realignment
• California SB 81, September 2007: required that only the most serious violent juvenile offenders continue to be placed in state facilities
• This trend—shifting responsibility of juvenile offenders from state to local levels--is occurring nationally—motivated by a desire for community alternatives, poor conditions & inadequate care in state facilities, reductions in serious juvenile offense arrests, and state budget concerns8
• DJJ population (California Youth Authority) was reduced from 10,000 in 1996 to 1,500 in 20109
• The majority of the Realignment-targeted non-violent offenders had MH treatment prior to placement10
• Counties received Youth Offender Block Grants to serve these youth • From county surveys in 20087, there was evidence that some of
these youth were being “placed” in juvenile hall
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Research Questions
1. What has been the proportion of youth in California’s juvenile detention facilities who are receiving mental health services?
2. What has been the proportion of youth in these facilities taking psychotropic medications?
3. Have these proportions changed as a result of the major policy change with DJJ Realignment?
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Method
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Source of Data • Detention population reports from counties to the
CA Dept. of Corrections and Rehabilitation11 – Monthly census population counts – Monthly counts of youth on psychotropic medications – Monthly counts of youth with “open mental health episodes” – No Individual youth identifiers or other variables in the data
• Eight years of data (2002-2009) were available for analysis
• Quarters rather than months used in analysis – to minimize serial correlation present in monthly counts – Sample size: 55 counties X 32 quarters (1,760 obs), with some
missing quarters leaving final sample sizes of 1,550 (medications) and 1,563 (open MH cases)
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Dataset Structure
Table 1
County Quarter
Avg monthly Population
Avg # youth with open MH
Avg # youth on medications
Alameda 1 292 131 14
Alameda 2 304 98 20
Alameda 3 282 104 23
Alameda 4 292 110 16
Etc. . . . .
N=55 counties N=32 quarters per county
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Variables from Data
• “Open mental health case” defined by the CDCR as “an actual open chart or file with the mental health provider when a juvenile is in need of, or receiving, documented mental health care or services”
– Some variation in definition across counties
• Youth on psychotropic medications – As in the general practice community, there may be
inconsistencies across counties about what is categorized as “psychotropic”
– Counties vary by how medication usage is tracked
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Created Variables Dependent variables:
– Proportion of population with open mental health case
– Proportion of population taking psychotropic medications
Independent variables: – Policy dummy variable—quarters beginning & after
September, 2007 coded 1, all other quarters coded 0
– Linear time trend—All 32 quarters numbered consecutively from -22 to 9 (with 0 being the 3rd quarter of 2007, when the policy was implemented)
– “Rural” dummy variable – Rural counties may differ in services to incarcerated youth.12 Rural counties (n=34) coded 1; non-rural coded 0
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Data Analysis
• Two interactions added as independent variables: – Policy dummy X Linear time trend—tests for any effect of the policy on
the time trend – Rural X Policy dummy—tests for any impact of the policy on rural vs.
urban counties
• Ordinary least squares regression models for each dependent variable. We tested two models for each: – Random, or “mixed,” effects model—doesn’t differentiate counties but
is best to see overall impact of policy – Fixed effects model—Controls for (holds constant) unmeasured
differences between counties and provides estimates of average within-county effects (what happens to the dep variable when counties change over time).13 This regression involved the inclusion of a dummy variable for each county (except one as the baseline)
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Results
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What proportion of youth used services?
Throughout the 8-year study period,
• A monthly average of 36% of youth had open mental health episodes – Still not enough to meet the need according to
prevalence research
• A monthly average of 17% of youth were prescribed psychotropic medications – % similar to previous research, but…
– Does medication use match need?
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Differences between rural & urban counties
In general (over the 8-year period) rural counties had smaller proportions of open MH cases and use of medications
Table: Comparison of
Rural and Urban
0
0.05
0.1
0.15
0.2
0.25
0.3
0.35
0.4
0.45
0.5
With Open MH Cases(p<.001 )
On Medications (p<.01)
0.2
0.15
0.49
0.19
Pro
po
rtio
n o
f Y
ou
th
Rural
Urban
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Did the policy change have an impact?
DJJ Realignment
Overall average proportion
Use of medications
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Did the policy change have an impact? • There was a significant statewide shift towards
higher proportions after the policy change ‒ The interaction of the Policy dummy X Linear time
trend was significant for both open MH cases (a) and medications (b)
• This finding held for the fixed effects model—the average “within-county” change in the dependent variables was also characterized by a shift towards higher rates after the policy change
• Rural counties were no more or less affected by the policy change than urban counties
(a) B = .010, p <.05 (b) B = .005, p <.01
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Conclusions and Implications
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How might the policy change have resulted in increased proportions?
• Possible explanations: – Judges may have used detention facilities as treatment options knowing
that state placements were no longer an option
– Over time there was an overall decrease in local detention populations (an average of 5 youth fewer, post-Realignment), and those youth detained may have had higher levels of MH acuity and impairment than prior to Realignment
– There may have been more proactive MH case finding in response to the policy change (increasing the number of known MH-diagnosed youth)
• Possible rival hypotheses: – There may have been an actual increase in the incidence of MH problems
for youth in general (and the detention population reflected that)
– There may have been more capacity for services as a result of California’s Mental Health Services Act
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Limitations of Study
• Data limitations
– Reliability of “open mental health cases”
– Reliability of “Psychotropic medications”
– Lack of case-level (individual youth) variables
• Design limitations
– No comparison state data available
• Generalizability
– Can findings for California be generalized to other states?
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Conclusions • MH services and psychotropic medications are
important components of the juvenile justice rehabilitative function
• Concern about detention facilities being used as treatment centers – They weren’t designed for this – Governor now proposing full shutdown of state DJJ
facilities – Implementation of similar realignment policies
nationwide—will this result in an increased burden on local facilities?
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Directions for further research • More county-based research—did counties which developed
more community resources show a reduction of detention-based need? – During this study period: there may have been a transition period for
counties in developing community alternatives—continue monitoring with new data
– Why the rural-urban differences in use of MH services?
• What factors lead to better continuity of care after release? – This is important, since these mental health problems can continue
into adulthood14
– Lack of existing data on substance abuse problems and tx impact
– Need for a more detailed analysis of youth characteristics, including the role of gender, ethnicity, seriousness of offense
• The need for quality of care studies about MH services during, and after, detention
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An article with most of this information is currently in press for a special issue of the Journal of Child and Family Studies on psychotropic medication and youth.
To cite or quote this material, contact: Edward Cohen, Ph.D. School of Social Work San José State University [email protected]
Phone: 408-924-5824
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References 1. Teplin, L. A., Abram, K. M., McClelland, G. M., Dulcan, M. K., & Mericle, A. A. (2002).
Psychiatric disorders in youth in juvenile detention. Archives of General Psychiatry, 59, 1133-1143
2. U.S. House of Representatives Committee on Government Reform. (2004). Incarceration of youth who are waiting for community mental health services in the United States. Washington, D.C.: Author.
3. Burrell, S., & Bussiere, A. (2005). "Difficult to place": Youth with mental health needs in California juvenile justice. San Francisco, CA: Youth Law Center.
4. Tennyson, D. H. (2009). Predicting medication costs and usage: Expenditures in a juvenile detention facility. Journal of Correctional Health Care, 15, 98-104.
5. Osterlind, S. J., Koller, J. R., & Morris, E. F. (2007). Incidence and practical issues of mental health for school-aged youth in juvenile justice detention. Journal of Correctional Health Care, 13, 268-277.
6. Stambaugh, L. F., Leslie, L.K., Ringeisen, H., Smith, K., & Hodgkin, D. (2012). Psychotropic medication use by children in child welfare. U.S. Department of Health and Human Services, Office of Planning Research and Evaluation Report #2012-33. Washington, D.C.: DHHS
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References
7. Cohen, E., & Pfeifer, J. (2011). Mental health services for incarcerated youth: Results from a statewide survey. Juvenile and Family Court Journal, 62, 22-34
8. Brown, S. A. (2012). Trends in juvenile justice state legislation: 2001-2011. Denver, CO: National Conference of State Legislatures.
9. California Dept. of Corrections and Rehabilitation Office of Research. (2010). Youth Population Overview as of December 31, 2010 Retrieved October 30, 2011, from http://www.cdcr.ca.gov/Juvenile_Justice/DJJ_Quick_Facts/Youth_Population_Overview.html
10. California State Commission on Juvenile Justice. (2009). Juvenile justice operational master plan: Blueprint for an outcome oriented juvenile justice system. Sacramento, CA.
11. California Dept. of Corrections and Rehabilitation. (2011). Juvenile Detention Survey: Online Query (2011) Retrieved November 15, 2011, from http://www.bdcorr.ca.gov/joq/jds/querySelection.asp
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References 12. Mendel, R. A. (2008). Detention reform in rural jurisdictions: Challenges
and opportunities. In B. Lubow (Ed.), Pathways to juvenile detention reform (Vol. 15). Baltimore, MD: The Annie E. Casey Foundation
13. Petersen, T. (2004). Analyzing panel data: Fixed- and random-effects models. In M. Hardy & A. Bryman (Eds.), The handbook of data analysis (pp. 331-345). London: Sage.
14. Abram, K. M., Choe, J. Y., Washburn, J. J., Romero, E. G., & Teplin, L. A. (2009). Functional impairment in youth three years after detention. Journal of Adolescent Health, 44, 528-535.
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