A process evaluation of Toronto's first youth mental health court.

Author:Davis, Krista M.
Position:Community Youth Court
 
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Introduction

Mental health courts were first introduced to Canada in 1998 to address the growing concern regarding the mental health needs of justice involved populations (Schneider, Bloom, and Heerema 2007; Slinger and Roesch 2010). Such programs seek to divert accused persons with mental illness out of the criminal justice system and into community treatment through a more collaborative and less adversarial process than in the traditional court system (Schneider et al. 2007; Steadman, Redlich, Callahan, Robbins, and Vesselinov 2011). Within the adult literature, mental health courts have been found to increase treatment service usage and are moderately effective in reducing recidivism (Boothroyd, Poythress, McGaha, and Petrila 2003; Sarteschi, Vaughn, and Kim 2011). With their apparent success, these courts have recently been adapted for youth. The first Canadian mental health court for youth was opened in Ottawa in 2008 (Perkins-McVey, McCormick, Leger, Breton, and Motayne 2009); since then, several similar programs have been established across Ontario.

Mental health court research

Despite their recent adaptation for youth, there is a dearth of research on youth mental health courts and little is known about their characteristics and operations. Callahan, Cocozza, Steadman, and Tillman (2012) conducted a national survey of juvenile mental health courts in the United States. They reported that programs were typically run by either the juvenile court or probation services, or by a combination of both. The most common diagnoses among participants were Bipolar Disorder (27%), followed by Depression (23%), and Attention Deficit/Hyperactivity Disorder (16%). A guilty plea was required in most courts and various incentives were used to promote participation (e.g., dismissal of charges, praise by the judge or probation officer, and gift cards). Multidisciplinary teams were also a common feature of the programs surveyed. Interestingly, many of the courts set a minimum time period of participation--with the most common being 6 to 9 months--but no maximum time limit. The authors highlighted that while mental health courts for youth share many similarities with adult programs, they face unique challenges with regards to diagnosis and treatment, as well as how to involve families and address school-related issues.

Evidence is also emerging that participation in youth mental health courts results in reduced rates of reoffending (Behnken 2008; Heretick and Russell 2013). Taken together, these findings suggest that mental health courts may be a promising option for justice-involved youth with mental health needs, but research documenting the operations of such courts is needed to better understand the mechanisms related to such outcomes.

Mental health, offending, and rehabilitation

The primary goal of mental health courts is the rehabilitation of offenders. Thus, mental health courts and mental health court research should consider existing empirical evidence relevant to rehabilitation. For example, research has identified strong and direct predictors of recidivism (termed criminogenic needs) that are essential to assess and address in order to reduce reoffending (Andrews and Bonta 2010; Andrews, Bonta, and Hoge 1990; Hollin and Palmer 2003; Schlager and Pacheco 2011; Simourd 2004). These variables are a critical component of the Risk-Need-Responsivity (RNR) framework, a theoretically grounded and empirically supported model based on three key principles: (1) that the most intensive treatment should be reserved for those at highest risk for recidivism, and low risk individuals should not be "over-programmed" (risk principle); (2) that treatment should address an offender's criminogenic needs (need principle); and (3) that treatment should be tailored to individual characteristics (e.g., motivation, learning style) that--while not directly predictive of offending--affect the effectiveness of interventions that target criminogenic needs (responsivity principle) (Andrews et al. 1990).

While there is strong empirical evidence for treating criminogenic needs to reduce recidivism, less is known on how best to treat offenders with mental health needs. In the RNR framework, several identified criminogenic needs are also features of mental health diagnoses (e.g., impulsivity, anger and aggression, anti-sociality), but for the most part, mental health diagnoses, while associated with criminal behaviour, are not strong predictors of recidivism (McCormick, Peterson-Badali, and Skilling, in press). (2) Within the RNR framework, most mental health needs (e.g., symptoms of mood and/or anxiety disorders) are better conceptualized as responsivity factors that influence an individual's ability to successfully engage in the treatment of criminogenic needs (Bonta 1995). Indeed, research indicates that, for a small proportion of individuals with mental health problems, there is a direct or causal relationship between mental illness and criminal behaviour, but for a substantial majority of offenders with mental illness, the relationship between mental illness and criminal behaviour is indirect and is mediated by criminogenic needs (Skeem, Manchak, and Peterson, 2011).

Understanding these different relationships has important implications for intervention. When mental health problems are directly related to an individual's offending, mental health intervention is an appropriate approach to achieve rehabilitation (i.e., reduce the likelihood and/or frequency of reoffending). However, where there is an indirect relationship between mental health and criminal behaviour, it is important that treatment consider both criminogenic and mental health needs when implementing interventions. This has clear implications for the functioning of mental health courts and for associated research and, for this reason, the current study considers the results in relation to the empirical knowledge on offender rehabilitation.

The current study

The current study is part of a larger process evaluation exploring the functioning of a youth mental health court in Toronto, Canada. It is a resolution court for young people charged with an offence who present with a significant mental health concern (e.g., mood, anxiety, developmental disorders, schizophrenia) or substance use problem (Ontario Court of Justice 2011). The court's goals are to improve access to community treatment services, reduce case-processing time, improve general well-being, reduce the likelihood of reoffence, and increase community safety.

A process evaluation is distinct from an outcomes evaluation and specifically looks at program implementation and how a program facilitates change (Rossi and Freeman 1993). Process evaluations are important to conduct before outcomes can be assessed in order to understand what the program is actually doing to achieve change (Steadman 2005). The objectives of the overarching evaluation were to (1) understand and represent the court's program theory, (2) explore program model implementation within the context of the YCJA, (3) describe how the court operates (with a particular focus on whether it is servicing its intended population), (4) examine what factors predict successful court completion, and (5) examine how the court addresses the mental health and criminogenic needs of its clients. The last three objectives are the focus of the current paper; the first two objectives are examined in a complementary paper (Davis, Peterson-Badali, and Skilling, 2014).

Study objectives

For a comprehensive and systematic mental health court evaluation, Steadman (2005:3) recommends collecting data on services received and participant characteristics to help answer the key question, "What works, for whom, and under what circumstances?" Accordingly, the first set of objectives aimed to describe the operations of the court, including basic court processes, case processing, and treatment services accessed by youth. The second set of objectives focused on describing the youth seen in the court, including participant characteristics, differences in the characteristics of youth who completed the program and those who did not, and sample characteristics that predicted successful completion of the program. Finally, a critical facet of the youth mental health court that requires exploration from a process perspective is how the court addresses both the mental health and criminogenic needs of youth. We examined the extent to which youths' treatment referrals matched their identified mental health needs as well as the broad areas of criminogenic need identified in the literature (Hoge and Andrews 2002).

Method

Participants

Youth between the ages of 12 and 18 who had suspected mental health needs and wished to resolve their charges were eligible to participate in the mental health court (having a formal diagnosis was not a criterion). Youth excluded from the court included those who did not have mental health needs or wished to contest their charges. A total of 184 young people participated in the mental health court from its inception in June 2011 until August 2013. Of those, information was collected on 127 youth (90 males and 37 females), representing all youths who participated meaningfully in the court (i.e., were engaged with the court long enough for a client file to be formally opened). Youths not included in the study had either not completed their court requirements at the time that data collection ceased (n = 27) or had not participated substantially in the program and, thus, a file was not opened (e.g., a young person was placed in the court but transferred out before a file could be opened, n = 15). The average age of participants was 16.35 (SD = 1.78). Further details regarding participant characteristics are reported in the results section.

Materials

Government database. Information regarding participants' prior offences (date and type) was obtained through a...

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