Mental health screening refers to the administration of a brief measure to children and adolescents entering a juvenile justice agency for the purposes of identifying individuals who have a mental health problem or behavioral health concern. Screening ensures that mental health treatment or interventions to prevent self-harm are given to juvenile offenders who are in need of these services. This topic is relevant to the field of criminal psychology because it reflects an application of clinical psychology to the juvenile justice system. This article focuses on mental health screening among juvenile offenders and describes (a) the purposes of mental health screening in juvenile justice settings, (b) characteristics of effective mental health screening tools, (c) examples of screening tools, and (d) considerations for juvenile justice agencies administering these tools.
Purposes of Mental Health Screening in Juvenile Justice Agencies
Since the mid-1990s, there has been an increasing amount of attention paid to the mental health needs of children and adolescents involved in the juvenile justice system. Policy makers such as the U.S. surgeon general note that many youth become involved in the juvenile justice system because of mental illness, and researchers note that youth with mental illness are disproportionately represented in the juvenile justice system. Although estimates vary depending on setting type and data collection method, most estimates suggest that about two thirds of juvenile offenders have some type of mental illness, such as depression, anxiety disorders, attention-deficit/ hyperactivity disorder, substance abuse or behavioral disorders. This is at least twice as high as the prevalence rates found among youth in the community.
Agency administrators look to researchers for guidance on how to better meet the needs of the youth under their care. This may include diverting youth out of the justice system to treatment in the community or providing treatment within juvenile justice facilities to improve the likelihood that juvenile offenders can be rehabilitated and avoid further entanglement with the juvenile (or adult) justice system. In addition, juvenile offenders who are held in detention facilities are entitled to mental health treatment when needed. Upon intake to these facilities, it is important that youth are assessed to determine whether they are taking any medications that need to be continued or assessed, and whether the individual is at risk of self-harm so that suicide prevention procedures can be implemented. In addition, mental illness can be exacerbated in the stressful environment of detention centers, and youth with mental disorders may be at risk of behavioral problems that pose a risk to staff or other youths. As such, nationally recognized experts in juvenile mental health described structured mental health screening as a crucial step in addressing the mental health needs of juvenile offenders.
Characteristics of Effective Screening Tools
There are several characteristics that define effective mental health screening tools for use with juvenile offenders. Importantly, measures developed for use with adults are not developmentally appropriate for use with children or adolescents. Although inquiring about past use of mental health services can be a useful source of information, it cannot be the only source of information regarding a juvenile offender’s current need for services, as many youth who need services do not receive them until they have contact with the juvenile justice system—this is particularly common among youth from ethnic minority groups.
Mental health screening tools in juvenile justice serve as a type of triage: distinguishing between youth who most likely do not have a problem needing immediate attention and youth who need immediate attention or further assessment. Screening tools should accomplish these goals in an economical and efficient manner and should assess for all types of mental health problems that warrant attention in juvenile justice settings; these include major mental illness (e.g., depression, anxiety disorders, psychosis), substance abuse, and behavioral disorders such as oppositional defiant disorder and conduct disorder. In addition, the tools should identify suicide risk.
Mental health screening measures are available in a variety of formats, including paper and pencil, interview, and computerized administration. To ensure that the tool is administered properly, there should be structured administration guidelines such that similar results are obtained regardless of who administered the tool; these guidelines typically are described in an accompanying manual with clear training procedures provided to teach staff members to administer the tool. In addition, there should be clear scoring guidelines with cutoff scores to aid decision-making. For example, a scale assessing suicide risk should have a clear cutoff score to separate youth who are not likely at risk of self-harm from those who need intervention.
Screening tools should be researched extensively before being put to use in aiding decision-making for youth in the juvenile justice system. For example, cutoff scores to determine whether the individuals need further assessment or not should come from evidence across multiple samples of justice-involved youth; there should be evidence that the cutoff score accurately categorizes individuals from a wide range of ethnic backgrounds and both genders. In addition, there should be evidence of strong psychometric properties of the measure. There are many properties that should be evaluated; some of the more important ones to consider are test–retest reliability, interrater reliability, and construct validity. In addition, there should be evidence of clinical utility or the extent to which the measure aligns with the problems it is intended to detect. Information regarding clinical utility can be gleaned by assessing the measure’s sensitivity and specificity; both of these reflect the measure’s degree of correct classifications (true positive and true negative, respectively). A number of mental health screening tools are routinely used in juvenile justice settings; two of these (the Massachusetts Youth Screening Instrument–Version 2 [MAYSI-2] and the Child and Adolescent Functional Assessment Scale [CAFAS]) are reviewed in the next section, although many others are available, such as the Problem Oriented Screening Measure for Teenagers and the Diagnostic Interview Schedule for Children (DISC) Predictive Scales.
Examples of Screening Tools
The MAYSI-2 is both the most well researched and widely used mental health screening tool developed for use in juvenile justice agencies. The MAYSI-2 was developed in samples in Massachusetts and California but has been tested in dozens of sites since its development. The MAYSI was designed to detect symptoms indicative of a wide range of mental health and substance abuse problems as well as suicide risk among youth between the ages of 12 and 17. It consists of 52 yes–no items and seven scales for boys and six for girls: Alcohol/Drug Use, Angry-Irritable, Depressed Anxious, Somatic Complaints, Suicide Ideation, Traumatic Experiences, and Thought Disturbance (the Thought Disturbance Scale is not valid for girls). Administration of the MAYSI-2 takes approximately 15 min and can be done via paper and pencil or with the MAYSIWARE software. Scoring the MAYSI-2 is done by summing the number of yes responses for each scale, and each scale (except Traumatic Experiences, which does not have a cutoff score) generates a score of Normal, Caution (indicating the individual may have a clinically significant problem in that domain), or Warning (the individual is in the 10% of youths on that domain). Since its development, it has been translated into at least 12 languages, although less research exists regarding the utility of the translations compared to the original English version. Substantial research on the English version of the MAYSI-2 supports its correspondence with lengthier measures of psychopathology including clinical interviews. The MAYSI-2 has been widely adopted across facilities in the United States and other nations.
Another available screening measure is the CAFAS. The CAFAS was developed to detect problems or risk of problems in a number of domains, including behavioral, mental health, and substance abuse. It is appropriate for use with youth between the ages of 5 and 19 in the juvenile justice system as well as other contexts (e.g., schools). The CAFAS has 10 subscales that yield a total score. Eight subscales assess the youth’s functioning across important domains (School, Home, Community, Behavior Toward Others, Moods, Self-Harm, Substance Abuse, and Thinking); two subscales assess the caregiver’s ability to meet the youth’s needs (Material Needs and Social Support). The CAFAS is designed to detect need for further evaluation or services across the domains it assesses in addition to change over time during intervention. The CAFAS is scored by a trained rater; items primarily assess observable behaviors gathered from observation and reports from the youth and caregivers. Subscales yield scores indicating the level of impairment in that domain: minimal or no impairment, mild, moderate, or severe impairment. The CAFAS is available in both English and Spanish versions. There is substantial evidence of the CAFAS’s ability to identify youth with serious problems in the juvenile justice system.
Implementation of Screening
For screening to be effective, every individual entering a juvenile justice agency should be screened at intake. In custodial settings, it is particularly important that screening occurs soon after entry (e.g., within a few hours) to quickly identify individuals at risk of suicide. It is important that screens are administered in a standardized manner, so staff who administer screening measures should receive appropriate training on administration of these tools. In addition, staff should be trained on how to maintain the privacy of youth both during the screening process and afterward when managing the data from these tools. It is recommended that agencies have clear policies on how staff should respond to youth who are identified by a screening measure as being in need of further attention.
When selecting a screening tool, implementing administration, and training staff, administrators should account for the specific needs of the specific population in their agency. This includes known differences in mental health needs for subgroups of juvenile offenders. For example, boys have higher rates of externalizing (behavioral) problems compared to girls, whereas girls have higher rates of internalizing (depression, anxiety) problems. Furthermore, girls have a higher prevalence of mental illness in general and higher rates of co-occurring mental illness and substance abuse. There is some evidence that ethnic minority youth report lower rates of mental health concerns, but it is not clear the extent to which this is due to differences in prevalence or reporting of symptoms. Importantly, ethnic minority youth who are in need of services are disproportionately less likely to receive services compared to European American youth; as such, careful attention should be paid to the needs of ethnic minority youth during screening and service referral.
Although researchers note that mental health screening has not yet been implemented universally, there is strong consensus that mental health screening is an important first step toward identifying youth in the juvenile justice system with mental health, substance abuse, or emergent behavioral problems so appropriate interventions can be administered.
References:
- Grisso, T., Vincent, G., & Seagrave, D. (2005). Mental health screening and assessment in juvenile justice. New York, NY: Guilford.
- Skowyra, K. R., & Cocozza, J. J. (2007). Blueprint for change: A comprehensive model for the identification and treatment of youth with mental health needs in contact with the juvenile justice system. Delmar, NY: National Center for Mental Health and Juvenile Justice. Retrieved from http://www.ncmhjj.com/ wp-content/uploads/2013/07/2007_Blueprint-for-Change-Full-Report.pdf
- Underwood, L. A., Warren, K. M., Talbott, L., Jackson, L., & Dailey, F. L. (2014). Mental health treatment in juvenile justice secure care facilities: Practice and policy recommendations. Journal of Forensic Psychology Practice, 14(1), 55–85. doi:10.1080/15228932.2014.86539
- Vincent, G. M., Grisso, T., Terry, A., & Banks, S. (2008). Sex and race differences in mental health symptoms in juvenile justice: The MAYSI-2 national metaanalysis. Journal of the American Academy of Child & Adolescent Psychiatry, 47, 282–290.
- Wachter, A. (2015). Mental health screening in juvenile justice services. Pittsburgh, PA: National Center for Juvenile Justice.
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- Wasserman, G. A., McReynolds, L., Ko, S., Katz, L., Cauffman, E., Haxton, W., & Lucas, C. (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 & Adolescent Psychiatry, 43, 629–639. doi:10.1097/01.chi00000116742.71662.b1