This presentation describes how to use standardized assessment to improve juvenile justice-behavioral health planning to engage youth in appropraite and effective community-based services.

1. SF AIIM Higher: A Cross-Agency, Data-
Driven Approach to Mobilize Juvenile Justice-
Involved Youth, Families and Systems
Towards Change*
Emily B. Gerber
Sai-Ling Chan-Sew San Francisco Department of Public Health
Nathaniel Israel Community Behavioral Health Services
Jen Leland Child, Youth & Family System of Care
*Any information in this presentation are the views of the authors and do not necessarily represent the
views of the San Francisco Department of Public Health

2. SF
Assess Youth
Identify Needs
Integrate Information
Match to Services
Higher
A U.S. DOJ-funded partnership
between the SF Juvenile Probation Dept. & the Dept. of Public
Health’s Child, Youth and Family System of Care

3. SF AIIM: Year 1
 The Problem
 Model & Goals
 Outcomes

4. Problem: An epidemic of untreated mental illness in
the Juvenile Justice System? Across the nation:
“Mentally Ill Offenders Strain Juvenile System”
~ New York Times, August 9, 2009
All Males Females
Any Disorder 70.4 66.8 81.0
Anxiety Disorder 34.4 26.4 56.0
Mood Disorder 18.3 14.3 29.2
Disruptive Disorder 46.5 44.9 51.3
Substance Use Disorder 46.2 43.2 55.1
Shufelt & Cocozza, 2006

5. In San Francisco, probation youth with behavioral
health needs are a shared challenge
Child, Youth and Family System of Care (CYF-SOC)
Romney, Turner, Bleecker, Israel & Lipton, 2008

6. How we view a problem changes what we do
Born Bad Born Good
Views
informed by
evidence or
prejudice?

7. A different view: A majority of SF probation
youth had received prior treatment
In 2009-10,
61% of
youth
screened
had prior
contact with
behavioral
health
services.
Butts, Bazemore, & Meroe, 2010

8. At detention intake, more prior treatment associated
with higher functioning
Correlation Between Acuity of Needs at Intake and Total Hours of
Services Received in Year Prior to AH Intake (N=38)
R=.34, p<.05

9. Multiple factors drive the different pathways to
detention for youth with serious mental illness (SMI)
System
Are needs identified?
Who are the decision-makers?
High stakes decision-points
Capacity & Cost
Neighborhood
Guns-Gangs-Drugs
Poverty
Family
“He’ll grow out of it”
Knowledge
Resources
School
Teacher Quality
Learning Supports
Disciplinary Policies
Truancy Response
PBS
Youth
Stigma - “I’m not crazy”
Avoidance - “Problem will go away”
Service Access – Safe, convenient, meaningful

10. SF AIIM Higher
 A U.S. DOJ-funded partnership
 An interdisciplinary team located at the Juvenile Justice Center
 On-site standardized clinical screening/assessment, and data-driven plan
development combined with linkage to and engagement in appropriate
interventions following discharge
 Designed to target multiple factors at the individual, program and systems
level associated with juvenile justice contact for youth with SMI
 Based on the National Center for Mental Health and Juvenile Justice’s
Blueprint for Change: A Comprehensive Model for the Identification and
Treatment of Youth in Contact with the Juvenile Justice System (Skowrya &
Cocozza, 2005) and on-the-ground expertise

11. Integrate justice and behavioral health perspectives
Cornerstones of an evidence-based
High comprehensive model*
Severity
High MI High MI 1. Juvenile justice & behavioral health systems
Low Risk High Risk should collaborate and communicate at
critical intervention points.
2. The behavioral health needs of youth should
Mental be systematically identified at all critical
stages of juvenile justice processing.
Illness
Low MI Low MI 3. The behavioral health needs of youth should
Low Risk High Risk be systematically addressed in the
dispositional planning process.
4. Youth with behavioral health needs in the
Low juvenile justice system should have access to
Severity
High
Severity
effective EBPs to meet their needs AND to
address their criminogenic risks.
Risk to Community Safety
*Skowyra & Cocozza, (2007). Blueprint for Change: A Comprehensive Model for the
Seriousness of Crime, Disposition, Identification and Treatment of Youth with Mental health Needs in Contact with the Juvenile
Type and Length of Placement Justice System, The National Center for Mental Health and Juvenile Justice.

12. Identify a critical and feasible
intervention point

13. Operationalize Steps and Deliver
Probation initiates referral @ critical
points: Intake, Detention, Supervision.
Build on existing PO presents case.
mechanisms.
Screen for eligibility.
Complete CANS in 72 hours.
Review CANS & YASI results &
possible interventions.
Plan, link, & outreach.
Youth & family access and engage in treatment.

14. Year 1 Goals
1. Standardize screening and assessment.
2. Share information, structure decision-making
and plan collaboratively.
3. Mobilize youth and families for change.
4. Monitor, feedback, and adjust for individual,
program and system level progress.

15. Goal 1. Standardize screening and
assessment.

16. Most AIIM clients were older, male
and African American (N=47)
Demographic Characteristics Percent N
Age
Ages 11-14 30% 14
Ages 15-17 70% 33
Gender
Male 64% 30
Female 36% 17
Race/Ethnicity
Asian/Pacific Islander 4% 2
Black or African Descent 62% 29
Latino/Hispanic 26% 12
Multiracial 2% 1
White 6% 3

17. Target eligible population with screening
Crisis Assessment Tool-10
(CAT-10) Indicators & Action Levels
Items 0 1 2 3
Eligibility
1.SF Resident
Suicide Risk If >“2” = +1
2.Under 19
Danger to Others If >“2” = +1 3.Detained for > 72 hours
4.SMI
Judgment If >“2” = +1 5.Multiple treatment “failures”
Psychosis If >“1” = +1
Impulsive/Hyper If >“2” = +1
Recommended Level of Care Key
Depression If >“2” = +1
0-1: No evidence of needs and/or
Anxiety* link to outpatient as needed
2-4: Moderate to High
Trauma* Needs/Intensive community services;
Complete full CANS & Link
Anger Control If “3” = +1
5-7: Acute/Immediate intervention
required; Complete full CANS &
Sub Abuse* Stabilize/Hospitalize
Total >”2” = SMI

18. Provide services to youth
with more acute needs

19. At intake,
judgment, danger to others, and anger control were
the most prevalent needs (N=47)
Items Actionable Needs
Suicide Risk 11%
Danger to Other 74%
Judgment 87%
Psychosis 6%
Impulsive/Hyperactivity 53%
Depression 55%
Anxiety* 66%
Trauma* 62%
Anger Control 73%
Substance Abuse* 47%

20. Most had intensive community treatment
prior to detention.
Level of Care Prior To Detention (N=47)
N=6
N=8
N=14
N=17

21. Most had not been in treatment for a year or more
Time between last session and detention (N=47)

22. A transparent collaboration tool:
CANS Ratings
 Behavioral/Emotional Needs
 Life Domain Functioning
 Risk Behaviors
 Child Needs
 Child Strengths
 Caregiver Needs/Strengths
 Foster Caregiver Resources and Fit
 Other Treatment Needs
None Moderate Severe Profound
Act Immediately
No Monitor Act
action

23. Other clinical concerns emerged with
full CANS assessment (N=47)
Clinical Concern
Behavioral & Emotional Needs
Anger 83% Clinical Concern
Anxiety 62% Risks
Oppositional 62% Judgment 68%
Substance Use 53% Delinquency 64%
Depression 51% Danger to Others 57%
Hyperactivity/Impulsivity 38% Run 23%
Trauma 38% Self Harm 17%
Conduct 11%
Psychosis 6% Caregiver Context
Safety 36%
Functioning Supervision 34%
School Achievement 75%
Resources 23%
School Behavior 72%
Trauma 23%
School Attendance 64%
Knowledge 21%
Family 64%
Living Situation 62% Residential Stability 21%
Recreational 45% Mental Illness 19%

24. Goal 2. Share
information, structure
decision-making and
co-plan.

25. Probation as partner in structured decision-making
every step of the way
•Based on Medi-Cal and program requirements
for entry into different levels of care.
•Considers both the presence of more risky or
immediate needs, as well as the breadth of
needs
•Increasing number and severity of needs
mean that the case is more complex, requiring
more intensive supports.
• Youth with more complex cases are more
likely to have multiple co-occurring diagnoses,
problems in multiple environments and to have
fewer supports.
• Recommendations for consideration of a
specific level of care are the result of an
algorithm that matches client case complexity
These tiers represent the minimum severity needed with the frequency and intensity of supports
to consider the use of services at a particular level. most likely to be helpful.
As such they do not require that services at that level
are provided, rather only that they are considered.

26. Paradigm shift: From service “pile-on” to
matching needs to level of care

27. Turn CANS Data into Action
• Provide brief written summary of results, LOC & menu of
services.
• Dialogue to offer options and build consensus around plan.
• Facilitate referrals and linkages
• Follow youth and family through until engagement.
“Based on the CANS, the Level of
Care determination to best meet
the behavioral health needs of this
child and family is TIER TWO:
INTENSIVE HOME BASED
SERVICES. Options include:
Seneca Connections, Family
Mosaic Project, and MST.”

28. Goal 3:
Mobilize youth and
families for change.

29. Identify key strengths to offer activities that foster
autonomy, connection, self-regard and safety
Useable Strengths
Child
Family 55%
Optimism 53%
Talent 53%
Interpersonal 49%
Religion 47%
Well Being 36%
Vocational 19%
Education 13%
Caregiver
Involvement 43%
Organization 36%
Knowledge 32%
Residential Stability 30%
Resources 28%
Supervision 19%

30. “How to do ‘you’ without getting picked up?”
Use strengths as leverage for change
•Develop & use skills and competencies
•Take on new positive roles and responsibilities
•Develop self-efficacy and confidence
“C is very interested in employment
•Develop and enjoy sense of belonging opportunities. Placement at JVS Pre-
employment Program while he
improves his school attendance might
“incentivize” his overall academic
progress. Once stable, he could easily
transition into a paid part-time job
working in his chosen area, MYEEP
Boys and Girls Club or weekend work
opportunities with the Giants
Stadium.”

31. Goal 4. Monitor, provide
feedback, adjust plan as
needed, repeat.

32. Scaffold progress with multi-level feedback
Level Tangible Benchmarks Outcomes
Individual Work with AH Follow-up CANS
“Makes appointments”
Follows the case plan
Improved well-being & functioning
No new charges
Program Immediate Access Aggregate CANS
Engagement for AH Clients linked to “MST”
Provide LOC indicated
System More collaboration (1 plan) Reduced recidivism
High AH-JPD Agreement Increased
Engagement for AH Clients overall and by functioning
tier.

33. When you get decision-makers on the
same page about needs and services…
Number of Needs on 3 Relevant CANS Number of Needs on 3 Relevant CANS
Domains by Recommended Level of Care Domains by Actual Level of Care (N=44)
(N=55)
R=.42, p<.001 R=.30, p<.05

34. Youth are more likely to engage in
appropriate services

35. Future Plans
 Examine outcomes at 6-month and 1-year as
compared to sample of “treatment as usual.”
 Look for and utilize the bright spots
o Develop a decision-making care algorithm that utilizes
specific strengths-needs clusters.
 Improve information sharing to better understand
pathways to juvenile justice involvement for youth
with SMI and pathways to health and well-being.