What factors make Youth Mental Health Courts successful at serving youth with mental illness?

Evidence Brief

What you need to know

  • Youth mental health courts (YMHCs) help direct youth with mental illness away from the justice system. They also adopt a more collaborative and less adversarial approach than a regular court.
  • YMHCs lead to improved mental health outcomes for youth, and may also help reduce rates of reoffending.
  • Successful YMHCs use a multi-disciplinary approach, and involve youth, families, and the community. 
  • The important components of YMHCs include use of systematic and comprehensive screening and assessment to identify mental health needs, level of motivation, problematic behaviour, and other factors associated with criminal behaviour. 
  • Other key ingredients of successful courts include a therapeutic relationship between the judge and youth and connecting youth with mental health services that meet their needs. Ensuring adequate supervision and monitoring for youth, as well as education and training for those working with youth are also critical. 
  • Successful YMHCs are those that can be sustained over time. Sustainability relies on use of evaluation to build and maintain funding, and to signal to other jurisdictions that the model is successful. 

Read the full rapid review below or download the PDF.

What’s the problem? 

A high proportion of youth involved in the criminal justice system experience mental illness, and do not receive the support they need to get better.1 To help address this concern, youth mental health courts (YMHCs) were established to divert these youth out of the court system and into community treatment.2 Modeled after adult mental health courts in the United States, YMHCs or juvenile mental health courts, as they are known in the U.S., adopt a more collaborative and less adversarial process than a regular court.2,3 

With a focus on age-appropriate services and cooperation with family members, YMHCs are an effective alternative to detention centres and psychiatric facilities.4,5 YMHCs have also been shown to improve mental health outcomes for youth, and may also help reduce rates of reoffending, especially for violent or aggressive offences.6,7,8,9 

While YMHCs have existed in the U.S. since the early 2000s, Canada opened its first YMHC in 2008. As a result, there is limited research on the effectiveness and functioning of YMHCs, especially within a Canadian context.3 Members of the Youth Mental Health Court Implementation Accelerator (YMHC IA) in Ottawa requested this rapid review to identify the factors that make YMHCs successful. The Centre for Addiction and Mental Health’s Provincial System Support Program provides implementation, knowledge exchange and coaching expertise to the YMHC IA. The YMHC IA project team will use these success factors, in conjunction with interviews from people involved in the Ottawa YMHC, to identify where program changes can be made to improve outcomes for youth. 

What did we do?

We conducted a rapid review of the literature on the success factors of YMHCs in Canada and the U.S. Given the lack of evidence on YMHCs,2,8,10 we looked at articles that discussed characteristics or components of YMHCs to discern the success factors. These factors could be anything from program elements that improve outcomes for youth (such as engagement of youth and their family), to specific aspects of the court process that authors suggest are essential for their success (such as training and education).

All of the articles included in this review either comment on those aspects of the court program and process that are working well, or recommend specific changes to existing courts to ensure their success. In one case, a process evaluation conducted on the Toronto YMHC isolated two factors associated with successful completion of the program. While both of these factors (the level of youth motivation and diagnosis) are individual-level characteristics they may be helpful when thinking about elements of the Ottawa YMHC that could be improved. To generate this list of success factors, each factor had to be mentioned by at least two authors as a critical or essential element of successful YMHCs across the studies reviewed. This number was chosen as a threshold, because only 14 articles were included in the review, so there were not many opportunities to see patterns in the literature. 

With help from CAMH library services, we searched the academic literature in August 2016 using the following databases: PsycINFO, Medline, and the Cochrane Database of Systematic Reviews. Google Scholar and Google were also searched to obtain non-published grey literature pertaining to YMHCs. Key words included: “mental health court” or “problem solving court” and “youth or young, or teen* or juvenile* or adolescen*”. All articles from the year 2000 onwards were included for review. Criteria for inclusion included any article that discussed youth or juvenile mental health courts in addition to one of the following areas:

  • characteristics or components of youth mental health courts;
  • success factors; or
  • outcomes.

The review excluded articles that:

  • mentioned YMHCs in passing;
  • combined information about adult and youth mental health courts where results or characteristics of the latter could not be teased out;
  • were purely theoretical in nature; or 
  • did not focus on one of the three aspects above.

What did we find?

Following a review of titles and abstracts, 14 articles were considered relevant. Below is a list of success factors or important components of YMHCs identified in the literature. Where possible, suggestions on how to put these components into practice are also noted. 

1. Multi-disciplinary team approach 

A common feature of YMHCs across jurisdictions is the use of a multi-disciplinary team approach that involves probation officers, court officials, social workers, and others.4,10 This approach involves people with various perspectives, goals, and practices working to divert youth with mental health issues away from the traditional court system.11 United by this shared vision, the team is able to tailor interventions to the young person and determine which services will produce the best outcomes.6,11,12 Several authors have suggested that this multi-disciplinary approach is the hallmark or greatest strength of the YMHC model11,12 and could be the key component in reducing reoffending among youth.6 

Including mental health nurses as part of this multi-disciplinary team has also been suggested as a specific component.1 As a result of their knowledge and experience assessing and treating youth with serious mental health concerns, such nurses could play an important role in collaborating with medical professionals, youth, and families.1 

2. Youth, family, and community engagement

Involving youth, families, and the wider community in the YMHC process was commonly cited as an important success factor.3,5,11,12 Parent support and cooperation is especially important, as they help keep youth accountable to the program.13 Family dysfunction and educational difficulties have also been identified as known risk factors for reoffending.2 Also, extending involvement to the entire community to garner support and commitment appears to help in sustaining mental health courts over time.13 

Establishing a series of evidence-based steps to engage families, both during the court process and the treatment process, is a potential mechanism to increase youth and family engagement.3 Another potential mechanism is to involve a trained parent whose own child has been through the system to provide information and encouragement to current participants.11 

3. Early screening and comprehensive assessment

A common recommendation is to include age-appropriate screening at the beginning of the court process, followed by a comprehensive assessment.2,3,5,11,13,14 System-wide or universal screening of youth who appear in any court ensures that those with mental health needs can be diverted to the appropriate system.2,3,14 Early screening has also been identified as the most important step of the entire YMHC process.5 

A well-designed, routine screening process could also solicit referrals from psychiatrists early, which will lead to early intervention and help ensure youth who need mental health treatment don’t slip through the cracks.11 Using evidence-based screening tools, such as the Massachusetts Youth Screening Instrument-Version 2 (MAYSI-2), and screening for trauma, substance use, and suicide risk, help ensure the young person’s suitability for the program.13 If the initial screener identifies a problem, youth should be given a more comprehensive assessment of mental health functioning, to better understand their unique needs and strengths.3 By providing this holistic clinical profile, teams are better able to make case-specific decisions and develop evidence-based treatment plans.3,13 

Findings from the Toronto YMHC showed that youth with higher levels of motivation and at least one confirmed mental health diagnosis were significantly more likely to complete the program.2 Courts should screen for these factors during intake and consider them when developing treatment plans. Implementing a motivational enhancement component for youth with low motivation could also help ensure these youth complete the program.14 

4. Addressing criminogenic needs

YMHCs are often premised on the idea that treating the mental health needs of youth within the court process will lead to reduced recidivism and increased well-being.3 However, in an evaluation of the Toronto YMHC, only one in five youth had charges that were a direct result of their mental health functioning.3 For the remaining 80% of youth, other factors played a role in their criminal behaviour and rates of reoffending, such as family functioning, antisocial attitudes, and delinquent peer groups.3 In addition to systematically assessing and addressing the mental health needs of youth, YMHCs should also be designed to assess and address their criminogenic needs. Criminogenic needs are internal and external factors that contribute to a youth’s criminal behavior and reoffending (such as lack of empathy, lack of self-control, and substance use).2,3,14 

Criminogenic needs can be modified by YMHC team members. Once a criminogenic needs assessment is complete, an individual treatment plan should be developed to ensure youths’ unique needs are met.2 Civil advocates can play a role in addressing some of these factors, such as lack of housing, education, and employment, by connecting youth to the appropriate services and supports.11 

5. Therapeutic jurisprudence 

Another successful aspect of YMHCs is the less formal and more collaborative relationship between the court or judge and the young person.3,13 The judge can create a supportive environment that helps youth succeed in the program by engaging with them by name and praising them for achieving specific milestones or adhering to conditions.3,8,13 This therapeutic approach to jurisprudence is a key reason for the reduced recidivism and mental health symptoms found in one study.8 

6. Treatment planning and services

Given the centrality of mental health treatment services in the YMHC model, it is unsurprising that many authors comment on the importance of individualized, intensive, consistent, and collaborative treatment planning and services.2,8,12,14 Involving youth, families, service providers, and the wider community (e.g., schools) in treatment planning, and sharing the completed plans with these stakeholders, are important for successful outcomes.2,12 However, involving multiple people in this care plan has to be balanced with the young person’s right to privacy regarding their medical, mental health, and school information.3,5 

The intensive nature of treatment and continuity of care have also been identified as two components associated with substantially reduced recidivism and psychiatric symptoms.8 Intensive case management may be one way to ensure that youth are connected to services and that those services are meeting their needs.3,11 Treatment services are most successful when they are informed by valid assessments and contain the following four characteristics: 

  • highly structured programs that target skills and beliefs instead of less structured programs such as general therapy or counseling;
  • a cognitive component incorporating anger management, problem solving, perspective taking, and empathy;
  • family engagement in treatment and efforts to reduce family risk factors; and 
  • efforts to address a variety of risk factors across several contexts (e.g. school, home).3 

7. Supervision and monitoring compliance

Intensive supervision and monitoring are vital to ensure youth complete the program and comply with treatment orders.10,14 Mechanisms to ensure youth comply with the program include judicial review hearings, community supervision, home visits, electronic monitoring, and use of an advisory group to coordinate progress across sectors.10,14 Probation officers can also play an important role by supervising youth in the community.10,13 It’s also important to draw up a list of actions to be taken if the young person violates the program requirements and discuss it with them at the beginning of the process.5 

8. Education and training

Formal training and education for families, judges, lawyers, police, and school officials is important for successful YMHCs.2,5,11,14 Education should be provided on the nature of the YMHC in general and the intersection between mental health and criminal behaviour.2,14 Specific training needs for YMHC team members could also include how to engage and understand youth with mental illness, diagnosis and treatment, and available community-based services and supports.11 

9. Evaluation and funding support

Adequate funding has been identified as a crucial factor in sustaining YMHCs over time.4,11 Instituting mechanisms to collect and report on outcome data for youth and families will help build and maintain funding.5,11 Positive outcome data can also be shared with other jurisdictions to show them the potential of the YMHC model.11 Data collection could include outputs (such as the number of youth screened), participant characteristics (such as types of mental illnesses), immediate outcomes (such as rates of program completion), and the long-term impact on youth and families.5 Surveys conducted at the beginning, middle, and end of the program will demonstrate if progress is being made and indicate areas that might be improved.5 

What are the limitations of this review?

The biggest limitation of this review is related to the definition of “success factor.” All of the articles reviewed commented on the characteristics of YMHCs. In most cases authors mentioned which characteristics they believed contributed to positive outcomes. However, without studies that isolate these variables, it is difficult to know which ones are causing the changes seen. It is also impossible to determine which success factors are most important or which mix of factors contribute to positive outcomes. This is a gap in the literature that requires further investigation. Given the subjective nature of determining which elements can be considered success factors, it is also possible that a different researcher could have reached alternative conclusions on the final list.

Another limitation concerns the specific scope of this review. Due to the research question, the articles that were included only focused on YMHCs and not on adult mental health courts, or other youth diversion programs (e.g., extrajudicial sanctions). Alternatively, the review could have looked at the successful outcomes of justice-involved youth with mental health problems, regardless of their court experience, to try and understand what factors contributed to their success. In both cases, expanding the scope could have yielded more information and, thus, could have influenced the results. 

What are the conclusions?

This rapid review has presented some of the initial work on YMHCs in Canada and the U.S. It is clear there is still much work to be done in looking at the specific components that lead to beneficial outcomes for youth involved in YMHCs. Future research should focus on process evaluations of YMHCs, especially within a Canadian context, to determine which factors or mix of factors make the most difference for youth.

Beyond the YMHC IA, this review may be helpful to other jurisdictions that have YMHCs or similar programs. Based on the information gathered, especially the recent work on the Toronto Community Youth Court, it is clear that YMHCs are of interest to policymakers and system leaders. Not only can they help improve mental health outcomes for youth who come into contact with the justice system, but they may also help reduce recidivism and significantly reduce violent aggressive offences.6,7,8,9 

 

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