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MENTAL HEALTH SERVICES FOR YOUTH IN THE SACRAMENTO COUNTY JUVENILE JUSTICE SYSTEM

Subject of Investigation

  1. Treatment programs, staff and funding available for mental health care for juveniles detained in correctional facilities.
  2. Adequacy of services and constraints to provide that care.
  3. Changes that are needed in existing procedures and policies.

Reason for Investigation

During tours of juvenile detention facilities in Sacramento County, Grand Jurors heard reports from those who work with youth that minors with serious psychiatric problems are placed in Juvenile Hall and other correctional facilities that are not equipped to care for them.

Method of Investigation:

Members of the Grand Jury:

  • toured juvenile facilities and met with correctional staff;
  • conducted interviews with staff of mental health, social services and probation departments;
  • reviewed Reports of two previous Grand Juries, the Human Resources Element of the Sacramento County General Plan, Title 15 Regulations, applicable sections of the Welfare and Institutions Code (W & IC) and California Code of Regulations (CCR), and the Comprehensive Juvenile Detention Plan; and
  • attended monthly meetings of the Juvenile Delinquency Subcommittee on Mental Health to hear reports regarding issues concerning delinquent minors with serious mental health problems.

Background

There is consensus among mental health and criminal justice professionals that a large proportion of youth passing through the juvenile justice system need treatment for serious psychiatric disorders. There is also widespread agreement that the criminal justice system is not equipped to provide that care.

Professional staff have expressed frustration about the scarcity of resources. fragmentation of the system, and lack of continuity of services. For lack of appropriate alternatives such as community treatment facilities, incarcerated minors who need mental health treatment are not getting it. As one professional put it, "The juvenile justice system is the mental health system of last resort."

Sacramento County's mental health system for treatment of children and youth is bifurcated. Services for incarcerated minors are provided through the Department of Medical Systems and are under the direction of the Chief Probation Officer. For all other minors, services are provided under a Director of Mental Health. Each has its own funding stream and eligibility criteria. Ultimately, all are answerable to the Administrator of the Public Protection and Human Assistance Agency of the County of Sacramento.

While California law generally precludes the use of MediCal funds for persons in correctional facilities, a California regulation (Title 22, Article 6, CCR Section 50273) permits the use of MediCal funds for incarcerated minors under certain conditions. It appears that the Department of Medical Systems has not tapped that source, as has at least one other large California county. Further, Section 11016 of the California W &IC provides for the following:

" Notwithstanding any other provision of law, no person for whom federal financial participation is available shall be denied benefits, for which federal financial participation is available, solely because such person is incarcerated in a county or city jail or juvenile detention facility."

As one official stated, "There is no system of mental health care now for youth in the criminal justice system, but pieces of a system that do not come together."

It has been estimated that anywhere from 20% to 60% of youth in detention have some form of mental illness or psychiatric problem. Last year the average daily population of youth in custody in Juvenile Hall, the Warren E. Thornton Center and Boy's Ranch ranged from 411 to 459. Bed capacity was exceeded by approximately 7%. Of that population, approximately 25 % needed mental health services. On one day, 18% were receiving psychotropic medication. Some are suicidal. These numbers continue to grow.

While counseling is provided by mental health workers for crisis management in some detention facilities and medication is administered by nurses, most youth in need of care receive no psychotherapy. At the time of one visit to Juvenile Hall by the Grand Jury, about 15 minors were receiving mental health counseling through a grant obtained for group therapy.

Juvenile Hall, with a total bed capacity of 261, was operating at 126% of capacity at the time of the Grand Jury's most recent visit. It is staffed with a nine-member team to provide mental health care. In addition to two consulting psychiatrists, one for 20 hours a week and the other for 30, it includes a full-time program manager; a full-time supervisor; five full-time and two part-time clinicians; and a full-time psychiatric nurse. None of this allows for 24-hour coverage.

The 50-bed Warren E. Thornton Youth Center (WETYC) has no treatment program. In March of this year, the center expanded on-site counseling services from eight hours a week to 40 hours a week. At WETYC there is one full-time behavioral health counselor and one full-time clinician whose time is devoted chiefly to crisis response and follow-up counseling.

At Boy's Ranch, with the capacity for 100 youth and an average daily population of 99, care for disturbed youth is provided by one psychiatrist who spends four hours a week overseeing psychotropic medications which are dispensed by nurses. There is also a full-time (40 hours a week) mental health worker who is available to help youth deal with personal problems such as sleep disorders or family crises. The number of contacts made by this worker, who could be a psychologist or a social worker, averages 155 in a month.

Placement facilities such as group homes, halfway houses or other transitional facilities are needed upon release from a correctional facility for juvenile offenders with psychiatric problems. The average length of stay in Juvenile hall is about 18 days, yet a minor for whom there is difficulty in finding placement could be consigned to Juvenile hall for as many as 400 days or more. Some have been held, waiting for placement, for up to 1000 days. During that time, minimal treatment is rendered.

Last year, 55 to 60 minors in correctional facilities were waiting for placement in group homes. Many of them were on psychotropic medications. Detention of minors with serious mental health conditions due to lack of alternative placements and facilities where they can receive treatment is considered a serious contributing factor to the overpopulation of Juvenile Hall. This creates safety risks to the staff and general population of the facility. The high demand for custodial services to these minors is a drain on the resources available to serve other minors in the facility.

The criminal justice system needs the ability, after a minor is diagnosed as needing mental health care, to place that youth in a mental health setting where he or she can be stabilized and treated. According to probation officials, there is no room at any of the correctional centers for mental health beds. All correctional officers to whom the Grand Jurors spoke agreed that a separate secure facility, staffed with mental health professionals, is needed for youth who present a danger to themselves or others. The estimated capacity, judging by current needs, would be 25 beds.

Youth with acute mental health disorders, approximately 15 on any given day, and from 30 to 40 with subacute conditions, constitute the population which, for lack of treatment, result in extended stays in Juvenile Hall. These youth would be better served in a free-standing, secured mental health facility or residential treatment center.

This is not a new issue. The 1992-1993 Grand Jury found that 90% of the population then at Juvenile Hall suffered from mental health problems, with nearly one-third in a state of crisis and 6-7% on psychotropic medications.

The Grand Jury recommended to the Sacramento County Board of Supervisors that no further cuts be made in mental health staff and that more funds be appropriated for services at Juvenile Hall. It was also recommended that alternatives be found for placement of juveniles with severe mental health problems.

The County Executive responded that the Chief Probation officer was trying to obtain grant funds for staff and treatment programs. The Chief Probation Officer responded that "psychiatric time" had been expanded by two hours a week and that the Probation Department had participated with other county agencies in applying for a grant with which to upgrade mental health services for minors.

In its 1999-2000 Final Report, the Grand Jury cited estimates of 22% of youth in detention as having some form of mental illness. The Grand Jury recommended that the Board of Supervisors direct the County Executive to develop a report on how to meet mental health needs of incarcerated juveniles with psychiatric problems. The response by county officials did not address the recommendation and, according to officials, no report was produced.

The Human Services Element of the County General Plan, adopted in 1994, cites the inadequacy of mental health services for minors. It lists goals, policies and strategies for improving them. Pointing to a fragmented system of human services, the County recognized in that report the need for "...a system of coordinated care which cuts across agency and categorical lines... to provide consistent services to mentally ill children". Explicit in the plan is a commitment to assure access to human services and to coordination of services, but those for incarcerated youth are still considered to be inadequate, understaffed and underfunded.

The County of Sacramento depends on state and federal grants for care and treatment of mentally ill children and adults. No county funds are expended for mental health treatment. Medical-eligible children and youth up to the age of 21, and their families, are entitled by federal mandate to services to treat or ameliorate any mental health condition. Funds to comply with that mandate, primarily Medical, for which there is a 100% entitlement, are limited only by lack of qualified professional staff, according to county officials. Children and youth for whom the County has responsibility - i.e. those held in correctional facilities - by state law are generally not eligible for most categories of funding available to others. Their treatment, for the most part, is paid for with funds under Realignment Legislation (W & I Code Section 5600.) which are derived from sales taxes and vehicle license fees and are limited, as they are affected by economic fluctuations. As noted, Sacramento County has not pursued available Medical funds for certain incarcerated minors, as has been done successfully in Los Angeles County.

Realignment funds are dedicated by the County to three main areas of services: public health, mental health and social services. The Board of Supervisors has the authority to move from 10% to 15% of these funds from one program to another. Recently, money was moved from mental health and social services to public health.

Conclusions

Many youth are in the correctional system because of a lack of community treatment facilities for those whose behavior is due to psychiatric disorders. Their criminality is directly related to their mental health status and correctional facilities are not staffed to deal with them. The care they receive is crisis based rather than treatment based.

Incarcerated youth do not have access to a system of care equal to that which is provided to youth outside of the criminal justice system. Resources allocated to the juvenile justice system for care and treatment of minors with psychiatric and behavioral disorders are inadequate.

Upon release from a detention facility, many minors need to be placed where they can receive appropriate treatment for psychiatric problems before they repeat behaviors that will return them to Juvenile Hall. If community treatment facilities were available, the time a youth waits for placement could be reduced as would overcrowding at Juvenile Hall.

In all juvenile detention facilities there is a need for coverage by mental health staff 24-hours a day, 7 days a week.

Findings and Recommendations

Finding # 1. Resources allocated for the criminal justice system for the care and treatment of minors with psychiatric and behavioral disorders are inadequate.
Recommendation # 1. Resources allocated to the criminal justice system for the care and treatment of minors with psychiatric and behavioral disorders should be increased to provide at least the level of care afforded to those not incarcerated.
The County should be proactive in seeking funds available for care and treatment of mentally ill juvenile offenders. If necessary, the County should advocate for changes in MediCal eligibility.

Finding #2. Juvenile Hall is not equipped with staff or space, and no secure treatment facility exists to treat youth with severe mental health problems and who present a danger to themselves or others.
Recommendation #2. The County should provide a 25-bed free standing, secure facility for juveniles whose mental conditions require acute and subacute levels of care. Such a facility should be staffed with qualified professionals and meet security and community health standards set by the Department of Corrections as well as accepted psychiatric accreditation and staffing standards.

Finding #3. Title 22, Article 6, CCR Section 50273 specifically allows for MediCal funding to be used for health care for minors in a juvenile detention center prior to disposition, under certain circumstances (for those awaiting placement).
Recommendation #3. The Board of Supervisors should direct the Director of Medical Systems to immediately pursue MediCal funds for mental health treatment for incarcerated juveniles, where legally appropriate.

Finding #4. Sacramento County separates mainstream care from care and treatment of those in the correctional system.
Recommendation #4. The County should establish procedures to facilitate collaboration and cooperation between departments and agencies responsible for mental health care for incarcerated youth that would provide a seamless continuum of care.

Finding #5. There is a lack of placement resources and long-term treatment facilities for youth with mental disorders being released into the community.
Recommendation #5. Release from a detention facility should be accompanied by a discharge plan that includes follow-up on prescription medications and other essential treatment, and the facility should have staff adequate to perform this function. Funding and records should follow the minor wherever the minor receives, or should receive, mental health care.

Finding #6. There is no evidence that policies in the Human Resources Element of the General Plan have been implemented, nor have recommendations of previous Grand Juries resulted in significant improvements.
Recommendation #6. The Board of Supervisors should review policies they have adopted and correct inequities that exist in the treatment of youth in need, whether in a group home, a correctional facility or on probation.

Response Required

Penal Code Section 933.05 requires that specific responses to both the findings and recommendations contained in this Report be submitted to the Presiding Judge of the Sacramento Superior Court by September 30, 2001, from:

  • Sacramento County Board of Supervisors
  • Chief Probation Officer
  • Director of Medical Systems
  • Administrator of Public Protection and Human Assistance Agency

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    2000/2001 Sacramento County Grand Jury - Final Report (Internet Version) June 30, 2001

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