Abstract
The goal of our study was to describe the availability of community child and adolescent mental health services, trauma-informed care, and the geographic accessibility of these services for juvenile justice-involved (JJ) youth who received mental health services while in secure detention. Data collection occurred through direct contact with the child and adolescent outpatient clinics listed on the New York State Office of Mental Health website. Zip codes were collected from the juvenile secure detention census. Of the clinics contacted, 88.5 percent accepted JJ youth; however, 43.5 percent accepted them on a conditional basis. Only 62.1 percent offered trauma-informed care, including evidence-based interventions and unspecified care. Although 84.5 percent of the clinics that would accept this population reported currently accepting new patients, reported wait times were as high as six or more months. When JJ residents’ home zip codes and those of the clinics were geographically mapped, there were few clinics in the zip codes where most residents lived. The clinics that accepted youth on a conditional basis often refused high-risk patients, essentially ruling out a large majority of this population. The geographical inaccessibility of these clinics limits their ability to provide care for this vulnerable population.
It is estimated that as many as 75 percent of juvenile justice-involved (JJ) youth meet criteria for a psychiatric disorder.1,–,9 Of those with a psychiatric disorder, approximately 75 percent meet criteria for two or more disorders and many have experienced significant childhood trauma.1,6,10,–,14 JJ youth report rates of substance use far above their same-aged peers, with two-thirds meeting criteria for a substance use disorder.4,5,11 Additionally, one-third of incarcerated youth reported recent suicidal thoughts and one-tenth reported prior suicide attempts.10 These youth experience four times the risk of death by suicide or homicide compared with their nonincarcerated peers.15
When left untreated, these mental health disorders are likely to endure and even worsen, which may lead to further negative outcomes.16 Youth with a history of trauma, posttraumatic stress disorder (PTSD), or co-occurring behavioral and emotional problems have higher rates of rearrest and future violent crimes.11,15,17 Youth who do not receive mental health services have higher rates of and reduced time to recidivism.7,18 Although referrals to mental health in this population have historically been low, engagement with these services improves success in reentry into the community.7,19
The literature on mental health treatment associated with the juvenile justice system is limited and generally focuses on treatment prior to or separate from arrest.7 The current data indicate that referrals to mental health care, during justice involvement and after release, improve outcomes. Despite this, as few as 15 percent of youth receive mental health treatment while detained.11 Of the therapeutic services provided, substance use counseling is the most common.2 Although some facilities provide initial screening services for mental health disorders, suicide risk, and substance use, many of these programs are not staffed by mental health professionals.2,11,20 Additionally, many facilities are unable to offer psychotherapy or other mental health services outside of crisis management.11
Continued mental health services after receiving care in juvenile justice facilities have been associated with increased success in pursuing education and employment.15 Furthermore, it is known that providing a first appointment eases the transition to community care.16 Although extensive reentry programs have been developed for adult populations, they remain largely unavailable for children and adolescents.11 As a result, youth are often released without aftercare referrals or reentry programming and must seek services on their own.4,18 In the community, JJ youth experience numerous barriers to accessing mental health services, including, but not limited to, scarcity of providers who accept JJ youth, long waiting lists, high costs, poor insurance coverage, mental health stigma, racial bias, onerous reentry paperwork, distrust of providers, lack of transportation, and lack of information provided by the justice system.8,11,15,16,18,21 When youth and their families have access to increased systemic coordination, referrals, and structured guidance, there is greater engagement with care.18 Although systematic coordination of care is a crucial component in the reentry process, success hinges on the availability and accessibility of reentry services.
In addition, it is well established that geographic accessibility of mental health services affects care utilization in both rural and urban areas.22,–,27 Increased travel time required to access mental health care reduces the likelihood of proper diagnosis and treatment.23,25,–,27 The burden of travel time disproportionately affects patients with limited resources and time flexibility.25 Yet the geographic accessibility of mental health services for JJ youth has not been studied.
Given the benefits of mental health aftercare for JJ youth and the barrier posed by lack of accessible services, this study examined the availability of child and adolescent aftercare in New York City for JJ youth. This study also documented the services offered by available clinics (i.e., therapy, medication management, trauma-informed care). Finally, geographic accessibility of clinics was examined by comparing clinic locations with the home zip codes of a sample of JJ youth.
Methods
This study employed the methods described by Cervantes et al.28 in their 2022 study of mental health service availability for autistic youth in New York City. The New York State Office of Mental Health (NYSOMH) manages their own psychiatric centers and provides certification and oversight for over 4,500 mental health programs run by local government and nonprofits across the state.29 NYSOMH offers an advanced search tool on their website that allows patients, families, and providers to search OMH-sponsored facilities using specific criteria. Utilizing this “Find a Mental Health Program” search tool30 on the NYSOMH website, we extracted a list of all NYSOMH-certified clinics in New York City that provide outpatient mental health services for children and adolescents (search criteria: region, New York City; program category, outpatient; program subcategory, clinic treatment; population serviced, children and adolescents). The search yielded 175 clinics across all five boroughs with two clinics having an additional site that was identified later during the research process. The final sample included 177 clinics.
Procedures
This project did not require review by the New York University (NYU) institutional review board as the research did not involve human subjects, did not access identifiable private information, and did not collect any private data or specimens.
The identified NYSOMH sites were divided between three authors (T.M., N.K., and E.W.). These authors contacted programs following a standardized protocol. Callers began by stating:“Hi, my name is (insert caller first name) and my team and I are building a resource for teens who have been involved in the juvenile justice system. Does your clinic offer treatment to patients with a history of juvenile justice involvement?”
If the answer was no, respondents were asked for reasons why such youth were not accepted. If the answer was yes, respondents were asked whether there were any qualifying conditions under which JJ youth were accepted. Next, callers targeted the types of treatments offered (medication management, therapy, or both). Callers were then instructed to ask, “Does the clinic offer trauma-informed care, such as Trauma-Focused CBT?” All affirmative responses were considered yes answers, and any spontaneous mention of specific evidence-based care was documented. Finally, callers asked if clinics were accepting new patients and about the wait time for a new intake appointment.
Replicating Cervantes et al.,28 callers made three total call attempts per clinic with at least 48 hours between calls. Callers used the NYSOMH-listed program phone number for the initial call. If the initial phone number used was incorrect, a Google search was used to identify an additional contact number. If a different contact number was offered by clinic staff during the initial call, this new number was used and documented for subsequent calls.
All calls were conducted between 10 a.m. and 4 p.m. from Monday to Friday, excluding federal holidays. If contact was not made with clinic staff after three call attempts, the clinic was marked as unreachable. If callers were redirected to another contact person or were told someone would call back, five total call attempts were allowed. If redirected to email, callers would send up to three emails in the case of no response or up to five emails in the case of an incomplete response (i.e., referred to another person, told someone would follow up, etc.). All phone and email contact attempts were completed during February and March 2023.
Each caller made at least three calls with the first author present prior to completing phone calls on their own to ensure consistency across callers. The first author trained the other callers on the standardized protocol for data collection and recording. After the initial calls, the remaining calls were completed by the callers independently.
Analysis
Following data collection, descriptive statistics (percentages) were generated for the answers to our three main questions. After reviewing all conditional reasons for acceptance provided by clinics, we created three primary categories based on the most frequent conditions cited: no high risk, per intake director, and other. The no high risk category included restrictions for conditions such as high risk or high acuity, sexual crimes, arson, domestic violence, and violent crimes. The per intake director category included any clinics that were unable to provide specific conditions for acceptance other than that youth would need to be approved by the director on a case-by-case basis. The other category comprised various reasons, including “no comorbid substance use,” “court mandated only,” and “no probation or mandated court.”
Geographic Data
Representative geographic data for residents of secure juvenile detention centers in New York City were collected using the complete census on February 1, 2023. This arbitrary date was chosen as it coincided with the start of the phone data collection protocol. Deidentified residential zip code data were extracted for all residents present on that date who were seen by mental health staff during their admission to a detention center. The data were extracted by a contractual administrator from the Administration for Children’s Services, which is a governmental agency that manages and funds the juvenile detention centers in New York City. This administrator holds the appropriate clearances, has access to the internal databases, and currently tracks admissions to the detention centers. As these zip codes were deidentified by the administrator and are not considered protected health information, Institutional Review Board (IRB) approval was not required beyond standard self-certification. Zip codes were then categorized by density, low for one or two residents, medium for three or four, and high for five or six. Zip codes were plotted onto a map of New York City and color coded by density. Clinics were denoted on the map if they provided confirmed or conditional care to JJ youth and were currently accepting new patients.
Results
Of the 177 clinics in our sample, 34 were unreachable, resulting in a participation rate of 80.8 percent. Unreachable clinics were in Manhattan (n = 18), Brooklyn (n = 5), the Bronx (n = 7), and Queens (n = 4). Twelve clinics were deemed ineligible for the study and were excluded. These clinics were considered ineligible because they only served patients over the age of 18 (n = 9), were school-based clinics (n = 2), or did not provide mental health services (n = 1). After excluding the ineligible and unreachable clinics, 131 clinics were included in the study sample.
Of the 131 clinics included in the study, 59 (45%) reported accepting JJ youth, 15 (11.5%) indicated that they did not, and 57 (43.5%) gave a conditional acceptance response (see Figure 1). Of the clinics that stated they did not accept JJ youth, none were able to provide a specific reason. There were 17 conditionally accepting clinics (13%) in the no high risk category, 37 clinics (28.2%) in the per intake director category, and three clinics (2.3%) in the other category.
Responses from clinics. JJ, juvenile justice.
Of the clinics accepting or conditionally accepting JJ youth (n = 116), 38 of the accepting (32.8%) and 34 of the conditionally accepting (29.3%) stated they offered trauma-informed care. Of the 38 accepting clinics, 36 responded that they had trauma-informed care and only two spontaneously specified the evidence-based trauma therapy offered. Of the 34 conditionally accepting clinics, 32 responded they had trauma-informed care and only two specified the evidence-based trauma therapy offered. Twenty-one of the accepting clinics (18.1%) and 23 of the conditionally accepting clinics (19.8%) stated that they did not offer trauma-informed care (see Figure 2).
Responses from clinics. CBT, cognitive behavioral therapy; JJ, juvenile justice.
All clinics contacted offered medication management and psychotherapy, except for one, which only offered psychotherapy. Of the clinics accepting or conditionally accepting JJ youth (n = 116), 50 of the accepting clinics (43.1%) and 48 of the conditionally accepting clinics (41.4%) stated that they were accepting new patients. Nine of the accepting clinics (7.8%) and nine of the conditional clinics (7.8%) reported they were not taking new patients (see Figure 3).
Responses from clinics. JJ, juvenile justice.
For the accepting clinics (n = 59), six either did not have a waitlist or were walk-in only, 11 offered a wait time of less than one month, 22 offered greater than one month, and 12 could not specify a wait time. For the conditionally accepting clinics (n = 57), none had a waitlist or were walk-in only, eight offered a wait time of less than a month, 22 offered greater than one month, and 18 could not specify a wait time. Notably, the longest wait time offered by an accepting clinic was eight or more months and the longest by a conditionally accepting clinic was four or more months. Many clinics provided additional, unprompted information regarding clinic parameters. These included age restrictions (n = 20), requirements to be in therapy to receive medications (n = 10), no developmental disability, intellectual disability, or autism spectrum disorder (n = 6), telehealth only (n = 4), therapy available at a maximum rate of once per week (n = 3), referrals from within their hospital system only (n = 3), Medicaid only (n = 2), must receive primary care at the same clinics (n = 2), must be deaf (n = 1), must have an incarcerated family member (n = 1), Bronx residents only (n = 1), eating disorder patients only (n = 1), must be registered for afterschool program (n = 1), and in-person treatment maximum of once per week (n = 1).
The geographic data indicated that there were 190 total youth in secure juvenile detention centers in New York City on February 1, 2023 who were seen by the mental health service during their admission. Of these, 28 zip codes were not available, resulting in 162 individual zip codes. These 162 zip codes were spread across all five boroughs: Bronx (n = 64), Brooklyn (n = 51), Queens (n = 18), Manhattan (n = 15), and Staten Island (n = 8). There was one New York state zip code located outside of New York City and five zip codes located in other states, which were not included in the map. Of the 59 accepting clinics, only 34 (58%) were located within the zip codes where JJ youth reside (see Figure 4). Clinics in Brooklyn and Queens were more likely to have conditional acceptances, and Staten Island only had two clinics represented on our list. The highest density zip codes often had only a single clinic within the area, and some had none.
Locations of child and adolescent clinics by JJ youth home zip codes. JJ, juvenile justice.
Discussion
Consistent with other descriptive accounts of poor service availability for this population,8,11,15,21 in this investigation, roughly one-fifth of NYSOMH-listed clinics were unreachable, with another nearly 7 percent not clinically appropriate. Only one-third of listed clinics stated they would accept JJ youth for evaluation and treatment without conditions. The conditions that were offered by clinics were frequently unspecified or ambiguous. Many indicated that a director or intake coordinator would approve these patients on a case-by-case basis. Likewise, many other clinics cited high risk as a catchall category that would prevent them from accepting JJ youth. In fact, many of the experiences that directly or indirectly lead youth to the juvenile detention system would place them in high risk categories, thus effectively excluding them from services. Further compounding the scarcity of available services for JJ youth, additional limitations were identified that make mental health services inaccessible to all youth. In addition to the various conditions for acceptance for JJ youth, wait times were frequently found to be as long as six weeks or more, with fewer than 20 clinics offering appointments within a month. More than 15 percent of clinics that would accept or conditionally accept JJ youth referrals were not accepting new patients at the time of this study.
Access to these clinics requires both that they be accepting new patients and that referred patients can readily travel to appointments. Our geographical data highlight the additional structural barriers to aftercare many JJ youth face. An examination of the map shows that available clinics are largely clustered in and around the central city and Manhattan, whereas JJ youth more commonly reside in the Bronx, Brooklyn, Queens, and Staten Island. The outer boroughs of New York City are home to millions of residents living in transit deserts, where there is a higher proportion of transit-dependent residents and a lower supply of public transportation.31 These transit deserts on average contain more young people, people of color, and families from a lower socioeconomic status.31 Although the increased prevalence of telehealth services presents a promising avenue for increasing access to care, this method of care delivery produces additional accessibility disparities for vulnerable populations.
As an example, consider the Brooklyn zip code 11224 in Coney Island (see star, Figure 4). On February 1, 2023, six JJ youth identified this zip code as their place of residence, but there were no unconditionally accepting clinics located there. Using the data just presented, we identified the three closest accepting clinics on Google Maps. Clinic A and Clinic B were both approximately 40 minutes away via public transit and required a transfer from a bus to a train. Clinic C was approximately one hour away and required a bus-to-bus transfer. For patients and families, these travel times do not just represent an inconvenience but also potentially missed school or work and loss of family income.
Looking beyond access and into quality of care, one positive finding of our investigation was the widespread availability of both psychotherapy and medication management in available clinics. Still, despite the high prevalence of trauma experienced by JJ youth, only about 60 percent of accepting or conditionally accepting clinics reported providing some form of trauma-informed care. These findings likely overstate the quality of treatment offered, as a much smaller fraction of clinics specifically cited evidence-based therapies that are the accepted standard of care.
There are several limitations to this study. These data are restricted to the New York City area and may not generalize to other geographical locations. New York City is a service-rich environment with long-standing NYSOMH-funded educational programs to educate the public mental health services workforce on evidence-based practices.32,–,34 Data were limited to the specific knowledge of staff who engaged with our callers, which may have influenced the information gathered, including the nature of conditional acceptances and the presence of evidence-based, trauma-informed care. Furthermore, for both practical reasons and to better emulate the potential efforts of a referring clinician or patient, clinics were only drawn from the official NYSOMH database and the number of outreach calls to each clinic were limited, so not all listed clinics were able to be contacted.
Conclusions
This study is the first to quantify, characterize, and geographically locate the outpatient mental health aftercare services for JJ youth. Even in the highly resourced setting of New York City, the available outpatient mental health resources are neither sufficient nor easily accessible for JJ youth with mental health challenges after their release from detention. Few clinics accept this population, fewer still have capacity for new patients, and a very limited number offer trauma-informed care of any kind. Those clinics that are available are often located a considerable distance from these youth who need care. These data emphasize the need for further investment in high-quality mental health resources for youth transitioning out of the juvenile justice system in and around the communities in which they reside.
Footnotes
Disclosures of financial or other potential conflicts of interest: None.
- © 2024 American Academy of Psychiatry and the Law
