A QI Initiative to Improve Mental Health Outcomes of Juvenile Offenders in Utah

Problem: The juvenile justice system was established to increase the rehabilitative potential of the court system and prepare youth offenders for re-entry into the community. Legislative changes in recent decades have resulted in increasing numbers of youth being committed to adult prisons. A review of existing literature revealed the estimated percentage of youth offenders with a diagnosable mental health disorder ranged from 50 to 75 percent. Youth housed in adult correctional facilities have limited access to age appropriate programming and treatment services resulting in poorer mental health outcomes. Previous work has failed to collect mental health data of youth offenders at the state level. The purpose of this study was to develop housing and treatment recommendations that would result in improved mental health outcomes for youth offenders in the state of Utah by comparing mental health data of youth offenders housed in a secure care facility with existing national data of youth housed within adult correctional facilities. Methods: A retrospective chart review was completed to gather data related to past psychiatric history, mental health and/or substance use diagnoses, and psychotropic medication use. The number of hours of mental health services provided to youth within the facility were logged for one month. All findings were quantified and visually presented to mental health providers in the facility. A literature review was conducted to evaluate the existing national data regarding the impact of incarceration in adult facilities on juveniles' mental health outcomes. Results: Over a selected five-year period, 145 youth offenders were housed within a secure care facility in the state of Utah, with the most common diagnoses (excluding behavioral disorders and substance use disorder) being sleep disorder, generalized anxiety disorder, and major depressive disorder. It was found that of all the youth, 37% were prescribed an antidepressant and 33% a sleep aid while detained. Conclusion: In order to generate housing and treatment recommendations for youth offenders in the state of Utah, additional research is required. The results of this study were limited due to the current documentation system in place. These limitations helped identify areas within the current documentation system that suggests implementing an electronic medical record (EMR) would improve the quality of care currently being provided. Additionally, implementation of an EMR would provide a more efficient and accurate system to gather and analyze data providing a more comprehensive evaluation of youth within the Utah juvenile justice system in the future.

IMPROVING MENTAL HEALTH OUTCOMES A QI Initiative to Improve Mental Health Outcomes of Juvenile Offenders in Utah Tonya M. Butler The University of Utah College of Nursing 1 IMPROVING MENTAL HEALTH OUTCOMES 2 Abstract Problem: The juvenile justice system was established to increase the rehabilitative potential of the court system and prepare youth offenders for re-entry into the community. Legislative changes in recent decades have resulted in increasing numbers of youth being committed to adult prisons. A review of existing literature revealed the estimated percentage of youth offenders with a diagnosable mental health disorder ranged from 50 to 75 percent. Youth housed in adult correctional facilities have limited access to age appropriate programming and treatment services resulting in poorer mental health outcomes. Previous work has failed to collect mental health data of youth offenders at the state level. The purpose of this study was to develop housing and treatment recommendations that would result in improved mental health outcomes for youth offenders in the state of Utah by comparing mental health data of youth offenders housed in a secure care facility with existing national data of youth housed within adult correctional facilities. Methods: A retrospective chart review was completed to gather data related to past psychiatric history, mental health and/or substance use diagnoses, and psychotropic medication use. The number of hours of mental health services provided to youth within the facility were logged for one month. All findings were quantified and visually presented to mental health providers in the facility. A literature review was conducted to evaluate the existing national data regarding the impact of incarceration in adult facilities on juveniles' mental health outcomes. Results: Over a selected five-year period, 145 youth offenders were housed within a secure care facility in the state of Utah, with the most common diagnoses (excluding behavioral disorders and substance use disorder) being sleep disorder, generalized anxiety disorder, and major depressive disorder. It was found that of all the youth, 37% were prescribed an antidepressant and 33% a sleep aid while detained. Conclusion: In order to generate housing and treatment recommendations for youth offenders in the state of Utah, additional research is required. The results of this study were limited due to the current documentation system in place. These limitations helped identify areas within the current documentation IMPROVING MENTAL HEALTH OUTCOMES 3 system that suggests implementing an electronic medical record (EMR) would improve the quality of care currently being provided. Additionally, implementation of an EMR would provide a more efficient and accurate system to gather and analyze data providing a more comprehensive evaluation of youth within the Utah juvenile justice system in the future. IMPROVING MENTAL HEALTH OUTCOMES 4 A QI Initiative to Improve Mental Health Outcomes of Juvenile Offenders in Utah Introduction Problem Description The goal of the Juvenile Justice and Delinquency Prevention Act of 1974 was to provide youth offenders with an alternative to the formal, punitive processing of the adult justice system (Underwood & Washington, 2016). The purpose of this juvenile system was to increase the rehabilitative potential of the court system, reduce the stigma of criminal convictions later in a youth's life, and protect vulnerable children from adult prisoners (Sullivan, 2014). However, during the drug epidemic of the 1980s and 1990s many communities saw a rise in violent offenses being committed by juveniles. The juvenile justice system came under scrutiny as to whether or not it lacked sufficient resources to rehabilitate these violent offenders. Community outrage resulted in "get tough" legislative changes that made it easier for juveniles, as young as 10-years-old in some jurisdictions, to be tried and sentenced as adults in the criminal justice system (Griffin, Addie, Adams, & Firestine, as cited in Wills, 2017). In recent decades, additional legislative changes have further eased the process of treating juveniles as adults by "lowering the minimum age at which juveniles may be waived under certain provisions, shifting power from judges to prosecutors, and expanding the sanctions available in the juvenile court" (Kolivoski & Shook, 2016, p. 1243). As a result, youth are being committed to adult prisons at younger ages. Youth minorities are overrepresented among the juveniles sentenced to adult prisons, and many of the juveniles being committed to adult prisons experience mental health problems (Bishop, 2000; Murrie, Henderson, Vincent, Rockett, & Mundt, 2009 as cited in Kolivoski & Shook, 2016). During adolescence youth are undergoing periods of dynamic cognitive, psychosocial, and behavioral changes that adult prisoners have already achieved. At this stage in life, youth are striving to develop a sense of self, and their character is still malleable (Steinberg & Scott, as cited in Kolivoski & Shook, 2016). Youth are also more prone to the intimidating influences of adult prisoners at this time. Placement within an adult facility prevents access to traditional caretakers, teachers, and mentors for positive guidance and support (Wills, 2017), and adult facilities typically do not offer "age appropriate IMPROVING MENTAL HEALTH OUTCOMES 5 programming and treatment services" (Kolivoski & Shook, 2016, p.1243). The U.S. Department of Justice (as cited in Zajac et al., 2013) suggests that the juvenile justice system is not currently equipped to provide the necessary mental health treatment to the large number of youth requiring services; estimating that only 15.4 percent of youth are being treated. Available Knowledge Diagnosis. The American Psychiatric Association (as cited in Wills, 2017) states that the "prevalence of serious mental disorders begins to increase during adolescence" (p. 26). Recent estimates reveal that approximately 50 to 75 percent of the two million youth entering the juvenile justice system meet criteria for a mental health disorder and two-thirds meet criteria for two or more disorders (Underwood & Washington, 2016). International studies of detained adolescent offenders found high rates of psychiatric disorders with approximately 70 to 90 percent of offenders suffering from at least one psychiatric disorder (Collins et al., as cited in Aebi, Linhart, Thun-Hohenstein, Bessler, Steinhausen, & Plattner, 2015). These findings estimate that the rate of psychiatric disorders among detained adolescent offenders is three or more times higher than the rate of psychiatric disorders in the general adolescent population (Ford et al., as cited in Aebi et al., 2015). Mental disorders most commonly diagnosed in youth offenders include: affective disorders, psychotic disorders, anxiety disorders, disruptive behavior disorders, and substance use disorders (Underwood & Washington, 2016). Within the juvenile justice system, estimates suggest that 15 to 30 percent of youth have the diagnosis of depression or dysthymia, 10 to 30 percent have a diagnosis of attention deficit hyperactivity disorder (ADHD), three to seven percent have a diagnosis of bi-polar disorder, 11 to 32 percent have a diagnosis of post-traumatic stress disorder (Underwood & Washington, 2016), and 51 percent have a diagnosis of substance use disorder (Chhabra, 2017). Medication. Pajar et al. (as cited in Cohen et al., 2014) state "juvenile detention facilities have become dispensaries of psychoactive medications for youth" (p. 738). However, there continue to be very few studies regarding psychotropic medication use within juvenile detention settings (Cohen, Pfeifer, & Wallace, 2014). Osterlind et al. (as cited in Cohen et al., 2014) describes one report whose results showed IMPROVING MENTAL HEALTH OUTCOMES 6 that approximately 17.5 percent of the detained youth sampled had a psychotropic medication prescription documented. Trauma. Youth entering the juvenile justice system have significant trauma histories, as well as, high rates of involvement with the child welfare system (Zajac et al., 2013). One study, conducted by the Northwestern Project, revealed that 93 percent of the youth involved in the study reported prior exposure to one or more traumas (OJJDR, 2013). This same study reported that maltreatment was common among their participants with 83 percent having experienced "physical abuse from parents, step parents, foster parents, or caretakers" (OJJDR, 2013). Sullivan, Veysey, Hamilton, & Grillo (as cited in Zajac et al., 2013) discovered data consistent with these findings, noting that 58 percent of youth within the juvenile system until the age of 19 had a family member who was the focus of a child protective services investigation. Research on the prison experience of juveniles found they have higher rates of victimization, suffer from higher levels of depression, and are more likely to attempt suicide in adult prisons (Kolivoski & Shook, 2016). "Trauma of sexual and other assault can contribute to the onset or worsening of mental disorders" (Wills, 2017, p. 28). Confining juveniles in the same facilities as adult offenders increases a youth's risk of being manipulated, assaulted, groomed, and influenced into an improper sexual relationship with an adult inmate (Wills, 2017). The Bureau of Justice Statistics reported that in 2005, youth under the age of 18 represented 21 percent of all substantiated victims of inmate-on-inmate sexual violence in jails, and 13 percent in 2006; these numbers are disproportionately high considering only one percent of jail inmates during these years were juveniles (Sullivan, 2014). "Research has found that juveniles housed in adult prisons were five times as likely to be sexually assaulted in adult prison rather than in a juvenile facility" (Sullivan, 2014, p. 3). An additional study found that 47 percent of juveniles in prisons (compared with 37 percent of youth in juvenile facilities) suffered violent victimization, and attacks with weapons were almost 50 percent more common in adult facilities (Sullivan, 2014). To avoid such instances of victimization, it is not uncommon for youth offenders to be placed in isolation for no other reason than to protect them from the adult inmates. IMPROVING MENTAL HEALTH OUTCOMES 7 Suicide. Approximately one in ten youth entering the juvenile justice system has previously attempted suicide (OJJDR, 2013). Suicide rates among youth offenders, housed in adult or juvenile facilities, are increased when placed in isolation (Sullivan, 2014). Sullivan (2014) reports that youth offenders housed in adult prisons are 36 times more likely to commit suicide than if confined in a facility for juveniles. Youth in adult prison successfully complete suicide at a rate 7.7 times higher than youth confined in juvenile detention facilities (Wills, 2017). Of all the mental health issues facing adolescents being incarcerated with adults, suicide is the most problematic. Rationale The goal of this project was to influence housing and treatment recommendations of youth offenders in secure care facilities within the state of Utah in an effort to influence future mental health outcomes. In order to achieve this goal, policy changes within the juvenile justice system need to occur. A frequently used theory of change designed "especially for areas characterized by high goal conflict, high technical uncertainty about the nature and causes of the problem, and a large number of actors from multiple levels of government" (Hoppe and Petersen as cited in Cerna, 2013, p. 6) is the Advocacy Coalition Framework (ACF). The sentencing, housing, and treatment recommendations of youth offenders are controversial topics, with multiple advocacy groups locally and nationally representing both victims and offenders advocating for policy changes making this an ideal framework for this project. The ACF "facilitates the study of change within policy processes that might include changes in beliefs through learning, changes in coalition members and their interconnections, and changes in policy" (Henry et al., 2014, p. 300). The framework specifies that public policy consists of a set of core ideas about causation and value, and coalitions form because common interests link them (Cerna, 2013). Also present within the framework are policy brokers, responsible for maintaining the level of political conflict within acceptable limits and mediating reasonable solutions to proposed problems (Sebatier as cited in Cerna, 2013). Decisions made by such policy-brokers will influence governmental programs, affecting policy outputs and impacts. Assessing demographics, providing descriptive data detailing the number of youth with mental health diagnoses and substance use disorders housed within secure care facilities from IMPROVING MENTAL HEALTH OUTCOMES 8 2012 to 2017 may provide the information needed to influence minor adjustments to policies or an individual's corresponding belief systems. The ACF serves as a common foundation, establishing the policy subsystem as an appropriate scale for analyzing policy processes (Henry et al., 2014). The subsystems consist of advocacy coalitions, made up of individuals all pursuing common policy goals. Individuals' behavior within the policy subsystem are based on a mixture of normative beliefs (beliefs surrounding the role of government in decision-making) and empirically-grounded beliefs (impact of a particular policy choice) (Henry et al., 2014). One way that policy change is thought to occur is through a combination of policy-oriented learning and belief change. Conducting a literature review on the current state of juvenile offenders' mental health in adult facilities may provide policy-oriented learning or belief change initiating the downstream process of policy change. Specific Aims The goal of this DNP project was to influence housing and treatment recommendations and improve mental health outcomes for youth offenders in Utah by comparing mental health data of youth offenders housed in a secure care facility in Utah with existing national data on youth housed in adult correctional facilities. In order to achieve this goal, the first step involved synthesizing the existing mental health data, specifically as it related to juvenile offenders housed in a secure care facility, in Utah for a five-year period beginning in 2012 and ending in 2017. In addition, the specific mental health services and treatments currently being provided within this same secure care facility were analyzed and quantified. The third step was to review the existing national data regarding the impact that incarceration in adult facilities has on juvenile's mental health outcomes. Lastly, a presentation of findings was developed and delivered to the facility. Methods Context This quality improvement project was completed at a secure care juvenile facility located in an urban area in northern Utah. This facility has three centers each capable of housing ten offenders. IMPROVING MENTAL HEALTH OUTCOMES 9 Offenders at this facility come from all socioeconomic backgrounds and ethnicities and can range in age from twelve to twenty-one years old. All youth in the facility have had previous encounters with the juvenile justice system or have committed serious offenses requiring secure confinement. The facility has two licensed clinical social workers and one registered nurse employed full-time and one part-time nurse practitioner employed at the facility providing mental health care to the youth. Intervention(s) The first step to the project was to identify all youth offenders housed within the identified secure care facility between the identified time frame of January 2012 to January 2017. The Utah Department of Human Services (DHS) conducted a data search and provided a comprehensive list of youth case numbers. In addition to the list of case numbers, DHS also provided demographic data for all listed youth which included sex, age, race, and ethnicity. This demographic data was then input into REDCAP ® database for later data analysis. Retrospective chart reviews were then conducted specifically gathering data related to mental health and/or substance use diagnoses, treatment, and psychotropic medications. The second step in the project was to analyze and quantify the mental health services and treatments currently being provided to youth in the same secure care facility for a period of one month. An Excel spreadsheet was created in collaboration with one of the facility's social workers including each type of service/treatment offered to youth each week. Each week, for one month, the researcher in collaboration with the social worker and facility staff updated the number of hours of each type of service provided to the youth that week. At the end of the month, each week's hours were combined providing a monthly overview of how many hours of each type of service a youth receives over a one-month period while in secure care. The third step in the project was to conduct a literature review to evaluate the existing national data regarding the impact of incarceration in adult facilities on juveniles' mental health outcomes. The literature search found descriptive statistics regarding mental health diagnoses, psychotropic medication use, demographics of incarcerated youth, as well as gaps in current knowledge. IMPROVING MENTAL HEALTH OUTCOMES 10 The last step in the project was to develop and deliver a presentation of findings and recommendations using Power Point to visually present collected data and gather informal feedback from the therapy supervisor, program director, and facility social workers. Study of the Intervention(s) At the time of this project there were no similar projects or comparison groups in existence within JJS or in the state of Utah. Measures The Utah JJS maintains databases containing information such as demographics of all of the youth having entered their system. However, JJS has historically lacked tracking more specific information such as percentage of youth with mental health or substance use diagnoses, youth with comorbid mental health diagnoses, or the number of youth requiring psychotropic medications. A checklist was developed for the retrospective chart review gathering information on mental health diagnoses, psychotropic medication use, trauma history, and duress involvement with each category consisting of multiple subcategories (Table 1.). Similar statistics have been gathered by advocacy organizations at a national level and were readily available for review and comparison. Prior to July 2018, JJS had no system in place to formally track and quantify the mental health services and treatment that youth were receiving on a weekly or monthly basis. Although each facility within the state was required to run certain types of mental health groups, and expectations were in place, there were no formal systems tracking actual therapy dosage hours being provided to each youth. Quantifying the number of hours of each type of mental health service/treatment being provided each week for one month provided accurate descriptive data regarding the number of hours of mental health services currently being provided to youth in the secure care facility during a one-month time period. In order to ensure completeness of this data, the facility social worker assisted with creating an Excel spreadsheet that logged the type and duration of each service provided to youth each day for one month. Analysis IMPROVING MENTAL HEALTH OUTCOMES 11 Demographic and outcome variables were identified by the chart review using frequency distributions and appropriate summary statistics for central tendency and variability. Ethical Considerations This study was determined to be a non-human subjects research quality improvement project by the University of Utah Institutional Review Board (IRB). The Utah Department of Human Services' Institutional Review Board determined this project to be exempt from IRB review per federal guidelines. Results A chart review checklist was drafted in late November 2018 and was both reviewed and approved by the faculty chair, content expert, and JJS IRB representative. A total of 145 youth were identified by JJS, but only 135 charts were located and available for review. Approximately eight charts were reviewed using the initial checklist, at which time necessary improvements to the checklist were identified. A total of six modifications were made to the checklist, and the original eight charts were reviewed a second time using the updated checklist. A review of the modifications made, and the subsequent results are discussed. The original checklist was designed to collect demographic age data by age groups (ex: age 1012, 13-14). The age category was changed to a single year to provide more descriptive data. This change allowed for the identification of youth aged 14 (0.7%, n=1), aged 15 (13.1%, n=19), aged 16 (29.7%, n=43), aged 17 (50.3%, n=73), and aged 18 (6.2%, n=9). Additional demographic data for the project are listed (Table 2). One focus of the chart review evaluated the extent of the youth's family involvement in their treatment, special intervention plans utilized, and follow-up services post-discharge. However, this data is documented in a separate electronic system, called C.A.R.E., that is used in conjunction with the justice system. Time limitations related to locating and reviewing paper charts, as well as, project duration prevented a full review of both medical charts and the electronic system. As a result, collection of this information was removed from the checklist and project results were generated from medical charts only. IMPROVING MENTAL HEALTH OUTCOMES 12 In regard to psychotropic medication use, 37% (n=50) of youth were prescribed an antidepressant and 33.3% (n=45) were prescribed a sleep aid while in secure care. Additional psychotropic medications used are listed (Table 3). The most prevalent mental health diagnoses seen were sleep disorder (37%, n=50), generalized anxiety disorder (34.1%, n=46), and major depressive disorder (33.3%, n=45). Approximately 77% (n=104) of youth met diagnostic criteria for substance use disorder. Other mental health disorders diagnosed among this demographic are shown (Table 4). Data was also collected showing the illicit drugs of abuse most commonly used among this demographic (Table 5). During the checklist modification, self-harm and suicide were each divided into two subcategories a "prior to detention" and a "while in detention" category. Results revealed that 23% (n=32) had a history of self-harm prior to entering secure care and 10.9% (n=15) self-harmed while in detention. The percentage of youth suicide attempts prior to detention was 15.3% (n=21) and 5.8% (n=8) while in detention. Lastly, instead of simply gathering data as to whether or not a youth was involved in a duress (incident resulting in staff intervention), the checklist was altered to track the number and type of incidents, and the intervention used. Overall, a total of 58.6% (n=85) of youth were involved in a duress with 65.5% (n=55) of the incidents being a use of force. Other duress information is listed (Table 6). In addition to retrospective chart reviews, data was collected on the type and number of hours of mental health services being provided to youth each week for one month. Results revealed that, at a minimum, youth were receiving 15 to 20 hours of dialectical behavioral therapy (DBT), two hours of individual and family therapy, 3.5 hours of mindfulness, and two hours of substance use treatment (if referred) per week. Additional services provided each month are listed (Table 7). Discussion Summary The present study was a first step toward gathering mental health data on the youth within Utah's secure care detention facilities. The results of this project reflect a partial review of the youths' entire clinical picture, and the initial findings would suggest that youth within the Utah JJS are similar to other juveniles nationally in terms of diagnoses. It is unlikely that informed housing and treatment IMPROVING MENTAL HEALTH OUTCOMES 13 recommendations can be generated without a more comprehensive review of the youths' mental health records located in areas other than the medical charts reviewed. Coordination of care between providers will increase the ease and accuracy of data collection moving forward, suggesting that future research activities should focus on the improved patient outcomes and fiscal benefits of implementing an electronic medical record (EMR). Interpretation Demographic results from this project are inconsistent with national data. Nationally, youth minorities are overrepresented (Kolivoski & Shook, 2016). Our data showed that 78 percent of youth detained over a five-year period were Caucasian, and 54 percent of the entire sample were predominantly not Hispanic or Latino (54 percent). These results were expected given that the statewide population of Utah in 2015 was 75 percent white (ACLU, 2015). Current data on psychotropic medication use in juvenile offenders is lacking nationally. Desai et al. (2006) estimated that in 2002, roughly 54 percent of youth treatment regimens included some form of psychotropic medication use. Existing state data on psychotropic medication use is also lacking. Our results estimate that one-third of youth during the study period were prescribed an antidepressant or sleepaid and a quarter having been prescribed an anti-psychotic. Findings from this project align with others who have also found the most common psychiatric disorders among youth offenders to be affective disorders, anxiety disorders, psychotic disorders, and substance use disorders. Consistent with previous research, our findings for major depressive disorder, attention deficit hyperactivity disorder, post-traumatic stress disorder, and generalized anxiety disorder were within a five percent range of the existing national data provided by Underwood & Washington (2016). Our rates of bi-polar disorder of 14.8 percent were higher than the national estimates of 3 to 7 percent. All diagnosis data gathered required a nurse practitioner diagnosis within the medical chart, with the exception of substance use disorder (SUD). Chhabra (2017) reports a national SUD prevalence of 51 percent, while our findings estimate roughly 77 percent. However, our data was generated from youths' reported use during their intake screening and a review of their medical record. This information was used IMPROVING MENTAL HEALTH OUTCOMES 14 to determine if criteria for SUD was met per Diagnostic and Statistical Manual of Mental Disorders 5th Edition (DSM-5). This is due, in part, to an absence of SUD diagnoses among youth with severe selfreported substance use, as well as, past medical treatment for drug detoxification and withdrawal. It may be that SUD is presumed in this population; it may not be diagnosed because it is not addressed in treatment plans by the nurse practitioner but rather the social workers. National data suggested high rates of trauma exposure at 93 percent and maltreatment at 83 percent which is inconsistent with our findings (OJJDR, 2013). Based on limitations discussed below, a full review of the youths' mental health progress notes and full psychological evaluations were unable to be conducted resulting in a large percentage of "unknown" trauma history (44 percent). This large percentage of "unknown" data makes it difficult to determine whether or not our results are comparable to national data. Findings from this project do not align with existing data on the juvenile justice system's ability to provide mental health treatment to juvenile offenders. Teplin, Abram, McClelland, Washburn, & Pikus (as cited in Zajac et al., 2013) reported that "only 15.4 percent of youth with a major mental health problem received mental health treatment while detained" (p. 15). Our initial findings showed that 100 percent of youth within the facility were receiving mental health treatment. It has been suggested that on a national level the juvenile justice system was not well equipped to provide effective mental health to the large number of youth requiring treatment (USDOJ, as cited in Zajac et al., 2013). Results found that licensed mental health providers are providing certain mental health services each week (individual and family therapy, SUD groups, and a portion of DBT hours). However, if services provided by unlicensed facility staff were not considered in treatment hour results, the project findings may appear consistent with national data. It is important to note that this project did not measure quality or effectiveness of the mental health services being provided at the facility. Limitations This study is limited in several ways. The small size and heterogeneity of the sample prevents the findings from being generalizable to a larger, more diverse juvenile justice population. Additionally, the IMPROVING MENTAL HEALTH OUTCOMES 15 time constraints of the project, coupled with an inconsistent paper charting and archiving system prevented a more comprehensive review of the youths' mental health records in the C.A.R.E. system. As a result, we were unable to collect additional information regarding family involvement in treatment, additional diagnoses made by social workers, substance use treatment, or special intervention placement data. Efforts were made to review each youth's mental health assessment (if present) conducted by facility social workers in C.A.R.E. to provide a secondary screen for trauma and decrease the percentage of "unknown" responses providing more accurate and reliable data. The initial purpose of this study was to gather state and national data on youth within the juvenile justice system to support housing and treatment recommendations in an effort to improve youths' mental health outcomes. However, limitations in data collection previously discussed have identified areas within the existing documentation system itself that can directly impact the care currently being offered. Housing and treatment recommendations were not provided due to the inability to conduct a comprehensive review of all information on youth in JJS. Thus, the recommendation made is improvement in the system used to create and maintain records of youth in JJS allowing for future analysis and recommendations made with a complete understanding. Conclusions The juvenile justice system was created to rehabilitate youth and provide them with the opportunity to lead healthy and successful lives upon re-entry into the community (ACLU, 2016). To provide this opportunity, a thorough understanding of the unique vulnerabilities of this population, as well as, the pre-existing substance use and mental health disorders, is imperative for success. Data collected during this study reveal that further research is needed in the prevalence of mental health diagnoses, pharmacological treatments, substance use, and trauma histories in juvenile offenders of all ages both statewide and nationally. The overall benefit of further research for the state includes identifying high-risk youth with co-morbidities, tracking services provided to youth more efficiently, and improving communication between mental health providers. Initiating this research will contribute valuable IMPROVING MENTAL HEALTH OUTCOMES 16 knowledge to a population for which minimal research exists and will assist the state with implementing evidence-based treatments to improve youth outcomes, thus resulting in better distribution of JJS services. Acknowledgements I would like to thank Heidi Favero, DNP, AGACNP-BC, CCRN who has been my faculty chair for this DNP project. Her mentorship and assistance in cultivating and editing this project were crucial to my success. I would like to thank Robby Lindquist, LCSW for providing professional guidance, sharing his wealth of experience, and his friendship. Additionally, I would like to thank Alex, Daemon, and Heather for being my village, and the rest of my DNP classmates for the camaraderie and comedic relief over the past three years. IMPROVING MENTAL HEALTH OUTCOMES 17 References Aebi, M., Linhart, S., Thun-Hohenstein, L., Bessler, C., Steinhausen, H.-C., & Plattner, B. (2015). Detained Male Adolescent Offender's Emotional, Physical and Sexual Maltreatment Profiles and Their Associations to Psychiatric Disorders and Criminal Behaviors. Journal of Abnormal Child Psychology, 43(5), 999-1009. American Civil Liberties Union. (2017). Racial disparities in Utah's juvenile justice system. Retrieved from www.acluutah.org American Civil Liberties Union. (2016). Guiding principles for justice reform. Retrieved from https://acluutah.org/blog/item/1191-principle-jjr Bureau of Justice Statistics. (2016). Prisoners in 2016.(U.S. DOJ Publication NCJ 251149). Washington, DC: U.S. Government Printing Office. Retrieved from www.bjs.gov/content/pub/pdf/p16.pdf Cerna, L. (2013). The nature of policy change and implementation: A review of different theoretical approaches. Organisation for economic cooperation and development (OECD) report. Retrieved from www.oecd.org/education/ceri/The%20Nature%20of%20Policy%20Change%20and%20Imp lementation.pdf Chhabra, D. K. (2017). Mental health and the juvenile justice system: Where has history taken us? The American Journal of Psychiatry: Residents' Journal, 12(10), 2-3. doi: 10.1176/appi.ajprj2017.121001 Cohen, E., Pfeifer, J. E., & Wallace, N. (2014). Use of psychiatric medications in juvenile detention facilities and the impact of state placement policy. Journal of Child and Family Studies, 28, 738744. doi:10.1007/s10826-012-9655-4 Desai, R. A., Goulet, J. L., Robbins, J., Chapman, J. F., Migdole, S. J., & Hoge, M. A. (2006). Mental health care in juvenile detention facilities: A review. The Journal of the American Academy of Psychiatry and the Law, 34(2), 204-214. Retrieved from jaapl.org/content/34/2/204#sec-4 Henry, A., Ingold, K., Nohrstedt, D., Weible, C. M. (2014). Policy change in comparative contexts: Applying the advocacy coalition framework outside of western Europe and north America. Journal of Comparative Policy Analysis: Research and Practice, 16(4), 299-312. doi: 10.1080/13876988.2014.941200 Kolivoski, K. M., & Shook, J. J. (2016). Incarcerating Juveniles in Adult Prisons: Examining the Relationship Between Age and Prison Behavior in Transferred Juveniles. Criminal Justice and IMPROVING MENTAL HEALTH OUTCOMES 18 Behavior, 43(9), 1242-1259. Office of Juvenile Justice and Delinquency Prevention. (2013). The northwestern juvenile project: Overview. (U.S. DOJ Juvenile Justice Bulletin). Washington, DC: U.S. Government Printing Office. Sullivan, J. M. (2014). From Monkey Bars to Behind Bars: Problems Associated with Placing Youth's in Adult Prisons. Retrieved from http://scholarship.shu.edu/cgi/viewcontent.cgi?article=1587&context=student_scholarship Underwood, L. A., & Washington, A. (2016). Mental Illness and Juvenile Offenders. International Journal of Environmental Research and Public Health, 13(2), 228. Van Fleet, R. K., Lambert, J. M., Fowles, T. R., Rundquist, L. T. (n.d.). The impact of the serious youth offender law. Utah Commission on Criminal and Juvenile Justice. Retrieved from https://justice.utah.gov/documents/research/juvenile/SYOLIMPACT Wills, C. D. (2017). Caring for juveniles with mental disorders in adult corrections facilities. International Review of Psychiatry, 29(1), 25-33. Zajac, K., Sheidow, A.J., & Davis, M. (2013). Transitional age youth with mental health challenges in the juvenile justice system. Washington, DC: Technical Assistance Partnership for Child and Family Mental Health. IMPROVING MENTAL HEALTH OUTCOMES 19 Table 1. Checklist item categories for retrospective chart review Demographics Age Mental Health Diagnosis Diagnosis Psychotropic Medication Use Prior to Admission Gender Illicit Drug Used During detention Race MHA completed w/in 7 days of admission At discharge Ethnicity Table 2. Demographics Characteristic Age 14 15 16 17 18 Ethnicity Hispanic or Latino Not Hispanic or Latino Race American Indian/Alaska Native Asian Native Hawaiian/Other Pacific Islander Black or African American White More than one race Trauma History Known history of trauma Reported selfharm prior to detention Self-harm while in secure care Reported suicide attempt prior to detention Suicide attempt while in secure care n % 1 19 43 73 9 0.7 13.1 29.7 50.3 6.2 66 79 45.5 54.5 9 6.2 2 2 1.4 1.4 14 114 4 9.7 78.6 2.8 Duress Involvement Duress while in secure care Number of incidents Type of incident Highest level of intervention IMPROVING MENTAL HEALTH OUTCOMES Table 3. Psychotropic Medication Classes Medication Class Antidepressants Mood Stabilizers Antipsychotics Stimulants Sleep Aid Anticonvulsants Anxiolytics Non-Stimulant ADHD Other Refused Medications Table 4. Mental Health Diagnoses Diagnosis ADHD PTSD MDD Bi-Polar SUD ODD Mood Disorder Psychotic Disorder GAD Sleep Disorder Autism Spectrum Disorder Adjustment Disorder Conduct Disorder OCD 20 n 50 8 33 17 45 9 9 27 27 5 n 44 13 45 20 104 16 16 3 46 50 1 1 2 2 % 37 5.9 24.4 12.6 33.3 6.7 6.7 8.1 20 3.7 % 32.6 9.6 33.3 14.8 77 11.9 11.9 2.2 34.1 37 0.7 0.7 1.5 1.5 IMPROVING MENTAL HEALTH OUTCOMES Table 5. Reported Drugs of Abuse Drug Type Tobacco Heroin Marijuana Alcohol Cocaine Ecstasy Methamphetamine Inhalants Benzodiazepines Opiates Prescription Medications Spice LSD Other None Table 6. Duress Involvement Variable Was the youth involved in a duress while in secure care? Yes No Average number of incidents per youth 1 2 3 4 5 6 7 8 or more Type of Duress Use of Force Self-Harm Suicide Attempt/Ideation Assault Physical Intervention Sexual Misconduct/Battery Other 21 n 79 14 90 76 26 18 39 5 3 10 6 21 15 4 42 % 76.7 13.6 87.4 73.8 25.2 17.5 37.9 4.9 2.9 9.7 5.8 20.4 14.6 3.9 29 n % 85 60 58.6 41.4 32 16 8 12 5 3 1 5 37.6 18.8 9.4 14.4 9.4 3.5 1.2 5.9 55 11 10 9 14 8 3 65.5 13.1 11.9 10.7 16.7 9.5 3.6 IMPROVING MENTAL HEALTH OUTCOMES 22 Table 7. Mental Health Services Average hours provided per week Average hours provided per month Individual Therapy 1 4 Family Therapy 1 4 Child Family Team Meeting 1-1.5 Dialectical Behavioral Therapy 15-20 60-80 Substance Use Group 2 8 SPARK 3.5 14 Mindfulness exercises 3.5 14 Advocate mentoring Youth dependent Carey Guides 1-4 (youth dependent) Gang Advocate (based on advocate availability) Recreation 7 (if referred for treatment) 4-16 28 Additional activities include: High school/College courses, tutoring services, Alcoholics Anonymous, Occupational Certifications, Reading/Life Skills Group