There is no single formula for planning a program to divert juveniles to alcohol and other drug (AOD) abuse treatment, but the consensus panel developing this Treatment Improvement Protocol (TIP) recognized that community focus is crucial. This focus will differ, however, from one community to another, depending on local problems, community perceptions of those problems, and the goals and objectives defined by the collaborating committee.
Regardless, the community is the key to the development and maintenance of a program to divert juveniles to AOD abuse treatment that will benefit them in time.
An individual or group of individuals will provide the initial impetus for the planning process, and it will be defined initially by their goals and objectives for juvenile diversion to AOD abuse treatment. As more individuals and groups become involved, the collaborative process will take on its own character.
This chapter is intended to help local collaborators get started and make the decisions that will define the diversion program. Whatever the makeup or the procedures of the collaborating committee, required decisions fall into the areas outlined in Chapter 3. Collaborators on the planning committee should develop a system composed of the community, the juvenile justice system (JJS), AOD abuse treatment services, and physical and mental health and social services, as well as a strong management component. Viewing the planning process this way can help collaborators to organize it.
Typical decisions that must be made by collaborators are the subject of this chapter. It is important to remember that the key decisionmakers for any particular set of decisions will be the representatives of the component most directly involved. But the combined thinking of representatives of all the components is required. That is why the consensus panel emphasized the term "collaborative" in defining the planning process.
The consensus panel felt strongly that communities must work to develop their own solutions to address juvenile AOD and delinquency problems. They should accept and acknowledge the fact that these problems must be treated locally, and they should conduct needs assessments to determine whether they have sufficient AOD abuse treatment resources to do so.
There has been extensive research on the antecedents of both delinquency and the early use of AODs. In Recidivism Among High-Risk Youths: Study of a Cohort of Juvenile Detainees, Dembo and associates write that
Youths whose behavior in the community has brought them into contact with the legal system often are experiencing multiple problems. These problems include drug use, histories of physical abuse and sexual victimization, and other emotional and psychological functioning difficulties. . . . Particular attention has been focused on the association between child maltreatment and delinquent behavior. . . . Children's physical and sexual abuse experiences are associated with illicit drug use and other delinquent behavior.
Chaiken and Johnson wrote about adolescent AOD abuse in 1988:
The primary factors that promote use are the general availability of alcohol or drugs, friends who are users, lack of parental supervision, and lack of attachment to school. The involvement of adolescent users in other destructive behavior is strongly associated with the number and types of harmful substances they use. . . . Youngsters who use multiple drugs are generally more likely to be seriously delinquent than those who use only alcohol or marijuana. . . . Those who use drugs -- even only alcohol or marijuana -- are more likely to smoke, be sexually active, and ride around in cars with drivers either drunk or on drugs. Over 75 percent of boys who use alcohol and marijuana commit minor assaults, vandalism, or other public disorder offenses. Both boys and girls who drink and use marijuana or other drugs are more likely to be truant and to steal. . . . The few studies that have followed delinquent youngsters into adulthood have shown that, in general, youngsters are most likely to continue to be offenders as adults if
They come from poor families
They have other criminals in their families
They do poorly in school
They started using drugs and committing other delinquent antisocial acts at an early age
They used multiple types of drugs and committed crimes frequently
They have few opportunities in late adolescence to participate in legitimate and rewarding activities.
Communities must recognize which risk factors have an impact on their youth and families and must develop resources to fill the gaps in the continuum of care and other service systems.
Communities also need to address cultural foci and influences that will affect programming. For a diversion program to achieve long-term success, it must be part of the natural care network of the community, which develops and supports healthy, successful, sober youth. This network can include church programs, after-school programs, recreation center programs, tutoring services, mentoring programs, and volunteer efforts.
Urban, suburban, and rural differences can present different challenges in determining how an AOD abuse treatment diversion program is developed. Issues for consideration include 1) access to transportation, 2) the accessibility of services (including the increased burden on families if services are not available locally), 3) availability of services, 4) drugs of choice, 5) special community needs, and 6) level of community acceptance of the problem.
Transportation to treatment services can be a problem anywhere. In rural areas without public transportation, treatment services may be at too great a distance from clients' homes. In urban areas, even youth with access to mass transit may not have the bus fare they need to travel to treatment. Budget problems are forcing many cities to curtail public transportation services. Residents of poor neighborhoods often feel these curtailments more deeply than others. Parental involvement is an important key to solving transportation and accessibility problems. Offering treatment services in or near a school may decrease transportation problems, as may the availability of mobile clinics (some rural outreach programs use a motor home) or in-home services. AOD use patterns vary somewhat from community to community and from region to region. Certain drugs are more available in some communities than others. Drug trafficking may be more visible in some urban settings, where it is often conducted openly on street corners. Smaller markets and more private settings make this high visibility less common in rural areas and in the suburbs. Many agricultural communities are aware that some of their production is devoted to marijuana.
Juveniles will use what is accessible and affordable. Their level of sophistication is another factor in influencing which drugs they will use. Each community will need to survey trends of AOD use among its youth and families.
In developing diversion programs, communities must seek strategies that address their particular needs and the specific issues they face. System development issues may differ according to the urban, suburban, or rural nature of the community. For example, in some areas, the planning committee may focus on keeping diverted juveniles in school. The youth in AOD abuse treatment may be amenable to treatment in an outpatient setting while continuing to attend school. In other areas, however, an early goal may be to remove the child from the community (including the school) where drugs are a pervasive influence.
When a case is referred to juvenile court, the court decides whether to process the case formally and file a petition (prosecute) or to handle the case informally without a court hearing. Diversion to AOD abuse treatment may occur at any point along the JJS continuum from juvenile court intake, when it may be part of informal adjustment or a preadjudication agreement, to postadjudication, when it may mean probation or placement in a community treatment facility rather than in a training school or other similar institution. It is important to remember that the juvenile is not removed from the JJS; rather, diversion exists as an alternative approach to accountability, focusing on the juvenile's need for AOD abuse treatment.
Successful completion of the AOD abuse treatment ordered may change the accountability demands on the juvenile. Sanctions should be proportionate to the degree of harm resulting from the underlying offenses. The juvenile may be discharged from court supervision, or in other cases, diversion to AOD abuse treatment may be only one part of a broader accountability approach such as restitution or community service.
The responsibility of the courts to hold juveniles accountable is not negated by diversion; rather, the court's authority to mandate treatment for AOD use should be seen as a significant asset to the balanced approach in the rehabilitative process. A youth may be diverted into AOD abuse treatment at all the points shown in Exhibit 4-1, Points for Youth Diversion to AOD Abuse Treatment, from the point of referral to the court through disposition after adjudication.
Planners must clearly define and state the appropriate target population for the AOD abuse treatment diversion program. The consensus panel defined the target population, for purposes of this TIP, as juveniles who come to the attention of the JJS from a variety of sources, including police referrals, parental referrals, and referrals from other community agencies, such as the schools. (Remember that the local planning committee's definition may differ from the one recommended by the Center for Substance Abuse Treatment (CSAT) consensus panel. What follows is the consensus panel's definition.)
A juvenile in the context of the JJS is a person who, by reason of age, falls under the jurisdiction of the court. Different States have different age ranges to determine juvenile court jurisdiction; however, it is common for a juvenile to be defined in the context of acts of delinquency as a youth who is older than 10 and younger than 18.
A delinquent offender is a juvenile who has committed an act, including a violation of State laws and local ordinances that would be a crime if committed by an adult. For example, if a juvenile is under the age of legal jurisdiction for an adult and commits a burglary, the juvenile has committed a delinquent offense and is subject to the jurisdiction of the juvenile court. A status offender is a juvenile who has committed an offense that would not be a crime if committed by an adult. Status offenses describe behavior by juveniles that society wants to control. For example, many communities institute curfews only for juveniles. Preadjudicated delinquent offenders, youth charged with a delinquent offense who have not yet been adjudicated as delinquents, may also be eligible for AOD abuse treatment diversion.
Youth targeted for diversion from the juvenile court must first be eligible for jurisdiction by the court. Most systems have juvenile court intake procedures designed to establish the jurisdiction of youth referred to the court. Establishment of juvenile court jurisdiction usually depends upon the following criteria: 1) determination that the alleged offense(s) occurred within the geographical boundaries of the court, 2) determination that the alleged offense(s) constitutes a delinquent or status offense as defined by law, and 3) determination that the youth referred meets the definition of delinquent or status offender.
A primary goal at intake. One of the primary goals of juvenile court intake is to investigate the circumstances surrounding the alleged offense(s) to determine whether court intervention is necessary. As a result, juvenile court intake should be a key decision point for establishing whether or not a juvenile will be diverted.
Courts must intervene early to increase the effectiveness of AOD abuse treatment. Therefore, any child within the JJS who has been identified as having an AOD problem may be considered eligible for diversion to AOD abuse treatment. An appropriate response to the offense is essential. A guideline for AOD abuse treatment diversion is to look for the youth for whom this type of intervention will be most effective, balancing against this benefit the need for appropriate sanctions and the need to maintain community safety. Specific target populations may include 1) status offenders, 2) youth who have been charged with delinquent acts but are not adjudicated delinquents, 3) those who have been adjudicated, and 4) juvenile offenders on probation who have violated the terms of their probation.
This population description should not be interpreted to mean that AOD abuse treatment diversion is the appropriate response for all juveniles or all criminal behavior in the JJS. Individualized justice is the legitimate goal of the JJS. Youth who are being waived to an adult court, for example, would not be candidates for AOD abuse treatment diversion. Youth who are charged with extremely serious offenses or those who have chronic patterns of delinquent behavior may be best suited for detainment in a secure residential facility or, in extreme cases, transferred to the adult system. Further, through the assessment process, specific youth may be returned to court without a recommendation for diversion (e.g., youth who have been through treatment or diversion previously). Diversion uses an individualized approach to respond to the AOD abuse of juveniles before the courts.
Status offenders. A substantial part of the population under consideration for AOD abuse treatment diversion is likely to consist of status offenders. All States have some type of status offense jurisdiction, but they may vary on different definitions of status offense, and even within a State, court jurisdictions may have different understandings of the term. This difference highlights the difficulty that is implicit in the process of bringing together two systems -- juvenile justice and AOD abuse treatment -- that may not always speak the same language. One system in two contiguous jurisdictions may not define behaviors in the same terms. AOD abuse treatment programs often serve clients in several jurisdictions.
Status offenses include truancy, running away from home, curfew violation, acting beyond the control of parents, and unruly behavior. Using tobacco and alcohol may be considered a status offense in some States. All States have laws that proscribe such behavior and place jurisdiction of status offenses in the juvenile courts.
While the juvenile court does not have the same power under Federal law to detain or incarcerate the status offender as it does with delinquents, status offenders with AOD problems may be best served in an AOD abuse treatment diversion program because they are at an appropriate age for diversion and may not yet pose a serious threat to the safety of the community. Status offenses are frequently "gateway" activities that may provide a useful net to catch youth who are at high risk of using AODs or becoming involved in more serious delinquent behavior. Usually, youth who commit status offenses can be diverted most successfully if they have access to a system to support their participation in the diversion program. These support systems can include the family, the school, and other community service providers.
A problem associated with diversion for status offenders is that the current understanding of status offense is that youth who have committed these offenses are beyond the scope of the JJS. The Juvenile Justice and Delinquency Prevention Act of 1974 required the separation of juveniles from adults during incarceration and removal of status offenders from secure detention and correctional facilities. In 1980, Congress amended the 1974 act to allow States to detain status offenders if detention occurred for the violation of a valid court order. Thus, it may be argued that there is little clout behind diversion for a status offender and not much enforcement capacity if the youth tries to leave treatment. Nonetheless, even though it appears the juvenile court's powers are limited, some measures can be taken. The juvenile court does have a limited power to detain under the valid court order exception. Also, some States have the authority to take away a youth's driving license for a status offense; other States can put responsibility on the parents through court order and require the youth to participate in the treatment process, with contempt options and fines as the consequences for parental noncompliance. Public sentiment is moving increasingly toward demanding accountability from parents for the actions of their children and diversion for status offenders.
Preadjudicated delinquent offenders. Preadjudicated delinquent offenders with AOD abuse problems may also be eligible for AOD abuse treatment diversion. Many cases are resolved at intake with juvenile court interventions, so this category includes youth charged with a delinquent offense who have not yet been adjudicated as delinquents. The juvenile may be within the jurisdiction of the court by referral, complaint, or affidavit, or may have been formally charged by petition. At either point, the youth may be referred to diversion. Successful completion of the diversion program may result in the dismissal of all charges. Expungement of the case record may also be a reward for successful completion. If the juvenile does not comply with diversion conditions, the juvenile court may reinstate the charging document or schedule or resume the formal adjudication of the case and impose appropriate dispositional sanctions.
Adjudicated youth. Youth who have been adjudicated as delinquents by the juvenile court may also be candidates for diversion into an AOD abuse treatment program instead of receiving formal dispositional sanctions. Even those who have been adjudicated and received formal dispositional sanctions other than AOD abuse treatment diversion and then have broken the conditions of their court-ordered sanctions may be eligible for referral to AOD abuse treatment rather than placement in a juvenile correctional institution or other secured setting.
Violators of probation. Probation violators are juveniles who have been adjudicated and have received probation as a formal dispositional sanction, who have not been diverted to AOD abuse treatment, and who have broken the conditions of their probation. If the probation violation is AOD-related, it is possible that these juveniles will be candidates for referral to AOD abuse treatment rather than placement in a juvenile correctional institution or other secured setting.
It is important to consider carefully certain categories of delinquent offenders when determining eligibility for diversion from traditional juvenile court sanctions to AOD abuse treatment. Specifically, AOD abuse treatment diversion criteria for violent offenders, arsonists, and sex offenders must be established.
Youth who commit violent offenses. The issue of violence is often pivotal in determining eligibility for diversion programs. A history of violence should not automatically exclude a youth from consideration for diversion into AOD abuse treatment. All youth should be considered for diversion on a case-by-case basis.
Many AOD abuse treatment programs have eligibility criteria that exclude violent offenders; the assumption is that these offenders will receive AOD abuse treatment through appropriate sanctions within the JJS and not through diversion. While categorical exclusion of violent youth from diversion to treatment may seem logical, the consensus panel recommends that exclusion or inclusion be considered on a case-by-case basis and that a youth's propensity for violence should be just one eligibility criterion, although a crucial one. As an approach that might balance and simultaneously address community protection, juvenile accountability, competency development, and individualized assessment and treatment, threshold questions can be posed before making this decision; for example, the following questions may be asked:
Does the youth under consideration have a history of violent behavior, or has he or she committed a single violent act?
What type of violent act did the youth commit?
Is the youth with a history of violent behavior amenable to treatment?
Does this youth pose a serious threat to the safety of the AOD abuse treatment staff or to participants?
To what degree is the youth's violent behavior linked to AOD use?
Is AOD diversion a consistent and appropriate sanction for the violent behavior?
It is important to consider the meaning of violence and the impact a violent offender might have on an AOD abuse treatment program. Generally, violence can be considered to be behavior that results in serious injury to oneself or others. Threatening or attempting to cause serious personal injury is also usually considered a form of violent behavior. Conversely, pushing, shoving, and fighting, which are common behaviors in the sometimes volatile population of juvenile AOD users under consideration in this TIP, are not necessarily violent behaviors with the same impact.
Therefore, in considering violence, it is necessary to look not just at specific acts and chargeable offenses but also at patterns of behavior that show a history of violence and that may be symptomatic of mental or emotional disorders that are diagnosable according to the Diagnostic and Statistical Manual, fourth edition (DSM-IV), the publication of the American Psychiatric Association that defines mental and emotional disorders. It is necessary to examine not just the youth's action but also the context of his or her actions and to learn as much as is known about the youth's life and psychological profile. The importance of individualization is critical in program matching.
Youth who set fires. Youth with histories of arson also pose special problems. They can be divided into at least three categories: 1) youth who commit arson for gain, on a dare, as part of a gang initiation, or for some similar motivation; 2) youth with an inner compulsion to set fires; and 3) youth with a long arson history that is related to physical or sexual abuse. (For more information, refer to the DSM-IV.)
All youth with a history of setting fires can pose a danger in treatment programs, especially residential programs, where they may place other residents and staff of the facility in danger. Their histories should be thoroughly assessed to identify their problems and determine their treatment needs and to ascertain how threatening they may be to others in the treatment program. Youth with a tendency to set fires may think that the quickest way to get out of treatment is to set a fire, and that potential motivation should be taken into consideration. These youth may be treatable, but their potential impact on a treatment program must also be a factor in diversion and placement decisions. All such cases must be considered on an individual basis.
Youth who commit sex offenses. Sex offenses are another form of violent behavior requiring special consideration. It is important to look at the nature of the sex offense before making a decision about disposition or diversion. For example, a youth charged with voyeurism is not necessarily a violent sex offender and may well be a good candidate for diversion to AOD abuse treatment; however, the presence and impact of voyeuristic behavior should not be minimized. In most jurisdictions, prosecutors have a great deal of discretion in deciding how these cases will be filed, and diversion should not be ruled out automatically just because the label of sex offender has been applied. A sex offender evaluation can assist the treatment provider in determining risk and appropriateness for diversion.
It should be noted that violent behavior or a history of setting fires or committing sex offenses is likely to decrease the youth's potential for diversion. Many AOD abuse treatment programs may not have the necessary clinical supports or facility design to serve all youth. Often the best course of treatment for these juveniles may be to incorporate AOD abuse treatment into programs that are specifically designed to treat these identified behavioral problems.
While a juvenile offender's diversion to AOD abuse treatment is an active engagement to address substance abuse, the development of understandings regarding noncompliance is equally important. The JJS has a responsibility to ensure that juvenile offenders are held accountable for their actions. In developing a protocol for noncompliance with the diversion program, planners should consider clear definitions of accountability for noncompliance. Examples of noncompliance include absconding from the program, a positive urine drug screen, commission of other delinquent acts, lack of participation in the treatment process, and failure to comply with the individualized diversion contract. From the defined behaviors, the ground rules for noncompliance should be established -- rules that cover issues such as reporting mechanisms; who reports the noncompliance, to whom, when, and how (for example, written messages or a phone call can be documented), and a set of sanctions for each type of noncompliance.
Examples of the accountability-based sanctions of noncompliance will differ depending on the point in the JJS where the diversion has occurred. Consequences should range from one-time events to significant changes in the youth's status. Possible sanctions include termination of the diversion contract, referral by petition to the JJS for adjudication, revival of suspended proceedings, or transfer to intensive supervision, detention, or a correctional institution. Accountability-based sanctions should be commensurate with the degree of noncompliance. The goal of such sanctions should be reparative or restorative. Sobriety may be a result of the reparative process. Further, accountability-based sanctions should be proportionate to the degree of harm resulting from the noncompliance.
Similar guidelines can be applied to completion of AOD abuse treatment. What is meant by completion of treatment should be clearly defined in cooperative agreements and individualized diversion contracts. Treatment completion should be defined by the achievement of specific behavioral markers rather than by the length of stay or an arbitrary number of clean drug screens. Just as there are consequences for noncompliance, the diversion agreement or court order should also provide for early rewards commensurate with early progress in treatment.
The contract can state program expectations and goals. For example, stated expectations might be that the juvenile
Actively engages in a positive manner on problems identified in the treatment plan and personal goal sheet
Demonstrates positive skills in school, home, community, and treatment
Continues to work on relapse prevention and recovery plan
Has long-term educational and vocational plan.
Benchmarks indicating that the youth has met diversion program goals and expectations might include when he or she
Resolves conflicts with family in positive manner
Readily accepts full responsibility for offending behavior and decisions
Maintains positive behavior and progress in school or work, home, and the community
Actively works toward personal goals
Can resist negative peer pressure in daily life.
The diversion contract or court order should clearly specify what objectives must be met for treatment to be considered completed. They will include the resolution of the individualized issues outlined in the treatment plan and other predetermined program expectations, such as continuing progress in school, securing or maintaining employment, making restitution to the victim, and remaining AOD-free.
The role of the court is pivotal to the overall success of any juvenile diversion program. Not only do judges set the tone for actions that are initiated in juvenile courts, but judges also have a mandate to ensure that AOD abuse treatment diversion programs are developed and sustained. A judge's respect for and support of a treatment program and the elements of that program can, in fact, make or break a program. As noted previously in this chapter, the effectiveness of treatment for a juvenile may depend on the authority and power of the court that orders the diversion. Thus, the court's requirement of accountability may support the treatment process itself.
Juvenile court personnel should be closely involved in designing the diversion programs. Juvenile court personnel, including special masters, referees, prosecutors, defense counsel, court services, and probation officers, should visit treatment programs to gain firsthand information about how the program is operating and insight into what the juvenile can expect from the program.
One way to support diversion programs is for judges and court services to assign priority status to diversion cases. With the crowded dockets that characterize many juvenile courts, this assignment can be difficult, especially since for every case prioritized, another is given lesser priority. The authority figure aspect of the judicial role is important, and one possible way to address the priority issue is for a jurisdiction to establish the position of a referee or special master to review diversion cases or establish a "drug court" approach to handling the AOD case.
Issues of accountability-based sanctions for noncompliance by youth in diversion programs must be handled expeditiously so that sanctions will closely follow noncompliant actions. In planning, it is necessary to allow the JJS to monitor, review, and support the performance of youth in AOD abuse treatment diversion and to return these youth to the court for further action in instances of noncompliance.
Individualization is an essential principle of the balanced approach used by the JJS. An AOD abuse treatment diversion program should be predicated upon the appropriate match of the juvenile to the necessary services. This match requires comprehensive, accurate, and timely screening and assessment, as well as preestablished eligibility and acceptance criteria so that arbitrary placement decisions are not made. The JJS goals and objectives in creating an AOD abuse treatment diversion program are that it be applied consistently and that appropriate accountability sanctions be imposed for every criminal act. Planners should allow for ongoing review of eligibility and acceptance criteria, recognizing that changes in AOD abuse patterns and social structures (for example, gang activity) can occur in a community.
The need for uniform criteria can be illustrated by two contrasting examples of how a system should NOT function. Some treatment programs may accept all juveniles who are referred, in order to stay at full utilization (which may be a requirement to maintain funding). Their outcomes will probably not be positive because the juveniles have not been appropriately matched to the program. Other treatment programs may decide to accept only juveniles with the greatest chance for success (skimming). While their outcomes will be positive, this approach will not provide the AOD abuse treatment services that are needed for children, families, and communities, nor will it reduce the harmful effects of juvenile AOD abuse.
As the planning committee works to fashion a partnership between the juvenile justice and AOD abuse treatment systems, it is essential that the two systems agree on uniform eligibility and acceptance criteria and then adhere to them.
In designing an AOD abuse treatment diversion program, planners should define the role of the JJS to provide the monitoring and support services necessary to ensure the juvenile's accountability. It is equally important that treatment staff understand this role. This deliberative process must include input from a variety of sources including judges, prosecutors, court services staff, probation officers, treatment providers, and former youth offenders and their families. If AOD abuse treatment staff are not involved in these deliberations as the diversion program is being developed, it will be much more difficult for them to buy into the process when the program is implemented.
A further design issue surrounds juvenile detention and probation standards that specify a certain staff/client ratio to ensure adequate security and supervision. Similar mechanisms should be established for treatment programs prior to program implementation so that both security and case management concerns are adequately addressed. In some cases -- for example, in a prefiling referral where there is no probation officer assigned to the case -- the primary supervision that is provided for the youth will come from the treatment provider. Planners might want to consider developing specialized court services units (trained to understand the nature of adolescent AOD addiction and treatment) to work with treatment providers in this capacity. The JJS is still responsible for monitoring the youth who, for example, are under supervision by a parent or grandparent or court volunteer who must report back to the court or to court services.
In designing a diversion program for juveniles, planners should define a set of realistic AOD abuse treatment expectations. These expectations must be grounded in the realization that AOD abuse is a chronic, relapsing disorder. Realistic treatment expectations should not be confused with long-range goals. For example, a goal of zero tolerance of AOD use or of drug-free, crime-free outcomes is rarely a realistic AOD abuse treatment expectation, and establishing it as such only sets up clients -- and systems
-- for failure.
Realistic AOD abuse treatment expectations establish objectives such as reduced AOD use, reduced deviant and delinquent behavior, improved school attendance and performance, and improved family functioning. Expectations must be individualized for each juvenile. The same treatment plan will not fit every youth. Universal, generalized expectations are impossible to meet. In planning, an understanding of this concept should be shared by all involved parties, so that an atmosphere can be created that is conducive to open discussion regarding realistic AOD abuse treatment expectations and expected outcomes.
The consensus panel recommends that collaborative groups planning juvenile diversion programs establish two mechanisms to define AOD abuse treatment expectations:
Cooperative agreements between juvenile justice and AOD abuse treatment agencies define and explain what roles each will take in working toward achieving AOD abuse treatment expectations. These cooperative agreements (also called shared service agreements, memoranda of understanding, or qualified service agreements) should state what each agency is responsible for, capable of, willing to do, and able to tolerate. Providers of ancillary social services need to be part of the process of developing cooperative agreements. Because at least two separate systems will be involved in cooperative agreements, each community should establish a formal structure that brings the systems into active collaboration. One system may take the lead. Some jurisdictions may consider the use of a liaison from each agency to link services to facilitate this process. Others may want to identify a lead agency, select a program director, or use a case manager. To be fully effective, the local community must decide who is capable of bringing a comprehensive AOD abuse treatment diversion program into perspective and then into action, and, most important, who can sustain the community efforts.
Individualization for each youth diverted from the JJS is specification of treatment expectations based on the youth's needs and the level of treatment available. Each juvenile's situation is defined by a unique set of circumstances and factors that have contributed to his or her behavior. The response by the AOD abuse treatment system to the juvenile should be individualized and related to an assessment of the unique contributing factors. These individualized case plans will list the sort of expectations described above as well as the juvenile's responsibility; for example, negative urine drug screens for a 12-month period, a grade point average improved by a factor of 1.0, no additional delinquency charges, and satisfaction of court-ordered restitution. These individualized case plans should list terms positively rather than negatively. For example, "I will attend school regularly," is preferable to "I will not be truant." Presenting objectives in this positive framework helps contribute to positive outcomes. Court-mandated treatment plans or the case plan agreed to should be accessible to all personnel who are involved in the diversion program with the youth on a "need-to-know" basis only in accordance with Federal and State confidentiality rules.
In developing these reporting mechanisms, planners must remember that Federal confidentiality regulations protect information about AOD abuse treatment. In the case of the juvenile client, the parent or guardian sometimes must sign consent forms for the release of information. Confidentiality regulations are discussed in greater detail in the TIP entitled Screening and Assessment of Alcohol- and Other Drug-Abusing Adolescents.
In planning a juvenile diversion program, it is important to define and locate the appropriate AOD abuse treatment services that are available within a community. The planning group should first ask what services are necessary to intervene effectively with AOD-abusing youths. Members should then determine which of these services exist and which are needed. Planners should define and locate those services in their areas that will be relevant to their program. It is important that juvenile court judges and juvenile court services personnel be familiar with AOD abuse treatment options, a goal that can be accomplished by invitation to personnel within the JJS -- including judges, court services staff, and prosecutors -- to visit AOD abuse treatment programs and establish contact with them.
In different communities across the country, different types of treatment may mean different things. Regulations vary from one jurisdiction to another. For example, in one area, intensive outpatient treatment may be defined as a minimum of 9 hours of treatment a week; in another, it may be defined as a minimum of 15 hours of treatment a week. All terminology should be defined to ensure a common understanding. Throughout the development of this TIP, it has become apparent that common terms may have significantly different meanings to each systems collaborator. Legal terminology, for example, may have different connotations than the same terminology does when used in AOD abuse treatment.
The continuum of treatment services available for youth is described in detail in another TIP in this series, Guidelines for the Treatment of Alcohol- and Other Drug-Abusing Adolescents. Services range from low-intensity outpatient treatment to intensive outpatient treatment (also called day treatment or day hospital services) to residential treatment or inpatient hospitalization.
Planners should also be aware that treatment options can contain a variety of components. AOD abuse treatment programs, for example, may include individual, family, and group counseling and psychoeducational sessions about the effects of AODs. AOD abuse treatment may be psychosocial in nature, or it may be medically assisted. Medically assisted treatment includes medical detoxification, methadone maintenance (which is rarely recommended for adolescents), or any type of treatment that uses psychopharmacology or a blocking agent to deal with the physiological addiction.
Some AOD abuse treatment programs include an assortment of treatment options. A "one-stop shopping" approach offers a range of treatment services, especially in large urban areas where many AOD-involved juvenile offenders have a complex variety of treatment needs. One-stop shopping means that a youth will have access to an entire array of services located at one site. Some communities may take one-stop shopping a step further to institute universal intake procedures, establishing a collaborative approach among a number of agencies, which makes it easier for youths to gain access the various services they need, including family, social, psychological, medical, and educational services as well as AOD abuse treatment. For youths with multiple problems, this approach can help avoid the fragmentation that often comes from being involved with multiple service providers.
Some communities, however, will have few if any AOD abuse treatment services specifically designed for youth. This problem can be compounded by the reluctance of treatment programs that do serve youth to provide treatment for juvenile criminal offenders. The planning committee must identify service gaps and recommend the creation of appropriate services. This is an important needs assessment function, even in communities that have some services. A system cannot be planned without accurate and up-to-date information about what services exist, what services are needed, and how they can be made appropriate, accessible, and affordable for youth and their families.
Identification of services should not be limited to those that are AOD-related. As noted above, many of the youth in diversion programs have a wide range of biopsychosocial needs, and those on the planning committee who are investigating the availability of services should look at adjunct services that cover areas such as job training, emancipation issues, medical needs, "clean and sober" support programs such as Alcoholics Anonymous and Narcotics Anonymous, and mental health treatment services.
Personnel who are familiar with the standardized instruments available for AOD screening and assessment of juveniles should take part in the planning process. State-of-the-art tools should be used for screening and assessment, and standardized tools should be agreed upon before the implementation of the diversion program. Another TIP in this series, Screening and Assessment of Alcohol- and Other Drug-Abusing Adolescents, discusses this subject in detail and includes a number of sample instruments designed for use with juveniles.
Screening helps determine the need for further assessment or direct referral to crisis health or mental health services. Screening should not be limited to AOD use but should briefly cover a broad range of health, mental health, and social issues that may require some sort of rapid intervention. Testing for AOD use at the time of arrest is a valuable screening tool, but the result is just one of several factors to consider in making decisions. A positive urine screen is an indicator of AOD use at one particular point in time; it should not be used as the sole determinant of whether a youth does or does not have an AOD problem. Even negative results should alert the assessment team to the need to further explore the possibility of AOD abuse if other indicators are present -- past AOD-related offenses, a drug-using peer group, or chemically dependent family members. If the result is negative and other factors show no indication of AOD abuse, the youth should not be referred for AOD abuse treatment.
Some juveniles who are not involved with AODs may claim to have AOD problems because they perceive this as a way to avoid being detained or incarcerated or to gain status with their peers. This behavior affects the JJS and AOD abuse treatment systems in two ways. Accountability under the law is essential, and an accountability approach should not allow youth to use AOD abuse as an excuse to escape the sanctions for unlawful behavior. AOD abuse treatment programs do not want these youth referred.
To avoid the risk of diversion being wrongfully applied, assessment must play a major role in any diversion program. It should be performed as soon as possible after the precipitating event (for example, the arrest). Screening and assessment should be initiated and coordinated in conjunction with the intake process within the juvenile court. When a juvenile diversion system is being planned, the role of assessment should be considered an integral part of the comprehensive diversion and treatment process. The more sophisticated the assessment process, the more successfully youth will be placed. Assessment does not end with placement. It is not a single event but should be viewed as an ongoing part of the AOD abuse treatment process.
When planning a juvenile diversion system, it is important to address appropriate training of personnel who will be doing screening and assessment. Assessment should be closely tied to treatment planning and to outcome evaluation. Most juveniles will not be in clinical withdrawal when they come to the attention of the assessor, but some may be. Procedures should be established so that these youth can be easily referred immediately to a detoxification program.
Cultural, gender, and ethnic sensitivity are important aspects of both juvenile justice and AOD abuse treatment. It is necessary that the JJS and the AOD abuse treatment system understand the need to incorporate cultural, gender, and ethnic concerns into the disposition and treatment of juvenile offenders. Training programs and in-service training in the development of cultural competency should be available for policymakers and personnel throughout both the JJS and AOD abuse treatment systems. AOD assessment and evaluations of youth to determine disposition should be performed by personnel competent in dealing with specific cultural, ethnic, and gender issues that may affect the interaction.
Among the aspects of cultural diversity that may influence and affect juvenile justice and AOD abuse treatment are language, ethnic background, gender, spiritual or religious beliefs, attitudes toward healing, family systems, social norms, and physical and emotional disabilities. The procedures developed by the planning committee must be sensitive to diverse cultural, ethnic, and gender issues; courts should be acquainted with the body of research demonstrating the efficacy of cultural competence.
While some accountability-based sanctions may be viewed as punishment by some youth but not by others, these views may relate to the youth's culture and background. For example, youth involved in gang culture may perceive referral to a correctional institution as a means of gaining status in the gang rather than as a punitive measure. Dealing with these perceptions will pose difficulties for juvenile judges and juvenile court services attempting to apply justice consistently and appropriately, but still must be considered.
An aspect of culture that should be considered in the context of diversion to AOD abuse treatment is the strength of family structures found in many cultural and ethnic populations in the United States. Effective parenting and family support can be a major influence that deters children from using AODs. These strengths should be drawn upon in building a program. For example, in today's society, where youth are often searching for identity and values, the traditionalism embodied in the Native American family, which respects the position of its elders, is a value that can be used by an AOD abuse treatment program as an illustration for all participants.
Elders are a resource not just in Native American populations but also in many other groups, and they can be of assistance in planning diversion programs -- not only culturally specific programs but also broad-based ones. Elders with experience to contribute can be actively recruited through organizations, through networking, and through other means to take part in the planning process.
Employing these resources can help expand the idea of what treatment means and can help increase awareness of the value of alternative forms of treatment. Examples of Native American treatments include sun dancing, cleansing rituals, cultural meditation, sweat houses, and medicine singing. The African American community's rites of passage for young males include traditions that can be adapted to the treatment context and can increase the positive bond to the cultural community.
In establishing the planning committee, attention should be given not just to potential members' academic degrees but also to life experiences.
While the incidence of female delinquent behavior is lower than that among males, there is little difference in their crime patterns. However, the young female offender is underidentified in the larger context of the juvenile offender population. Official statistics show that girls are arrested far less frequently than boys, and then for relatively minor offenses.
Most research and practical experience with juvenile offenders have been with males, and JJS program designs range from the farm, ranch, or forestry camp to the paramilitary ("boot camp") models. Females may not easily fit into these programs, and the relevance to females of these male-oriented program designs has proven inconclusive. Male and female juveniles are likely to respond differently to accountability-based treatment strategies and thus need to be approached differently. Fortunately, data exist regarding gender-specific treatment approaches. Among other differences, programs for female clients must supply a range of services not needed in programs for male clients, including child care, parenting classes, feminine hygiene supplies, baby supplies, and access to obstetric and gynecologic services.
Because of the special needs of young women, which may include prenatal and child care, it is more expensive to treat them, and many treatment programs have been wary of accepting them. While the number of slots needed for young women may be only a fraction of the number needed for young men, the rapidity with which slots for young women are filled when they are made available is convincing proof of the need for them. A continuum of services for young women similar to the continuum of services that already exists for young men is needed. Treatment models must be sensitive to the gender-specific needs of the population, including the availability of female staff to work with young women. For example, while many young male-oriented delinquency intervention models (such as boot camp regimens or VisionQuest) stress confrontation, nonconfrontational models may be more suitable for young female offenders. See Practical Approaches in the Treatment of Women Who Abuse Alcohol and Other Drugs, a publication of the CSAT Division of Clinical Programs, Women and Children's Branch.
Staff training improves understanding and awareness of resources. It would be valuable for AOD abuse treatment providers, together with judges and juvenile court services personnel, to share a cultural diversity curriculum so that each can develop some common understanding of culturally sensitive issues in their community. This understanding must be specifically developed by each community and should be done on an ongoing established basis.
Another important part of the planning process is to survey and analyze the social and cultural indicators in a needs assessment, which should address issues of cultural diversity with an accurate, up-to-date list of existing resources that support youth and families participating in an AOD diversion program. Such a list can provide insight into what needs are met in a community, where more attention must be focused on policy, and the continuing development of the AOD diversion program.
One way to address issues of cultural diversity is for both the juvenile justice and AOD abuse treatment systems to include staff who are representative of the populations being served (for example, women should be available to work with female offenders). It is also important to recognize that just because an individual represents one cultural, racial, or ethnic group, this does not mean he or she is sensitive to all issues of that group. For example, African Americans are a diverse population in this country, and some black people (for instance, Haitians) are not African American. Some communities may be dealing with cultural differences within the same racial or ethnic group or among recent immigrants into a large established ethnic community.
Procedures must be established for the referral of juveniles between the AOD abuse treatment system, the JJS, and the community health and social services agencies that will provide services to the youth in the AOD abuse treatment program.
Each participating agency should clearly define its target population, the array of services, and fees for service, and specify all limitations. The collaborating committee may be able to negotiate a simplified linking system. Many agencies have developed quite elaborate referral information requirements to assist in providing services to the most appropriate youth. Often these requirements are so stringent as to be insurmountable barriers to service. To help achieve the goal of a "seamless" service system and decrease duplication of effort, a single referral document should be developed for all participating agencies.
The importance of an easily understood and simple referral process cannot be overemphasized. In a fully integrated system, services are matched to the identified needs of the youth and his or her family. Each service becomes essential to the achievement of a positive outcome.
Sufficient care should be taken to acknowledge and support the specialized requirements of some services. The diversion program's effectiveness or funding support may be based on some specific limitations or documentation requirements. Other programs and services are effective for a specific subgroup of youth, and not acknowledging their uniqueness may compromise a valuable service.
Although families are the first level of responsibility in our society, the family's economic status can be another influencing factor to consider in program development. Juveniles from middle-class families, with well-established networks of financial supports, may benefit more from AOD abuse treatment and may have better outcomes than juveniles from poor families with less developed support networks.
It is also important to note that a family's commitment to getting treatment for its youth should not be related to socioeconomic factors. Parents should be included in all decisions regarding the youth. AOD abuse treatment programs should actively engage the family in participation in the youth's treatment plan. Families should see their role as part of the solution, not just part of the problem. AOD abuse treatment providers should be skilled enough to alleviate the fears of entering treatment or receiving services that are expressed by many youth and their families but, when appropriate, there should be no hesitation in mandating that family members actively participate.
The family plays a key role in the youth's behavior, activities, and attitudes in the AOD abuse treatment diversion program, and it is important that "family" be defined as broadly as necessary to encompass different arrangements and living situations. A family may be defined as those individuals who provide shelter, nurturance, and guidance for a child. The Commission on Families of the National Association of Social Workers defines a family as two or more people who consider themselves a family and who assume obligations, functions, and responsibilities generally essential to healthy family life. The functions of the family include child care, child socialization, income support, long-term care, and other types of caregiving.
This concept goes beyond that which is traditional for the biological family (mother, father, and siblings) and includes a wide variety of possible arrangements. Examples of families include a grandmother and her grandchildren; a single mother, her children, and her boyfriend; and foster parents raising several children. Family support can come from a community elder or from a recovering adult. Children may also get family-like identity and support from friends, or even from gangs, although support from the latter is not considered healthy.
Ideally, parents (or individuals filling the parental role) should participate in the treatment process. It is difficult for the youth to progress without family involvement. Whoever is identified as the family of a youth who participates in the diversion program must make a long-term commitment to the treatment and recovery process. The family should have a physical presence in youth diversion programs because parents remain responsible and accountable under the law for their child's activities and behavior. Family members should participate with the youth in the diversion process. The diversion agreement or court order should specify incentives for family participation in treatment and the expected benefits to the family when the youth successfully completes treatment.
Defining appropriate expectations for the family is an important part of the diversion plan. Ideally, family members should understand how critical their role is and be supportive in all efforts. At a minimum, the family should participate in the development of the diversion plan, sign the diversion agreement, or be a party to the court order, monitor it, and report to a contact person on either compliance or noncompliance by the juvenile. Contact persons could be court services staff members such as probation officers or case managers or AOD abuse treatment providers.
Families must recognize that their own response to the juvenile's AOD problem may be inappropriate, and members should be willing to seek assistance in developing parenting skills, addressing their own AOD problems, and dealing with vocational and educational issues. Parents should recognize what puts their children at risk, and should address that risk. One example is teaching a juvenile conflict resolution skills; it is only marginally useful for a juvenile to learn alternative ways to solve problems if parents and other family members are not also instructed in these skills. Families also can facilitate treatment by providing transportation, babysitting for teenaged mothers in treatment, and being an active and informed advocate for youth in treatment.
Family involvement is a significant contribution to the success of AOD abuse treatment, but it may also prove problematic in some situations. For some youth, the risk factors within the family are a substantial part of their problem. For example, if the juvenile is a third- or fourth-generation AOD abuser, removing the juvenile from the home may offer the best chance for success in treatment. Sometimes, families will not cooperate with treatment. Recognizing that authority to mandate treatment for family members varies from jurisdiction to jurisdiction, the consensus panel recommends that where there is no authority to mandate family participation, States consider enacting legislation that would allow courts to order parents to comply with AOD abuse treatment diversion, when appropriate.
It is important that a youth not be penalized or excluded from diversion opportunities because of the lack of a responsible or cooperative family. When necessary, the court should arrange for a relative, a guardian ad litem (for the particular action or proceeding), or a foster family to fulfill the role of the family.
The National Center for Service Integration identifies four principles that form the foundation for strategies to finance new service systems. These principles should be set forth in the implementation manual and referred to throughout the process of developing, financing, and implementing the diversion program:
Financing should reflect and reinforce a new set of principles and characteristics for service delivery and should be driven by a compelling and well-conceived program agenda.
Effective fiscal strategies should incorporate multiple funding sources and cut across traditionally separate service domains.
Financing strategies should make use of dollars already being expended in the service system.
Fiscal changes require parallel alterations in service governance and service delivery technologies if they are to be effective (Farrow and Bruner, 1993).
When considering the funding of AOD diversion programs for juveniles, cost and funding sources must be considered, including the use of nontraditional sources and reallocation of current resources. The impact of healthcare reform on AOD abuse treatment resources is another important consideration.
AOD use endangers not only youth and families but the community as well. However, both the costs of the AOD abuse to a youth's life, liberty, and property and the cost that is offset by AOD abuse treatment must be considered. Costs of AOD abuse include 1) human costs, 2) economic costs, 3) physical healthcare costs, 4) mental healthcare costs, 5) criminal costs, 6) morbidity, 7) increased social welfare costs, 8) loss of work production, and 9) loss of education.
The benefits of AOD abuse treatment are many, with successful treatment offsetting potential expenditures in all of the above categories. Numerous studies show that every dollar spent on treatment leads to a sizeable reduction in AOD abuse and that criminal behavior declines as a result of treatment (Young, 1994).
The identification of funding sources available for diversion programs should be a priority in the planning process. Since diversion programs will integrate services from several systems (JJS, AOD, and community health and social services) with separate funding streams, it is important that representatives from all the systems who are familiar with the funding streams be part of the planning team.
Funding sources might include Federal block grants, specially designated funds from the State legislature; county and community grants; Medicaid; private and public foundations, health insurance; local businesses; client fees; family and memorial foundations; the United Way; the Job Training Partnership Act; and the Office of Juvenile and Delinquency Prevention, Department of Justice, for training court personnel. Revenue sources could be derived from community fees, fines, levies, and forfeitures resulting from drug trafficking and other criminal offenses associated with AOD abuse.
Although AOD abuse treatment is expensive, new dollars are not always necessary to fund diversion programs. It may be a matter of being innovative or creative. Sometimes reallocation of current resources, both financial and human, can go a long way toward funding services. If the major partners in the systems develop cooperatives that combine their existing resources, many needs may be met. The development of working partnerships can lead to shared staff, relocation of staff, and reallocation of existing AOD resources to the target population.
As public funds become less available, communities are given the opportunity to reconfigure current systems. The collaboration should address funding issues from the viewpoint of what services the funds can purchase. Only then can the true lack of fiscal resources be documented.
Making use of volunteer services is another way to augment traditional funding sources. Volunteers can assist with followup, tracking, and case management tasks. As previously noted, community elders can be a valuable source of volunteer efforts. Recovering youth can serve as mentors to youth just entering the treatment system. (Youth volunteers should always be monitored by adults.)
Planners should be aware that the use of volunteers may involve some costs and can raise procedural problems. Developing volunteer services requires the development of clear procedures and guidelines covering what a volunteer may and may not do. Screening, training, and insurance coverage for volunteers are issues that must be considered. For example, residential programs may discover that their liability insurance covers only paid employees and not volunteers. Confidentiality rules may pose a barrier for the use of some types of volunteers. Juvenile justice and AOD abuse treatment planners should turn for guidance to both private and public agencies that have experience working with volunteers.
At a minimum, the names of volunteers should be screened through the National Crime Information Center database, Federal and State criminal records, and child abuse registries. Procedures for performance evaluation of volunteers should be in place, as well as formalized training and ongoing supervision. Clear guidelines should be established for transporting youths, or for any other situation that may involve potential liability or security issues. Recruiting and training volunteers should be ongoing processes, and agencies should consider funding a position for a staff member to do these tasks. Recognition programs to acknowledge the contributions of volunteers should also be planned periodically.
Creative use of other nontraditional sources can also help fund diversion programs. A potential significant resource may be found in the physical facilities of established institutions. Schools, businesses, or government facilities can be used to house programs. For example, schools might be kept open during evening hours for parent training programs or other after-hours programs or to provide office space for onsite AOD abuse treatment. Use of these resources can result in significant savings in operational costs.
Another possibility is to explore incorporating existing programs into diversion efforts. For example, Boys' and Girls' Clubs in some regions sponsor tutorial programs. In other parts of the country, local exchange clubs, service clubs dedicated to youth issues, sponsor parenting classes and child advocacy projects. Building on existing programs in the community avoids duplication and overlap and brings community organizations into worthwhile partnerships with the juvenile justice and AOD abuse treatment systems. However, these organizations should be involved in the planning process so that they can commit the resources they have available. Another nontraditional means for obtaining funding is the specific allocation of community taxes on gambling, alcoholic beverages, or cigarettes. Future healthcare policy reform at State and perhaps national levels is likely to affect these funding issues profoundly. Planners of juvenile diversion systems should be mindful of the forces that will be shaping healthcare policy on both the State and national levels. As healthcare policy is being developed, special attention should be paid to how youth programs will be covered and to what extent AOD abuse treatment will be covered by new healthcare proposals.
Adequate communication is extremely important to a collaboration such as that of the planning committee. Communications regarding AOD abuse treatment are strictly regulated by Federal confidentiality regulations (42 C.F.R.), although it may sometimes seem that the concepts of confidentiality and communication are mutually exclusive. For example, without express written consent, an AOD provider may not be able to notify the court that a diverted youth failed to enter treatment. Planners should be open, creative, innovative, and focused in developing information sharing strategies within the confines of the rules.
To be effective, court-mandated treatment plans must be monitored to ensure that the diverted juvenile is participating as required and that the diversion program is meeting the juvenile's needs. Thus, sharing of information is an issue that should be addressed specifically and comprehensively in the planning process. A key to overcoming communication problems is to build trust among all the agencies involved. The regulations define arrangements that facilitate the sharing of information. For example, qualified service organization agreements, as described in the Federal regulations, allow for the sharing of information in relevant situations.
The basis for decisions regarding confidentiality and communication should be the best interest of the youth. The question that should be asked is: What information sharing is necessary to determine the best treatment and disposition for the youth? Information should be shared in order to 1) avoid duplication of services, 2) ease the youth's access to services, 3) ease intake, 4) facilitate planning, 5) encourage informed decisions, and 6) positively influence outcomes.
Decisions regarding confidentiality and communications should not be made unless the following issues have been carefully addressed:
All agencies that have a need to share information concerning each youth should be involved.
The reasons why the agency needs the information should be documented. For example, much evidence exists regarding widespread child abuse in the AOD-involved delinquent youth population; this documentation is necessary for a "need to know" of the abuse history recorded at various agencies involved with a youth. Relevant child abuse reporting statutes should be included in this discussion.
Agencies must agree that the needs for shared information are acceptable, relevant, and nonthreatening to the youth.
What information is each agency willing to share, and with whom?
How best to protect specific information that one agency does not wish to share or is restricted from sharing (such as HIV status) must be resolved, with clearly established boundaries set as part of the planning process.
The purpose of confidentiality (to protect the youth) must be reinforced. In some circumstances, confidentiality regulations may protect the system, not the youth.
An approach to the changing policies and regulations that prohibit sharing of information must be developed.
Automation of information with interagency access must be addressed. Current sophisticated computer systems can facilitate this. Information-sharing software is in the public domain, and jurisdictions should consider state-of-the-art management information systems that are available by modem.
Procedures for uniform sharing of information must be developed. This process can be conducted incrementally, a piece at a time, beginning with the least sensitive information to be shared.
Uniform informed-consent guidelines and forms must be developed. When possible, these guidelines and forms should be automated to ensure interagency access and protection.
System management refers to the ability to effectively plan, implement, and maintain AOD abuse treatment alternatives for JJS-involved youths. It includes the following components: 1) program management capabilities, 2) system oversight and organization, and 3) interagency cooperation and collaboration.
Licensure and other approvals are the foundation for a system of AOD abuse treatment services, and planners of juvenile diversion programs should carefully examine these requirements. It is important that they not plan services that require complicated licensing procedures that current providers may not be capable of achieving or cannot afford. An example is the accreditation of residential programs that is provided by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO). Attaining this accreditation may present formidable barriers in some cases. A different sort of example is the nonprofit status that is required of agencies wishing to receive some grants.
Third-party billing capability is another important concern. A third-party payer is an insurance company, managed care organization, health maintenance organization, or similar entity. (First-party payers are clients themselves; second-party payers are government sources such as Medicaid and Medicare.) Planners should assess current service providers' abilities to participate in third-party billing, which is often essential to the establishment of a consistent funding stream.
Past experience with the target population is another management issue that will be indicative of program management capabilities. Adolescent services are difficult to provide, whether they are AOD-related, educational, psychological, or social. In looking for programs to incorporate into a juvenile diversion system, planners may want to focus on organizations that have experience and expertise in providing services to the target population. An agency's experience in providing AOD abuse treatment services for adults does not necessarily qualify that agency to provide similar services for youth. It is also true that treating AOD-abusing delinquent youth may call for different skills and resources than those that are needed for treating either of these populations (AOD-abusing youth and delinquent youth) separately.
This requirement does not mean that programs that do not have a history of treating the target population should automatically be excluded from involvement in the development of a juvenile AOD abuse treatment diversion program. However, programs and system planners must be aware of the particular challenges in treating this population and seek technical assistance when necessary before implementing a diversion program.
When systems are brought together, it is necessary to continue the process of identifying what individual or agency is responsible for which service or product. Planners should define explicitly which agencies will have oversight and responsibility and under what circumstances. Monitoring procedures, governmental regulatory activities, and site visits should be planned carefully. These monitoring activities should cover not only established programs, but also programs that may have started informally in churches or community facilities and escaped oversight processes.
Comprehensive reviews of how components work together should be scheduled periodically. Programs and their progress should also be reviewed regularly, with more frequent reviews earlier in the development of the program.
Program oversight and organization can present difficult challenges. System organization and oversight can be even more difficult. That is the nature of collaboration.
A critical component to the functioning of the interrelated services is an advisory board of representatives of all the services involved in the diversion program. This board should be relatively small to allow for efficiency of operation, and it should have staff support (donated by one of the agencies involved) to notify members of meetings, keep minutes, and perform other administrative tasks.
An advisory board can begin its work by adopting a clear vision statement, establishing a scope of work and appropriate procedures, and electing a structure of leadership. It should conduct meetings according to an agreed format, which will facilitate translating ideas and recommendations into action. The board should be aware of barriers that could interfere with its work. One example is the hidden agendas of participants. If the board can acknowledge that there are hidden agendas and be sensitive to them, this may offset potential negative effects.
Another barrier that often arises is the inclination of people to protect their institutional and organizational "turf." To plan for that, advisory board leaders should focus early on preventing turf issues from stalling the planning process. They should meet individually with key stakeholders and identify and discuss their needs, concerns, and support. A clear, concise agenda will help avoid setbacks and misunderstandings.
As emphasized throughout this TIP, interagency cooperation and collaboration are the critical elements in developing a successful juvenile diversion program. It is essential at every point in the planning process.
Documentation of program design and operating policies and procedures is an essential part of a juvenile diversion program and should be incorporated into the planning process. In order to operate smoothly, programs should reach consensus on procedures and guidelines and have them in place before they begin taking referrals. This written documentation covers issues large and small, ranging from general policy to detailed procedures regarding specifics, such as program check-in and security measures.
A policies and procedures manual for AOD abuse treatment providers should be approved by the provider's overseeing agency and should be open for review throughout the planning process. In most cases this approval and review will not involve extra work for the treatment provider, since AOD abuse treatment agencies are usually required by current licensing and oversight agencies to develop policies and procedure manuals.
However, additional efforts will be required on the part of the juvenile justice and AOD abuse treatment communities to agree upon written procedures for referrals from juvenile justice to AOD abuse treatment. The procedures described should be specific and should address questions such as what the role of a court services officer is in making a referral, whether treatment programs should maintain a physical presence in the court in order to facilitate diversion, and which forms should be shared among cooperating agencies.
The need for training and cross-training -- multidisciplinary training that raises awareness of the philosophical approaches, skills needed, and tasks performed by staff in JJS, AOD, or physical and mental health and social services -- of all personnel involved in a juvenile diversion program is central to the success of the program. It is only through cross-training that the different perspectives of the JJS, the AOD abuse treatment system, and other involved agencies can be reconciled.
One way to accomplish this reconciliation is to establish a broad-based curriculum in a training institute that includes trainers from courts, law enforcement, AOD abuse treatment agencies, and schools to provide training sessions for all involved personnel. While much of the curriculum will be relevant to all participants, specific lessons may be directed to specific participants. For example, prosecutors and other court personnel should be instructed in the nature of addiction as a chronic, relapsing disease, while treatment providers should be taught about public safety, law enforcement, and juvenile justice procedures.
Conflict resolution should also be a component of the comprehensive training program. Part of teaching juveniles to deal with addiction is teaching them how to deal with conflicts, and program staff also should learn conflict resolution and anger management in order to work most effectively with their clients. These strategies could also become the basis for resolving inevitable interagency staff conflicts.
The consensus panel acknowledges that training can be an expensive process but believes it is a valuable and essential one. Expenses can be moderated by using a number of techniques. Local universities can be a source of interns or volunteers. State-of-the-art technology such as teleconferencing can present a program to widely scattered participants without requiring them to be at the training site. Local cable access and educational television stations can further broaden access to training by reaching community members, including parents and family members of juveniles who are involved in the programs. Informal training programs, such as "brown bag" lunches, where staff with specific expertise can make brief presentations, has many extra benefits. The programs acknowledge staff expertise and allow staff from the other participating agencies to experience the depth of local knowledge. Often local agencies and their staffs tend to discount their knowledge and level of skill.
Printed media can play a role in public education efforts, particularly on the community level. For example, resource guides can be developed and inserted in local newspapers. Hospitals and schools can also distribute printed material to help educate the public about addiction and delinquency.
Evaluation is a facet of program design that should be considered from the first phases of planning. Good programs require systematic evaluation, and good evaluation requires an investment of personnel and financial resources. Experienced evaluators should be involved from the outset. An effective evaluation design must begin with program development in order for results to be objective and unbiased.
Many field reviewers of this TIP were concerned about the ability of communities to secure adequate evaluation resources. There are many untapped resources even in isolated rural communities. State universities have been increasingly involved in providing technical resources to the rural areas of their States. Rural medical outreach training programs bring medical and nursing students to underserved areas. Most of these programs have large research and evaluation departments, and the uniqueness of the evaluation may be attractive to them. In addition, linkage to the State higher education system can be made through the local extension and 4-H agent.
The evaluation component of the diversion program should be designed by an individual who is not only experienced in evaluation but also familiar with the fields of juvenile justice and AOD abuse treatment and who has a clear understanding of the goals of the programs and systems involved. The evaluator must be sensitive to adolescent, family, community, and cultural issues. Further, there must be an understanding by the evaluator of the type of data that must be collected in order to measure system performance, not individual program or client outcomes. If an independent evaluator is contracted, the specifics of these data needs should be spelled out in the contractual agreement, along with a timeline for all anticipated reports and a clarification of ownership of the data.
Many elements are involved in the design of an outcomes monitoring system, and this document can sketch only a broad outline of that process. Design and implementation of outcomes monitoring systems are described in detail in another TIP in this series, Developing State Outcomes Monitoring Systems for Alcohol and Other Drug Abuse Treatment.
In evaluating the results of a juvenile diversion system, two primary outcomes will be measured -- relapse in AOD use and recidivism in illegal behavior. These outcomes may mean different things to juvenile justice and AOD abuse treatment personnel, and clear criteria for successful outcome measures should be identified and established during the planning process. Neither relapse nor recidivism are absolutes, and outcome measures should recognize this important point.
Evaluation requires collection of data at intake, and a number of standardized instruments in the public domain are available for this purpose. (The TIP Screening and Assessment of Alcohol- and Other Drug-Abusing Adolescents includes an appendix with several of these instruments.) Followup data should be collected 30, 60, and 90 days and 1 year after completion of treatment. Collection of data related to the youth's offending behavior does not require a formal court review, but can be based on reports from, for example, a juvenile justice case manager. Urine screen results or self-reports to identify relapse will usually come from AOD abuse treatment providers.
Outcome data must be tied closely to AOD diversion program expectations, which have been determined on a community-by-community basis. Individual interpretation is what makes evaluation successful; this is a particularly important point in the context of juvenile diversion, where success and failure are not always clear concepts. For example, while reinvolvement or reentry into the JJS may seem a negative outcome, some individual diversion contracts may provide that reinvolvement or reentry for a lesser offense than the original arrest will be considered as some measure of improvement. Likewise, one positive urine screen is not necessarily interpreted as failure if a contract stipulates that a youth must have, for example, no more than one positive test every 3 months. In addition to AOD abuse and law-offending behavior, other outcomes that can be measured include school performance and family functioning.
Because diversion programs are usually time limited, it is important that evaluators measure outcomes beyond the formal termination of the AOD diversion. It is only with such data that determinations can be made about the overall success or failure of the AOD abuse treatment diversion program.
Evaluative data should be kept in an accessible and useable format. In most States, a single State agency has the responsibility of collecting AOD-related data and reporting it to the Federal Government to determine distribution of block grant funds. These data can provide a foundation for system evaluation. Uniform crime reports collected by law enforcement officials and State crime prevention offices can also serve as part of a foundation for evaluation.
Evaluation should be sensitive to issues of culture, gender, and ethnicity, with an appreciation of the cultural nuances and subtleties that may be involved. Cultural competence requires knowledge about cultural issues and distinctions, awareness of how they affect a community, and sensitivity to the specific needs of cultural groups.
Research consistently shows that criminal behavior and juvenile AOD abuse are strongly correlated. System evaluation can lead to ongoing research, which can help a community develop a unified juvenile diversion program. Currently, there is a sparsity of existing research on diversion programs. More is needed to determine whether diversion assists the JJS in reaching its goals and whether it leads to positive long-term outcomes for youth, their families, and the communities in which they live. The consensus panel recommends that all efforts to develop interagency diversion programs place a heavy emphasis on research and evaluation.
Research and evaluation are essential to ascertain what kinds of programs work and -- just as important -- what kinds do not work. Research information based on valid evaluation should be widely disseminated so that successful projects can be replicated and poorer models avoided.
This chapter has addressed the many issues that are critical to comprehensive planning for a system of diverting AOD-abusing youths from juvenile court interventions to AOD abuse treatment. One of the most critical tasks (and perhaps the most difficult) is to arrive at a broad consensus regarding what is meant by diversion in this context. This concept must be defined unambiguously and all of the planning partners must endorse the definition.
Other critical planning issues that were addressed included the identification of the appropriate target population for diversion, appropriate diversion points, and key system leaders to be involved in the planning process. In addition, effective planning requires attention to such diverse issues as 1) screening and assessing, 2) attaining adequate funding, 3) managing confidentiality while adequately sharing information, 4) designing and documenting an AOD diversion system, 5) using system management techniques, 6) training staff, 7) evaluating effectively, and 8) conducting ongoing research and development.
Chapter 5 synthesizes much of the material presented here. That chapter provides a summary of the tasks that must be accomplished in developing an operations manual for implementing a collaborative program -- a program for diverting AOD-abusing youths from the JJS to appropriate AOD abuse treatment.
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