Journal of Child and Family Studies

, Volume 23, Issue 4, pp 738–744 | Cite as

Use of Psychiatric Medications in Juvenile Detention Facilities and the Impact of State Placement Policy

  • Edward CohenEmail author
  • Jane E. Pfeifer
  • Neal Wallace
Original Paper


The use of psychotropic medications is a significant factor in the overall effort to respond to detained youth with mental illness, yet there are very few studies of psychotropic medication use in juvenile detention settings. It is important to understand the factors that influence the use of mental health services and psychoactive medications in these settings since youth with emotional problems are overrepresented in them. This paper addresses the proportion of youth in these settings who receive mental health services and psychoactive medications. In addition, the impact of a major statewide policy change—the shift of juvenile placement responsibility from the state to local government—on these proportions was examined using 8 years of publicly available data from county probation departments. Multivariate regression analyses of 1,760 observations of quarterly reports from 55 counties showed that the use of both mental health services and psychoactive medications in detention facilities increased concurrently with the policy change. While these proportions had already been gradually increasing in these facilities, it appears that after the policy change they increased even more. This contradicts the aim of most juvenile justice planners—to divert non-violent youth offenders with emotional problems away from incarceration settings and towards community based treatment alternatives. If adequately available, these support services could provide diversion alternatives to prevent inappropriate detentions, and to provide post-detention treatment to prevent lapses in continuity of care and, ultimately, to prevent reoffending.


Juvenile justice Mental health Psychotropic medications Detention facilities Placement 


Almost all juvenile detention facilities have become dispensaries of psychoactive medications for youth (Pajar et al. 2007). These medications are a significant cost factor in the overall effort to respond to detained youth with mental illness (Cohen and Pfeifer 2008; Tennyson 2009). There are very few studies of psychotropic medication use in juvenile detention settings, however there have been growing concerns about the use of psychoactive medications for children and youth in out-of-home settings. For example, in the child welfare system a recent review of data from a national survey showed that many more children and youth in child welfare placements have been prescribed these medications compared to children living informally with kin (Stambaugh et al. 2012).

A report from one Midwestern state showed that 17.5 % of sampled youth in detention settings had psychotropic medication prescriptions documented, and many of them were receiving multiple medications (Osterlind et al. 2007). Even when elsewhere the percentage of youth receiving these medications may be relatively low, the cost is still substantial. In one Southeastern state cost study, while 7 % of youth admitted to a county funded juvenile facility were prescribed psychotherapeutic medications, these medications accounted for 83 % of the annual budget for all healthcare medication categories (Tennyson 2009).

It is thought that appropriate and continuous follow up mental health and substance care for juvenile offenders returning to the community is important to minimize recidivism and re-offending (Abram et al. 2009; Trupin et al. 2004). However, surveys indicate that there are serious barriers to continuity of care for these youth once released from custody, and continuity of medication prescriptions is thought to be a large part of the problem (California State Commission on Juvenile Justice 2009; Cohen and Pfeifer 2011). Respondents point to the lack of follow through by youth and families in filling medication prescriptions and keeping appointments with treatment providers, regardless of whether these appointments involved medication monitoring or psychotherapy. There are a variety of reasons for this related to characteristics of youth, families, and treatment systems. Some feel that gaps in capacity of the mental health treatment system also contribute to breaks in treatment, as budget reductions result in fewer resources and increasingly narrow definitions of target populations for whom the publicly-funded mental health system is responsible. In addition, the often fragmented separation of probation, mental health and substance abuse treatment systems has resulted in poor communication and a lack of coordination of treatment. The extent to which this problem exists may be influenced by the number of youth who need treatment. It is therefore important to understand the factors that influence the population mix of youth in juvenile detention facilities, and the use of mental health services and psychoactive medications are partial indicators of the need for mental health services.

Youth with mental disorders are especially vulnerable to longer detention stays as shown by surveys of states (U.S. House of Representatives Committee on Government Reform 2004) and reviews of case records (Burrell and Bussiere 2005). A combination of factors, including lack of staff training and gaps in community services or placement alternatives deleteriously affected length of stay for these youth. Detention facilities cannot say “no” when youth are brought in due to placement failures, behavioral problems, or more serious crimes that might have been a result from a mental disorder, yet juvenile justice professionals tend to agree that many of these youth could potentially be served in community settings if they were available. Judges and probation personnel are often hard pressed to find appropriate placements for youth with serious behavioral or psychiatric problems who cannot return home, made even more difficult when the iatrogenic effects of the detention setting itself further impairs the youth’s mental status.

Policy shifts that affect local jurisdictions may influence the mental health case mix of youth in juvenile detention facilities. On September 1, 2007, California implemented a realignment of Division of Juvenile Justice (DJJ) responsibilities as part of California Senate Bill 81. This bill required that only the most violent and serious juvenile offenders continue to be referred to state-administered Youth Correctional Facilities. There is a national trend towards reducing the size and scope of state-operated juvenile facilities, as can be seen by recent media attention in Indiana (Harrell 2012), Michigan (Asanova-Taylor 2012), and Illinois (Plan to close juvenile detention centers pits advocates against labor 2012), to name a few examples. Reasons for these policy changes include budget concerns, reductions in the number of incarcerated juveniles, and an interest in promoting community-based alternatives to incarceration for youth.

California runs four facilities for committed youth. These facilities are expressly designed for education, vocational training, mental health, substance abuse, and sexual offender treatment. This number of these facilities was higher before DJJ Realignment. After the policy change, those youth with less serious offenses were no longer referred to such facilities, and instead became the responsibility of the local jurisdiction (i.e. counties). The impact of this legislation on the state DJJ has been significant—the population of DJJ facilities and juvenile parolees was reduced from a high of over 10,000 in 1996 to 1,500 in 2010 (California Department of Corrections and Rehabilitation Office of Research 2010). Are these non-serious offenders more prone to have mental illness than those who would not have been referred to state placement prior to the policy change? Because systematic risk assessments have only recently been implemented in most jurisdictions, there does not seem to be a summary report of these youths’ diagnostic profile. However, the majority of these non-serious offenders had mental health and substance abuse treatment episodes prior to their adjudication and placement (California State Commission on Juvenile Justice 2009), so it is likely they will continue to need these services after release from state placement. The research evidence as summarized in Grisso (2004) has found some linkages between aggressive behavior and mental disorders, especially for youth with “externalizing” conduct and behavioral disorders, youth with co-morbid mental disorders and substance abuse, some youth with post-traumatic stress disorder, and even some youth with “internalizing” disorders such as depression. Given that youth with mental disorders are overrepresented in juvenile detention settings to begin with (Teplin et al. 2007), it is reasonable to assume that the state’s release of non-violent offending youth will require counties to provide more resources for mental health and substance abuse treatment alternatives.

As part of DJJ Realignment, Youth Offender Block Grants were made available to counties to fill important gaps in local programs to support their work with these offenders (California State Commission on Juvenile Justice 2009). While innovative programs have been implemented statewide and local resources expanded with the use of these grants, surveys of counties find that there continue to be significant gaps in the availability of secure treatment facilities as well as other supportive community-based services for these youth (California State Commission on Juvenile Justice 2009; Cohen and Pfeifer 2008). Consequently, some of these realignment-targeted youth who were re-arrested may have been “placed” in juvenile detention facilities that were never intended to serve as long-term placements or mental health treatment programs. There was some preliminary evidence that this was occurring in California soon after the realignment legislation (Cohen and Pfeifer 2008).

Given concerns about the case mix of youth with mental health needs in juvenile detention facilities, we posed the following research questions: (a) What has been the proportion of youth in California’s juvenile detention facilities who have mental health needs? (b) What has been the proportion of youth in these facilities taking psychoactive medications? (c) Have these proportions changed as a result of the major policy change with DJJ Realignment?


Study Design and Sampling

This study involved an analysis of existing, publicly available data summaries. The data consisted of “snapshot” counts of juveniles in facilities as reported by counties to the California Department of Corrections and Rehabilitation (CDCR). These counts were taken on a monthly basis and posted on a query website for the general public (California Department of Corrections and Rehabilitation 2011). Data were available from January, 2002 through December, 2009. The data reports were downloaded and arranged by county, year, and month. These data did not include case-level information or information identifying individual youth, and required no special approvals to obtain access.

Since the monthly data reports are required by the state for all juvenile detention facilities, we assumed that the reports reflect all juvenile detention facilities in the state, and that, as per the instructions given to counties for their reports, the counts reflected a daily snapshot of all youth within those facilities at the time of the report. For purposes of this analysis, we combined months into quarters to minimize any possible autoregressive relationships between consecutive months. There were 55 (out of 58) counties that had published reports on the query website over a period of 8 years (32 quarters), resulting in 1,760 (55 × 32) county × quarter observations.

Variables and Measurement

Variables used for this study are shown in Table 1.
Table 1

Means and frequencies of study variables


Pre-DJJ Realignment

N = 1,188a

Post-DJJ Realignment

N = 540a


Average percentage of open mental health cases in daily population



.36 (.32)

Average percentage of daily population on psychotropic medications



.17 (.12)

“Rural” counties


34 (62 %)

** Difference pre- and post DJJ Realignment, p < 0.01

a County × quarters

There are two dependent variables of interest. The first variable is a proxy for mental health need—the percentage of the juvenile detention population with “open mental health cases.” This is an imperfect indicator of need since service use may not always accurately match the need for services, however for this population there exists no central database containing diagnostic information and level of functioning. An “open mental health case” is defined by the reporting requirements as “an actual open chart or file with the mental health provider when a juvenile is in need of, or receiving, documented mental health care or services” (California Department of Corrections and Rehabilitation 2005). There may be some variation among counties about how this definition is operationalized, as reported elsewhere (Cohen and Pfeifer 2008). For example, some counties define an “open mental health case” as an active treatment file in the county’s mental health agency information system while others define those youth as having had at least one visit by a specialty mental health provider, such as a psychiatrist, without necessarily having an open file in the county mental health agency. The reporting requirements do not define what being “in need of care” means, and it can be assumed that each facility may have different assessment and screening procedures to determine this. To construct this variable we divided the number of youth with “open mental health cases” with the snapshot daily population which was reported at the same time.

The second dependent variable is the percentage of youth in detention facilities taking psychoactive medications. This variable was constructed by dividing the number of youth on psychoactive medications with the snapshot daily population which was reported at the same time. There are two important limitations to the use of this variable. We do not have information about which medications were counted as “psychoactive” and we suspect there may be inconsistencies between counties in their methodologies. Adding to this reliability concern is that there are varied organizational structures for prescribing and dispensing medication among these facilities (Cohen and Pfeifer 2008), which could also result in different methodologies across counties for tracking medication usage. Despite the reliability concerns for both variables, these data were used since there exists no other single data source in the state with information about juvenile detention populations and their use of mental health services and medications.

We constructed a dummy variable to indicate DJJ Realignment. The variable was coded 0 for all quarters prior to the policy shift, and all other quarters (beginning with the 3rd quarter of 2007 and subsequent quarters) were coded 1. We also created a linear time trend variable. The 3rd quarter of 2007 was coded 0, and all previous quarters were coded with negative reverse numbering (−1, −2, etc. until the first quarter, coded −22). All subsequent quarters were coded in positive ascending order (1, 2, etc.). The coefficient for this variable would indicate the general trend for the dependent variables. The interaction of “DJJ Realignment × Time” was included to assess any shift in the trend over time after the implementation of DJJ Realignment.

We included the variable “Rural” since there is evidence of distinct differences in California between predominantly urban and rural counties in the trends and patterns of mental health service use (Snowden et al. 2008). We suspected that these county-specific dynamics might play a role in the health services available to detained youth, and that there might be differential effects of the policy shift on rural versus urban counties. For example, rural counties are more likely than urban counties to use a private, for-profit forensic healthcare vendor to supply psychoactive medications (instead of the county’s mental health agency) (Cohen and Pfeifer 2008), although we cannot hypothesize whether or how this would result in differences of access to medications. Many also feel that there are differences in rural juvenile detention facility resources as well as the distribution of community alternatives that affect rural juvenile diversion programs (Mendel 2008), which would thereby result in a different case mix of youth in rural versus urban detention settings. To categorize counties we used the Rural–Urban Continuum Codes (RUCC) developed for the U.S. Office of Management and Budget and other federal agencies (U.S. Department of Agriculture-Economic Research Service 2004). The RUCC ordinal scale categorizes local county areas by population density and metropolitan area or adjacency to a metropolitan area on an eight-point scale (the higher the number, the more rural the county). Counties coded a 3 by the RUCC (“County in metro area of fewer than 250,000 population”) or greater were coded as rural in our dataset. To this list of 31 counties we added three others that were not included, but which have county populations under 250,000. These three counties (Placer, Yolo and El Dorado) are members of the California Association of Rural Counties. An additional independent variable was constructed of the interaction between “Rural” and “DJJ Realignment” in order to see if the policy shift had any different impact on rural versus urban counties.

Analysis Plan

One separate multi-variate linear regression was conducted for each of the dependent variables. Both regressions involved the independent variables “DJJ Realignment,” “Time Trend,” “Rural,” the interaction of “DJJ Realignment” and “Time Trend,” and the interaction of “Rural” and “DJJ Realignment”.


As shown in Table 1, the overall average proportion of youth with an open mental health case during the study period was .36 (SD .32). The overall average proportion of youth on psychoactive medications during the study period was .17 (SD .12). Table 1 also shows the bivariate comparison of means for both dependent variables, pre- and post-DJJ Realignment. Both the percentage of open mental health cases (t = −2.92, p = .004) and the percentage of youth on psychoactive medications (t = −3.19, p = .001) increased after DJJ Realignment.

Table 2 shows the results of the linear regression analyses predicting the average number of open mental health cases.
Table 2

Predictors of the average proportion of open mental health cases


Unstandardized coefficients

Standardized coefficients


p value


Std. error








Linear time trend






DJJ Realignment (=1)






DJJ Realignment  × time interaction






Rural (1) versus Urban (0)






Rural × DJJ Realignment interaction






The coefficient for the interaction of the policy shift and linear time trend was statistically greater than zero, indicating that there was a shift over time of increasing the percentage of open mental health cases in the daily population, after the implementation of DJJ Realignment (B = .010, p = 0.04). While rural counties in general had a lower percentage than urban counties of youth with open mental health cases (B = −2.79, p < 0.001) this trend did not change significantly as a result of DJJ Realignment (B = −.041, p = 0.194). The policy shift did not appear to affect rural counties any more than urban counties. Results were similar for the percentage of youth on psychotropic medications, as shown in Table 3.
Table 3

Predictors of the average proportion of youth on psychotropic medications


Unstandardized coefficients

Standardized coefficients


p value


Std. error








Linear time trend






DJJ Realignment (=1)






DJJ Realignment × time interaction






Rural (1) versus urban (0)






Rural × DJJ Realignment interaction






There was a corresponding increase of the percentage of youth on psychotropic medications after DJJ Realignment (B = .005, p = 0.009). Again, rural counties, which had a lower proportion than urban counties of youth on medications (B = −.040, p < 0.001) were no more affected by the policy shift than were urban counties (B = .003, p = 0.795).

For both of these analyses, modeling the regression on the transformed (logged) dependent variable resulted in similar findings (not shown in table).


These findings confirm previous reports that the provision of mental health treatment and psychotropic medications continues to be an important function of juvenile detention facilities. According to the administrative data we analyzed, over one third of youth in these facilities had received mental health treatment. Considering that 50–75 % of youth in juvenile detention and correctional facilities have diagnosable mental disorders (Shufelt and Cocozza 2006; Teplin et al. 2002), even this rate of treatment might be insufficient.

It is less clear whether or not the proportion of youth on psychotropic medications in this study (almost one out of five youth) represents an adequate treatment response with the use of medications. Our study did not attempt to judge whether or not the amount of care received was adequate or of good quality. Although there were examples of strong collaboration in service delivery reported in surveys, probation staff also expressed concern about both over-medication as well as under-medication of youth—both issues pointing to quality concerns and gaps in provide capacity (Cohen and Pfeifer 2008). Similar issues have been addressed in the child welfare system—many children (especially those in informal care) need services but do not access them, while those in out-of-home care are inappropriately prescribed medications without adequate attention to psychosocial issues (Stambaugh et al. 2012). To better understand the quality of care in juvenile detention settings, further research is needed to explore, at an individual level, the objective need (as measured by past and current functioning) compared with the adequacy of the treatment offered.

It was interesting that rural counties, in general, have lower proportions of youth on medications and those receiving mental health services. It is unclear whether this is a result of a lower need for care in rural detained populations compared to urban counties, or whether the actual need for care may be the same but rural counties have less capacity to provide services. This is an area worth further study.

The study’s findings also point to the impact of a significant policy change—the implementation of a statewide realignment of placement responsibilities for youth who previously were ordered into DJJ custody, but who are now being diverted to dispositions at the county level. It appears that concurrent with the policy change there was an increase in the proportion of detained youth who use mental health services and who are prescribed psychotropic medications. While these proportions had been gradually increasing in the state’s detention facilities since 2002 (California Department of Corrections and Rehabilitation 2005), it appears that after the policy change they increased even more as seen by the significant change in the policy-time trend interaction. The effect of the change at the time of the policy shift was modest—percentages of open mental health cases and youth on medications increased by 5 and 2 percentage points, respectively, and the statistically significant regression coefficients also showed incremental impact.

Nevertheless, the steady increase in these percentages, despite the policy change and accompanying block grant funding for service expansion, supports the interpretation of the findings that the policy shift had some impact, either directly or indirectly, on the case mix of youth in detention facilities. This poses additional challenges, as it contradicts the aim of most juvenile justice planners—to divert non-violent youth offenders with emotional problems away from incarceration settings and towards community-based treatment alternatives. Since most states are considering or have implemented similar shifts in responsibility of juvenile offenders from the state to the local level, these findings are cause for concern that existing detention facilities will be faced with the challenge of providing rehabilitative services beyond what they were originally intended to provide.

One possible interpretation of these findings is that, mindful of the new policy, judges began using juvenile detention facilities as temporary placements, as part of an overall attempt to make more services available. In some jurisdictions it has been reported that the greatest level of care is available in juvenile hall, more so than in the community. Previously mentioned studies about placement delays underscore the inherent risks of this strategy for youth with mental disorders, since the detention setting can have iatrogenic effects on mental status which can then increase the length of stay as, over time, it becomes more and more difficult to find a therapeutic discharge placement.

Whether or not judges’ decisions were affected in this way, it would be reasonable to assume that local jurisdictions may have needed more time in developing expanded community resources, and that the trend shown shortly after the policy change reflects the transitional nature of developing innovative and individualized services. It may also be the case that the block grants were insufficient to fund regional structured residential treatment programs, one of the most-cited placement gaps identified in surveys with probation staff (Cohen and Pfeifer 2011). The implication is that the policy has succeeded in significantly reducing the state’s responsibility, but adequate mental health services are not consistently available to address the existing need at the local level. It appears that the policy change and concurrent block grants have yet to result in reducing reliance on juvenile detention centers as mental health treatment sites, at least during the time period analyzed for this study. Confirming this trend with further site-based analysis would be a necessary next step.

There are important limitations of this study. The reliance on aggregate reports rather than individual-level data limited the study to very general conclusions. Future studies using case-level data would provide a closer look at the experiences of youth using variables that are known to be related to both the utilization of services and post-detention outcomes. These variables would include individual diagnostic and level-of-functioning indicators, risk assessment measures, the extent of substance abuse, types and dosages of medications received, extent of previous involvement with the criminal justice system, severity of offense, and duration of the detention stay, among other variables. In addition, case-level data would allow for comparison of youth demographics and SES indicators (including ethnicity) pre- and post- policy change in attempt to control for them statistically.

From the standpoint of research design, the study did not have the benefit of data from a comparison state that has not implemented a similar policy shift, so that trends in the use of mental health services and medications can be compared to those of California. It also may be that, rather than having a direct effect, the realignment legislation had an impact on other unmeasured factors in addition to those mentioned above that would have more directly affected the proportions of youth needing mental health care. An example of this would be an increase of surveillance on the part of juvenile probation staff and mental health clinicians to proactively identify youth with emotional problems, as a result of DJJ Realignment. Other contemporaneous factors affecting case mix that cannot be ruled out include a) an increase in capacity of the mental health system in general due to the implementation of the state’s Mental Health Services Act which was legislated in 2004 (Felton et al. 2010) and the potential of increased incidence in the need for mental health services by youth in general.

Site differences are also important in understanding what services are available and provided to youth during, after, or in lieu of incarceration (Mulvey et al. 2007). There may have been county to county variation in the case mix of youth in detention facilities and the availability of community services. DJJ Realignment may have had varying effects on individual counties, which our analysis would not have detected and which was beyond the scope of this study. Further research is needed to identify these differences, and explore whether or not the development of local resources was successful in minimizing the burden on local detention facilities. The availability of these supportive resources could serve to provide diversion alternatives to prevent inappropriate detentions, and to provide post-detention treatment to prevent lapses in continuity of mental health care and, ultimately, to prevent re-offending.


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Copyright information

© Springer Science+Business Media, LLC 2012

Authors and Affiliations

  1. 1.School of Social WorkSan Jose State UniversitySan JoseUSA
  2. 2.Chief Probation Officers of CaliforniaSacramentoUSA
  3. 3.Hatfield School of Government, College of Urban and Public AffairsPortland State UniversityPortlandUSA

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