Breaking the cycle: connecting youth under community supervision to effective behavioral health services

Abstract

Youth involved in the juvenile justice system (YIJ), including those under community supervision, have disproportionately high rates of behavioral health disorders compared to community samples, yet the vast majority do not receive the care they need. When left unaddressed, youths’ behavioral health concerns can contribute to deepening juvenile justice involvement, which is frequently accompanied by increasing severity of behavioral health disorders and negative long-term ramifications for youth, families, and communities. The majority of YIJ are under community supervision, meaning they reside in the community and must receive behavioral health treatment through the community-based behavioral health system. To highlight the need for innovative approaches that break this cycle by closing the gap between clinical need and uptake of effective treatment for these high-risk and often overlooked youth, we synthesize existing literature on the prevalence of psychiatric disorders and intersecting domains of risk for disorder and justice involvement among youth under community supervision, drawing on ecodevelopmental and ecological systems theory to advance an understanding of specific barriers to services for youth under community supervision. We review existing efforts to facilitate treatment access and conclude with data-driven recommendations for future research, clinical practice, and policy changes.

In the United States, youth involved in the juvenile justice system (YIJ) have substantially higher rates of behavioral health concerns (Substance Abuse and Mental Health Services Administration, 2013) compared to community samples (Adams et al., 2013; McClelland et al., 2004; Teplin et al., 2002, 2021; Wasserman et al., 2010). Despite the availability of evidenced-based treatments and substantial clinical need, the majority (60–90%) of YIJ with identified psychiatric distress do not receive services (Aalsma et al., 2012; Burke et al., 2015; Henggeler, 2016; Luna et al., 2024; Miller et al., 2020; Wasserman et al., 2021b). Untreated behavioral health concerns in YIJ are associated with numerous poor outcomes, including continued and deepening justice involvement (Zeola et al., 2017). Therefore, prevention and treatment for YIJ is a both a justice system and a public health priority.

In the context of YIJ’s considerable burden of frequently intersecting risk factors, there is a critical need for programs that target factors across different levels (e.g., youth and family, justice and behavioral health systems) to increase YIJ’s uptake of and retention in services. Yet, linkage-to-treatment efforts to promote YIJ’s access to, and engagement with services through identification of treatment need, referral, and initiation remain largely undeveloped and unexamined. Innovative approaches are necessary to address this gap by closing the space between clinical need and uptake of effective treatment for these high-risk and often overlooked youth. To this end, we (a) synthesize existing literature on the prevalence of psychiatric disorders and intersecting domains of risk for disorder and justice involvement; (b) detail specific barriers to services for youth under community supervision at each step of the behavioral health care cascade (screening, referral, initiation, and retention; Belenko et al., 2017); (c) review existing efficacious linkage programs or approaches for youth under community supervision; and (d) offer data-driven recommendations for future research, clinical practice, and policy changes. These recommendations address three primary systems or levels of influence for youth under community supervision: juvenile justice/behavioral health systems (policies and procedures, cross-system collaboration between behavioral health and juvenile justice); agency/staff (e.g., promoting climates that support identification and treatment, workforce development, supporting clinical decision-making), and families (e.g., caregiver engagement, system mistrust, familial supports).

Behavioral health concerns among YIJ

Several landmark epidemiological studies have shown that YIJ have substantially higher rates of psychiatric disorders compared to youth in the general population (Teplin et al., 2002; Wasserman et al., 2002). For example, nearly 50% of detained adolescents have at least one substance use disorder (McClelland et al., 2004) compared to 26% of youth in the general population (Volkow et al., 2021). Similarly, 11% of male and 15% of female YIJ have a diagnosis of PTSD compared to 5% of their non-justice involved counterparts (Merikangas et al., 2010). Rates of disorders increase as youth move further into the justice system from arrest/intake (35%), to detention (59%), to placement/incarceration (64%) (Wasserman et al., 2010). Many psychiatric disorders develop in adolescence (Merikangas et al., 2009) and, if untreated, are linked to numerous poor short- and long-term outcomes in YIJ (van der Molen et al., 2013). These adverse outcomes include the development of comorbid disorders in late adolescence and adulthood (Copeland et al., 2023), school dropout, unemployment, and poverty (Mousteri et al., 2019), violence and early mortality (Aalsma et al., 2016), relational difficulties (Schlack et al., 2021), and continued involvement with the juvenile and eventually adult justice systems (Hoeve et al., 2013). Deepening system involvement is associated with more acute psychiatric distress, however, preventing and addressing youths’ psychiatric disorders can reduce risk for multiple deleterious outcomes (e.g., recidivism), and promote positive development (Hoeve et al., 2014; Zeola et al., 2017). For example, youth with substance use or externalizing disorders have lower rates of recidivism when they receive a referral to services (Hoeve et al., 2014). Taken together, these findings underline the importance of accessing and engaging in treatment for YIJ with psychiatric distress.

YIJ under community supervision

For the remainder of this manuscript, we focus on barriers and solutions to treatment access among YIJ who are under community supervision. These youth include those screened at “intake” into the system ahead of determination of disposition (e.g., detention, family court, etc.), those under court supervision, those diverted from court, and those on probation or parole following a stay in a locked facility. As the name implies, youth under community supervision are supervised while residing in their communities and typically receive behavioral health services within the community treatment system. There are two reasons for this focus. First, the overwhelming majority of YIJ are under community supervision rather than in a locked facility (i.e., detention or placement), with 362,712 youth under supervision compared to 170,365 in facilities (OJJDP, 2024). Therefore, programming developed specifically for these youth will serve the largest proportion of YIJ. Second, community supervision agencies are charged with reducing recidivism via service coordination with community treatment systems, making these settings ideally situated to identify behavioral health need and either deliver treatment/prevention, or provide referrals and achieve successful cross-systems linkage within the community (Belenko et al., 2017). However, unlike detention and placement settings (locked, residential facilities), community supervision settings such as probation agencies are not constitutionally mandated to address youths’ treatment needs. This means that policies and protocols are state or locally driven, and the quality and completeness of practices vary. Given high rates of unidentified and unaddressed behavioral health need, failure of probation settings to screen or successfully refer youth to treatment in the community results in substantial missed opportunities for treatment among many YIJ.

The ecology of risk

Ecological Systems Theory (Bronfenbrenner, 1979; Bronfenbrenner & Morris, 2006) and Ecodevelopmental Theory (Coatsworth et al., 2002; Szapocznik & Coatsworth, 1999) posit that in order to understand adolescent risk behaviors (and subsequent justice involvement), it is necessary to understand risk and protective factors as being influenced by interactions between multiple systems at different levels. These models are particularly concerned with complex reciprocal interactions, including between youth and their external environments, as well as interactions within and between systems external to, but nonetheless impacting, youth. Microsystems constitute patterns of activities, and interpersonal interactions directly experienced by youth, for example in the context of their family, school, or the juvenile justice system. Where these microsystems overlap, but do not touch the developing person directly, they form mesosystems (for example, interactions between a probation officer and a youths’ parent constitutes a mesosystem; an overlapping of the microsystems of the juvenile justice and family systems which does not directly involve a youth). Interactions occurring at the overlap of two or more settings, at least one of which does not directly contain a youth, but which indirectly influence the immediate setting of the youth, constitute the exosystem. For example, a parent’s workplace constitutes an exosystem. Finally, processes at the level of the macrosystem, which can involve factors such as cultural values and beliefs, influence interactions in all other systems. Ecodevelopmental Theory, developed by Szapocznik and Coatsworth (1999) and adapted by Elkington et al (2015), builds on Ecological Systems Theory by emphasizing the dynamic and mutual interactions between youth and the systems in which they are imbedded across time. Ecodevelopmental Theory underscores how both the individual and the systems in which they are embedded continually influence one another in complex ways.

In Fig. 1 we present a depiction of Ecodevelopmental Theory, adapted to reflect the interacting systems most relevant for youth under community supervision (Elkington et al., 2015; Szapocznik & Coatsworth, 1999). When risk factors predominate the interactions occurring within and between (i.e., at the intersection of) these systems, youth may be more likely to detach from potentially protective systems such as family, pro-social peers, schools, and treatment systems that could offset risks for justice system involvement (Szapocznik & Coatsworth, 1999). Moreover, when youth become detached from, or do not receive the care they need in other systems, the juvenile justice system can become a prominent microsystem where behavioral health need is finally addressed, especially for minoritized youth (Elkington et al., 2015). However, as we describe below, the mesosystem defined by the overlap of the juvenile justice and behavioral health systems can further serve to exacerbate youths’ risk, if youths’ need for care go unaddressed due to issues at the intersection of the behavioral health and probation systems.

Fig. 1.

Ecological contexts of risk

Youth under community supervision are at greater risk for psychiatric disorders for a host of well-documented reasons including a confluence of often-intersecting risk factors at the youth (e.g., trauma), family (e.g., parental behavioral health, family relationships), and social/environmental levels (i.e., poverty, neighborhood violence, socioeconomic inequalities, structural racism; Shanahan et al., 2008). As described above, risk factors can be offset by protective factors across various domains including youth psychiatric treatment and parental/family therapy (behavioral health microsystem; behavioral health/family mesosystem; Aazami et al., 2023; Hoeve et al., 2014; Kurtz & Zavala, 2017; Lamari-Fisher & Bond, 2021; Zeola et al., 2017) parental monitoring and positive caregiver-child relationships and support (family microsystem), school engagement (school microsystem; Lamari-Fisher & Bond, 2021), and familial social support (microsystems such as youth mentoring programs and mesosystems such as caregiver peer supports; Ghazarian & Roche, 2010; Meadows, 2007).

Unfortunately, many of the risk factors for psychiatric disorders are similar to those that are associated with youth justice involvement. These same factors serve as barriers to treatment uptake, and are frequently inversely correlated with the presence of protective factors (Yampolskaya & Chuang, 2012). For example, youth under community supervision are more likely to reside in neighborhoods with high levels of poverty and violence (Leventhal & Brooks-Gunn, 2000). They may also face complex familial circumstances that include multiple and often competing stressors, challenges and conflicts in youth-caregiver relationships, caregiver trauma, unaddressed caregiver behavioral health (including substance use) concerns (Herz et al., 2010), and low levels of social support (Voisin et al., 2017).

In the past, an ecological systems approach has been used to understand and intervene upon delinquent behavior in youth (Broidy et al., 2003; Farrington, 1995; Loeber, 1990) and identify upstream foci for prevention and treatment (Sheerin et al., 2023). Building on this approach, we argue that interventions or programming designed to promote access to needed services for youth under community supervision must also consider systems beyond the microsystem (e.g., family; school) and identify both proximal as well as more distal targets.

Barriers to service use at each step of the behavioral health services cascade

There are numerous evidence-based programs developed specifically to address co-occurring behavioral health (e.g., substance use and mental health; comorbid mental health) concerns among YIJ, including those under community supervision. Many of these programs are family focused and delivered in community settings (e.g., home, clinic, school), such as Multisystemic Therapy (Henggeler, 2016; van der Stouwe et al., 2014), Functional Family Therapy (Littell et al., 2023), Treatment Foster Care Oregon (Åström et al., 2020), and Multidimensional Family Therapy (Liddle, 2014). However, the impact of existing efficacious prevention and treatment programs will be minimal if youths' treatment needs are not identified, or youth do not attend. Unfortunately, when youths’ treatment needs must be met in the community – as is the case for those under community supervision – the majority do not receive necessary services, despite their clinically significant symptoms. (Goldman & Wilson, 2023; Stanley et al., 2024; Wasserman, et al., 2021b; Yurasek et al., 2021) Youth with co-occurring problems are even less likely to be referred and initiate care compared to youth with less complex presentations (Stanley et al., 2024). Community supervised youth often “fall off” at various stages of the behavioral health cascade, a framework that maps each point of the behavioral health care continuum from screening and assessment to referral, treatment uptake/initiation, and treatment engagement/continuing care (Belenko et al., 2015). Consistent with an ecological lens, an overview of the various steps of the behavioral health care cascade and the barriers across multiple systems or domains (i.e., behavioral health and probation system, staff, and family/youth) that prevent movement through the cascade are described in the following sections.

Barriers to screening for behavioral health concerns

Ideally, behavioral health screening occurs upon entry into the probation system to reach as many youth as possible and facilitate service access. However, youth under community supervision are often screened outside of probation contexts or are not screened at all (Belenko et al., 2017; Scott et al., 2019). In a nationally representative survey of community supervision agencies from the Juvenile Justice Translational Research on Interventions for Adolescents in the Legal System (JJ-TRIALS), a research cooperative involving 36 community supervision (including probation) agencies and their behavioral health partners across 7 states, 71% of agencies reported screening for behavioral health concerns, and only 43% were using evidence-based instruments (Wasserman, et al., 2021b).

System or agency level barriers to systematic screening via use of evidence-based tools may include cost (Center for Substance Abuse Treatment, 1999), and a lack of perceived importance of screening for behavioral health concerns among probation staff (Knight et al., 2019). Additional barriers may include fears that screening may result in “net-widening” (i.e., screening results could further incriminate youth and lead to increased sanctions), or that screening would document a level of treatment need that would be impossible to address (Grisso, 2007; Grisso & Underwood, 2004). As a result, some juvenile probation departments refer youth out to the community behavioral health system for voluntary screening (Scott et al., 2019). In these situations, receipt of a behavioral health screen is predicated on caregiver ability and desire to schedule and follow through with a referral to an outside agency, adding complexity and increasing the likelihood that youths’ needs go unidentified. Staff-level barriers to screening include concerns about validity of youth/family reports of behavioral health symptoms, staff discomfort with screening for behavioral health concerns, and staff concerns about what to do if behavioral health need is identified (Nelson et al., 2024; Sichel & Elkington, 2023).

Family-level barriers (e.g. attitudes and beliefs) may also hinder behavioral health screening in probation settings, as some families may decline youth participation. This may be due to system mistrust, negative prior experiences with probation or behavioral health systems, or stigma. For example, families may be hesitant to believe that the probation system will act in the best interest of their child if behavioral health concerns are revealed (e.g., they may be worried that identification of such concerns will result in escalation of justice involvement). They may also believe that identification of behavioral health concerns is not the purview of probation and/or not relevant to their child’s involvement in the probation system. Or, they may be uncomfortable sharing information about behavioral health concerns and family functioning with probation personnel (e.g., due to fears of child protective services involvement), and as such may decline to disclose about youths’ behavioral health needs (Piper et al., 2024; Sichel & Elkington, 2023).

Barriers to referral

Following screening, if a behavioral health need is identified, probation officers ideally refer the youth to necessary services. For most probation agencies, this referral is to services within the community as opposed to services offered onsite at probation (Scott et al., 2019). However, youth under community supervision are frequently not referred to services, despite having identified behavioral health need. For example, in a sample of over 8,000 youth under community supervision, among those in need of substance use treatment, only one fifth were referred to treatment (Wasserman et al., 2021b).

System/organizational-level barriers that may hamper systematic referral to services following the identification of behavioral health need include an organizational culture within probation agencies that emphasizes zero-tolerance supervision, rather than rehabilitation or harm-reduction, as is typical of behavioral health care systems. A lack of, or poorly developed, referral procedures and problems with interagency collaboration between probation and behavioral health systems can further complicate matters. Finally, a dearth of appropriate services available for youth in the community can mean that there are insufficient options for youth behavioral health treatment (e.g., no available youth-focused substance use groups; Elkington et al., 2020; Henggeler & Schoenwald, 2011).

Staff-level barriers to referral include incomplete knowledge of the behavioral health system to make appropriate referrals and negative prior experiences with referral and cross-system collaboration. Additional barriers include staff’s discomfort discussing sensitive issues associated with behavioral health need (e.g., traumatic experiences; suicide risk), beliefs that systematic behavioral health screening/referral is outside their purview and/or unnecessary, and biased perceptions of youth’s treatment need depending on the youth’s prior treatment history, gender, or race/ethnicity (Wasserman et al., 2021b). For example, youth of color, particularly females of color, are less likely to be referred to behavioral health treatment compared to their white counterparts despite clinically significant need (Ryan et al., 2023; Wasserman et al., 2008).

Barriers to treatment initiation

Among youth under community supervision who are referred to treatment, only about two-thirds actually initiate services (Wasserman et al., 2021b). As with screening and referral, there are both system/staff and family-level reasons youth may fail to initiate and engage (beyond the first session) with treatment. Receipt of a referral is frequently not sufficient to translate into service access and uptake (Wasserman et al., 2021b; Yonek et al., 2019).

Systems-level barriers related to interagency collaboration to support youths’ treatment initiation include communication difficulties, mistrust/prior negative experiences, and challenges in coordination (Elkington et al., 2020; Nelson et al., 2024; Sichel & Elkington, 2023). Additional system level barriers on the behavioral health side include long waitlists and appointment times that are not conducive to youth schedules (e.g., appointment slots during school hours; Barnert et al., 2020). Staff-level variables also contribute to lack of treatment uptake and initiation. For example, some behavioral health staff have a poor understanding of the various individual-level barriers that impede youth from initiating care and may perceive youth and caregivers as being disinterested or unwilling to engage in services (Sichel & Elkington, 2023).

At the family/youth (i.e., consumer) level, barriers to treatment initiation are similar to those for screening. These barriers may include low perceived need for treatment, low social support, negative attitudes toward services, and mistrust of systems, such that even after screening and referral they are hesitant to engage with services (McBrayer et al., 2024; Sichel & Elkington, 2023). For example, youth and caregivers may mistrust probation and/or behavioral health systems due to a belief that these systems are not designed to work in their best interest, which may stem from negative prior experiences. Indeed, youth and families often do not distinguish one system from the other in the behavioral health services cascade (e.g., juvenile justice from behavioral health); as such, a bad experience in one of these systems may lead to a negative bias toward both systems. Families/youth may also experience practical/logistical barriers to initiating treatment, such as difficulties securing transportation, childcare, or insurance coverage for behavioral health care (Barnert et al., 2020; McBrayer et al., 2024; McKay et al., 2004; Yonek et al., 2019).

Promising approaches to increase progression across the behavioral health care cascade for youth under community supervision

Examining the behavioral health care cascade allows for the identification of where interventions are needed across the domains of screening, referral, and initiation, to address barriers to care for youth under community supervision. Intervention strategies may target one or more of the primary systems of influence for youth under community supervision (juvenile justice/behavioral health system level, agency/staff level, or youth/family level), and strategies may be bundled into programs that address multiple steps along the cascade. In the following sections we discuss examples of intervention approaches, drawn from our own work as well as that of others. Our summary is organized around the primary target level (probation/behavioral health system, agency/staff, or youth/family), as some intervention approaches (e.g., those that are bundled) may target barriers at multiple steps along the cascade and/or incorporate multiple levels among the primary systems of influence for youth under community supervision.

Systems-level interventions target policies, practices, and organizations/contexts. Mandated, universal screening is one example of a systems-level intervention to improve the identification of behavioral health need among high-risk populations. As we have seen in our own work, universal screening can be effectively combined with systems-level interventions to facilitate referral to care. To date, scholarship has emphasized the practical importance, feasibility, and effectiveness of simultaneously implementing systematic referral practices in the context of screening (Elkington et al., 2023b; Modrowski et al., 2024; Wasserman et al., 2009). For example, along with colleagues, we developed a digital clinical decision support system called e-Connect to facilitate behavioral health screening, referral, and initiation of care for youth under community supervision. In e-Connect, we integrated an evidence-based screener (Dennis et al., 2006), with an algorithm to stratify youth based on the risk level of their responses (Elkington et al., 2023b; Sarapas et al., 2025). We combined screening in a web-based application with systematically developed referral pathways for each risk level (decision rules), informed by needs assessments and tailored to local resources and preferences for a seamless screening-and-linkage solution. The development of these pathways was accomplished collaboratively, through a process involving probation departments as well as local behavioral health partners and other relevant representatives (e.g., county leadership/executives, law enforcement). Such collaborative efforts allow for joint decision making processes that support the most efficient and effective use of limited county behavioral health resources, expedite the identification/facilitation of high-quality, and available referrals (e.g., through setting aside appointments; MOUs or other agreements), improve information/data sharing (e.g., through the building of coalitions and regular workgroups), and lay the groundwork for more effective, collaborative communications (e.g., shared language and understanding; Chuang & Wells, 2010; Sichel & Elkington, 2023; Wasserman et al., 2021a). e-Connect, which is implemented at the systems-level (i.e., incorporated into standard probation intake procedures), resulted in probation officers being five times as likely to identify youth under community supervision with suicidal ideation and behavior and over 11 times more likely to refer youth to treatment compared to standard probation practices. Youth, in turn, were nearly 17 times as likely to initiate treatment (Elkington et al., 2023b). Thus, our systems-level intervention succeeded at addressing barriers to care across multiple steps along the behavioral health care cascade.

Staff/agency-level interventions to increase progression across the behavioral health care cascade

Staff-level interventions, such as coaching (i.e., consultation; Beidas et al., 2013; Duda & Barrett, 2013; Gunderson et al., 2018), have been linked to increased organizational readiness for the implementation of new programs within probation departments to support the adoption of screening, identification, and initiation practices to link youth to care (Taxman et al., 2014). The Juvenile Justice Translational Research on Interventions for Adolescents in the Legal System (JJ-TRIALS) project found that both staff and agency-level strategies including training, data-driven decision making, supportive goal selection, and facilitation, can increase youth access to, and engagement with, behavioral health services for youth under community supervision (Belenko et al., 2022; Knight et al., 2016).

Staff-level interventions may be particularly important in contexts in which screening is left to the discretion of intake staff (i.e., in the absence of mandated, universal screening). Even in contexts where screening is universal, staff knowledge and perceptions of available services, youth/families, and behavioral health treatment may influence not only their decisions to refer, but also the ways in which they make those referrals, which in turn may impact youths’ subsequent likelihood of service initiation (Brown et al., 2014; Cabaniss et al., 2007; Faulkner et al., 2025; Holloway et al., 2013; Stiffman et al., 2004). Additionally, staff-level interventions have been successfully enacted alongside/as part of systems-level interventions (e.g., when staff receive training in using evidence-based screeners as part of a systems-level, universal screening program), as was the case with e-Connect (Elkington et al., 2023a, 2023b).

Family/youth-level interventions to increase progression across the behavioral health care cascade

There is preliminary support for the feasibility, acceptability, and effectiveness of navigator, peer, mentorship, and advocacy interventions (including gender-specific programs), which target the youth/family level. Although more research is needed, these programs show promise in increasing youth’s access to and engagement with a host of services, including behavioral health treatment (Dir et al., 2023; Elkington et al., 2023a; Javdani & Allen, 2016). While navigator, peer, mentorship, and advocacy programs employ different models, key components of these interventions include the provision of emotional, social, and informational support by non-clinicians located outside of the juvenile justice/probation system (Dir et al., 2023). For example, following the identification of treatment need and referral, these programs can work not only by addressing concrete barriers to care (e.g., transportation; insurance barriers) but also by increasing youth/family motivation for, and future engagement with, services (Kemp et al., 2021), and building on their existing strengths (e.g., by leveraging community/social supports). In doing so, they have the potential to address stigma, increase motivation for treatment, and address the barriers highlighted above. Indeed, prior work has found that parents of youth under community supervision participating in family peer programs report increased ability to advocate for their child (Viano et al., 2019) and improved self-efficacy in navigating the justice system (Walker et al., 2015). Additionally, natural mentoring approaches, in which probation youth identify mentors in their networks, have been shown to be feasible, and associated with long-term positive outcomes (e.g., reduced recidivism) for YIJ, including youth under community supervision (Boering et al., 2024; Cero et al., 2018; Young et al., 2023).

Data-driven recommendations to advance research, practice, and policy

Future research directions

Continue to tailor, develop, and test interventions and approaches to increase screening, referral, and initiation

In the United States, probation policies and practices vary by state. Given this diversity, there is a need for the development, systematic adaptation, and evaluation of more programs to support screening, referral, and treatment initiation for youth under community supervision that are customized to the requirements and workflows across different contexts. This is particularly important, given the heterogeneity of current practices nationally. A department that has already undertaken screening but has gaps in referral may require different supports than one standing up efforts at systematic screening and referral de novo.

There is also a need to systematically tailor programs to local culture and family preferences, and test to ensure continued effectiveness. For example, a program to support treatment initiation among youth in an urban setting in the northeast may not be acceptable or appealing to youth and families from the southwest. Including the voices of families and youth involved in the probation system at the point of program development can increase the likelihood that approaches to screen, refer and achieve treatment initiation will be acceptable to the target population. Such tailoring can increase likelihood of treatment initiation and lay the groundwork for long-term treatment retention and successful completion. Prior evidence suggests culturally appropriate adaptations can improve treatment outcomes among minoritized groups such as youth under community supervision (Barrera Jr. et al., 2013; Ellis et al., 2022), and existing, generic interventions may be ineffective (Galbraith & Huey, 2023). Moreover, adapted interventions can also help to accommodate the needs of specific groups of youth under community supervision (e.g., females; multiply minoritized youth; Galbraith & Huey, 2023; Irvine-Baker et al., 2019; Mallon & Perez, 2020) and address barriers to care at the youth/family level. Given elevated rates of trauma exposure and posttraumatic stress disorder among youth under community supervision, (Dierkhising et al., 2013), it is also critical that the systems and services for this population are trauma informed. For example, VOICES is a 12-session, trauma-informed, gender responsive substance use intervention for girls informed by the principles of trauma informed care (Substance Abuse and Mental Health Services Administration, 2014). Participants in VOICES reported significantly less cannabis use compared to an active control condition over a 9-month follow-up period in a sample of girls including those under community supervision (Tolou-Shams et al., 2021).

Develop and test implementation strategies to support scale-up and sustainment of programming

Much is unknown about how to effectively scale-up cross-systems implementation initiatives targeted at identifying and treating behavioral health concerns in youth under community supervision and this area requires continued study. The JJ-TRIALS implementation cooperative was a critical first step in advancing knowledge on best practices to improve service delivery for youth under community supervision. Replication and expansion of this work is sorely needed, including research to identify implementation strategies (e.g., implementation facilitation, coaching, interagency work groups) that will optimize and support the scale-up of programs that screen, refer and support treatment initiation among probation youth. For example, implementation facilitation, which involves interactive problem solving and support with the goal of transforming structures and processes within systems to increase the use of evidence-based practices (Kilbourne et al., 2023; Powell et al., 2015; Proctor et al., 2013), is considered effective for implementing programs in routine clinical settings (Kirchner et al., 2010; Stetler et al., 2006). Additionally, a burgeoning body of research has examined the influence of different facilitation approaches on implementation and sustainability of clinical practice (Braganza & Kilbourne, 2021; Connolly et al., 2020; Penney et al., 2021; Waterman et al., 2015). However, relatively little is known about possible adaptations that might be required to ensure that implementation facilitation strategies work in low-resource environments like probation settings (Belenko et al., 2022; Ritchie et al., 2015). Relatedly, although challenges to sustainment of evidence-based practices have been identified in various treatment settings, they are also not well-studied in probation (Pescosolido et al., 1998). Recent research has identified organizational characteristics critical to the successful adoption, implementation, and sustainability of evidence-based practice (Belenko et al., 2015; Herz, 2001; Lengnick-Hall et al., 2020; Stiffman et al., 2001, 2004; Wasserman et al., 2021a). Yet, research is limited on the organizational predictors of delivering sustained service delivery models that initiate in probation. A deeper understanding of the facilitators and barriers to program implementation and sustainment is crucial for the successful dissemination and wide implementation of evidence-based programs to support cross-system linkage and treatment initiation.

Understand treatment retention among youth under community supervision

In the general population, the modal number of treatment sessions attended is one and rates of treatment dropout range from 28–75% (De Haan et al., 2013). The limited research on youth under community supervision suggests their rates of treatment engagement and retention are worse than those of the general population (Dennis et al., 2019). Additionally, the consequences of poor treatment engagement and retention are likely to be particularly dire for these youth, given the negative outcomes associated with untreated behavioral health concerns (Zeola et al., 2017). There is a need for rigorous epidemiological study of retention, treatment, and recidivism outcomes among youth under community supervision. Moreover, in-depth study of family and provider perspectives on barriers to continuous treatment engagement and treatment retention should guide both treatment and system changes to enhance treatment retention and completion among youth under community supervision.

Clinical practice and policy implications

Use digital clinical decision support systems and targeted referral pathways more broadly in the juvenile justice system

Digital clinical decision support systems, which incorporate evidence-based screeners, automatic scoring, and risk classification, have been used successfully during probation intake processes to efficiently and equitably identify youth behavioral health care needs (Elkington et al., 2023b; Ryan et al., 2023). These technologies could be adopted in other justice settings as well, such as detention or juvenile assessment centers, where there is a need to rapidly screen for and identify youths’ behavioral health care needs. Moreover, this technology can be paired with targeted and locally tailored referral pathways to successfully guide the linkage of youth to community-based treatment during processes such as re-entry planning, to ensure that youth are referred to care based on their service needs and locally available resources.

Expand the use of youth/family supports

Given high levels of need among youth under community supervision, and promising preliminary support for navigator, peer, mentorship, and advocacy interventions, these programs should be more broadly integrated in probation settings. Indeed, these supports may also be potential low-cost supplements to services provided by clinicians and/or help address workforce shortages. Although these programs primarily target youth/family-level barriers, they may also be helpful for overcoming challenges associated with cross-system coordination and treatment access. Prior research suggests that such approaches may be particularly effective for minoritized youth under community supervision and their families, who may have experienced stigma and had negative prior experiences with youth-serving systems such as the juvenile justice, child protective services, schools, and health/behavioral health systems (Corrigan et al., 2017; Dir et al., 2023).

Enact policy and funding to support linkage and engagement interventions

Despite calls for mandated universal behavioral health screening for youth under community supervision, nationally only 24 out of 50 states currently require youth to be screened upon entry into the juvenile justice system (Christian, 2023). Universal screening entails offering an evidence based behavioral health screener to all youth as a standard part of probation intake and should be enacted to identify and address youth behavioral health concerns. Elsewhere, scholars have called for an expansion of public health services available to treat the behavioral health problems of YIJ, including those under community supervision (Teplin et al., 2021). Such an expansion is critical – these youth need more evidence-based services – however, it is not enough. An increase in service offerings will likely not translate into engagement for youth under community supervision and their families without funding for and careful attention to cross-system linkage and access. Policy initiatives to address the behavioral health needs of youth under community supervision must include financial support for efforts that foster coalition building (e.g., through the creation of local workgroups), and coordination and collaboration across systems (probation and behavioral health as well as other systems which touch these youth such as child protection, schools, and law enforcement). There is an also an urgent need for ongoing funding (e.g., through Medicaid reimbursement) to support the integration and sustainment of innovative programs to bridge youth to care, increase their engagement (e.g., peer programs, programs that build on youths’ existing sources of strength such as social support) and address barriers to treatment.

Conclusion

In the U.S. only a fraction of adolescents in the general population with psychiatric disorders receive any treatment, the majority of which is provided in medical settings by providers with minimal behavioral health training (Costello et al., 2014). Youth under community supervision experience a substantially higher burden of behavioral health need compared to the general population yet utilize a disproportionately small share of local behavioral health resources. For these youth, the service gap is confounded by system-, staff- and family/youth-level barriers that intersect and result in the often-inequitable distribution of behavioral health treatment. These youth do not get the services they need. Effective behavioral health treatment has the potential to adjust the negative trajectories that youth under community supervision may face, including preventing continued involvement in the juvenile and later the adult criminal justice systems. Given this treatment gap, which exists in the context of two settings (probation and community behavioral health) characterized by high clinical need and limited resources, there is a critical need for the continued development and expansion of comprehensive, innovative interventions and approaches that systematically identify and triage probation youth to appropriate treatments.

Authors' contribution

CS and KE conceptualized the manuscript. All authors wrote manuscript text. All authors read and approved the final text.

Funding

This research was funded by the National Institute of Mental Health (NIMH) of the National Institutes of Health under award numbers R01MH113599 (PI: Elkington) and L40MH131143 (PI: Sichel). The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

Data Availability

No datasets were generated or analysed during the current study.

Declarations

Ethics approval and consent to participate

Not applicable.

Competing interests

The authors declare no competing interests.