Falling between two systems of care: Engaging families, behavioral health and the justice systems to increase uptake of Substance Use treatment in youth on probation

Abstract

Justice-involved youth (JIY) in the US have high rates of substance use (SU) problems, yet 50%-80% of these youth do not receive necessary services. There has been no systematic exploration of the use of treatment services for JIY that examines viewpoints across stakeholders in justice- and treatment-systems as well as the families. We conducted qualitative interviews and focus groups with n=58, youth, their caregivers, SU treatment providers and probation officers in a Northeastern state. Interviews explored how families, staff- and system-level factors influence uptake of and retention in SU treatment services in youth on probation. We conducted a thematic analysis of all interview texts. Caregiver engagement is essential for youth treatment uptake and retention. Difficulties achieving caregiver engagement and agreement that treatment was necessary stemmed from distrust in the “system”; denial or minimization of youth’s SU problem; relational barriers; and overburden and chaos within the family system. Structural barriers to service uptake were lack of available treatment options, SU agency practices and policies, and interagency collaboration between SU treatment agencies and probation. Enhancing family engagement at the point of referral to SU treatment is essential. Improvements in interagency collaboration and communication between SU treatment and probation agencies are necessary. Implications for policy and intervention are discussed.

1. Introduction

In the US, Justice-involved youth (JIY) have much higher rates of substance use (SU) problems or disorders (SUDs)^1–6 compared to youth in the general population⁷; an estimated 25%-50% of JIY have an SUD^{1, 4, 6} compared to 4.0% in general population youth⁸. Adolescent SU is a risk factor for the onset of SUD in later adolescence⁹ and adulthood^10–12 and may contribute to a youth’s continued involvement with the juvenile and eventually the adult justice systems^13–16. Additionally, SU problems have been linked to other poor outcomes such as HIV/STIs^{17, 18}, violence^{19, 20} and early mortality²¹.

Over the last two decades, in the US, there has been an increase in the development of evidence-based treatment of SUDs, including those developed specifically for JIY such as Functional Family Therapy (FFT), Multisystemic Therapy (MST) and Multidimensional Family Therapy (MDFT). Because almost half of all SUDs begin by age 20²², adolescence is a critical period for intervention. SU treatment in adolescence has been shown to offset trajectories of SUDs in adulthood and effectively decrease related negative outcomes, including recidivism and violence for JIY^23–25. However, despite such high need for, and increasing availability of, evidence-based SUD treatment for adolescents, between 50% and 80% of JIY with SUD do not receive services^26–29. However, our understanding of reasons for low uptake of and retention in SU treatment remains incomplete in JIY.

The majority of the literature focusing on barriers to behavioral health treatment in youth is focused on mental health treatment^30–32 or involves non-JIY^33–35. Taken together, this prior research has identified both family (including youth)- and system-level factors associated with treatment or service use^36–38. Within the family, factors have been divided into perceived and structural or practical barriers. Perceived barriers include attitudes towards services, perceived need for treatment, and stigma^{32, 33, 39–42}. Practical factors such as availability of transportation, clinic appointment availability, and child care are also important predictors of service use. At the system-level, organizational climate and culture factors (e.g. job stress, leadership, resources) or staff factors (e.g. knowledge of the behavioral health system, perceptions of youth treatment need) have been shown to influence behaviors around referral, linkage, and treatment in other settings^{37, 43–49}. Moreover, fragmented systems of care^{50, 51} are also likely to cause JIY to “get lost” in the referral process between justice and behavioral health systems^36–38 as these youth move from the justice system to the community behavioral health system for SU treatment.

Models of treatment seeking and service use among youth frequently acknowledge that they enter into behavioral health services via several different pathways (e.g. parent, behavioral health providers, child welfare, juvenile justice, or education workers)^52–54. In particular, due to age and lack of independence, caregivers play an important role in how and when youth access treatment services; youth tend not to self-refer. Conversely, because adolescents are granted more autonomy over their behaviors as compared to children, their role in service use initiation is also a critical component³⁰. Yet, despite multiple drivers in youth service use, prior work typically examines barriers and facilitators to treatment from a single perspective or system (e.g. parent^{30, 32}, staff or youth⁵⁵). The importance of examining the perspectives across all viewpoints (e.g. family, treatment provider, and justice system) is critical to identify opportunities for intervention and training that can increase uptake and retention in treatment³³.

Within the justice system, juvenile probation departments represent important settings in which to explore system-, as well as family-level, barriers to cross-system linkage and enrollment in SU services. Probation departments are charged with coordinating SU services for youth on their caseloads, and services are typically then provided offsite in local behavioral health agencies, necessitating involvement and interaction of multiple systems (probation, behavioral health, and the family). Such exploration may directly inform policy via generation of agency and provider practice guidelines for SU service referral. Data gathered may also inform interventions that promote interagency collaboration and family engagement, ultimately increasing use of and retention in SU services for JIY.

Given the dearth of research looking at factors from family, treatment and justice systems that influence uptake of SU services for youth on probation, a study exploring what inhibits uptake and retention of SU services by JIY was considered an important first step. Moreover, the majority of the research described above has been quantitative and does not provide an in-depth description of the underlying processes that drive linkage and enrollment in treatment, and reasons for disparities in SU service use within specific groups. Qualitative methods are best suited for providing a rich understanding of the unique experiences and perceptions of specific groups or populations.

The current study sought to understand the factors that influence uptake of and retention in SU treatment services in youth on probation, triangulating data from probation staff, substance use providers, and caregivers/youth to explore how specific processes in one system (i.e. family, probation, treatment) may be influenced by another. This work uses the Gateway Provider Model (GPM)^{54, 56} to guide the exploration of interrelated factors within justice, treatment, and family systems on uptake of substance use treatment for JIY (see Figure 1). The GPM acknowledges that the “gateway provider” into behavioral health services is not always a parent or behavioral health provider, but often other system providers (child welfare, juvenile justice, or education). The GPM considers the interdependence of gateway provider, organizational contextual factors, and the youth/family when understanding or determining service use/provision. After identifying need, gateway providers make decisions based on their services knowledge and attitudes toward treatment and the availability of services within an organizational context that supports or hinders this process.³⁷ The family plays a critical role in this process, interacting with the gateway provider and organizational context, and family enabling (availability, accessibility, affordability, acceptability) and predisposing (demographics, family support, finances, system involvement) factors, as well as youth’s treatment need (disorder presence/severity, comorbid conditions) are also considered.

Figure 1.

Study Design

The GPM has been utilized in a variety of contexts to examine service access including youth in the foster/child welfare system^{57, 58} and the juvenile justice system⁵⁹. Prior work has shown that probation officers are particularly well positioned to serve in the role of gateway provider, as they are more attuned to recognizing youth behavioral health needs compared to other gateway providers^{54, 60}. However, their role in youth’s linkage and engagement to services, particularly substance use treatment, has been less well examined. Existing work found probation officers balancing the tension between rehabilitation and public safety⁵⁹. The current work builds upon this existing work and incorporates the perspectives of treatment providers.

2. Method

2.1. Participants and Sampling

Participants were recruited from two county probation departments and two substance abuse treatment programs with adolescent treatment tracks located in two counties in a Northeastern state between December 2015-May 2016; treatment programs all provided treatment to youth on probation. Youth and caregivers were recruited as dyads. Youth on probation were eligible if they were between 10-17 years of age, fluent in English, had a score of ≥4 (‘caution’ cut-off) on the MAYSI-2⁶¹ drug and alcohol use subscale, indicating ‘probable clinical significance’⁶², or other documented evidence of substance use problems (e.g. school/parent complaint; current complaint/charge; positive urine toxicology), had been referred to SU treatment by probation, and had a caregiver willing to participate in the study. Caregiver participants were eligible if they were fluent in English, had a youth willing to participate in the study, and were the legal guardian of the youth. All probation officers (POs) or substance abuse treatment providers employed within each of the two study probation departments or three treatment agencies, respectively, were eligible to participate. Youth and caregivers were compensated for their time; all study procedures were approved by the New York State Psychiatric Institute Institutional Review Board.

2.2. Procedures

All juvenile POs (n=15) in each department and adolescent SUD providers (n=30) at each agency were invited to participate. Almost all staff approached agreed to participate (73% POs and 90% SU providers). Of the n=34 families referred by POs, n=21 caregivers were successfully contacted via phone regarding participation and of those, n=2 were in-eligible and n=9 were no longer interested in participation.

All POs (n=15) and adolescent SU treatment providers (n=30) were informed of the study by the research team and asked to contact research staff directly if interested in participation; 73% of POs and 90% of treatment staff. POs were also asked to describe the study to all youth on their caseloads and then provided contact information of interested families to study research assistants. Of the n=34 families referred by POs, n=21 were successfully contacted via phone regarding participation and of those, n=2 were in-eligible, n=9 were no longer interested in participation, and the remaining n=10 were eligible and agreed to participate. In-depth interviews were conducted with youth, caregivers and POs. POs were interviewed separately in their offices at the probation agency; youth and caregivers were interviewed separately but simultaneously at probation offices or family home as they chose. Two focus groups were conducted with treatment providers (n=14 and n=13 participating providers respectively) as they were frequently unavailable for one hour during the day to conduct an in-depth interview; a previously scheduled hour (team meeting) was used for the focus group. All participants were assured confidentiality. All in-depth interviews and focus groups were audio recorded to facilitate transcription and each lasted approximately one hour.

2.3. Assessments

2.3.1. Demographic information.

Youth and caregiver demographics were assessed using a 19-item questionnaire that elicits demographic (e.g. age, gender, race and ethnicity, number in household, family income) and juvenile justice involvement information (e.g. length of time on current probation, number of prior juvenile justice contacts). Demographic information for POs and treatment providers was assessed using a 9-item questionnaire that elicits demographic (e.g. age, gender, race and ethnicity) and job information (e.g. length of time in current position, current job responsibilities).

2.3.2. Qualitative interview guides.

Interview guides were informed by the GPM. The interview for youth and caregiver explored 1) enabling characteristics: norms, beliefs, values about SU services; perceived need (recognition of problem) and importance of SU treatment; attitudes and expectations toward treatment; intentions to use SU treatment; knowledge of available services; and other practical barriers (e.g. work, other child care, transportation, insurance); 2) predisposing characteristics: environmental resources and constraints (e.g. social networks/interactions and supports within family); juvenile justice (JJ) system/probation involvement (e.g. perceptions of JJ staff working relationship and ability). The interview/focus group guide for the probation officer (PO)s and treatment staff explored staff perceptions, knowledge and experiences associated with referring and engaging youth for SU services; engaging JJ system families; perception of professional role; inter-agency collaboration. Key structural/organizational characteristics relevant to successful referral and linkage were also explored, including: climate/culture; training; resource adequacy. See Table 1 for examples of questions from interview guides.

Table 1.

Examples of in-depth interview and focus group questions

Youth and Caregiver Interview Domain/Topic	Youth Example	Caregiver Example
Social norms and beliefs about teen substance use	Why do you think someone uses drugs? Have you ever had or did other people think you had a problem with substances before?	Why do you think someone uses drugs? What about a teenager – why do they use drugs? How do you think someone goes from using drugs or alcohol once in a while for “fun” to needing to use them all the time? Is this different for a teenager?
Salience of and attitude/expectations toward SU services	What do you think substance abuse treatment is like? What do you think you do?	If you had to send your teen to substance abuse treatment, who would you talk to about it, either before going or during treatment, and why?
Knowledge and access – barriers and facilitators	How do you think you actually get into substance abuse treatment services if you need them?	How easy or difficult do you think it would be for a friend or someone from your neighborhood to get their teen into substance abuse treatment if they needed to?
Environmental resources and constraints - family	For some teens, their families play a big role in telling them about their problem and helping them get to treatment. For others, family seems to get in the way. What role do you think your family would play?	If I were to sit in on a discussion between you and your teenager in which you are talking to your teen about his/her problems with substance use and need to go to substance abuse treatment, what would I hear you say? What would s/he say to you?
Engagement in the JJS	Do you think Probation is the appropriate place to identify and refer youth to substance use treatment if they need it? Why/why not?	What has your experience been like coming here (probation office) with your teenager?
Probation Staff Interview Domain /Topic	Example
Individual experiences working with families of youth on probation	When working with youth on your caseload, what’s your typical philosophy or approach you use in order to work and connect with these youth? Why? What are some of the reasons that caregivers of youth on your caseload have rejected your referral to substance abuse treatment for their youth? How often does this happen?
Approach to handling non-compliance	Can you describe for me a time when a youth was identified as using substances or having a substance use problem, and would not stop using. How do you address this issue? What strategies or options are available for you to use?
Referral and Linkage Process between Treatment and Probation	Can you describe your experiences (or the general process) of referring youth on probation to SU treatment? If you can walk me through a specific case, once SU problems have been identified, what happened?
Substance Use Treatment Staff Focus Group Domain/Topic	Example
Perceived need for actively seeking SU referrals for youth in probation/Appropriateness of treating JJ youth	Describe for me how this clinic conducts outreach to probation departments to gather referrals?
SU staff members experiences working with probation system	What are some of the biggest barriers you face when working with the probation department when treating a youth on probation?
Understanding of the referral process between agencies	Can anyone describe their experiences receiving referrals from POs for youth on probation? Walk me through a specific case.
SU and Probation interagency collaboration	Does anyone currently have or has anyone had a youth on your caseload who is also on probation? (If no case move on to #5). Describe the working relationship you had/have with the youth’s PO?
SU staff’s experience working with probation youth and families	If we were to walk into a clinic staff meeting in which a case of a youth on probation was being discussed, what types of things might we hear being discussed? What are some of the reasons that youth on probation or families do not engage in treatment? How often does this happen?

2.4. Data Coding and Analysis

All transcripts were entered into NVivo 12.0, a qualitative data software package. Using GPM to guide the coding and analysis, the central research question focused on understanding factors involved in accessing substance use treatment at family, staff and system/organizational levels for youth on probation with a substance use problem. Our thematic analysis of the interview texts employed inductive and deductive approaches. The initial coding scheme focused on exploring 1) youth and caregiver enabling and predisposing characteristics; 2) PO perceptions and knowledge; and 3) structural/organizational contextual factors. Secondary codes were developed to expand primary codes as necessary. Coders then applied this final code list to the remaining transcripts individually and then met to discuss each interview and compare codes for all interviews. Whenever any discrepancies arose the coders discussed until a consensus was reached. This coding process is standard in qualitative methods and known as focused and intensive coding for primary and secondary themes^{63, 64}

Qualitative data analysis was driven by GPM as themes from the data emerge to determine what key facilitators and barriers at the youth/family-, staff/organizational-levels are relevant to youth/family engagement, linkage and enrollment in SU services. Analysis of in-depth interviews began by developing summaries of primary and secondary themes within interviews and conducting cross-case (e.g., probation staff; families) analysis on key GPM domains as well as themes that come to the fore during coding (e.g., differences in perceptions of need for youth SU treatment)⁶⁵.

3. Results

3.1. Sample characteristics

The total sample comprised n=10 youth and n=10 caregivers (dyads), n=11 POs and n=27 substance use treatment providers. Among youth, 70% were male, 50% were African American, 40% were non-Hispanic white and 30% were Hispanic. Mean age was 15.7 years (sd=1.64 years). The gender distribution largely reflected the demographic breakdown of the probation agencies where the study took place. Most youth reported to probation weekly (n=60%). For 40% of youth, this was their first contact with probation and the majority (n=60%) had not received SU services before; n=2% had been mandated for substance abuse services as a condition of their probation. Most caregivers were female (n=90%) with a mean age of 43.4 years (sd=9.62) and married or living with partner (n=70%); 70% were employed. Almost all POs were female (90.9%) and white (90.9%); 9.09% were Hispanic. POs had a mean age of 47.6 years (sd=11.1), 54.55% had a Masters-level degree (half were MSW) and had an average of 5.72 years of employment in their current position (sd= 5.61). For SU treatment providers, 70.4% were female, 92.6% were white and 7.4% were Latino with a mean age of 37.07 years (sd =15.14) and 85.19% had a bachelors or a Masters-level degree; mean years of employment in their current position was 2.34 (sd=2.92).

3.2. Family-level factors

Table 2 displays the main themes that emerged from narratives by respondent. POs and SU providers repeatedly noted that caregiver engagement was essential for a youth to begin and remain in treatment. Difficulties achieving caregiver engagement stemmed from: (1) distrust in the “system”; (2) denial or minimization of youth’s SU problem; (3) relational barriers; and (4) overburden and chaos within the family system.

Table 2.

Summary of themes by respondent

Theme	Domain	Description	Respondent
(Dis)Trust of the System	Family-level	External directives to seek treatment are often rejected by caregiver/youth as directives emerge from the justice system, which families may distrust. Negative experiences in the treatment system further compound family distrust	SU and PO staff Youth and caregiver
Denial or minimization of youth’s SU problem		Denial or minimization of the youth’s SU problem by the caregiver or youth as a substantial barrier to treatment, significantly driven by the caregiver/family own substance use stigma and shame* experienced by caregivers.	SU and PO staff (*Caregivers – stigma and shame only)
Relational Barriers		Relational difficulties between the youth and caregiver (i.e. being overwhelmed or being detached) frequently derailed treatment access	SU and PO staff
Overburden and chaos within the family system		Family system must manage youth’s treatment in the face of multiple competing demands (e.g. low social support, financial strains); subsequently treatment is placed towards the bottom of a hierarchy of competing needs.	SU and PO staff
Lack of (appropriate) available treatment options	Structural Characteristics	Lack of available adolescent-focused treatment programs	PO
Treatment agency policy/procedures.		Policies in place at treatment agencies that prevent families accessing treatment such as Pos not being able to make appointments, appointment times, mandatory ‘wait times’	PO
Interagency collaboration and communication: punishment vs rehabilitation		Differing philosophies held by POs and SU staff contributed to difficulties in understanding roles and collaboration (e.g abstinence only versus harm reduction).	PO and SU staff

3.2.1. (Dis)Trust in the “system.”

POs and SU providers noted caregiver distrust in the system was a significant reason for families failing to initiate and remain in treatment. SU providers highlighted a key characteristic that set justice-involved families apart from non-justice involved families was the decision to seek services. Among non-justice-involved families, the decision to seek treatment was typically made from within the family unit whereas youth on probation frequently arrive at treatment under the auspices of the court. Providers also noted that many families of youth on probation were noted to have been involved with other service systems (e.g. child welfare), and substance abuse treatment represented to the families one more service that may not operate fairly or transparently.

We have much less parent involvement with kids that are on probation, -- they’re on probation because of something that doesn’t really have anything to do directly with the parent. The kids that are mandated here, the parents are much less involved than if a parent brings the kid here because they‘re concerned about the behavior. (SU provider, male, 51)

This sentiment was echoed by youth and caregivers who described a general distrust of the “system,” which they feared would likely split up the family, and as a result influenced how referrals and suggestions for services were initially received.

“….the system doesn‘t really care about anybody and there’s a bunch of people that work there that probably don‘t, ….., ‘OK, this is going on, we’re going to go over there andjust split everybody up. ‘So why should we talk to them? Why would I let my teen go?” (Mother, 32)

Youth also expressed the belief that the way in which probation tackled a youth’s substance use problem (after it had been identified) was not effective and could lead to increasing use.

it doesn’t help. It just makes everything worse. ’Cause you -- like, you can’t stop some -- ’cause I -- I can’t -- drug testing -- you can’t stop someone from doing drugs if they wanna do it. You can’t stop ’em because then it makes them, like, sneakier, and it makes them wanna do it more (Youth, male, 16)

As a result, youth and caregivers believed that probation was not the best place to identify a youth’s substance use problem, in part due to the fear of getting the youth into more significant trouble. With respect to the treatment system, family distrust was attributed to prior negative experiences or a pervasive belief that treatment would not work and/or lead to worse outcomes.

I mean, to be honest with you, ….the little time that he spent there [in treatment] he learned so much more about drugs. It’s like, you know, damn, I sent him there so he can get better and what happens? He gets more knowledge. (Mother, 58)

3.2.2. Denial or minimization of youth’s SU problem.

POs and SU providers described denial or minimization of the youth’s SU problem by the caregiver or youth as a substantial barrier to treatment. Denial was hypothesized to be a function of the caregiver’s (or other family member’s), SU or mental health problems, how the youth’s treatment might expose family SU, and the subsequent effect on the family system.

I think a lot of the kids are afraid that what’s going to happen -- what we’re going to hear here is going to impact the family dynamics, because in a lot of these cases, the parents are actively using, and the kid is like, sitting in that courtroom as the problem. And that’s serving a really specific function, the kid’s use is serving a function in that family system. So, to disturb that is disturbing the whole -- like the whole house of cards is going to come down. (SU provider, female, 27)

For parents and teens, minimization about the youth’s substance use, and the associated risks or consequences, consistently led to a disagreement between the caregiver and POs and/or SU providers about the youth’s need for treatment. This was particularly true for marijuana, which was the substance most commonly used by youth.

People who smoke weed and still go there [treatment], they shouldn’t be going there at all, because weed doesn’t do anything wrong (Youth, male, 17).

My daughter, she’s doing real good -- on high honor role… she be smokin’ weed too, but she still do what she got to do, you know. (Mother, age 37)

“…somebody is referred by probation because they’re testing positive for marijuana or something. Then the parent comes in and says, I smoked weed when I was younger, you know, it’s not really a big deal, you know, they’ve said they’ve stopped. Whatever, I mean they don’t see that there’s an issue.” (SU provider, female, 32)

A significant driver of denial or minimization appeared to be the shame and stigma associated with substance use and treatment. Providers acknowledged that a key barrier to youth remaining in treatment was the shame and blame parents experienced with respect to the child’s use.

So, one of the barriers is, um, it’s seems to me is the shame around, you know, “here’s this kid and I really fucked this up.” Um, and to admit that or have that be seen, will keep somebody away from it being explored (SU provider, male, 62)

Caregivers echoed this sentiment and acknowledged feeling shame that their child’s substance abuse problem was brought to their attention by someone else, or that that their ability to parent or provide a stable environment for their child was thereby called into question.

Everybody tries to focus on the parents. You know, and I’m sure in some cases they have good reason to. But I almost have to answer for everything that my kids do. I know they try to find where the problem could have started, or what could have caused it? I understand that, but it gets so repetitious, like, ‘No, I don’t beat my children. No, there’s no sexual abuse. No, I don’t drink. No, I don’t smoke.” It just -- it gets kind of upsetting sometimes. (Mother, 58)

3.2.3. Relational barriers.

Although never discussed by the families, POs and providers described how relational difficulties between the youth and caregiver frequently derailed treatment access. Treatment staff and POs described caregiver disengagement as a) a result of being overwhelmed by youth or b) a function of a caregiver no longer wanting to fulfill the parental role. In either scenario, these caregivers were unable or unwilling to engage with POs or treatment staff to facilitate treatment access for the youth or involve themselves in the youth’s recovery.

They want to -- they want to just slow the car down and dump the child here, which is understandable, because they’re done, they have very little hope. (SU provider, male, 51)

The other obstacles -- you can fix, you can work with, like you can change your appointment, I don’t mind staying here till 7:00pm if I have to meet them and they’re, you know, whatever time we can, I’ll do that. But really, it’s very difficult to fix somebody that doesn’t want to be a parent. (Probation officer, female, 53)

3.2.4. Overburden and chaos within the family system.

Beyond the youth-caregiver relationship, POs and SU providers also discussed how overburden and chaos within the family system contributed to a youth’s failure to begin or remain in treatment. For these families, the youth’s treatment needs became yet another problem to address, in the context of low social support, financial strains, multiple service commitments, and poor relational family dynamics, and were subsequently placed towards the bottom of a hierarchy of competing needs.

Financial issues emerged as a significant family burden and consequently a barrier to accessing treatment services across all respondents. Caregivers working multiple jobs had limited available time and financial resources to take youth to appointments. Insurance difficulties, either lack thereof or difficulty affording co-pays associated were raised by POs, SU providers and caregivers as significant barriers to treatment use.

the one thing would be maybe their expectation that um, the youth attends program three times a week, and me knowing that, you know, this kid is dependent on a mom who works overnight, and who is half asleep, and they don’t have the money in their grip (Probation officer, female, 54)

Finally, providers described the net result of such family environments on treatment retention and success. Even if youth attended treatment, retention and long-term behavior change in the youth was often difficult in the face of an unchanging chaotic family system or environment.

one thing we talked about today was like, the lack of change within the family. And, you know, trying to determine how they can stay healthy when the family doesn’t change, because they don’t understand what addiction is, …there’s this, like, total lack of understanding that it is a family problem and everybody has to change if they want the addict change. (SU provider, female, 62)

3.3. Structural characteristics

POs, SU providers and caregivers identified structural barriers faced by caregivers and youth when attempting to access treatment. In addition to shortfalls from the systems themselves, the issue of interagency collaboration or engagement emerged as a critical theme to promoting successful treatment use and engagement.

3.3.1. Lack of (appropriate) available treatment options.

POs identified being challenged by the lack of sufficient treatment options to refer youth on their caseload. POs noted that while they would prefer to send youth to adolescent-focused programs, such programs were not always available. Instead, youth would receive treatment in group format alongside adults, which resulted in considerable pushback from the youth based on exposure to adults with more long-term or serious addiction problems. POs were often sympathetic to this pushback and expressed concern that referring youth to treatment programs that include adults could be more detrimental to the youth.

They just don’t like them having to be with the adults. I have younger kids and I just feel like I’m overexposing them. So, I always have to kind of say to myself, “Is this one worth referring?” Because, if they’re so young, they’re going to learn things there, or they’re going to meet people there….you know, my kid is 13, he’s hanging out with some 30-year-old that he met in treatment. And, that really bothers me. But there’s no other way. I have to make that referral. I have to cover my butt on that end …. (Probation officer, female, 36)

3.3.2. Treatment agency policy/procedures.

POs noted a number of treatment agency-based challenges that they perceived as barriers for families attempting to access treatment. In particular, the agency policy that POs cannot schedule the appointments on behalf of a family was cited as a considerable barrier. In cases where the caregiver, youth, or both, are resistant to attending treatment, or in cases where families are over-taxed, the first critical step to attendance (making the appointment) is delayed or may not happen without PO intervention.

A related challenge noted by POs was the lack of convenient appointment times offered by treatment agencies, especially when attendance conflicted with school hours. Mandatory waiting times for accessing treatment if a youth had previously “failed” at treatment were a further challenge: a youth non-compliant with treatment might be subject to a mandatory 30 day waiting period before re-entering treatment.

One of the barriers is that once, if they’ve already had is—sometimes even before coming to probation. They’ve already dealt with substance treatment, and they have their policy, which is, you know, if you failed out of treatment, you have to wait 30 days before you can reapply. So sometimes, when I’m getting it, they are in the 30-day period (Probation officer, female, 47)

3.3.3. Interagency collaboration and communication: punishment vs rehabilitation.

Among the narratives of POs and SU providers, a recurrent theme emerged regarding the critical nature of interagency collaboration in guiding youth successfully beyond the justice system and into treatment. However, despite agreement on the importance of interagency collaboration, actual collaboration reported by POs and SU providers varied. Communication between PO and SU providers, was highlighted by both as critical with respect to achieving effective collaboration which in turn translated into successful linkage, treatment retention, and outcomes.

However, POs and SU providers described two key and conflictual themes that appeared to interfere with their working relationships and reduce communication. The first is role confusion with respect to who was responsible for ensuring youth and caregiver accountability related to treatment attendance. POs noted that treatment non-attendance or continued substance use was a treatment issue that they would not punish for fear of further ensnaring the youth in the justice system.

So to me, for continuing to smoke marijuana while he’s going to program once a week, I’m not going to make a recommendation to pull a kid -- a teenage kid -- out of his home, -- send him to a detention center, with kids who stab, rape, hurt people -- because he’s in treatment for -- to-to be in recovery. So that’s a treatment issue. That’s not a detention issue. If he hasn’t gotten arrested or he hasn’t hurt anyone, there’s no way I’m bringing him to court. (Probation officer, female, 50).

This approach served to frustrate SU providers who disagreed with probation’s lack of “teeth” and with respect to follow-through on non-compliance with youth attendance or continued use. Some providers argued that this was one more example of adults in a youth’s life not being consistent or following through. The net result appeared to be a lack of ownership on who could or should ensure that a youth attends treatment and thus an opportunity for the youth to fall through the cracks between systems.

POs and SU providers also described conflicting approaches or philosophies to youth SU treatment. However, this conflict appeared at odds with disagreements over whose role was to ensure treatment attendance. POs who noted they would not punish a youth for non-attendance at treatment often employed an abstinence-based approach to youth treatment, with anything less than that falling short of probation requirements. These officers described their frustration around seeing youth be given too many “breaks” by treatment providers around failing to achieve sobriety before more intensive or restrictive treatment was begun.

We’re sending the kids to treatment not to go kill time or waste taxpayer money. It’s supposed to be helpful. Helpful to them reaching abstinence and stopping using drugs. But [Agency] doesn’t really strive for abstinence. They strive for trying. Well, we can’t do that here. (Probation officer, female, 50)

In contrast, SU providers who described harm reduction approaches as a central tenant of their treatment approach struggled with their perception of fear-based tactics to substance use reduction implemented by probation/the courts that required unrealistic, or unreasonable expectations. These competing views meant that SU providers were reluctant to engage or communicate with POs and let them know if a youth was struggling and that POs who often disagreed with SU provider recommendations.

is it against the law for an 18-year-old to have alcohol? Absolutely. Does the majority of the world, in -- in the United States, do they do? Absolutely. There’s no room for ‘I understand why you did that. Was that a good choice? Probably not, because you have all these troubles going on.’ But to say to a kid, you can’t -- because we have this handful of kids who’ve gotten themselves caught in the legal system, their whole world is different than any other adolescent, and it -- becomes unmanageable for them…..they’re demanding perfection from, you know…….and the bar is set too high. (SU provider, female, 28)

4. Discussion

To our knowledge, this is the first study to explore specific facilitators and barriers to the use of SU services by JIY, integrating perspectives of POs, SU providers, and families. Guided by the Gateway Provider Model, findings reveal specific family enabling and predisposing factors, probation officer views and knowledge (as gateway providers) as well as key structural characteristics that appear to influence service use among this high risk and often hard-to-engage population. Overall, narratives across all responders revealed that caregiver engagement with both the justice system as well as with the behavioral health systems was essential to a youth’s initiation and engagement in treatment, and that such engagement was often lacking. Similarly, the engagement of justice and treatment systems with each other also emerged as critical to this process.

Family enabling and predisposing factors.

Challenges within the family system to engagement echoed prior work on families of youth with psychiatric problems^30–32. Specifically, disagreements relating to a youth’s actual need for treatment, negative perceptions of SU treatment, family stress, including family discord and poverty, and stigma were described by all respondents in the current study as reasons youth failed to use SU services. Extending the extant literature around the impact of stigma on SU treatment uptake³³, POs and SU providers described caregiver shame related to their own or familial substance use and concern over what might be revealed during the youth’s treatment as key concerns when deciding whether or not to accept a referral. This finding appears in conflict with quantitative studies that have identified caregiver mental health problems to be positively related to youth’s service use³¹. Differences between prior studies and findings here may reflect the justice-involvement of the current sample. Further exploration of this theme is warranted so as to develop protective policy practices as well as PO and SU provider engagement strategies to carefully and nonjudgmentally address this issue without raising caregiver fear of further legal (e.g. CPS, arrest) ramifications for themselves, family members or the youth.

An additional theme that emerged in the narratives of SU providers and families is the idea of distrust in “the system.” Families are mandated or strongly advised by a system that they perceive as unfair or intrusive to begin treatment within another system that they question as having adequate concern or support for their needs. For many families, distrust was a result of involvement in numerous systems (e.g. ACS, schools, justice) which resulted in few positive outcomes for their youth. System distrust was echoed in narratives of some youth and caregivers who questioned whether probation was the correct place to identify youth in need of substance use treatment. However, that 60% of youth in the current sample had not received prior treatment, despite having indication of treatment need, shows the criminal justice system’s critical role in substance use prevention and treatment via the identification of at-risk youth and subsequent linkage of these youth to treatment and/or early prevention.

The need for successful family engagement in the justice process in order to improve youth treatment outcomes and reduce recidivism is clearly reflected in the policies of juvenile justice agencies (e.g., Office of Juvenile Justice and Delinquency Prevention), professional organizations (e.g., the National Council for Family and Juvenile Court Judges), and “white papers”^66,67 Indeed, families in the current study who saw probation as an asset and a source of support when addressing youth substance use were frequently those who accepted treatment referrals.

Promoting family engagement in probation settings is particularly challenging, given the asymmetrical nature of PO/family relationships, wherein POs’ responsibilities may prompt directive and sanction-based interactions with probationers and their families. Findings from the current study suggest providing social support for caregivers, recognizing and working collaboratively in the face of family overburden and chaos may be key strategies for POs (and providers). A greater understanding of how this distrust can be addressed and alleviated within the justice system is required. However, to our knowledge, there are no studies that have examined how characteristics of all members of this system triad influence reciprocal and transactional social relationships and shape the meaningful engagement of families in probation activities.

Structural characteristics.

Infrequently mentioned in narratives of caregivers or youth were structural barriers to service use, such as transportation or child care reported in prior studies. This suggests that for justice involved families, perceived, as opposed to concrete barriers,⁴² are more critical to using services. However, key structural factors were described in the narratives of POs and SU staff that served as significant challenges to youth accessing services. Several of these challenges have been identified in prior studies, including lack of available and appropriate treatment options to refer a youth, and specific behavioral health agency polices or factors, such as limited appointment times and requirement of family to make the initial appointment^{40, 41, 68}. Implementing treatment options in a manner that permits a wide array of schedules, family circumstances, and recognition of system distrust may address some of these barriers external to the family system.

Staff Perceptions and Knowledge.

Promoting the importance of interagency collaboration and engagement to successfully get youth who have been identified in one system as in need into treatment in another emerged as significant. Poorly developed or absent referral and linkage procedures as a result of limited communication and differing philosophies or understanding of role responsibilities seemed to hamper collaboration between systems and resulted in POs and SU staff working at odds. Consistent with prior work (Holloway et al), POs were split with respect to their views on the emphasis or role of probation: a punitive approach (zero tolerance for substance use and expectations of abstinence) versus a rehabilitative approach (belief that treatment attendance was the responsibility of the treatment system and not punishable by probation, which would result in further sanctions for the youth). Extending work on PO philosophies, the current study also found variation in SU providers views with some frustrated at probation’s lack of willingness to enforce treatment attendance, expressing a more punitive approach whereas others described feeling at odds with probation as the providers worked within a harm reduction model. Without intervention to improve the engagement and collaborative process between these two systems, which includes the management of differing working philosophies, the likelihood of youth falling between the cracks and failing to make the transition across systems is further increased. Moreover, without treatment youth are at risk for further penetrating the system due to either issues related to non-compliance, or to behavioral problems stemming from worsening substance use²³.

4.1. Limitations

This study has several limitations. This analysis relies on data collected from a sample of largely male youth on probation and their caregivers in medium-sized peri-urban/rural towns in a northeastern state and may not be representative of youth of differing socio-economic statuses and ethnic/racial groups, in other types of juvenile justice facilities, or in other parts of the country. Although the youth sample comprised few females, their numbers reflect typical gender distribution for youth on probation Engagement of families in research studies is difficult⁶⁹. This sample may be biased towards families who were engaged in the probation process (i.e. attending probation supervisory visits that would allow them to be recruited from the probation department) and thus, they may have had fewer negative experiences from which to draw and describe their actions around SU service use. Given the sample size, our ability to analyze data to discern patterns related to other characteristics such as race/ethnicity and gender was limited and warrants replication in a larger sample; cross-case analysis comparing differences by youth who had ever been in treatment compared to those who had not yielded no differences. Our study relied on self-report. Due to reasons of confidentiality about study participation, we did not seek corroborating evidence from the youth’s probation officers (probation officers were asked to talk about their caseload in aggregate), nor did we seek corroborating reports from other sources such as teachers or peers.

4.2. Implications for practice

Despite these limitations, the current findings have important implications for intervention. Multi-level interventions that improve communication and collaboration between behavioral health and probation staff/agencies, that emphasize achieving respect or understanding for variations in working philosophies, and that develop agreed-upon standardized screening, referral, linkage and retention practices, while also working to engage families could improve the success of referrals, uptake of treatment as well as reduce recidivism. Two of the most promising approaches to engagement in mental health settings are training the workforce^70–72 and expanding resources for embedded linkage or family support specialists^{73, 74} to deliver evidence-based service engagement/ linkage interventions that address concrete and perceived barriers. A program that utilizes a hybrid of the two approaches to linkage and engagement may be necessary for justice-involved families in probation settings. Interventions that have trained staff and used local change teams or interagency work groups in the service of working towards mutually agreed upon goals have shown evidence of improved interagency communication and collaboration, improved staff practices and increased service access in justice and youth focused settings^{44, 75, 76}. Such an approach may also serve to minimize the space between various staff philosophies regarding professional. However, training POs to deliver intensive family engagement strategies is not currently a core component of their role. Additionally, given large supervision caseloads and limited time, this is not likely to be sustainable⁷⁷. Furthermore, the dynamic between POs and families is often framed by sanction-based interactions, particularly for substance using youth⁷⁸, and influenced by the youth/family’s prior experiences with and mistrust of child-serving systems. Therefore, training POs to deliver engagement strategies may involve practical and process elements that are at odds with the probation setting context and, thus, compromise adoption and sustainability. Rather, an intervention that also expands the workforce and uses a Linkage Specialist embedded within probation agencies may further enhance referrals and service uptake. After the PO has screened the youth, the Linkage Specialist will work exclusively to improve caregiver (and youth) engagement and successfully link the youth to treatment, while enhancing communication between POs and SU providers. Such interventions will also have implications for other child-serving systems such as schools, child protective agencies that must also collaborate to improve youth outcomes.

5. Conclusions

Approximately 40% of youth on probation will reoffend⁷⁹. High rates of recidivism may be due, in part, to difficulties linking and retaining youth in SU treatment, warranting a more intensive and systemized approach. Within the justice system, juvenile probation departments are critical settings in which to implement programs that close the treatment gap for youth with SU problems through cross-system linkage and enrollment in community SU services. Our findings suggest that developing multi-level interventions that target engagement at both system- as well as family-levels may be successful in achieving treatment linkage that starts in the probation agency and successfully moves the youth between systems and into SU treatment in the community.

Highlights.

Caregiver engagement linked to distrust in the “system.”

Denial of problem, relational barriers, family chaos influence youth service use.

Collaboration between justice and behavioral health systems essential for linkage.

Enhancing family engagement at the point of referral to SU treatment is essential