I have been working with the Court for nine years, and during those nine years, I have frequently been told that service agencies will not accept our detained juveniles at any price, because our children are so difficult to deal handle. I have also heard that many of these same juveniles have Conduct Disorder, and there are no treatments available for them. Since we are located in St. Louis, Missouri, a metropolitan area, it seemed unusual that there were no service agencies willing to work with these children. I have also heard that our State of Missouri Department of Mental Health provides little to no mental health treatment for children, and these children are "falling through the cracks." The above statements may be folklore, but these beliefs seem to be engrained in our Family Court-Juvenile Division, one of the three Divisions of our Family Court.

My personal experience is that juveniles with mental illness appear to be without treatment alternatives, although there are significant funds and many treatment programs for juveniles with drug problems. For the past five years, I have been asking mental health professionals which treatments are effective for juveniles with mental illness. For example, does individual psychotherapy, medication, or a combination of medication and psychotherapy work? None of the professionals I have spoken to seem to have data to support which treatments are effective, that is, which treatments, if any, have positive outcomes for juveniles with mental illness. It appeared to me that treatments are given and paid for without any data to support the value or effectiveness of such treatments.

Since courts have a duty to act in the best interests of a child, to order mental health assessments and treatments, and to maximize the use of few resources, effective court representatives need to know what valid assessment tools are available, and what treatments have positive outcomes for juvenile offenders.

It is possible that by simply focusing on the mental health problem of Conduct Disorder, and gathering data for a snapshot view of the situation that exists, we can discuss, plan, and develop solutions which will lessen the misery that we will face when these children become adults. By a review of the research literature, we may be able to make a sound inference about which treatments for Conduct Disorder have positive outcomes for juvenile offenders. By comparing effective mental health treatments with the treatments currently provided through Missouri juvenile courts, we may be able to infer whether we are effectively treating juvenile offenders. It is assumed that we should identify the child in need of mental health services at the earliest stage.

I also thought that by focusing on the DSM-IV diagnosis(*1) of one mental disorder, Conduct Disorder, I might find some state-of-the-art treatment for a condition that is in great need of treatment. I compiled information on the mental health assessment and treatment of juvenile offenders with Conduct Disorder in Missouri's forty-five juvenile courts.

My court is the Twenty-Second Judicial Circuit, St. Louis City, Missouri, an urban trial court with limited resources. We have thirty-one judges. Our citizen population is predominantly young children and older adults, and we have a significant amount of poverty. Our Family Court -Juvenile Division detains 60 to 100 children in our Detention Center on a daily basis. We have one Family Court-Juvenile Division Judge and three Family Court Commissioners. Many of the children we detain have little in the way of family support, emotionally and financially. Juvenile offenders with Conduct Disorder have multiple problems. Many of these juveniles have co-morbid conditions such as depression, lead poisoning that affects brain functioning, and drug abuse. Some of these children come to our facility on psychotropic ("acting on the mind") medications, and some come in need of psychotropic medication.

Our most senior psychologist, a court employee, estimates that 90 percent to 100 percent of our detained juvenile offenders have Conduct Disorder, and only 20 percent of these juveniles are formally assessed. The sheer number of the children with Conduct Disorder who come within the jurisdiction of our court dictates that, if we are to be effective, we must provide valid mental health assessments and treatments with positive outcomes.

The goal is to identify what valid mental health assessment tools and treatments with positive outcomes exist. Systematic application of this knowledge should result in positive outcomes for our juvenile offenders. Better outcomes, at a minimum, should result in fewer negative contacts with juvenile justice and adult corrections. Ideally, assessments and better outcomes will occur sooner, and all of us will reap the long-term benefits of early intervention.

If there is a state-of-the-art assessment tool for conduct disorder, and there are state-of-the-art effective mental health treatments for children with conduct disorder, this information should be provided to courts who detain juveniles. If not, efforts should be made to identify tools which will assist in promptly assessing juvenile mental health disorders, including conduct disorder, and to determine which mental health treatments have positive outcomes for juveniles with conduct disorder.

This report reviews current literature on mental illness and conduct disorder in juveniles in the United States, and includes data gathered from experts in the treatment of such juveniles. It also summarizes data gathered from questionnaires and telephone interviews from Missouri Circuit Family Courts and Juvenile Courts on the current practices in Missouri in the assessment and treatment of juvenile offenders with Conduct Disorder. A limited number of Missouri Circuit Courts have a group of Divisions (courtrooms) under the term "Family Court," which includes Juvenile and Domestic Relations Divisions. All other Missouri Circuits contain a Juvenile Court (a Division), along with their other Court Divisions.

In Missouri, it is estimated that 58 percent of detained juveniles exhibit or have conduct disorder. A majority of circuit juvenile courts do not assess the mental health of the juveniles they detain. In those circuits where mental health assessments are conducted, an estimated average of 60 percent of detained juveniles who have or exhibit conduct disorder are assessed as having conduct disorder. Nineteen percent of Missouri circuits use the Massachusetts Youth Screening Inventory (MAYSI), an assessment tool, with more to follow. An estimated average of 37 percent of detained juveniles with conduct disorder receive mental health services or treatment. The data indicates that assessment does not shorten the time for receipt of mental health services or treatment. In Missouri, the mental health services provided to detained juveniles with conduct disorder are varied, and there is no consistency statewide in the type of mental health services or treatment provided. As with other states, there is no scientific evaluation of mental health services or treatments provided to juveniles in Missouri for the purpose of determining whether these services or treatments are effective. Therefore, we do not know which mental health treatments have positive outcomes for these children.

Courts are in the best position to get the stakeholders, including agencies in juvenile justice, education, mental health and primary care, to share their knowledge and information. The issues that must be resolved need to be identified if the mental health needs of juveniles are to be met, including juveniles with conduct disorder. The shared knowledge and information includes scientific knowledge as to what is effective mental health treatment, and job knowledge gained from personal experience in working with juveniles. Social work and law enforcement juvenile justice personnel have much to contribute, and those divergent viewpoints must be shared. The problems that exist and the solutions needed are not theoretical. Missouri's Department of Mental Health (DMH) will need to work hard to gain the confidence of Missouri juvenile court staff, because of the perceived neglect of the mental health needs of juveniles by DMH.

The state-of-the-art of assessment of conduct disorder is that there is no formal assessment tool. The diagnosis of conduct disorder rests on clinical grounds. The use of the Massachusetts Youth Screening Inventory (MAYSI), an assessment tool, is a good idea for Missouri courts, because it will assist in identifying whether certain children are in need of mental health services.

State-of-the-art of treatment for conduct disorder is multi-disciplinary. Multisystemic Therapy (MST) is a multi-disciplinary treatment, but the results showing the efficacy of MST need to be reproduced by others, and research needs to determine whether the same benefits can be demonstrated with less support from the experts. Co-morbidity of mental disorders in juveniles with conduct disorder is quite significant, and often ignored to the detriment of both the child and society. Many children with conduct disorder have bipolar disorder, depression and/or anxiety disorder. Anxiety disorder and depression are very treatable. These co-morbid conditions are more treatable than conduct disorder, and if they are not treated, the child will not get better. If these conditions are treated, a good portion of the conduct disorder behaviors may disappear. There are no medications for conduct disorder, but there are some proven medications for controlling the aggressive behavior that often accompanies conduct disorder. If the aggressive behavior is controlled, the other conduct disorder behaviors may become less significant. Many children with conduct disorder also have learning disabilities. Structure, that is, imposing and maintaining externally imposed boundaries, is the best treatment for these children. Parents need to be trained not to inflame the child when the child transgresses. Dramatic improvements in the behavior of children with conduct disorder have occurred by providing non-school after school skill-related programs, such as fishing and basketball. Early interventions for very young children in high risk families, such as home visitations and high-quality day care, have been shown to be effective in producing positive outcomes. There is no cure for conduct disorder.

In the United States, mental health services provided to juveniles with conduct disorder are not supported by scientifically controlled studies showing that they are effective. Academic interventions can greatly improve the chances for children with conduct disorder. There is no comprehensive vision for targeting improvement in the recognition, diagnosis and management of the mental health needs of juveniles.

The questionnaire pretest was conducted with the most senior psychologist employed by our court, St. Louis City Circuit Court. As a result of the pretest, the telephone survey interview was modified to a shorter document with fewer questions. Conduct Disorder became the specific focus, and more general questions about mental health services provided for juveniles were eliminated.

A questionnaire was sent and telephone interviews were conducted with court personnel in forty-five jurisdictions (all family and juvenile courts in the state of Missouri) to obtain current court practices in Missouri with regard to assessment and treatment of Conduct Disorder in children detained by family and juvenile courts.

The questionnaire was sent to the top juvenile officer, usually the Chief Juvenile Officer (under Missouri statutes, the top Juvenile Officer is titled "Juvenile Officer."). Responses were received from all 5 urban circuits. Data was obtained from 34 of the 45 circuits (76 percent), and collected from January 7, 2000 through March 3, 2000.

Much of the data was not quantifiable, because there were so many individual differences in the data provided.

To obtain a copy of this research paper, please contact:

Knowledge Information Services
National Center for State Courts
300 Newport Avenue 
Williamsburg, VA 23185
Phone: (800) 616-6164