Abstract
The use of videoconferencing technology in the provision of mental health services is expected to increase rapidly over the next several years. Given the high rates of juvenile offenders in need of such services and the new norms of communication among young people in general, technology-based service modalities are a promising approach for increasing the availability and intensity of services, as well as engagement and compliance with treatment recommendations. This article will discuss the current state of the juvenile justice system, the literature on the use of telemental healthcare (TMH) with delinquent youth, how TMH fits within the generally accepted model of correctional rehabilitation, and special considerations for applying TMH to this population and setting. Although there is no evidence to suggest negative outcomes associated with TMH, future research is greatly needed to justify its use.
Introduction
D
Many of these delinquent youth experience psychological and emotional disturbances that can perpetuate their involvement in the criminal justice system (Moffitt 1993; Constantine et al. 2013; Hoeve et al. 2013). One recent survey (Constantine et al. 2013) of <10,000 youth revealed that offenders with psychotic and disruptive disorders were more than twice as likely to experience high rates of arrest into adulthood as were those without a psychiatric diagnosis. Another study of juvenile offenders detained in secure facilities found that up to 75% met diagnostic criteria for a psychiatric disorder at baseline, ∼50% met criteria for multiple disorders, 93% had been exposed to at least one traumatic event, and 10% had contemplated suicide within the past 6 months (Teplin et al. 2013). The authors (Teplin et al. 2013) also reported that, among youth with a major psychiatric disorder, only 15% received treatment while in detention and even fewer (8%) received treatment once released into the community. Similarly, only about half of juvenile detainees nationwide are housed in facilities where on-site mental health professionals assess them for treatment needs (Hockenberry et al. 2013). Difficulty obtaining mental health services is prevalent in community-based settings (e.g., probation or specialty/diversion courts) as well, where as many as 75% of juveniles adjudicated delinquent are placed (Livsey 2012). Outpatient services for juvenile offenders tend to be associated with a high rate of attrition (Hunter and Figueredo 1999; Bender et al. 2007) for a variety of reasons. including travel distance to service agencies and lack of transportation (Lockwood 2012). Treatment noncompliance among these youth has been associated with notable increases in future criminal conduct (Lockwood and Harris 2013).
Given their developmental vulnerabilities, youth offenders are generally considered to be more amendable to behavior change than their adult counterparts. Therefore, unlike criminal court, which emphasizes culpability and punishment, the juvenile court was established primarily to address identified targets for treatment that will reduce the risk of continued antisocial behavior. (Redding et al. 2005). The most widely accepted and empirically supported model of correctional rehabilitation – for both adults and juveniles – is Risk-Need-Responsivity (R-N-R) (Andrews and Bonta 2010). R-N-R suggests that higher risk offenders should receive more intensive services than lower risk offenders (Risk), that interventions should address identified dynamic risk factors (i.e., criminogenic needs) associated with continued criminal behavior (Need), and that these interventions should be consistent with offenders' developmental, cognitive, or physical abilities and resources (Responsivity) (Andrews et al. 1990; for a more detailed review see Morgan et al. 2013). Adherence to these basic principles has been shown to produce substantial reductions in criminal recidivism (Gendreau and Goggin 2013; Morgan et al. 2013). Therefore, the lack of available services for youth offenders is not only contradictory to the traditional rehabilitative values underlying the juvenile justice system, but is also placing the safety and security of youth and their communities in jeopardy.
The advancement of the Internet, and in particular social media sites such as Twitter and Facebook, has propelled technology into a primary outlet for communication (Jones 2014). Notably, adolescents access and use electronic forms of communication significantly more frequently than adults (Valkenburg and Peter 2011). It is not surprising, then, that similar technological advances have been observed throughout the healthcare system as well, including the practice of psychology and psychiatry (Batastini et al. 2013). It has been projected that the use of technology in mental health sectors will expand substantially over the next decade (Norcross et al. 2013). The hope is that technology-based approaches will enhance treatment outcomes by offering a wider array of options and helping to bridge the gap between need and availability in areas where resources are limited. For youth offenders who are growing up in an increasingly technology-dependent world, technology is a promising solution to the deficit of mental health services (Kazdin and Blasé 2011). In particular, including communication technologies in service delivery may improve the efficacy of treatment interventions by increasing adherence to the principles of R-N-R. Typically, telehealthcare (also referred to as telemedicine, telemental healthcare, telepsychology, telepsychiatry, among others) involves the use of real-time audiovisual equipment, such as videoconferencing programs, that allows clients and providers to interact over a distance (Ax et al. 2007). For the purpose of consistency, telemental healthcare (TMH) will be used to describe technology-based services that address a psychiatric or psychological need.
TMH with Youth Offenders: What We Can Infer from the Research
Although the role of TMH in juvenile justice settings is not well understood at present, evidence supporting its use in providing mental health services to children and adolescents in other clinical settings, as well as adult forensic and correctional populations, has been gaining attention. The application of TMH to non-offender youth populations is detailed elsewhere in this issue, but in general, TMH has been associated with high levels of service satisfaction (Myers et al. 2008), reliable assessment outcomes (Elford et al. 2000; Diamond and Bloch 2010), and positive treatment gains (see Slone et al. 2012 for a review) when compared with in-person modalities for emotionally disturbed children and adolescents.
Among offender populations specifically, a majority of the emerging research on the use of TMH has focused on adults. Although limited, the literature is generally optimistic toward technology-based interventions. Several studies have demonstrated that adult offenders perceive the quality of mental health treatment they receive via TMH as satisfactory (Brodey et al. 2000; Magaletta et al. 2000; Zaylor et al. 2000; Morgan et al. 2008). For example, Morgan et al. (2008) found that inmates who received psychological and psychiatric services did not significantly differ on measures of post-session mood, overall treatment satisfaction, and perceived working alliance across videoconferencing and in-person modalities. Additionally, correctional staff has reported that TMH services are easily integrated into routine care (Zaylor et al. 2000). Preliminary research on the reliability and validity of psychodiagnostic and forensic assessment outcomes (Nelson et al. 2004; Lexcen et al. 2006; Manguno-Mire et al. 2007; Antonacci et al. 2008;), as well as the effectiveness of treatment interventions (Zaylor et al. 2001; Antonacci et al. 2008; Morgan et al. 2008) delivered remotely is also promising. In the only known longitudinal study conducted among an inmate sample, Zaylor and colleagues (2001) found that participants receiving psychiatric services via videoconferencing reported experiencing less distress over time. Additionally, provider ratings of mental health functioning were consistent with inmates' self-reported improvements.
Unfortunately, even less empirical evidence is available for juvenile offenders. However, existing research has generated results similar to those found in the non-offender youth and adult offender literature. Myers and colleagues (2006) surveyed client satisfaction with a telepsychiatry clinic that provided psychodiagnostic evaluations, treatment needs assessments, medication management, and brief follow-up consultations to youth offenders detained in a rural, minimum-security detention facility. Results suggested that the adolescents were adequately satisfied with the services they received (mean=3.97 on a five point scale). In addition, the treating psychiatrist in this study expressed comfort in delivering services to mentally impaired youth via this modality and denied difficulty establishing and maintaining therapeutic rapport (Myers et al. 2006). Another study of delinquent youth who received behavioral health counseling via telepsychiatry revealed that participants actually perceived their provider to be more focused on them than in their previous experiences with in-person interactions (Fox et al. 2008). Likewise, providers perceived the youth as more open to sharing their thoughts and feelings through interactive video than through in-person contact.
The ability of TMH interventions to produce positive treatment gains among juvenile offenders has also been explored. Fox and colleagues (2008) evaluated the efficacy of a behavioral health program that included a videoconferencing component across four adolescent detention facilities. Participants' level of goal attainment was assessed 1 year before the implementation of video services and again 1 and 2 years after implementation. For this program, goals were related to health, education, social skills, personality, and behavior, and family and community reunification. Results showed that participants were able to identify more goals and successfully achieve those goals at significantly higher rates following the addition of the videoconferencing component. Although the extant research is sparse and lacks strong scientific integrity, it nonetheless implies that technology-based interventions can be an appropriate and beneficial tool for targeting the needs of justice-involved youth.
TMH and the Principles of R-N-R
Technology also has the potential to enhance agency and client adherence to each of the basic principles of the R-N-R model, thus maintaining the traditional values of the juvenile justice system and improving public safety.
Risk-needs
As noted, juvenile detention centers and community corrections agencies across the country struggle to provide appropriate mental health assessment and treatment (Hockenberry et al. 2013; Teplin et al. 2013). Part of this problem is the scarcity of qualified professionals willing to work with such a challenging population. Juvenile correctional employees generally report high levels of job-related stress (Blevins et al. 2007). However, according to R-N-R, intervention strategies informed by adequate assessments are necessary for accurately identifying and subsequently targeting the juvenile's criminogenic needs. Thus far, research has demonstrated that little is lost when using TMH to conduct psychodiagnostic and forensic assessments (e.g., Elford et al. 2000; Lexcen et al. 2006; Manguno-Mire et al. 2007; Diamond and Bloch 2010) and that TMH-based treatments can lead to successful outcomes without diluting the impact of the intervention during its delivery (e.g., Zaylor et al. 2001; Nelson et al. 2003; Slone et al. 2012). Therefore, it appears that TMH is not only a promising solution for addressing the burden of mental health need by expanding the list of possible providers, but that it also affords the opportunity to acquire those with a higher quality, specialized skill set. For example, when institutions or community supervision departments do not have in-house service providers, they can contract with outside professionals (e.g., in private practice, other juvenile justice agencies) who have the proper training and experience to conduct risk-needs evaluations and implement treatment programming that is consistent with current best practices for youth offenders.
Additionally, TMH allows for the provision of more intensive interventions by including a variety of individuals or systems in an offender's treatment plan. This capacity is particularly beneficial for chronically delinquent or high-risk youth (Kaliebe et al. 2011), who often require comprehensive treatments that depend upon the participation of multiple entities. For example, multisystemic therapy – a well-established intervention model shown to reduce delinquency among violent juvenile offenders (e.g., Schaeffer and Borduin 2005) – includes a complex network of caregivers, service providers, correctional staff, educators, peers, and neighbors to target important criminogenic needs and promote positive behavioral changes. Technology-based interventions can build stronger connections and enhance continuity of care within this network by offering a faster, more convenient mode of communication.
Furthermore, research suggests that high-risk juveniles who are placed in treatment together can contribute to iatrogenic effects (e.g., substance use, violence, adult maladjustment) (Dishion et al. 1999); that is, group associations among delinquent youth impair their ability to develop positive peer associations and prosocial communications skills, while also threatening their safety or the safety of staff. The use of technology can allow for interpersonal interactions to take place in a controlled, yet therapeutic environment. Studies among non-offender adult populations have shown that clinical (e.g., symptom reduction) and process (e.g., cohesion) outcomes remain intact when group therapy is conducted through TMH modalities such as videoconferencing (Greene et al. 2010; Morland et al. 2011). Finally, other TMH services such as Web-based interventions, text message check-ins, or smart phone apps could be used to increase the intensity and accessibility of treatment for youth offenders (Kazdin and Blase 2011).
Responsivity
As technology becomes the preferred method of communication, social interaction, and learning (Ahmedani et al. 2011; Jones 2014), it is likely that many youth experience greater comfort with TMH than with traditional in-person approaches (see Myers et al. 2006; Fox et al. 2008). For example, technological services may help juveniles “warm up” to adult providers who are able to communicate through a modality that is familiar or perceived as more youthful and relatable.
A survey of juvenile detainees revealed a number of perceived treatment barriers that may prevent youth from seeking out or participating in appropriate, in-person interventions. Self-reported concerns included 1) the belief that obtaining help was too difficult, 2) concern for what others would think, and 3) the high cost of treatment services (Abram et al. 2008). TMH may be able to alleviate many of these issues. First, not only are more providers available, but they can also be accessed without leaving the juvenile's home or secure facility. Community-sanctioned youth could also attend sessions without having to rely on guardians to transport them to appointments. Second, meeting with a mental health professional over a distance may contribute to a greater sense of privacy. In institutional settings, juveniles may be able to participate in sessions without other residents knowing who is on the other end. Similarly, in community settings, youth have the opportunity to meet discreetly with a professional in their own private space. Given the distance inherent with TMH interventions, participation is also likely to be seen as less intimidating or intense to youth offenders and their families, which may further reduce apprehension about treatment. Third, evaluations of cost effectiveness consistently demonstrate that TMH is cheaper than in-person methods. In adult corrections, it is estimated that a conventional, in-person consultation for an inmate carries an average cost of $173 compared with $71 per telehealth consultation (National Institute of Justice 2002). All of these potential advantages of TMH could substantially improve adherence to the Responsivity principle.
Barriers to TMH Implementation
Despite its benefits, the use of TMH has several limitations that must be acknowledged. First, access to technology may not be readily available to delinquent youth, who often come from underprivileged or poor socioeconomic backgrounds (Ng 2010). Additionally, TMH alone cannot address other barriers such as lack of insight, stigma, or misperceptions of treatment. In their survey of juvenile detainees, Abram and colleagues (2008) found that >50% of respondents did not seek treatment services because they believed that their problems would subside without help or that they could solve the problems themselves. Additionally, 27% expressed denial of the problem and lack of interest in treatment (Abram et al. 2008).
Another obstacle to implementing TMH may lie with the treatment providers. Mental health professionals are typically trained in models of therapy that assume clients will receive in-person services in the same room. The remoteness of TMH has led to concerns about lost emotional connectedness with clients (Magaletta et al. 2000). However, some studies suggest that this concern may be less prevalent among providers of youth services (Elford et al. 2000; Myers et al. 2006; Fox et al. 2008). TMH also introduces issues of confidentiality. For example, technology is a method of communication that is subject to hacking or other forms of intrusion (e.g., accidental dissemination of information to unauthorized personnel; data transmission interference). Furthermore, confidentiality may be compromised in secure facilities where juveniles cannot be left unsupervised with technological equipment, as well as community-based settings where juveniles may be subject to a chaotic and interruptive home environment. Other limitations include the inability of technology to capture all relevant information, such as behavioral cues that occur beyond camera view (e.g., fidgeting under the table or desktop) (Diamond and Bloch 2010).
Conclusion
There is no evidence thus far to suggest that TMH contributes to negative outcomes for juvenile offenders; however, many of the potential benefits discussed here are speculative and/or inferred from the limited research that has been conducted to date. To better justify the use of TMH with delinquent youth, methodologically rigorous empirical studies are greatly needed. It is possible that these young offenders present unique challenges to the application of TMH approaches. Research initiatives should seek to understand the nuances of using TMH to identify re-offense risks, target individual treatment needs, and match service implementation with client capacities and resources. Findings from this line of work will help inform best practice guidelines for TMH with juvenile offenders and ultimately maximize the rehabilitative efforts of the juvenile justice system.
Footnotes
Disclosures
No competing financial interests exist.