From Referral to Treatment: Implementation Processes in Juvenile Drug Treatment Court Programs

Abstract

Juvenile Drug Treatment Courts (JDTCs) provide a critical opportunity to identify and treat youth with substance use disorders (SUD). Structuring JTDCs to minimize process complexity and time to treatment is important. Results across eight JDTCs indicate the number of steps between referral and enrollment varied from 2 to 7, and the potential wait time varied from 1 to 58 days. The number of steps between referral and SUD treatment varied from 3 to 8, and the potential wait time varied from 2 to 118 days. Information regarding JTDC process can inform the field about JTDC practice, including barriers to treatment as well as areas for improvement.

Keywords

implementation juvenile justice substance use disorder treatment youth

Juvenile Drug Treatment Courts

In the United States, Juvenile Drug Treatment Courts (JDTCs) provide a critical opportunity to identify and treat youth with substance use disorders (SUD). Despite a steady decline in the juvenile arrest rate for drug violations over the past 20 years in the United States (Office of Juvenile Justice and Delinquency Prevention (OJJDP), 2020), the number of drug offense cases remains very high. In 2018, 14 percent of delinquency cases (over 100,000) handled by courts with juvenile jurisdiction were for drug offenses (Hockenberry and Puzzanchera, 2020). In addition, a national study conducted in the United States with nearly 10,000 youth across 18 states found that a third of justice-involved youth met criteria for SUD (Wasserman et al., 2010). The juvenile justice system is the largest referral source to SUD treatment in the United States, accounting for 43 percent of adolescent treatment admissions (Substance Abuse and Mental Health Services Administration (SAMHSA) Center for Behavioral Health Statistics and Quality, 2017).

Juvenile Drug Courts were established in the mid-1990s and aim to divert youth with substance use issues, as identified through screening and assessment as a process of justice system involvement, from incarceration to alternative responses that could include treatment, court supervision, drug testing, and family and community linkages. Although many Juvenile Drug Courts initially had the component of treatment, not of all them did; however, currently they all include treatment and are now JDTCs. As dockets within juvenile courts specifically designed for youth with SUDs, JDTCs enable access to treatment and needed services that youth may otherwise not receive. For many justice-involved youth, JDTCs are the main identifier of their SUD and their main pathway to treatment. Therefore, it is important to examine the pathway and related barriers within the process.

Best Practices

Historically, there has been an emphasis on best practices and integration of research-informed, or evidence-based, approaches in JDTCs (Belenko and Logan, 2003; Chassin, 2008; Henggeler et al., 2012). A critical component is to support timely access and successful linkage to SUD treatment services once need is determined (Garnick et al., 2006; Scott et al., 2018). A standard for timely referral to treatment is 14 days from the time of determined need (Belenko et al., 2017; Garnick et al., 2009; Knight et al., 2016). Reducing barriers that impede linkage to treatment is also critical (Priester et al., 2016; Rapp et al., 2006). This includes considering structural barriers related to treatment provision, service location, and service availability (Priester et al., 2016), lack of transportation and limited access to support services (Godley et al., 2000), and addressing long wait times, which have been found to be deterrents to treatment (Grella et al., 2004). Screening and assessment to identify need, treatment planning, and an active treatment assignment or ‘handoff’ between juvenile justice and treatment providers are critical components of JDTC implementation; however, depending on the process and system, the number of steps to accomplish these core activities can be a barrier for youth to initiate and engage in treatment (Belenko et al., 2017; Models for Change, 2007; Priester et al., 2016; reclaimingfutures.org; Wasserman et al., 2003). JDTCs need the ability to respond quickly and efficiently to ensure participants receive rapid provision of treatment services.

US federal leadership has prioritized efforts to integrate evidence-based practices by providing considerable funding as well as guidelines to support JDTCs and effective practice. As an early joint effort, a decade after the first JDTC was established in the United States, the Bureau of Justice Assistance, the National Council of Juvenile and Family Court Judges (NCJFCJ), the National Drug Court Institute (NDCI), and OJJDP created the Juvenile Drug Court: Strategies in Practice (NCJFCJ, 2014; National Drug Court Institute and National Council of Juvenile and Family Court Judges (NDCI and NCJFCJ), 2003) to serve as a framework for planning, implementing, and operating a JDTC. The Strategies in Practice include strategies such as collaborative planning, family engagement, community partnerships, and comprehensive treatment planning, which when implemented, expand opportunities and reduce barriers for youth and families to access treatment. The approach emphasizes the need for JDTCs to adapt the program structure to their specific youth population and their specific court and community characteristics to have an efficient implementation process (NCJFCJ, 2014; NDCI and NCJFCJ, 2003). Operationally, for many years, the Strategies in Practice served as guiding principles for implementing JDTCs as they did at the time of the present study.¹

More recently, US federal leadership has prioritized efforts to integrate evidence-based practices aiming to ensure rapid provision of treatment services by providing considerable funding to support JDTCs to implement such integrated models. Funded by a joint OJJDP and Substance Abuse and Mental Health Services Administration (SAMHSA) initiative, multiple JDTCs were charged with engaging in such a comprehensive approach by integrating the Strategies in Practice and Reclaiming Futures (reclaimingfutures.org) (Dennis et al., 2016; Korchmaros et al., 2016). Reclaiming Futures is a system-wide change intervention and provides a model of juvenile justice reform that prioritizes reducing barriers to improve treatment access, quality, and continuing care through coordinated individualized response and community directed engagement (Nissen et al., 2004). The Reclaiming Future approach prioritizes critical components of the JDTC implementation process, such as rapid initial screening and initial assessment using an evidence-based instrument. Emphasizing the importance of process, Reclaiming Futures is focused on decreasing the number of steps and minimizing the time to treatment. As such, JDTCs that enacted the combined Strategies in Practice and Reclaiming Futures approach were particularly focused on decreasing barriers to treatment, including the length of time and the complexity of the process related to the number of activities required for youth to access services.

An examination of these particular JDTCs can provide a significant contribution to the field of juvenile justice. The juvenile justice literature is lacking descriptions of the process by which JDTCs enroll youth and initiate SUD treatment. Examinations of JDTCs processes that have focused efforts on decreasing widespread identified barriers to treatment initiation – service location, service availability, long wait times – are especially informative to the field as they could illuminate ways in which other JDTCs could decrease these barriers, and consequently increase the efficiency of their programs. Two main indicators of such efficiency are the number of steps and timing of the implementation processes. Examining JDTCs’ implementation processes, especially JDTCs that are specifically focused on removing barriers, is critically important for making continuous quality improvements for prompt diagnosis and treatment of SUDs. Highlighting different JDTC approaches that are based on contextual and structural circumstances, as well as particular population characteristics, provides an opportunity for practitioners and other stakeholders to learn what processes other JDTCs have successfully implemented to support use of best practices.

Study Purpose

This study examined the process and time span from referral to and enrollment in JDTCs and SUD treatment assignment. The study focused on JDTCs that were funded to implement integrated Strategies in Practice and Reclaiming Futures model aimed at minimizing barriers and improving program enrollment and treatment initiation processes. Using data from the National Cross-site Evaluation of Juvenile Drug Courts/Reclaiming Futures (University of Arizona – Southwest Institute for Research on Women, 2016), we examined JDTC site characteristics and described the implementation processes employed, focusing on recognized barriers to treatment. Specifically, we examined (1) JDTC tracks/specialty courts, (2) the SUD treatment delivery system (including time to treatment assignment), and (3) the JDTC enrollment processes (including time to enrollment) to assess potential wait times to treatment. Treatment assignment occurs when JDTC personnel assign a youth a particular SUD treatment program, such as a residential, intensive outpatient, or outpatient treatment program provided by a particular agency. JDTC enrollment occurs when a youth is added to the JDTC docket and considered a participant of the JDTC as opposed to being assigned to a different court program or otherwise processed through the justice system.

The JDTCs included in this study, like most JDTCs, were required to follow the Strategies in Practices. Thus, we expected that there would be similarities across sites in implementation processes. Furthermore, we expected many similarities in the steps of the processes associated with the Reclaiming Futures model specifically related to the utilization of evidence-based screening and assessment instruments, family engagement, treatment planning, and active treatment assignment or ‘hand-off’ between juvenile justice and treatment providers.

However, because JDTCs are impacted by the local context and structural circumstances as well as the characteristics of their particular populations, we also expected some differences across JDTCs related to the number of steps and the timing of the processes of program enrollment and treatment assignment. Many contextual and structural factors influence JDTC implementation possibilities, such as (1) the kinds of resources available through collaboration with partnering agencies, within the JDTC, and in the local community; (2) the ability to provide SUD treatment on-site and/or in the community, the ability to work with multiple treatment providers or a single provider, access to providers; and (3) requirements and directives of the court all influence the implementation possibilities available to JDTCs. In addition, participant barriers and challenges, such as transportation and limitations of parent time (Priester et al., 2016; Rapp et al., 2006), may also impact JDTC’s approach to implementation as well as their success in engaging youth in their program and in SUD treatment. Therefore, we expected differences in the processes by which JDTCs implemented their programs even though their implementation was guided by the same best practices.

Method

Participants

Participants were eight JDTCs that were geographically and demographically diverse. Two sites were located in each of the following regions: The West Coast, the Midwest, the Great Lakes region, and the Southeast. Three sites were located in large, metropolises (populations greater than 500,000), four sites were located in mid-sized cities (populations between 100,000 and 500,000), and one site was located in a small, rural town (population less than 10,000). The sites were selected because their charge to implement the integrated Strategies in Practice and Reclaiming Futures model included improvement to the process by which youth were referred to and enrolled in JDTC, and initiated SUD treatment services. This charge, which was supported by grant funds, provided an opportunity to examine JDTC processes after sites spent 4 years striving to make improvements.

Measures

The research team developed a JDTC implementation process data collection tool (University of Arizona Southwest Institute for Research on Women and Carnevale Associates, LLC (SIROW and CALLC), 2012) specifically for the National Cross-Site Evaluation of Juvenile Drug Courts/Reclaiming Futures. The researchers developed this tool primarily to identify the processes of referral to and engagement in JDTCs. The data collection tool contained implementation process questions in six areas: (1) technological scan (e.g. What infrastructure is in place that is used to link different agencies and individuals within their JDTC?), (2) general site and SUD treatment information (e.g. What type(s) of adolescent SUD treatment is your program providing and for each intervention/modality who provides the treatment?), (3) training (e.g. Are staff cross-trained or do some tasks/process elements rely solely on specific people?), (4) operations of the JDTC, particularly in relation to the Strategies in Practice and Reclaiming Futures integrated model (e.g. Please walk us through the process youth go through with your JDTC to initiate treatment services), (5) modifications and adaptations to the implementation plan (e.g. What, if anything, was originally planned that is not occurring and why?), and (6) interventions that support matching clients to resources (e.g. How do youth get referred to services in the community?).

For the present study, researchers analyzed data collected regarding JDTC operations and general site and SUD treatment information. Most of the questions in this section of the instrument were open-ended, but some were closed-ended. Both types of questions at times elicited responses that prompted follow-up questions for clarification or further understanding. The relevant section of the JDTC implementation process data collection tool contained ‘core questions’ that were asked of every JDTC as well as site-specific questions that were developed based on a review of their grant proposal. As a result, the number of questions varied by JDTC site as the tool was individualized. Completing the JDTC implementation process data collection tool took several hours and required interviewing several different JDTC staff members. The focus for the present study was on the processes that were in place after sites implemented the integrated Strategies in Practice and Reclaiming Futures model.

Process steps

The term ‘steps’ refers to the different required activities – for example, the meetings, screenings, assessments – that occurred at each JDTC site as part of the initial enrollment process and the process of accessing SUD treatment services from the point of referral to the JDTC program. For the present study, all actionable activities that needed to occur in the process were considered steps, regardless of whether it required action on behalf of the youth/family, the court/juvenile justice system, or the treatment provider. The only exception was the scheduling of an activity, which was not counted as a step. This operationalization of step was consistently applied across sites. For the present study, the number of steps was defined by how many individual processes or activities were implemented at each JDTC site. Once the steps were identified, simple counts of the steps indicated number of steps between point of referral and JDTC program enrollment and between point of referral and treatment assignment for each site. Some sites had multiple steps occurring simultaneously or over the same period of time; if both steps needed to be conducted as part of the process for an individual, they were each counted as a step and in no particular order. In the case where the nature of the step varied depending on the need of the youth, such as whether a screening with a mental health or a SUD treatment provider was needed, only one was counted as a step. Treatment assignment and enrollment were each counted as steps. For sites where enrollment came first, enrollment is included as a step in the treatment assignment count. For sites where treatment assignment came first, treatment assignment is included as a step in the enrollment count. The researchers followed this same process and applied these conditions consistently to each site. The average number of steps across sites was calculated using a simple arithmetic mean of the number of steps for each site.

Number of days between steps

Sites often presented the number of days between steps as a range to capture the variability in the timing potentially experienced by youth. For some sites, these reported windows of time resulted in multiple sets of ranges across the steps involved in the entire implementation processes (e.g. 2–7 days between referral and screening meeting; 14–21 days between screening meeting and assessment; 3–7 days from assessment to treatment assignment). In these cases, the low and high ends of the ranges were summed to determine the range of the entire process. For the given example, the range of days from point of referral to treatment assignment was 19–35 days ([2 + 14 + 3] = 19; [7 + 21 + 7] = 35). For each site, the average number of days was calculated as the mean of the range, except for one site that did not have a range for number of days between referral and treatment assignment. For the given example, the average number of days was 27 ([19 + 35] = 54/2 = 27). The average number of days across sites was calculated using a simple arithmetic mean of the average number of days for each site.

Procedure

The researchers examined each site’s process from referral to JDTC through program enrollment and assignment of SUD treatment services. Researchers started with a review of each site’s grant proposal and extracted relevant process information to incorporate into the JDTC implementation process data collection tool (SIROW and CALLC, 2012). As part of an initial in-person site visit, researchers scheduled meetings with key informants at each site who could provide specific details regarding their JDTC processes. This meeting typically included speaking with more than one staff member. Discussions always included a project coordinator/manager and often included representatives from probation, a prosecutor’s office, and treatment. Researchers conducted multiple data collection site visits with each site, reviews of the data, and telephone calls with site representatives to clarify, confirm, and gather additional data. For the purposes of the current study, researchers analyzed the program entry process the JDTCs had in place at the end of their grant-funded period, after they had spent 4 years implementing an integrated Strategies in Practice and Reclaiming Futures model.

The researchers developed site-specific ‘process flows’ as visual representations of how each site implemented their JDTC. Researchers diagrammed the different activities and time frames involved to illustrate the process each site used to enroll youth into the JDTC program and initiate SUD treatment. Researchers sent each site a draft of their process flow for review and held a series of teleconferences with site representatives to clarify and confirm the information and process represented. Researchers made changes, as needed, repeating the review and revision process until site representatives approved the flows as accurate. This process ensured that the flows accurately represented how youth traveled from initial JDTC referral to JDTC enrollment and SUD assignment. The timing indicated in the process flows reflects the possible length of time that a youth could experience from referral to enrollment and to treatment, rather than the typical experience of youth and families at and across JDTC sites. For the purposes of this article, the process flows have been de-identified.

The process flows illustrate all processes of the JDTCs, including multiple tracks within the JDTCs as they existed. However, for the four JDTC sites that had multiple treatment tracks, one track per JDTC site was used in the cross-site analysis of number of steps and days. One multi-track site had a primary JDTC track that was used in the analysis. For the other multi-track sites, researchers received track selection input from the sites and designated the track most consistent with JDTC to include in the analysis. Notably, the tracks within those three sites were largely similar in steps and days.

All data and procedures related to this study were approved by the Human Subjects Institutional Review Board at the University of Arizona.

Results

The results of this study focused on JDTC enrollment and SUD treatment systems. Specifically, we examined (1) JDTC tracks/specialty courts, (2) the SUD treatment delivery system, (3) the steps and timing from youth referral to and enrollment into the JDTC program, and (4) the steps and timing between youth referral to the JDTC program and treatment assignment.

JDTC tracks/specialty courts

The eight JDTC sites had a total of 13 tracks or specialty court programs (Figure 1). Four sites had only one track and four sites had more than one track. Of the four JDTCs with multiple tracks, three sites had two treatment tracks and one site had three treatment tracks. At one of the sites with two treatment tracks, the tracks differed in that one track simply provided more intensive SUD treatment services than the other (Figure 1, Panel A). At another site with two tracks, the primary difference was that one track served youth on probation who are court-ordered into the JDTC, while the other was a diversion program that youth entered voluntarily (Figure 1, Panel B). In the last two-track site, one track was for juvenile ‘offender youth’ who have committed a crime, while the other was for ‘at risk youth’ (Figure 1, Panel C). At this site, ‘at risk youth’ referred to youth who had not actually committed a crime, but engaged in risky behavior and had been brought to the court at the request of the youth’s parents. At the three-track site, there was a mental health-only treatment track, a substance use treatment track, and a recovery classroom, which was a court-ordered school-based program that offered substance use treatment and behavioral health services in addition to academic schooling (Figure 1, Panel D).

Figure 1.

Process flows.

SUD treatment delivery system

Although all JDTCs partnered with treatment providers to connect youth to SUD treatment, there were implementation variations in the SUD treatment delivery system utilized by the JDTCs (Table 1). Generally, JDTCs either had a single treatment provider or a network of treatment providers. However, within those groups there were extensive differences. Three sites contracted with multiple SUD treatment providers basing referrals on level of need and ease of access. Five sites relied predominantly on a single provider, through a variety of mechanisms. Three of the five sites that predominately used one provider, contracted with a single SUD treatment provider that was an external entity employed by an agency external to the court and JDTC. Two of the five sites used an internal entity to provide SUD treatment. These two sites along with one additional site co-located treatment services at the JDTC. Four of the five sites that predominately used one provider referred to other providers based on level of care needed and provider continuum of care availability. Only one JDTC had access to only one provider.

Table 1.

JDTC SUD treatment delivery characteristics.

Site	Treatment providers	Co-location of treatment providers with JDTC personnel	Provider entity internal or external to JDTC	Treatment assignment and JDTC enrollment interdependence
Site 1	Single^a	Yes	Internal	Independent process
Site 2	Single^a	No	External	Dependent (Enrollment first)
Site 3	Multiple	No	External	Dependent (Treatment first)
Site 4	Single^a	No	External	Dependent (Enrollment first)
Site 5	Single^a	Yes	Internal	Dependent (Treatment first)
Site 6	Multiple	No	External	Dependent (Treatment first)
Site 7	Multiple	No	External	Dependent (Enrollment first)
Site 8	Single	Yes	External	Dependent (Enrollment first)

JDTC: Juvenile Drug Treatment Courts; SUD: substance use disorders.

Predominantly single as majority of youth were referred to one provider; could refer to other provider(s), as needed.

Importantly, treatment was assigned prior to JDTC enrollment at three sites (Table 1; Figure 1, Panels C, E, and F). And at one site, treatment assignment was independent of JDTC enrollment as it was a completely separate process from the JDTC (Table 1; Figure 1, Panel A); at this site, youth could be assigned to treatment before or after JDTC enrollment. Allowing treatment assignment to occur prior to JDTC enrollment reduced a barrier that impacted length of time from referral to treatment assignment as youth could begin treatment soon after the need was identified. Four of the JDTCs were structured such that youth had to go through the enrollment process into the JDTC first and then treatment assignment could occur.

A critical component of JDTCs is the connection to treatment, ideally to evidence-based, or research-informed, substance use treatment models (i.e. treatment models that have been studied and found to be effective at reducing substance misuse), which all JDTC sites implemented. However, there were differences in the primary treatment models used. Two of the eight JDTC sites used the Adolescent Community Reinforcement Approach (A-CRA; Dennis et al., 2004; Godley et al., 2001, 2011) as their primary treatment model, while five of the eight JDTC sites used The Seven Challenges^® Program (Korchmaros, 2018; Schwebel, 2004, 2015). The eighth evaluation site used A-CRA for individual counseling and The Seven Challenges Program for group counseling. Other secondary models were also implemented at some sites. These included, for example, Motivational Enhancement Therapy and Cognitive Behavioral Therapy-5 Sessions (Dennis et al., 2004; Sampl and Kadden, 2001).

JDTC enrollment activities, steps, and timing

All eight JDTCs implemented identified critical components of JDTC. The sites all screened youth for program eligibility and need and conducted at least one clinical assessment to determine whether youth were suitable candidates for their JDTC. All JDTCs had at least one court appearance and one staffing/team meeting to discuss appropriateness of youth placement in the program. Five JDTC sites had family meetings, two sites had intake interviews, and one site had referrals to case management as part of the JDTC enrollment process (Figure 1).

Table 2 presents the number of steps and days to JDTC enrollment and treatment assignment. The results reflect the possible length of time an individual youth could experience based on the site-specific range of days; they do not reflect typical experience. As indicated, across sites, the number of steps between referral and enrollment into JDTC varied from two steps to seven steps, with a cross-site average of 4.5 steps. Length of time to complete the process from referral to JDTC enrollment varied by site and within site. The quickest possible enrollment was at Site 1 where youth could be enrolled within 1 day, though it could take up to 8 days. Site 7 had the longest possible process where it could take up to 58 days to enroll in JDTC, though it could take as few as 22 days. The variation in possible number of days from referral to JDTC enrollment within sites ranged from 7 to 8 days (Sites 1, 3, 4, 8) to 36 days (Site 7). As shown in Figure 2, across sites, the average number of possible days it took to formally enroll youth in the JDTC program varied from 5 to 40 days from the time of referral, with a cross-site average of 19 days. However, based on the site-specific ranges in number of days, across all of the sites, youth could have been enrolled within 1 day of referral or waited up to 58 days after referral.

Table 2.

JDTC enrollment and treatment assignment process.

Sites	JDTC enrollment		JDTC treatment assignment
Sites	Number of steps	Range of days	Number of steps	Range of days
Site 1	2	1–8	–^a	–^a
Site 2	3	9–23	5	13–37
Site 3	7	21–28	5	15–25
Site 4	5	4–12	8	21
Site 5	5	17–42	4	5–42
Site 6	6	7–17	3	2–12
Site 7	4	22–58	6	34–118
Site 8	4	13–21	6	20–21
Cross-site averages	4.5	12–26	5.3	13–26^b 16–39^c

JDTC: Juvenile Drug Treatment Courts.

Data unavailable.

Site 7 (atypical instance) excluded from cross-site average.

Site 7 (atypical instance) included in cross-site average.

Figure 2.

Average number of possible days to enrollment and treatment assignment by site.

JDTC time to SUD treatment assignment

Seven of the eight JDTC sites provided the number of steps and days from referral to JDTC to treatment assignment. Site 1 had a dedicated SUD assessment and referral system that allowed youth to initiate treatment independently of the JDTC program and, therefore, did not have data specific to the number of steps and days to treatment assignment. Consequently, these data were not available to be included in the cross-site analysis. The cross-site average number of days was based on the available data from the seven sites.

As indicated in Table 2, across seven sites, the average number of steps between youth referral to JDTC and SUD treatment assignment varied from three to eight, with a cross-site average of 5.3 steps. Length of time to complete the process from referral to treatment assignment varied by site and within site. The quickest possible treatment assignment was at Site 6 where youth could be enrolled within 2 days, though it could take up to 12. Site 7 had the longest possible process where it could take up to 118 days to obtain a treatment assignment, though it could take as few as 34 days. The variation in possible number of days from referral to treatment assignment within sites ranged from zero days (Site 4) to 84 days (Site 7). As shown in Figure 2, across seven sites, the average number of possible days between youth referral and treatment assignment varied from 7 to 76, with an average of 28 days per JDTC site. While the cross-site average possible wait time for youth to initiate treatment was 28 days, based on the site-specific ranges in number of days, across all of the sites, youth could have initiated treatment as few as two days after referral or needed to wait up to 76 days. Site 7 was atypical compared with the other sites, particularly in the high end of the range. Excluding Site 7, the cross-site average for the remaining six sites is 20 days but based on site-specific ranges youth could have initiated treatment in as quickly as 2 days or needed to wait as long as 42 days after referral to JDTC.

Discussion

Supporting youth’s access to SUD treatment, once the need is identified, is a high priority of JDTCs. JDTCs recognize the importance and value of implementing critical core components and using evidence-based tools to do so (Belenko et al., 2017; Godley et al., 2011; Henggeler et al., 2012 reclaimingfutures.org). Yet, it is challenging to translate these priorities to an efficient implementation process that results in rapid access to treatment. For JDTCs in this study, the site-specific enrollment processes result in different wait times to access treatment. While most sites have a similar average number of days to treatment assignment, the site-specific ranges portrayed greatly varied experiences for justice-involved youth. At some JDTCs, even though the average length of time to treatment assignment is 3–4 weeks, some youth could access treatment within 1–2 weeks, a strength and potential success indicator of the implementation process. However, at the same sites because the range of the number of possible days to treatment assignment is so wide, other youth in the program may wait up to 5 or 6 weeks. In addition, at one JDTC, youth may need to wait nearly 4 months to be assigned to treatment. Results also indicate that the youth experience varied within site much more for some JDTCs than for others. Some sites were fairly consistent across youth in the length of time it took for the youth to move through the process, whereas other sites had large variation in the number of days youth could expect from referral to enrollment and to treatment assignment. Each site’s specific context and implementation practice shaped the youth experience as there was no standardized implementation process in place for JDTCs. The focus of this study was on the JDTC process, the activities and critical components, and the potential resulting wait times. Future research with youth could examine if typical wait time is impacted by the presence and timing of critical components.

The average wait times of the study sites are well beyond the 14-day standard from determining need to referral to treatment (Belenko et al., 2017; Garnick et al., 2009; Knight et al., 2016). These longer wait times pose undue barriers for youth (Grella et al., 2004) as well as challenges for families and JDTC staff. In addition, for youth and families involved in JDTCs with a large variation in the number of days to move from referral to treatment assignment, there is a lack of clarity regarding expected wait time. For JDTC staff, increased wait times increase the burden of monitoring and managing cases and there is limited regularity. For SUD treatment providers, there is less predictability as to the timing of referrals. Overall, the greater wait time potentially increases the risk for subsequent serious substance-related harms among youth identified as needing SUD treatment (DeBeck et al., 2016; National Institutes on Drug Abuse (NIDA), 2014). Improving JDTC processes and wait times could potentially impact a significant number of youth as the largest proportion of adolescents who receive SUD treatment, are referred by the juvenile justice system (NIDA, 2014). Note that these are expected wait times at JDTCs that received training, technical assistance, and funding specifically focused on minimizing barriers to improve treatment access. Thus, even with concerted efforts and supports in place, it is challenging to implement JDTCs with minimal barriers.

Although this study examined only eight sites, it provides an informative view of the similarities and variation across JDTCs and it contributes to the limited literature describing JDTC processes and timing to enrollment and treatment. The processes JDTCs use to enroll youth in their programs and initiate services varies greatly. While there are steps and activities common to all JDTC implementation processes (e.g. screening, connection to evidence-based treatment), the way the process is structured, the number of activities or steps that occur, and the time to enrollment and to treatment is different at each site. While the findings are specific to the eight participating sites, they are informative to JDTCs in general as the Strategies in Practice were the initial framework for all JDTCs in the United States and over 40 JDTCs additionally utilize the Reclaiming Futures model (NDCI and NCJFCJ, 2003; reclaimingfutures.org). Thus, it is not surprising that the JDTCs in this study implemented the identified critical components of JDTCs (Belenko et al., 2017; Models for Change, 2007). Yet, they varied in terms of the particulars of the process by which they screened, assessed, enrolled, and initiated services.

The variations in JDTCs’ processes can be further understood by considering the influence of the contextual, structural, and participant characteristic factors at each site. The diversity of SUD treatment delivery systems within JDTCs provides an illustration. Programs should strive to have access to a range of treatment services to effectively respond to the specific level of SUD treatment needs of their youth (Belenko et al., 2017). Small rural communities, as well as small to mid-size cities, tend to be more limited in SUD treatment provider availability and continuum of care services, such that use of single providers may be the only option. Relationships and collaborations between SUD treatment providers and the courts need to be established to operate a JDTC; however, co-locating treatment at the JDTC requires not only physical space but may necessitate a greater degree of partnership. Two of the eight sites had developed this level of collaboration and hosted external treatment providers on-site at the JDTC. The level of dedicated JDTC staff effort may impact what is possible for contracting with providers and building necessary relationships. As an alternative strategy to providing SUD treatment on-site at the JDTC, one site trained and certified their own staff to provide an evidence-based model. Yet, they referred youth to other local SUD treatment providers as necessary based on level of care needed. Barriers such as SUD treatment provider availability, establishing collaborative relationships between SUD providers and the courts, and ensuring an adequate level of dedicated JDTC staff are important factors for JDTCs to consider and try to address to facilitate engagement in treatment and increase effectiveness of JDTCs.

Examining the number of steps and the timing is a meaningful approach to making improvements in the JDTC implementation process. This is useful for all JDTCs, regardless of whether or not they are implementing the integrated Strategies in Practice and Reclaiming Futures model. Focusing on ways to simplify the process will result in an easier experience for youth and families, JDTC staff, and treatment personnel. Sites adjusted and adapted within their own context and in consideration of their particular community characteristics. Some sites in this study used creative strategies, such as developing an independent pathway to treatment or having treatment initiation occur early in the process so that youth could access SUD treatment as quickly as possible. One JDTC had an independent pathway to treatment that was not dependent on JDTC enrollment. An additional three JDTCs structured their process such that treatment initiation occurred prior to JDTC enrollment. These processes led not only to a shorter possible wait time to treatment overall, but to a shorter time frame to treatment as compared with the wait time to enrollment. Structural factors and/or the local context may get in the way of creating such a pathway to treatment that is not dependent on or can occur prior to JDTC enrollment. However, it is a recommended strategy for sites to consider the identified treatment need regardless of whether the youth are enrolled in the JDTC. If sites assess the possibility of separating the process of treatment assignment and engagement from that of JDTC enrollment in the implementation process and structural factors can be worked out to incorporate this approach (e.g. paying for treatment services), youth would have less wait time to treatment. Some sites also co-located treatment at the JDTC, a strategy that may help facilitate moving through the process and reduce wait times for youth. JDTCs could also consider other ways to reduce complexity in the process by focusing on how to adjust their approach to the steps they currently have in place. For instance, assessing whether there are steps that currently occur across multiple meetings that could be merged, or whether there are steps that consume a particularly long period of time that could be eliminated or changed in order to reduce wait time.

Another consideration for JDTCs is to map out their implementation process using a visual diagram. Illustrating the process in this way can instigate internal team discussions among JDTC staff of ways to make quality improvements and consider alternative approaches, such as a pathway to treatment independent of the JDTC enrollment process. Although our development of the process flows was for evaluation purposes, some sites reported that sharing the information with the research team triggered internal discussions that illuminated their implementation process, as did the process of reviewing, updating, and confirming their process flow with the researchers. Thus, developing a process flow, inclusive of time frames to treatment assignment, is a recommended strategy.

The integrated models of Strategies in Practice and Reclaiming Futures provided the implementation framework for the JDTCs in this study. Sites received training and technical assistance on each individual model as well as integrating the two approaches (Greene et al., 2016; NDCI and NCJFCJ, 2003; reclaimingfutures.org). These activities supported JDTCs in the translation and application of the integrated model to examine and focus on decreasing barriers, including minimizing time to SUD treatment. All JDTCs were able to develop processes that included using evidence-based tools to implement identified the critical components to increase effectiveness of their JDTC. This accomplishment improves process and potential effectiveness. It is recommended that JDTCs utilize available supports such as the Juvenile Drug Treatment Court Guidelines (OJJDP, 2016) to inform the planning and implementation of JDTCs.

The study examined the processes of JDTCs that exerted substantial effort and were focused on minimizing barriers to timing and number of steps involved in the process. Yet, findings indicate that some sites’ processes remained fairly complex and took considerable time for youth to progress from referral to JDTC enrollment and to treatment assignment. Therefore, there is still room for improvement. Future studies should examine the particular structural, contextual, and participant-specific factors at JDTCs that make it difficult to reduce the number of steps and the number of days to SUD treatment. This additional information could help inform ways to simplify the process and decrease wait times. Examination of these factors could also help in differentiating JDTCs program design in urban, suburban, and rural settings to appropriately support youth and families while trying to minimize barriers (e.g. differences in SUD treatment service availability; contextual factors such as accessible public transportation).

Conclusion

The JDTC sites included in the present study implemented best practices to improve their program enrollment and treatment initiation processes. To that end, all sites provided core critical components to identify need, plan, and support youth in accessing treatment. Some sites used innovative strategies to decrease treatment wait time. However, even with a strong integrated model and concerted effort devoted to minimizing barriers to treatment access, youth at some sites potentially faced long wait times and a complex process. Examination of the program entry and treatment referral process can identify areas in need of greater efficiency to reduce wait time from determined need to SUD treatment for justice-involved youth.

Footnotes

Acknowledgements

The authors wish to acknowledge the contributions of the participating JDTCs as well as the research team and partners, University of Arizona-Southwest Institute for Research on Women (SIROW), Carnevale Associates LLC, and Chestnut Health Systems. In addition, the authors are appreciative of support from the Library of Congress – Federal Research Division and the Office of Juvenile Justice and Delinquency Prevention (OJJDP), Office of Justice Programs, US Department of Justice.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: The National Cross-Site Evaluation of Juvenile Drug Courts/Reclaiming Futures was funded by the Office of Juvenile Justice and Delinquency Prevention (OJJDP) through an interagency agreement with the Library of Congress – contract number LCFRD11C0007 and was supported by Grant Number 2013-DC-BX-0081 awarded by OJJDP, Office of Justice Programs, US Department of Justice.

ORCID iD

Alison Greene

Notes

Author biographies

Alison Greene is an assistant professor at Indiana University’s Department of Applied Health Science in the School of Public Health, and a research affiliate at the University of Arizona’s Southwest Institute for Research on Women. Her research focuses on adolescent risk-taking and intervention as she strives to promote healthy behaviors and to mitigate the harmful effects of substance use, trauma, and health disparities among marginalized groups. Dr. Greene has led multiple federally funded research projects focused on harm reduction, sexuality education, HIV prevention, capacity-building, and adolescent treatment.

Dr. Josephine D. Korchmaros is Director of the University of Arizona’s Southwest Institute for Research on Women. Since earning her doctoral degree in Social Psychology with a focus on quantitative research methods in 2003, Dr. Korchmaros has developed, implemented, evaluated, and provided training and technical assistance for multiple grant-funded research projects of importance to underserved populations. Her research has focused on treatment models; reduction of risk behaviors; addressing group-based health disparities; and system and policy improvement in such areas as sexual health, substance use, and justice-involvement.

Raanan G. Kagan is the Chief Operating Officer at Carnevale Associates, LLC. Over a 15+ year career, he has conducted nearly a dozen evaluations of substance use and criminal justice programs, provided extensive training and technical assistance, and overseen policy research for federal agencies, state and local governments, and non-profits. His published work concentrates on evaluating juvenile drug courts, regulatory issues related to marijuana legalization, and substance use prevention.

Erika M. Ostlie is President and Chief Executive Officer of Carnevale Associates, LLC. With over 20 years in the field, she is a subject matter expert in program evaluation, juvenile and adult drug courts, substance use and mental health treatment, and the use of medications to treat opioid use disorder within the criminal justice system. She has led dozens of evaluations and surveys at the nexus of behavioral health and criminal justice across all levels of government.

Monica Davis is an Assistant Research Social Scientist at the University of Arizona’s Southwest Institute for Research on Women. Monica Davis has been working in the human services field since 2000 and has focused most of her work with communities that have been economically/socially underrepresented including youth and adults involved in the justice, behavioral health, and family welfare systems. Monica joined SIROW in 2006 and has served on over 10 state-, privately-, and federally-funded projects and has been involved in multiple national cross-site evaluations.

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