The impact of managed behavioral health care on youth in the juvenile justice system

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The Impact of Managed Behavioral HealthCare on Youth in the Juvenile

Justice SystemJoan Thomas, Greta K. Gourley, and Nancy Mele

The purpose of this study was to describe how managed behavioral healthcare affects youth in the juvenile justice system with behavioral healthdisorders. A multiple case study consisting of 30 semistructured inter-views of officials in the local, state, and federal juvenile justice system wasperformed. The study found that agreement exists among officials thatmanaged behavioral health care acts as a barrier to behavioral health carefor juvenile justice youth. A major conclusion of the study was that therelinquishment of youth custody to the state for the purpose of accessingbehavioral services must cease.© 2004 Elsevier Inc. All rights reserved.

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ETWEEN 1987 AND 1996, the volume ofcases handled by the U.S. juvenile justice

ystem increased 49% (Teplin, 2001). During thisame period, youth in the general population havexperienced increases in behavioral health prob-ems, including both mental health, and substancebuse disorders (Burns, 1999; Cocozza & Skew-ra, 2000). Not surprisingly there have been re-orted increases in behavioral health problems inouth served by the juvenile justice system (Co-ozza & Skewyra, 2000; Teplin, 2001). Currently,here is little available research on the prevalencend types of behavioral health problems amongouth in the juvenile justice system. However,ome general conclusions can be made regardingrevalence rates (Coccoza & Skewyra, 2000;risso, 2000; Teplin, 2000).First, it has been estimated that youth in the

uvenile justice system experience significantlyigher prevalence rates of behavioral disordershan youth in the general population. In fact, it isecognized that the prevalence rates of behavioralisorders in juvenile justice youth is twofoldreater than the prevalence rates in the generalouth population (Coccoza & Skewyra, 2000;risso, 2000; Teplin, 2000).Secondly, it is estimated that approximately one

ut of every five youths in the juvenile justice
ystem has a serious behavioral health disorder
rchives of Psychiatric Nursing, Vol. XVIII, No. 4 (August), 20

esulting in functional impairment that affects fam-ly, school, or community activities (Cocozza &kewyra, 2000). Unfortunately, it is difficult tobtain reliable estimates of the prevalence of seri-us behavioral health disorders among youth be-ause of varying measures and definitions of seri-us behavioral illness. However, if the prevalenceates of serious behavioral disorders for youth inhe general population is approximately 9% to 13%nd researchers have consistently found the prev-lence rate of disorders for youth in the juvenileustice system to be twofold greater, it can reason-bly be expected that the prevalence rate of seriousehavioral health disorders for youth within theuvenile justice system is approximately 18% to6% (Coccozza & Skewyra, 2000; Grisso, 2000;eplin, 2000).Finally, many of the youth in the juvenile justice

ystem with serious behavioral health problemslso experience a substance abuse disorder (Coc-

From the University of Memphis, Memphis, TN andniversity of Tennessee Health Science Center, Nash-ille, TN.Address reprint requests to Joan Thomas, PhD, APRN,

C, 610 Goodman Street, Loewenberg School of Nurs-ng, University of Memphis, Memphis, TN38152. E-mail:thomas1@ memphis.edu

� 2004 Elsevier Inc. All rights reserved.0883-9417/04/1804-0004$30.00/0
doi:10.1016/j.apnu.2004.05.005
13504: pp 135-142

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136 THOMAS, GOURLEY, AND MELE

oza & Skewyra, 2000; Grisso, 2000; Teplin,000). Although researchers are only beginning toocus on youth, it has been estimated that approx-mately 50% of all adolescents receiving behav-oral health care in the general population are du-lly diagnosed with a mental health and substancebuse disorders. It is reasonable to expect thatmong the juvenile justice system population, theates may be even greater (Cocozza & Skewyra,000).While increases in behavioral health disorder

revalence rates have occurred, the behavioralealth treatment system has experienced sweepinghanges as a result of managed behavioral healthare (Stroul, Pires, Armstrong & Meyers, 1998).here is a current trend toward contracting withrivate-sector, for-profit corporations to administeranaged behavioral health benefits. Moreover,

ublicly funded health insurance programs oftense some type of carve-out of general medical carerograms to finance managed behavioral servicesJellinek & Little, 1998). Changes in financing andelivery of behavioral health care have led to un-ertainty regarding access to services for enrolleesf managed behavioral health care programsStroul et al., 1998).

Currently, there is no available research address-ng the impact of managed behavioral health caren juvenile justice youth needing behavioral healthervices. This study was performed as a componentf a larger study examining access to behavioralealth care for juvenile justice youth (Thomas,002; Thomas, 2004). The purpose of this studyas to describe how managed behavioral health

are affects youth in the juvenile justice systemith behavioral health disorders. This research

tudy was performed by way of a multiple casetudy (Yin, 1994) consisting of semi-structurednterviews of officials in the local, state, and fed-ral juvenile justice system.

REVIEW OF LITERATURE

There is no available research examining man-ged behavioral health care’s impact on juvenileustice youth needing behavioral health services.herefore, this review of literature will describetudies that examine the affect of managed behav-oral health care on youth in the general populationith behavioral health disorders.The era of managed care was initiated at a time

hen the mental health community was only be- a

inning to understand the significance of behav-oral health disorders in youth. Under the managedehavioral health care system, the community be-avioral health system has been financially under-unded. The resulting inadequacy of the commu-ity behavioral health system led to a greaterumber of youth becoming acutely ill and enteringsychiatric inpatient facilities in states of crisesWatkins, 1999). This observation was supportedy a comparative descriptive study that investi-ated children’s and adolescent’s cost and utiliza-ion patterns in carve-out plans and compared themith the utilization patterns of adults in these plans.welve-month data on utilization and costs of be-avioral health care from one managed behavioralealth care organization were examined for76,000 youth in three age groups, birth to 5 years,to 12 years, and 13 to 17 years. Data for 434,000

dults enrolled in the same managed behavioralealth plan were also examined. The study foundhat youth from 13 to 17 years of age were morehan twice as likely as adults and about 7 times asikely as children aged 6 to 12 years to use inpa-ient services. Youth from 13 to 17 years of agelso had a slightly higher probability of usingutpatient care than adults, while children aged 6o 12 had lower rates of outpatient care than youth3 to 17 years of age or adults. When examininghe intensity of behavioral health service use, youth3 to 17 years of age were also more likely thandults and other children to have very high costs ofnpatient care. The researchers concluded thatouth ages 13 to 17 may benefit most from thelimination of caps on inpatient mental health careosts covered by insurance (Gresenz, Liu, &turm, 1998).An observational study (Dickey, Normand, Nor-

on, Rupp, & Azeni, 2001) examined changes inreatment patterns and costs of care for youth afterhe implementation of the Massachusetts Medicaidarved-out managed behavioral health plan. Theesearchers studied 16,664 Medicaid beneficiariesnd found that after the introduction of managedehavioral health care, per-youth expendituresere lower, especially for youth with serious emo-

ional disturbances or physical disabilities with lesserious mental illness. Furthermore, continuity ofare also seemed to decline. The study also foundhat the most seriously ill youth were more likelyo be admitted to inpatient psychiatric facilities,
nd when admitted, their length of stay was longer

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137THE IMPACT OF MANAGED BEHAVIORAL HEALTH CARE

han before the initiation of managed behavioralealth care.The advent of TennCare Partners, Tennessee’sanaged behavioral health care program, resulted

n the disintegration of the community behavioralealth system. (Chang et al., 1998). With the frag-entation of the community-based behavioral

ealth safety net, came an increase in the utiliza-ion of intensive inpatient psychiatric services forouth in the general population (Dickey et al.,001). Research suggests that managed behavioralealth care acts as a barrier to youth in the generalopulation accessing behavioral health services.owever, it is not known how managed behavioralealth care affects juvenile justice youth needingehavioral health care.

METHODOLOGY

This study was performed using Yin’s casetudy design and method (Yin, 1994). Yin de-cribes five components of case study researchesign: research question(s), propositions, units ofnalysis, logic linking the data to the propositions,nd interpreting the results.

esearch Questions and Propositions

Guiding this study were the research questionnd propositions derived from the review of liter-ture and the researcher’s experience. The follow-ng research question guided this study: How doesanaged behavioral health care affect youth in the

uvenile justice system with behavioral health dis-rders?According to Yin, propositions direct, “attention

o something that should be examined within thecope of the study” (Yin, 1994, p. 21). The studyas directed by the following four propositions:

1. Managed behavioral health care lacks sub-stance abuse treatment options for juvenilejustice youth.

2. A lack of health insurance parity impedescare for juvenile justice youth needing behav-ioral health services.

3. Family income limits access to behavioralhealth service options.

4. Managed behavioral health care organiza-tions limit access to behavioral health treat-
ment for juvenile justice youth. m
nits of Analysis

In this study, the terms units of analysis andases are synonymous. Three units of analysiscases) were examined. The first unit of analysiscase) was comprised of interview data from 15ocal city and county juvenile court officials whoncounter juvenile justice youth needing mentalealth and substance abuse services. A subset ofhis unit (case) was two behavioral health profes-ionals holding contractual relationships with theocal juvenile justice court. Three officials with thetate juvenile justice agency comprised the secondnit of analysis (case). Ten officials within theederal justice department who deal with issuesffecting juvenile justice youth with mental healthnd substance abuse issues formulated the thirdnit of analysis (case). The three units yielded aotal sample of 30 key informants. All potentialey informants agreed to participate in this study.he offices of the 30 key informants were theettings for this research study. The university’snstitutional Review Board granted this study anxempt status. Written informed consent was ob-ained and key informants gave consent to use theiresponses. The investigator developed a semistruc-ured interview guide for the purpose of collectingnterview data. The researcher’s experience and theeview of literature lead the development of theemistructured interview guide. A panel of experts,hree mental health professionals not selected asey informants, judged the interview guide as pos-essing face validity (Burns and Grove, 2002).

ogic Linking the Data to the Propositions

A qualitative method known as pattern-match-ng was used to link the data to the propositions. Ineeping with Yin’s design and methodology (Yin,994), the study’s propositions guided the analysisf the interview data and the search for thematicontent. This form of data analysis was accom-lished by using pattern-matching, one of severalata analysis techniques Yin recommends. Usinghe pattern-matching analysis method, a predictedattern of events was compared alongside a non-redicted pattern of events. The pattern-matchingata analysis technique allowed the researcher toxamine the data for emerging themes and theirelationships to each proposition.

The researcher’s initial step in the pattern-
atching analysis procedure was to create a list of

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escriptive phrases, or thematic codes, related tohe four propositions. After creating the codes, theext step for the researcher was to classify wordsn the interview data into the thematic codesBurns & Grove, 2001). After the coding of thenterview data was completed, the pattern-match-ng analysis began. With the pattern-matchingnalysis method, two potential a priori patternsased on the propositions were formulated. Thewo patterns used in this study were a “managedehavioral health care impedes access to care”attern and a “managed behavioral health carenables access to care” pattern (see Table 1). Anal-sis of the coded interview data determined whichf the two a priori patterns was validated. With thepriori patterns representing opposing hypotheses,

a “managed behavioral health care impedes accesso care” pattern and a “managed behavioral healthare enables access to care” pattern), the pattern-atching analysis technique became a method of

xamining the coded interview data’s relationshipso each of the four propositions. Each unit ofnalysis (case), the local, state and federal juvenileustice systems, was analyzed to determinehether the interview data validated or discon-rmed each of the propositions (Yin, 1994).

nterviewing Key Informants

The chief administrative officers at the local,tate, and federal juvenile justice agencies wereailed letters seeking permission to perform the

tudy. After permission to perform the study wasranted, the researcher solicited names of potentialey informants by contacting the offices of the

Table 1. Patterns of Managed Behavioral Health

Nonpredicted Pattern: Managed Behavioral Health CareEnables Access to Care

Nonpredicted Propositions:1. Managed behavioral health care has substance

abuse treatment options for juvenile justiceyouth

2. Health insurance parity enables care forjuvenile justice youth needing behavioral healthservices.

3. Family incomes do not limit access tobehavioral health service options.

4. Managed behavioral health care organizationsenable access to behavioral health treatmentfor juvenile justice youth.

hief administrators of the local, state, and federal d

uvenile justice agencies. Each potential key in-ormant received a letter explaining the study.efore beginning the interview, the researcher

equested permission to tape-record the inter-iew session. The tape-recorded interviews wereranscribed; however one key informant declinedo be tape-recorded and in this instance the re-earcher’s notes were word-processed followinghe interview. Each key informant was mailed aranscript of the interview session with a letterrom the researcher asking the key informant toeview the transcript for any additions orhanges. A self-addressed, stamped envelopeas included in the mailing should the key in-

ormant make any corrections to the transcript.he researcher informed the key informants that

he transcript would be considered accurate ifhe transcript were not returned with any modi-cations, additions, or deletions within 10 daysf the post-marked date. Five key informantseturned their transcripts of their interviews withodifications. The requested modifications in-

luded minor wording and/or spelling changesith no substantive modifications indicated.hanges to the transcripts were made before thenalysis of the interview data.

esults of Pattern-Matching Withropositions

The results will address each proposition and theelated viewpoints of local, state, and federal juve-ile justice officials. It should be noted that juve-ile justice officials sometimes use the term “chil-

Affect on Youth in the Juvenile Justice System

Predicted Pattern: Managed Behavioral Health CareImpedes Access to Care

Predicted Propositions:1. Managed behavioral health care lacks substance

abuse treatment options for juvenile justiceyouth.

2. A lack of health insurance parity impedes carefor juvenile justice youth needing behavioralhealth services.

3. Family incomes limits access to behavioralhealth service options.

4. Managed behavioral health care organizationslimit access to behavioral health treatment forjuvenile justice youth.

Care’s

ren” to refer to all juvenile justice youth.

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Proposition 1: Managed behavioral healthare lacks substance abuse treatment optionsor juvenile justice youth.

ocal City and County Juvenile Justicefficials

A local juvenile justice official summarized theiewpoints of fellow local court officials regardinghe lack of substance abuse treatment optionsor juvenile justice youth by stating, “There areone . . . Accessing substance abuse treatment inhis state is a nightmare. In this county [it] isverwhelming. You can not get any [substancebuse treatment].”

tate Juvenile Justice Officials

State juvenile justice officials also supported theiewpoint that managed behavioral health lacksubstance abuse treatment options for juvenile jus-ice youth. A state official discussing TennCareartners, Tennessee’s managed behavioral healthare program, noted:

Substance abuse services for children have contracted sig-nificantly since [the implementation of] TennCare Partnersand managed care in Tennessee. The number of childrengetting substance abuse services is substantially less nowthan it was before. To access the services, they . . . need togo through the block grant route rather than through [the]TennCare [Partners] route, and then may have to wind upin state custody to access services. What it has meantfor . . . juvenile justice is that they focus on the mentalhealth [treatment needs] because rather than the substanceabuse [treatment needs] because it is a little bit easier toaccess mental health services than it is substance abuseservices, but either way it is problematic.

ederal Juvenile Justice Officials

A federal juvenile justice official succinctlyummed the views of federal colleagues by stating,My understanding is that they [substance abusereatment options] may even be more limited thanhe mental health care that’s available to kids.”

Proposition 2: A lack of health insurance par-ty impedes care for juvenile justice youth need-ng behavioral health services.


The viewpoints of local juvenile justice officialsegarding the lack of health insurance parity was
ummarized by a local official who said, “As bad e
s our managed care system is in Tennessee forhysical ailments, it’s practically nonexistent foryouth with] behavioral [health] issues.”


A state juvenile justice official viewed the lackf health insurance parity as leading to parentselinquishing custody of their youth to the state tobtain behavioral health care. A state officialoted, “When children have private insurance thatoesn’t cover mental health adequately or whenhey have exhausted their benefits, sometimes theyind up in state custody to access services.”


A federal juvenile justice official viewed theack of health insurance parity as leading to youthntering the juvenile justice system. The federalfficial stated:

It [lack of parity] actually can contribute to kids ending upin the [juvenile justice] system. . . . Because of managedcare and . . . the lack of parity, kids aren’t getting appro-priate mental health treatment and they may end up inthe [juvenile justice] system. Then once they’re in the[juvenile justice] system the question is how [will man-aged behavioral health care] . . . pay for that treatment,and . . . managed care typically doesn’t want to touch ju-venile justice kids because there’s not much money in it.

Regarding health insurance parity, another federal officialsaid, “I think there is still reluctance on the part of medicalinsurers to treat these as diseases.”

Proposition 3: Family incomes limits access toehavioral health service options.


The proposition that family income limits accesso behavioral health service options was supportedy the interview data of the local juvenile justicefficials. A local official summarized the views ofolleagues by stating:

The vast majority of families we [juvenile court] dealwith . . . don’t have good insurance and. . .the best insur-ance plans don’t have good behavioral coverage . . . [fam-ily income] limits their ability to access the behavioralhealth care . . . and it’s a tragedy. We have kids out therewho need help and they can’t get help because theirparents don’t have the money.


State juvenile justice officials also acknowl-
dged family income limits access to behavioral

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ealth service options. A state official noted, “Theore income you have, the more you can pay for

ervices in the private sector. On the other hand,f . . . income is low enough then you’re TennCarePartners] eligible. Then you . . . have some poten-ial . . . access to services through TennCare [Part-ers].”


A federal official made the following observa-ion regarding family income and access to behav-oral health care, “If you have money, you can buyretty much whatever services you need. The lessoney you have, the less access to services you are

ikely to have.” Another federal official describedow families with higher incomes are able to pre-ent their youth from entering the juvenile justiceystem. This federal official said:

The more income you have, the better able you’re going tobe [to] access [services], especially through private pro-viders . . . and a number of parents I know do that. Theyget kids in private treatment-type settings somewhere andsome are extremely expensive . . . it’s their [parents] wayof ensuring that their kids aren’t going to fall formally intothe juvenile justice system.

Proposition 4: Managed behavioral healthare organizations limit access to behavioralealth treatment for juvenile justice youth.


A mental health professional affiliated with theocal juvenile justice system described managedehavioral health care as resulting in the, “denial ofccess [and] the decrease in number of facilities.. . In recent years the range of facilities has de-reased. Compensation in the market place hasecreased. Competition among providers has de-reased.” When asked about managed behavioralealth care limiting access to behavioral healthreatment for juvenile justice youth, a local officialaid that limits on the access to care occurred, “allay every day at multiple levels. In home treatmentecause they haven’t had enough contact withhoever. Residential care because they aren’t sick

nough or residential care because they’re too sick.ultitude of reasons.”


State juvenile justice officials also supported the
priori proposition that managed behavioral health j
are organizations limit access to behavioral healthreatment for juvenile justice youth. A state officialade the following observation, noting that youth

ose TennCare eligibility when in locked facilitiessecure placements):

What the managed care organizations are really doing ismanaging cost instead of managing care. When childrenare in secure placements they are not eligible for Tenn-Care . . . If they are in a state training school or detentioncenters, they are not eligible for TennCare under federallaw.


A federal official noted that the structure ofanaged care is not suited for the treatment of

ong-term behavioral health disorders. This federalfficial said: “Managed care has limits. It is set upo that you can get in and get out. It is not set upor long term care.” Another federal official de-cribed the loss of Medicaid eligibility that oc-urred when youth enter a secure facility. Theederal official noted:

Kids who enter residential facilities, secure corrections,and detention, they lose their eligibility for Medicaid . . .Especially for the poor kids and the uninsured kids, Med-icaid has been their only source of financing for servicesand now they have lost that [Medicaid]. So . . . now thejuvenile justice system has to pick up these costs and they[the juvenile justice system] don’t have the resources ei-ther.

The same federal official also addressed man-ged care’s inability to provide the preventive caret originally promised. The federal official said:

When managed care first started . . . one of its strengths. . . was that they [managed care] really placed a lot ofemphasis on preventive care . . . and certainly they wereweaker in the mental health area than in [the] physical[care] but there was still this emphasis on preventionwhich you didn’t get with standard insurance. If they hadfollowed through with that,[it] would have been quitehelpful because disorders would have been identified ear-lier, treatment would have been provided earlier, andmaybe some of these kids could have been kept out of the[juvenile justice] system.

RESULTS

All four predicted propositions were validatedy the key informants. Agreement exists withinnd among local, state, and federal juvenile justicefficials that managed behavioral health care actss a barrier to behavioral health care for juvenile
ustice youth.

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nterpreting the Results

Key informants reported that the lack of sub-tance abuse treatment services is a major problemithin managed behavioral health care. Parents

elinquishing custody of their youth to the stateas noted as a means of obtaining substance abuse

ervices. The policy implication is two-fold. First,he community mental health treatment systemsnd inpatient treatment facilities must expand theirervice capacity to treat youth with substancebuse disorders. Second, the relinquishment ofouth custody to the state for the purpose of ac-essing substance abuse services must cease. Theeneral Accounting Office (GAO) reported that in001, parents in 19 states placed 12,700 youth inuvenile justice and/or state welfare agencies toccess behavioral health treatment for their youth.oreover, that estimate is considered low because

1 states did not respond to the GAO survey (Ba-elon Center for Mental Health Law, n.d.). Theeeping Families Together Act (S. 1704/H. R.243), introduced in Congress on October 2, 2003,s bipartisan federal legislation designed to endustody relinquishment. With the successful pas-age of this legislation, parents will no longer beorced to relinquish custody of their youth to se-ure necessary mental health and substance abusereatment (National Alliance for the Mentally Ill,003).The lack of parity between behavioral health

isorders and general medical conditions was iden-ified as an additional barrier to juvenile justiceouth accessing behavioral health care. The Na-ional Institute of Mental Health (1999) reports thatnequities in public and private insurance coverageor behavioral health and general medical care arehe products of stigma and discrimination againsthose with mental health and/or substance abuseisorders. The policy recommendation calls forassage of federal legislation that would requirequal health insurance coverage for mental healthisorders and physical disorders.Key informants reported that affluent families

an prevent their youth from formally entering theuvenile justice system by providing private psy-hiatric care. In effect, this situation has resulted intwo tier system for youth with behavioral health

isorders: those able to afford the long-term pri-ate treatment systems and those with limited
eans who enter the juvenile justice system due to
he inability to afford behavioral health care. Theolicy implication calls for an increase in the ser-ice capacity of community behavioral health ser-ices to prevent youth from entering the juvenileustice system.

A limited family income was viewed as a barriero the access of behavioral health services for ju-enile justice youth. Family income appears highlyorrelated with insurance status. The fully coveredave the highest incomes while the uninsured havehe lowest income (Paulin & Dietz, 1995). A lackf health insurance is associated with reduced ac-ess to health care, a lower prevalence of recom-ended preventive services, potentially avoidable

ospitalizations, and a subsequently higher mortal-ty independent of other risk factors (Barton,998). The policy implication is for managed be-avioral health care to provide youth with behav-oral health services, regardless of family income.

It was noted by key informants that the place-ent of juvenile justice youth in secure facilities,

uch as residential treatment and secure correc-ions, results in the loss of Medicaid eligibility.

ithout Medicaid or Medicaid-type programs, itay be difficult for youth to access behavioral

ealth treatment. The policy recommendation ishat youth in secure facilities not lose eligibility for

edicaid.The interview data also indicated that preventive

ehavioral health care was an early promise ofanaged behavioral health care that never came to

ruition. The policy implication is that managedehavioral health care return to its focus on pre-entive services.

OTHER RECOMMENDATIONS

1. The community mental health service capac-ity requires expansion to meet the behavioralhealth needs of youth in the juvenile justicesystem. Further studies are required to deter-mine how to best enhance the service capac-ity of the community mental health system.

2. The ineligibility of youth in secure facilitiesto receive Medicaid benefits requires exami-nation. How effectively these youth are re-ceiving mental and physical health care with-out the benefit of Medicaid needs study.

3. Managed behavioral health plans lack pre-ventive care for youth. Research is needed todetermine how preventive services can be
effectively provided by managed behavioral

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health plans. Furthermore, comparing the be-havioral health expenditures of youth whoreceived preventive services with those whodid not receive preventive services is a rec-ommended study.

REFERENCES

arton, P.L. (1998). Understanding the U. S. Health System.Chicago: Health Administration Press.

azelon Center for Mental Health Law. (n.d.). Keeping familiestogether act. Retreived November 5, 2003, from http://www.bazelon.org/issues/children/kfta_summary.pdf

urns, B.J. (1999). A call for a mental health services researchagenda for youth with serious emotional disturbance.Mental Health Services Research, 1, 5-20.

urns, N., & Grove, S.L. (2002). The practice of nursingresearch: Conduct, critique, and utilization (4th ed.).Philadelphia: W. B. Saunders Company.

hang, C.F., Kiser, L.J., Bailey, J.E., Martins, M., Gibson,W.C., Schaberg, K.A., Mirvis, D.M., & Applegate,W.B. (1996). Tennessee’s failed managed care programfor mental health and substance abuse services. Journalof the American Medical Association, 279, 864-869.

ocozza, J., & Skewyra, K. (2000). Youth with mental healthdisorders: issues and emerging responses [Electronicversion]. Juvenile Justice. 2000, 7, 3-13.

ickey, B., Normand, S.L., Norton, E.C., Rupp, A., & Azeni,H. (2001). Managed care and children’s behavioralhealth services in Massachusetts. Psychiatric Services,52, 183-188.

resenz, C.R., Liu, X., & Sturm, R. (1998). Managed behav-ioral health services for children under carve-out con-tracts. Psychiatric Services, 49, 1054-8.

risso, T. (2000). Law and psychiatry: The changing face of
juvenile justice. Psychiatric Services, 51, 425-6.
ellinek, M., & Little, M. (1998). Supporting child psychiatricservices using current managed care approaches. Ar-chives of Pediatric and Adolescent Medicine, 152,321-6.

ational Alliance for the Mentally Ill. (n.d.). Policy advocacyaction: Support federal legislation to help end custodyrelinquishment. Retrieved October 29, 2003, fromhttp://www.nami.org

atonal Institute of Mental Health. (1999). Mental health: Areport of the Surgeon General. Rockville, MD: Author.

aulin, G.D., & Dietz, E.M. (1995). Health insurance coverage.Monthly Labor Review, August, 13-23.

troul, B.A., Pires, S.A., Armstong, M.I., & Meyers, J.C.(1998). The impact of managed care on mental healthservices for children and their families. Future Child, 8,119-133.

eplin, L. (2000). Held without help: Youth and adults withmental illnesses in jail. NAMI Advocate, 22, 21-2.

eplin, L.A. (2001). Assessing alcohol, drug, and mental dis-orders in juvenile detainees. Retrieved March 23, 2001,from National Criminal Justice Reference Center Website: http://www.ncjrs.org/txtfiles1/ojjdp/fs200102.txt

homas, J.D. (2002). Access to behavioral health services forchildren within the juvenile justice system: Enablingand barrier factors (Doctoral dissertation, University ofTennessee Center for the Health Sciences, 2002). Dis-sertation Abstracts International, 63, 04B.

homas, J.D., Gourley, G.K., & Mele, N.C. (2004). Screeningyouth in the juvenile justice system for behavioral healthdisorders. Journal of Psychosocial Nursing and MentalHealth Services, 42, 28-36.

atkins, J. (1999). Commitment to care: Managed care andchild incarceration. Journal of Psychosocial Nursingand Mental Health Services, 37, 24-29.

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