Literature Reivew

The Behavioral Health Needs of First-Time Offending Justice-Involved Youth: Substance Use, Sexual Risk, and Mental Health

Marina Tolou-Shamsa,b, Larry K. Brownc,d, Brandon D. L. Marshalle , Emily Dauriaa,b, Daphne Koinis-Mitchellc,d, Kathleen Kempc,d and Brittney Poindexterc

aUniversity of California, San Francisco, San Francisco, CA, USA & Weill Institute for Neurosciences; bZuckerberg San Francisco General Hospital, San Francisco, CA, USA & Weill Institute for Neurosciences; cWarren Alpert Medical School of Brown University, Providence, RI, USA; dRhode Island Hospital, Providence, RI, USA; eBrown University School of Public Health, Providence, RI, USA

ABSTRACT This study examines substance use, emotional/behavioral symptoms, and sexual risk among first-time offending, court-involved, non-incarcerated (FTO-CINI) youth. Youth and caregivers (n¼ 423) completed tablet-based assessments. By the time of first justice contact (average 14.5-years-old), 49% used substances, 40% were sexually active and 33% reported both. Youth with co-occurring substance use and sexual risk had more emotional/behavioral symptoms; youth with delinquent offenses and females had greater co-occurring risk. Time of first offense is a critical period to intervene upon high rates of mental health need for those with co-occurring substance use and sexual risk to prevent poor health and legal outcomes.

KEYWORDS adolescent; HIV/STIs; juvenile justice; mental health; sexual risk; substance use

Introduction

Estimates indicate that over 2 million youth under the age of 18 are arrested annually (Puzzanchera, 2009) and 31 million are under juvenile court jurisdiction (Puzzanchera, 2011). Involvement in the juvenile justice system (JJS) is associated with a variety of adverse health out- comes, such as substance use (Dembo et al., 2007), psychiatric symptoms (Teplin et al., 2002), sexual risk behavior (Elkington et al., 2008; Teplin et al., 2003) and sexually transmitted infections (STIs) (Belenko et al., 2008). Most past research has focused on the high-risk subsample of incarcerated juvenile offenders but little is known about the nearly 80% (Furdella & Puzzanchera, 2015) of non-detained youth. Examining the rates of drug use, HIV/STI risk behavior, and emotional/behavioral symptoms among juveniles at their earliest point of juvenile court contact will critically inform the develop- ment and implementation of early public health screening, prevention, and treatment interventions.

Studies involving juvenile detainee samples document high rates of drug and alcohol use, psychiatric symptoms, and HIV/STI risk behav- iors (Abram et al., 2003; McClelland et al., 2004; Romero et al., 2007; Teplin et al., 2002). Nearly half of juvenile detainees have one or more sub- stance use disorders (Mauricio et al., 2009). Estimates of diagnosable psychiatric disorders of detained juvenile offenders range between 50 and 70% (Abram et al., 2003; Fazel et al., 2008; Teplin et al., 2002; Wasserman et al., 2004). The likelihood of acquiring HIV/STIs is also substan- tially increased among justice-involved youth due to high rates of sexual activity, and problems are compounded when these behaviors co-occur (Conrad et al., 2017; Tolou-Shams et al., 2019). Mental health problems are linked to crimino- genic risk and when paired with substance use, contribute to poor outcomes (Doherty et al., 2008; Elkington et al., 2008; Schubert et al., 2011). Studies of juvenile detainees with co- occurring substance use and psychiatric concerns demonstrate that most are sexually active and

CONTACT Marina Tolou-Shams Marina.Tolou-Shams@ucsf.edu University of California, San Francisco, Division of Infant Child and Adolescent Psychiatry, Zuckerberg San Francisco General Hospital, 1001 Potrero Ave., San Francisco, CA 94110, USA. � 2020 Taylor & Francis Group, LLC

JOURNAL OF CHILD & ADOLESCENT SUBSTANCE ABUSE 2019, VOL. 28, NO. 5, 291–303 https://doi.org/10.1080/1067828X.2020.1774023

more than half have had multiple partners and unprotected sex during the past month (Teplin et al., 2005, 2003).

The current study and theoretical framework

Project EPICC (Epidemiological Project Involving Children in the Court) is a 2-year longitudinal study of male and female first-time offending, court-involved, non-incarcerated (FTO-CINI) youth assessed within a month of initial juvenile court contact and uses ecodevelopmental theory as guiding framework, which has been widely used in the HIV prevention literature and with substance-using, delinquent youth (Szapocznik & Coatsworth, 1999). Ecodevelopmental theory (Szapocznik & Coatsworth, 1999) extends Bronfenbrenner’s ecological model of human development (i.e., micro-, meso-, exo- and macro-system influences on behavior; Bronfenb renner, 1986) by providing a framework to understand risk and protective factors for adoles- cent substance use, psychiatric symptoms, and HIV/STI risk behavior while accounting for the role of different contexts and developmen- tal processes.

Prior community-based study pathway model studies, such as those within the Office of Juvenile Justice and Delinquency Prevention’s program of Research on Causes and Correlates of Delinquency (e.g. Pittsburgh Youth Study, the Denver Study; Loeber & Hay, 1997; Loeber et al., 1997; Loeber et al., 1993), help identify “at-risk” youth to develop primary prevention interven- tions prior to the onset of delinquency; these youth may or may not ever come into contact with the justice system. Tertiary prevention stud- ies, such as the Pathways to Desistance Study (Mulvey et al., 2004), provide data on factors that may reduce recidivism among the most violent and dangerous of juvenile offenders and are not designed to capture juvenile risk behavior trajec- tories prior to their severe and violent criminal offenses. Teplin and colleagues’ seminal juvenile detainee studies have highlighted the importance of studying HIV/STI risk behavior among juven- ile offenders to prevent infection into adulthood and focus on detention and community reentry (Teplin et al., 2005, 2003). To date, there is one

other study, aside from Project EPICC, with pub- lished data that examines similar relationships and trajectories among FTO offenders, but differs from Project EPICC by only including FTO male offenders arrested for a range of low-level offenses and does not include a focus on HIV/ STI risk behavior (Fine et al., 2016, 2017). To fill an essential gap in the field, Project EPICC uses ecodevelopmental theory to achieve two primary aims: (1) examining (from the caregiver and juvenile perspectives) initial risk behavior profiles subsequent to the first point of contact with the juvenile justice system and (2) identifying multi- level factors associated with those initial profiles to inform intervention development in a setting that lacks evidence-based programing (Schwalbe et al., 2012). Distinct from other studies, Project EPICC focuses on a secondary prevention per- spective by measuring youth’s risk behaviors from the time of very first court contact, which may serve as a “turning point” for substance use and co-occurring risk behaviors (Hussong et al., 2008). This information is urgently needed given that most diversion programs for CINI youth do not improve behavioral health outcomes or reduce recidivism (Schwalbe et al., 2012).

The current analysis focuses on the first ecode- velopmental theory layer, the microsystem, that encompasses the youth (e.g., their emotional and behavioral health functioning) and their relation- ships within immediate social contexts, including peers and family. We sought to fill a gap in the literature by examining youths’ initial risk behav- ior profiles and intersecting risks. Literature sup- ports the importance of assessment and intervention for the sexual and reproductive health needs of justice-involved youth (Tam et al., 2019), but only a few studies of justice- involved youth have incorporated measurement of substance use and HIV risk (Tolou-Shams et al., 2019). Of those studies, rates of co- occurrence of these behaviors among justice- involved youth are high (e.g., Abram et al., 2017; Tolou-Shams et al., 2007; Tolou-Shams et al., 2010; Tolou-Shams et al., 2017). Yet, to our knowledge, there are no published studies to inform the field as to whether and how co-occur- ring substance use and HIV/STI risk behaviors may potentiate the need for mental health

292 M. TOLOU-SHAMS ET AL.

intervention at time of first offense. Understanding how these behavioral risk factors co-occur to promote or protect against mental health needs at this early justice contact can inform the development of resource-efficient, multi-component integrated interventions to potentially offset poor public health and legal outcomes for these underserved youth.

Hypotheses

This paper presents baseline Project EPICC data collected between June 2014 and July 2016 from 423 FTO-CINI youth and involved caregiver dyads, with specific emphasis on demographics and youth risk behaviors (e.g., substance use and HIV/STI risk) and mental health needs. The mental health focus includes emotional symptoms, such as trauma and affects dysregulation, and behavioral symptoms such as to conduct and delinquency because these emotional and behavioral symptoms have been most commonly studied in other samples of just- ice-involved youth and tied to health risk behaviors such as substance use and risky sexual activity (McReynolds & Wasserman, 2011; Tolou-Shams et al., 2008; Tolou-Shams et al., 2011; Tossone et al., 2018). We hypothesized that FTO-CINI youth would report higher rates of drug and alco- hol use, sexual (HIV/STI) risk behaviors, and emo- tional/behavioral symptoms than those published among general adolescent and community-based delinquency samples, but below that reported on detained youth. Among FTO-CINI youth, we hypothesized that those with co-occurring substance use and sexual risk behaviors would report higher rates of recent emotional/behavioral symptoms than all others. We also hypothesized that FTO-CINI girls would show heightened risk on all outcomes relative to FTO-CINI boys consistent with prior lit- erature demonstrating unique, gender-specific needs for justice-involved girls (Conrad et al., 2017; Dembo et al., 2017; Holzer et al., 2018).

Methods

Sampling and recruitment procedures

Participants A total of 423 FTO-CINI youth and caregiver dyads were enrolled. Youth, ages 12–18, and

caregivers were approached for study participa- tion if the juvenile had an open status and/or delinquent petition filed through a large Family Court in the Northeastern region of the United States. Status petitions were defined as those filed for an offense that would typically not be consid- ered illegal if an adult committed the same offense (e.g., truancy, alcohol use, curfew). Delinquency petitions were defined as those filed for offenses that are considered illicit regardless of age (e.g., breaking and entering, assault). Of 423 dyads, 194 (46%) had a first-time status offense (FTO-status) and 229 (54%) had a first-time delinquent offense (FTO-delinquent). FTO-CINI girls with a delinquent FTO were oversampled to have sufficient power to conduct male–female comparisons.

Exclusion criteria Study exclusion criteria included being a repeat offender (at time of initial recruitment), outside of the 12 to 18-year-old age range at the initial court intake appointment, juvenile or caregiver cognitive impairment that would preclude the ability to complete assessment, and/or caregiver unable or unwilling to participate or had not lived with the youth for at least the prior 6 months.

Retention and assessment procedures

All caregivers of FTO-CINI youth were sent a study flyer along with the standard court appointment date notification letter and then approached in the court setting for study partici- pation. Interested youth and families were screened for eligibility in a private space at the court and assent and consent was obtained off- site (home, private community space, or research lab), when appropriate. To enhance engagement and retention, we used a variety of strategies including: obtaining a locator form in which youth and caregiver provided contact info of up to five individuals who will always know where they are and could help us locate them in the future; scheduling subsequent appointments at the time of the prior assessment; sending out weekly reminder emails, texts (and making phone calls as needed if no response to texts) to remind youth and caregivers of appointments and make

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any relevant changes to locator information; obtaining releases of information from youth and caregivers for permission to contact the court to help us locate them; reminding youth and care- givers of home or community-based visit options for assessment; sending birthday and holiday cards from the project, in order to enhance recall and familiarity with the project; mail or drop off to hard-to-reach families’ homes a personalized letter from study staff, that would include study contact information and the scheduled follow-up appointment (if applicable). We also provided project pens and other items with the project logo and name to youth, caregivers, and court stakeholders. These items served as reminders of participation in the study for both families and system stakeholders. Lastly, we set up a profile on the social networks, Facebook, Twitter, and Instagram only to notify participants about their appointments. We did not “friend” or “follow” any of the participants or accept the “friending” of participants. The page contained the project’s contact information for participants who needed to schedule appointments but were not reachable by text, phone, or in-person. Our page did not reveal the nature of the study but was recogniz- able to participants by its logo. The Principal Investigator’s university and collaborating sites’ Institutional Review Boards approved all recruit- ment and study procedures.

Youth and caregivers completed separate assessments (�2 h per assessment) using tablet- based, audio-assisted computerized assessment (ACASI) in English and Spanish (parent-only). ACASI has been shown to improve the reliability of self-report (Romer et al., 1997), which is easy to administer and is time and cost-effective. The majority of assessments were conducted in pri- vate space the participants’ homes, at the research offices, the courthouse, and on occasion, at other community locations (e.g., library or coffee shop). Caregivers and youth were separated for the administration when it was logistically pos- sible—and when not possible (e.g., due to being in a small home, in a single room coffee shop), they were positioned at opposite ends of the room so that neither would be directly distracted by the other’s presence or able to see any responses on the tablet.

Measures

Self-reported baseline measures assessed basic demographics, school and treatment history along with lifetime and recent (past 120 days) substance use, sexual risk behaviors, and emotional/behav- ioral symptoms.

Youth and caregiver demographics, youth aca- demic, and treatment history Demographics included, but were not limited to, age, gender, race, ethnicity, and sexual orientation. The Arrest and Treatment History (ATH) Questionnaire (developed for this study) queried mental health and substance use treatment history, treatment needs, and utilization, a state agency (e.g., out-of-home placement) and legal involve- ment. Self-report data were also collected on cur- rent school status, grades, history of repeated grades, and receipt of special education services (e.g., individualized education plan [IEP]).

Youth substance use and sexual (HIV/STI) risk behaviors The Adolescent Risk Behavior Assessment (ARBA; Donenberg et al., 2001) assesses the type of sex- ual behavior (i.e., oral, vaginal or anal), frequency of condom use and intercourse (e.g., condom use at last sexual intercourse), age of sexual debut, number of sex partners, and substance use by self and/or partner preceding and/or during sex. This measure also included self-reported (lifetime and past 120 days) nicotine, alcohol, marijuana, and other drug use (e.g., cocaine, prescription drugs) with respect to quantity, frequency, and other past use descriptives (e.g., age of onset).

Youth emotional and behavioral symptoms Emotional symptoms included: (1) the National Stressful Events Survey PTSD Short Scale (NSESSS; ) that corresponds with DSM-V diag- nostic criteria for posttraumatic stress disorder (PTSD). It is a brief, 9-item measure of posttrau- matic stress symptoms over the past 7 days for those youth who endorse a particularly stressful event/experience. Youth report the extent to which they have been bothered by problems the stressful event (1¼ not at all bothered to 5¼ extremely bothered) suggesting a degree of

294 M. TOLOU-SHAMS ET AL.

traumatic stress severity. Average scores range from 0–4; and (2) the Affect Dysregulation Scale (ADS), a six-item instrument utilized and vali- dated in our prior studies of youth in psychiatric care to assess youth’s frequency of difficulties with affect regulation (Brown et al., 2012). The youth responded on a 4-point scale (1¼ not at all to 4¼ often) and summed scores ranged from 6–24; higher scores indicate greater affect dysre- gulation (alpha ¼ 0.79). Behavioral symptoms include: (1) the National Youth Survey Self- Reported Delinquency (NYS-SRD; Elliott et al., 1985) scale, a well-validated, 40-item, self-report measure of delinquent acts (e.g., larceny, fighting, selling drugs). Scores were used from the General Delinquency subscale ranging from 0–23 with higher scores indicating a greater number of delinquent acts (in the past 120 days) endorsed1

and (2) two yes/no items concerning gang involvement from the National Youth Risk Behavior Survey (YRBS; Eaton et al., 2012).

Analysis plan

Descriptive statistics were calculated for all varia- bles of interest and scales. Given our hypotheses related to poorer behavioral health outcomes associated with cumulative and co-occurring risk, behavioral risk indices were developed for sub- stance use and sexual risk behaviors as follows:

Substance use risk index Variables used to create the substance use risk index included: ever used alcohol ¼ 1; recent (past 120 days) alcohol use ¼ 1; ever used mari- juana ¼ 1; recent (past 120 days) marijuana use ¼ 1; ever used other illicit drugs ¼ 1; recent (past 120 days) other illicit drug use ¼ 1. Scores ranged from 0–6, with scores of 0 indicating no lifetime alcohol, marijuana or drug (i.e., sub- stance) use, a score of 1 indicating less substance use/risk, and 6 indicating maximum substance use/risk.

Sexual (HIV/STI) risk behavior index Variables used to create the sexual risk index included: ever sexually active ¼ 1; recently (past 120 days) sexually active ¼ 1; no condom use at last sex ¼ 1; self or partner substance use during

sex ¼ 1. Scores ranged from 0–4, with a score of 0 indicating no lifetime sexual activity, 1 indicat- ing less sexual behavior risk, and 4 indicating maximum sexual behavior risk.

Risk indices comparison Descriptive statistics on each index were exam- ined and each index was then dichotomized into 0 versus any risk. Risk indices were defined as “No risk” (neither substance use nor sexual risk behavior); “single risk” (either substance use or sexual risk behavior) and “co-occurring risk” (substance use and sexual risk behavior). A Venn diagram (Figure 1) presents the extent of overlap between participants reporting both sexual and substance use-related risks. The overlapping group was categorized as having a “co-occurring risk.” Sociodemographic differences between the “co-occurring risk” group, the sub-group report- ing “single risk” and the “no risk” groups were examined using Chi-square tests. The interrela- tionship of risk indices and their association with the third primary study outcome of emotional/ behavioral symptoms (ADS, NSESSS, NYS) was examined using multivariate analyses of covari- ance (MANCOVA). All MANCOVA analyses were adjusted for age, sex, and FTO status (i.e., an indicator of FTO severity). For each outcome of interest, we conducted post-hoc tests (i.e., to determine statistical significance between groups) if the omnibus one-way MANCOVA test statistic was significant at p< 0.05. All statistical analyses were conducted in SAS version 9.3, and all p-values are two-sided.

Results

Demographics, education, and treatment/agency involvement

FTO-CINI youth were an average of 14.6 years (SD ¼ 1.5), and 46% were female (see Table 1). Racial and ethnic minority CINI youth were dis- proportionately represented in the system relative to regional census figures. Youth and caregivers reported high rates of youth past psychiatric his- tory (including diagnosis, medications, and hospi- talization). Caregivers/families of FTO-CINI youth was predominantly female, birth parents

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with an average age of 41 years. Caregivers’ racial and ethnic self-identification largely mirrored that of their youth. Caregivers were predomin- antly single parents, low-income, and receiving public assistance (Table 1).

Primary outcomes (lifetime and past 120 days)

Substance use Twenty-one percent of CINI youth reported life- time cigarette use and early age of onset (13- years-old; Table 2). Over half of youth lifetime smokers reported recent, frequent smoking (used 40 out of past 120 days). Alcohol use was reported by a third of youth (average age of onset of 14 years) and two-thirds of those youth reported recent, but on average infrequent, alco- hol use (used 6 out of past 120 days). Marijuana use was most prevalent with almost 50% of youth endorsing lifetime use and the average age of onset of 13 years. Of those youth, 80% endorsed recent and frequent use (used 38 out of the past 120 days). Thirteen percent of FTO-CINI youth reported other lifetime drug use.

Sexual (HIV/STI) risk behaviors Approximately 40% of FTO-CINI youth reported lifetime sexual activity (Table 2). Most sexually active CINI youth reported vaginal (86%) and oral (81%) sex. Of youth ever sexually active, 74% reported recent sexual activity, 63% reported condom use at last sex and 49% reported recent

substance use (either themselves and/or their partner) during sex. Sexually active CINI youth reported having a median of 2 (IQR: 1–5) life- time and 1 (IQR: 1–3) recent sexual partner. The history of pregnancy and STIs was low (1 and 2%, respectively).

Emotional symptoms Juveniles reported an average ADS score of 12.8 (SD¼ 4.4; range 6–24; Table 2). Over three-quar- ters (79%) of youth endorsed trauma exposure with an average traumatic stress severity (NSESSS) score of 1.2 (SD¼ 1.1; range 0–4).

Behavioral symptoms On average, the youth in this sample reported a low score on the NYS delinquency scale (M¼ 2.1; SD¼ 2.6). Twenty-seven youth (6.4%; predomin- antly male) reported any history of gang involvement.

Bivariate gender analyses

Male and female CINI youth differed on certain demographics, risk behaviors, and emotional and behavioral symptoms (Table 2). In terms of pri- mary outcomes of interest, males reported signifi- cantly more condom use at last sex than females. Females reported overall higher rates of nicotine use and marijuana use than males with the caveat that males who were recent smokers endorsed more frequent recent use and differences in

Figure 1. Venn diagram of co-occurring substance use and sexual risk (n¼ 423). 174 (41.1%) participants reported no sexual or substance use risk and are not shown in the Venn diagram. There were 82 youth reporting only substance use risk and 26 youth reporting only sexual risk.

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marijuana use were at the trend level of signifi- cance (p¼ 0.06). There were no gender differen- ces in alcohol use. Lastly, females reported significantly greater effect dysregulation than boys; there were no other statistically significant gender differences on measures of emotional or behavioral symptoms.

Risk indices

Substance use index Scores ranged from 0–6; 47% of youth (n¼ 200) fell in the “no substance use risk” category, 8%

(n¼ 35) received a score of 1, 15% (n¼ 62) received a score of 2, 9% (n¼ 39) received a score of 3, 12% (n¼ 51) received a score of 4, 5% (n¼ 20) received a score of 5 and 4% (n¼ 16) received a score of 6.

Sexual risk index Scores ranged from 0–3 with 61% percent of youth (n¼ 256) with scores of 0 or “no risk” cat- egory; 22% (n¼ 95) received a score of 1, 12% (n¼ 51) a score of 2; and 5% (n¼ 21) a score of 3 (no youth had the maximum score of 4).

Table 1. FTO-CINI youth demographics, education, and treatment/agency involvement (n¼ 423). Total (n¼ 423) Male (n¼ 226) Female (n¼ 193)

Test statisticMean (SD) or n (%)

Demographics Age 14.55 (1.53) 14.62 (1.51) 14.49 (1.55) 0.88 Gender (% female) 193 (45.63%) Racea

Caucasian 189 (44.68%) 102 (46.36%) 85 (45.21%) 0.05 Black, African-American, or Haitian 74 (17.49%) 37 (16.82%) 37 (19.68%) 0.56 American Indian 39 (9.22%) 18 (8.18%) 21 (11.17%) 1.05 Asianb 5 (1.18%) 4 (1.82%) 1 (0.53%) 0.38 Native Hawaiian or other Pacific Islander 6 (1.42%) 6 (2.73%) 5.20� Multi-racial 71 (16.78%) 43 (19.55%) 28 (14.89%) 1.52 Other 79 (18.68%) 34 (15.45%) 44 (23.40%) 1.39

Hispanic or Latinx 181 (43.61%) 100 (45.45%) 79 (41.36%) 0.70 Ethnic origin 1.52 Puerto Rican 94/181 (51.93%) 54 (54.00%) 39 (51.32%) Dominican 55/181 (30.39%) 33 (33.00%) 22 (28.95%) Other Latinx 29/181 (16.02%) 13 (13.00%) 15 (19.74%)

Sexual orientation (% non-heterosexual) 81 (19.15%) 13 (5.91%) 65 (34.21%) 53.01��� Caregiver relationship to youth (% female birth parent) 344 (81.32%) 280 (79.65%) 160 (82.90%) 0.72 Number of children <18 years living in the home 2.61 (1.67) 2.63 (1.50) 2.60 (1.85) 0.19 Presence of another parent/caregiver in the home 182 (43.03%) 98 (43.36%) 84 (43.52%) 0.001 Primary caregiver currently employed 220 (52.01%) 119 (52.65%) 98 (50.78%) 0.15 Receive public assistance (current) 274 (64.78%) 143 (63.56%) 129 (66.84%) 0.48 Educationb p¼ 0.0036 Middle school 163 (38.53%) 88 (38.94%) 73 (37.82%) High school 256 (60.52%) 138 (61.06%) 116 (60.10%) Not currently in school 4 (0.95%) 4 (2.07%)

Ever repeated a grade in school 138 (32.62%) 87 (38.50%) 50 (25.91%) 7.58��� Ever received special education services 143 (33.81%) 94 (41.78%) 46 (24.08%) 14.49��� Ever had individualized education plan 171 (40.43%) 107 (47.56%) 61 (31.94%) 10.47��� Ever been expelled from school 32 (7.57%) 18 (8.00%) 14 (7.33%) 0.07 Ever been suspended from school 259 (61.67%) 149 (66.22%) 108 (56.54%) 4.10� Psychiatric and substance use treatment history Psychiatric diagnosis, lifetime 126 (29.79%) 65 (28.89%) 60 (31.41%) 0.31 Prescribed psychiatric medications, lifetime 130 (30.73%) 66 (29.33%) 64 (33.86%) 0.98 Prescribed psychiatric medications, past 4 months 91/130 (70.00%) 47/66 (71.21%) 44/64 (68.75%) 0.09

Psychiatric inpatient hospitalization, lifetime 71 (16.78%) 34 (15.04%) 36 (18.95%) 1.12 Day hospital or partial hospitalization, lifetime 63 (14.89%) 31 (13.72%) 30 (15.87%) 0.38 Day hospital or partial hospitalization, past 4 months 11/63 (17.46%) 5 (16.13%) 6 (20.00%) 0.15 Visited community outpatient drug or alcohol

clinic, lifetimeb 4 (0.95%) 2 (0.88%) 2 (1.05%) p¼ 1.00

Visited community outpatient drug or alcohol clinic, past 4 monthsb

3/4 (75.00%) 1 (50.00%) 2 (100.00%) p¼ 1.00

Visited a mental health center for psychiatric or mental health problems, lifetime

97 (22.93%) 47 (20.80%) 49 (25.79%) 1.45

Visited a mental health center for psychiatric or mental health problems, past 4 months

58/97 (59.79%) 28 (59.57%) 29 (59.18%) 0.002

Note. N’s may vary according to patterns of missing data due to non-response, including 4 participants who did not respond to gender (male/female) item. aIndividuals were able to select more than one racial category and as such, percentages may not equal 100. bChi-square statistics not reported for categories containing cells with n< 5, instead we report the Fisher’s Exact Test; �p¼ 0.05; ��p< 0.05���p< 0.01.

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Substance use and sexual risk indices were positively correlated and when identifying co- occurring risk, three categories emerged (see Figure 1): those who had “no substance use or sexual risk” (n¼ 174; 41%); those who had “either sexual or substance use risk” (n¼ 108; 26%) and those who had “co-occurring sexual and substance use risk” (n¼ 141; 33%).

Bivariate associations First-time offense type and age were associated with risk indices such that youth with a delin- quent first-time offense and older youth (15–18 years) were more likely to have

co-occurring risks than first-time status offenders [v2 (2, n¼ 423) ¼ 5.86, p¼ 0.05] and youth aged 12–14 years, respectively [v2 (2, n¼ 422) ¼ 87.25; p< 0.0001]. There were no statistically significant differences in the proportion of males to females in any of the risk categories [v2 (2, n¼ 419) ¼ 2.59, p> 0.05].

Models of risk MANCOVA results examining the association of substance use and sexual risk indices with emo- tional/behavioral symptoms and delinquent behavior are presented in Table 3. Twenty-two percent of youth were missing an NSESSS score

Table 3. MANCOVA models of behavioral health risk and emotional/behavioral symptoms.

Co-occurring risk (n¼ 123), Mean (SE)

Sexual risk or substance use

behavior (n¼ 78), Mean (SE)

No risk (n¼ 122), Mean (SE) Multivariate (F) p-Value

Variable Affect Dysregulation Scale (ADS) 14.10 (0.39)a 13.10 (0.46)a 11.83 (0.39)b 7.34 0.0008 Delinquency (NYS) 3.70 (0.23)a 2.01 (0.27)b 0.68 (0.23)c 37.26 <0.0001 Trauma symptoms (NSESSS) 1.40 (0.10)a 1.11 (0.12)a,b 0.87 (0.10)b 6.13 0.0024

Note: All models controlled for age, sex, and offender status. Different superscripts in the same row indicate a significant difference (p< 0.05) between the indicated groups. MANCOVA requires listwise deletion and due to reduced sample size on the NSESSS symptom reporting (21% denied any trauma exposure and were not included for symptom scores), overall sample size was reduced accordingly.

Table 2. FTO-CINI youths’ baseline lifetime and recent substance use, HIV/STI risk and psychiatric symptoms (n¼ 423). Total (n¼ 423) Male (n¼ 226) Female (n¼ 193) Test statistic

Mean (SD), Median (IQR) or n (%)

HIV/STI risk Sexually active, lifetimea 167/414b (40.34%) 90 (41.28%) 77 (40.10%) 0.06 Condom use at last sex (% yes) 105/167 (62.87%) 64 (72.73%) 41 (55.41%) 5.29� Sexually active,a past 4 months 124/167 (74.25%) 64 (71.11%) 60 (77.92%) 1.01 Substance use at last sex (self/partner) 61/124 (49.19%) 27 (42.86%) 34 (58.62%) 3.00

Number of sex partners (oral, vaginal, anal), lifetime (median, IQR) (n¼ 167) 2.00 (1-5) 4.29 (5.49) 3.23 (3.18) 1.48 Number of sex partners, past 4 months (median, IQR) (n¼ 124) 1.00 (1-3) 5.25 (13.85) 2.15 (2.39) 1.69

Getting pregnant or getting someone else pregnant, lifetimec 6 (1.42%) 1 (0.45%) 5 (2.60%) p¼ 0.10 Sexually transmitted infections (STI) diagnosis, lifetimec,d 9 (2.13%) 3 (3.37%) 6 (7.79%) p¼ 0.31 Sexually transmitted infections (STI) diagnosis, past 4 monthsc,d 4/9 (44.44%) 2 (66.67%) 2 (33.33%) p¼ 0.52 Substance use Cigarette use, lifetime 90 (21.28%) 38 (17.04%) 51 (26.56%) 5.55� Cigarette use, past 4 months 50/90 (55.56%) 21 (55.26%) 28 (54.90%) 0.001 Number of days smoking, past 4 months (mean, SD) 40.45 (46.41) 56.45 (53.27) 27.13 (35.71) 2.18� Alcohol use, lifetime 138 (32.62%) 64 (28.83%) 71 (36.79%) 2.98 Alcohol use, past 4 months 93/138 (67.39%) 40 (62.50%) 51 (71.83%) 1.33 Number of days drinking, past 4 months (mean, SD) 5.86 (11.27) 5.63 (6.16) 6.08 (14.19) �0.20 Marijuana use, lifetime 205 (48.46%) 100 (45.25%) 104 (54.74%) 3.68t

Marijuana use, past 4 months 164/205 (80.00%) 76 (76.00%) 87 (83.65%) 1.86 Number of days of marijuana use, past 4 months (mean, SD) 37.99 (44.24) 34.66 (42.44) 39.82 (45.20) �0.70 Other drug use, lifetimee 55 (13.00%) 26 (11.82%) 28 (14.97%) 0.87 Other drug use, past 4 months 22/55 (40.00%)

Emotional and behavioral symptoms Affect Dysregulation Scale score (mean, SD) 12.87 (4.38) 11.66 (3.89) 14.12 (4.44) �5.88��� Trauma symptoms (National Stressful Events Survey Short Scale; NSESSS) 1.15 (1.07) 1.02 (1.01) 1.23 (1.09) �1.77 NYS Delinquency (General Delinquency subscale) 2.10 (2.68) 2.26 (2.92) 1.88 (2.38) 1.48

Note. aVaginal, oral, or anal; bn¼ 9 persons refused to answer the sexual activity questions; cChi-square statistics not reported for categories containing cells with n< 5 , instead we report the Fisher’s Exact Test; dGonorrhea, Chlamydia, trichomonas, or syphilis; eOther drug use includes any other drug use outside of marijuana use (e.g., methamphetamines, opioids), but includes synthetic marijuana use; �p¼ 0.05; ��p< 0.05;���p< 0.01; t(trend)p¼ 0.06.

298 M. TOLOU-SHAMS ET AL.

(due to reporting no lifetime trauma exposure); thus, due to listwise deletion inherent in MANCOVA, the sample size was reduced to 323 youth (n¼ 123 with co-occurring risk, n¼ 78 reporting sexual or substance use risk behavior, and n¼ 122 youth with no risk). Controlling for variables both empirically and theoretically expected to be associated with primary outcomes (i.e., age, sex, and offender status), we observed statistically significant associations between all three outcomes and the risk groups (see omnibus F statistics and corresponding p-values in Table 3). Thus, post-hoc tests were conducted for all three measures. Youth with co-occurring risk had significantly higher mean scores than youth with single risk on measures of delinquent behav- iors (p< 0.001) and significantly higher mean scores than youth with no risk on measures of emotional/behavioral symptoms and delinquent behaviors (p< 0.001 and p¼ 0.004, respectively). Youth with single risk (either sexual or substance use) risk had significantly higher mean scores than youth with no risk on measures of affect dysregulation and delinquency (p¼ 0.036 and p< 0.001, respectively). Females with co-occur- ring risk reported more delinquency (F(1, 322) ¼ 10.33, p¼ 0.001) and affect dysregulation (F(1,322) ¼ 23.33, p< 0.001) than all other groups (i.e., versus male co-occurring risk or females in the “no risk” or “single risk” group).

Discussion

Project EPICC is among the first to document across a uniquely large sample of FTO-CINI youth that rates of substance use, emotional/ behavioral symptoms, and sexual risk behaviors are high and co-occur. Rates of risk behaviors and emotional/behavioral symptoms appear to fit in squarely between those previously reported in community-based delinquency prevention studies [e.g., OJJDP’s Program of Research on the Causes and Correlates of Delinquency (Office of Juvenile Justice and Delinquency Prevention, 2016)] and those with detained youth (e.g., Elkington et al., 2008; Teplin et al., 2005). Our data suggest that integrated care is relevant and needed for youth at this early intercept of justice involvement. Substance use and sexual activity start as early as

13–14 years of age. For the almost 50% already using marijuana by the time of first legal contact, use is recent and frequent, averaging 10 days of marijuana use per month. Trauma exposure is as high as that reported for detained youth, who are presumed to be further entrenched in the system and more severe in their psychiatric presentation and needs. Almost one-third of FTO-CINI youth have a lifetime history of psychiatric diagnosis and 31% have a history of psychotropic medica- tion. These findings support our hypothesis that this is a critical group of youth to target for sec- ondary prevention of substance use, psychiatric co-morbidity, and co-occurring sexual risk behaviors.

Consistent with other literature indicating that youth with psychiatric symptoms have higher rates of substance use and sexual risk behaviors (Brown et al., 2014, 2010; Conrad et al., 2017), FTO-CINI youth with co-occurring substance use and sexual risk behaviors appear to endorse higher rates of emotion dysregulation and trau- matic stress symptoms. Thus, even for youth whom the courts and community might perceive as “low level” offenders and less severe in terms of behavioral health risk when compared to detained youth, substantial substance use and sexual risk behaviors are occurring at an early stage of legal contact and are highly associated with emotional/behavioral difficulties. The Juvenile Justice Translational Research on Interventions for Adolescents in the Legal System (JJ-TRIALS) implementation behavioral health study suggests that more research is urgently needed to understand how to improve the behav- ioral health services cascade of care for commu- nity-supervised justice-involved youth, particularly as it relates to improving substance use services (Belenko et al., 2017; Knight et al., 2016). Our data strongly support the relevance and need to enhance the juvenile justice behavioral health cascade of care for this commu- nity-supervised population and highlight that psychiatric and sexual health services should be incorporated with substance use cascade of care efforts. This integration of care will require a concentrated partnership between public health and juvenile justice systems to identify ways in which they can embed behavioral health

JOURNAL OF CHILD & ADOLESCENT SUBSTANCE ABUSE 299

resources into court or community-based diver- sion settings. Innovative examples might include partnerships to develop juvenile court clinics and/or incorporating behavioral health screening and intervention resources for FTO-CINI youth served through collaborative court models (e.g., juvenile drug court).

Key implications and next steps

There are some key ways in which our data sug- gest behavioral health services should be tailored to adeptly meet the needs of FTO-CINI youth. The first is the need for family engagement. Caregiver data suggest that the close majority of families are impoverished, single-parent house- holds and have a history of child welfare involve- ment. Behavioral health efforts will require considerable support resources and specific fam- ily engagement strategies to improve youth out- comes. Family motivation and engagement may be high at this initial stage of justice contact before the youth may become more system- entrenched and caregivers have more system fatigue or frustration or feel “failed” by the sys- tem. Researching ways that court-involved fami- lies can be more successfully engaged in linkage for youth substance use treatment, for example, is sorely needed. The second is gender-responsive programming. Our hypothesis that FTO-CINI females with co-occurring risk would report more delinquent behaviors and emotional symp- toms than all other groups was supported. Training court and diversion staff on gender- responsive approaches to behavioral health screening, assessment, and intervention that con- sider the unique pathways of girls into the system and their ongoing gender-specific needs is imperative. Research is needed on the efficacy and implementation of gender-responsive sub- stance use and mental health treatment for just- ice-involved girls, given that these CINI girls have a higher prevalence of risk factors for recid- ivism, such as sexual abuse, relative to justice- involved boys (Conrad, Placella, Tolou-Shams, Rizzo, & Brown, 2014). The third is the incorpor- ation of culturally congruent services. Consistent with justice system statistics at large, racial and ethnic minority youth in our study were

disproportionately represented at first justice con- tact; within the jurisdiction that these data were collected, Latinx and African American youth representation were double that of existing census data. Data are clear—across settings (e.g., pediat- ric, community)—that racial and ethnic minority youth confront different challenges to engage- ment in substance use and psychiatric care than their white counterparts that perpetuate health and legal disparities (Marrast et al., 2016). Efforts in addressing the substance use, mental and sex- ual health needs of FTO-CINI youth must dir- ectly address cultural differences, needs, and desires of justice-involved minority families.

Limitations

Data were collected from families in one region of the Northeastern US and therefore may limit representativeness and generalizability. Self-report data may be associated with under-reporting of risk and/or sensitive behaviors and in some cases, having to assess caregivers and youth within the same location or room might have affected responding; however, our data suggest that under-reporting may not have been a concern given that rates of risk behaviors were high, including reports of marijuana use. Cross-sec- tional data limits our ability to understand causality and direction across variables of inter- est; however, future longitudinal analysis with this same cohort will be able to disentangle, for example, the temporal relationships between substance use, psychiatric symptoms and re-offending to further inform the field as to how and when best to intervene to improve FTO- CINI youth outcomes.

Conclusions

Our data support a critical need to identify ways in which we can improve early access to sub- stance use, sexual and mental health services for a group of youth who have significant behavioral health needs but are typically overlooked as being less risky or “in need.” Increasing access to and engagement with substance use and mental health services could have profound implications for later public health and legal outcomes. Future

300 M. TOLOU-SHAMS ET AL.

Project EPICC analyses will be able to identify trajectories of youth in each risk index and asso- ciation with future behavioral health and legal outcomes to inform more tailored prevention and intervention efforts for these vulnerable youth and families.

Note

1. The original subscale includes 24 items. Due to an error in ACASI development, item 24 of the NYS general delinquency scale, “Have you had sexual intercourse with a person who was not your serious partner when involved in a relationship?” was not administered to study participants; therefore, subscale scores range from 1-23 but still accurately indicate that greater scores represent greater number of delinquent acts.

Acknowledgments

The authors extend their gratitude to the adolescents and families who participated in this study as well as to the col- laborating court system, staff and stakeholders who sup- ported successful study implementation.

Funding

This work was supported by National Institute on Drug Abuse [R01DA034538 (Dr. Tolou-Shams) and R25DA037190 (Dr. Dauria)] and National Institute of Mental Health [K23MH111606 (Dr. Kemp)]. The content is solely the responsibility of the authors and does not neces- sarily represent the official views of the National Institute on Drug Abuse, National Institute of Mental Health or National Institute of Health.

ORCID

Brandon D. L. Marshall http://orcid.org/0000-0002- 0134-7052

References

Abram, K. M., Stokes, M. L., Welty, L. J., Aaby, D. A., & Teplin, L. A. (2017). Disparities in HIV/AIDS risk behav- iors after youth leave detention: A 14-year longitudinal study. Pediatrics, 139(2), e20160360. https://doi.org/10. 1542/peds.2016-0360

Abram, K. M., Teplin, L. A., McClelland, G. M., & Dulcan, M. K. (2003). Comorbid psychiatric disorders in youth in juvenile detention. Archives of General Psychiatry, 60(11), 1097–1108. https://doi.org/10.1001/archpsyc.60.11.1097

Belenko, S., Dembo, R., Weiland, D., Rollie, M., Salvatore, C., Hanlon, A., & Childs, K. (2008). Recently arrested

adolescents are at high risk for sexually transmitted dis- eases. Sexually Transmitted Diseases, 35(8), 758–763. https://doi.org/10.1097/OLQ.0b013e31816d1f94

Belenko, S., Knight, D., Wasserman, G. A., Dennis, M. L., Wiley, T., Taxman, F. S., Oser, C., Dembo, R., Robertson, A. A., & Sales, J. (2017). The Juvenile Justice Behavioral Health Services Cascade: A new framework for measuring unmet substance use treatment services needs among adolescent offenders. Journal of Substance Abuse Treatment, 74, 80–91. https://doi.org/10.1016/j.jsat.2016. 12.012

Bronfenbrenner, U. (1986). Ecology of the family as a con- text for human development: Research perspectives. Developmental Psychology, 22(6), 723–742. https://doi.org/ 10.1037/0012-1649.22.6.723

Brown, L. K., Hadley, W., Donenberg, G. R., DiClemente, R. J., Lescano, C., Lang, D. M., Crosby, R., Barker, D., & Oster, D. (2014). Project STYLE: A multisite RCT for HIV prevention among youths in mental health treat- ment. Psychiatric Services, 65(3), 338–344. https://doi.org/ 10.1176/appi.ps.201300095

Brown, L. K., Hadley, W., Stewart, A., Lescano, C., Whiteley, L., Donenberg, G., & DiClemente, R. (2010). Psychiatric disorders and sexual risk among adolescents in mental health treatment. Journal of Consulting and Clinical Psychology, 78(4), 590–597. https://doi.org/10. 1037/a0019632

Brown, L. K., Houck, C., Lescano, C., Donenberg, G., Tolou-Shams, M., & Mello, J. (2012). Affect regulation and HIV risk among youth in therapeutic schools. AIDS and Behavior, 16(8), 2272–2278. https://doi.org/10.1007/ s10461-012-0220-3

Conrad, S. M., Placella, N., Tolou-Shams, M., Rizzo, C. J., & Brown, L. K. (2014). Gender differences in recidivism rates for juvenile justice youth: The impact of sexual abuse. Law and Human Behavior, 38(4), 305–314. https:// doi.org/10.1037/lhb0000062

Conrad, S. M., Queenan, R., Brown, L. K., & Tolou-Shams, M. (2017). Psychiatric symptoms, substance use, trauma, and sexual risk: A brief report of gender differences in marijuana-using juvenile offenders. Journal of Child & Adolescent Substance Abuse, 26(6), 433–436. https://doi. org/10.1080/1067828X.2017.1322017

Dembo, R., Faber, J., Cristiano, J., DiClemente, R. J., Krupa, J. M., Terminello, A., & Wareham, J. (2017). Health risk behavior among justice involved male and female youth: Exploratory, multi-group latent class analysis. Substance Use & Misuse, 52(13), 1751–1764. https://doi.org/10.1080/ 10826084.2017.1310246

Dembo, R., Jainchill, N., Turner, C., Fong, C., Farkas, S., & Childs, K. (2007). Levels of psychopathy and its corre- lates: A study of incarcerated youths in three states. Behavioral Sciences & the Law, 25(5), 717–738. https:// doi.org/10.1002/bsl.784

Doherty, E. E., Green, K. M., & Ensminger, M. E. (2008). Investigating the long-term influence of adolescent delin- quency on drug use initiation. Drug and Alcohol

JOURNAL OF CHILD & ADOLESCENT SUBSTANCE ABUSE 301

Dependence, 93(1–2), 72–84. https://doi.org/10.1016/j.dru- galcdep.2007.08.018

Donenberg, G. R., Emerson, E., Bryant, F. B., Wilson, H., & Weber-Shifrin, E. (2001). Understanding AIDS-risk behavior among adolescents in psychiatric care: Links to psychopathology and peer relationships. Journal of the American Academy of Child and Adolescent Psychiatry, 40(6), 642–653. https://doi.org/10.1097/00004583- 200106000-00008

Eaton, D. K., Kann, L., Kinchen, S., Shanklin, S., Flint, K. H., Hawkins, J., & Wechsler, H. (2012). Youth risk behavior surveillance - United States, 2011. Morbidity and Mortality Weekly Report, 61(SS04), 1–162.

Elkington, K., Teplin, L., Mericle, A., Welty, L., Romero, E., & Abram, K. (2008). HIV/sexually transmitted infection risk behaviors in delinquent youth with psychiatric disor- ders: A longitudinal study. Journal of the American Academy of Child and Adolescent Psychiatry, 47(8), 901–911. https://doi.org/10.1097/CHI.0b013e318179962b

Elliott, D., Huizinga, D., & Ageton, S. (1985). Explaining delinquency and drug use. Sage Publications.

Fazel, S., Doll, H., & Långstr€om, N. (2008). Mental disor- ders among adolescents in juvenile detention and correc- tional facilities: A systematic review and metaregression analysis of 25 surveys. Journal of the American Academy of Child and Adolescent Psychiatry, 47(9), 1010–1019. https://doi.org/10.1097/CHI.ObO13e31817eecf3

Fine, A., Mahler, A., Steinberg, L., Frick, P. J., & Cauffman, E. (2017). Individual in context: The role of impulse con- trol on the association between the home, school, and neighborhood developmental contexts and adolescent delinquency. Journal of Youth and Adolescence, 46(7), 1488–1502. https://doi.org/10.1007/s10964-016-0565-4

Fine, A., Steinberg, L., Frick, P. J., & Cauffman, E. (2016). Self-control assessments and implications for predicting adolescent offending. Journal of Youth and Adolescence, 45(4), 701–712. https://doi.org/10.1007/s10964-016-0425-2

Furdella, J., Puzzanchera, C. (2015). Delinquency cases in juvenile court, 2013. Juvenile Offenders and Victims National Report Series website. https://www.ojjdp.gov/ pubs/248899.pdf

Holzer, K. J., Oh, S., Salas-Wright, C. P., Vaughn, M. G., & Landess, J. (2018). Gender differences in the trends and correlates of major depressive episodes among juvenile offenders in the United States. Comprehensive Psychiatry, 80, 72–80. https://doi.org/10.1016/j.comppsych.2017.09. 005

Hussong, A. M., Curran, P. J., Moffitt, T. E., & Caspi, A. (2008). Testing turning points using latest growth curve models: Competing models of substance abuse and desistance in young adulthood. In P. Cohen (Ed.), Applied data analytic techniques for turning point research (pp. 81–104). Routledge.

Knight, D. K., Belenko, S., Wiley, T., Robertson, A. A., Arrigona, N., Dennis, M., Bartkowski, J. P., McReynolds, L. S., Becan, J. E., Knudsen, H. K., Wasserman, G. A., Rose, E., DiClemente, R., & Leukefeld, C. (2016). Juvenile

justice-translational research on interventions for adoles- cents in the legal system (JJ-TRIALS): A cluster random- ized trial targeting system-wide improvement in substance use services. Implementation Science, 11(57), 57–18. https://doi.org/10.1186/s13012-016-0423-5

Lebeau, R., Mischel, E., Resnick, H., Kilpatrick, D., Friedman, M., & Craske, M. (2014). Dimensional assess- ment of posttraumatic stress disorder in DSM-5. Psychiatry Research, 218(1-2), 143–147. https://doi.org/ 10.1016/j.psychres.2014.03.032

Loeber, R., & Hay, D. (1997). Key issues in the development of aggression and violence from childhood to early adult- hood. Annual Review of Psychology, 48, 371–410. https:// doi.org/10.1146/annurev.psych.48.1.371

Loeber, R., Keenan, K., & Zhang, Q. (1997). Boys’ experi- mentation and persistence in developmental pathways toward serious delinquency. Journal of Child and Family Studies, 6(3), 321–357. https://doi.org/10.1023/ A:1025004303603

Loeber, R., Wung, P., Keenan, K., Giroux, B., Stouthamer- Loeber, M., Van Kammen, W. B., & Maugham, B. (1993). Developmental pathways in disruptive child behavior. Development and Psychopathology, 5(1–2), 103–133. https://doi.org/10.1017/S0954579400004296

Marrast, L., Himmelstein, D. U., & Woolhandler, S. (2016). Racial and ethnic disparities in mental health care for children and young adults: A national study. International Journal of Health Services, 46(4), 810–824. https://doi.org/10.1177/0020731416662736

Mauricio, A. M., Little, M., Chassin, L., Knight, G. P., Piquero, A. R., Losoya, S. H., & Vargas-Chanes, D. (2009). Juvenile offenders’ alcohol and marijuana trajec- tories: Risk and protective factor effects in the context of time in a supervised facility. Journal of Youth and Adolescence, 38(3), 440–453. https://doi.org/10.1007/ s10964-008-9324-5

McClelland, G. M., Elkington, K. S., Teplin, L. A., & Abram, K. M. (2004). Multiple substance use disorders in juvenile detainees. Journal of the American Academy of Child and Adolescent Psychiatry, 43(10), 1215–1224. https://doi.org/10.1097/01.chi.0000134489.58054.9c

McReynolds, L. S., & Wasserman, G. A. (2011). Self-injury in incarcerated juvenile females: Contributions of mental health and traumatic experiences. Journal of Traumatic Stress, 24(6), 752–755. https://doi.org/10.1002/jts.20699

Mulvey, E. P., Steinberg, L., Fagan, J., Cauffman, E., Piquero, A. R., Chassin, L., Knight, G. P., Brame, R., Schubert, C. A., Hecker, T., & Losoya, S. H. (2004). Theory and research on desistance from antisocial activ- ity among serious adolescent offenders. Youth Violence and Juvenile Justice, 2(3), 213–236. https://doi.org/10. 1177/1541204004265864

Office of Juvenile Justice and Delinquency Prevention. (2016). Program of research on the causes and correlates of delinquency. https://www.ojjdp.gov/jjbulletin/9810_2/ program.html

302 M. TOLOU-SHAMS ET AL.

Puzzanchera, C. (2009). Juvenile arrests 2008. Juvenile Justice Bulletin. https://www.ncjrs.gov/pdffiles1/ojjdp/ 228479.pdf

Puzzanchera, C. (2011). Juvenile arrests 2011. Juvenile Justice Bulletin. https://www.ojjdp.gov/pubs/244476.pdf

Romer, D., Hornik, R., Stanton, B., Black, M., Li, X., Ricardo, I., & Feigelman, S. (1997). Talking computers: A reliable and private method to conduct interviews on sen- sitive topics with children. Journal of Sex Research, 34(1), 3–9. https://doi.org/10.1080/00224499709551859

Romero, E. G., Teplin, L. A., McClelland, G. M., Abram, K. M., Welty, L. J., & Washburn, J. J. (2007). A longitu- dinal study of the prevalence, development, and persist- ence of HIV/sexually transmitted infection risk behaviors in delinquent youth: Implications for health care in the community. Pediatrics, 119(5), e1126–e1132. https://doi. org/10.1542/peds.2006-0128

Schubert, C. A., Mulvey, E. P., & Glasheen, C. (2011). Influence of mental health and substance use problems and criminogenic risk on outcomes in serious juvenile offenders. Journal of the American Academy of Child & Adolescent Psychiatry, 50(9), 925–937. https://doi.org/10. 1016/j.jaac.2011.06.006

Schwalbe, C. S., Gearing, R. E., MacKenzie, M. J., Brewer, K. B., & Ibrahim, R. (2012). A meta-analysis of experi- mental studies of diversion programs for juvenile offenders. Clinical Psychology Review, 32(1), 26–33. https://doi.org/10.1016/j.cpr.2011.10.002

Szapocznik, J., & Coatsworth, J. (1999). An ecodevelopmen- tal framework for organizing risk and protection for drug abuse: A developmental model of risk and protection. In M. Glantz & C. Hartel (Eds.), Drug abuse: Origins and interventions (pp. 331–366). American Psychological Association.

Tam, C. C., Dauria, E. F., Cook, M. C., Ti, A., Comfort, M., & Tolou-Shams, M. (2019). Justice involvement and girls’ sexual health: Directions for policy and practice. Children and Youth Services Review, 98, 278–283. https://doi.org/ 10.1016/j.childyouth.2019.01.009

Teplin, L. A., Abram, K. M., McClelland, G. M., Dulcan, M. K., & Mericle, A. A. (2002). Psychiatric disorders in youth in juvenile detention. Archives of General Psychiatry, 59(12), 1133–1143. https://doi.org/10.1001/ archpsyc.59.12.1133

Teplin, L. A., Elkington, K. S., McClelland, G. M., Abram, K. M., Mericle, A. A., & Washburn, J. J. (2005). Major mental disorders, substance use disorders, comorbidity, and HIV-AIDS risk behaviors in juvenile detainees.

Psychiatric Services, 56(7), 823–828. https://doi.org/10. 1176/appi.ps.56.7.823

Teplin, L. A., Mericle, A. A., McClelland, G. M., & Abram, K. M. (2003). HIV and AIDS risk behaviors in juvenile detainees: Implications for public health policy. American Journal of Public Health, 93(6), 906–912. https://doi.org/ 10.2105/AJPH.93.6.906

Tolou-Shams, M., Brown, L. K., Gordon, G., & Fernandez, I. (2007). Arrest history as an indicator of adolescent/ young adult substance use and HIV risk. Drug and Alcohol Dependence, 88(1), 87–90. https://doi.org/10.1016/ j.drugalcdep.2006.09.017

Tolou-Shams, M., Brown, L. K., Houck, C., & Lescano, C. M. (2008). The association between depressive symp- toms, substance use, and HIV risk among youth with an arrest history. Journal of Studies on Alcohol and Drugs, 69(1), 58–64. https://doi.org/10.15288/jsad.2008.69.58

Tolou-Shams, M., Dauria, E., Conrad, S. M., Kemp, K., Johnson, S., & Brown, L. K. (2017). Outcomes of a fam- ily-based HIV prevention intervention for substance using juvenile offenders. Journal of Substance Abuse Treatment, 77, 115–125. https://doi.org/10.1016/j.jsat. 2017.03.013

Tolou-Shams, M., Harrison, A., Hirschtritt, M. E., Dauria, E., & Barr-Walker, J. (2019). Substance use and HIV among justice-involved youth: Intersecting risks. Current HIV/AIDS Reports, 16(1), 37–47. https://doi.org/10.1007/ s11904-019-00424-x

Tolou-Shams, M., Houck, C. D., Conrad, S. M., Tarantino, N., Stein, L. A. R., & Brown, L. K. (2011). HIV preven- tion for juvenile drug court offenders: A randomized controlled trial focusing on affect management. Journal of Correctional Health Care: The Official Journal of the National Commission on Correctional Health Care, 17(3), 226–232. https://doi.org/10.1177/1078345811401357

Tolou-Shams, M., Stewart, A. M., Fasciano, J., & Brown, L. K. (2010). A review of HIV prevention interventions for juvenile offenders. Journal of Pediatric Psychology, 35(3), 250–261. https://doi.org/10.1093/jpepsy/jsp069

Tossone, K., Wheeler, M., Butcher, F., & Kretschmar, J. (2018). The role of sexual abuse in trauma symptoms, delinquent and suicidal behaviors, and criminal justice outcomes among females in a juvenile justice diversion program. Violence against Women, 24(8), 973–993. https://doi.org/10.1177/1077801217724921

Wasserman, G. A., Ko, S. J., & McReynolds, L. S. (2004). Assessing the mental health status of youth in juvenile justice settings. Juvenile Justice Bulletin, 1–7.

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