The impact of co-occurring mental health problems on referral to and initiation of treatment among youth under probation supervision: Findings from a cluster randomized trial.

Introduction: Many youth under community supervision have substance use and co-occurring mental health issues. Yet, access to treatment is limited, and many programs cannot address co-occurring disorders. This study examines how co-occurring symptoms among youth on probation affect referral to and initiation of treatment. We hypothesize that both referral and initiation rates will be lower for youth with any co-occurring indicators.

Methods: This study collected administrative data from 14 sites in three states between March 2014 and November 2017 using JJ-TRIALS, a cluster randomized trial. Among 8552 youth in need of treatment (screened as having a substance use problem, drug possession arrest, positive drug test, etc.), 2069 received a referral to treatment and 1630 initiated treatment among those referred. A co-occurring indicator (n = 2828) was based on symptoms of an internalizing and/or externalizing issue. Descriptive analyses compared referral and initiation by behavioral health status. Two-level mixed effects logistic regression models estimated effects of site-level variables.

Results: Among youth in need with co-occurring internal, external, or both indicators, only 16 %, 18 %, and 20 % were referred to treatment and of those referred, 63 %, 69 %, and 57 % initiated treatment, respectively. Comparatively, 27 % and 83 % of youth with a substance use only indicator were referred and initiated treatment respectively. Multi-level multivariate models found that, contrary to our hypothesis, co-occurring-both (p = 0.00, OR 1.44) and co-occurring-internal indicators (p = 0.06, OR 1.25) predicted higher referral but there were no differences in initiation rates. However, there was substantial site-level variation.

Conclusions: Youth on probation in need of substance use treatment with co-occurring issues have low referral rates. Behavioral health status may influence youth referral to treatment depending on where a youth is located. Depending on the site, there may be a lack of community programs that can adequately treat youth with co-occurring issues and reduce unmet service needs.