School of Occupational Therapy

Touro University Nevada

OCCT 643 Systematic Reviews in Occupational Therapy

CRITICALLY APPRAISED TOPIC (CAT) WORKSHEET
Focused Question:
Do skill-based interventions reduce recidivism rates amongst youth with mental health
disorders?
Prepared By:
Sydney Carnevale and Faith Wilkins
Date Review Completed:
September 15, 2015
Clinical Scenario:
Studies have consistent findings that sixty five to seventy percent of youth placed in the
juvenile justice system have a diagnosable mental health disorder (Wasserman, Ko, &
McReynolds, 2004). This statistic means that on average one out of every five youth within the
juvenile justice system have a serious mental health disorder (Cocozza & Skowyra, 2000).
Mental illness, in conjunction with environmental influence and behavior patterns, is a red flag
for juvenile justice systems and parole officers. Incarcerated youth with mental illness make up a
significant portion of those youth that return to jail after parole. Measuring juvenile recidivism
rates is difficult as the numbers are influenced by how states define, measure, and report
recidivism. For example, in the state of Nevada re-incarceration is only measured when the
second crime occurred while the adolescent was on parole or under state commitment. This
means that Nevadas recidivism rates only account for those rapidly re-occurring crimes and
provide little information longitudinally (Office of Juvenile Justice and Delinquency Prevention
[OJJDP], 2014). Recidivism proves to be a significant problem among youth, especially for
those with a diagnosable mental health disorder. The current juvenile justice system has limited
programming in place that not only addresses the psychological components of crime behaviors,
but that teaches these youth valuable skills that can be generalized to daily life.
Many of the incarcerated youth come out of jail with no direction, no help to manage their

mental health conditions, and limited life skill sets. The U.S. Department of Justice has
repeatedly examined current programs aimed at reducing recidivism rates among youth offenders
with mental health disorders, and they have found that most facilities are inadequately prepared
to address the mental health needs of the youth (U.S. Department of Justice, 2005). Many
programs utilize one on one psychotherapy as the basis of treatment to address intrinsic
motivating factors of criminal behaviors. These psychotherapeutic programs are aimed at the
individual who is incarcerated only and addresses their concerns in a vacuum. A series of
investigative reports examined the influence of familial involvement in recidivism and crime
rates among youth offenders and found that an overwhelming amount of children, approximately
94%, wish to be in more contact with their families while incarcerated (Sedlack & McPherson,
2010). Despite this evidence, many programs are still utilizing an individualized psychotherapy
approach to treatment rather than an approach involving the adolescent and their support network
(i.e. family, caregiver, teachers, etc.). However, there has been a recent push to have incarcerated
youth with mental health disorders placed in community based settings in order for them to have
greater access to evidence-based treatments aimed at reducing criminal behaviors and addressing
life skills development. This paradigm shift is a major contributor to increased funding in
research and host treatment for this population in attempts to develop effective skill-based
programming.
The average cost of incarceration within a juvenile detention facility is between $32,000
and $65,000 per year (Juvenile Detention Alternatives Initiative, 2007). The estimated total cost
resulting from long-term outcomes of ineffective intervention treatments could cost taxpayers
between $8 billion to $21 billion a year nationwide (Justice Policy Institute, 2014). The
development of alternative programming can address not only the needs of the youth, but can
significantly reduce the financial burden on prisons within the United States. Research has
shown through the use of programming such as Multisystemic Therapy (MST), every $1 spent
will have a $13 return. Programs focused on reducing recidivism rates through the development
of positive coping skills, social skills, and life skills can save the public almost $5.7 million in
costs over the childs lifetime (Cohen & Piquero, 2007). During the 2014 fiscal year in Nevada,
the cost of incarcerating a juvenile offender was approximately $150,000 (Justice Policy
Institute, 2014).
Effective programming that encompasses symptom and behavioral management, coping
strategies, and the development of useful life skills is necessary to address the multifaceted needs
of incarcerated youth with mental illness. The implementation of occupational therapy services
with this population could help decrease recidivism rates and involved costs. Occupational
therapists can help to create programming that focuses on building positive social networks,
developing independent living and vocational skills, and addressing psychosocial factors often
associated with incarceration and crime. Occupational therapists can help incarcerated youth
with mental illness identify vocational and leisure opportunities that could improve the

development of meaningful occupations. The development of skills required for community

reintegration is paramount to reducing recidivism rates and decreasing the return to prior
mischievous roles and crime behavior patterns.

Summary of Key Findings:

Summary of Levels I, II and III:
Level I:
Psychotherapy interventions alone are not effective in decreasing recidivism rates as
incarcerated youth often lack the life and coping skills to manage daily life. Further
research needs to be conducted in order to determine effective strategies for developing
positive coping skills, adaptability, problem solving skills, communication skills, and
daily life skills within the environmental confines of juvenile detention centers.
Mindfulness based interventions are a low risk, inexpensive and effective method for
targeting negative behaviors and reducing recidivism rates among incarcerated youth
with mental health conditions (Himelstein, Saul, & Garcia-Romeu, 2015).
Diversion and community based programs have a greater rate of effectiveness in
reducing recidivism rates among incarcerated youth with mental health conditions when
compared to psychotherapy alone (Cuellar, McReynolds, & Wasserman, 2006).
Decrease in crime severity and rates of recidivism were statistically significant for those
youth that participated in a diversion program.
Reductions in delinquent behaviors and increases in self-regulation, positive coping
strategies, and positive social networks was found when youth were enrolled in
programs that included familial participation. Programs such as FIT and MST focus on
the externalization of negative emotions through positive coping strategies and positive
communication while incorporating the entire family (Latourneau et al., 2009; Ogden &
Hagen, 2006; Timmons-Mitchell, Bender, Kishna, & Mitchell, 2006).

Level II:
Mindfulness based interventions have a statistically significant impact on levels of selfregulation, perceived stress, and incidence of mindful behaviors. The use of group
discussion and reflection allowed for the youth to process mindfulness teachings and
learn how to apply them to their daily life (Himelstein, Hastings, Shapiro, & Heery,
2012; Barnett, Himelstein, Herbert, Garcia-Romeu & Chamberlain, 2013).
Psychotherapy alone is not as effective as skill based intervention strategies targeting
incarcerated youth with substance abuse disorders. A mindfulness program tailored to

address self-regulation and perceived risk can lead to the youth having a greater
understanding of susceptibility to drug use and control over ones impulses (Himelstein,
2010).
Family and community based programs are more effective in decreasing recidivism
rates among youth with mental health conditions than psychotherapy alone. Current
programs-as-usual are not equipped to deal with co-occurring substance abuse and
mental health disorders in relation to reducing criminal behaviors (Trupin, Kerns,
Walker, DeRobertis, & Stewart, 2011).

Level III:
Yoga interventions can be a highly effective method for decreasing perceived stress
levels and increasing self-control (Ramadoss & Bose, 2010).
Skills learned through yoga based interventions, such as mindful movement, slow
breathing, and self-reflection, can be readily generalized and applied to daily life
activities (Ramadoss & Bose, 2010).
Incidence of violent behaviors was found to decline among incarcerated youth who
participated in the Yoga Based Transformative Life Skill Program. Findings related to
violent behaviors had good clinical significance; however, the results were not
statistically significant.

Summary of Level IV and V:

No level IV or V studies were appraised.
Contributions of Qualitative Studies:
No qualitative studies were appraised.

Bottom Line for Occupational Therapy Practice:

Clinical and Community-Based Practice of OT:
In summation the clinical and community implications of this systematic review are relevant to
occupational therapy. Programs utilizing the principles of mindfulness, MST, FIT or yoga have
proven meaningful gains for youth who are incarcerated. These youth may be able to better
regulate their behaviors in order to avoid future incarceration with individualized and appropriate
intervention. The EQUIP program was not effective as there was a high turnover rate and poor
active participation by the youth. Further research should be done to determine the key
components of programming that yield the highest gains among this population. There was not

one study without flaws; however, meaningful implications can be drawn from each study such
as the importance of considering the youth and their family, contextual factors, and the
importance of promoting self-efficacy, self-esteem and a sense of control amongst the
individuals. Individually tailored programming is difficult, and near impossible, to implement in
a juvenile justice center, however the basic tenets of programs can be adapted in order to meet
the unique needs of all those who participate. Programs focusing on familial involvement,
communication, self-regulation, self-efficacy, and the establishment of positive coping skills had
the greatest impact on recidivism rates. Facilitating social abilities, life skills, and emotional
regulation skills needed to cope with prison life all fall under occupational therapys scope of
practice. Occupational therapists can assist in the development of the capacity for successful
community reintegration through meaningful and skill-based interventions that promote
occupational engagement and improved self-efficacy.

Program development:
None of the studies reviewed incorporated occupational therapy services; however, future
programs would benefit from implementing occupational therapy services. Occupational
therapist are skilled in providing client-centered evaluations and interventions that consider
pertinent intrinsic and extrinsic client factors along with factors that improve clients
independence and functional abilities. Program protocols must relate to the needs of the youth
and address them as occupational beings, rather than as inmates. Further program refinement
should be done to adapt the program for on-site and community based implementation.
Regardless of health care discipline, all professionals delivering services must be well versed in
the methodologies of the program and intervention.

Societal Needs:
It is imperative youth be given opportunities to be successful in life despite legal system
involvement. Further information needs to be provided regarding program protocols and
standards in order for the research to be beneficial for treatment. The current programming
provided for this population is scarce and often ineffective in reducing recidivism rates.
Recidivism costs, legal costs, and costs payed to harmed parties still make up a large portion of
taxpayer dollars every year. Society could benefit financially, civically and communally by
developing therapeutic programs for this population. All parties included youth, their families,
and their communities would benefit from more effective programming aimed at the
development of positive life skills.

Healthcare delivery and policy:

The current lack of research in the area of therapeutic interventions for this population has
resulted in limited healthcare delivery and policy. All results of the research reviewed, warranted
future investments in youth mental health services including their families, communities, and
therapeutic services offered within detention centers and juvenile correction facilities. With time
and investment, healthcare delivery models and policies for youth who are incarcerated will be
established and benefit the greater good.

Education and training of OT students:

In totality the research reviewed is relevant to the education of future occupational therapist.
Specifically, future occupational therapist need to be trained in the areas of adolescent mental
health, group interventions, client and family dynamics, implementation of standardized
protocols and the impacts of trauma on occupational engagement. Occupational therapy students
should be comfortable applying ecologically based models and frames of reference to guide
therapeutic interventions. Incarceration presents youth with a challenge to adapt to a very rigid
external environment, therefore they need to adapt and develop appropriate problem solving and
self-regulation skills.

Refinement, revision, and advancement of factual knowledge or theory:

There is significant room for improvement within the constructs of therapeutic services for youth
who are incarcerated. Specifically, it is imperative future studies have a greater sample size with
a more heterogeneous population and generalizable results. While psychotherapist are working
this population, it is also time for the occupational therapy profession to form and implement
models to address this population in such need. Further emphasis needs to be placed on how to
refine ecological theories to address the occupational deprivation associated with incarceration.
A more comprehensive and national effort needs to be made to determine true measures of
recidivism rates among youth offenders, especially those with diagnosed mental illness.

Review Process:
The focus question was developed to explore current programming options offered for
incarcerated youth with mental health conditions that could fall under the scope of practice of
occupational therapy.
Given the variety of programming available, the authors chose to hone in on programming aimed
at reducing recidivism rates. These programs also had to include skill based interventions rather
than psychotherapy alone.
The focus question was then amended to encompass all important aspects of the authors search:
Do skill-based interventions reduce recidivism rates amongst youth with mental health
disorders?
The focus question was reviewed and approved by Dr. Donna Costa.
A comprehensive literature review was conducted utilizing key terms in various databases in
order to exhaust available research studies.
A total of 34 articles were found as a result of the comprehensive literature search.
The articles were reviewed by both authors in order to determine their fit with the inclusion
criteria.
23 out of the 34 articles were eliminated based on the inclusion criteria. The eliminated articles
focused on the use of psychotherapy or pharmacological treatments to address the needs of
incarcerated youth with mental health disorders.
11 articles met the inclusion criteria and were analyzed in the evidence table.
The evidence table was reviewed by Dr. Donna Costa for accuracy.
Upon approval of the evidence table, appraised articles were compiled and evaluated as a
critically appraised topic.

Procedures for the Selection and appraisal of articles:

Inclusion Criteria:
Participants < 18 y/o
Diagnosed mild, moderate, and severe mental illness
Incarceration
Diversion Program
Youth with history of incarceration
Skill based treatments
Mental illness as a primary diagnosis

Studies conducted after 2006

Studies with Level III evidence or better

Exclusion Criteria:
Participants > 18 y/o
Physical disability only
House arrest
Pharmacological treatment
Studies conducted before 2006
Studies with less than Level III evidence

Search Strategies:
Categories

Key Search Terms

Patient/Client Population

Key Words: youth, adolescents, mental health, mental health

disorders, mental illness, young adult, incarceration, jail,
parole, juvenile detention center, legal system

Intervention

Key Words: occupational therapy, mindfulness, multisystemic

treatment, intervention, treatment, family intervention

Outcomes

Key Words: recidivism rates, parole, crime rates, decreased

crime
Databases and Sites Searched

Google Scholar, CINAHL, hand searching through articles, EBSCO Host, OTSearch
Quality Control/Peer Review Process:
The focus question was reviewed and approved by Dr. Donna Costa.

Both researchers made revisions to the focus questions to include skill based interventions.
The researchers identified key terms to conduct a comprehensive literature review.
A comprehensive literature review was completed by both authors.
The focus question was again amended and approved by Dr. Donna Costa following literature
review feedback.
The inclusion and exclusion criteria were amended by both authors in response to changes in the
focus question.
Both researchers reviewed each article and agreed upon the inclusion of each article.
Both researchers worked together to complete critical review forms for quantitative studies for
each article.
Information from each critical review form was compiled into an evidence table.
Dr. Donna Costa reviewed this evidence table for accuracy and rigor.
CAT was completed based on revisions and consultations between authors and Dr. Donna Costa.

Results of Search:
Summary of Study Designs of Articles Selected for Appraisal:
Level of
Evidence

Study Design/Methodology of Selected Articles

Number of Articles
Selected

Systematic reviews, meta-analysis, randomized

controlled trials

II

Two groups, nonrandomized studies (e.g., cohort,

case-control)

III

One group, nonrandomized (e.g., before and after,

pretest, and posttest)

IV

Descriptive studies that include analysis of outcomes

(single subject design, case series)

Case reports and expert opinion, which include

narrative literature reviews and consensus statements

Other

Qualitative Studies

0
TOTAL:

Limitations of the Studies Appraised:

11

Levels I, II, and III

Level I Limitations:
Small sample size resulting in poor generalizability was a limitation seen among the
appraised Level I studies (Himelstein, Saul, & Garcia-Romeu, 2012); (TimmonsMitchell, Bender, Kishna, & Mitchell, 2006).
The short duration of the study may not have captured accurate recidivism changes over
time post-treatment (Latourneau et al., 2009); (Ogden & Hagen, 2006).
The lack of intervention description interfering with validity and reliability of research
limits the ability to replicate studies in the future (Timmons-Mitchell, Bender, Kishna, &
Mitchell, 2006); (Ogden & Hagen, 2006); (Latourneau et al., 2009).
Research participants were court mandated to participate in the research study (Cueller,
McReynolds, & Wasserman, 2006).
There was limited generalizability to high risk or serious criminal offenders (Cueller,
McReynolds, & Wasserman, 2006); (Timmons-Mitchell, Bender, Kishna, & Mitchell,
2006); (Latourneau et al, 2009).
The inconsistent implementation of treatment between sites and administrators limited
the results. (Ogden & Hagen, 2010); (Himelstein, Saul, & Garcia-Romeu, 2015).
Some studies may not have gathered accurate data regarding behavioral changes as
insensitive and limited outcome measures were used. (Ogden & Hagen, 2010);
(Latourneau et al., 2009).
Contamination was very possible given the nature of juvenile detention centers and the
studied population (Himelstein, Saul, & Garcia-Romeu, 2015).

Level II Limitations:
Court ordered versus voluntary participation in both experimental treatment and
treatment as usual conditions may have skewed results (Himelstein, 2010).
Small sample size limited generalizability to more heterogenous populations
(Himelstein, 2010); (Trupin, Kerns, Walker, DeRobertis, & Stewart, 2011); (Himelstein,
Hastings, Shapiro, & Heery, 2012); (Helmond, Overbeek, & Brugman, 2012); (Barnett,
Himelstein, Herbert, Garcia-Romeu, & Chamberlain, 2013).
Inconsistent training and professional backgrounds of treatment administrators limited
the findings (Helmond, Overbeek, & Brugman, 2012).
Limited information regarding specific treatment protocols impacted analysis and
comparison (Trupin, Kerns, Walker, DeRobertis, & Stewart, 2011).

Level III Limitations:

The lack of a control group and a high dropout rate may have skewed results (Ramadoss

& Bose, 2010).

Program administrators were not properly educated on the prevalence, symptomatology,
and severity of the participants mental health disorders (Ramadoss & Bose, 2010).

Levels IV and V:
No Level IV or IV studies were appraised.
Other:
No qualitative studies were appraised.

Articles Selected for Appraisal:

Barnett, E., Himelstein, S., Herbert, S., Garcia-Romeu, A., & Chamberlain, L. (2014). Exploring
an intensive meditation intervention for incarcerated youth. Child and Adolescent Mental
Health, 19(1), 69-73. doi: 10.1111/camh.12019
Cuellar, A., McReynolds, L., & Wasserman, G. (2006). A cure for crime: Can mental health
treatment diversion reduce crime among youth? Journal of Policy, Analysis, &
Management, 25(1), 197-214. doi: 10.1002/pam.20162
Helmond, P., Overbeek, G., & Brugman, D. (2012). Program integrity and effectiveness of a
cognitive behavioral intervention for incarcerated youth on cognitive distortions, social
skills, and moral development. Children and Youth Services Review, 34(9), 1720-1728.
doi: http://dx.doi.org/10.1016/j.childyouth.2012.05.001
Himelstein, S. (2010). Mindfulness-based substance abuse treatment for incarcerated youth: a
mixed method pilot study. Transpersonal Studies.
Himelstein, S., Hastings, A., Shapiro, S., & Heery, M. (2012). Mindfulness training for selfregulation and stress with incarcerated youth: A pilot study. Probation Journal, 59(2),
151-165. doi: 10.1177/0264550512438256
Himelstein, S., Saul, S., & Garcia-Romeu, A. (2015). Does mindfulness meditation increase
effectiveness of substance abuse treatment with incarcerated youth? A pilot randomized
controlled trial. Mindfulness, 1-9.
Letourneau, E., Henggeler, S., Borduin, C., Schewe, P., McCart, M., Chapman, J. & Saldana, L.
(2009). Multisystemic therapy for juvenile sexual offenders: 1-year results from a
randomized effectiveness trial. Journal of Family Psychology, 23(1), 89. doi:
10.1037/a0014352
Ogden, T., & Hagen, K. A. (2006). Multisystemic treatment of serious behaviour problems in
youth: Sustainability of effectiveness two years after intake. Child and Adolescent
Mental Health, 11(3), 142-149. doi: 10.1111/j.1475-3588.2006.00396.x
Ramadoss, R., & Bose, B. (2010). Transformative life skills: Pilot studies of a yoga model for
reducing perceived stress and improving self-control in vulnerable youth. International

Journal of Yoga Therapy 20, 75-80.

Timmons-Mitchell, J., Bender, M., Kishna, M., & Mitchell, C. (2006). An independent
effectiveness trial of multisystemic therapy with juvenile justice youth. Journal of
Clinical Child and Adolescent Psychology, 35(2), 227-236.doi:
10.1207/s15374424jccp3502_6
Trupin, E., Kerns, S., Walker, S., DeRobertis, M., & Stewart, D. (2011). Family integrated
transitions: A promising program for juvenile offenders with co-occurring disorders.
Journal of Child & Adolescent Substance Abuse, 20(5), 421-436. doi:
10.1080/1067828X.2011.614889

Other References:
Cocozza, J. & Skowyra, K. (2000). Youth with mental health disorders: Issues and emerging
responses. Office of Juvenile Justice and Delinquency Prevention Journal, 7(1), 3-13.
Cohen, M. & Piquero, A. (2007). New evidence on the monetary value of saving a high risk
youth. Vanderbilt Law and Economics Research Paper No. 08-07. Retrieved from:
http://ssrn.com/abstract=1077214.
Juvenile Detention Alternatives Initiative. (2007). Detention reform brief 1: Detention reform: A
cost-saving approach, Annie E. Casey Foundation. Retrieved from:
http://www.aecf.org/upload/PublicationFiles/jdai_facts1.pdf.
Juvenile Justice Institute. (2014). Sticker shock: Calculating the full price tag for youth
incarceration. Retrieved from: http://www.justicepolicy.org/research/8477
Office of Juvenile Justice and Delinquency Prevention. (2014). Juvenile offenders and victims:
2014 national report. Retrieved from:
http://www.ojjdp.gov/ojstatbb/nr2014/downloads/NR2014.pdf
Sedlack, A., & McPherson, K. (2010). Conditions of confinement: Findings from the survey of
youth in residential placement. Washington, DC: U.S. Department of Justice, Office of
Justice Programs, Office of Juvenile Justice and Delinquency Prevention