A More Compassionate Approach to Juvenile Evaluations

• Juvenile Court Evaluations
• Danielle’s Interview
• Collateral Information
• The Clinical Formulation
• The Effects of Court Clinic Evaluations

During a recent question-and-answer panel discussion I was asked, “What do you consider the most important qualities for therapists entering the forensic field?” It dawned on me that, while providing psychotherapy is in stark contrast to performing forensic evaluations, in terms of requisite clinical skill, it’s not so different.

Sure, it’s quite a change going from a therapy dynamic to meeting strictly for assessments. Then, of course, there’s the weight of your work having legal consequences. And the work is pretty sedentary and often solitary, as a lot of time is spent sifting records and writing long evaluations. However, if you can perform therapy well, and you’re open to learning to navigate the mental health/legal nexus and style of writing it demands, you’re more than halfway there.

I’ve worked in the forensic arena for 22 years, which is the bulk of my career. My graduate school internship was at a local house of correction, which attracted me because it sounded much more interesting than doing therapy in an outpatient office or inpatient unit. Within the correctional environment, I was quickly immersed in performing crisis assessments, psychotherapy, and diagnostic assessments. Coupled with the fact that many inmates suffered from chronic and severe mental illnesses presented significant characterological disturbances. It was a baptism by fire.  

After nine years of the correctional work, and moonlighting in my private psychotherapy practice, an opportunity arose for me to apply my enjoyment of assessment work within the forensic arena I had developed quite an interest in. In 2012, I had the good fortune of transitioning to the juvenile courts where I went on to provide psychological evaluations that help the court work more effectively with troubled kids and their families.

From their inception in Victorian era England, juvenile courts have viewed children as more malleable and therefore more “correctable.” Before there were mental health courts, and even mental health care in jails, juvenile courts maintained a focus on rehabilitation while also holding children accountable.  

Juvenile Court Evaluations

In juvenile courts, psychologists provide competency to stand trial and criminal responsibility evaluations, while master’s level clinicians perform a range of diagnostic assessments. In this case, diagnostic doesn’t necessarily mean providing a DSM or ICD diagnosis, though that is not unusual when second opinions are requested, but rather diagnostic in terms of understanding the dynamics that contribute to the child’s problematic behavior and what might help remedy them. Other evaluations might be for aid in sentencing, such as suggestions the judge might consider for the type of setting best suited for rehabilitation while holding the child accountable.

Still other evaluations could regard specific dangerousness assessments, such as when problematic sexual behavior or fire setting is involved. There is also the occasional psychiatric crisis assessment a judge may order, like if a child unravels in the court, is presenting acute symptoms, or makes threats during the proceeding. Evaluations for involuntary commitment for substance abuse treatment, known in Massachusetts as “section 35,” also arise.

All evaluations have similarities, but eventually veer into their respective, specific territory. There are always interviews with the kids and parents/guardians, about not only the present concern, but developmental matters, family, mental health, medical, substance abuse, educational history, and current mental status. The court clinician then collects data from collateral sources like mental health and medical providers, schools, and social service agencies. Years worth of these documents are reviewed, their information added to the material from the interviews, and recorded into a document wherein the information is first categorically organized, then synthesized into the evaluator’s clinical formulation/opinions and recommendations to the court.  

How this all gets pulled together relies on skills any good therapist is familiar with, as it involves solid rapport building, interviewing and listening skills, and a great dose of curiosity.

A considerable hurdle to overcome for some therapists entering the forensic evaluation arena is that, unlike practicing therapy, there’s not a lot of time to develop a relationship with interviewees. Breaking the ice and getting to business happens quickly when you only have a couple of hours, but it can’t be too businesslike. We want an interview, not a regimented interrogation that’ll leave the person feeling defensive. Keeping it business-casual and starting with a social tone is likely to build faster rapport, like with Danielle (conglomerate identity), whom I visited in a juvenile detention facility for her evaluation.

Danielle’s Interview

“Did you have to wake up early for this?” I asked Danielle as she entered the interview office.

“Nah,” she clucked, looking me over.

“I’m Tony, from the Court Clinic. Did anyone tell you I’d be coming to see you?”

“You’re the guy for my psych eval?”

“That’s me.”

“Cool. My lawyer said you’d be coming. It might help me get out of here.”

“Well, I can’t really speak for that. That’s up to your attorney and the judge to work out, but the good news is you have court again next week, so you’ll find out soon. Is this your first time in a place like this?” Danielle, forlornly, said it was. “Wow. Must be quite a change. How have you been managing being away from home like this?”

Danielle explained she kept it together knowing she could talk to home on the phone, and she was to get a visit from her grandmother and sister that weekend.

Edging towards the more formal interview, I transitioned with, “It sounds like you’re in pretty good shape for the shape you’re in for such a big shift from home,” I smiled at her.

Then, I explained to her that the evaluation was meant to help the court effectively work with her and her family, and not because she was in any extra trouble, as some have wondered. Danielle nodded her understanding.

“Danielle, before we really jump in, there’s a few things I need to fill you in on, so I’m going to ask you to listen carefully, and then to repeat back to me your understanding of some of the stuff, OK?”  

She was then provided with details about how the information would be used, along with her right to refuse to participate and matters of confidentiality. Specifically, confidentiality is not the same as in a therapy relationship, as the purpose is to inform the judge, attorney, and probation officer so they can better work with the kid/family. Also, given the pretrial nature of the case, I informed her not to give me details about the current accusations.

“Do you have any questions about all that?”

With a shake of her head, Danielle fired the starting gun for the evaluation.   

Like most initial meetings, it makes sense to start slow, asking basic information to keep the tension down. Sitting in front of a therapist for the first time can be nerve-racking for anyone, never mind when someone is evaluating you for the court. Picking up where the small talk left off to merge into the interview more naturally, I began, “Earlier we were talking about it being your first time in a place like this. Tell me about where you were living before you got here.” Leaving the questions as open ended as possible makes for a more comfortable conversation where someone doesn’t feel interrogated, and I’ll likely get a more detailed picture.

Danielle laid out a complicated history, bouncing between her parents’ respective houses early on, then, for the past couple of years, in residential programs after her mother’s whereabouts were unknown and her father relapsed. Danielle revealed that she was “always pissed” during this time because her mother would be high, and her father would say he’d come get her and half the time he didn’t. Danielle recently landed at her grandmother’s house, with whom she always got along, and who was now retired and had the time to help.

“How was it being able to live with your grandmother after all that moving?” I asked. Danielle explained that she felt more connected to someone, but that her grandmother couldn’t handle her.

“Couldn’t handle you, like . . .”  

“Look, she’s old and just retired. She dealt with my mom’s shit all these years. She deserves a break. I know I’m not an angel and she worries about me.”

“Fill me in about that last part, not being an angel and she worries about you.”

Looking away, Danielle revealed she is prone to getting in trouble at school.

“The school calls her very time I fart because the school hates me. Yup, I might have a fight or be mouthy with a teacher sometimes, but they just remember my mother who was worse than me. One even says, ‘apple didn’t fall far’ when they accuse me of ‘acting up.’ I hate it. I’ve got enough to deal with, so I just leave sometimes.”

“What do you do when you get home?”

“Not much. I might call my friends when school gets out and they come over.”

“Do you ever go out into the community with them, or to their houses?”

“Sometimes. I’d rather be home.”   

After some probing, it came to light that last school year her grandmother fell and damaged a knee, requiring serious surgery and a long recovery. Danielle shared that she was worried about her and did everything she could. At the same time her mother, in a period of sobriety, visited off and on, and she enjoyed getting to know her mother in a different light. Unfortunately, Danielle’s mother began stealing her grandmother’s pain pills, and once outed, was not welcomed back.

“Ouch,” I sympathized. “This might sound like a silly question, but how did that affect you? What did it mean to you?”

“It seemed I might have a relationship with my mother, and I lost my chance.”

“I couldn’t help but notice the way you worded that. ‘I lost my chance,’ makes it sound like how it played out was somehow your fault.”   

Danielle, in an air of confession, reflected, “I was the responsible one for my grandmother. I should’ve been watching her medications. I knew my mom was an addict, but I didn’t know those pain pills were almost the same as heroin. If my mother couldn’t have gotten to them, she wouldn’t’ve have relapsed, and she maybe would still be OK.”

“Thanks for explaining,” I went on. “I’m not clear how that has to do with why you’d rather stay home now, though.” 

“Ugh. I don’t know. I don’t like leaving her. What if she falls again, or my mother comes around looking for pills? She threatened my grandmother when she was kicked out. I don’t think she would do anything, but, like, what if she did come around?”

“Correct me if I’m wrong, but what I’m hearing is you feel like you need to protect her?”

“I guess,” said Danielle.

“It’s sort of like if you get sent home you can be there for her, and if you don’t get sent home, you can send yourself by walking out?”

“I never thought of it that way, but I feel a lot less nervous when I’m home with her. I also don’t have to feel like an idiot trying to concentrate and not get anything done.”

Somewhat ironically, given her wish to protect an elderly person, Danielle was in a juvenile detention facility for shoving a teacher over 60 years old who tried to get in her way as she exited the classroom. It was noted in the police report that the teacher felt the full load of an incensed, athletic-statured teen’s shove, and sustained injuries. When the police caught up with Danielle as she walked home, she was arrested and charged with assault and battery on 60+ with bodily injury. The school also filed a child requiring assistance (CRA) habitual truancy petition as her unexcused absences were piling up since the start of the new school year. In Massachusetts, a CRA, a civil matter, renders a child to have court oversight to get them back on track.  

At the time, Danielle was accused of being a delinquent and assumed to be an “angry kid with problems at home,” but school is where Danielle’s story became more three-dimensional, delivering just the kind of information that can get overlooked in helping a troubled child.

“Danielle, part of what I like to know about is peoples’ learning experience in school. You mentioned you can feel like an ‘idiot’ about academic work. Without talking about the incident that got you here, tell me about your general school experience.”

“Not great,” she replied. “I mean, I like my friends, and even some classes, but doing the work isn’t my thing.”

“Not your thing? Like keeping up with class lessons or homework, or . . .”

“Yeah. All of the above.”

“How so?”

Danielle answered, “I get irritated because I can’t remember the lessons well, then I don’t do great on homework. I used to get good grades, but the past couple of years, 7th and 8th grade, I just don’t focus.”

We talked about a variety of other topics, including any history of mental health care. Danielle said she took an antidepressant from her pediatrician, which seemed to just help with sleep. Her only other treatment was a dialectical behavioral therapy (DBT) group her grandmother enrolled her in at the school’s urging and she was on a wait list for an individual therapist for the past couple of months.   

Upon review, Danielle’s academic records indeed reflected better grades. The picture became clearer, however, about what was contributing to her global downfall.

Collateral Information

Danielle’s grandmother, Emma, was a gracious lady and eager to help.

“The girl has had her share of difficulties,” said Emma. “Even though I’ve not always had custody of her, I’ve been there for just about everything.”

Emma was able to give me details about Danielle’s gestation and birth, early development and family dynamics. “Despite her parents’ neglect, she actually seemed OK until the last couple of years,” Emma reflected.

“What do you think accounted for that earlier resilience?”

“Well, I can’t take all the credit,” Emma laughed, “but she looked up to me and I encouraged her to be educated. She used school as a respite from that house. She got praise from teachers for being a bright kid. Danielle got the good attention she wasn’t getting at home.”

“So, what happened?” I wondered aloud. “Did she start really struggling when she was removed and placed in residential settings?”

“It certainly correlates,” Emma replied. She detailed how Danielle was placed in settings where she had to be around other troubled kids, couldn’t stay after like she had been because of the program’s transportation schedule, and didn’t have as much access to Emma.

“Emma, Danielle described that you got hurt last summer and needed surgery, and her mother came around at the same time. What can you tell me about that?”

Emma replied, “I did take a spill tripping on a low branch in the yard. It was two months of getting back on my feet after the knee surgery. Her mother got wind of it and wanted to visit. I saw she was clean; she came after work, wearing her uniform. She seemed OK.”

“How did Danielle get along with her?”  

“It had been some time since she saw her mother stable, and I could tell she was trying to forgive her and finally have something with her,” said Emma, her tone trailing off in a pregnant pause. “Danielle probably told you, however, that her mother discovered the pain pills I was prescribed, and she couldn’t resist. I told her to never come back around us.”

“What was her mother’s reply?”

“I know she was high and would never hurt me, but she said, ‘You’re killing my relationship to my daughter. Maybe I’ll kill you someday.’ Danielle heard it.”

As we talked further, I asked if, given Danielle’s abrupt downturn in performance with everything going on if the school ever provided psychoeducational testing or if Danielle had an individualized education plan (IEP).

“No. Her mother had that years ago, so I asked if the school could do it for Danielle. They said, ‘Look at her achievement history. She’s too smart. She doesn’t have a learning disability. She just doesn’t want to cooperate these days and would rather walk out.’”

Upon obtaining records from the school and talking to personnel, the sentiment was indeed that Danielle was smart and given to “acting out” as she aged. Because Danielle was understandably defensive, she was stubborn and didn’t talk to the counselor or administrative staff; Danielle thus remained a bit of an enigma.

Emma unfortunately didn’t know that she could request psychoeducational testing and that the school legally had to oblige. Some school districts, struggling with resources, may keep mum on making suggestions that could increase their workloads in the areas they are lacking. Knowing the struggles this district experienced over the years, I suspected that was the case. Nonetheless, they also were likely making things more difficult for themselves. An IEP could improve Danielle’s outcomes and de-escalate her challenging activity.  

The Clinical Formulation

As readers are probably seeing in the case of Danielle, more often than not, there is more to it than a kid simply trying to be a problem. It is a court clinician’s job to illustrate this not only for specific recommendations to help keep them court-free, but helping tell the child’s story can be conducive to generating an empathic lens through which the court decides to work with them, whereas they may just know the child otherwise through school rap sheets and parental or police complaints.

To provide such a three-dimensional experience of the child to the court, evaluations are written in a data and formulation section, similar to an “intake” form at a provider’s office, but more detailed. While documenting data to inform clinical decisions is generally important, in a legal arena, which operates on evidence, communicating data collected is a particularly meticulous process. In Massachusetts, court clinicians undergo two years of training, complete with supervision, mentoring, and an exam, to master collecting and conveying data and creating effective clinical formulations and recommendations to satisfy the court’s needs to better work with the child/family.

The court clinician creates a detailed narrative, drawing from, and referencing, the data, which helps answer the question(s) the court poses about the child’s psychological profile, behaviors, needs, or other opinion requests. Cour clinicians then pull all of this information together in as ordinary a manner as possible given the vested parties requiring it are not going to be psychology. While in general clinical settings a formulation may be a large paragraph or two, usually to justify a diagnosis/treatment plan within that clinical setting, court clinic clinical formulations are pages long given the need to clearly explain, cite data, and paint the bio-psycho-social-legal nexus picture.

In this case, it was explained to the court that Danielle’s attachment anxiety made it hard to be at school. Add to this that she felt stupid given that the anxiety pervaded her and she couldn’t focus, and that some staff compared her to her mother––what incentive did she have to attend? Being at home assuaged her separation anxiety. For Danielle, her mental resources were spread thin tending to everything else going on outside of school, and clearly she didn’t have the ability to apply herself.  

Acting out and walking out sheltered her from tasks that reminded her she wasn’t as academically capable as she once was, and once she was off school grounds, she could avoid being compared to her mother which, while not to justify her violent reaction to the teacher, is what led to her court clinic evaluation.

The court was informed that Danielle required psychoeducational testing to work towards accommodations that could help her successfully learn despite her emotional impairments. It is a fact that children can receive an IEP not only for specific learning disabilities like dyslexia, but also for social-emotional complications that make learning difficult. Further, it was recommended that Emma reach out to an educational advocate to help navigate any challenges the school might present along the way. Lastly, suggestions were made for specific therapists that might work well with Danielle, so she was not beginning work with one only find out it was not a good fit and have to move to another––never good for a child with attachment complications.   

The Effects of Court Clinic Evaluations

Being neither loyal to prosecution nor defense, court clinicians provide an unbiased opinion that can provide another level of intervention for more thorough growth, to both to the child/family and the community. The uniqueness of court clinicians is not only in them being mental health professionals that provide assessments for legal proceedings, but also that help expose barriers that community providers, including schools, may not have realized or acknowledged. This could be due to anything from it being impossible for therapists to review years’ worth of records and interview other parties to sift for details for missing links, or because of schools towing the district’s agenda and walking careful lines with budgetary and staffing matters.

Understanding these limits, court clinicians sometimes suggest, in the recommendations, that the evaluation be released to a certain provider or school if they feel it will help accelerate the child/family’s gains. While I can only speak for Massachusetts, providers, if they are aware of a court clinic diagnostic evaluation, can request a copy from the court if they feel it might help in treatment or education. While the evaluations are HIPAA protected, they are also considered legal documents and thus owned by the state. Therefore, parents/guardians cannot simply sign a release of information form or provide a “third party release” of the document if they happen to have a copy.

Providers seeking copies must contact the clerk’s office or judges’ lobby of the particular juvenile court and completed paperwork as to the reason they want to review the document. This in turn is reviewed by a judge, who, if they feel it is appropriate for the requesting party to read the evaluation, may order portions redacted, and send other instruction such as forbidding third party release, that it cannot be copied, and/or ask for its return to the court after a certain amount of time. 

***

Danielle’s case may seem starkly in contrast to popular culture ideas of court psychology work, full of interrogations and profiling ostensibly for maximum accountability. The truth is, even the criminal allegation-related evaluations such as for competency and responsibility have a human side. They’re meant to understand the accused three-dimensionally and what struggles may have contributed to the allegation(s) or what struggles might keep them from participating in their own defense. 

Courts aren’t only judicial, but part of the correctional system. Without evaluations to understand the dynamics of the accused, whether civil or criminal, there would only be punishment and no corrections. Consequences alone do not serve to correct. Without addressing the issues that kindled the court involvement, and providing guidance on resolving those issues, there would be no rehabilitation.

Imagine if Danielle was before the court, accused by finger wagging officials about struggles that she didn’t even understand and being expected to somehow learn to act more constructively by being told to “behave, or else!” She would be back in the same classrooms without special education accommodations, utilizing the same defenses, for that’s all she knows. The same behaviors would continue, creating a revolving door of “bad kid” accusations, reifying her already poor image, potentially leading to dropping out or self-medicating, and the inherent complications of each.

If that was to occur, what’s the real crime?

Ultimately, court involvement can truly be an opportunity as there is not only more understanding of dynamics and what’s needed, but with court oversight, steps to obtain what is needed are more likely to be carried out.  

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