Reducing the Duration of Untreated Illness Among Youth in the Juvenile Justice System With Psychosis-Spectrum Disorders
Phase: NA
Conditions: Psychotic Disorders, Psychosis Nos/Other
Sponsor: Brown University

Study Protocol 
 
Reducing the Duration of Untreated Illness Among Youth in the Juvenile Justice System 
With Psychosis-Spectrum Disorders  
 
NCT03583073  
Unique Protocol ID: R34 MH 115457  
9-1-2018

Specific Aims 
According to the PAR-16-264 FOA, “approximately 100,000 adolescents and young adults in the United 
States experience a first episode of psychosis (FEP) every year.” Among these individuals, a substantial 
proportion report having experienced clinically significant positive symptoms (e.g., hallucinations or delusions) 
prior to the age of 18, suggesting that adolescence may be a critical period for employing early intervention 
efforts. In this planning grant application, we focus on adolescents in contact with the juvenile justice system 
(JJS) because the literature indicates that 50-75% of youth in the JJS meet criteria for mental health disorders 
and most are not engaged in mental health services1,2. Among adolescents in the JJS, an estimated 3% have 
a psychotic illness1, and it can be reasonably assumed that many more experience subthreshold psychotic- 
spectrum symptoms that may be indicative of risk. Evidence suggests that as many as 25% of those with FEP 
have their first contact with care through criminal justice agencies3. Among FEP individuals, duration of 
untreated psychosis (DUP), a negative prognostic factor, has been shown to be longer among those within the 
criminal justice system3. This suggests that youth with psychotic symptoms who end up in the JJS may not 
receive appropriate mental health care and may be more susceptible to the negative sequelae associated with 
prolonged DUP. Considering the early phase of illness, literature suggesting an association between longer 
DUP and a host of poor outcomes has led to efforts to identify individuals experiencing emerging psychosis- 
spectrum symptoms as early as possible4–6. Early identification facilitates initiation of empirically-supported 
intervention services such as those offered through Coordinated Specialty Care (CSC) programs. CSCs are 
becoming more widely available across the nation, yet access is often limited due to lack of awareness of 
these services in the mental health community as well as poor patient follow through with referrals to CSCs. 
The current study will be conducted in the Rhode Island JJS in which all youth receive a mental health 
screen (Massachusetts Youth Screening Instrument – 2nd Ed; MAYSI -2). All youth will also be screened with 
the Prodromal Questionnaire – Brief Version (PQ-B7). If they screen in on either the MAYSI-2 or the PQ-B, 
they will be given referral information for CSC services by JJS staff. They will also be offered the opportunity to 
participate in the research assessment, regardless of whether they pursue the CSC referral, which involves the 
Structured Interview for Psychosis-risk Syndromes [SIPS] and other measures to thoroughly assess history of 
psychotic symptoms, comorbid difficulties, and mental health care engagement. A comparison sample of youth 
who do not screen positive on both the MAYSI-2 Thought Disturbance subscale and PQ-B will also be 
assessed with the SIPS to determine accuracy of the MAYSI-2 and PQ-B in the identification of psychosis-risk. 
During the first part (12 months) of the study, JJS staff will follow standard procedures in referring youth to the 
state CSC. In the second part of the study (also 12 months), JJS staff will be instructed in the enhanced 
referral/linkage to care protocol, including a “warm hand-off” where referrals will be put in direct and immediate 
contact with CSC staff CSC staff will also be trained in procedures to increase the likelihood of follow through 
with the referral to the CSC. The research team will conduct 3 month follow-up qualitative interviews and 
quantitative assessments regarding referral pathways, bottlenecks and gaps in care, youth psychiatric 
symptoms, and JJS contacts. The following specific aims, mapped to the four stated goals of PAR 16- 264, 
will be examined: 
Aim 1A: Identify baseline rates of psychosis-spectrum disorders within the JJS by exploring the 
occurrence of psychotic disorders and psychosis-risk syndromes as identified through clinical interview with the 
SIPS. 1B: Examine Duration of Illness (DUI) for sub- and DUP for full- threshold psychosis, in the JJS 
population based on SIPS interview data.1C: Examine the accuracy (i.e., sensitivity, specificity) of the 
MAYSI-2 and PQ-B in identifying youth with psychosis-spectrum disorders, as defined by the SIPS. 
Aim 2A: Examine whether an enhanced referral procedure results in higher rates of completed referrals 
to the CSC compared to standard referral procedures by comparing rates of completed referrals in Phase I, 
standard care, versus Phase II, when an enhanced referral/linkage to care procedure is instituted in JJS. 2B: 
Identify implementation and service level factors that promote/hinder linkage to the CSC by assessing 
feasibility, as determined by penetration (i.e. number of JJS personnel trained, and consistency in using the 
enhanced referral protocol) and acceptability (i.e., JJS staff perceived roles in screening and referral). Barriers 
and facilitators to linkage to CSC services will be examined as will equity of the linkage across gender, race, 
and ethnicity. Efficiency will be rated by the number of text message and phone contacts necessary to 
complete the referral to the CSC. These data will improve understanding of service level factors that influence 
implementation of these procedures, with implications for both a future trial and real world practice. 
Aim 3A: Investigate client level factors, including attitudes about CSC referrals and the rates of treatment 
initiation/retention in CSC services. This data, collected at the 3 month follow-up, will also allow examination of 
the effects of the intervention on DUP as well as treatment barriers and motivation for treatment. 3B: 

Investigate mental health indicators at follow-up including psychotic symptoms and other outcomes (i.e., 
symptoms, social/role functioning), as well as juvenile justice contacts. Aim 3C. Investigate the relationship 
between service mechanisms (treatment linkage/attendance) and psychotic symptoms/DUP. 
Research Strategy 
A. Background. Psychotic disorders are among the most costly and emotionally devastating mental health 
conditions. Psychosis typically emerges in late adolescence or young adulthood, a period of development 
when individuals are pursuing critical milestones in the formation of their identities and life goals8. The 
emergence of psychotic symptoms during adolescence can cause a great deal of distress and disruption, 
oftentimes leading to long-term illness and functional impairment, with poorer prognosis for those with earlier 
onset symptoms9. Those with psychosis-spectrum disorders have markedly increased rates of suicidal 
behaviors10, and although severe violence is uncommon in this population, individuals in their first episode of 
psychosis are at high risk of committing violent acts and coming into contact with the legal system prior to 
receiving treatment11. Evidence supporting the benefits of psychosocial intervention in the early stages of 
psychosis has inspired ongoing efforts to identify individuals experiencing subthreshold symptoms and initiate 
appropriate services for symptom monitoring and/or treatment prior to the onset of full-threshold psychosis. 
Prodromal psychosis. Although psychotic symptoms may emerge acutely within a “first episode” of 
psychosis, colloquially termed a “psychotic break,” schizophrenia spectrum disorders are often insidious in 
nature, with positive symptoms initially emerging as low-level attenuated experiences that, over time, become 
increasingly distressing and impairing. This gradual onset of symptoms is not only associated with prolonged 
distress, but also poorer long-term outcomes. While the incubation period for psychotic symptoms varies 
greatly between individuals, many report a period of months to years during which psychotic-like experiences 
increase in frequency, intensity, and associated interference before they receive appropriate care. Insidious 
symptoms often go unrecognized for a host of reasons including confusion (among patients and individuals 
close to them), lack of insight, embarrassment, attempts to minimize the significance of or hide symptoms, and 
belief that symptoms will resolve on their own. Thus, psychosis-spectrum symptoms often progress, untreated, 
until acute level care is warranted, and onset characterized by gradual progression of symptoms is associated 
with longer duration of untreated psychosis (DUP12). Not surprisingly, longer DUP is associated with 
particularly poor clinical, functional, and cognitive outcomes, and the more broadly defined duration of 
untreated illness (DUI; which includes prodromal and full-threshold stages of illness) may be more strongly 
linked to psychosocial outcomes13. Overall, the DUI/DUP evidence suggests a need to recognize and treat 
early psychosis-spectrum symptoms to maximize recovery and minimize the personal and financial sequelae 
of illness9. 
Clinical high-risk states. Advances in understanding the prodromal stages of psychosis have led to the 
development of a relatively new diagnostic category, Attenuated Psychosis Syndrome (APS), that is now 
included in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). Individuals with 
APS are those determined to be at clinical high-risk (CHR) for psychosis based on their endorsement of 
subthreshold positive symptoms (i.e. delusions, paranoia, grandiosity, hallucinations, and disorganized 
communication/thoughts) that are distressing and interfering, yet lacking in intensity, frequency, or conviction 
necessary to meet a full-threshold psychosis diagnosis14,15. Individuals with APS have been shown to have a 
markedly high risk of developing future psychosis, as approximately 36% of those identified will transition to 
psychosis within three years16. Fortunately, treatment initiated among those determined to be at CHR, prior to 
psychosis onset, has the potential to alleviate severity, delay onset, and, in some cases, prevent the 
development of full-threshold symptoms17. Evidence showing positive outcomes associated with the initiation 
of treatment during the prodromal phase and proximal to the onset of psychosis calls for early identification 
initiatives aimed at recognizing potentially prodromal symptoms and related markers of early illness. 
Identifying individuals at risk for psychosis. Advances in understanding the prodromal stages of 
psychosis have led to the development of assessment tools aimed at identifying individuals at CHR for 
psychosis14,15. Interviews that focus on subthreshold positive symptoms that can be reliably rated and 
classified have been shown to identify individuals with a notably heightened risk for psychosis16. Unfortunately, 
these interview-based assessments are costly and require significant training and administration time. Given 
these hurdles, as well as the low base-rate of psychosis-risk, full interviews are not likely to be widely adopted 
for clinical use outside specialty psychosis clinics. Therefore, efficient and low-cost first-line screening methods 
may be more practical tools for identifying individuals who may benefit from thorough psychosis-risk 
assessment within community settings. 
The use of brief psychosis-risk screening tools has the potential to conveniently identify individuals who 
may benefit from a thorough interview-based evaluation7,18. Several screening tools have been developed and 
validated among help-seeking clients in the context of psychosis-risk clinics19, however, given constraints 
related to implementation of new, specialized measures within community settings, it is likely that a more 
feasible and acceptable approach to screening would include the use of key items within a broad measure of 
mental health concerns. Key-item screening is defined as the use of a limited number of specific items across 

a wide range of clinical domains to, 1) assess risk, and 2) prompt further probing within specific areas of 
concern. If a client endorses a key item, the clinician follows up with additional questionnaires and/or clinical 
interviewing. Many non-specific mental health questionnaires have been developed to screen across multiple 
diagnostic categories, and success in the prediction of certain concerns (e.g., anxiety) has been 
demonstrated20–24. The validity of key items to screen for psychosis risk, however, has never been 
systematically examined as a means to facilitate more widely adopted intervention for early psychosis. 
Youth in the Juvenile Justice System. One high risk group that receives relatively little attention in the 
literature with respect to identification and referral to treatment for psychotic symptoms is youth involved in 
Juvenile Justice (JJ). This study will focus specifically on court-involved, but non-incarcerated (CINI) juveniles, 
who comprise approximately two-thirds of the JJ population seen in the Juvenile Justice System (JJS). In 
Rhode Island, these youth, typically ranging in age from 11-18, have their first contact with the JJS in the 
Rhode Island Family Court (RIFC) Juvenile Intake Department (JID), a diversion based program for first-time 
offending youth. Most first-time offending, CINI juvenile offenders are diverted through monitoring (typically 90 
days) by a juvenile intake coordinator who makes various referrals (e.g., substance abuse treatment, mental 
health evaluation) and closely monitors adherence with the caveat that intake requirements must be completed 
to avoid further JJ involvement (see letter of support from Chief Judge Michael Forte). 
Linkage to treatment among JJ youth. In RI, the majority of youth (67%) who made their first contact 
with the JJS fell into the caution or warning range of at least one mental health subscale of the Massachusetts 
Youth Screening Instrument- Second Edition (MAYSI-2) with 40% flagging on at least 2 subscales25. For many 
youth, the JJS is the ﬁrst point of contact for mental health support26 and often their only access to these 
services27. CINI youth who endorse recent psychiatric symptoms on screening tools generally do not have 
immediate access to a medical or mental health provider for services28,29. For example, Burke and colleagues 
(2015) found that 74% of youth who made their first contact with the JJS had a psychiatric disorder, yet only 
20% reported receipt of mental health services at follow-up assessments30. In another study, youth in the JJS 
had the lowest rates of mental health treatment utilization in a large sample of adolescents who received 
services in at least one public sector of care, e.g., alcohol and drug services, child welfare, etc31. Lack of 
access to needed mental health services among JJ youth32, may increase risk for a range of future 
psychopathology, including psychotic symptoms. Connecting JJ youth to care is a priority of this application. 
At the RIFC JID, evidenced-based screening measures, including the MAYSI-2, were implemented in 
2014 to screen CINI youth for mental health and substance use issues. To date, 11% of these youth flag in the 
caution or warning range on the MAYSI-2 Thought Disturbance subscale33. Unless they are floridly psychotic 
and require emergency care, the overwhelming majority of these CINI youth return home with referral 
information to a community mental health clinic or, at best, a future mental health appointment with a poor rate 
(48-62%) of treatment uptake in the RI community33. The National Center for Mental Health and Juvenile 
Justice (NCMHJJ) Blueprint for Change goals include access to mental health treatment for all youth who 
endorse mental health symptoms indicating risk for a possible crisis or self-harm34, a frequent concern of 
individuals with psychotic symptoms. 
What prevents use of mental health services in JJ youth? Nationally, a commonly cited barrier to JJ 
involved youth receiving mental health care includes poor identification of mental health problems and referral 
to care. Mental health screenings are underutilized within the JJS and psychiatric disorders are often not 
detected35. For example, Hoeve et al. (2014) found that only 60% of youth with a psychiatric disorder received 
a treatment referral following probation or detention intake, with the lowest rates of referrals given to those with 
internalizing disorders35. In another study of substance using CINI youth, only 18% received referrals to JJ 
drug and alcohol services36. Of youth endorsing suicide ideation at the JID screening, 14% of youth were not 
referred to mental health services37. Minority and disadvantaged youth, who are overrepresented in the JJS, 
have particular problems with access to care38–41. In the Rhode Island JID, for example, white youth had 3.37 
greater odds of being referred compared to black youth (p < .01) who endorsed a lifetime history of trauma. 
In addition, when given referrals, CINI youth and their families often do not follow through with court 
recommendations and referrals, posing significant challenges for JJ staff in monitoring and enforcing juveniles’ 
compliance with court orders. Factors related to nonadherence include living situation42, poor family and social 
functioning43, and social disadvantage44. Many adolescents and guardians may also exhibit low levels of 
motivation to change as a result of being court ordered to seek intervention45,46. In this application’s 
intervention protocol, we pay particular attention to educating caregivers about mental health treatment and 
improving access to care by linking families to appointments for specialized psychosis-spectrum care at the 
time of their positive screen at the JID. 
Early psychosis intervention through Coordinated Specialty Care. Given the rise in recognition of 
psychosis-risk syndromes and the promising benefits of early psychosocial care, specialized psychosis- 
spectrum intervention services are being established across the nation. Coordinated Specialty Care (CSC) 
intervention programs offer tailored services to clients with psychosis-spectrum disorders to help individuals 
effectively manage early symptoms and comorbid concerns (e.g., difficulties related to mood, anxiety, 
attention, and substance abuse), preserve functioning, and reduce the long-term impact of illness. As stated in 

the FOA, “CSC treatment involves integrated, team-based care and typically features use of single 
antipsychotic medications, prescribed in low doses; family psychoeducation; supported employment and/or 
education; cognitive-behavioral therapy oriented to recovery; coordination with primary care services; and 
continuity of care across inpatient and outpatient treatment settings”. Rhode Island has two CSC clinics funded 
by the 2014 SAMSHA set-aside in the Community Mental Health Block Grant Program grant to the state. In 
this research project, we will partner with the CSC based at the Kent Center, the mental health clinic based in 
Warwick, RI, which is the second largest city in the state and only a 15-minute drive for families that live in 
Providence, RI, where the largest JID is located. The CSC based in Warwick, called the Healthy Transitions 
program, uses a team approach to provide case management, family psychoeducation, individual and group 
therapy, coordination of mental health and primary care by a nurse clinician, psychiatry consultation, substance 
abuse specialty care, employment and education counseling, and wraparound case management. The CSC 
accepts patients regardless of insurance status; schedules evaluations typically within 2 weeks; provides 
evening appointments and can be reached by public transportation. Families can be reimbursed for travel 
costs. (See letter of support from Barbara Lamoureux, Program Director). 
Model for dissemination and implementation. The manner in which best practice is implemented in JJ 
settings is important given challenges specific to the JJS. More than 60 dissemination and implementation 
(D&I) research models were identified in a D&I literature review47. The Conceptual Model of Implementation 
Research (CMIR)48, developed from the mental health service field, is most consistent with the current study’s 
goals to utilize strategies to introduce evidence-based practice within a specific setting, juvenile justice48–50. 
CMIR was chosen because of its focus on implementation research with mental health interventions across 
socio-ecological levels relevant to the court setting (e.g., system, organization, and individual levels). 
Successful implementation ensures feasibility, fidelity, context/population responsiveness, and sustainability49. 
In this application, we will train front-line staff in the JID to implement an enhanced referral procedure to 
CSC when an adolescent has screened positive as potentially at risk for psychosis (based on their responses 
on the MAYSI-2 Thought Disorder subscale or the Prodromal Questionnaire – Brief Version; PQ-B7) in order to 
develop a feasible, disseminable process of referral for appropriate mental health services. We will also test 
whether this enhanced referral process results in better linkage to care and improved outcomes compared to 
the baseline control condition. We will examine CMIR-specific implementation strategies, separate from the 
intervention strategies, with the goal of evaluating outcomes at the: implementation-level, such as the number 
of personnel trained and using screening and referral procedures for adolescents with psychosis-spectrum 
symptoms in the JJS; service-level, e.g., quality of the referral performed by CSC staff and the percentage of 
time treatment linkage is completed; and consumer (patient)-level, in particular, outpatient treatment 
attendance, and psychosis-spectrum symptoms. While the ultimate goal of implementation efforts is improving 
clinical outcomes, this model also provides an understanding of the mechanisms through which gains are 
conferred in order to improve both conceptual models of referral processes and the referral process itself. 
SIGNFICANCE. The current study proposes a scalable intervention designed to increase identification and 
linkage to CSC for adolescents involved in the JJS who present with psychosis spectrum symptomatology. 
Juvenile courts, and the JJS broadly, are increasing the proactive screening of youth for mental health 
symptoms. However, there is an inevitable lag between screening and an outpatient mental health 
appointment which, in turn, is followed by generally poor uptake of outpatient treatment. This application’s 
approach is consistent with FOA language, specifically the NIMH interest in “better signal detection of 
psychosis onset, or symptoms suggesting high clinical risk of psychosis, within …. criminal justice agencies,” 
as well as “methods to achieve expeditious referral of persons with first episode psychosis (FEP), or those at 
high clinical risk of psychosis, to an appropriate specialty care treatment program”. As specified in the FOA, 
this planning grant application will also: “identify a baseline rate of DUP”, as well as explore the occurrence of 
psychosis-spectrum symptoms among high risk JJ youth, “identify bottlenecks and gaps in the pathway to CSC 
care”, and “develop and pilot test feasible strategies for substantially reducing DUP”. The scientific premise of 
this research is supported by the need to develop more effective screening and linkage to service strategies 
during a youth’s contact with the JJS, the virtual absence of such studies in the literature, and its enhancement 
by use of a conceptual model for implementation. Our study will provide data on screening delivered by JJS 
staff and improved linkage to follow-up mental health care as the clinical services mechanism hypothesized to 
reduce the DUI/DUP. As requested in the FOA, we will also “provide evidence of the association between 
those targets”, i.e. latency to treatment linkage and engagement in treatment, and “the outcomes of interest 
(e.g., DIU/DUP, symptoms, and functioning)”. In exploratory analyses, we will also assess potential moderators 
that may inform which youth most benefit from this screening/referral intervention, including adolescent sex, 
gender, race, ethnicity, and socioeconomic status, as well as service level factors, i.e., fidelity of JID and CSC 
staff to the referral process. This research also has the potential to directly inform clinical practices in JJS 
settings and has significant implications for scalability and dissemination. Scientific rigor is maintained by 
ensuring fidelity to the brief screening/referral protocol, study retention procedures, blinding of research 
assessors, data analytic strategies including missing data procedures, which are described in detail in the 
approach section below. Additionally, relevant biological variables, specifically sex, are considered in the 

experimental design. If the number of females is sufficiently large, we will report results separately by sex but 
do all primary hypothesis testing without sex stratification. We will also conduct analyses with boys alone 
because the sample will be largely boys. 
B. INNOVATION: The proposed study is innovative in that it proposes a new approach to screening and 
referral with adolescents at high risk for or in the early stages of psychosis by: 1) using a protocol that is 
designed from the start to be readily disseminable to other JJS settings; 2) measuring moderators and 
mechanisms of action underlying the enhanced referral protocol; 3) examining the MAYSI-2/PQ-B as screens 
for psychosis risk; and 4) examining gender identity, given that those who identify as transgendered have high 
rates of psychotic symptoms 51 but this question has not been examined in the juvenile justice population. 
C. APPROACH 
Overview of study procedures. This study will be implemented as a roll-out trial, a commonly used 
approach in system-wide intervention designs52,53. During the JID intake process, all juveniles attend their 
appointment with a caregiver/legal guardian and complete the MAYSI-254 and PQ-B. Youth will be eligible to 
participate in the study if they flag on either the caution (2 items endorsed) or warning (3 or more items 
endorsed) cut-offs on the 5-item MAYSI-2 Thought Disturbance subscale, or the cut-off score (> 6) on the PQ- 
B. Using both measures will allow us to examine rates of false positives on the MAYSI-2, which is commonly 
used in juvenile justice settings, enhance identification of females at risk, which is a relative weakness of the 
MAYSI-2, but not the PQ-B, and collect data on the PQ-B with this population, adding to the database of this 
commonly used measure in NIMH-funded studies (Personal communication, PO Susan Azrin). 
JID intake workers will contact the research team when a youth screens in. As a back-up system, the JID 
workers turn in their MAYSI-2/PQ-B forms to the RIFC Mental Health Clinic (MHC) each day so the mental 
health team can determine if any further mental health evaluation is necessary for endorsement of any 
symptom. Co-Is Thompson and Kemp will be involved in this process so that if a youth who screened in on the 
Thought Disturbance subscale was not referred by the JID intake worker, they will be contacted by research 
staff if they signed the consent to contact form. Co-I Thompson, the Research Coordinator, or an RA, both of 
whom will have an office in the RIFC MHC on the same hallway as the JID, will consent/assent families. 
Research staff will be registered as court interns which will allow access to court records and the court 
calendar. Co-I Kemp, who also has an office in the MHC, will be the back-up for approaching families. 
Because there are several research projects being conducted in the RIFC JID, Co-I Kemp has established 
a procedure whereby all families in the waiting room are approached by an RA and asked to sign a “consent to 
contact” form. If a parent signs this form, and the teen subsequently screens positive and qualifies for a study 
being conducted in RIFC after the JID intake worker administers the MAYSI-2/PQ-B, research staff will then 
meet separately with parent/caregiver and the juvenile to describe study procedures in detail and 1) obtain 
juvenile assent without parental presence (note: no juvenile will ever be sanctioned by the court for not 
agreeing or being unable to participate in the research study; see Human Subjects/RIFC Chief Judge Letter of 
Support), and 2) obtain written informed consent from the parent/caregiver. If the research team is unable to 
meet with the family while they are at their intake appointment, the family will be contacted by phone/text and 
an appointment, either at the RIFC or at the family home, to consent/assent the parent and teen, and conduct 
the baseline assessment. Consenting procedures will also include permission to access court records. 
Intervention condition overview. The intervention will have two phases: 1) a Standard Care (baseline 
control) condition, followed by, 2) an Enhanced Referral/Linkage to Care condition. Because this is a roll-out 
trial, the two conditions will be compared using a non-randomized open trial design. Design Consideration: 
We decided against randomization due to the following reasons: a) use of front line workers, as opposed to 
research staff specifically employed for the purposes of the research study, could result in contamination 
across the two study conditions; b) randomization would create the potential for therapist characteristics having 
a primary effect on referral outcomes; and c) JJS administrators and staff, at this site have expressed concerns 
that randomization is an unacceptable practice in the JJS because it results in the denial of what is assumed 
to be a superior service, the Enhanced Referral condition, to 50% of the youth. 
Families approached in months 3 - 14 (n = 100; 12 months of recruitment) will be in the standard care, 
baseline control condition and receive standard court procedures, with one exception. If the youth screens 
positive on the Thought Disturbance subscale or PQ-B, the intake worker will be instructed to refer the family to 
the CSC, rather than their local mental health clinic. 
During months 6 – 17, follow-up assessments of the standard care group will be completed and in 
months 18 – 19, JID intake workers will be trained in the Enhanced Referral/Linkage to Care protocol as will 
the CSC staff who receive the referral from JID intake workers. 
Youth consented in months 20 –31 (n= 100; 12 months of recruitment), will receive the Enhanced 
Referral/Linkage to Care protocol. Details regarding the content of this condition are described below. 
Design Consideration: We considered enrolling an older sample because we will likely identify a larger 
proportion of prodromal (CHR) rather than syndromal psychotic disorder youth in juvenile justice. Nonetheless, 
this application’s approach is consistent with FOA language, specifically in “better signal detection of psychosis 
onset, or symptoms suggesting high clinical risk of psychosis, within …. criminal justice agencies,” as well as 

“methods to achieve expeditious referral of persons with first episode psychosis (FEP), or those at high 
clinical risk of psychosis”. As specified in the FOA, this planning grant application will also: “explore the 
occurrence of psychosis-spectrum symptoms”. 
We also considered having staff from the RIFC MHC perform a full evaluation before referring to the 
CSC but MHCs are not consistently associated with JJS nationwide so we opted for a procedure that would be 
generalizable to the JJS nationwide. Similarly, we considered having CSC staff meet the family at the JID but 
again felt this would not be a typical service delivery approach and consequently would affect eventual 
dissemination of our protocol. 
Qualifications of research team. This application brings together clinical researchers with expertise in 
screening, brief intervention, and referral (PI Spirito, Co-I Wolff) and mental health in the JJS (Co-I Kemp). PI 
Spirito and Co-I Wolff have collaborated on 7 NIH treatment grants, primarily on adolescents with mood 
disorders and high levels of affect dysregulation. They are very experienced in conducting treatment trials with 
adolescents with major psychopathology55 39 , and just completed two studies (MH01783; AA020705). All of 
these studies have included an in-depth assessment of psychopathology. Co-I Wolff also works on the 
adolescent inpatient unit at Brown’s child psychiatric hospital, Bradley Hospital, and routinely supervises 
treatment teams making differential diagnostic decisions regarding adolescents with psychotic symptoms. PI 
Spirito is currently conducting a screening/brief electronic intervention for substance misuse in juvenile justice 
with Co-I Kemp. Co-I Thompson brings experience in working with youth with psychosis-spectrum disorders. 
She has specific expertise in psychosis-risk assessment, having been trained by SIPS creators and worked as 
a graduate assistant for five years administering comprehensive diagnostic interviews including the SIPS to 
young people (aged 12-25) as part of the Maryland Early Intervention Program (funded through the Maryland 
Department of Health and Mental Hygiene, Behavioral Health Administration through the Center for Excellence 
on Early Intervention for Serious Mental Illness OPASS# 14-13717G/M00B4400241). Co-I Thompson also has 
experience in the development and administration of DUP interviews among young adults within an FEP clinic 
at the Maryland Psychiatric Research Center. Co-I Yen brings expertise in assessment and brief interventions 
with high risk adolescents, and has collaborated with PI Spirito on 6 NIMH and 2 private foundation grants. She 
is currently the PI on a brief intervention for psychosis and suicidality in adolescents/young adults with patients 
recruited from an inpatient psychiatric unit (AFSP grant SRG-0-158-14). She is also the Director of the Training 
and Assessment Unit at the Department of Psychiatry and Human Behavior at Brown University. Co-I Kemp 
collaborated on three prior NIH funded grants focused on youth involved in the JJS (HD080780; DA034538; 
DA035231). Currently, PI Spirito is the primary mentor on Co-I Kemp’s Mentored Career Award (MH111606), 
focusing on suicidality among JJS involved youth. Co-I Kemp has received extensive training in qualitative 
research methods and interviewing. She is the Director of the RIFC MHC, which conducts forensic mental 
health evaluations with youth throughout the JJS continuum, including screening of adolescents with psychotic 
symptoms. She is very experienced in conducting research and examining clinical need with JJS involved 
youth. Co-I Kemp has worked extensively with the Chief Judge and Deputy Court Administrator, Kevin Richard, 
to implement research protocols within the court setting. She also oversees JID intake workers on screening 
youth for mental health and substance use issues with the MAYSI-2. 
The assembled research team collectively brings expertise in the assessment of adolescents with a broad 
range of psychopathology, including psychosis-spectrum disorders, experience in conducting community- 
based research, and experience in improving assessment and referral within the juvenile justice system. 
Participants. JJS offenders, ages 12- 17, will be eligible for enrollment with the following criteria: 1) legal 
guardian available to consent for juvenile’s participation, and adolescent assents to participate; 2) juvenile is 
English speaking; parents may be Spanish-speaking because we will have Spanish-speaking research staff 
and interpreter services available; and 3) juvenile flags positive on the MAYSI-2 Thought Disturbance subscale 
or the PQ-B. Exclusion criteria include: 1) observable developmental delays that would interfere with obtaining 
assent and/or accurate assessment, and 2) juvenile meets hospital level of care for imminent risk due to 
severity of symptoms, in which case they will be transported to Emergency Department per existing JID 
procedures. In addition, we will collect a comparison sample (n = 70) meeting these same inclusion/exclusion 
criteria with the exception that they will screen negative on the MAYSI- 2 Thought Disturbance subscale and 
PQ-B. This subgroup will be used in analyses exploring the sensitivity/specificity of the MAYSI-2 Thought 
Disturbance subscale and PQ-B.. The MAYSI-2 is a 52-item self-report measure for ages 12-17 that screens 
for current MH symptoms. The Thought Disturbance Subscale consists of 5 items, 4 of which refer to altered 
perceptions of reality and the fifth to de-realization. The developers do not recommend use of the subscale 
with girls. The PQ-B, a 21 item measure for both males and females, with an 8th grade reading level and takes 
3-4 minutes to complete. In a sample of 141 adolescents and young adults referred for assessment to 
prodromal research centers, the instrument achieved specificity of 0.68 and sensitivity of 0.88 with regard to 
SIPS diagnoses using a cutoff distress score threshold of six or greater on the weighted distress measure. A 
recent review indicated sensitivity ranging from .70-.97 across different samples19. 
Racial and ethnic minority considerations. Consistent with 2016 RIFC statistics, ethnic representation 
will be approximately 18% Hispanic and racial representation will be about 22% African American or Black 

(and other) and 72% White. Consistent with US nationwide statistics, African American juveniles are 
disproportionately represented (22% of juvenile offenders, yet only 6% of the entire Rhode Island population). 
Approximately 9% of intake cases involve parents who speak only Spanish (see Facilities & Enrollment Table). 
Females are increasingly represented in the system (29% in 2016) and are disproportionately represented 
among status offenders (account for 46% of status offenses relative to 11% of violent offenses). We expect our 
sample to reflect these demographics, but we will over-sample girls if possible to lower the ratio of boys to girls. 
Estimated sample size and retention rates. In 2016, the RIFC handled offenses for 2,634 juveniles of 
whom 764 (29%) were female and 2,581 (98%) who were in the 12-17 year old age range. The JID, for 
example, typically screens more than 900 juveniles per year and, of those youth who are screened, 
approximately 11% (N= 99) flag for thought disturbance. With a conservative enrollment rate of 70%, and 12 
months of enrollment in both the baseline control (n = approximately 100 positive screens) and experimental 
intervention condition (n = approximately 100 positive screens), we would be able to meet our projected 
enrollment goals for both baseline standard care (n = 70) and enhanced referral (n=70) conditions. Using a 
conservative follow-up rate of 80% of the 140 enrolled and retained participants, approximately 55 families in 
both the baseline control and experimental condition are expected to complete the 3-month follow-up. In 
addition, we will recruit 70 youth in Phase I and Phase II who do not screen positive on the MAYSI-2 or PQ-B 
in order to conduct the sensitivity/specificity analyses. These projections are feasible given our excellent 
working relationship with the Rhode Island JJS including the RIFC and prior experience recruiting from the JID 
(see RIFC Chief Judge Letter of Support). Co-I Kemp collaborated on a 24-month longitudinal epidemiological 
study of first-time CINI offenders at the RIFC and she successfully recruited the entire sample of 400 first-time 
offending CINI youth (DA034538). Co-I Kemp is also currently recruiting at the RIFC JID for a baseline sample 
of suicidal CINI youth for her NIMH K23 Mentored Career Award. PI Spirito also successfully established a 
referral system from RIFC to two completed grants, NIAAA (AA017659) and NIDA (DA0029871) trials for youth 
with substance use-related court involvement. 
Protection against attrition. To maximize participant retention, we will employ procedures routinely used 
in our studies to reinforce with JJS families the value of the follow-up portion of the study and to use all 
available resources to locate participants. Contact information will include the names and phone numbers of 
two friends/family members who can be contacted if staff is unable to reach the teen. We will also ask for the 
parent and teen cell phone numbers and emails. Contact information will also be updated periodically prior to 
the 3-month follow-up assessment. Participants will also be given refrigerator magnets and pens with the 
program’s contact information as well as a card with the date for the follow-up assessment. Reminder 
postcards, text messages, and emails will be sent to participants. Telephone calls will also be made to 
participants. Weekly case review meetings will be held with the PI and Co-Is to review no-shows and plans 
discussed to complete contact with the participant. We have used these procedures with success in prior 
projects. Participants will be contacted 1 week prior to their follow-up appointment. In PI Spirito’s NIAAA- 
funded study with CINI youth, retention rates were 94% at 3 months and 84% at 6 months 
Compensation for participation. Families will be compensated $100 for each assessment ($50 each, for 
a parent and the teen, at baseline and 3-month follow-up). 
Referral Conditions 
Phase I, months 3 – 14: Standard Care (baseline control) condition. In the Standard Care condition, if 
a teen has a positive screen on the MAYSI-2/PQ-B screening battery, JJS staff members determine whether 
there is need for further evaluation or concern of imminent risk. If there is concern for imminent risk, then the 
staff member contacts a clinician in the RIFC Mental Health Clinic for an emergency evaluation. If the teen is 
not at imminent risk, a referral to a community mental health clinic is arranged by the JJ intake worker. In this 
application, we will follow the same procedures, but if there is no imminent risk, the JID staff member will refer 
to the CSC rather than a community mental health clinic. The CSC will evaluate the teen and offer services at 
the CSC if psychotic symptoms are a primary concern. CHR youth with other primary issues (e.g., trauma, 
substance use) are typically seen by other services in the mental health clinic which houses the CSC. All CHR 
youth who consent to the study will be seen for follow-up assessments and can be referred back to the CSC or 
mental health clinic to resume/initiate treatment if symptoms worsen. In the data analysis, we will record the 
percentage of youth referred to the CSC who are CHR/psychosis risk, as well as the services they receive and 
clinical outcome data at the 3 month follow-up assessment. Data collected by Co-I Kemp indicates that 26% of 
the youth that present to JID report that they are already receiving mental health treatment. In such cases, the 
families will be referred back to their mental health provider with the recommendation to consult the CSC. 
Phase II, months 20 – 31: Enhanced Referral/Linkage to Care condition. The Enhanced 
Referral/Linkage to Care condition follows the same steps as described in the Standard Care described above 
if there is imminent risk. If there is no imminent risk, the JJ intake worker contacts the CSC program directly for 
a “warm hand-off”. The CSC intake worker will speak with the parent and arrange for an intake evaluation, 
either at the CSC clinic or at the family’s home. For families that are already receiving mental health treatment, 
the JID intake worker will arrange the referral to the CSC for a consultation, at the CSC or family home. After 
the appointment is arranged, the JID intake worker reviews some psychoeducation material about the role of 

mental health care in emotional/behavioral problems (see below). 
In addition, the CSC clinician who takes the phone call will use a motivational interviewing style to 
encourage families to follow up with their scheduled appointment. This portion of the protocol is based on a 
module from PI Spirito/Co-I Wolff’s protocol that was recently tested in two randomized controlled trials 
(MH01783; AA020705) that are nearing completion (see below). 
Psychoeducation material. The JID intake worker will review a handout on common symptoms of 
emotional distress and how youth and parents benefit from seeking mental health services. More specifically, 
the document outlines how to recognize warning signs of emotional distress, and the importance of finding 
support for difficulties that interfere with functioning and quality of life. We decided to use a generic description 
of emotional problems, including some psychosis-like experiences as well as other common concerns, rather 
than a description of specific psychosis-spectrum symptoms, because we believe it is more consistent with the 
level of training of JID workers and avoids the premature implication of a psychotic disorder diagnosis. In 
addition, to ensure these procedures can be easily disseminated in the future if they appear useful, we kept 
this aspect of the protocol very straightforward. The JID Intake worker will just be asked to read through the 
handout with the parent and not required to learn any interview material about mental health care or psychosis- 
spectrum symptoms. The review of the psychoeducation material will be presented with the goal of enhancing 
the chances that the family will follow through with the CSC appointment. 
Motivational interviewing prompts. Similar to the psychoeducation aspect of the protocol, the CSC 
clinician will not be required to learn any interview material but instead will have a sheet with the following 
prompts adapted from motivational interviewing protocols by Drs. Spirito and Wolff. The decision to keep this 
aspect of the protocol very structured was to ensure its eventual disseminability. Prompts include: 
Do you think it is necessary for your child to be seen at the clinic? 
May I share a few concerns I have? 
Some teens who have thoughts such as [specify] often get worse as they get older. For many teens, it’s only 
temporary and they start to feel better after they start talking to someone. 
And for some teens there are medicines that can help with these thoughts quite a bit. 
Getting help for these thoughts early is important so we really encourage parents to get it checked out. 
How are you feeling about going to the clinic appointment? 
What might get in the way of you being able to do that (i.e., transportation, insurance, time of day)? 
Is there anything we can do to help make it easier for you to get to the appointment? 
We can call you the day before or the morning of the appointment to remind you -- would you like that? 
Follow-up reminders to set up a CSC appointment. Three and seven days after the referral to CSC, the 
JJ intake worker will text the teen’s parent/caregiver to see if the family kept their appointment with the CSC. If 
not, the intake worker will text the parent the phone number for the CSC and will also ask permission to contact 
the CSC to further assist the family in setting up another appointment. JID workers can also choose to contact 
families by phone. A record of contacts will be recorded in order to examine feasibility, acceptability, and 
efficiency of these procedures. 
Training JID and CSC workers in Enhanced Referral protocol (months 18 -19). A one hour training in 
this protocol will be conducted to mimic the type of training that would occur in typical circumstances. For the 
JID intake workers, we will: 1) review the MAYSI-2 Thought Disturbance subscale and PQ-B and discuss why 
these symptoms might be potentially significant for these youth; 2) review the handout about symptoms of 
mental health problems in youth as well as the importance of a follow-up evaluation; 3) review the concept of 
the CSC and why a referral to the CSC would be potentially helpful to the adolescent; 4) review the need to 
arrange a referral to the CSC for a consult even if the youth is already receiving mental health care elsewhere; 
and 5) role play the “warm hand-off” procedures used when referring families to the CSC. 
There will be no ongoing supervision of the JID intake worker because that would be the most likely 
situation in a typical JJS intake department. Instead, we will: 1) as part of routine staff meetings, the JID intake 
workers will be reminded about screening for mental health problems with the MAYSI-2/PQ-B and the referral 
procedures for youth flagging in on any problem, i.e. substance use, suicidal ideation, or thought disturbance; 
2) have the JID intake workers complete procedural checklists at the end of the interview that prompt them to 
follow referral procedures (we have had success with improving procedures with this type of self-monitoring in 
two recently completed RCTs); 3) as part of the research procedure, in their daily review of MAYSI -2 and PQ- 
B forms, research staff will identify anyone who screened positive on these measures and check with the JID 
intake workers about whether they completed the self-monitoring checklist, reviewed the handout with the 
parents and made a direct referral to the CSC. This procedure serves as a feedback mechanism to JID staff 
and as a reminder to complete the referral protocol with youth. 
Fidelity to the Enhanced Referral/Linkage to Care condition. We will have the CSC clinician, who will 
be employed by the research project but also work at the CSC, audiotape their conversation with the family in 
the enhanced referral phase of the study. The CSC clinician will use a hand-held audio recorder so that only 
the CSC clinician’s portion of the conversation will be recorded. Fidelity will also be rated by interviewing the 
parent/caregiver at the baseline research assessment, which will typically occur within a week of the JID 

appointment. Caregivers will be asked what the CSC intake worker said to them about scheduling a CSC 
appointment. The RA conducting the assessment will record verbatim the parent’s responses. In both the 
clinician reported and parent reported data collection, fidelity will be rated by PI Spirito and Co-Is Wolff and 
Yen on a two-point scale (0= not satisfactory; 1= satisfactory). If there is disagreement, a consensus meeting 
will be held to resolve discrepancies in ratings. 
Baseline and follow-up assessment. Families in both phases of the study will complete the same 
assessments at baseline and 3-month follow-up to gather data on treatment history, psychosis-spectrum 
symptoms, general psychiatric symptoms and functioning, as well as JJS contacts (see details below under 
Measures). In addition, at follow-up, we will interview families about barriers to treatment linkage and treatment 
satisfaction. The RA and Co-I Thompson will be blind as to whether the families were seen for follow-up CSC 
or mental health care until after the interviews are completed. 
 
Implementation 
Outcomes 
• Measures 
• Acceptability 
• Qualitative 
interview and 
Self-report 
measure 
• Feasability 
• Data % receiving 
intervention 
• Penetration (i.e., 
how many staff 
trained and 
consistently use) 
• Observation 
 
Service Mechanisms 
• Fidelity 
• Ratings of 
protocol fidelity 
• Efficiency - data on 
follow-up contacts 
to complete 
referral 
• Equity of services 
• Data on linkage by 
subgroups 
 
 
Client Outcomes 
• Treatment 
attendance and 
collateral treatment 
• Psychosis symptoms 
• Other psychiatric 
symptoms 
• Motivation for 
treatment 
• Barriers to treatment 
• Treatment 
satsifaction 
• Recidivism 
• Court records 
We will also interview 
JID intake workers and 
CSC staff to assess both 
services and 
implementation factors 
related to referral process 
and completion. The 
baseline and follow-up 
assessment battery were 
designed to minimize 
participant burden and to 
thoroughly assess 
psychosis-spectrum 
symptoms. The follow-up 
assessment will be 
scheduled 3-months 
post-referral to the CSC. 
The 3-month follow-up 
period will allow us to 
assess whether high risk 
youth engage in 
treatment with the CSC 
or other mental 
healthcare. Both baseline and follow up interviews will be conducted in-person and last approximately 1.5- 2 
hours. 
Co-I Thompson will administer the Structured Interview for Psychosis-risk Syndromes (SIPS), described 
below. She has received formal training and certification by SIPS developers to conduct the interviews, and 
she was trained to research quality reliability (ICC>.8) within her prior research team. She will administer all the 
SIPS interviews in order to maintain consistency across the two phases of the study as well as across 
participants. At baseline, when we will assess youth with both positive and negative screens, Co-I Thompson 
will be “blind” to whether youth have screened positive or negative. At follow-up, she will know that all youth 
have screened positive on the MAYSI-2 and PQ-B, but the RA and Co-I Thompson will instruct families not to 
disclose whether they followed through with the referral to the CSC or whether they have received any type of 
follow-up mental health care until after the assessment is completed. 
Training in assessment. Training in the assessment protocol will occur during the first 2 months by Co-I 
Wolff, following procedures we used in other RCTs. Under Co-I Kemp’s oversight, research staff conducting 
baseline assessments will also receive training on working in the JJS and on how to appropriately respond to 
logistical questions that participants’ may have about the JJS. Co-I Kemp will oversee the baseline assessment 
and Co-I Wolff will oversee the follow-up assessment component of the protocol. If parents request it, the 
results of the evaluation will be shared with the CSC in both phases of the study. 
Procedures for mental health deterioration/safety concerns. It is possible that some participants will 
report symptoms during their research assessment that may warrant additional mental health care. If any youth 
indicates serious psychotic symptoms or suicidal/homicidal thoughts, a safety plan will be established by Co- 
Thompson. Either Dr. Spirito, Wolff, Kemp, or Yen all licensed clinical psychologists, will be notified and review 
the safety plan. In all cases, if families are in treatment at the CSC, or a mental health clinic, a mutually 
agreeable plan will be derived with the CSC clinical team. In the event of an acute crisis, patient will be 
transferred to the Rhode Island Hospital (RIH) psychiatric Emergency Department, where all the PI and Co- 
Investigators Wolff and Kemp have staff appointments and clinical privileges (See Human Subjects). 
Measures. The selection of measures was designed to be realistic for the court system with an emphasis 
on eventual implementation in a larger effectiveness trial. All assessments will be administered via laptops 

using REDCap (Research Electronic Data Capture), a secure web-based application.48 An advantage of 
computer-administered self-report assessments is that participants using this medium have been found to be 
more comfortable disclosing personally sensitive information and to be less likely influenced by social 
desirability in their responses49. Using REDCap instead of traditional pencil and paper measures will also save 
time and labor that would otherwise be required for data entry, double entry, and resolution of discrepancies. 
To ensure participant safety, all items will be reviewed by research staff before the end of the assessment in 
case there is a need to review responses with the youth or caregiver. 
1. Background variables (obtained at baseline only). 
Standard demographic variables including age, sex, race, ethnicity, and education will be assessed, 
including gender identity. Gender identity will be assessed using items listed in “Current Measures of Sexual 
Orientation and Gender Identity in Federal Surveys, August 2016”. Specifically, we will ask “Do you currently 
describe yourself as male, female, or transgender?” If transgender, we will ask “Just to confirm, you were 
assigned [M or F] at birth and now describe yourself as [M or F], is that correct?” Legal history, as well item- 
level responses on the MAYSI-2 and PQ-B, will be obtained from JID records as part of the consent process. 
The collection of much of the data from legal records and existing JJ system procedures is an additional 
strength of this service-based application as it improves feasibility and the potential for scalability in the future. 
2. CMIR implementation level measures 
These data will be collected and measures will be administered to JID staff and administrators at the 
conclusion of Phase II of the project. 
Feasibility will be defined as the percent of youth who screen positive on the MAYSI-2 Thought 
Disturbance subscale and/or PQ-B who receive the Enhanced Referral/Linkage to Care protocol in Phase II of 
the project. Follow-up rates of texting/phone calls will also be examined separately with respect to its feasibility. 
Penetration will be measured by the percent of personnel who are trained to deliver the Enhanced 
Referral/Linkage to Care condition brief intervention. 
Acceptability will be assessed using qualitative interviews with JJ staff related to their perceived roles in 
screening and using the Enhanced Referral/Linkage to Care protocol. In addition, the Attitudes Toward Mental 
Health Screening, a 15-item scale that assesses clinician’s attitudes towards and self–efficacy in relation to 
screening and intervention58, will be administered at baseline and follow-up. The measure has 4 subscales: 
positive attitudes, level of confidence, perceived barriers, and role congruence towards mental health 
screening. Staff rate each item on a five-point scale from “not at all” to “a very great extent”. 
3. CMIR service-level measures 
Fidelity will be assessed using the rating procedure described above. Fidelity will also be considered a 
marker of the quality of treatment linkage in conjunction with the percent of referrals completed to the CSC. 
Efficiency will be rated by the number of text message and phone contacts necessary to complete the 
referral to the CSC. 
Equity will be measured by examining differences by sex/gender and racial/ethnic subgroups in the 
numbers of at-risk youth who receive the Enhanced Referral/Linkage to Care condition, fidelity/quality of the 
Enhanced Referral/Linkage to Care protocol, and actual completion of the referral to the CSC. 
4. CMIR client (patient) level mechanisms 
CSC services. These data will be collected from the CSC with signed, written consent of the parent, and 
assent for those adolescents under age 18. 
Other non-CSC services. The Child and Adolescent Services Assessment [CASA59] is a parent-report 
instrument designed to assess at follow-up the use of mental health services for youth across 31 settings 
including inpatient, outpatient, and informal services. The measure has acceptable psychometric properties. 
Collateral60 information on treatment attendance (attendance at first treatment appointment and total number of 
treatment sessions attended) will also be collected by contacting each juveniles’ treatment provider at the 3- 
month follow-up. A release of information is requested at baseline, for both primary care physicians (PCP) and 
their mental health provider/agency, as part of the court intake process. The consent form will also contain 
language allowing the research team to collect this information from the youth’s treatment providers. 
Treatment motivation (self-report and parent/caregiver report). The Motivation for Youth’s Treatment 
Scale61, an 8-item measure, will be used to assess the youth’s motivation to engage in treatment at baseline 
and at follow-up. The total scale and two subscales (Problem Recognition and the Treatment Readiness) 
produce alpha coefficients of above .80. 
Barriers to treatment. The Barriers to Treatment Participation Scale62, a 44-item measure, will be 
completed at baseline and 3-month follow-up by caregivers to assess barriers that parents/caregivers 
experienced since intervention and the role those barriers may play in treatment engagement. Alpha 
coefficients range from 0.61 to 0.80. 
Treatment satisfaction information will be gathered as part of the follow-up qualitative interview. Youth 
and caregivers will be interviewed about their satisfaction with the Enhanced Referral process as well as 
treatment at the 3-month follow-up. 
5. CMIR client (patient) level outcomes 

General psychopathology. The Brief Problem Monitor (BPM63) will be completed at baseline and 3 month 
follow-up by youth and caretakers to assess general psychopathology including items for rating Internalizing 
(INT), Attention (ATT), and Externalizing (EXT) problems. The items are drawn from the Youth Self Report 
(YSR) and the Child Behavior Checklist for Ages 6-18 (CBCL63/6-18). The reliability and validity of these 
measures have been documented. Each item is rated 0 = not true, 1 = somewhat true, or 2 = very true. The 
BPM was chosen because it assesses behavior over various time periods whereas the CBCL/YSR are 
designed to assess behavior over a 6-month period. 
The Mini International Neuropsychiatric Interview for Children and Adolescents (MINI-KID64) is a structured 
diagnostic interview used to characterize adolescents’ past and current psychiatric diagnoses and can be 
completed in 20-30 minutes. Parents of adolescent participants will complete a collateral assessment of their 
child’s past and current psychiatric diagnoses using the MINI-Kid-P collateral interview. Psychometric 
properties are acceptable and results in reliable and valid psychiatric diagnoses for children and adolescents. 
Psychotic symptoms. The Structured Interview for Psychosis-risk Syndromes (SIPS14) is a semi- 
structured interview targeting interviewees’ experiences of attenuated symptoms and other indicators of 
psychosis risk. The SIPS takes approximately 45-90 minutes to complete and assesses the presence of 
positive, negative, disorganized, and general symptoms. Respondents are determined to meet criteria for 
psychosis-spectrum disorders/syndromes based on their endorsement and description of five positive 
symptoms including odd or delusional thoughts, paranoia/suspiciousness, grandiosity, perceptual 
abnormalities, and disorganized communication. Factors such as the frequency and intensity of positive 
symptoms, along with the level of conviction (belief that the experience is real) and interference (i.e. associated 
distress or impairment), are used to determine whether individuals meet criteria for full-threshold psychosis or 
any of three risk syndromes. The SIPS is the most widely-used psychosis-risk assessment in North America; it 
has been used to identify individuals with significantly elevated risk for psychosis16. Additionally, the SIPS is 
designed to consider comorbid disorders that may better account for symptoms that could, in isolation, be 
conceptualized as psychosis-spectrum. The MINI will be completed prior to the SIPS so that comorbid 
diagnoses will be available. Elevations on the symptom scales of the BPM will also be available and will inform 
specific SIPS prompts to help with differential diagnosis considerations. In addition, in order to ensure 
collection of reliable and valid data from the SIPS, Co-I Thompson will audiotape interviews, with participant 
permission, and she will present the case to two of the Investigators on the study. Differential diagnoses will be 
discussed as well as whether symptoms might be better explained by other disorders. 
In addition to rating current symptomatology at the date of interview, the SIPS is designed to track the 
emergence and progression of symptoms over time. For all positive symptoms that meet either risk or 
psychosis threshold, a timeline is established to retrospectively track when symptoms first reached clinical 
significance and the date when respondents would have first met risk or psychosis criteria. The SIPS is also 
designed to track symptom progression across assessment time points. At each assessment, the rater 
determines whether individuals meeting psychosis/risk criteria are best characterized as having progressing 
(i.e. worsening), persisting (i.e. stable), or remitting (i.e. partially or fully remitting) illness. This onset and 
trajectory information will be used to define the start of illness as well as to measure DUI and DUP. 
Duration of Untreated Illness (DUI). DUI (including DUP) is defined as the time between the onset of 
symptoms and the initiation of adequate treatment. DUI will be measured using a combination of measures, 
specifically the SIPS to track positive symptom onset, the CASA to track adequate treatment, and a summary 
measure to calculate both DUI and DUP. Given that many DUP measures exist, no particular tools stand out 
as superior65, and the specific tool used to measure DUP does not seem to have a significant impact on mean 
or median DUP66, we will derive DUP in conjunction with established measures of symptoms and treatment. 
Using a validated measure of psychosis-spectrum symptoms, namely the SIPS, we will be able to create a 
thorough timeline of symptom onset and progression. Given the lack of consensus in the literature surrounding 
what constitutes adequate or effective treatment across psychosis and risk populations67, two reasonable 
treatment variables will be included in the measurement of DUI and DUP: 1) date of first completed course of 
antipsychotics for one month or more, or 2) date of initiation of consistent psychosocial treatment (attending 4 
or more sessions within 6 weeks), including psychosis-specific symptom monitoring and/or intervention65–67. 
Both of these variables will be captured by follow-up questions on items contained on the CASA, and the 
earlier of the two dates will be considered the date of adequate treatment provision. We will synthesize SIPS 
and treatment date in order to calculate DUP and DUI. The DUI summary form will be reviewed with parents to 
determine if the onset of psychosis symptoms aligns with their perspective of when symptoms emerged (to 
help account for lack of insight that may interfere with accurate reporting from youth), and clinical judgment will 
be used to navigate discrepancies and determine approximate DUI/DUP in the consensus meeting. 
Functioning. Global Functioning- Role and Social Scales (GF-R and GF-S68) are clinician rated scales 
measuring functioning across two domains: role fulfillment and social integration/engagement. This set of 
scales was developed for the North American Prodrome Longitudinal Study (NAPLS68–70), a large multisite 
study investigating psychosis-risk, as a way to obtain consistent ratings across study sites. The measure was 
designed for individuals in the age range of highest risk for psychosis (i.e., ages 12-29), and it includes detailed 

rating anchors based on developmentally appropriate activities and difficulties that may emerge in early stages 
of psychosis. Each GF scale includes 10 categories of functioning rated 1-10, with lower scores indicating 
more impairment. In addition to rating an individual’s current level of functioning, the GF scales include ratings 
of the individual’s highest and lowest rating within the past year (rated on the same scale, 1 to 10) to track 
changes in functioning across time. The GF scales are rated using information gathered through clinical 
evaluation (e.g., SIPS and MINI). In a recent study comparing the GF scales to similar functioning scales 
among help-seeking young people, Wilson and colleagues (2014) reported moderate to strong correlations 
between the measures. In addition to establishing adequate concurrent validity, this study looked at depression 
in relation to the GF scales and results suggested that the GF scales may successfully separate functioning 
from psychiatric symptom severity. This possibility, in addition to the brief and easily scored format of the GF 
scales, made the GF-R and GF-S appealing options for the current study. 
Recidivism (collateral data from RIFC database). Juveniles’ recidivism rates (e.g., new arrests), description 
of related charges (e.g., substance-related, property) and time detained/incarcerated (all tracked by the RIFC 
database) will be available. 
Data Analysis Plan 
Prior to conducting analyses for the project aims, a series of routine procedures will be conducted to ensure 
the data accuracy/adequacy. All forms will be checked for missing data. Descriptive statistics will be examined 
for distributional properties of the variables (e.g., normality, internal consistency). The data will be transformed 
to achieve normality if needed. Attrition/missing data: It is anticipated that less than 20% of subjects will not 
have follow-up. We will test for differential attrition across the standard care and experimental condition. 
Sex as a biological variable. Our study does include specific a priori hypotheses about sex differences. 
However, we will tabulate our results separately by sex, although all hypothesis tests will use a unified sample. 
For the qualitative analyses described below, stakeholder interviews will be audiotaped, transcribed, and 
entered into NVivo, a qualitative data management program. Co-I Kemp, who has received extensive training 
in qualitative methods, will develop coding process in collaboration with PI Spirito and Co-Is Wolff and Yen for 
qualitative information related to the systems-level factors and implementation process. These coding schemes 
will be used as a guide and adapted based on emergent themes from the data collected for the evaluation of 
the Enhanced Referral/Linkage to Care condition. The coherence between qualitative coding schemes and 
established quantitative measure subscales such as the Attitudes toward Mental Health Screening will allow for 
triangulation of the rich data captured by this process. As described below, we will examine interest in and 
acceptability of screening and referral in the JJS stakeholder’s perspective, and barriers and facilitators of 
screening and referral, from both JJS staff and families perspectives. 
Aim 1: Identify baseline prevalence of psychotic disorders and psychosis-risk syndromes within 
the JJ system. We will calculate the percentage of youth who screen positive on the MAYSI-2 Thought 
Disturbance subscale and/or PQ-B over the 2-year period of the study. We will also calculate mean, median, 
and range of DUI/DUP in months, for both sub- and full- threshold psychosis. Correlations and regression 
techniques will be used to explore the relation between attenuated psychosis (both individual symptoms and 
syndromes) and co-occurring symptoms (BPM symptomatology; MINI symptoms and diagnoses). Prevalence 
estimates will make use of a weighted sample that takes into account the selection probability for SIPS 
evaluation given MAYSI-2 and PQ-B results, so that our results are generalizable back to the population of JJS 
youth. We will also examine the utility of the MAYSI-2 Thought Disturbance subscale and PQ-B as screeners 
for psychosis-spectrum syndromes and disorders by determining the criterion-related validity (e.g., sensitivity, 
specificity, positive and negative predictive value) of number of items endorsed for predicting psychosis risk, as 
confirmed by clinical interview with the SIPS, as well as compare the two screens. This analysis will also use 
the weighted data from the MAYSI-2 and PQ- B and SIPS evaluation sample, and logistic regression 
procedures. 
Aim 2A: Examine whether an enhanced referral procedure results in higher proportion of completed 
referrals to the CSC compared to standard referral procedures by calculating the proportion of completed 
referrals in Phase I, standard care, versus Phase II, when an enhanced referral/linkage to care procedure is 
instituted in JJS. An 80% linkage will be considered a success, and reflects the expected linkage proportion in 
Phase II. The probability of linkage will be contrasted across phases using logistic regression procedures. 
Aim 2B: Identify implementation and service level factors that promote/hinder linkage to the CSC. 
Feasibility and Penetration, the number and percentage of JID personnel trained and consistency (% of time) 
using the enhanced referral protocol will be calculated with descriptive statistics. A rate of 80% will be the 
benchmark. Efficiency will be rated by the number of text message and phone contacts necessary to complete 
the referral to the CSC. A benchmark of two contacts will be considered an indicator of efficiency. Equity of 
enhanced referral protocol fidelity and treatment linkage across gender, race, and ethnicity will be compared 
across Phase I (Standard Care) and Phase II (Enhanced Referral/Linkage to Care condition), as well as cross- 
sectionally in the Enhanced Referral/Linkage to Care condition only, using cross-tabulation approaches. 
Acceptability. JJS staff perceived roles in screening and referral will be reported in percentages based on 
qualitative interviews as well as by mean, median, and range of scores on the Attitudes toward Mental Health 

Screening measure. A total of 80% of the JID personnel scoring within one standard deviation of the mean on 
this measure based on the literature will be the benchmark. 
Aim 3A: Investigate client level factors at follow-up. Attitudes about CSC referrals. These analyses 
follow the qualitative interview procedure described above. Rates of treatment initiation/retention in CSC 
services or other mental health care. Percentages of CSC participation will be calculated with 80% set as the 
benchmark as will other types of mental health care as rated on the CASA. For those already in mental health 
care at the time of enrollment, percentages of consultation to the CSC will be calculated, as will the types of 
treatment received and frequency/intensity of the services. Treatment barriers and motivation. Scores on the 
Motivation for Youth’s Treatment Scale61 and the Barriers to Treatment Participation Scale62 will be analyzed 
using a paired t-test to determine any changes in these measures from baseline to three month follow-up. 
Treatment Satisfaction. These analyses follow the qualitative interview procedure described above. 
Aim 3B: Investigate mental health indicators at follow-up. Psychosis-spectrum symptoms will be 
assessed on the SIPS (which will also allow examination of the effects of the intervention on DUP, DUI, and 
functioning) and other clinical outcomes on the subscales of the BPM. The goal of this aim is to obtain a 
reasonably precise estimate of the standard deviation for the outcome variables, and pre-post correlations of 
outcome variables, which are essential statistics for powering a definitive trial. Following Leon and colleagues 
(2011)71 and Kraemer and colleagues (2006)72, our goal is not to obtain a preliminary estimate of the treatment 
effect size, but as per Teare and colleagues (2014)73, the size of the pilot we propose is sufficient to obtain 
sufficiently precise estimates of key variance and covariance parameters necessary to design a definitive trial. 
Our approach will be to conduct an analysis consistent with the testing of the hypothesis that JJS youth 
enrolled in the Enhanced Referral/Linkage to Care condition will have fewer psychosis-spectrum symptoms 
and other clinical outcomes at 3 month follow-up relative to youth in the baseline control. 
The main outcomes are individual and total symptom scores (reflecting intensity, interference, and 
conviction) as well as diagnosis (i.e., low-risk, high-risk, or psychosis) and illness trajectory (i.e. progression, 
persistence, and partial or full remission) from the SIPS. We will also examine treatment attendance, 
motivation for treatment, and treatment barrier reduction. The analysis framework will be linear regression, with 
psychosis-spectrum symptoms as the outcome and Enhanced Referral/Linkage to Care condition as the main 
predictor. In a randomized design, we would be certain that randomization introduced control for measured and 
unmeasured factors. In the baseline control design, we cannot be sure that secular trends might not cause 
different kinds of adolescents to become referred to JJ and/or influence their responses to questions about 
psychotic-like symptoms. For this reason, we will control for a select set of a priori identified confounding 
variables (sex, gender, race, ethnicity, and age), past history of psychosis-spectrum symptoms, and ongoing 
mental health treatment at the time of enrollment. The sign and standard error of the enhanced referral/linkage 
to care condition describes the magnitude and significance of the treatment effect at the threshold level of the 
screen55. For the purposes of this pilot, key outcome parameters are the standard deviation of the SIPS 
positive symptom scores, the pre-post correlation of the SIPS scores, and the overall R2 in follow-up SIPS 
scores given pre-specified covariates. These parameters would be necessary to estimate the sample size 
requirements for a definitive trial. 
Aim 3C. Relationship between service mechanisms (treatment linkage and attendance) and 
psychotic symptoms/DUP. Correlation and regression techniques will be used to examine how use of 
services over the 3-month study period is related to change in psychosis-spectrum symptoms as assessed by 
the SIPS as well as general symptomatology, as assessed by the BPM. 
Exploratory analyses. In exploratory analyses, we will also assess potential moderators of the Enhanced 
Referral protocol effect. We are particularly interested in whether or not the effect of the Enhanced Referral 
protocol varies by sex, gender, race, ethnicity, and socioeconomic status, as well as service level factors, i.e., 
fidelity of JID and CSC staff to the referral process. These exploratory analyses will be accomplished by 
repeating our main analysis models, described above, but including main and interaction effects of selected 
potential moderators with study phase. Inference will be based on effect size statistics for interaction effects 
and used as hypothesis generating results for future studies. 
Power: As mentioned above, per simulation studies conducted by Teare and colleagues (2014)73, a total 
sample size of 60 is sufficient to obtain reasonably precise estimates of key design parameters necessary to 
power a definitive trial with continuous outcomes. Therefore, our total sample of 140 at baseline and 110 at 3 
month follow-up should be sufficient to conduct a simulation study and determine power for a definitive trial. 
Timeline: Months 1 - 2: Start-up; Months 3- 14: 12 months of baseline data collection on Standard Care 
condition (baseline control); Months 6 - 17: 3 month follow-up on Standard Care condition; Months 18 - 19: 
Training of JID intake workers in Enhanced Referral/Linkage to Care protocol; Months 20 - 31: 12 months of 
data collection on the Enhanced Referral/Linkage to Care condition; Months 23 – 34: 3 month follow-up on 
Enhanced Referral/Linkage to Care protocol; Months 35 - 36: Analyze data and prepare manuscript. 
Future research. As stated in the FOA, this R34 planning grant proposes “the developmental work to be 
performed that enhances the probability of success in a larger study” and “develops and refines the research 
strategies to be utilized in the subsequent large-scale study….as well as close gaps in the pathway to specialty 

FEP care”. If successful, this planning grant will set the stage for a Type III Effectiveness-Implementation 
design to test this implementation strategy while also collecting data on the Enhanced Referral protocol’s effect 
on linkage to CSC level care, DUP, and psychosis-spectrum symptoms. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
1. 
Fazel S, Doll H, Långström N. Mental Disorders Among Adolescents in Juvenile Detention and 
Correctional Facilities: A Systematic Review and Metaregression Analysis of 25 Surveys. J Am Acad 

Child Adolesc Psychiatry. 2008;47(9):1010-1019. doi:10.1097/CHI.ObO13e31817eecf3. 
2. 
Underwood LA, Washington A. Mental Illness and Juvenile Offenders. Int J Environ Res Public Health. 
2016;13(2):228. doi:10.3390/ijerph13020228. 
3. 
Bhui K, Ullrich S, Coid JW. Which pathways to psychiatric care lead to earlier treatment and a shorter 
duration of first-episode psychosis? BMC Psychiatry. 2014;14(1):72. doi:10.1186/1471-244X-14-72. 
4. 
Drake RJ, Haley CJ, Akhtar S, Lewis SW. Causes and consequences of duration of untreated psychosis 
in schizophrenia. Br J Psychiatry. 2000;177:511-515. http://www.ncbi.nlm.nih.gov/pubmed/11102325. 
Accessed February 23, 2017. 
5. 
Harrigan SM, McGorry PD, Krstev H. Does treatment delay in first-episode psychosis really matter? 
Psychol Med. 2003;33(1):97-110. http://www.ncbi.nlm.nih.gov/pubmed/12537041. Accessed February 
23, 2017. 
6. 
Marshall M, Lewis S, Lockwood A, Drake R, Jones P, Croudace T. Association Between Duration of 
Untreated Psychosis and Outcome in Cohorts of First-Episode Patients. Arch Gen Psychiatry. 
2005;62(9):975. doi:10.1001/archpsyc.62.9.975. 
7. 
Loewy RL, Pearson R, Vinogradov S, Bearden CE, Cannon TD. Psychosis risk screening with the 
Prodromal Questionnaire--brief version (PQ-B). Schizophr Res. 2011;129(1):42-46. 
doi:10.1016/j.schres.2011.03.029. 
8. 
Schiffman J, Dixon L. Treatment issues and challenges facing young adults with chronic mental illness. 
Maryl Psychol. 2011;56:19-21. 
9. 
Díaz-Caneja CM, Pina-Camacho L, Rodríguez-Quiroga A, Fraguas D, Parellada M, Arango C. 
Predictors of outcome in early-onset psychosis: a systematic review. npj Schizophr. 2015;1(1):14005. 
doi:10.1038/npjschz.2014.5. 
10. 
Kelleher I, Corcoran P, Keeley H, et al. Psychotic Symptoms and Population Risk for Suicide Attempt. 
JAMA Psychiatry. 2013;70(9):940. doi:10.1001/jamapsychiatry.2013.140. 
11. 
Large MM, Nielssen O. Violence in first-episode psychosis: A systematic review and meta-analysis. 
Schizophr Res. 2011;125(2-3):209-220. doi:10.1016/j.schres.2010.11.026. 
12. 
Nishii H, Yamazawa R, Shimodera S, Suzuki M, Hasegawa T, Mizuno M. Clinical and social 
determinants of a longer duration of untreated psychosis of schizophrenia in a Japanese population. 
Early Interv Psychiatry. 2010;4(2):182-188. doi:10.1111/j.1751-7893.2010.00179.x. 
13. 
Crumlish N, Whitty P, Clarke M, et al. Beyond the critical period: longitudinal study of 8-year outcome in 
first-episode non-affective psychosis. Br J Psychiatry. 2009;194(1):18-24. 
doi:10.1192/bjp.bp.107.048942. 
14. 
Miller TJ, McGlashan TH, Rosen JL, et al. Prodromal assessment with the structured interview for 
prodromal syndromes and the scale of prodromal symptoms: predictive validity, interrater reliability, and 
training to reliability. Schizophr Bull. 2003;29(4):703-715. 
http://www.ncbi.nlm.nih.gov/pubmed/14989408. Accessed March 8, 2017. 
15. 
Yung AR, Yung AR, Pan Yuen H, et al. Mapping the onset of psychosis: the Comprehensive 
Assessment of At-Risk Mental States. Aust N Z J Psychiatry. 2005;39(11-12):964-971. 
doi:10.1080/j.1440-1614.2005.01714.x. 
16. 
Fusar-Poli P, Bonoldi I, Yung AR, et al. Predicting Psychosis. Arch Gen Psychiatry. 2012;69(3):220. 
doi:10.1001/archgenpsychiatry.2011.1472. 
17. 
Fusar-Poli P, Borgwardt S, Bechdolf A, et al. The Psychosis High-Risk State. JAMA Psychiatry. 
2013;70(1):107. doi:10.1001/jamapsychiatry.2013.269. 
18. 
Miller TJ, Cicchetti D, Markovich PJ, McGlashan TH, Woods SW. The SIPS screen: a brief self-report 
screen to detect the schizophrenia prodrome. 2004;70:78. 
19. 
Kline E, Wilson C, Ereshefsky S, et al. Psychosis risk screening in youth: A validation study of three self- 
report measures of attenuated psychosis symptoms. Schizophr Res. 2012;141(1):72-77. 
doi:10.1016/j.schres.2012.07.022. 
20. 
Kopta SM, Lowry JL. Psychometric Evaluation of the Behavioral Health Questionnaire-20: A Brief 
Instrument for Assessing Global Mental Health and the Three Phases of Psychotherapy Outcome. 
Psychother Res. 2002;12(4):413-426. doi:10.1093/ptr/12.4.413. 
21. 
Veijola J, Jokelainen J, Läksy K, et al. The Hopkins Symptom Checklist-25 in screening DSM-III-R axis-I 
disorders. Nord J Psychiatry. 2003;57(2):119-123. doi:10.1080/08039480310000941. 
22. 
Kessler RC, Green JG, Gruber MJ, et al. Screening for serious mental illness in the general population 
with the K6 screening scale: results from the WHO World Mental Health (WMH) survey initiative. Int J 
Methods Psychiatr Res. 2010;19(S1):4-22. doi:10.1002/mpr.310. 
23. 
Rumpf HJ, Meyer C, Hapke U, John U. Screening for mental health: validity of the MHI-5 using DSM-IV 
Axis I psychiatric disorders as gold standard. Psychiatry Res. 2001;105(3):243-253. 
http://www.ncbi.nlm.nih.gov/pubmed/11814543. Accessed March 8, 2017. 
24. 
Berwick DM, Murphy JM, Goldman PA, Ware JE, Barsky AJ, Weinstein MC. Performance of a five-item 

mental health screening test. Med Care. 1991;29(2):169-176. 
http://www.ncbi.nlm.nih.gov/pubmed/1994148. Accessed March 8, 2017. 
25. 
Tolou-Shams M, Kemp K, Yurasek A, Levine A, Lopes C, Richard K. Implementing the MAYSI-2 with 
First-Time Offending Diverted Youth. 
26. 
Chapman JF, Desai RA, Falzer PR. Mental Health Service Provision in Juvenile Justice Facilities: Pre- 
and Postrelease Psychiatric Care. Child Adolesc Psychiatr Clin N Am. 2006;15(2):445-458. 
doi:10.1016/j.chc.2005.11.002. 
27. 
Burns BJ, Costello EJ, Angold A, et al. Children’s mental health service use across service sectors. 
Health Aff (Millwood). 1995;14(3):147-159. http://www.ncbi.nlm.nih.gov/pubmed/7498888. Accessed 
November 19, 2016. 
28. 
Need to Know: A Fact Sheet Series on Juvenile Suicide Juvenile Court Judges and Staff. Washington, 
DC; 2013. 
29. 
Hayes LM. Juvenile Suicide in Confinement A National Survey Report.; 2009. 
30. 
Burke JD, Mulvey EP, Schubert CA. Prevalence of Mental Health Problems and Service Use Among 
First-Time Juvenile Offenders. J Child Fam Stud. 2015;24(12):3774-3781. doi:10.1007/s10826-015- 
0185-8. 
31. 
Hazen AL, Hough RL, Landsverk JA, Wood PA. Use of Mental Health Services by Youths in Public 
Sectors of Care. Ment Health Serv Res. 2004;6(4):213-226. 
doi:10.1023/B:MHSR.0000044747.54525.36. 
32. 
Liebenberg L, Ungar M. A comparison of service use among youth involved with juvenile justice and 
mental health. Child Youth Serv Rev. 2014;39:117-122. doi:10.1016/j.childyouth.2014.02.007. 
33. 
Kemp K, Yruaske A, Poindexter B, Tolou-Shams M. MAYSI-2 Suicide Ideation Scale with court-involved 
non-incarcerated youth. Prep. 2016. 
34. 
Skowyra KR, Cocozza JJ. Blueprint for Change: A Comprehensive Model for the Identification and 
Treatment of Youth with Mental Health Needs in Contact with the Juvenile Justice System.; 2007. 
35. 
Hoeve M, McReynolds LS, Wasserman GA. Service Referral for Juvenile Justice Youths: Associations 
with Psychiatric Disorder and Recidivism. Adm Policy Ment Heal Ment Heal Serv Res. 2014;41(3):379- 
389. doi:10.1007/s10488-013-0472-x. 
36. 
Lennings CJ, Kenny DT, Nelson P. Substance use and treatment seeking in young offenders on 
community orders. J Subst Abuse Treat. 2006;31(4):425-432. doi:10.1016/j.jsat.2006.05.017. 
37. 
Tolou-Shams M, Kemp K, Yruaske A, Levine A, Lopes C, Richard K. Implementing the MAYSI-2 with 
First-Time Offending Diverted Youth. 
38. 
Wolff J, Frazier EA, Weatherall S, Thompson A, Liu RT, Hunt J. Effectiveness and implementation of an 
evidence informed treatment on an adolescent inpatient unit. 
39. 
Esposito-Smythers C, Spirito A, Kahler CW, Hunt J, Monti P. Treatment of co-occurring substance 
abuse and suicidality among adolescents: A randomized clinical trial. J Consult Clin Psychol. 
2011;79(6):728-739. http://search.ebscohost.com/login.aspx?direct=true&db=psyh&AN=2011-23878- 
001&site=ehost-live. 
40. 
Spirito A, Wolff J, Seaboyer L, et al. Concurrent treatment for adolescent and parent depressed mood 
and suicidality: Feasibility, acceptability, and preliminary findings. J Child Adolesc Psychopharmacol. 
2014. 
41. 
Wolff J, Frazier EA, Weatherall S, Thompson A, Hunt J. Mind the gap: A model for implementing 
empirically informed treatment in an inpatient psychiatric setting . 
42. 
Amodeo M, Chassler D, Oettinger C, Labiosa W, Lundgren LM. Client retention in residential drug 
treatment for Latinos. Eval Program Plann. 2008;31(1):102-112. 
doi:10.1016/j.evalprogplan.2007.05.008. 
43. 
Sayre SL, Schmitz JM, Stotts AL, Averill PM, Rhoades HM, Grabowski JJ. Determining predictors of 
attrition in an outpatient substance abuse program. Am J Drug Alcohol Abuse. 2002;28(1):55-72. 
http://www.ncbi.nlm.nih.gov/pubmed/11853135. Accessed March 9, 2017. 
44. 
Patra J, Gliksman L, Fischer B, et al. Factors Associated with Treatment Compliance and its Effects on 
Retention among Participants in a Court-Mandated Treatment Program. Contemp Drug Probl. 
2010;37(2):289-313. doi:10.1177/009145091003700206. 
45. 
Moore LE, Tambling RB, Anderson SR. The Intersection of Therapy Constructs: The Relationship 
Between Motivation to Change, Distress, Referral Source, and Pressure to Attend. Am J Fam Ther. 
2013;41(3):245-258. doi:10.1080/01926187.2012.685351. 
46. 
O’Hare T. Court-Ordered versus Voluntary Clients: Problem Differences and Readiness for Change. 
Soc Work. 1996;41(4):417-422. doi:10.1093/sw/41.4.417. 
47. 
Tabak RG, Khoong EC, Chambers DA, Brownson RC. Bridging research and practice: models for 
dissemination and implementation research. Am J Prev Med. 2012;43(3):337-350. 
doi:10.1016/j.amepre.2012.05.024. 

48. 
Proctor EK, Landsverk J, Aarons G, Chambers D, Glisson C, Mittman B. Implementation research in 
mental health services: an emerging science with conceptual, methodological, and training challenges. 
Adm Policy Ment Heal. 2009;36(1):24-34. doi:10.1007/s10488-008-0197-4. 
49. 
Glisson C, Schoenwald SK. The ARC Organizational and Community Intervention Strategy for 
Implementing Evidence-Based Children’s Mental Health Treatments. Ment Health Serv Res. 
2005;7(4):243-259. doi:10.1007/s11020-005-7456-1. 
50. 
Proctor E, Silmere H, Raghavan R, et al. Outcomes for implementation research: conceptual 
distinctions, measurement challenges, and research agenda. Adm Policy Ment Health. 2011;38(2):65- 
76. doi:10.1007/s10488-010-0319-7. 
51. 
Rajkumar RP, Philip R. Gender identity disorder and schizophrenia: neurodevelopmental disorders with 
common causal mechanisms? Schizophr Res Treatment. 2014;2014:463757. doi:10.1155/2014/463757. 
52. 
Brown CH, Ten Have TR, Jo B, et al. Adaptive designs for randomized trials in public health. Annu Rev 
Public Health. 2009;30:1-25. doi:10.1146/annurev.publhealth.031308.100223. 
53. 
Brown CH, Wyman PA, Guo J, Peña J. Dynamic wait-listed designs for randomized trials: new designs 
for prevention of youth suicide. Clin Trials. 2006;3(3):259-271. 
http://www.ncbi.nlm.nih.gov/pubmed/16895043. Accessed November 21, 2016. 
54. 
Grisso T, Barnum R, Fletcher KE, Cauffman E, Peuschold D. Massachusetts Youth Screening 
Instrument for Mental Health Needs of Juvenile Justice Youths. J Am Acad Child Adolesc Psychiatry. 
2001;40(5):541-548. doi:10.1097/00004583-200105000-00013. 
55. 
Brent D, Emslie G, Clarke G, et al. Switching to another SSRI or to venlafaxine with or without cognitive 
behavioral therapy for adolescents with SSRI-resistant depression: The TORDIA randomized controlled 
trial. Jama. 2008;299(8):901-913. 
http://search.ebscohost.com/login.aspx?direct=true&db=psyh&AN=2008-02702-001&site=ehost-live. 
56. 
Harris PA, Taylor R, Thielke R, Payne J, Gonzalez N, Conde JG. Research electronic data capture 
(REDCap) - A metadata-driven methodology and workflow process for providing translational research 
informatics support. J Biomed Inform. 2009;42(2):377-381. doi:10.1016/j.jbi.2008.08.010. 
57. 
Turner CF, Ku L, Rogers SM, Lindberg LD, Pleck JH. Adolescent sexual behavior, drug use, and 
violence: Increased reporting with computer survey technology. Science (80- ). 1998;280(5365):867- 
873. doi:10.1126/science.280.5365.867. 
58. 
Hides L, Carroll S, Catania L, et al. Outcomes of an integrated cognitive behaviour therapy (CBT) 
treatment program for co-occurring depression and substance misuse in young people. J Affect Disord. 
2010;121(1-2):169-174. doi:10.1016/j.jad.2009.06.002. 
59. 
Burns Angold, A., Magruder-Habib, K., Costello, E., & Patrick, M B. Child and Adolescent Services 
Assessment (vs. 4.2). Durham, NC: Duke University; 1997. 
60. 
Ascher BH, Z. Farmer EM, Burns BJ, Angold A. The Child and Adolescent Services Assessment 
(CASA): Description and Psychometrics. J Emot Behav Disord. 1996;4(1):12-20. 
doi:10.1177/106342669600400102. 
61. 
Breda CS, Riemer M. Motivation for youth’s treatment scale (MYTS): a new tool for measuring 
motivation among youths and their caregivers. Adm Policy Ment Health. 2012;39(1-2):118-132. 
doi:10.1007/s10488-012-0408-x. 
62. 
Kazdin AE, Holland L, Crowley M, Breton S. Barriers to Treatment Participation Scale: evaluation and 
validation in the context of child outpatient treatment. J Child Psychol Psychiatry. 1997;38(8):1051-1062. 
doi:DOI: 10.1111/j.1469-7610.1997.tb01621. 
63. 
Achenbach TM, Mcconaughy SH, Ivanova MY, Rescorla LA. Manual for the ASEBA Brief Problem 
MonitorTM (BRM). Burlington, VT: University of Vermont; 2011. http://www.aseba.org/ASEBA Brief 
Problem Monitor Manual.pdf. Accessed March 9, 2017. 
64. 
Sheehan D V., Sheehan KH, Shytle RD, et al. Reliability and Validity of the Mini International 
Neuropsychiatric Interview for Children and Adolescents (MINI-KID). J Clin Psychiatry. 2010;71(3):313- 
326. doi:10.4088/JCP.09m05305whi. 
65. 
Register-Brown K, Hong LE. Reliability and validity of methods for measuring the duration of untreated 
psychosis: A quantitative review and meta-analysis. Schizophr Res. 2014;160(1-3):20-26. 
doi:10.1016/j.schres.2014.10.025. 
66. 
Large M, Nielssen O, Slade T, Harris A. Measurement and reporting of the duration of untreated 
psychosis. Early Interv Psychiatry. 2008;2(4):201-211. doi:10.1111/j.1751-7893.2008.00080.x. 
67. 
Compton MT, Carter T, Bergner E, et al. Defining, operationalizing and measuring the duration of 
untreated psychosis: advances, limitations and future directions. Early Interv Psychiatry. 2007;1(3):236- 
250. doi:10.1111/j.1751-7893.2007.00036.x. 
68. 
Cornblatt BA, Auther AM, Niendam T, et al. Preliminary Findings for Two New Measures of Social and 
Role Functioning in the Prodromal Phase of Schizophrenia. Schizophr Bull. 2007;33(3):688-702. 
doi:10.1093/schbul/sbm029. 

69. 
Addington J, Cadenhead KS, Cannon TD, et al. North American Prodrome Longitudinal Study: A 
Collaborative Multisite Approach to Prodromal Schizophrenia Research. Schizophr Bull. 2007;33(3):665- 
672. doi:10.1093/schbul/sbl075. 
70. 
Wilson C, Kline E, Thompson E, et al. Comparison of measures of functioning for use with treatment- 
seeking adolescents experiencing attenuated symptoms of psychosis. Early Interv Psychiatry. 
2016;10(1):81-87. doi:10.1111/eip.12189. 
71. 
Leon AC, Davis LL, Kraemer HC. The role and interpretation of pilot studies in clinical research. J 
Psychiatr Res. 2011;45(5):626-629. doi:10.1016/j.jpsychires.2010.10.008. 
72. 
Kraemer HC, Mintz J, Noda A, Tinklenberg J, Yesavage JA. Caution regarding the use of pilot studies to 
guide power calculations for study proposals. Arch Gen Psychiatry. 2006;63(5):484-489. 
doi:10.1001/archpsyc.63.5.484. 
73. 
Teare M, Dimairo M, Shephard N, Hayman A, Whitehead A, Walters SJ. Sample size requirements to 
estimate key design parameters from external pilot randomised controlled trials: a simulation study. 
Trials. 2014;15(1):264. doi:10.1186/1745-6215-15-264.