Hortensia Amaro, Ph.D.: I think that this panel is a great example of our NHSN approach to really take our work from basic research to application and to practice, into our communities. So, I hope you enjoy it. I want to now turn it over to Sergio Aguilar-Gaxiola, our esteemed and dear colleague who's going to introduce the speakers.

Sergio Aguilar-Gaxiola M.D., Ph.D.: Gracias, Hortensia. Buenos dÃ?as. By the way, this is our Hortensia Amaro, our co-chair for this panel, but one of the founding members of the network, of the red. I'm very excited about this morning's panel. We have a great lineup of speakers in a theme, and a topic, that I consider to be one of the hot potatoes in terms of policy. This is what's happening especially with our youth. You know, people have talked about the criminalization of youth behavior, and we're going to hear you know, from research what we know in terms of epidemiology, all the way down to what happens in the ground with the work that Commissioner Totten is doing in Los Angeles.

Sergio Aguilar-Gaxiola: The first speaker is Dr. Linda Teplin. Dr. Teplin is the Owen L. Coon Professor of Psychiatry and Behavioral Sciences at the Feinberg School of Medicine at Northwestern University, where she is the director of the psycholegal studies program. Her studies have addressed the criminalization of the mentally ill, alcohol, drug and other psychiatric disorders, and other epidemiologic characteristics of the link with youth and about jail detainees, and correlates the violence in HIV/AIDS/race behaviors.

She has numerous awards, and I just want to name three of them. One is that she was distinguished with the National Institute of Mental Health Merit Award. This is a very prestigious award given by NIMH. And, the American Psychological Association's career award for Distinguished Contribution to Research in Public Policy, and the National Commission of Correctional Health Bernard Harrison Award of Merit. She's currently conducting the Northwestern Juvenile Project, the first large-scale longitudinal study of alcohol, drug and mental health needs and outcomes for juvenile detainees. Linda? Welcome.

Linda Teplin, Ph.D.: Good morning. Thank you so much, Sergio, that was a presentation that my mother would have approved of, a lovely introduction.

Today, I'll be presenting some rather depressing, although I believe important, findings on the Northwestern Juvenile Project. This study, I joke, is not the best longitudinal study of detained youth, but it's the only one looking at health needs and outcomes of kids after they were arrested and detained.

And it's a very unusual study because - and let me explain to you what happens when I go to cocktail parties. Because we study very interesting issues, we study alcohol and drugs, and psychiatric disorders and violence; I'm actually fairly popular at cocktail parties.

People often say, "Well what are you studying recently? What are you studying now?" and I say, "Well now we're doing this very exciting study of health needs and health outcomes of delinquent kids." Well they're polite and they don't run off to get another martini, but they scratch their heads and say, "But don't we know that already?"

The shocking thing, if you look at the literature, is when you look at studies that have delinquent in the title, almost invariably they are studies of general population kids and looking at who becomes delinquent.

So that we have almost no information on health needs and health outcomes of kids once they became involved with the juvenile justice system. Now, if I'm talking to a person who knows something about research at the cocktail party, they may ask something like, "Well, but aren't these kids included in general population studies?"

And when you think about it, you realize that they're not. And that's because, how are general population studies sampled? You sample kids in school. And so kids in detention are often truant or else they're housed in detention facilities so that they're not going to be drawn. They're not part of household-based surveys because they're too highly mobile to be drawn in a household. And a lot of them come from families that are homeless.

And then the great irony is that even if they are sampled in a school-based study or a household based survey, once they are incarcerated they are lost to follow-up. And that's because of the rather difficult HHS [Department of Health and Human Services] regulations governing research on imprisoned populations. You need special dispensation to include incarcerated populations in a general population study, and most researchers are not able to negotiate that very difficult path to obtain that consent. And so, as a consequence, they're simply dropped from the study.

So, we have this key omission in the literature about a group that is likely to have very poor outcomes and also be very costly to the systems as they age. So let's look at some of the findings.

Linda Teplin: I want to thank our funding agencies which include the National Institute of Drug Abuse and many other funding agencies, because without their support you would not be able to do these kinds of large scale longitudinal studies.

Linda Teplin: I also want to acknowledge the help of my rather large team of devoted faculty and graduate students, current and prior.

Linda Teplin: Let's look first at the number of delinquency cases disposed over the year. Now, these are cases, not people. What we see is that even though there's been a drop somewhat since 1995, in fact we still have about 1.6 million cases going through juvenile court every year. 1.6 million.

Linda Teplin: And the one-day count of juvenile offenders in custody is right now about 97,000 on an average day. Now, this translates by the way to about 2.2 million people who are incarcerated in the United States in juvenile justice jails, state prisons, and federal prisons. The U.S. has the highest incarceration rate in the world. Of note, we estimate that about three quarters of the increase in prison populations over the years, youth and adult, is related to drugs.

Linda Teplin: Now the irony, because I am basically a public health researcher, a health disparities researcher, the irony is that if you want to study health among minorities you have to study kids in detention and adults in jail. I think that's an absolutely incredible statement to say about U.S. public health policy, but that's where you go if you want to understand health disparities and health.

This chart shows that although, for example, African-Americans are only about 13% of the U.S. population, they're nearly 40% of kids in detention and adults in jail and prison.

I'm not presenting the stats on Latinos because amazingly, it's not really counted well. Sometimes, Latinos are combined with non-Hispanic Whites, sometimes Latinos are their own category, sometimes Latinos are divided among African-Americans and Whites. It's done in such a way that we actually don't even know the over-representation of Hispanics in the correctional system.

However, one estimate from the Department of Justice is that by the year 2010 Latinos will comprise nearly one quarter of kids in detention and by the year 2050 nearly a third of kids in detention.

Linda Teplin: Today I'll be presenting and waltzing you through a number of findings on substance use and substance abuse, looking at disorders and other psychiatric disorders, and looking at the consequences of drug use in terms of these outcomes.

I will also if time permits and I'm not dragged off the stage, talk a little bit about public health implications of our findings.

Let me tell you a little bit about the research methods. It's a simple study. We randomly sampled 1829 kids as they came into detention in Cook County. We sampled them between 1995 and 1998, and we have been tracking and following them and re-interviewing them ever since.

So, we do face to face interviews. Our participants are not the kind of people that we could simply ask to show up at our offices and be interviewed. Rather, we hit the streets. We go into the field where they live. We also note when they are incarcerated, we go to that facility to interview them. So, no one is omitted from our study because they become re-incarcerated.

So, we trek up the stairs in Cabrini-Green, a notorious housing project in Chicago, and we go to Cook County Jail, we go to all the state facilities in the country. It's an exciting study because it is so inclusive. And because of that, we have very high participation rates in the high 80% and then for the first couple of follow-ups, the participation rates were 97%.

I should also mention that even when we drew the sample, we had terrific participation rates because so many of our kids said to us, "You don't have to pay me, it's enough that you'd listen." So for so many of these kids, they were ages 10 to 18 when they were sampled, it's the first time somebody even sat down and listened to them.

We interviewed them using the diagnostic interview schedule as well as a slew of other instruments to look at all the variables that I'm going to be presenting today. At the baseline interview, we had only about 3.8% refusals, that was all.

This slide shows the sample characteristics of our study, and I want to highlight that the red line going across shows the actual proportion of these characteristics in the detention center. So, perhaps you won't be shocked to know but I find it very shocking that if you look at the slide on the right, for example, that non-Hispanic Whites comprise only about 5% of the detention center in Cook County in Chicago. And this mirrors what happens in detention centers around the country, which is that it's a place where minority kids go.

So we oversampled whites, ironically, to have enough of them. We oversampled males to have enough of them.

Linda Teplin: We also oversampled younger kids to have enough of them. We also oversampled kids who were processed as adults in adult court. I want to emphasize that many of those crimes that cause kids to be bounced to adult court are not necessarily violent crimes; they're often drug-related crimes such as selling drugs within a certain number of feet within a housing project or a school. When you live, by the way, in a highly dense neighborhood, which most poor neighborhoods are, often times if you do sell drugs of course it will be near a school or a housing project.

Linda Teplin: This chart shows the prevalence and gender differences of psychiatric disorders at that baseline interview. I want to highlight that about two-thirds of the males, and about three-quarters of the females, had one or more disorders. And that substance use disorders, alcohol, drug or both, were the most prevalent disorders at baseline. This is disorder. It is not just use.

Linda Teplin: This shows the racial and ethnic differences among African-Americans, Latinos, and non-Hispanic Whites. And what we see again is that pretty much for all groups, substance use disorders are the most prevalent disorder in this group, affecting about half of African-Americans, and nearly two-thirds of Whites, and over half of Latinos.

Linda Teplin: This chart, the Venn diagram, shows the overlap of different types of disorders in these kids. This is a depressing chart, and that's because there's so much overlap in these circles. And that demonstrates that these kids don't just have one psychiatric disorder, but they tend to have more than one as you see. Many of them even have all four types of psychiatric disorders.

Linda Teplin: This chart shows the overlap of substance use disorders, because kids can have more than one. Many kids don't have only an alcohol use disorder, but they may also have some other type of drug use disorder. And again, the overlap of these circles show that comorbidity is the rule, not the exception.

Linda Teplin: This chart shows the prevalence of disorders and racial-ethnic differences among the girls, and we see that patterns are somewhat similar then for the boys although the girls tend to have higher prevalence rates of all of these disorders.

Linda Teplin: Again, a Venn diagram. The patterns are different than the boys. But the message is the same, which is that comorbid disorders are the rule, not the exception, among these kids.

Linda Teplin: And among girls, the same thing for substance use disorders. Again, comorbid substance use disorders are the rule, not the exception.

Linda Teplin: Well, maybe kids get into detention and it's a good place to get treated. Maybe that's how poor kids get their treatment. If they get in trouble, they get arrested, they get detained and maybe - detained, and then they get treated. We found that among kids who had major mental disorders, major affective disorders, psychosis, only about 16% received some sort of treatment.

Linda Teplin: And for substance use disorders, only about 13% received treatment for their addictions.

Linda Teplin: There are racial-ethnic differences among who gets treated. Girls tend to get treated more often than boys. Younger kids tend to get treated more often than older kids. And as we would expect, there are distinctly different patterns of service provisions for whites, much lower among Latinos, and much, much lower among African-Americans.

Linda Teplin: Disorders go down over time; clearly we sampled these kids when they were going through crises. Of note however, in the five year follow up, the prevalence rates of disorders are still very high, especially for substance use disorders. So, among males, about 30% still have one or more substance use disorders.

Linda Teplin: Substance use disorders also were the most likely to persist.

Linda Teplin: They were the most likely to develop.

Linda Teplin: And, also, these kids engage in many HIV and AIDS risk behaviors related to their drug use. We have further detail on this in our papers, but this is a shocking finding, I find, that so many of our kids had engaged in ten or more risk behaviors, both at the baseline interview and the follow-up.

Linda Teplin: Incarceration. These kids don't do well. They don't have good outcomes. As we see, many, many of our kids were re-incarcerated by the time of the five year follow-up, and the re-incarceration rates are actually very similar for Latinos as for African-Americans.

Linda Teplin: Death. Normally, death rates are reported in one line in a methods section. Our death rates were so high that we wrote an article published in Pediatrics just on our death rates. To date, 89 kids of our original 1800 have died. And, I show this chart to you which you can't read, because - to show you, to emphasize the enormous number of these young people who died.

Now to put this in perspective, the Columbine shootings and shootings like them took the lives in the entire country of 52 kids over 10 years. In a similar period in my study, 65 kids died. And to date, since the study was begun, we have had 89 deaths, almost all of them from homicide.

Linda Teplin: This shows the deaths that took place in the Chicago area, and what you see is that most of them are from homicide. Those are the little red dots. Homicides tended to take place in the city. The drug-related deaths interestingly, that's the green dot, tend to take place outside of the city.

Linda Teplin: Cause of death is almost always violent, nobody's died from disease yet, and almost always homicide. So that this is a chart from the six-and-a-half year follow-up, and we see that 90% of our kids died from homicide, and combining homicide and legal intervention meaning you're shot by a police officer, it's 95%.

Linda Teplin: This is the racial distribution of the death rates, again shown on the map. And what you see interestingly is the clustering. Chicago is a terribly segregated city, both for people to live and both where they die.

Linda Teplin: This chart shows the standardized mortality compared to the general population. And again, compare the heights of the bars, in blue, to the heights of the bars to a demographically similar sample. We obtained those statistics from the CDC. And what we see is that the death rates are just unbelievably high both among African-American males and Latino males.

So, these are very depressing statistics. And this situation is not really going to get better. We see when we do the follow-up interviews a cycle of disorder. And it doesn't just affect this generation, but the next generation as well. When we interview our girls, for example, the first interview took place three years after they were included into the study.

We often go to their homes, I mentioned, to interview them. And nearly all of our girls were holding an infant and also had a couple of toddlers running around. And remember, they were 10 to 17 when they were sampled. So that we must have a call to action on studying the health needs and outcomes of these kids, so we can help not only the current generation but the next generation. Thank you very much.

Sergio Aguilar-Gaxiola: Many thanks, Dr. Teplin, for such a thought provoking and sobering presentation. I think that it sets the stage for the rest of the session.

And now is the turn of Jorge Villatoro VelÃ?squez. Dr. VelÃ?squez is an investigator in the Department of Epidemiology and Social Psychology at the RamÃ?n de la Fuente National Institute of Psychiatry in Mexico. He is working closely with MarÃ?a Elena Medina-Mora who is one of our members of the network.

His research area of expertise is in epidemiology and mental health. Dr. VelÃ?squez has received a number of honors and awards, including the best research presented at the 12th National Congress of the Mexican Psychiatric Association and Regional Symposium of the World Psychiatric Association.

Dr. VelÃ?squez has been a distinguished investigator for the program of the National Coordination of the National Institutes of Health since its inception. I can tell you that Jorge has been one of the leaders in the national surveys that have been done in Mexico in terms of addictions, especially as they relate to youth and youth in school. So with that, then - and he's going to present to us in Spanish. So, Jorge?

Jorge Velasquez: Muchas gracias, buenos dÃ?as.

En primer lugar [quiero] agradecer la invitaciÃ?n a este evento. He tenido la fortuna en los Ã?ltimos 5 aÃ?os de estar asistiendo constantemente y ha sido un placer departir con los miembros de la NHSN y poder ser parte de la misma asociaciÃ?n.

Vamos a ver entonces algunos resultados propiamente de conducta antisocial, especialmente con consumo de drogas y salud mental en adolescentes.

Los datos que aquÃ? voy a presentar, mÃ?s que ser propiamente diagnÃ?sticos psiquiatras, son posibles trastornos, posibles causas, mÃ?s como una cuestiÃ?n de "screening" que como una cuestiÃ?n de, ya directamente diagnÃ?stico, debido a la forma en como derivamos las preguntas.

Dr. Jorge VelÃ?zquez: Vamos a ver en primera instancia una problemÃ?tica que sabemos que estÃ? pasando fuertemente en nuestro paÃ?s, y es cÃ?mo estÃ? la cuestiÃ?n del trÃ?fico de sustancias, vemos aquÃ? la parte correspondiente a la heroÃ?na, sabemos que MÃ?xico produce el 5% de la heroÃ?na mundial, Colombia produce otro tanto, incluso mÃ?s, una buena parte viene aquÃ?, la llamada heroÃ?na blanca, y tenemos la heroÃ?na negra o morena en el caso de MÃ?xico directamente y este va a lo que es el mercado de los Estados Unidos en buena medida.

Y el problema como seÃ?alÃ?bamos ayer de consumo de heroÃ?na estÃ? muy enfocado en nuestra frontera, especialmente la parte relacionada tanto con Texas como una buena parte con Arizona.

Jorge VelÃ?zquez: El trÃ?fico de cocaÃ?na tambiÃ?n es un problema muy importante, la mayor parte del mismo procede de Colombia y los paÃ?ses andinos y una buena parte se va a lo que es el mercado de Estados Unidos y otra parte se va directamente a EspaÃ?a, que, tanto MÃ?xico como EspaÃ?a en tÃ?rminos de situaciÃ?n mundial son de los paÃ?ses que se tiene mayor consumo de cocaÃ?na y no hemos podido evolucionar en lo que se refiere a la parte de decrementar el uso de sustancias.

Jorge VelÃ?zquez: La Mariguana es la droga que mÃ?s se produce en nuestro paÃ?s, hay una gran cantidad de trÃ?fico aÃ?reo en lo que es la frontera entre Arizona y Sonora directamente, y bueno, la cantidad de Mariguana que se mueve es enorme aunque esto ha ido decrementando un poco debido entre otras cosas a los decomisos, ya que hay una producciÃ?n importante de esta situaciÃ?n en lo que serÃ?a los Estados Unidos.

Jorge VelÃ?zquez: Las meta-anfetaimnas, si bien MÃ?xico no es un paÃ?s que las estÃ? en un momento determinado consumiendo, hay una gran cantidad de pseudo-efedrina y derivados que provienen directamente de China y se mueven sobre todo por toda la costa del pacÃ?fico, y aquÃ? vemos mÃ?s o menos dÃ?nde se ubican la mayor parte de los laboratorios, en donde la mayor parte de las meta-anfetaminas que se ven pues van al mercado mÃ?s importante que es California y a Arizona directamente, que es la parte que estÃ? mÃ?s colindante con California.

Jorge VelÃ?zquez: Sin embargo y afortunadamente lo que son la parte de los decomisos pues tambiÃ?n se han incrementado en nuestro paÃ?s hay una gran cantidad de operativos en los cuales Ã?ltimamente de cada dÃ?a estamos oyendo una serie de decomisos fuertes, el aÃ?o pasado hubo un decomiso muy importante, este aÃ?o van decomisos muy fuertes donde se han encontrado buques en lo que serÃ?a Colima y tambiÃ?n en Quintana Roo, con mÃ?s de una tonelada de cocaÃ?na, que viene directamente en los contenedores que traen distintos barcos sobretodo de Colombia en el caso de la cocaÃ?na.

Jorge VelÃ?zquez: Y adicionalmente tenemos lo que serÃ?an los aseguramientos que se han incrementado y vemos cÃ?mo estos tambiÃ?n se dan en esta parte del pacÃ?fico y que van directamente al mercado de los Estados Unidos.

Jorge VelÃ?zquez: En cocaÃ?na tambiÃ?n es una situaciÃ?n similar, donde se estÃ? presentando muchÃ?simo es en el estado de Campeche, de hecho aquÃ? se tienen una gran cantidad de aeropuertos clandestinos en donde se trafica la droga proveniente de los paÃ?ses andinos y de aquÃ? se mueve ya sea para el mercado de los Estados Unidos o hacia Europa, especÃ?ficamente a EspaÃ?a.

Jorge VelÃ?zquez: TambiÃ?n tenemos una gran cantidad de decomisos, bueno, mÃ?s fuertes el caso de lo que es la cocaÃ?na, y lo que es la efedrina y la pseudo-efedrina, en menor medida, pero que tambiÃ?n han crecido Ã?ltimamente, esto sÃ? ha habido un impacto en las medidas, sin embargo una de las crÃ?ticas que se hace a esta situaciÃ?n es que muchas veces son como des-coordinadas y no se tiene un plan directo de como enfrentar lo que serÃ?a el crimen organizado.

Jorge VelÃ?zquez: Y como estamos relacionando directamente con la parte de lo que serÃ?an los encarcelamientos pues vemos aquÃ? que los de mayor incidencia son los robos y asaltos en la poblaciÃ?n, y la parte de venta de drogas tiene una prevalencia mÃ?s baja en aquellos que han sido detenidos, y estÃ?n al mismo nivel de lo que serÃ?a los homicidios.

Jorge VelÃ?zquez: DÃ?nde se dan principalmente los delitos en contra la salud? y es de manera especÃ?fica en tÃ?rminos de los narcÃ?ticos en los estados seÃ?alados con rojo, en este caso vemos como Sonora que es donde estÃ?n, ha sido seÃ?alado en varias ocasiones, pues estÃ? como de los mÃ?s altos, y el nivel intermedio son todos los estados amarillos donde muchos de ellos son directamente la frontera con los Estados Unidos.

Jorge VelÃ?zquez: De la misma forma en tÃ?rminos de un aspecto importante es el arma de fuego en el momento en la detenciÃ?n. DÃ?nde se presenta esto: pues observamos los estados con verde tenemos esto. Y una de las cosas muy importantes donde no se ha trabajado y deberÃ?a de estarse trabajando es justamente en el control de armas de fuego. En MÃ?xico si bien estÃ? prohibida la venta, hay un trÃ?fico muy importante en este caso al revÃ?s de Estados Unidos hacia MÃ?xico y esto permite precisamente pues que se facilite toda la conducta delictiva.

Jorge VelÃ?zquez: Pero, cÃ?mo ha sido el problema en MÃ?xico entonces dada esta situaciÃ?n del narcotrÃ?fico y de comisiÃ?n de delitos tanto asociados al narcotrÃ?fico como en general? Pues en MÃ?xico ha cambiado muchÃ?simo la situaciÃ?n, todavÃ?a a principios de la dÃ?cada de los 90s hablÃ?bamos de que Ã?ramos un paÃ?s de paso, que la droga pasaba y que no tenÃ?amos consumos muy altos. Sin embargo ahora hemos visto que hay incrementos importantes segÃ?n los datos de la encuesta del 2002. Lamentamos no estar presentando ya los datos del 2008 sin embargo hemos finalizado apenas el 80% del campo de esa encuesta y por eso es que no estÃ? incluido en estos datos directamente.

Jorge VelÃ?zquez: Vemos las diferencias importantes entre los Estados Unidos y MÃ?xico, en donde las prevalencias de dependencia al alcohol y de lo que serÃ?a consumo de drogas pues son mucho mÃ?s bajas de nuestro paÃ?s, sin embargo, dado el "binge-drinking" o el uso intensivo de lo que son drogas, los problemas asociados en MÃ?xico son mucho mÃ?s elevados que los que se llegan a encontrar en muchas ocasiones en los Estados Unidos a pesar de tener prevalencias mÃ?s altas. Sin embargo cuando por ejemplo analizamos lo que serÃ?a la poblaciÃ?n entre los 26 y los 65 aÃ?os por lo menos en cuanto a la dependencia de alcohol vemos porcentajes bastante parecidos en ambos paÃ?ses.

QuÃ? pasa con la parte de la migraciÃ?n Y que era parte de lo que hablÃ?bamos en la plÃ?tica de ayer que coordina el Dr. Vega? pues vemos directamente como aquellos que son migrantes y regresan las prevalencias son mucho mÃ?s elevadas de cualquier situaciÃ?n de consumo de drogas, abuso o dependencia de sustancias, y que en aquellas familias donde alguno de los miembros es migrante es el segundo lugar de estas prevalenciase, en tanto que aquellas donde no estÃ? presente algÃ?n migrante, observamos que las prevalencias son mÃ?s bajas.

Jorge VelÃ?zquez: Estamos hablando de migrantes que van y que regresan en el caso del primer grupo. En este contexto es muy importante tambiÃ?n tomar en cuenta lo que es la pirÃ?mide poblacional, los jÃ?venes de 14 a 29 aÃ?os ya son el 28.3% de toda la poblaciÃ?n, pero este crecimiento desafortunadamente no viene asociado con lo que es la parte de mejor educaciÃ?n ni empleo, de manera tal que solamente el 45% de los adolescentes entre 15 a 19 aÃ?os estÃ?n actualmente estudiando lo que serÃ?a el "high-school" en este momento no?, y aproximadamente el 70% estÃ? estudiando lo que serÃ?a de sÃ?ptimo a noveno grado. Entonces es muy importante tomar en cuenta esto porque una gran cantidad de adolescentes ya salen directamente de la escuela y en ese contexto se tienen que, o bien ir al mercado formar, o al mercado informal, o en un momento derivar en lo que serÃ?a conducta delictiva, no?. y evidentemente pues el Ã?ndice migratorio en los Ã?ltimos aÃ?os dada esta situaciÃ?n de de desigualdad, pues ha subido a aÃ?n cuando las fronteras han sido cerradas a partir del 11 de Septiembre, los flujos migratorios hacia los estados unidos siguen siendo bastante elevados.

Jorge VelÃ?zquez: En ese contexto entonces, cuÃ?l es la situaciÃ?n de salud mental de nuestros jÃ?venes?. Estos son datos de estudiantes de bachillerato y universidad ("high-school" y pre-grado) directamente, en donde se muestran lo que serÃ?an las curvas, las incidencias acumuladas en cuanto a las edades de inicio de distintas conductas por las que pueden pasar los jÃ?venes. Cada lÃ?nea representa el 100% de cada una de estas conductas, y a un lado estamos poniendo lo que serÃ?n las prevalencias de cada una de ellas en este caso para los hombres. Lo que nos indica aquÃ? es que por ejemplo el 50% de quienes han sufrido abuso sexual, esto se logra a los 14 aÃ?os, en tanto que lo que serÃ?a para los 15 aÃ?os, las conductas que se presentan es lo que serÃ?a el consumo de inhalables, y asÃ? a los 16 aÃ?os se tiene un 50% de la poblaciÃ?n que ha iniciado sus relaciones sexuales y que estÃ? consumiendo marihuana en tanto que el consumo de cocaÃ?na se inicia un aÃ?o despuÃ?s, esto es en el caso de los hombres.

Jorge VelÃ?zquez: En el caso de las mujeres vemos como, evidentemente lo que es el abuso sexual se presenta mÃ?s en lo que serÃ?a a una edad mÃ?s temprana a los 10 aÃ?os, mucho mÃ?s temprano en las mujeres, y la edad de la conducta sexual es bastante similar igual que el intento suicida y el consumo de tabaco y de los hinalables. En cuanto a la marihuana se da en las mujeres hacia los 16 aÃ?os y las relaciones el 50% se posterga un aÃ?o mÃ?s en comparaciÃ?n con lo que serÃ?a los hombres directamente. Entonces vemos trayectorias ligeramente distintas entre hombres y mujeres especialmente en cuanto a la edad.

Jorge VelÃ?zquez: QuÃ? pasas con las distintas conductas antisociales? Pues lo que vemos es como las mayores prevalencias se presentan en lo que serÃ?an los hombres y las mas bajas prevalencias en las mujeres. Este porcentaje es haber cometido alguno de estos actos, estos y los que vienen mÃ?s adelante, en la poblaciÃ?n, y vemos evidentemente que es mÃ?s alta la prevalencia en los hombres y tenemos un seguimiento en este caso en Ciudad de MÃ?xico, desde mucho atrÃ?s de 1997 nada mÃ?s presentamos esta serie debido a que es mucho mÃ?s comparable.

Jorge VelÃ?zquez: En algunos actos mÃ?s graves como en lo que serÃ?a el forzar cerraduras, vender drogas, atacar a alguien con un objeto o durante el acto usar un cuchillo vemos una situaciÃ?n similar aunque la parte de lo que serÃ?an los atracos es mucho mÃ?s elevada y en crecimiento constante en esta poblaciÃ?n aÃ?n y cuando sigue estudiando.

Jorge VelÃ?zquez: QuÃ? nos dicen los datos? En este caso Francisco JuÃ?rez, un compaÃ?ero del Instituto que es quien ha estado estudiando mÃ?s esta conducta nos presenta un esquema en un modelamiento estructural inicial que hizo. En los distintos elementos que conllevan a lo que es la conducta problemÃ?tica y los elementos mÃ?s cercanos pues son justamente la relaciÃ?n con padres, los problemas de adaptaciÃ?n en la escuela, y lo que serÃ?a la existencia de problemas familiares como predictores de esta conducta.

Jorge VelÃ?zquez: En los datos que les presentÃ? de las edades de inicio directamente pues tenemos aquÃ? lo que serÃ?an los "odds-ratio", y vemos de manera importante cÃ?mo distintos elementos que valuamos con lo que es la escala de Alabama en esta poblaciÃ?n, pues vemos como los que son los silos de parentalidad son predictores importantes de el cometer actos antisociales graves en buena mediad y vemos como esta situaciÃ?n de que en los hombres es mucho mÃ?s alto el riesgo de cometer dichas acciones.

Jorge VelÃ?zquez: En otras encuestas en este caso particular de lo que serÃ?an encuestas de hogares tambiÃ?n vemos una relaciÃ?n importante entre lo que serÃ?a drogas y el cometer actos antisociales y en mujeres en prisiÃ?n del trabajo que hace la Dra. Martha Romero vemos algunas caracterÃ?sticas importantes como el hecho de que un porcentaje importante cuando cometiÃ? el delito por el cual estÃ? encarcelada estÃ? asociada con el consumo de sustancias.

Jorge VelÃ?zquez: Finalmente la comarbilidad es una conducta muy relacionada con la conducta antisocial. Vemos en general como aquellos adolescentes, esto es el porcentaje de quienes han cometido algÃ?n acto antisocial, vemos como estÃ?n casi del doble las prevalencias, sea del abuso de alcohol, que es emborracharse por lo menos una vez en el Ã?ltimo mes, el consumir cualquier droga en el Ã?ltimo aÃ?o, o drogas ilegales, o drogas mÃ?dicas, lo mismo en el caso del tabaco en el Ã?ltimo mes.

Jorge VelÃ?zquez: Y en cuanto a algunos aspectos mÃ?s de corte afectivo vemos cÃ?mo la sintomatologÃ?a depresiva es tambiÃ?n mÃ?s alta, las relaciones sexuales son mÃ?s altas entre los que han cometido ya actos antisociales.

Jorge Vel�zquez: Y ahora observando ya lo que son las mujeres es una situaci�n tambi�n similar, aunque en lo que de lo que ser�a el consumo de sustancias es menor lo que ser�a las prevalencias, sin embargo, la proporci�n entre quienes han cometidos actos y no, a diferencia de los hombres que era de 2 a 1�

Jorge Vel�zquez: �en algunos casos las mujeres es de 3 a 1 con quienes han cometido actos antisociales y vemos una gran cantidad de presencia de sintomatolog�a depresiva.

Jorge VelÃ?zquez: En ese contexto, y dados estos retos que, dada esta problemÃ?tica fuerte que hemos presentado, pues CuÃ?l es la perspectiva en MÃ?xico?. Tenemos un problema fuerte de lo que serÃ?a impunidad, y esto es algo importante en tÃ?rminos de los panelistas que nos acompaÃ?an hoy. CuÃ?l es ese reto. Pues el reto es que hay bastante impunidad. Hay mucha gente que no se estÃ? en un momento determinado arrestando o la gente comete actos antisociales, es muy fÃ?cil en Ciudad de MÃ?xico que pasan 5 segundos de que se puso el semÃ?foro en rojo y la gente se sigue pasando independientemente de que ya estÃ? el rojo, por ejemplo no?

Y eso lo hace gente sin estudios y gente con postgrados y cosas por el estilo, entonces es una problemÃ?tica y no hay un policÃ?a ni nada por el estilo que estÃ? llevando a cabo lo que es el cumplimiento de las reglas y las normas de mejor convivencia, entonces debe haber una polÃ?tica social directamente que estÃ? encaminada a un mejoramiento de la aplicaciÃ?n de leyes y adicionalmente en el contexto de la comunidad de la familia, pues sÃ? es muy importante tomar en cuenta que debe haber mejores polÃ?ticas sociales, pero especialmente yo creo que podemos incidir en 2 aspectos muy importantes, por un lado el trabajar mucho lo que son las prÃ?cticas de parentalidad donde sabemos directamente cÃ?mo hay una incidencia de los propios cuadros que les presentÃ? de cÃ?mo afecta directamente estas prÃ?cticas sobre la presencia de conducta antisocial, sÃ? tiene un efecto, es algo en lo que se estÃ? trabajando poco.

Hemos estado en contacto con la Dra. Melany Domieshi, con Marion del grupo de lo que es el Oregon Center Lending y entonces aquÃ? vemos cÃ?mo a travÃ?s de estos elementos podemos incidir en forma de desde la perspectiva de salud, aunque lo que hace mÃ?s falta es sÃ? trabajar desde las polÃ?ticas sociales para mejorar muchos de los aspectos en el cumplimiento de la ley y sobretodo las condiciones de vida de la gente.

MuchÃ?simas gracias.

Sergio Aguilar-Gaxiola: Thank you, Jorge, for putting in context what's happening in Mexico. And we're looking forward to hearing about the 2008 National Addiction Survey as well. And I know that there are some interesting things that that want to happen in terms of the increase of the use of alcohol and drugs, especially in the young population. Okay.

Now, I would like to introduce Dr. Bill Arroyo, who is the Medical Director of the Child Youth and Family Administration of Los Angeles County, Department of Mental Health. He's a clinical Assistant Professor of Psychiatry at the USC School of Medicine. He represents the Los Angeles County Department of Mental Health in program development and policy implementation efforts in the children's mental health arena at both the county and state level. Also, in this area, he is one of the leaders especially in juvenile delinquency issues nationally. He has been a spokesperson for the American Psychiatric Association as well as other things related to that. He's a principal investigator of a SAMHSA-funded project on systems of care. He serves on several state and national advisory bodies including the California Commission on Juvenile Justice in the California Rehabilitation Oversight Board. It is a pleasure to introduce Bill Arroyo.

Bill Arroyo, M.D.: Buenos dÃ?as.

Bill Arroyo: Good morning. My comments are going to be primarily directed to the group of youth that I'm familiar with in Los Angeles County. And you will probably note some overlap between some of my comments and the previous two speakers. I hope to give you some information regarding that detention and confinement in Los Angeles County. Prevalence of mental disorders in that population, address some of the challenges that for purposes of this presentation are faced by the two primary agencies that are responsible for providing services to the youth, and that is the L.A. County Department of Mental Health for which I work, and the L.A. County Alcohol and Drug Program Agency.

Some treatment services and prevention practices that we have attempted to implement in the past couple of years.

Bill Arroyo: Los Angeles County is certainly known for some of its rising stars. Dr. Teplin may not like to see this since her team lost to this team yesterday. And this star, you're all familiar, and you get extra credit if you know who this former star is, who is now battling a judge in Las Vegas. Former Heismann trophy winner from USC.

The point of this slide, though, is that L.A. County is a very large jurisdiction. And of the nearly 3 million children in the county, almost 60% are of Latino descent.

Bill Arroyo: As you can see from here, the probation department has many such youth in its clientele. I don't say this proudly, but L.A. County incarcerates more children than any other local jurisdiction in the country. This represents those youth in holds and camps, and these are children who are on probation in the community.

Bill Arroyo: What you see here, the point of this slide is that of all the youth who are detained and confined by the probation department, 61% of that population is Latino. So, just a little bit more than that representing the general population of children in Los Angeles County.

Bill Arroyo: In terms of the racial-ethnic distribution of children who are on probation, similarly we see 61% being of Latino descent.

Bill Arroyo: This is a study recently completed by the National Center for Mental Health and Juvenile Justice. It was an epidemiologic study; really expanding on some of Dr. Teplin's earlier work, the most important findings here was the fact that 60% of those with at least one mental disorder had a co-worker in substance abuse disorders.

So, as Dr. Teplin initially indicated, this is more the rule than the exception. So we're speaking about youth who have comorbid conditions, one of which is frequently substance-related disorder.

Bill Arroyo: In this study, this mirrors some of Dr. Teplin's work. We see a large proportion of youth that have multiple comorbid conditions.

Bill Arroyo: Prevalence rates of mental disorders in this same study show a preponderance of mental disorders among the female population. For those of you who have any experience in working with this population, you will note that the girls are generally much more impaired than the boys in this population.

Bill Arroyo: Approximately four years ago in Los Angeles, we administered in an attempt to do a prevalence rate of mental disorders among our detained and confined youth, we administered the voice DISC.

For some of you who don't know, the DISC is - really mirrors the criteria from DSM IV and as you'll note here in the last bullet, 55% of these youth had a substance use disorder.

Bill Arroyo: The reason why I bring this up is because we have found that - and we don't know exactly how they're connected, but - those youth with PTSD oftentimes develop substance-related disorder, and sometimes it's vice-versa. We just know that they are closely linked.

Bill Arroyo: And in support of this hypothesis, there are a number of studies actually done beginning in 1994 with Burton. Two of these studies happened to be of LA detained youth. Two of the other studies are samples of youth done in the state prison system for youth, and one is done in another state, and I can't remember which state exactly. But as you can see here, the prevalence rate of PTSD among this population is quite high, varies from 20 here to approximately 50 in this study done by Cauffman.

Bill Arroyo: And when we separate out the males and females from these studies, we find here on the right, the females have almost at twice the rate as that of males. Again, and these are all youths who have been incarcerated.

Bill Arroyo: So, what does my department do? You'll hear from Honorable Totten that we don't do much for some of these kids, but let me tell you what we attempt to do. Our department is mandated to serve youth with severe emotional disturbance, not those with primary substance-related disorder. We may serve youth that have co-occurring mental illness and substance-related disorder, but that gets tricky because many of our providers will tell us that they're at risk of audit exceptions. That is a major disincentive for serving youth with substance-related disorders by our network of mental health providers.

The funding streams for mental illness are for all intents and purposes, separate. Medicaid, for mental health services for children, which is EPSDT, which really is the foundation of most systems across the country, almost exclusively pays only for those services provided to children with MS - with SED or a mental illness. That excludes substance use, or substance-related disorders. And then there's a Medicaid drug treatment funding stream that only pays for substance-related disorder treatment. And frequently, the providers of drug treatment and those of mental health services are not the same.

Bill Arroyo: Our department does not mandate routine entry of substance-related disorder data and therefore I can't share with you what the prevalence rate is among the population of 60,000 children that are within our public mental health system. More recently, however, our department has strongly encouraged our provider network to start identifying routinely, co-occurring substance related disorder, and to attempt to provide integrated treatment.

A little bit about the county Alcohol and Drug Program Administration. In the last fiscal year there were 10,000 admissions. Not surprisingly, most of those were of the male gender. These are ages 12 to 20, as you can see. Latino youth there was 61%. This county agency is not mandated to serve youth with severe emotional disturbance. What is the racial ethnic distribution of those who received services from the alcohol and drug program, LA County as you can see, 61% of them are of Latino descent.

Bill Arroyo:So, that mirrors the general population as you can see from this slide, this preponderance of 15 to 18 year-olds in that group. The alcohol and drug program classifies its services among these different for outpatient counseling. This is abilitiative counseling, detoxification, residential services. And you can see the relative percentages there.

Bill Arroyo: The Alcohol Program Administration, both of the county and of the state does not require providers to focus on outcomes. In fact, there are some guidelines issued by the state alcohol and drug program that speak to effective interventions. What, exactly, that means, is unclear. This guidance does not mention evidence supported treatment, nor does it mention evidence-based practice.

Bill Arroyo: So, what are we doing in Los Angeles? Again, we've just started to implement some evidence-based practices that we believe, and have demonstrated in other communities and certainly in other communities in California, to be effective with Latino populations.

Bill Arroyo: Although some of these have been tweaked, and the primary ones that we have instituted are multisystemic therapy (MST), which some of you may be familiar with.

Bill Arroyo: Functional family therapy.

Bill Arroyo: And multidimensional treatment foster care. Now, of course, for those of you familiar with these three evidence-based practices, there needs to be a family who's willing to participate. These strategies are useless for any homeless youth who has alcohol and drug problems. And so, that although they may be useful with some families, they're not a panacea by any means. The good news is that there are some scientifically supported outcomes which a lot of parents are also endorsing.

And so, some of these practices are easy to market to families, but not everyone wants to be engaged. Some of the more preventive types of services that we're just beginning to engage in are some of the following.

Bill Arroyo: Now, this motivational interviewing, and some of you may know, is primarily used with adults. The probation department has decided to start providing training to all of its probation offices, so that they can work with the older youth who are in their custody.

Bill Arroyo: And then, I just wanted to mention this, some of you may be familiar with these pharmacological interventions which are used as adjunctive treatments in the adult population. We rarely use these with youth.

Bill Arroyo: This is another preventive approach that we are hopefully going to expand shortly. Nurse family partnership developed by Olds, which has terrific outcomes both for young moms and their offspring.

Bill Arroyo: Life skills training is one that can be administered in classrooms, something that is already operational in several school districts in Los Angeles County.

Bill Arroyo: But we have our challenges. I've already mentioned the funding structures; the alignment of mandates is a problem. We first restricted these practices to youth and child welfare because of a lawsuit. Families disengage without court supervision at times. Spanish-speaking direct service personnel are hard to come by as many of you would know. Some of our practitioners don't want to go into some of the neighborhoods where services need to be provided in the home.

Political will is a big challenge.

Bill Arroyo: Retraining of veteran service providers, curriculum professionals, schools all leave a lot to be desired. Some of these approaches are proprietary such as MST, are expensive as you're launching them. Supervisory infrastructure is a challenge for us. Coordinating with other children's service departments, integrating with health services, and then identifying approaches that address comorbidity which Dr. Teplin and I know is critical in working with these.

Bill Arroyo: And then I just want to end on a report that was recently published by a nonpartisan body in California that advises the state legislature and the governor in regard to substance abuse treatment, and what they conclude is that state and federal dollars from widely-divergent approaches, there's minimal oversight or accountability. Billions are spent on consequences of abuse. Treatment is reserved for most dependent and not those with early signs.

Bill Arroyo: And finally, state leaders have not used priority control funding. Treatment advances are not systematically implemented, and funding is limited and not used strategically. So I'll conclude with that. Thank you.

Sergio Aguilar-Gaxiola: Thank you, Bill, for bringing these issues to our attention. And I don't know if you notice, but there is a little bit of rivalry that Bill you know, raised about, you know, Dr. Teplin and Arroyo, and let's see if our next speaker, Commissioner Totten, can help us settle this. And divert that.

Let me introduce now the next speaker, is the Honorable Robert Totten. He was elected to the Los Angeles Juvenile Delinquency Court in 1997 by the Superior Court Judges. In 1997, Commissioner Totten successfully piloted into existence Los Angeles County's first juvenile drug court, which was situated in Sylmar, California. Since then, the Sylmar Juvenile Drug Court has been at the forefront for successfully treating and applying innovative drug treatment modalities to juveniles. From 2001 through 2004, this drug court, the Sylmar Juvenile Court, was designated as a national mentor site and training corps for newly formed and existing drug courts. He has since chaired committees bringing into existence additional drug courts in the delinquency system and one in the Los Angeles County, dependency court. After ten years presiding over the court, Commissioner Totten transferred to the Eastlake Court, where he continues to hear delinquency cases and now supervises the Eastlake Drug Court. I can tell you that in addition to these court duties; Commissioner Totten is also very actively involved with coaching soccer to about 300 kids. He has been honored twice as the Judge of the Year, because of the excellent work that he has done.

The Honorable Robert Totten: That's enough. That's enough.

Sergio Aguilar-Gaxiola: We do; Commissioner Totten.

Robert Totten: Thank you. I know you're saddened to learn that I do not have graphs, I don't have charts, and I don't have statistics.

I am listening to the two doctors speak about the statistics, nationally I was sitting going, "Tsk, tsk, it's terrible, oh my goodness, it reflects what I see in Los Angeles County." As I'm listening to Dr. Arroyo, when he's talking about my kids, I started to get angry.

I've got my kids out there in significant dire straits, and we don't have the resources for them. I was asked to talk about challenges and solutions for drug-abusing Latino youth, and I noticed in this schedule it talked about me talking about mental health. So let me deal with the mental health issue in Los Angeles County. I know Dr. Arroyo, who is a good friend of mine, talked a bit about it.

Robert Totten: Mental health services for kids who before they enter into our juvenile system, basically non-existent. Juvenile mental health services for kids in our juvenile system, we have them, they're fractured, and they're out there. Dr. Arroyo does the best he can with the limited resources he gets. But you saw the studies that deal with it; he talked about dealt with adults. They get unlimited resources, kids don't vote, they get nothing.

Sitting at - creating a cohesive post-judicial involvement, mental health program, that consists of, "Hey mom, can you go find a program out there so I can release your kid to you?" She comes back with a program, "I got one, here it is Judge, it's at Kedrin or it's at this other place, and they're going to be able to see him in two weeks." I say "Okay, I'm going to hold him another 12-13 days and you can have him in that time and then he can go home to you." That's what it amounts to. That's what we do. We have some mental health residential programs; kids have to voluntarily wish to go in there. It's a fractured system, but it's fractured because it's underfunded. And we need to develop the political will to create and develop programs that will effectively deal with youth.

Robert Totten: Now, I was asked to deal with challenges and solutions of Latino youth. When I was first contacted, I said, "Sure, I'd love to talk about anything you want to talk about, Bill, anything you want, you got." He said, "Okay. Challenges for Latino youth." And I said, "Okay." I got nothing. Right? I got nothing. And I thought about it, I said, "Let me think about this."

So I hung up and I thought about it. I go, "The reason I got nothing is I'm a judge." I'm not a researcher. I don't categorize. I don't group. I don't put people into - try to find consistent cause and effect for groupings of individuals. I have to deal with an individual that comes in front of me who has either broken the law, or, basically he's broken the law. And I have to apply the law to the facts that are before me. I have to, and I teach other judges, not to group. Not to stereotype. Not to look at someone and say, "That's a Hispanic person, have to deal with that person that way," or a black person, or a woman, a girl in my case since dealing with children, or a boy. We teach ourselves, and we try really hard, not to base our decisions based upon those groupings.

So I have to sit back, okay, that's why I haven't got - I couldn't answer him. And now I've got to sit back and come up with some answers. And I think I did. I think I've come up with some consistent problems and solutions that I see that need to be addressed, or problems that need to be addressed within the Latino population. The group that I deal with now at Eastlake, which is in East Los Angeles, is a majority Mexican-American. You have Salvadorian and Guatemalan tied in there. A smattering of Anglos and a smattering of Koreans, that's the population I now deal with at Eastlake. In the Sylmar court, I was dealing with a much broader, diverse population, diverse economically and diverse culturally. But that does not exist in the Eastlake court.

When dealing with drug abusing youth, now let's just - let me back up a step. Drug abuse; in the 90s, it became the dialogue surrounding drug abuse was, that public policy has failed. The policy of taking people, incarcerating them for drug abusing or drug involved crimes, not providing treatment to them, releasing them and then expecting change, didn't occur. We just kept cycling them in and out of custody. Police officers were frustrated. Judges were frustrated and our prisons were getting full. And as we see, they're still full.

Robert Totten: So, we created - so what was the dialogue we were surrounded was creating drug courts. And drug courts were deemed to be an effective tool in dealing with this problem. We would stop incarcerating our adults, we would instead on an outpatient basis bring together a collaborative, and a team approach of professionals coupled with the criminal justice system. So you'd have sitting at a table your public defender, your defense counsel, your DA, prosecuting counsel, your probation officer, treatment under the umbrella and aegis of the power of the court.

And what we ended up doing differently in this situation just on a very bare level, a base level, is that when somebody went to treatment normally and they didn't comply with treatment, what was the result? What did treatment do? Well, we're kicking you out of treatment. Well, that was successful. So instead of doing that now, now with the power of the court, you are still going to go to treatment, we're still forcing you to go to treatment, but here's a consequence. And I will - at this point just go as an aside, research has taught me that you're going to a positive reinforcement; we're working with people you're going to get better outcomes than with negative reinforcement.

So, that consequence of the negative of incarceration or potentially maybe some community service or whatever, we try to balance with the positive reinforcement that when you do well here's a benefit. Here is a movie; we used to give new movie tickets in my court, or gummy bears, much sought after gummy bears for the kids. Anything that you could do that'd be a benefit to reinforce the positive behavior.

Robert Totten: Most of the population I deal with is Mexican-American. Possibly - and I don't know because I don't ask whether they're born in the country or not, but one of the - some of the things that I am observing on a regular basis that's frustrating as all get-out is a lack of interest in education, is a family that is hard-working, that is holding down two jobs, trying to make a dollar to support their family, but then forgetting about they need to supervise their family. I've got kids who mothers go to work at 4:00 in the morning and the kids are expected to go to school at 8:00 or 7:00. We both know that that kid's not going to school. That when they get tired they'll lie in there, they're not going to get up.

I've got kids who come home from school at 3:00; mom doesn't come home until 7:00. And ask what the plan is for this child, this 13-14 year old child? "Well they'll take care of themselves, I did when I was 12-13, when I was in Mexico or whatever, and I didn't have a problem. My dad expected me, our family expected me, to do these different jobs and I did them, and I expect my son to do that." Well the problem is that that's not what's happening. They're walking outside and they're hanging out with the gang, and hanging out with the negative influences, and learning things they don't need to be learning. I don't know what the solution is to that, but a lot of times I'm finding that these parents are completely ignorant to the fact their kids are doing these things. They just don't see it. They're not aware at all of what is going on, and the solution as I see it, or part of the solution, is intense parenting classes. Not just individuals talking at you, but parenting classes that involve the group modality where you have other families there telling about their experiences, we are learning from their experiences.

Whenever we talk to parents, and I think some research has shown this as well, is that the major influence causing problems is peers. I'm not buying that. You know, as a parent if I'm asked what the problem with the child is, I'm not going to go like this. I go, "It's over there, and the problem's them." A lot of the problem I think is coming from the parent; it's the parents, not the outside forces. It's allowing those outside forces in, but as a parent it's causing the problem.

I see single moms, and this is just scatters outside the Latino community, but I see single moms who abdicate their authority. And when a kid learns that your authority is apparent is illusory, you're dead. When they recognize that when they come home at 2:00 in the morning and there's nothing you can do. When they cuss at you and there's nothing that you can do or you do. You're dead. And one of the purposes that I find for myself is to re-invest the power of the parent. Is to back up that parent, so that when the parent comes in and says, "Hey, I told him to do this, X, Y and Z, they didn't do it," "You didn't do it? What your parents said? You're in custody, you're detained."

Robert Totten: I talked to my treatment provider, which is Latino Services, and I said, "What would you, what do you see that needs to be the problems with the Latino population are and how we can help?" And they listed out a couple things to me. And this is from them, not from me. They say "Latinos view treatment as a sign of weakness. Latinos' view is that addiction is a moral issue, i.e., you are bad when you become addicted. Drug use is starting earlier, 8 & 9 being the norm. The families need education on alcohol, a gateway drug, must be provided to the big time beer drinking Latino culture." And the comment that my counselor gave me was, "No beer, no party."

The basic idea of Latino culture is that when you become addicted, you lose everything. It is okay to be a functioning addict, as long as you bring home the paycheck. Everything will be brushed under the carpet. We need to have Latino moms become more aware of what drug alcohol use is, looks, smells like, etc. There is a lack of awareness of what drug abuse and drugs are that they blind themselves and don't see it. I would share one little vignette, they talked about soccer.

I took a group of 14 year olds to Hawaii for a soccer tournament. And some of them were from the inner city, a good 6-7 of them, diverse group. And as I was in Hawaii, one of the other coaches bought a six pack of beer for his fridge and my wife bought a bottle of that god awful wine, pink Zinfandel, that white Zinfandel stuff. And I noticed that the kids, there was concern the kids were going to go in the fridge and take that, and they talked about "Well, you know, I'll take some of the of the wine" or "I'll take some of the beer" and we kept saying, "No, no, no, no, don't, you don't talk about that," and it was the Latino kids were talking about that, not the other kids. Not from the other, the other racial backgrounds.

And I put it aside and I said, "Okay, it's just kids, and the group mentality, and one starts saying it and the other pick up on it and they started doing it." Well I took this same group of kids to a soccer game over at Home Depot Center to watch the Galaxy. And as we were - one of the other dads had a glass of beer; I had a glass of beer in my hand. As we're walking, the kids, we said to the kids who walked up to us and said, "What do you want to get, let's go get something," they all - and the five Latino kids in unison said, "We want what's in your hand," which was the beer. The other group of kids didn't talk about that. I don't know what to make of that. All I know is, I'm observing this and I don't know why it is that these groups of Latino kids are so focused on alcohol and that that means something to their maturization or their growing up. And I don't know what to do with that, I don't - I'm looking for some sort of solution or an answer as to why that's happening. I just share that experience as something that causes me great concern, it raises my antenna significantly.

In closing, I'd like to say that I'm awed by the research that is presented. I have - I never get enough of it to - and I never, we don't implement enough of it. I'm awed by the work that you do and it's an honor to be here. And I look forward to you continuing in the arena, particularly of juveniles. And there's a paucity of information out there with regard to juveniles, how to effectively treat juveniles. They're just not little adults. The statistics on adults and the drugs that we give to adults, we just can't do that to juveniles. It just doesn't work. Thank you.

Sergio Aguilar-Gaxiola: Thank you so much, Commissioner Totten, and to all the speakers, we are going to move to questions. Thank you so much for your patience of waiting until now. We have a few minutes to deal with questions, but just to let you know, that on purpose, we designed this session to come full circle. From research, to on the ground, you know, what's happening in terms of interventions and in terms of these kids that get into the juvenile justice. So I hope that this gives you kind of an overview about how this happened, and emphasized the translational aspects of the research that we are all engaged with. So, we have a question.

Audience Member: For any of you to respond, what do you see as the critical age points for the developmental risk trajectory and intervention points? I mean, are they one in the same, and how do you see them differently for men - for girls versus boys?

Robert Totten: I think boys are at much greater risk earlier than girls for negative behaviors. As to the age of the trajectory, it's always been my opinion that we ought to be doing assessments at age zero. Right at birth we ought to be doing assessments for mental health issues. Any other potential issues. But in reality with society, 12? They start being at risk as I see it?

Bill Arroyo: If I may add, one of the other things, the other things that I do is I'm a treating psychiatrist, and I work in one of these camps that I alluded to in my presentation. And in working with these youths, I've learned that many of them start at age eight, nine, and ten years of age. So, you know when I speak to my colleagues, who primarily work with adults I'm saying you know starting providing intervention when you know, someone's 25 or 35, it's maybe missing the boat. We need to start at a much, much - we need to start in elementary school, frankly. And so I think that approaches not unlike life skills training, not unlike the nurse family partnership approach is the way to go with many of these populations.

Sergio Aguilar-Gaxiola: Yeah.

Audience Member: I think we'll stop ___________ to show that girls have the most comorbidity then followed by non-Hispanic whites. And so we, we planted the similar kind of findings in Miami and we brought in a group of community leaders to ask them, you know, why, why are these different across gender and ethnic groups. And so what they told us is, the communities that have more police surveillance, kids get arrested more often for the same delinquent activity as someone who may be in a white neighborhood, who has less police surveillance. So by the time they get to the judge, someone who's African-American or Hispanic is likely to have a longer rap sheet given the same number of delinquent activities. So, kids with higher comorbidity are likely to get arrested out of the system more quickly.

Linda Teplin: I also want to emphasize the racial and ethnic and class bias in arrest decisions. Most of the research demonstrates that self-reported delinquency is fairly equal across race and ethnicity, but yet we see as I showed, that in the Cook County Detention Center, which is pretty typical of large detention centers in large cities nationwide, that you just don't see white kids. When I present to audiences, which are often non-Hispanic White, I ask people not to show me, but to think about if their child or any other child ever committed delinquent acts. And then what happened. And what happens pretty uniformly is that wealthier kids who are disproportionately white get help, they get treatment, and it's minority kids who get processed through the juvenile justice system and then once on that path, as I showed you in the re-arrest and re-incarceration rates, their lives are lost.

Robert Totten: If I could add to that, for ten years now I've been teaching a class at USC, and whenever I get an opportunity to talk to other judges, and I provide a non-scientific type of example where I have a fact pattern that deals with the domestic battery and the only thing I do is change the name from Jose Rodriguez to Beatrice O'Malley. And then I give out an equal number of the papers with the different names to the people and have them sentence, be the judge and say, "Okay, what's your sentence on this fact pattern." And in the ten years I have done it, I have never seen the Irish woman come back with a worse sentence than Jose. At times, they have been equal. But for the most part, Jose always gets hit harder than Beatrice. And we have a discussion about that. But if you accept that that happens, and you look at that through systemically throughout our system, that magnifies as you move through the criminal justice system.

Linda Teplin: I want to emphasize that these systematic racial and ethic biases are pervasive even before kids enter the justice system, because what happens is one of your children does something in school. They bring a knife to school. You're called; you'll be able to be reached because you're not on a factory floor. You will go to the police lock-up and you will most likely negotiate just a station adjustment for your kid. But for poor people who are disproportionately racial and ethnic minorities in this country, their neighborhoods are over-patrolled, more infractions are likely to be noticed and reported because the neighborhoods have greater patrol by police, once arrested the parent may not be available, may not be sophisticated enough to negotiate a station adjustment, may not be sophisticated enough to hire a lawyer to negotiate a station adjustment, and one of the school psychologists at the detention center mentioned to me once that she had never seen a kid from Glencoe or Kenilworth or Winnetka. For those of you who know Chicago, that's the wealthier north shore. She said, "In all my 20 years of being at the detention center, I've never seen a kid from the north shore." And we know that self-reported delinquency is fairly equal. But it's the sophistication, also, of wealthier people so they can negotiate their kids getting services instead of going into the justice system. So it's pervasive. The discrimination. And every single point from the time of the perpetration of delinquent act.

Sergio Aguilar-Gaxiola: Okay. One more question and then we will close. And I'm going to have Hortensia close the session.

Audience Member: This is a question for all the panelists. You know, I've come to this meeting and the situation is really negative, in terms of - or it's actually not getting better, actually it's worse. And it really worries me so much that every year you hear, you know, our picture of where we're going here - so I guess the question for all of the panelists is, thinking about researchers, what do you do as a researcher to have more impact in terms of solving this problem? In the next five years.

Linda Teplin: As a researcher, I would like to see more investigations of large scale studies of kids who are not part of general population investigations. So that we have to get beyond studying patients, beyond studying kids in school, beyond just doing household surveys, and focus on kids at risk in terms of doing epidemiologic studies as well as treatment interventions for these kids who so often don't get into treatment. Our findings show that a paltry proportion of kids receive treatment for either major mental disorders or substance use disorders. So clearly, the justice system is not an appropriate port of entry in order to obtain services.

In this day and age, unfortunately, we need large scale longitudinal studies to highlight the kinds of problems. We also need funds to provide appropriate interventions, because these are not inexpensive interventions.

So it's a partnership we have, really, with the people who do the research, the people who do the treatment, outcome studies, and then the people like many of my panelists who work in the trenches, so they can let the research and both epidemiologic and treatment outcomes, guide public health decisions.

Robert Totten: As a comment, just one of that the only way some of these kids get services is to get in the criminal justice system. If they don't penetrate the criminal justice system, they don't receive services, because they're not there.

Sergio Aguilar-Gaxiola: Jorge, and then we're going close with Dr. Amaro.

Jorge VelÃ?zquez: Bueno, yo espero que el trabajo por lo menos en MÃ?xico estÃ? mÃ?s enfocado hacia programas de prevenciÃ?n con niÃ?os. Ya hay varios proyectos en relaciÃ?n con eso, de la infancia, desde lo que serÃ?a el preescolar y muy enfocados hacia aspectos de cuidado de salud mental y enfocados al desarrollo de habilidades como mencionaba.

Me parece que necesitamos hacer una inversiÃ?n fuerte en ese sentido y por otro lado yo creo que tambiÃ?n a nivel social en tÃ?rminos de polÃ?tica, como mencionaba, yo creo que necesitamos reunirnos con la sociedad y hablar fuerte para que la situaciÃ?n tan desigual que estÃ? privando en MÃ?xico y muy probablemente en muchos paÃ?ses de LatinoamÃ?rica sea menos grave, no? yo creo que se estÃ?n viendo una serie de problemas muy fuertes debidos a tan mala distribuciÃ?n de los recursos y demÃ?s, y eso es parte del pacto social que tenemos que hacer, porque eso es parte de la misma problemÃ?tica.

Gracias.

Sergio Aguilar-Gaxiola: Bien dicho. Please help me once again thank the panelists. And to wrap up, we have Dr. Amaro.

Hortensia Amaro: Well, I want to thank the panelists also, and the audience. Clearly, this is something we could be discussing for a long time. It's a complex and critical issue in our communities. And I think just as an ending point, what I wanted to bring up is the need, I think, to step back and really look beyond individual interventions with specific kids. We have to think about why the parents are not providing supervision and the economic context in the communities that are forcing parents to work two and three jobs, which is why they're not home until 7:00 or 9:00 at night and unable to provide supervision. So, I think the economic context that's impacting on families, and the kind of stressors it's creating and how it then dominos out to parenting and impact on kids, is really something important for us to look at in our research.

And as we look at policies, I also think we need to look at the context in which families are living. So, when you have these economic stressors that force parents to work several jobs and at the same time you have communities that are falling apart, for some of the same reasons in terms of lack of infrastructure, social infrastructure and organizations that can hold those kids, in a way that keeps them out of trouble. And then, you add to that lack of youth services in communities because of cutbacks, etc., you really have kids who have been abandoned not only by their parents, but by their communities and our society. And I think that while it's challenging to look at these issues from this broader perspective, I think it's really important that we do that. Because I think parents are not attending to kids in some situations, not because that's what they choose to do but sometimes what they have to do to survive.

And it's going to require interventions at the individual level, once kids are in trouble. It's going to require intervention with their families. But it's also going to require much earlier prevention efforts in the schools but also in strengthening communities. So, I would hope that that's where we can contribute, Margarita, and where some of the research can direct us. So that we can really use research to reform policy changes that are needed in terms of integrating the systems cross the board - substance abuse, mental health, and the correctional system. But also in addressing the really, I think, group costs, you know, that are resulting in the kind of data that we're seeing. Thank you very much.