foster care placement. One effective strategy has been to develop teams that can visit adolescents who are at risk and individually link them to an agency or program that can help with the immediate problem. After a year of operation, the program has seen a one-third decline in arrests and rearrests among young people who were enrolled.

The principal challenge Sharfstein cited, apart from lack of insurance coverage, was lack of capacity. Baltimore has not been able to put in place interventions there is reason to believe can be very successful, such as screening for sexually transmitted diseases among middle school students, or to cover all the adolescents who could be helped by others, such as the Operation Safe Kids violence prevention program. Sharfstein reiterated the lack of reimbursement for mental health services as a critical deficit. For example, he described multisystemic therapy, an intervention recommended by the Surgeon General, in which a team addresses the mental health problems of serious juvenile offenders comprehensively by providing therapy to build the skills of the parents as well as the child, intervening at the school if necessary, and so on. While this intervention has demonstrated significant benefits and has become a reimbursable expense in other states, Baltimore is able to offer this intervention to a tiny fraction of the roughly 2,000 adolescents he believes would qualify for it. Sharfstein believes that without this kind of therapy, adolescents who might benefit from it end up costing the city and the state far more when they require detention, out-of-home foster care, and other programs.

Sharfstein had three ideas for improving adolescent care. First, the federal government should develop clear incentives for states to follow best practices as soon as evidence becomes clear. Second, the state governments should both hold agencies accountable for outcomes and provide leadership from the top to facilitate interagency collaboration. Third, local governments should take the lead in identifying innovative ways to link community resources.

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