Mental Health Needs

Recently, researchers and juvenile justice administrators have recognized that rates of mental health disorders are remarkably high among adolescent offenders. This finding carries significant implications for policy and practice. Youth justice facilities are mandated to provide necessary mental health treatment to detained adolescent offenders with mental health needs. Furthermore, mental disorders may interfere with youths’ capacities to stand trial and/or culpability. This entry discusses some recent advances that have been made in our understanding of mental health issues among juvenile offenders and points out key gaps in knowledge.

Rates and Types of Mental Disorders among Juvenile Offenders

The mental health needs of adolescent offenders has been identified as one of the single most important issues currently faced by the youth justice system. Reported rates of mental disorders among youths vary depending on how mental disorders are measured and at what point in the system youths are assessed. However, it is apparent that rates of mental disorders among juvenile offenders are much higher than those of general community samples of youths.

Recent studies have indicated that approximately 60% to 70% of youths in juvenile detention facilities meet the criteria for at least one mental disorder. The types of disorders found in adolescent offenders are diverse. Not surprisingly, many adolescent offenders meet the criteria for conduct disorder, a disorder that is characterized by illegal and antisocial behaviors, such as violence and stealing. However, even after conduct disorder is excluded from definitions of mental disorder, estimated rates of mental disorders remain extremely high among adolescent offenders; as many as 60% of detained male youths and 70% of detained female youths meet the criteria for a disorder other than conduct disorder.

Besides conduct disorder, a number of other mental disorders are very common among adolescent offenders, including major depression, which includes symptoms such as depressed or irritable mood; post-traumatic stress disorder, which is characterized by symptoms such as flashbacks and avoidance of experiences that are reminiscent of the earlier trauma; attention deficit/hyperactivity disorder, which includes symptoms such as difficulties attending to information, hyperactivity, and impulsivity; and substance use disorders, which involve inappropriate use and overuse of substances such as alcohol and drugs in a manner that has detrimental effects on a youth’s functioning. Many detained youths meet the criteria for multiple disorders.

The rates and types of mental disorders exhibited by mentally ill youths differ depending on the demographic characteristics of the youth. Female offenders experience some disorders, such as posttraumatic stress disorder and major depression, at considerably higher rates than male offenders. In addition, preliminary research has reported that many types of mental disorders are more common among detained non-Hispanic White youths than among detained Black or Hispanic youths. However, it may be that the tools that are used to detect mental disorders are less accurate when used with minority populations. For instance, individuals from ethnic minority groups may be less likely to reveal mental disorders.

Future research on mental disorders in detained youths could benefit from international perspectives. Most existing research has focused on mental disorders among detained American youths, although there is some preliminary evidence that young offenders in other countries, including Canada and the United Kingdom, may also have high rates of mental ill-nesses. International research could help us develop a better understanding of variations in rates of mental disorders within different youth justice systems, as well as the different types of efforts that countries have taken to respond to these mental health issues.

In addition, Thomas Grisso, the leading expert in this field, has offered a number of useful concepts to guide research on the mental health of juvenile offenders from the perspective of developmental psychopathology. A key point of this perspective is that mental disorders must be understood within a developmental context. Some characteristics that are often interpreted as symptoms of a mental disorder (e.g., impulsivity, egocentricity) could possibly reflect normal adolescent development. Thus, if we are to understand mental disorders among detained youths, it is necessary to also understand adolescent development. Also, as noted by a developmental psychopathology perspective, psychopathology may take multiple paths and lead to multiple outcomes. This principle emphasizes the importance of examining various possible outcomes of mental disorders on adolescent offenders’ functioning within the youth justice system and the community, as well as reassessing psychopathology at different points, as symptoms may change and fluctuate.

Implications for Service Delivery

Grisso has noted three primary reasons to be concerned about mental disorders among juvenile offenders. First, the youth justice system has a legal responsibility to provide mental health services to youths who are in their custody. Just as youth detention and correctional centers must provide medical services to youths with conditions such as diabetes or heart disease, so too must they provide mental health services to mentally ill adolescents who are in need of treatment.

Second, the youth justice system has due process obligations to youths with mental disorders. Specifically, jurisdictions have increasingly required that juvenile defendants be competent to stand trial (also called competent to proceed to adjudication or fit to stand trial). Mental disorders may lead to impairments in competence-related legal capacities for some youths. For instance, a youth with a thought disorder may have a paranoid delusion that her or his attorney is conspiring against her or him and thus refuse to tell her or his attorney critical information regarding her or his case, or a youth with a depressive disorder may be unmotivated to adequately defend herself or himself due to feelings of worthlessness. In some jurisdictions, youths with mental disorders may also raise the insanity defense and can be found “not guilty by reason of insanity” (not guilty by reason of mental disorder) if mental disorders interfered with their ability to understand that their illegal behavior was wrong and/or rendered them unable to control their behavior.

Finally, the justice system has a responsibility to protect the public to the extent possible. While mental disorders are not the primary cause of most youth violence, there is some preliminary evidence that violent behaviors perpetrated by youths with mental disorders may sometimes relate to mental health issues, such as attention deficit/hyperactivity disorder, substance use disorders, and possibly even some internalizing types of disorders. To the extent that mental health issues contribute to youth violence, the youth justice system has a responsibility to treat and manage psychopathology so as to help prevent violence.

Assessment of Mental Health Issues in Juvenile Offenders

In 2003, an expert panel including Gail Wasserman and colleagues developed a consensus statement with best practice recommendations for assessing mental health issues among adolescent offenders. The panel recommended that the assessment process involve multiple steps. The first step is to screen all adolescent offenders who are admitted to detention and custody centers using an evidence-based tool. Ideally, this screening should occur within 24 hours of the youth being admitted to the facility and should focus on issues such as short-term risk of harm to self and others, active substance abuse, current medications, and mental health history.

If a youth is identified as having mental health needs through this screening process, a more comprehensive assessment may be necessary. This comprehensive mental health assessment should cover a broad range of mental health issues, including Axis I disorders and suicidality, and ideally should be conducted prior to the determination of disposition so as to guide dispositions and service delivery. Those youths who are identified as having significant mental health needs should continue to be reassessed periodically throughout their detention, as youths’ mental health needs may change considerably over the course of detention. Also, to help facilitate youths’ transition back to the community, Wasserman and colleagues recommend that secure facilities assess all youths who are preparing to return to their communities.

A number of jurisdictions have recently made significant efforts to implement a mental health screening process for detained youths. These efforts have been advanced by the development of the Massachusetts Youth Screening Instrument-Version 2 (MAYSI-2) by Thomas Grisso and Richard Barnum. The MAYSI-2 is a brief self-report mental health screening tool that has received empirical support. In 2006, this tool was routinely administered in more than 35 states. A number of other tools may also be useful in assessing adolescent offenders’ mental health needs, including more comprehensive instruments, such as the Diagnostic Interview Schedule for Children-IV (Voice Version).

Despite the progress in the screening process for adolescent offenders, there are a number of issues that still need to be addressed. Most jurisdictions do not routinely reassess youths who are being reintegrated into the community to ensure that service continues. In addition, many youth justice staff who screen adolescent offenders are frontline staff, who do not necessarily have adequate training in this area.

Treating and Managing the Mental Health Needs of Juvenile Offenders

Due to the high cost of providing treatment services for offenders, the primary focus of research and interventions in the juvenile justice system has traditionally been on reducing recidivism rather than improving mental health outcomes. Research regarding treatment that is specifically aimed at addressing the mental health needs of juvenile offenders is scarce. However, it is clear that juvenile offenders do not receive adequate treatment services for their mental disorders, particularly in the case of minority youths. Less than a quarter of offenders with mental disorders in the juvenile justice system receive the services they need.

Recognizing that the juvenile justice system may not be the optimal setting for youths with mental health needs, some jurisdictions strive to divert mentally ill youths from the youth justice system. At various stages after arrest, youths may be referred out to community-based agencies for counseling or intervention services. Though the focus of diversion pro-grams has also tended to be on reducing recidivism, some recent research has examined the impact of diversion programs as well as other types of programs on mental health outcomes.

Treatment programs using a “wraparound” approach, which focuses on strong interagency collaboration to address youths’ individualized treatment needs, have shown reduced emotional problems and mental health symptoms in referred youths, in addition to improved social and school functioning, and reduced rearrest rates. Some preliminary research has also reported that postrelease treatment services contributed to improved outcomes. Finally, researchers have found that multisystematic treatment, a leading treatment for high-risk youths, is associated with reduced psychiatric symptomatology as well as decreased recidivism.

As another alternative to the juvenile justice system, some jurisdictions have developed specialized mental health courts and drug courts. While there is preliminary evidence that juvenile drug courts are sometimes associated with reduced substance abuse among adolescent offenders, there is an absence of research on juvenile mental health courts. Like many of the treatment options for juvenile offenders, mental health courts and drug courts are downward extensions of adult treatment strategies. It is important for these treatment strategies to be empirically investigated for youths as juvenile offenders may experience unique barriers to treatment not faced by adults.

Furthermore, approaches that have been found to be effective with youths in community mental health settings may not easily generalize to youths in juvenile justice settings. For instance, adolescent offenders have high rates of cognitive deficits, which may interfere with their ability to engage in complex cognitive processes that are central to some therapeutic modalities. Also, the youth justice system is not an ideal treatment environment. Interventions administered within the youth justice system are often ordered by the court, and youths who receive interventions may experience considerable stigma. As such, adolescent offenders may be resistant to comply with interventions.

Though research is finally moving from evaluating criminal outcomes to mental health outcomes, there is still a dearth of evidence supporting mental health treatment services for juvenile offenders. Given the significant mental health needs of adolescent offenders, it is critical that future research continue to investigate effective strategies to manage and treat mentally ill adolescent offenders.

References:

  1. Grisso, T. (2004). Double jeopardy: Adolescent offenders with mental disorders. Chicago: University of Chicago Press.
  2. Grisso, T., Vincent, G. M., & Seagrave, D. (Eds.). (2005). Mental health screening and assessment in juvenile justice. New York: Guilford Press.
  3. Teplin, L. A., Abram, K. M., McClelland, G. M., Dulcan, M. K., & Mericle, A. A. (2002). Psychiatric disorders in youth in juvenile detention. Archives of General Psychiatry, 59, 1133-1143.
  4. Teplin, L. A., Abram, K. M., McClelland, G. M., Washburn, J. J., & Pikus, A. K. (2005). Detecting mental disorder in juvenile detainees: Who receives services. American Journal of Public Health, 95, 1773-1780.
  5. Wasserman, G. A., Jensen, P. S., Ko, S. J., Cocozza, J., Trupin, E., Angold, A., et al. (2003). Mental health assessments in juvenile justice: Report on the consensus conference. Journal of Child and Adolescent Psychiatry, 42, 751-761.

Read more about Juvenile Offenders in Forensic Psychology.