Most individuals in law enforcement, politics, education, and research agree that Mental Health issues have an important impact on the creation and maintenance of criminal behaviour. This may be especially true for younger individuals dealing with mental health issues, including anxiety, depression, and substance abuse. It has been suggested that mental disorders constitute the largest burden of disease in youth and it has been estimated that as many as 20% of youth experience serious mental health problems, usually as a result of mental disorders (Waddell, Hua, Garland, Peters, & McEwan, 2007). “Mental disorders are highly prevalent in young people, comprising approximately one-third of the global burden of disease in this age group; approximately 75% onset before 24 years of age”(Kutchner & McDougall, 2009). Mental health issues in adolescence may reflect disorders of childhood that have persisted, or they may the first onset of a disorder that may well last into adulthood. The consequences of mental illness include “life-long difficulty with substantial morbidity, significant socioeconomic consequences and increased early mortality.”
Although the prevalence of mental disorders in young people is well documented, it would seem that only a portion of youth suffering with mental illness will receive the proper assessment, diagnosis, and treatment that they require. Recent studies suggest that only 25-30% of youth who require mental health treatment will actually receive it (Leitch 2007; Kirby & Keon, 2006). “Two of every three depressed children do not receive an approporiate diagnosis by a primary care physician, and even when a diagnosis is given, only 50% receive appropriate treatment” (Kutchner & McDougall, 2009). For a myriad of reasons there are not enough mental health services available to meet the needs of Canadian youth. Many of these problems include “long waiting lists for specialty mental health service, lack of mental health care in primary care, inadequate numbers of health providers with necessary mental health competencies, poor coordination among institutions and organizations serving young people and government agencies tasked with ensuring service provision, and lack of specific child and youth mental health polices at both the provincial and federal levels.”
To further complicate the matter, there are growing concerns that increasing numbers of youth suffering from mental health problems are being directed into the juvenile-justice system due to a lack of accessible and appropriate mental health care (Canadian Institute for Health Information, 2008; McDougall & Kutcher, 2008). A convincing body of research shows that the majority of children and youth within correctional settings suffer from one or more mental disorders (Andre, Pease, Kendall & Boulton, 1994; Uzlen & Hamilton, 1998). Not surprisingly, the mental health prognoses for many of these youth is poor and urgent calls are being made to respond to the treatment and rehabilitation needs of youth within these settings” (Odgers, Burnette, Chauhan, Moretti, & Reppucci, 2005). While not created or intended for this purpose, detention facilities are now the largest providers of mental health services for young people, yet the juvenile justice system is not equipped for the proper assessment, diagnosis, and treatment of mental health problems.
Recent research suggests that 25% of those hospitalized for a mental illness have a history of criminal behaviour (Canadian Institute for Health Information, 2008). Other research shows that up to 70% of incarcerated adolescents suffer from mental disorders that significantly impair their functioning in multiple domains (Kutchner & McDougall, 2009; Odgers, Burnette, Chauhan, Moretti, & Reppucci, 2005). The prevalence of mental disorders in the criminal justice system is at least two to four times greater than in the general adolescent population (Canadian Institute for Health Information, 2008). The large number of young people in institutions who require mental health services has overwhelmed the justice system, which is ill-equipped and ill-prepared to deal with the pressing needs of so many. This has lead to poor outcomes for youth with mental illness who become incarcerated. “Only one-third of incarcerated males and one-fourth of incarcerated females needing mental health services receive them, raising concerns that custodial interventions are replacing the need for therapeutic mental health care. Effectively addressing the mental health needs of young people before their becoming involved in the juvenile justice system may result in fewer incarcerations and improved short-and long-term person, social and economic outcomes“ (Kutchner & McDougall, 2009).
There are numerous reasons for the high rates of mental disorders among incarcerated youth. While some reasons may be fairly obvious, others are less clear. Certainly, one factor adding to the problem is the fact that “the presence of a mental disorder at the time of apprehension for suspicion of a criminal act increases the likelihood of a negative outcome in terms of subsequent contact with the justice system.” This includes “higher rates of arrests at the scene of the offense, longer detention periods and higher rates of recidivism” (Kutchner & McDougall, 2009). Whatever the reasons may be, it is clear that the juvenile justice system is not the type of environment that will help in attaining optimum outcomes with youth that have serious mental health concerns, in fact, it is likely that institutionalization in the justice system may lead to or exacerbate mental health issues. The possibility of victimization by staff or other inmates, new access to controlled substances, confinement, and separation from social support systems are only some of the potential problems that can lead to a worsening of mental health in at risk youth. These factors, as well as others, also increase the risk of suicide in a population of youth whose risk is already elevated due to mental illness (Sanislow, Grilo, & Fehon, 2003).
In one study it was found that “[n]early two thirds of males and nearly three quarters of females met diagnostic criteria for one or more psychiatric disorders. Excluding conduct disorder (common among detained youth), nearly 60% of males and more than two thirds of females met diagnostic criteria and had diagnosis-specific impairment for one or more psychiatric disorders.” It was also found that half of all males and nearly half of all females in incarceration met Diagnostic and Statistical Manual IVtr (DSM-IV) criteria for a substance use disorder. As well, more than 20% of females met criteria for a major depressive episode (Teplin, Abram, McClelland, Dulcan, Mericle, 2002). The results of this study suggest substantial co-morbidity of mental disorders among juvenile detainees and the authors suggest that “[y]outh with psychiatric disorders pose a challenge for the juvenile justice system and, after their release, for the larger mental health system.”
In another study conducted on newly arrested and incarcerated youth in Cook County, Illinois it was found that 56.6% of females and 45.9% of males met criteria for 2 or more of the following disorders: major depressive, dysthymic, bi-polar, psychotic, panic, separation anxiety, generalized anxiety, obsessive-compulsive, attention-deficit/hyperactivity, conduct, oppositional defiant, alcohol, marijuana, and other substance. They also found that the “odds of having co-morbid disorders were higher than expected by chance for most demographic subgroups”. . . and that “[n]early 14% of females and 11% of males had both a major mental disorder (psychosis, manic episode, or major depressive episode) and a substance use disorder. Compared with participants with no major mental disorder (the residual category), those with a major mental disorder had significantly greater odds (1.8-4.1) of having substance use disorders” (Abram, K.M., Teplin, L.A., McClelland, G.M., Dulcan, M.K., 2003). The study also states that nearly 30% of females and more than 20% of males with substance use disorders also met criteria for at least one other major mental disorder. The link between substance abuse and other mental disorders is well established. As a cause or a symptom of mental illness, issues regarding substance abuse remain paramount in the factors contributing both to mental illness and participation in the juvenile justice system.
It would seem that the “general consensus across studies is that the vast majority of incarcerated youth meet formal criteria for at least one DSM-IV disorder . . . with approximately 20% of youth meeting diagnostic criteria for a serious mental health disorder – defined as serious emotional disturbance resulting in functional impairment” (Odgers, Burnette, Chauhan, Moretti, & Reppucci, 2005). With over 120,000 children and adolescents being held within juvenile justice facilities across North America on any given day, this represents a huge number of young people in need of proper psychiatric and psychological care. However, as stated previously, the justice system is not designed or equipped to deal with the mental health needs of such an overwhelming number of youth. Mental health issues represent a risk factor for youth to be involved in substance abuse and the juvenile justice system. Thus, efforts should be directed towards diversion of youth from the justice system and prevention and proper treatment of mental health issues.
Diversion from the Justice System to the Mental Health System
There are a number of specific programs that attempt to divert individuals with mental health issues from the criminal justice system to a wider range of community support systems, particularly, mental health treatment and support. “Preliminary results demonstrate a number of positive outcomes including reduced risk for recidivism, less jail time, more involvement with mental health professionals and increased use of community–based services.” (Kutchner & McDougall, 2009; Canadian Institute for Health Information, 2008) However, the success of these types of programs is dependent upon multi-agency communication and participation including “the availability of highly trained staff, a judiciary that is familiar with and supportive of this approach, and effective collaboration with health, mental health and community service providers.”
In British Columbia, the policy framework for diversion of persons with a mental disorder states “there are a disproportionate number of people with mental disorders in the criminal justice and correctional systems. This is not only seen as an inappropriate consequence for illness related behaviour, but is also increasingly seen as a waste of valuable law enforcement and criminal justice system time, and of resources that may be more effectively spent on improving community mental health services.” This policy statement is arguably even more fitting for youth and the juvenile justice system. The Youth Criminal Justice Act encourages diversion and conferencing. Conferencing is a set of processes that bring concerned parties together to consult about decisions that must be made following the commission of a serious crime by a young person. Conferencing uses practices from diversion, as discussed above, and restorative justice movements in juvenile justice. Placing an emphasis on the importance of mental health issues during conferencing is one possible way to address the mental health needs of youth involved in the justice system. (Hillian, Reitsma-Street, & Hackler, 2006).
Acknowledgment of the fact that the rate of youth with mental health needs is disproportionately high in the juvenile justice system has led to other diversion programs being introduced such as wraparound programs. Wraparound planning involves families and providers in helping to coordinate mental health, juvenile justice, and any other services and supports. One study compared data from two groups of juvenile offenders with mental health problems and found that youth in the Connections program were significantly less likely to recidivate at all, less likely to recidivate with a felony offense, and served less detention time. Another study done in four New York counties looked at a program called Project Connect. Project Connect is a multilayered program aimed at “linking juvenile probationers to needed mental health and substance use services.” Interventions included “cooperative agreements between probation and mental health authorities, program materials to facilitate referral, in-service training for probation officers, and systematic screening for mental health needs. . . Compared to Baseline, under Project Connect, referred youths were 2.7 times as likely to access services, regardless of youth or county characteristics, service availability, or when the intervention took place.” Diversion programs with an emphasis on proper mental health treatment have shown some promising results.
Which Disorders have the Greatest Impact on the Justice System
Given the full range of mental disorders seen in youth today there are several disorders that are commonly associated with youth involved in the justice system. As mood and anxiety disorders are the most prevalent mental disorders in North America it is not surprising that they are overrepresented in incarcerated youth populations. Ulzen and Hamilton (1998) found that 30.4% of incarcerated youth met criteria for depression compared to only 4.1% in the community sample. They also found that 21.3% of males and 30.8% of females met criteria for an Anxiety disorder compared to only 4.1% among community youth. Studies in the United States report similar prevalence rates of depression and anxiety for incarcerated youth (Teplin et al. 2002). As stated previously, substance use disorders are highly prevalent in youth and incarcerated youth populations. Substance use disorders are also highly comorbid with mood and anxiety disorders (DSM-IV, 2008).
Other disorders that are less prevalent, but deserve special attention, due to the prolonged course of the disorders include Conduct disorder, Oppositional Defiance Disorder, and Attention Deficit Hyperactivity disorder. These disorders are likely present from before adolescence and respond best to early interventions. Diagnosis of these disorders is more difficult, but the consequences of these disorders not being treated may be severe with regard to general functioning and risk for entering the juvenile justice system.
Increased Access to the Best Treatments Available
Many youth with mental health problems do not get adequate treatment. One of the reasons mentioned above was long waiting lists for specialty mental health service. Standard waiting times for Anxiety or Mood disorder clinics is often 6 months to a year. Also, there is lack of mental health care and training in primary care physicians resulting in the standard treatment for anxiety and depression being anti-depressant and anti-anxiety medications. Even those who are referred to a specialist and go on to see a Psychiatrist will still likely find anti-anxiety and anti-depressant medication as the recommended treatment. However, “[f]rom an evidence-based perspective, cognitive-behavioral therapy is currently the treatment of choice for anxiety and depressive disorders in children and adolescents.” (Compton, March, Brent, Albano, & Weersing, 2004)
This creates a major problem for treatment outcomes, as those in need of cognitive behavioural therapy (CBT) will be unlikely to receive this form of treatment. CBT is a model that is practiced in greater numbers by clinical Psychologists, whereas, Psychiatrists are less likely to be trained in this particular form of psychotherapy. In Ontario, treatment by a clinical psychologist is not covered by the Ontario Health Insurance Plan. In order to see a clinical Psychologist for CBT, unless the psychologist is attached to a hospital clinic, patients will have to pay through insurance or out of pocket. Thus, access to CBT is restricted to those who are patient enough to remain on the waitlist or those that can pay by other means. In Peel region for example, it is very difficult to get a referral from a primary care physician to a psychiatrist that is willing or able to perform cognitive-behavioural treatments. As stated above, inadequate numbers of health care providers have the necessary mental health competencies to practice CBT. Specifically, there is a lack of access and availability for cognitive-behavioural treatment and therapies, which is the treatment of choice for anxiety, depression, and substance abuse in children and adolescents. Heavy and sole reliance on medication as treatment for anxiety and depression is an issue in all populations, but particularly with children and adolescents.
Prevention of Mental Illness through Education
In addition to supporting governmental adoption of youth mental health courts, the creation of diversion programs that emphasize mental health issues, and increasing access to the best available treatments for mental illness, efforts should be directed towards the prevention of mental illness. Almost invariably, early intervention and treatment will bring about better treatment outcomes. By educating the judiciary, first responders, those involved in youth justice services, and community members in general, mental health issues can be better understood and acted upon at an earlier stage, before they contribute to the likelihood of contact with the justice system.
In the practice of Cognitive-Behavioural therapy, one of the first steps in creating any treatment plan involves Psycho-education. Psycho-education is simply learning about the current knowledge and research concerning all aspects of the disorder the person suffers from. Information like prevalence rates can decrease stigma and let the person know that they are not alone in having this particular disorder. Information about course, symptoms, treatments, etc…, can help inform the person understand the facts regarding their disorder, including important information like co-morbidity with substance abuse for example.
Specific educational programs for middle and high school could be created that educate about anxiety, depression, and substance abuse, as well as the links between these disorders. Once again, a better informed community lessens the stigma of having mental illness, increases understanding among community members and service providers, and it has the potential to promote early intervention by giving youth the information necessary to identify and seek help for mental illness as early as possible. Psycho-education programs could be created for parents and community members as well. Intensive psycho-education programs could also be designed for high-risk youth and those who have had extensive contact with the justice system.
Whatever programs are designed and implemented, it is crucial that they are properly evaluated for outcomes and that they meet the fundamental criteria of program accountability and scientific merit. And, as always, financial resources and feasibility remain constant constraints on any proposed programs.
Conclusion
It is well understood that mental health is an important contributor to the issues of crime and deviance in any society. While many reports cite mental health as an area to consider, there are very few programs that emphasize the important link that mental illness plays in criminality, especially in the juvenile justice system. Hopefully, there will be continued support for governmental programs like youth mental health courts, diversion programs that place an emphasis on the mental health needs, conferencing, and others.
In addition to some of the traditional problems that create a lack of access to mental health care, the issue of limited access to cognitive-behavioural treatments is a particular problem for youth with depression, anxiety, and substance abuse. Most youth who receive treatment for their mental illness will be treated using medications alone, which does not represent the treatment that shows the best outcomes and is known to have many more complications and risks associated. Improving access to CBT may involve a changing of the services included under OHIP. Perhaps, at the very least, this could be established for youth or at risk youth, or youth that have had initial contact with the justice system.
Finally, as stated above, a more immediate solution involves educational programs. Education at all levels and to all relevant audiences will help people to understand mental illness in order to lessen stigma, improve ability to identify mental illness, improve chances of seeking treatment, and improve treatment outcomes by having earlier interventions and knowledge about the best available treatments. Psycho-education programs in the community should also demonstrate clearly the links between mental illness, substance abuse, and criminal behaviour.
It should be possible to create a “detour from delinquency” by preventing, properly assessing, and efficiently treating mental illness in young people, thereby keeping them from a future that involves the juvenile and criminal justice systems.
References
Abram, K.M., Teplin, L.A., McClelland, G.M., Dulcan, M.K. (2003) Comorbid Psychiatric Disorders in Youth in Juvenile Detention. Archives of General Psychiatry. 60:1097–1108.
Andre, G., Pease, K., Kendall, K., & Boulton, A. (1994). Health and Offence Histories of Young Offenders in Saskatoon, Canada. Criminal Behaviour and Mental Health. 4:163–180.
Canadian Institute for Health Information Improving the health of Canadians: Mental health, delinquency and criminal activity. < www.cihi.ca>. (Version current at October 31, 2008).
Leitch, K.K. (2007). Reaching for the top: A report by the advisor on healthy children & youth. Ottawa: Health Canada; 2007. < http://www.hc-sc.gc.ca> (Version current at October 31, 2008).
Hillian, D., Reitsma-Street, M., & Hackler, J. (2006). Conferencing in the Youth Criminal Justice Act of Canada: Policy Developments in British Columbia. Canadian Journal of Criminology and Criminal Justice, 46(30), 343-366.
Kirby, M.J. & Keon, W.J. (2006). Final Report of The Standing Senate Committee on Social Affairs, Science and Technology. Out of the shadows at last: Transforming mental health, mental illness and addiction services in Canada.
Kutcher, S. & McDougall, A. (2009) Problems with access to adolescent mental health care can lead to dealings with the criminal justice system. Pediatrics and Child Heath,v. 14(1).
Odgers, C.L., Burnette, M.L., Chauhan, P., Moretti, M.M., Reppucci, N.D. (2005). Misdiagnosing the problem: Mental health profiles of incarcerated juveniles. Can Child Adolesc Psych Rev. 14:26–9.
Sanislow, C.A., Grilo, C.M., Fehon, D.C., Axelrod, S.R., McGlashan, T.H. (2003). Correlates of suicide risk in juvenile detainees and adolescent inpatients. J Am Acad Child Adolesc Psychiatry.42:234–40.
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.
Ulzen, T.P.M., & Hamilton, H. (1998). The nature and characteristics of psychiatric comorbidity in incarcerated adolescents. Canadian Journal of Psychiatry. 43:57–63.
Waddell C, Hua JM, Garland OM, Peters RD, McEwan K. (2007). Preventing mental disorders in children: A systematic review to inform policy-making. Can J Public Health. 98:166–73.
Wasserman, G.A., McReynolds, L.S., Musibegovic, H., Whited, A.L., Keating, J.M., & Huo, Y. (2009). Evaluating Project Connect: Improving Juvenile Probationers’ Mental Health and Substance Use Service Access. Adm Policy Ment Health. Nov;36(6):393-405. Epub 2009 Jul 7.
Back to Anniversary Issue 2011
