Beyond Detention

Even though research indicates that the majority of youth in the juvenile justice system have been diagnosed with psychiatric disorders, reports issued by the Surgeon General and the President’s New Freedom Commission on Mental Health show that juvenile detainees often do not receive the treatment and services they need.

This bulletin series presents the results of the Northwestern Juvenile Project, the first large-scale, prospective longitudinal study of drug, alcohol, and psychiatric disorders in a diverse sample of juvenile detainees. Individual bulletins examine topics such as suicidal behaviors in youth in detention, posttraumatic stress disorder and trauma among this population, functional impairment in youth after detention, and barriers for youth who need to receive mental health services.

Nearly all detained youth eventually return to their communities and the findings presented in this series provide empirical evidence that can be used to better understand how to meet youth’s mental health needs and provide appropriate services while in detention and after their release. The Office of Juvenile Justice and Delinquency Prevention hopes this knowledge will help guide innovative juvenile justice policy and create a better future for youth with psychiatric disorders in the justice system.

About This Series

Studies in this series describe the results of statistical analyses of the Northwestern Juvenile Project, a longitudinal study of youth detained at the Cook County Juvenile Temporary Detention Center in Chicago, IL, between 1995 and 1998. The sample included 1,829 male and female detainees between ages 10 and 18. The data come from structured interviews with the youth.

Topics covered in the series include the prevalence of suicidal thoughts and behaviors among juvenile detainees, posttraumatic stress disorder and trauma within this population, functional impairment after detention (at work, at school, at home, or in the community), psychiatric disorders in youth processed in juvenile or adult court, barriers to mental health services, violent death among delinquent youth, and the prevalence of psychiatric disorders in youth after detention. The bulletins can be accessed from the Office of Juvenile Justice and Delinquency Prevention’s (OJJDP’s) Web site, ojjdp.gov.

In addition to the funding that OJJDP provided, the research also was supported by the National Institute on Drug Abuse, the National Institute of Mental Health, the National Institute on Alcohol Abuse and Alcoholism, the Substance Abuse and Mental Health Services Administration (Center for Mental Health Services, Center for Substance Abuse Prevention, and Center for Substance Abuse Treatment), the Centers for Disease Control and Prevention (National Center for Injury Prevention and Control and National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention), the National Institutes of Health Office of Research on Women’s Health, the National Institute on Minority Health and Health Disparities, the Office of Rare Diseases, the Office of Behavioral and Social Sciences Research, the U.S. Departments of Labor and Housing and Urban Development, the William T. Grant Foundation, and the Robert Wood Johnson Foundation. The John D. and Catherine T. MacArthur Foundation, the Open Society Foundations, and the Chicago Community Trust provided additional funds.

The Northwestern Juvenile Project: Overview

Linda A. Teplin, Karen M. Abram, Jason J. Washburn, Leah J. Welty, Jennifer A. Hershfield, and Mina K. Dulcan

February 2013

Highlights

The Northwestern Juvenile Project (NJP) studies a randomly selected sample of 1,829 youth who were arrested and detained in Cook County, IL, between 1995 and 1998. This bulletin provides an overview of NJP and presents the following information about the project:

• NJP is a longitudinal study that investigates the mental health needs and long-term outcomes of youth detained in the juvenile justice system.

• This study addresses a key omission in the delinquency literature. Many studies examine the connection between risk factors and the onset of delinquency. Far fewer investigations follow youth after they are arrested and detained.

• The mental health needs of youth detained in the juvenile justice system are far greater than those in the general population.

• The mental health needs of youth in detention are largely untreated. Among detainees with major psychiatric disorders and functional impairment, only 15 percent had been treated in the detention center before release.

The Northwestern Juvenile Project (NJP) is the first large-scale, prospective longitudinal study of mental health needs and outcomes of juvenile detainees. The Office of Juvenile Justice and Delinquency Prevention (OJJDP) and a consortium of eight other federal agencies and five private foundations have funded NJP. Data from large-scale studies such as NJP provide an empirical basis for decisionmaking in the juvenile justice system.

NJP includes a diverse sample of 1,829 youth who were arrested and detained between 1995 and 1998 in Cook County, IL, the metropolitan area that includes Chicago and its surrounding suburbs. At baseline, the participants were between 10 and 18 years old.

NJP continuously tracks and reinterviews participants. Following participants over time allows for the study of patterns and sequences of disorders, the impact of these disorders on functioning, and the important risk and protective factors in this population. Researchers interview participants where they are living (either in their communities or in correctional facilities). In addition to conducting face-to-face interviews with participants, NJP also obtains records from 16 correctional and service agencies to cross-validate self-reported data on criminal justice involvement and to confirm the use of mental health and substance use services.

Background

A significant proportion of the nation’s youth are involved in the juvenile justice system. In 2009, approximately 1.9 million arrests were made of persons younger than age 18; juveniles accounted for 12 percent of all Violent Crime Index arrests and 17 percent of all Property Crime Index arrests nationwide (Puzzanchera and Adams, 2011). In 2010, nearly 71,000 juveniles were in custody on an average day (Sickmund et al., 2011). Because of the large number of juvenile detainees, it is important to gather accurate epidemiologic data on psychiatric disorders.

Comprehensive, accurate, and reliable data are needed to guide the development of innovative juvenile justice policy. NJP provides empirical evidence that communities can use to develop and provide appropriate services within detention centers. Because the study is longitudinal, it also provides information about the long-term outcomes of these youth after they leave detention. Findings from NJP, to be presented briefly in this bulletin and in greater detail in subsequent bulletins, provide important information on how to facilitate successful reentry into the community and successful transition to adulthood for youth in the juvenile justice system.

Differences Between NJP and Other Longitudinal Studies of Psychiatric Disorder Among Detained Youth

Many excellent cross-sectional studies have examined mental disorders among detained youth (Atkins et al., 1999; Lewis et al., 1987; McCabe et al., 2002; Steiner, Garcia, and Mathews, 1997; Timmons-Mitchell et al., 1997). Far fewer studies, however, have examined how youth fare after they leave detention. Only two large-scale longitudinal studies of juvenile detainees, in addition to NJP, have examined psychiatric disorders among youth in the juvenile justice system. Table 1 lists key characteristics of these longitudinal studies and NJP. The Youth Support Project (Dembo et al., 2000), an intervention study, reported on substance use, not substance use disorder or other psychiatric disorders. The Pathways to Desistance study (Mulvey, 2004) (also funded by OJJDP) sampled only serious offenders; that is, those who were adjudicated delinquent for felonies or serious misdemeanors. Thus, the Pathways to Desistance study provides data on an important subgroup, but one that comprises a relatively small fraction of youth in the juvenile justice system (Stahl, 2003; Puzzanchera and Kang, 2011).

NJP’s Overall Approach and Goals

NJP was designed to investigate the mental health needs and long-term outcomes of youth in the juvenile justice system. NJP has three primary goals:

1. Assess the prevalence, development, and persistence of psychiatric disorders as youth in the juvenile justice system become adults. As part of this goal, the researchers do the following:

• Assess affective, anxiety, psychotic, disruptive behavior, and substance use disorders; and patterns of comorbid disorders.

• Examine functional impairment and outcomes associated with these disorders.

• Focus on gender and racial/ethnic disparities in psychi-atric and substance use disorders.

• Examine how well community mental health and justice systems respond to the needs of these youth.

2. Examine the dynamic relationships among patterns of psychiatric disorders, risky behaviors, mortality, and other long-term outcomes in adulthood. As part of this goal, the researchers do the following:

• Examine the development and persistence of risky behaviors such as gang involvement, criminal activity, risk behaviors related to sexual activity and drug use, involvement in the drug trade, and perpetration of violent crimes.

• Focus on the antecedents of these risky behaviors (e.g., exposure to violence, abuse, and neglect) and how different types of risky behaviors are interrelated.

• Determine the consequences of these behaviors on adult social role performance: educational attainment, employment, residential independence, intimate relationships, parenting, and desistance from crime.

3. Examine how patterns of incarceration during adolescence and adulthood affect long-term outcomes in adulthood. As part of this goal, the researchers do the following:

• Collect data on age at incarceration, number of incarcerations and releases, length of incarcerations, time spent in the community between incarcerations, terms of release, and experiences with community corrections (parole, probation, and community supervision).

• Examine how incarceration during adolescence affects subsequent psychiatric disorders, gang involvement, criminal behaviors, involvement in the drug trade, violent perpetration and victimization, and mortality.

• Study the consequences of incarceration on adult social role performance, as defined in goal 2 above.

• Examine how factors in adolescence and young adulthood influence disproportionate minority contact with the justice system in adulthood.

Sampling and Interview Methods

The following section discusses how the researchers carried out the study, including the demographic characteristics of the sample, the interview design, and the methods they used to track and retain sample participants.

Demographic Characteristics of the Sample

NJP recruited a stratified random sample of 1,829 youth at intake to the Cook County Juvenile Temporary Detention Center (CCJTDC) in Chicago, IL, between November 20, 1995, and June 14, 1998. CCJTDC is used for pretrial detention and for offenders sentenced for fewer than 30 days. To ensure adequate representation of key subgroups, researchers stratified the sample by gender, race/ethnicity (African American, non-Hispanic white, Hispanic, or other), age (10–13 years or 14 years and older), and legal status (processed in juvenile or adult court).

All detainees awaiting the adjudication or disposition of their case were eligible to participate in the study. Among them, the researchers randomly selected 2,275 detainees; 4.2 percent (34 youth and 62 parents or guardians) refused to participate. There were no significant differences in refusal rates by gender, race/ethnicity, or age. Twenty-seven youth left the detention center before an interview could be scheduled, 312 left while the researchers attempted to locate their caretakers for consent, and 11 others were excluded from the sample because they were unable to complete the interview. The final sample size was 1,829. It was composed of 1,172 males and 657 females; the ethnic breakdown was 1,005 African Americans, 296 non-Hispanic whites, 524 Hispanics, and 4 “other race/ethnicity.” The age range was 10 to 18 years old with a mean of 14.9 years and a median of 15 years. Sample weights are used in statistical analyses; therefore, findings reflect CCJTDC’s population rather than the stratified sample. Table 2 presents unweighted sample characteristics and figure 1 presents information about sample stratification.

The sample has several strengths:

• Size. The sample is large enough to investigate uncommon risk factors and outcomes.

• Large subsample of females. There are enough females (657, more than one-third of the sample) to examine gender differences. It is critical to study females because they comprise a substantial proportion of persons in the juvenile and adult justice systems: 30 percent of juvenile arrests, 14 percent of juveniles in residential placement, 25 percent of adult arrests, and 9 percent of incarcerated adults (Puzzanchera, 2009; Snyder, 2011; Sickmund et al., 2011; Glaze, 2010).

• Racial/ethnic diversity. The sample is racially and ethnically diverse; it is composed of 1,005 African Americans (54.9 percent), 524 Hispanics (28.7 percent), 296 non-Hispanic whites (16.2 percent), and 4 from other racial/ethnic groups (0.2 percent).

• Wide age range. At baseline, the age range was 10 to 18 years old (a mean of 14.9 years). Youth 10 to 13 years old were oversampled to provide adequate numbers to examine age differences.

Inclusion of youth processed in juvenile and adult court. The sample includes youth processed as juveniles and oversampled those who were transferred to adult court.

Interviews

Baseline interviews began in November 1995; 13 waves of followup interviews, spanning 16 years, began in November 1998 and are ongoing.

Researchers conduct followup interviews with participants where they are living when their interview is due (in the community or in a correctional facility). A small proportion of participants are interviewed by telephone if face-to-face interviews are not feasible.

Sample Retention

Sample retention is critical to the integrity of longitudinal data. NJP participants are highly mobile and can be difficult to locate. The researchers developed an extensive tracking system to maintain the sample. Participants receive thank-you notes, birthday cards, and routine mailings with gifts throughout the year. All mailings include change of address cards. Returned mail indicates the participant has been lost to followup and more extensive tracking procedures are required. Interviewers update contact information at every interview. To track participants, researchers use the telephone, Internet, agency contacts, and contacts the participant has previously provided; they also visit last-known addresses. Table 3 shows participation rates (82–97 percent).

Considerations for Measurement

The following goals have guided the choice of measures.

Ensure comprehensiveness. Content areas reflect prior empirical studies of psychiatric and substance use disorders, criminal recidivism, and risk and protective factors.

Maximize sensitivity. Because many of the participants’ responses score at the extremes of conventional measures (e.g., very low on cognitive assessments and very high on many behavioral assessments), the researchers selected instruments that are sensitive in extreme ranges (Dowling, Johnson, and Fisher, 1994; Hawkins et al., 2003; Needle et al., 1995; Weatherby, Needle, and Cesari, 1994). Whenever possible, the researchers chose instruments designed for high-risk populations who, on average, have more verbal deficits than general population youth. As needed, the research team refined the coding to capture smaller gradations of symptoms, behaviors, and attitudes.

Minimize cultural bias. Standardized measures in some areas—demographics, family structure, and family functioning—are inappropriate for many delinquent youth because they often do not live in traditional families. It is common for these youth to live in single-parent households, move frequently, or be cared for by siblings or extended family. The researchers revised standard instruments to capture variations in these family systems.

Maximize comparability to the researchers’ baseline data. In some cases, the research team developed new instruments that were superior to those used in the baseline assessments or that better addressed participants’ evolving developmental stages. Where they used new instruments, researchers maximized their comparability to the instruments used at earlier waves.

Maximize efficiency. To complete interviews within the limits of most participants’ attention span and motivation, the researchers combined some instruments and condensed others, with advice from authors or experts in the field. Researchers worked with participants to construct a timeline of events since their last interview, in the past year, and in the past 3 months to help them recall the timing of behaviors throughout the interview. Interviewers conducted reliability checks with mock participants following training and annually thereafter to maintain consistency.

Maximize comparability to other studies. Whenever possible, the research team selected commonly used instruments to maximize the likelihood that these data could be compared with other large studies of adolescents and at-risk populations. NJP draws questions from the National Institute of Mental Health’s Methods for the Epidemiology of Child and Adolescent Mental Disorders study (Goodman et al., 1998); the National Survey on Drug Use and Health (Substance Abuse and Mental Health Services Administration, 2004); the National Institute on Drug Abuse’s Risk Behavior Assessment (Dowling, Johnson, and Fisher, 1994; Needle et al., 1995; Weatherby, Needle, and Cesari, 1994); the Denver Youth Survey (Institute of Behavioral Science, 1991); the Seattle Social Development Project (Hawkins et al., 2003); the Washington, DC, Metropolitan Area Drug Study of Juveniles (National Institute on Drug Abuse, 1995); the Child and Adolescent Functional Assessment Scale (Hodges, 1994); and the Child and Adolescent Services Assessment–Modified (Burns et al., 1994).

The sidebar “Northwestern Juvenile Project: Key Areas of Measurement” lists key variables that NJP assesses.

Northwestern Juvenile Project: Key Areas of Measurement

Sociodemographic Characteristics

Educational performance and attainment

Employment

Characteristics of employment

Employment stability

Compensation

Attitudes and satisfaction

Perceived barriers to securing employment

Income

Legal vs. illegal source

Allocation of resources

Public assistance status

Other financial assistance (e.g., benefits, resources)

Residential stability and living situation

Type of residence

Homelessness

Marital status

Acculturation (Hispanic participants)

Psychiatric Disorders

Psychotic disorders

Psychosis

Schizophrenia

Affective disorders

Major depressive disorder

Dysthymic disorder

Mania

Hypomania

Suicidality

Anxiety disorders

Separation anxiety disorder

Overanxious disorder

Generalized anxiety disorder

Panic disorder

Posttraumatic stress disorder

Attentional/disruptive behavioral disorders

Attention-deficit/hyperactivity disorder

Oppositional defiant disorder

Conduct disorder

Antisocial personality disorder

Gambling disorder

Substance use disorders

Alcohol abuse and dependence disorder

Marijuana use and dependence disorder

Other drug use and dependence disorders

Substance Use

Type of substance

Recency of use

Mode of use

Use during pregnancy

Context of use

Inhibition

Habitual use

Readiness for change

Criminal Activity

Onset

Type

Frequency

Recency

Context

Relationship to victim

Working alone or with others

Arrest history

Access to and use of guns

Incarceration History

Stays in correctional facilities

Age at incarceration(s)

Length of stay

Type of facility

Reentry from incarceration

Number of release(s) into the community

Resources at release

Living arrangement after release

Employment after release

Relationship with community corrections (e.g., parole, probation)

Health and Impairment

Functional impairment

Global impairment

Domain-specific impairment

Physical functioning

Infection, disease

Injury

Chronic pain

Sexually transmitted infections

Sex risk behaviors

Drug risk behaviors

Global health and exercise

Cognitive functioning

Intellectual functioning (composite IQ, verbal, nonverbal)

Academic achievement (reading, arithmetic)

Quality of life

Mortality

Life Events

Milestones

Marriage

Childbirth

Educational attainment

Employment

Adverse life events

Childhood maltreatment

Physical abuse

Sexual abuse

Neglect

Loss of intimates

Trauma and exposure to violence

Victimization

Sexual

Domestic

Criminal

Attitudes and Beliefs

Self-esteem

Self-efficacy

Religiosity

Future orientation

Attitudes toward deviance and risky behavior

Service Utilization

Mental health and substance use services

Provider

Level of care

Community-based services

Inpatient services

Correctional services

Characteristics of services

Satisfaction with services

Payment for services

Perceived barriers to mental health and substance use services

Physical healthcare utilization

Interpersonal and Community Characteristics

Family of origin characteristics

Household composition

Biological parental contact

Parental monitoring and disciplinary practices

Primary caretaker(s) during childhood

Caretaker risk factors

Substance use

Psychiatric problems

Criminal involvement

Marital and intimate relationships

Quality of relationship

Behaviors and employment of partner

Parenting practices and attitudes

Social support

Deviant and peer associations

Peer criminal activity

Peer substance use

Gang involvement

Gang pressure toward deviance

Structure and function of social support network

Sense of “mattering” to other(s)

Neighborhood characteristics

Neighborhood safety

Ease of obtaining drugs

Perceived violence

Overview of Selected Findings from the Northwestern Juvenile Project

Characteristics of Youth in Detention

Prevalence of Psychiatric Disorders

• Psychiatric disorders are prevalent: 66 percent of males and 74 percent of females met the criteria for at least one disorder at the baseline interview in detention.

• Substance use disorders are the most common: 51 percent of males and 47 percent of females met diagnostic criteria at baseline.

• Rates of many disorders were greater among females and non-Hispanic whites.

Multiple Disorders

• Having more than one disorder is common: 46 percent of males and 57 percent of females had two or more disorders at baseline.

• Compared with participants who did not have a major mental disorder (MMD), those with an MMD had significantly greater odds of also having a substance use disorder.

• Multiple substance use disorders are also common: Among participants with an alcohol disorder, four out of five also had one or more drug disorders.

Prevalence of Psychiatric Disorders Among Youth Processed as Adults

• Rates of psychiatric disorder among youth processed in adult criminal courts are similar to the rates for youth processed in juvenile courts: 66 percent had at least one psychiatric disorder and 43 percent had two or more psychiatric disorders.

Trauma and Posttraumatic Stress Disorder

• Ninety-three percent of participants had been exposed to one or more traumas prior to baseline.

• Significantly more males than females reported at least one trauma.

• Eleven percent of the sample met diagnostic criteria for posttraumatic stress disorder (PTSD) in the past year; more than half of participants with PTSD reported witnessing violence as the precipitating trauma.

• Among participants with PTSD, 93 percent also met diagnostic criteria for at least one comorbid psychiatric disorder.

Suicidality

• More than one in three juvenile detainees (and nearly half of female detainees) had felt hopeless or thought about death in the 6 months prior to detention.

• One in ten juvenile detainees reported thinking about committing suicide in the past 6 months; 1 in 10 had ever attempted suicide.

• Recent suicide attempts were most common in females and in youth with major depression and generalized anxiety disorder.

• Less than 50 percent of detainees with recent thoughts of suicide had told anyone about their ideation.

Child Maltreatment

• Four out of five juvenile detainees reported ever having been physically abused.

• Official records underestimate the prevalence of childhood maltreatment; only 17 percent of participants who reported any physical abuse, 22 percent who reported the greatest level of abuse, and 25 percent who required medical attention as a result of abuse had a court record for this maltreatment.

Prevalence of HIV/AIDS Risk Behaviors

• Ninety-five percent of the sample engaged in 3 or more HIV/AIDS risk behaviors; 65 percent engaged in 10 or more risk behaviors.

• Participants with substance use disorders were more likely to engage in HIV/AIDS risk behaviors.

• HIV/AIDS risk behaviors are persistent: More than two-thirds of youth who engaged in 10 or more risk behaviors at baseline persisted with at least 10 risk behaviors 3 years later.

Perceived Barriers to Accessing Mental Health Services

• Eighty-five percent of youth with psychiatric disorders reported at least one perceived barrier to accessing services.

• The most common barriers were the belief that the problem would go away or could be solved on its own, uncertainty about the appropriate place to get help, and difficulty obtaining help.

Outcomes of Juvenile Delinquents

Detecting and Treating Psychiatric Disorders

• Among detainees with major psychiatric disorders and functional impairment, 15 percent received treatment in the detention center and 8 percent received treatment in the community by the time of case disposition or 6 months after detention.

• The likelihood of detection and treatment was greater among youth with a current major psychiatric disorder or a history of receiving treatment, or among youth who reported suicidality.

• The likelihood of detection and treatment was lower among racial/ethnic minorities, males, older detainees, and youth transferred to adult court.

Functional Impairment

• Twenty-two percent of youth had marked global impairment that required intensive interventions from multiple sources of care.

• Only 8 percent of the sample had no noteworthy impairment.

Development of Antisocial Personality Disorder

• Three years after the baseline interview, 17 percent of detained youth had developed antisocial personality disorder (APD).

Significantly more males than females developed APD.

Mortality

• The overall mortality rate of juvenile detainees an average of 7.1 years after they were detained was more than four times as large as the rate in the general population.

• The mortality rate of female detainees was nearly eight times the rate in the general population.

• Ninety-six percent of deaths were homicides or legal interventions (e.g., the youth was killed by police); among homicides, 93 percent resulted from gunshot wounds.

Diagnostic Measures

NJP employs standardized diagnostic instruments that are appropriate for the developmental stage of the participants at each wave. The baseline assessments used the Diagnostic Interview Schedule for Children (DISC), version 2.3 (based on the revised third edition of the Diagnostic and Statistical Manual for Mental Disorders (DSM–III–R)), which was the most recent version available (in both English and Spanish) at the time of those assessments (Bravo et al., 1993; Shaffer et al., 1996). The DISC is a highly structured diagnostic interview that contains detailed probes into symptoms.

For followup interviews, the research team modified diagnostic assessments in accordance with improvements in diagnostic technology and the age of participants. The team administered the DISC version 4.0 (DISC–IV, which is based on the DSM–IV), which its authors modified for use with young adults, at the followup interviews (Fisher et al., 1997; Shaffer et al., 2000). In addition, the team used the Diagnostic Interview Schedule, version IV (DIS–IV, which is based on the DSM–IV) to assess disorders that either were not assessed or that the DISC–IV did not adequately assess, including substance use disorders, schizophrenia, cognitive impairment, and antisocial personality disorder (Shaffer et al., 2000).

By 2002, most of the participants in the sample were 18 years old or older, at which time NJP stopped using diagnostic tools designed for children and adolescents and began administering the World Mental Health–Composite International Diagnostic Interview (WMH–CIDI) for adults. The researchers use the WMH–CIDI to assess the following DSM–IV disorders: depression, mania, panic, generalized anxiety, and posttraumatic stress disorder (PTSD), as well as suicidality (Kessler and Üstün, 2004). The WMH–CIDI is a comprehensive measure that provides information on both prevalence and severity of these disorders. It builds on earlier versions of the CIDI and DIS–IV (Kessler and Üstün, 2004).

NJP continues to use sections of the DIS–IV to assess (1) antisocial personality disorder because it is not included in WMH–CIDI 2000, (2) substance use disorders because the WMH–CIDI collapses many types of drugs into an “other” category rather than identifying specific drugs abused, and (3) schizophrenia because the WMH–CIDI screens for psychosis only.

Other Measures

More information about the measures used to assess other variables listed in the sidebar “Northwestern Juvenile Project: Key Areas of Measurement” will be provided in subsequent bulletins.

Overview of Selected Findings From NJP

Published data from NJP have been cited in the Report of the Surgeon General’s Conference on Children’s Mental Health (U.S. Department of Health and Human Services, 2000), by national advocacy groups, and in reports to Congress. Analyses of data from NJP are ongoing. To date, articles have been published in the Archives of General Psychiatry, American Journal of Public Health, Journal of Adolescent Health, Journal of the American Academy of Child and Adolescent Psychiatry, Journal of Consulting and Clinical Psychology, Pediatrics, and Psychiatric Services. A brief summary of some key findings follows (also see the sidebar, “Overview of Selected Findings From the Northwestern Juvenile Project”).

Characteristics of Youth in Detention

This section discusses characteristics of the youth who were sampled at detention.

Prevalence of psychiatric disorders. Psychiatric disorders are prevalent among juvenile detainees; in NJP, almost three-quarters of females and two-thirds of males in detention had one or more psychiatric disorders. The rates of disorder remained high even after excluding conduct disorder. Substance use disorders, the most common type of disorder, affected more than 50 percent of males and 47 percent of females (Teplin et al., 2002, 2006). Overall, females were significantly more likely than males to have a psychiatric disorder. Non-Hispanic whites were also significantly more likely than African Americans or Hispanics to have any disorder.

Multiple disorders. Many youth have more than one disorder; 57 percent of females and 46 percent of males met diagnostic criteria for two or more disorders at baseline. Detained youth were more likely to have substance use disorders comorbid with attention-deficit/hyperactivity disorder or other behavioral disorders than any other combination of disorders. Participants with a major psychiatric disorder (e.g., major depression, mania, psychosis) were significantly more likely to also have a substance use disorder than were those without major psychiatric disorders (Abram et al., 2003; Teplin et al., 2006). Multiple substance use disorders are also common; more than 21 percent of participants had two or more substance use disorders. The most prevalent combination of substance use disorders was alcohol and marijuana. Among participants with an alcohol disorder, four out of five detainees also had one or more drug use disorders (McClelland et al., 2004).

Prevalence of psychiatric disorders among youth processed as adults. Youth processed in adult criminal court had rates of psychiatric disorder similar to those among youth processed in juvenile court; 66 percent of youth processed in criminal court had at least one psychiatric disorder and 43 percent had two or more types of disorder. Among youth transferred to criminal court, those sentenced to prison had significantly greater odds of having a disruptive behavior disorder, a substance use disorder, or comorbid affective and anxiety disorders (Washburn et al., 2008).

Trauma and PTSD. Exposure to trauma is common among juvenile detainees; nearly all of the NJP participants (93 percent) experienced one or more traumas in their lifetime at baseline. Significantly more males than females reported having experienced a traumatic event (Abram et al., 2004). More than 1 in 10 detainees met diagnostic criteria for PTSD during the year prior to the baseline interview. Of those participants who met these criteria, more than half reported witnessing violence as the precipitating trauma. Among participants with PTSD, 93 percent also met criteria for at least one comorbid psychiatric disorder (Abram et al., 2007).

Suicidality. More than one-third of juvenile detainees felt hopeless or thought about death in the 6 months before detention. Approximately 1 in 10 juvenile detainees (10.3 percent) reported thinking about committing suicide in the past 6 months, and 11 percent had attempted suicide at some point in their lives. Recent suicide attempts were most prevalent among females and among youth who experienced major depression and generalized anxiety disorder. Fewer than half of detainees with recent thoughts of suicide had told anyone about their ideation (Abram, Choe et al., 2008).

Child maltreatment. Child maltreatment is common among detained youth; 83 percent of detainees reported physical abuse received from parents, stepparents, foster parents, or other caretakers. Despite the high rates of self-reported physical abuse, a small proportion of all incidents of maltreatment come to the attention of authorities: Only 17 percent of those who reported any type of physical abuse, 22 percent of those who reported the most severe level of physical abuse, and 25 percent of those who reported needing medical attention as a result of physical abuse had a court record of abuse or neglect (Swahn et al., 2006).

Prevalence of HIV/AIDS risk behaviors. Risk for HIV/AIDS infection is high among detained youth, regardless of gender, race/ethnicity, or age. Approximately 95 percent of detained youth engaged in 3 or more HIV/AIDS risk behaviors, and 65 percent engaged in 10 or more HIV/AIDS risk behaviors. Significantly more African Americans than non-Hispanic whites engaged in sexual risk behaviors, while significantly more non-Hispanic whites than African Americans engaged in drug risk behaviors (Teplin et al., 2003). Detained youth with substance use disorders, either with or without comorbid major psychiatric disorders, were more likely to engage in HIV/AIDS risk behaviors (Teplin, Elkington et al., 2005). Youth continue to engage in HIV/AIDS risk behaviors over time; more than two-thirds of youth who engaged in at least 10 risk behaviors at their baseline interviews persisted in at least 10 risk behaviors 3 years later (Romero et al., 2007).

Perceived barriers to accessing mental health services. Approximately 85 percent of detained youth with psychiatric disorders reported at least one perceived barrier to accessing services. The most common barrier was the belief that problems would go away without help or that the individual could solve problems independently. Youth also reported that they were unsure of where or how to obtain help and that help was too difficult to obtain. Many participants denied having a problem; detained youth who do not recognize their mental health needs or who feel that they can resolve their problems alone are unlikely to seek services or cooperate with services when they receive them (Abram, Paskar et al., 2008).

Key Outcomes of Study Participants

This section presents some of the outcomes of the youth who participated in NJP.

Detecting and treating psychiatric disorders. Among detainees who had major psychiatric disorders and associated functional impairments, records showed that only 15 percent had been treated in the detention center before release and that even fewer (8 percent) had been treated in the community during the 6 months following their interview in detention (Teplin, Abram et al., 2005). The likelihood that disorders would be detected or treated was greater among youth who had a current major psychiatric disorder, a history of receiving treatment, or who reported suicidality at intake, whereas the likelihood was lower among racial/ethnic minorities, males, older detainees, and detainees transferred to adult court for legal processing (Teplin, Abram et al., 2005).

Functional impairment. Three years after detention, most participants continue to struggle in one or more major life domains; more than one in five participants had markedly impaired functioning that required intensive intervention. These youth failed to meet age-appropriate social, occupational, and interpersonal indicators. Only 8 percent of the entire sample demonstrated no noteworthy impairment (Abram et al., 2009).

Development of antisocial personality disorder. Nearly one-fifth (17 percent) of male juvenile detainees developed antisocial personality disorder (APD) approximately 3 years after detention. Significantly more males than females developed APD, but no differences were found by race/ethnicity. A diagnosis of conduct disorder (CD) and the number of CD symptoms endorsed were significantly associated with developing modified APD (M–APD; i.e., APD without the CD requirement). Subsequent analyses, however, indicated that the number of CD symptoms affects risk for M–APD: Participants with five or more CD symptoms were significantly more likely to develop M–APD than those with fewer than five symptoms. Analyses also indicated that several other disorders were significantly associated with developing M–APD, including dysthymia, alcohol use disorder, and generalized anxiety disorder (Washburn et al., 2007).

Mortality. Based on the total number of deaths of 15- to 24-year-old participants that occurred an average of 7.1 years after baseline, standardized mortality rates among juvenile delinquents were more than four times greater than rates in the general population. Mortality among females was nearly eight times greater than in the general population. For both males and females, all deaths resulted from external causes; 96 percent of the deaths were the result of homicide or legal intervention (e.g., the study participant was killed by police). Gunshot wounds were the primary means of death (93 percent of the homicides) (Teplin, McClelland et al., 2005).

Summary

As the first large-scale, prospective longitudinal study of drug, alcohol, and psychiatric disorders in juvenile detainees, the Northwestern Juvenile Project provides much-needed insight into the types of services and treatment that youth in the juvenile justice system most require. Findings from the study have been published in peer-reviewed journals, cited in the Surgeon General’s Report on Children’s Mental Health and in reports to Congress, and used by national advocacy groups.

The findings presented in this and future bulletins will help build the empirical foundation on which practitioners will develop and implement appropriate services to facilitate youth’s successful reentry into the community. Analyses and data collection are ongoing.

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Acknowledgments

Linda A. Teplin, Ph.D., is the Owen L. Coon Professor and Vice Chair for Research in the Department of Psychiatry and Behavioral Sciences at the Feinberg School of Medicine, Northwestern University, Chicago, IL, as well as Director of the Department’s Program in Health Disparities and Public Policy.

Karen M. Abram, Ph.D., is Associate Professor and Associate Director, Health Disparities and Public Policy, in the Department of Psychiatry and Behavioral Sciences at the Feinberg School of Medicine.

Jason J. Washburn, Ph.D., ABPP, is Assistant Professor and Director of Education and Clinical Training in the Division of Psychology, Department of Psychiatry and Behavioral Sciences at the Feinberg School of Medicine. He is also Director of the Center for Evidence-Based Practice at Alexian Brothers Behavioral Health Hospital, Hoffman Estates, IL.

Leah J. Welty, Ph.D., is Assistant Professor in the Department of Preventive Medicine and the Department of Psychiatry and Behavioral Sciences at the Feinberg School of Medicine. She is also a biostatistician in the Biostatistics Collaboration Center at the Feinberg School of Medicine.

Jennifer A. Hershfield, M.A., is a doctoral candidate in the Division of Psychology, Department of Psychiatry and Behavioral Sciences at the Feinberg School of Medicine.

Mina K. Dulcan, M.D., is a Professor in both the Department of Psychiatry and Behavioral Sciences and the Department of Pediatrics at the Feinberg School of Medicine. She is also the Head of the Department of Child and Adolescent Psychiatry at the Ann & Robert H. Lurie Children’s Hospital of Chicago.

The authors thank all of their agencies for their collaborative spirit and steadfast support. They also thank the research participants for their time and willingness to participate as well as the Cook County Juvenile Temporary Detention Center, Cook County Department of Corrections, and Illinois Department of Corrections for their cooperation.

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NCJ 234522

PTSD, Trauma, and Comorbid Psychiatric Disorders in Detained Youth

Karen M. Abram, Linda A. Teplin, Devon C. King, Sandra L. Longworth, Kristin M. Emanuel, Erin G. Romero, Gary M. McClelland, Mina K. Dulcan, Jason J. Washburn, Leah J. Welty, and Nichole D. Olson

June 2013

Highlights

This bulletin examines the results of the Northwestern Juvenile Project—a prospective longitudinal study of youth detained at the Cook County Juvenile Temporary Detention Center in Chicago, IL. The authors discuss their findings on the prevalence of trauma and posttraumatic stress disorder (PTSD) among juvenile detainees and PTSD’s tendency to co-occur with other psychiatric disorders.

Some findings include the following:

• Of the study sample, 92.5 percent of youth had experienced at least one trauma, 84 percent had experienced more than one trauma, and 56.8 percent were exposed to trauma six or more times.

• Witnessing violence, the most common trauma, was far more common in this study sample than in most community studies of youth and young adults.

• More than 1 in 10 detainees had PTSD in the year prior to the interview.

• Among participants with PTSD, 93 percent had at least one comorbid psychiatric disorder. Among males, having any psychiatric diagnosis significantly increased the odds of having comorbid PTSD.

Each year there are approximately 2.11 million arrests of youth, accounting for 16 percent of all violent crime and 26 percent of all property crime arrests (Puzzanchera, 2009). On a typical day, approximately 81,000 youth are detained (Sickmund, 2010). The number of youth with psychiatric disorders in the juvenile justice system is a considerable public health problem. Two-thirds of males and three-quarters of females in juvenile detention have one or more psychiatric disorders (Teplin et al., 2002; Wasserman et al., 2002).

The related literature suggests that posttraumatic stress disorder (PTSD) may be more common in youth in the juvenile justice system than in community samples (Cauffman et al., 1998; Steiner, Garcia, and Matthews, 1997; Wasserman et al., 2002). PTSD is an anxiety disorder that may develop in response to traumatic events—or traumas—in which there is severe injury or the threat of death. Symptoms include flashbacks, avoidance of reminders, emotional numbing, and increased arousal (American Psychiatric Association, 1994).

Lifetime diagnoses of PTSD in community samples of youth and young adults range from 6.3 percent of youth (by age 18; Giaconia et al., 1995) to 2.8 percent of males and 10.3 percent of females (ages 15–24; Kessler et al., 1995). “Current” diagnoses (i.e., diagnoses active at the time of the assessment) are 3.5 percent among females ages 16–22 who had ever experienced a trauma (Cuffe et al., 1998).

Estimates of the prevalence of PTSD among youth in the juvenile justice system vary considerably, depending on sample type, the measure used, and the time frame assessed (i.e., within the past year, within the past month, or at the time of the interview) (Wasserman et al., 2002; Steiner, Garcia, and Matthews, 1997; Burton et al., 1994; Cauffman et al., 1998; Duclos et al., 1998). For example, estimates of PTSD are 2.3 percent among American Indian male detainees (past year; Duclos et al., 1998); 4.8 percent among male youth in “secure placement” (past month; Wasserman et al., 2002); 24.2 percent among male juvenile felons in “secure custody” (at the time of the interview; Burton et al., 1994); and 32.3 percent among “incarcerated” male youth (at the time of the interview; Steiner, Garcia, and Matthews, 1997). Far fewer data are available on females in the juvenile justice system. Duclos and colleagues (1998) found no cases of PTSD within the past year in 64 American Indian female juvenile detainees. In contrast, Cauffman and colleagues (1998) found that 47 of 96 incarcerated females (48.9 percent) had PTSD in the past 3 months.

PTSD often co-occurs with other psychiatric disorders (Giaconia et al., 2000; Brady, 1997; Jacobsen, Southwick, and Kosten, 2001). Comorbid disorders have an adverse impact on the prognosis and treatment of individuals with PTSD. Youth with PTSD and comorbid disorders have significantly more behavioral and health problems and more impaired interpersonal relationships than those with PTSD and no comorbid disorders (Giaconia et al., 2000). In a community sample, Giaconia and colleagues (1995) found that nearly four-fifths of those who ever had PTSD had one or more additional disorders. Studies of detained adolescent males in Russia (Ruchkin et al., 2002) and detained adolescent females in Australia (Dixon, Howie, and Starling, 2005) found that all of the detainees with PTSD had at least one additional, or comorbid, psychiatric disorder, such as depression, substance use disorder, or conduct disorder.

Unfortunately, most studies examining PTSD in youth in the juvenile justice system are too small in sample size (Steiner, Garcia, and Matthews, 1997; Burton et al., 1994; Cauffman et al., 1998), lack generalizability (Duclos et al., 1998), or lack sufficiently standardized diagnostic assessments (Burton et al., 1994) to generate reliable national estimates. To date, no large-scale study has examined the prevalence of trauma and PTSD across demographic subgroups that make up increasing proportions of the juvenile justice population—African Americans, Hispanics, females, and younger children. Furthermore, there is no known epidemiological study of detainees in the United States that has examined PTSD and comorbid psychiatric disorders.

PTSD is associated with severe functional impairment (Giaconia et al., 1995). Left untreated, PTSD may become chronic (Burger and Lang, 1998; Kessler et al., 1995; Terr, 1991), with enormous personal and societal costs (Kessler, 2000).

In this bulletin, the authors present the prevalence of PTSD and trauma among youth in detention, compare the prevalence of psychiatric disorders among those with and without PTSD, and examine the prevalence of PTSD among those with and without other psychiatric disorders.

Methods

This section provides a brief overview of the authors’ methods. Additional, detailed information on the methodology can be found in Abram et al. (2003, 2004, 2007) and Teplin et al. (2002, 2003).

Participants and Sampling Procedures

Participants were part of the Northwestern Juvenile Project (NJP), a longitudinal study of 1,829 youth (ages 10–18) arrested and detained between November 20, 1995, and June 14, 1998, at the Cook County Juvenile Temporary Detention Center (CCJTDC) in Chicago, IL. The random sample was stratified by gender, race/ethnicity (African American, non-Hispanic white, Hispanic), age (10–13 years, older than 14 years), and legal status (processed as a juvenile or as an adult) to obtain enough participants to examine key subgroups (e.g., females, Hispanics, younger children).

The gender, age, and offense distributions of the CCJTDC detainees are similar to detained juveniles nationwide (Snyder and Sickmund, 2006). As in other urban facilities, most youth detained in the center belong to racial/ethnic minority groups. The CCJTDC population is 77.9 percent African American, 5.6 percent non-Hispanic white, 16 percent Hispanic, and 0.5 percent other racial/ethnic groups.

The authors chose the detention center in Cook County (which includes Chicago and surrounding suburbs) for three reasons:

• Nationwide, most juvenile detainees live in and are detained in urban areas (Pastore and Maguire, 2000).

• Cook County is ethnically diverse and has the third-largest Hispanic population in the United States (U.S. Census Bureau, 2001). Studying this population is important because Hispanics are the largest minority group in the United States (U.S. Census Bureau, 2000).

• The detention center’s size (daily census of approximately 650 youth, intake of 20 youth per day) ensured that a large enough pool of participants would be available.

The authors began collecting data on PTSD 13 months after sampling for the larger study began. Therefore, the final sample size for this study was 898 and was composed of 532 males (59.2 percent) and 366 females (40.8 percent); 490 were African American (54.6 percent), 252 were Hispanic (28.1 percent), 154 were non-Hispanic white (17.1 percent), and 2 were from other racial/ethnic groups (0.2 percent). Participants ranged in age from 10 to 18; the mean age was 14.8, and the median age was 15.

Detainees were eligible to be sampled regardless of their psychiatric morbidity, state of drug or alcohol intoxication, or fitness to stand trial. Participants were interviewed in a private area, almost always within 2 days of intake. Most interviews lasted 2 to 3 hours, depending on how many symptoms were reported.

Measures

The authors used the Diagnostic Interview Schedule for Children, version IV (DISC–IV; Shaffer et al., 2000), based on criteria from the American Psychiatric Association’s (APA’s) Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM–IV; APA, 1994), to assess PTSD. They also used DISC version 2.3, based on the APA’s Diagnostic and Statistical Manual of Mental Disorders, Third Edition, Revised (DSM–III–R; APA, 1987) criteria, to assess the occurrence of the following psychiatric disorders in the last 6 months: affective disorders (major depressive episode, dysthymia, and manic episode); anxiety disorders (panic, separation anxiety, overanxious, generalized anxiety, and obsessive-compulsive); behavioral disorders (attention-deficit hyperactivity, conduct, and oppositional defiant); and substance use disorders (alcohol and drug abuse or dependence). At the time the study began, DISC version 2.3 was the most recent DISC available.

The PTSD module assessed whether youth had ever experienced any of eight traumatic experiences (listed in table 1). Participants then identified the event that was “the most difficult for you in your entire life.” DISC–IV assessed PTSD diagnosis within the past year for this “worst” trauma. The data are based on youth’s self-reports because it was not feasible to interview caretakers.

Findings

The study described in this bulletin has two main advantages over existing studies: (1) the inclusion of a stratified, random sample large enough to examine demographic characteristics and comorbid disorders, and (2) the use of a standardized measure of PTSD—DISC–IV.

Following is an overview of the results of the study.

Trauma

Overall rates. Table 1 shows that 92.5 percent of participating youth had experienced at least one trauma. Most (84.0 percent) had experienced more than one trauma. Significantly more males (93.2 percent) than females (84.0 percent) reported a traumatic experience. No significant differences in overall prevalence of trauma across race/ethnicity for males and females were found. Among both male and female detainees, significantly more youth ages 14–18 (94.2 percent of males; 86.5 percent of females) reported trauma than youth ages 10–13 (82.4 percent of males; 59.1 percent of females).

Specific traumas. As table 1 illustrates, the three most frequently reported traumas among both males and females were having seen or heard someone get badly hurt or be killed (“witnessing violence,” reported by 74.9 percent of males and 63.5 percent of females), having been threatened with a weapon (reported by 59.3 percent of males and 47.3 percent of females), and being in a situation where they thought they or someone close to them was going to be badly hurt or die (reported by 53.5 percent of males and 49.1 percent of females).

Significantly more males than females reported having been in a bad accident. Significantly more females than males reported being forced to do something sexual. Among males, non-Hispanic whites were more likely to have been attacked physically or beaten badly than were African Americans. Among females, Hispanics were more likely to have been attacked physically or badly beaten than were African Americans.

Posttraumatic Stress Disorder

Table 2 shows that 11.2 percent of the sample experienced PTSD in the year prior to the interview. Although prevalence rates appeared to differ by gender and across race/ethnicity for males and females, none of these differences were statistically significant.

Precipitating traumas. The authors examined precipitating traumas for persons diagnosed as having PTSD. Among male participants, witnessing violence (“having seen or heard someone get hurt very badly or be killed”) was the most frequent precipitating trauma for PTSD, significantly higher among males (58.9 percent) than females (23.5 percent). Among female participants, thinking “you or someone close to you was going to be hurt very badly or die” was the most frequent precipitating trauma, significantly higher among females (27.8 percent) than males (9.5 percent). Other precipitating traumas were too rare to analyze further.

The authors also examined the age at which the participants had experienced their worst precipitating trauma. Most participants (88.7 percent) reported that their worst traumas occurred within 2 years prior to the interview. However, being forced to do something sexual—when that was identified as the worst trauma—occurred 5 years before the interview for most participants.

Prevalence of Comorbid Psychiatric Disorders Among Youth With and Without PTSD

Among participants without PTSD, 64 percent had at least one type of psychiatric disorder (affective, anxiety, behavioral, and/or substance use). However, among participants with PTSD, 93 percent had at least one type of comorbid psychiatric disorder, 54 percent had two or more types of comorbid disorders, and 11 percent had all four types of comorbid disorders.

Males and females with PTSD were between 2 and 3.7 times more likely to have any substance use disorder, alcohol use disorder, and both alcohol and drug use disorders than did males and females without PTSD. Males with PTSD also were between 3.2 and 9 times more likely to have a comorbid psychiatric disorder, an anxiety disorder, or a drug use disorder compared to males without PTSD. Having PTSD did not significantly increase the odds of having an affective or behavioral disorder for either males or females. Males with PTSD were 3.4 times more likely to have a comorbid psychiatric disorder than females with PTSD.

Prevalence of PTSD Among Youth With and Without Specific Psychiatric Disorders

Among males, 15 percent of those with any psychiatric disorder had PTSD compared to only 2 percent of those with no other psychiatric disorder. Any affective, anxiety, behavioral, or substance use disorder significantly increased the odds of having comorbid PTSD, compared with males who had no other psychiatric disorder. Similarly, among females, 16 percent of those with any psychiatric disorder had PTSD compared to 11 percent of those with no other psychiatric disorder. Any alcohol use disorder and having both an alcohol and drug use disorder significantly increased the odds of having PTSD among females. No significant difference in prevalence rates of PTSD was found between males and females with specific psychiatric disorders.

Discussion of Findings

Trauma

Exposure to trauma is common among detained youth. More than 90 percent of the participants experienced at least one traumatic event; 56.8 percent were exposed six or more times. These findings are comparable to reports from smaller studies of youth in correctional facilities (Carrion and Steiner, 2000; Cauffman et al., 1998; Crimmins, 1999; Steiner, Garcia, and Matthews, 1997).

It is difficult to compare findings from NJP with community studies because findings vary, depending on the sample (e.g., urban, suburban, minority) and which traumas were assessed. However, the overall prevalence of trauma in NJP’s participants is substantially greater than reported in most studies of youth and young adults (ages 15–24), especially for severe and violent trauma (Breslau et al., 1991, 1998; Costello et al., 2002; Cuffe et al., 1998; Lipschitz et al., 2000; Singer et al., 1995). Also, witnessing violence, the most common trauma, was far more common in this study sample (63.5 percent of the females and 74.9 percent of the males) than in most community studies of youth and adults (4.9 percent to 35.6 percent, males only) (Breslau et al., 1991, 1998; Costello et al., 2002; Giaconia et al., 1995; Kessler et al., 1995). The authors’ findings are most comparable to general population studies of urban teenagers (Lipschitz et al., 2000; Schwab-Stone et al., 1995, 1999; Shakoor and Chalmers, 1991; Singer et al., 1995).

Posttraumatic Stress Disorder

The authors found that more than 1 in 10 detainees (11.2 percent) had PTSD in the year prior to the interview. These estimates are lower than those reported by Burton and colleagues (1994) (24 percent, current disorder), Cauffman and colleagues (1998) (48.9 percent of females, past 3 months), and Steiner, Garcia, and Matthews (1997) (31.7 percent of males, current disorder). The authors used different instruments and methods than did Burton, Cauffman, and Steiner, which may explain the variation. Burton used a symptom checklist, whereas Cauffman and Steiner used the PTSD module of the Psychiatric Diagnostic Interview, Revised (Othmer et al., 1981), which assesses symptoms of PTSD independent of a particular trauma. In contrast, DISC (used by these authors) assesses PTSD based on the participant’s perceived worst trauma.

On the other hand, the prevalence of PTSD in the authors’ study sample was greater than that reported by Garland and colleagues (2001) (3.1 percent, past year), Wasserman and colleagues (2002) (4.8 percent, males only, past month), and Duclos and colleagues (1998) (1.3 percent, past year). The authors’ findings may differ from these studies because of the point at which the sample was drawn. The authors sampled youth immediately after they were detained and before their adjudication hearings. Garland and Wasserman sampled convicted juveniles in secure placement. Duclos’ findings may be different from those reported in the current study because that sample was composed only of American Indian detainees.

The prevalence of PTSD in this study sample (during the 12 months prior to the interview) exceeds lifetime estimates of PTSD reported in community samples, which range from 3.5 percent to 9.2 percent (Breslau et al., 1991, 1998; Giaconia et al., 1995; Kessler et al., 1995). More than half of the participants with PTSD reported witnessing violence as the precipitant in the current study. These findings likely reflect the fact that the study participants, like most juvenile detainees nationwide, live in urban areas that have high rates of violence (Duhart, 2000; Peeples and Loeber, 1994). These findings also are consistent with research linking traumatic victimization in childhood and subsequent psychosocial problems, such as delinquency, perpetration of violence, and drug use (e.g., Famularo, Kinscherff, and Fenton, 1992; Flannery, Singer, and Wester, 2001; Kilpatrick et al., 2003; Schwab-Stone et al., 1999; Widom, 1989).

Comorbid Disorders

Juvenile detainees with PTSD almost invariably have a comorbid disorder. In this study, 93 percent had at least one comorbid disorder and more than half had two or more types of comorbid disorders. The prevalence rate of drug use disorder—the most common comorbid disorder among youth with PTSD—is more than 2 times greater for females and 3 times greater for males than rates of drug dependence found in a sample of predominantly white high school seniors with PTSD (Giaconia et al., 1995). Rates of PTSD among detainees with substance use disorders in this study also are similar to or greater than rates among youth with substance use disorders receiving psychiatric or substance use treatment (Deykin and Buka, 1997; Garland et al., 2001).

Although comorbidity is a significant problem for both male and female detainees with PTSD, males were more likely than females to have comorbid disorders. The National Comorbidity Survey reported similar findings among adults (Kessler et al., 1995); however, the opposite pattern was reported in a sample of chemically dependent adolescents (Deykin and Buka, 1997). This gender difference warrants further study.

Demographic Characteristics

Most of the demographic differences in the NJP sample corroborated prior investigations of community samples (Breslau et al., 1997, 1998, 1999; Giaconia et al., 1995; Kessler et al., 1995). Although male detainees were significantly more likely than female detainees to have experienced trauma, female detainees were as likely to have PTSD as were male detainees. In community samples, females are twice as likely as males to develop PTSD following exposure to trauma (Breslau et al., 1998; Kessler et al., 1995).

Like prior studies in the community, the authors found few racial/ethnic differences in rates of trauma or PTSD (Breslau et al., 1991; Kessler et al., 1995). Those few differences pertained to the type of trauma reported most frequently. In the NJP sample, African American males were more likely to have witnessed violence than were non-Hispanic whites, consistent with the high levels of violence exposure among inner-city, minority youth (Bell and Jenkins, 1991). Non-Hispanic white males were more likely to have experienced actual and threatened violence than were other males. Among females, Hispanics were most likely to have experienced violent victimization.

Study Limitations

The authors’ findings are drawn from one site and may pertain only to youth in urban detention centers with a similar demographic composition. In addition, the findings are based on a sample of pretrial detainees and may not be generalizable to adjudicated juveniles serving sentences.

Also, because it was not feasible to interview caretakers, the data are subject to the reliability and validity of the youth’s self-reports. Youth and their caretakers, however, are comparable reporters of youth’s anxiety disorders (Jensen et al., 1999). Although arrest and detention may affect recall of traumas, a youth’s recall of events may be less subject to the distortions of time than recall by adults (Breslau et al., 1998).

DISC, like most measures, probes for PTSD based on the single-worst trauma that the participant identified; hence, the authors were unable to estimate the age at onset of PTSD or the vulnerability to PTSD by type of trauma (Breslau et al., 1998).

Despite these limitations, the authors’ findings have important implications for research on PTSD and for mental health policy.

Directions for Future Research

The authors suggest the following three directions for future research:

• Increase studies of vulnerability to PTSD among high-risk youth. More than 90 percent of the sample had been exposed to one or more traumas. More than 1 in 10 youth in the sample met the criteria for PTSD in the year prior to the interview. Future research must determine the relative risk of PTSD for types of trauma (e.g., witnessing murder, being shot, witnessing ongoing domestic violence, sudden loss of a loved one) among youth who are frequently exposed to trauma and violence, such as the study participants. Such studies could document factors that increase resilience to PTSD among high-risk youth and guide the development and implementation of prevention strategies (Miller et al., 1999; Kliewer et al., 1998).

• Conduct longitudinal studies of chronic community violence and its relationship to PTSD. Research suggests that chronic exposure to violence may have more deleterious effects on children than acute violence (Bell and Jenkins, 1991). Living with widespread or chronic community violence in the inner city has been compared with living in a war zone (Schwab-Stone et al., 1995). Future research must study the effects of chronic community violence on high-risk youth as they become adults (Cuffe et al., 1998) and should examine the role that witnessing violence plays in perpetuating the cycle of violence. Such research could improve both trauma-informed care and violence prevention interventions among youth and adults in high-crime areas.

• Standardize measures of PTSD and trauma. There is a scarcity of research on the validity and reliability of diagnostic measures of PTSD (Ohan, Myers, and Collett, 2002). Moreover, the definitions of trauma in DSM–IV are somewhat ambiguous (World Health Organization, 1997); hence, little consistency exists among diagnostic instruments that measure traumas. For example, most measures assess violent victimization (DISC–IV and the Composite International Diagnostic Interview [CIDI] 2.1) (Davis and Siegel, 2000). Some measures (DISC–IV, CIDI 2.1) assess victimization by any perpetrator; others specifically ask about victimization by family members (DIS–IV [Robins, 1996] and the National Comorbidity Survey Replication [2001–2002]). These differences reduce the validity and reliability of diagnoses. A consensually understood and empirically validated framework must be created to define and measure traumatic events.

Implications for the Juvenile Justice System

The juvenile justice system must collaborate with mental health professionals to improve mental health services for youth in the juvenile justice system. The National Center for Mental Health and Juvenile Justice’s Blueprint for Change provides a practical framework for juvenile justice and mental health systems to use when developing policies and programs aimed at improving mental health services for youth in the juvenile justice system (Skowyra and Cocozza, 2007). Such collaborations must:

• Improve the detection of PTSD in residential facilities for juveniles. PTSD is frequently overlooked, even in the best psychiatric settings (Cascardi et al., 1996; Mueser et al., 1998). Traumatic experiences are rarely included in standard screens or volunteered by patients (Brady, 1997). Because PTSD frequently co-occurs with other psychiatric disorders (Giaconia et al., 1995; Kessler et al., 1995), it can be difficult to detect without targeted questions and systematic screening. Screening also should determine the relative onset of comorbid disorders, which may indicate which disorder should be the primary target for treatment.

• Fully explore the treatment ramifications of comorbid disorders and tailor treatment to each individual. Even brief psychosocial and pharmacologic interventions for detainees with PTSD must address comorbid disorders, especially substance use disorders. Detoxification or withdrawal from substances can worsen the symptoms of PTSD (Brady, 1997). Exploration of traumatic experiences, a common psychotherapeutic tool for treatment of PTSD, may worsen symptoms of comorbid mood disorders or precipitate self-medication and relapse for those in recovery (Brady, 1997). Medication management requires special attention to the potential for abuse and drug interactions (Jacobsen, Southwick, and Kosten, 2001; Arroyo, 2001). Finally, the high-risk behaviors associated with certain psychiatric disorders, such as attention-deficit hyperactivity disorder, mania, and substance use disorder (Deykin and Buka, 1997; Wozniak et al., 1999), may increase the likelihood of experiencing additional traumas.

• Avoid retraumatizing youth. It is important for the juvenile justice system, law enforcement, and the mental health system to incorporate knowledge about trauma into existing services (i.e., trauma-informed care) (Hodas, 2006). The conditions of confinement often exacerbate symptoms of mental disorder, including PTSD (Coalition for Juvenile Justice, 2000). Juvenile justice providers must reduce the likelihood that routine processing will retraumatize youth. Common practices, such as handcuffing and searching, may exacerbate symptoms of PTSD (Prescott, 1998; Veysey, 1998). In detention centers, symptomatic detainees undergoing psychiatric crises are often isolated or restrained. These practices can trigger or escalate symptoms of PTSD (e.g., severe anxiety, aggression, and numbing of emotions) (Prescott, 1998; Veysey, 1998). Psychiatrists can work with correctional staff to implement strategies to manage emergencies humanely—and, ultimately, more cost effectively.

• Improve the continuity of care for victims of trauma. It is estimated that juvenile detainees typically remain in facilities for only 2 weeks before release (Snyder and Sickmund, 2006). Hence, both correctional service systems and community psychiatry systems must address these youths’ mental health needs. Yet, youth who experience trauma rarely receive services in the community (Costello et al., 2002). The treatments most likely to succeed will address past traumas and the diagnostic complications that often follow. Timely interventions may avert subsequent and often chronic social problems common among traumatized youth (Bell and Jenkins, 1991; Davidson et al., 1991; Giaconia et al., 1995). To the extent that PTSD is correlated with subsequent perpetration of violence, effective treatment is also a matter of public safety (Cauffman et al., 1998; Fehon, Grilo, and Lipschitz, 2001; Wekerle et al., 2001).

Conclusion

The number of youth with psychiatric disorders in juvenile detention is alarming: two-thirds of males and three-quarters of females in juvenile detention have one or more psychiatric disorders (Teplin et al., 2002). In the current study, the authors found that more than 1 in 10 have posttraumatic stress disorder. The presence of PTSD increases the likelihood that at least one other psychiatric disorder is present, a challenge to the criminal justice and mental health systems. Youth with PTSD and comorbid disorders have significantly more behavioral and health problems and more impaired interpersonal relationships than those with PTSD and no comorbid disorders.

This nation’s delinquent children are among its most traumatized. The resources used to punish them must be balanced with the resources needed to treat them.

For More Information

This bulletin was adapted from Abram, K.M., Teplin, L.A., Charles, D.R., Longworth, S.L., McClelland, G.M., and Dulcan, M.K. 2004. Posttraumatic stress disorder and trauma in youth in juvenile detention. Archives of General Psychiatry 61:403–410; and Abram, K.M., Washburn, J.J., Teplin, L.A., Emanuel, K.M., Romero, E.G., and McClelland, G.M. 2007. Posttraumatic stress disorder and psychiatric comorbidity among detained youth. Psychiatric Services 58:1311–1316.

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Acknowledgments

Karen M. Abram, Ph.D., is Associate Professor and Associate Director, Health Disparities and Public Policy, in the Department of Psychiatry and Behavioral Sciences at the Feinberg School of Medicine, Northwestern University, Chicago, IL.

Linda A. Teplin, Ph.D., is the Owen L. Coon Professor and Vice Chair for Research in the Department of Psychiatry and Behavioral Sciences at the Feinberg School of Medicine as well as Director of the Department’s Program in Health Disparities and Public Policy.

Devon C. King, Ph.D., is a psychologist practicing in Bethesda, MD, as well as Assistant Professor of Clinical Psychology at the Center for Professional Psychology, George Washington University.

Sandra L. Longworth, M.S., is a school counselor at St Charles North High School in St. Charles, IL.

Kristin M. Emanuel, Ph.D., is a psychologist at Pine Rest Christian Mental Health Services in Zeeland, MI.

Erin G. Romero, Ph.D., is a psychologist and team leader for the PTSD clinical team in the Veterans Administration Maryland Health Care System in Baltimore, MD.

Gary M. McClelland, Ph.D., is a Research Assistant Professor and Director of Data Operations in the Mental Health Services and Public Policy program, Department of Psychiatry and Behavioral Sciences at the Feinberg School of Medicine.

Mina K. Dulcan, M.D., is a Professor in both the Department of Psychiatry and Behavioral Sciences and the Department of Pediatrics at the Feinberg School of Medicine. She is also the Head of the Department of Child and Adolescent Psychiatry at the Ann & Robert H. Lurie Children’s Hospital, Chicago, IL.

Jason J. Washburn, Ph.D., ABPP, is Assistant Professor and Director of Education and Clinical Training in the Division of Psychology, Department of Psychiatry and Behavioral Sciences at the Feinberg School of Medicine. He is also Director of the Center for Evidence-Based Practice at Alexian Brothers Behavioral Health Hospital, Hoffman Estates, IL.

Leah J. Welty, Ph.D., is Assistant Professor in the Department of Preventive Medicine and the Department of Psychiatry and Behavioral Sciences at the Feinberg School of Medicine. She is also a biostatistician in the Biostatistics Collaboration Center at the Feinberg School of Medicine.

Nichole D. Olson, M.S., is a doctoral candidate in the Division of Psychology, Department of Psychiatry and Behavioral Sciences at the Feinberg School of Medicine.

The authors thank all of their agencies for their collaborative spirit and steadfast support. They also thank the research participants for their time and willingness to participate as well as the Cook County Juvenile Temporary Detention Center, Cook County Department of Corrections, and Illinois Department of Corrections for their cooperation.

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The research described in this bulletin was supported in part by grants 1999–JE–FX–1001, 2005–JL–FX–0288, and 2008–JF–FX–0068 from the Office of Juvenile Justice and Delinquency Prevention (OJJDP), U.S. Department of Justice.

Points of view or opinions expressed in this document are those of the authors and do not necessarily represent the official position or policies of OJJDP or the U.S. Department of Justice.

The Office of Juvenile Justice and Delinquency Prevention is a component of the Office of Justice Programs, which also includes the Bureau of Justice Assistance; the Bureau of Justice Statistics; the National Institute of Justice; the Office for Victims of Crime; and the Office of Sex Offender Sentencing, Monitoring, Apprehending, Registering, and Tracking.

Access OJJDP publications online at www.ojjdp.gov/publications/index.html.

NCJ 239603

Functional Impairment in Delinquent Youth

Karen M. Abram, Jeanne Y. Choe, Jason J. Washburn, Erin G. Romero, Linda A. Teplin, and Elena D. Bassett

December 2013

Highlights

This bulletin is one in a series that presents the results of the Northwestern Juvenile Project—a longitudinal study of youth detained at the Cook County Juvenile Temporary Detention Center in Chicago, IL. The authors present the results of their examination of youth’s functional impairment as assessed 3 years after their release from detention. Key findings include the following:

• Only 7.5 percent of youth had no notable impairment in functioning.

• Approximately one of every five youth had markedly impaired functioning.

• Markedly impaired functioning was much more common in males than in females; however, females were more likely to be severely impaired in the moods/emotions and self-harm domains than males.

• Among males living in the community, African Americans and Hispanics were more likely to be severely impaired in school and work than non-Hispanic whites.

Most youth in the juvenile justice system have psychiatric, social, and academic difficulties (McCabe et al., 2002; Teplin et al., 2002). Studies suggest that these youth continue to be substantially impaired in their day-to-day functioning as they age. In an often-cited classic longitudinal study of 500 incarcerated juvenile males sampled in the 1940s, Glueck and Glueck (1968) found that by young adulthood, few delinquent males had graduated from high school and they were far more likely to be unemployed or poorly employed than nondelinquent controls. Nearly two-thirds of the delinquent males had at least one arrest when they were ages 25 to 31, and many reported poor marital relationships and residential transiency. Lewis and colleagues, in another longitudinal study, followed 97 incarcerated boys (Lewis et al., 1994) and 21 girls (Lewis et al., 1991) for as long as 12 years from study intake. At followup, most had criminal records (94 percent of males and 71 percent of females) and had not graduated from high school (59 percent of males and 71 percent of females). Poor relationships, poor parenting skills, unstable jobs, drug addictions, suicidal behavior, and mortality were also common (Lewis et al., 1991, 1994). More recently, Giordano and colleagues (Giordano, Cernkovich, and Lowery, 2004; Giordano, Cernkovich, and Rudolph, 2002) followed 254 serious juvenile offenders for 13 years. As young adults, most of these offenders were still engaged in criminal activities and were earning annual incomes at less than the poverty level (Giordano, Cernkovich, and Lowery, 2004; Giordano, Cernkovich, and Rudolph, 2002). Furthermore, roughly half of females and three-quarters of males had lost or never had custody of at least one biological child (Giordano, Cernkovich, and Lowery, 2004).

Although existing studies have found substantial impairment in functioning among juvenile offenders as they age, the literature has two significant limitations. First, most studies examined only one or two types of functioning, which primarily included criminal recidivism (Benda, Flynn Corwyn, and Toombs, 2001; Bullis, Yovanoff, and Havel, 2004; Heilbrun et al., 2000; Wilson et al., 2001), employment and school enrollment (Bullis, Yovanoff, and Havel, 2004), or level of substance use (Dembo et al., 1993, 2000; Wilson et al., 2001). Second, the few studies that examined multiple areas of functioning either had small samples (Lewis et al., 1991, 1994) or used samples that do not reflect the social and demographic characteristics of youth currently involved in the juvenile justice system (Giordano, Cernkovich, and Lowery, 2004; Giordano, Cernkovich, and Rudolph, 2002; Glueck and Glueck, 1968). Specifically, the study by Glueck and Glueck (1968) did not include racial/ethnic minorities or females, whereas Giordano and colleagues (2002, 2004) did not include Hispanic individuals and focused exclusively on serious offenders. These omissions are problematic because racial/ethnic minorities now comprise nearly two-thirds of youth in the juvenile justice system, and the proportion of incarcerated females continues to rise (Puzzanchera and Kang, 2011).

This bulletin examines youth’s functional impairment as assessed 3 years after they were initially detained. Functional impairment refers to a youth’s day-to-day social, psychiatric, and academic difficulties. Interviewers assessed participants’ functioning in the past 3 months at home, at school, at work, and in the community; their moods and emotions; patterns of substance use; self-harmful behavior or intent; and rational thinking. The research represents the first large-scale, prospective study to examine global and specific types of functional impairment using a diverse and representative sample of juvenile detainees.

Methods

This section provides a brief overview of the authors’ methods. Additional, detailed information about the authors’ methods and statistical analysis can be found in Teplin et al. (2002, 2005). To assess the effect of attrition, the authors compared the gender, race/ethnicity, and age of participants who were reinterviewed with those who were not reinterviewed. There were no significant differences except that (1) males were more likely than females to have died and (2) both non-Hispanic white and Hispanic individuals were more likely than African Americans to have been lost to followup. The researchers weighted the statistical analyses by sampling strata to adjust the potential bias from demographic differences in attrition.

Participants and Sampling Procedures

Participants were part of the Northwestern Juvenile Project (NJP), a longitudinal study of 1,829 youth (ages 10–18) arrested and detained between November 20, 1995, and June 14, 1998, at the Cook County Juvenile Temporary Detention Center (CCJTDC) in Chicago, IL. The random sample was stratified by gender, race/ethnicity (African American, non-Hispanic white, Hispanic, or other), age (10–13 years or 14 years and older), and legal status (processed in juvenile or adult court) to obtain enough participants to examine key subgroups (e.g., females, Hispanics, younger children).

Like juvenile detainees nationwide, the majority of CCJTDC detainees are male and most belong to racial/ethnic minority groups (77.9 percent African American, 5.6 percent non-Hispanic white, 16 percent Hispanic, and 0.5 percent other racial/ethnic groups). The age and offense distributions of the CCJTDC detainees are also similar to detained juveniles nationwide (Snyder and Sickmund, 2006).

The authors chose the detention center in Cook County, which includes Chicago and surrounding suburbs, for three reasons:

• Nationwide, most juvenile detainees live in and are detained in urban areas (Pastore and Maguire, 2000).

• Cook County is ethnically diverse and has the third-largest Hispanic population in the United States (U.S. Census Bureau, 2001). Studying this population is important because Hispanics are the largest minority group in the United States (U.S. Census Bureau, 2000).

• The detention center’s size (daily census of approximately 650 youth and intake of 20 youth per day) ensured a large enough pool of participants would be available.

CCJTDC is used for pretrial detention and for offenders sentenced to less than 30 days. It houses detainees younger than age 17 (and as old as 21 if they are being prosecuted for an arrest that occurred when they were younger than 17). Participants were initially interviewed within 2 days of intake and reinterviewed 3 years later, whether they were living in the community or incarcerated. Of the original 1,829 participants, 1,751 (95.7 percent) were interviewed at followup. Participants who were interviewed more than 4.5 years after their baseline interview (n = 94) were excluded from the final sample. Four other participants did not receive the functional impairment assessment due to interviewer error and were also excluded from the final sample.

Because this sample is high risk and highly mobile, a cutoff earlier than 4.5 years would restrict its generalizability. To ensure that the cutoff did not bias the findings, the researchers compared the gender, race/ethnicity, and age of participants who were interviewed between 3.5 and 4.5 years (n = 214) after baseline with those interviewed within 3.5 years after baseline and found that there were no significant differences. In addition, the researchers examined whether the inclusion of these participants affected the findings. The researchers repeated all analyses using only those participants who were interviewed within 3.5 years; again, the findings were substantially similar.

The final sample size was 1,653 participants, composed of 1,051 males (63.6 percent) and 602 females (36.4 percent); 922 (55.8 percent) were African American, 267 (16.2 percent) were non-Hispanic white, 460 (27.8 percent) were Hispanic, and 4 (0.2 percent) were from other racial/ethnic groups. Participants ranged in age from 10 to 18 years at the initial interview. At followup, participants ranged in age from 13 to 22 years. Time to followup was between 2.8 and 4.5 years.

Measures

Master’s level clinical research interviewers completed the Child and Adolescent Functional Assessment Scale (CAFAS) (Hodges, 1994) following a comprehensive 3- to 4-hour interview with the participant. Interviewer ratings were based on participants’ behaviors in the past 3 months.

The CAFAS assesses eight domains of functioning (Hodges, 2005):

• School/work. Measures youth’s ability to perform satisfactorily in a group educational or work environment.

• Home. Measures how well youth observe reasonable rules and perform age-appropriate tasks wherever they are living.

• Community. Assesses the extent to which youth respect the rights of others, respect others’ property, and conform to laws.

• Behavior toward others. Assesses appropriateness of youth’s interpersonal behavior (e.g., ability to resolve conflicts constructively, ability to create interpersonal relationships that are not exploitive to the youth or others).

• Moods/emotions. Determines youth’s moods and psychiatric problems, including depression, anxiety, and trauma-related reactions.

• Self-harm. Assesses the severity of self-harmful thoughts or behaviors.

• Substance use. Determines the severity of youth’s substance use problems.

• Thinking. Examines youth’s ability to use rational thought processes.

Each domain is scored as 0 (minimal impairment), 10 (mild impairment), 20 (moderate impairment), or 30 (severe impairment). A total score of 0–10 that sums all eight domains indicates no noteworthy impairment; 20–40, the need for treatment on an outpatient basis; 50–90, the need for additional services beyond traditional outpatient care; 100–130, the need for more intensive care than outpatient and/or multiple sources of supportive care; and 140 or more, the need for more intensive treatment (Hodges, 1994). For this study, the authors defined “marked global impairment” as a total score of 100 or more on the CAFAS. To examine impairment in specific domains of functioning, the authors identified ratings of “severe impairment” on CAFAS subscales (i.e., scores of 30).

Findings

More than one-fifth (21.6 percent) of the 1,653 youth in the final sample had marked global impairment (a total score of 100 or more; see table 1). Seven percent of youth had severe global impairment (a total score of 140 or more). Only 7.5 percent of the sample demonstrated “no noteworthy impairment” (a total score of 10 or less).

Among youth with total scores of 100 or more, 94.2 percent had severe impairment (a score of 30) on two or more of the eight domains, 65.2 percent had severe impairment on three or more of the eight domains, and 21.8 percent had severe impairment on four or more of the eight domains.

Significantly more males than females had marked global impairment. Data showed no significant racial/ethnic differences in marked global impairment for males or females.

Impairment Within Domains

The authors analyzed results in each of the eight domains (see table 1 for more details).

School/work. More than one-third (34.1 percent) of youth were severely impaired in the school/work domain. Significantly more African American and Hispanic males than non-Hispanic white males had severe impairment in this domain. The authors did not observe gender differences.

Home. Seven percent of youth were severely impaired in this domain. The authors did not find racial/ethnic or gender differences.

Community. More than half (51.4 percent) of youth were severely impaired in the community domain. Significantly more males than females were impaired in this domain and significantly more African American and Hispanic males than non-Hispanic white males were impaired.

Behavior toward others. Nearly 1 in 10 (9.1 percent) of youth were severely impaired in this domain. Significantly more males than females were impaired in this domain. The authors did not observe racial/ethnic differences.

Moods/emotions. Approximately 2 percent (2.2 percent) of youth were severely impaired in this domain. Significantly more females than males were impaired in this domain. The authors did not observe racial/ethnic differences.

Self-harm. Less than 1 percent (0.4 percent) of youth were severely impaired in this domain. Significantly more females than males, and significantly more Hispanic than African American males were impaired in this domain.

Substance use. More than one-quarter (25.7 percent) of youth were severely impaired in this domain. Significantly more white males were impaired in this domain than African American or Hispanic males. The authors found no differences between genders.

Thinking. Less than 1 percent (0.4 percent) of youth were severely impaired in this domain. The authors observed no racial/ethnic or gender differences.

Differences by Age

After adjusting for racial/ethnic differences, the authors found no significant age differences in global impairment for males and few differences across domains for males and females. Among females, significantly more girls between 10 and 13 years than girls between 14 and 15 years and girls 16 and older1 had marked global impairment at baseline (26.7 percent versus 12.6 percent and 12.4 percent). This pattern was similar for their impairment in the home domain at baseline (15.6 percent versus 6.4 percent and 3.7 percent).

Among males, a greater number of boys between 14 and 15 years or 16 years and older than boys between 10 and 13 years at baseline were severely impaired in the school/work domain (37.5 percent and 35.2 percent versus 14.1 percent) and in the substance use domain (25.7 percent and 28.2 percent versus 13.9 percent). Significantly more males between 10 and 13 years than males between 14 and 15 years or 16 years and older at baseline were severely impaired in the home domain (14.0 percent versus 5.4 percent and 7.2 percent).

Functional Impairment in Males and Their Incarceration Status

Because incarceration was common among males, the authors examined differences in impairment across the specific domains by incarceration status (whether or not they were predominantly incarcerated during the past 3 months). Participants incarcerated within the 3 months before the followup interview received an automatic scale score of 30 (severe impairment) in the community domain. As a result, the authors excluded the community domain from these analyses because those who were predominantly incarcerated in the past 3 months could not be rated. Not enough females were reincarcerated (n = 48) for further analyses. Table 2 presents race/ethnicity information on functional impairment for incarcerated males and those in the community.

Among males living in the community in the past 3 months, significantly more African Americans and Hispanics were impaired than non-Hispanic whites in the school/work domain. After adjusting for racial/ethnic differences, significantly more incarcerated males were impaired in the home domain (for incarcerated youth, “home” is the corrections facility)2 and had more severely impaired thinking than males living in the community. In contrast, significantly more males living in the community were severely impaired in the substance use domain than incarcerated males.

Discussion of Findings

Three years after detention, approximately one of every five youth had markedly impaired functioning, indicating a need for improved interventions and care after release. Youth who have been detained struggle to occupy age-appropriate social, occupational, and/or interpersonal roles. Among youth with marked global impairment (CAFAS scores of 100 and more), nearly two-thirds were severely impaired in three or more areas of functioning. For example, these youth may have been expelled from school, engaged in serious violations of the law, and been addicted to drugs. These findings underscore the fact that failure to provide effective rehabilitation services during detention and after release creates ongoing costs for society and for the youth themselves.

Functional impairment at followup varied by youth’s social and demographic characteristics. Consistent with patterns of mental health needs among detained youth (Cauffman, 2004; McCabe et al., 2002; Teplin et al., 2002) and youth in the general population (Grunbaum et al., 2004), non-Hispanic white youth and females had greater impairment in the moods/emotions, self-harm, and substance use domains. Hispanic males had a greater likelihood of self-harm than African American males. Yet, 3 years after detention, African American and Hispanic males were more likely to be impaired than non-Hispanic whites in school/work and in the community, and males were more likely than females to have marked global impairment and impaired functioning in the community and in their behavior toward others.

Compared with non-Hispanic whites, minority males may experience a continuity of disadvantage (Sampson and Laub, 1997), including disproportionate rates of poverty, incarceration, reduced access to education and health care, and limited community resources (Elliott et al., 1996; James et al., 2007). Mental health services may improve these youth’s emotional problems and associated functioning over time (Dembo, Schmeidler, and Wothke, 2003; Lyons et al., 2003); however, minority males may be the least likely to receive these services during or after detention (Teplin et al., 2005).

Studies of other high-risk youth have also found that females fare better than males in education and employment and have less criminal involvement as they get older (Bullis and Yovanoff, 2002; Bullis, Yovanoff, and Havel, 2004; Werner, 1992). This may have to do with the fact that females receive services more frequently than males (Dembo et al., 1998; Shapiro et al., 1984; Teplin et al., 2005). Active parenting also may mitigate some problems (Chilcoat and Breslau, 1996) and, when they return to their communities, females are more likely to be active parents than males (Kalenkoski, Ribar, and Stratton, 2005). Nonetheless, research has not determined what role parenting may play in long-term functioning for female detainees.

These findings highlight the extensive unmet needs of young minority males. The arrest rate for racial/ethnic minority youth is 50 percent greater and the detention rate is 30 percent greater than for non-Hispanic whites (Snyder, Puzzanchera, and Adams, 2007).

Age differences may also be a consideration in how youth fare after release. At home, the youngest participants may have more difficulties than older participants. They are more likely to live with caretakers who try to manage their behavior, which may lead to more conflicts. In contrast, older males may have more difficulty than the youngest males in the school/work domain because they are more likely facing a workforce in which they are ill-prepared to compete. Finally, older males may be more likely to have substance abuse problems than younger males because they tend to have greater freedom and can obtain substances more easily (Chilcoat and Breslau, 1996).

Incarceration status was also associated with functional impairment among males. Compared with males living in the community, incarcerated males were significantly more likely to have impaired thinking and impaired functioning in the home domain. The characteristics of prison life, such as being separated from loved ones (Pogrebin, 1985), crowding (Parent et al., 1994), and solitary confinement (Parent et al., 1994), may increase the risk for this form of impairment. These findings, however, may simply reflect the characteristics of individuals who go to prison.

Incarcerated males were substantially less likely to have substance use problems than males living in the community. Substance use problems may be less common in prison due to decreased access to substances and random testing for substance use (Prendergast et al., 2004). Although the findings suggest that males have a lower risk for substance abuse while incarcerated, drug use may escalate for these youth after release (Keene, 1997).

Study Limitations

The study described in this bulletin had some limitations:

• The CAFAS ratings that determined youth’s level of functional impairment were based on the interviewers’ assessments following one structured interview. Although these interviews were extensive and allowed the interviewer to establish good rapport with the participant, the reliability of data is subject to the limitations of self-reporting.

• The interviewers did not administer the CAFAS at baseline; therefore, the authors could not compare ratings at followup with ratings at detention.

• The study interviewed youth from a large juvenile detention center in Chicago, so findings may only be generalized to detained youth in urban detention centers with a similar demographic composition.

• The authors’ analyses only show types of functional impairment in different races/ethnicities and genders and cannot comment on the causes of this impairment.

Directions for Future Research

The authors suggest that future studies should do the following:

• Identify changes in functional impairment as youth age. Future studies should examine how youth’s impairment changes as they become young adults. Studies should determine which areas of functioning remain stable, which improve, and which decline. This information will guide the development of long-term prevention and intervention programs.

• Investigate which factors are associated with positive outcomes. Studies should identify which factors (e.g., a positive role model, regular mental health treatment) are associated with positive outcomes in youth’s lives as they age. Understanding what helps is the first step to improving care.

Implications for Public Policy

The authors suggest the following public policy initiatives:

• Connect more youth with community services after detention. Youth held in detention must be connected to effective mental health, substance abuse, and educational or vocational support services in the community after release. Receiving such interventions during adolescence can improve a youth’s health and functioning over the course of his or her development (Odgers et al., 2007; Petras et al., 2008). Severe impairments that go untreated can lead to increasing disadvantage throughout youth’s lives (Sampson and Laub, 1997). For example, if a youth fails a grade in school, success in subsequent years becomes even more difficult. Recurrent experiences of school failure may increase youth’s risk for dropping out, substance abuse, criminal behavior, and emotional problems. If youth receive interventions such as mental health care and tutoring services, they may have a better chance of achieving school success.

• Target services to youth with the greatest need. Males and minorities have the greatest risk for impaired school and work performance and for continued delinquency. Detention provides an opportunity to engage these high-risk youth in services that will improve their social adjustment.

• Provide long-term interventions. Most juvenile detainees have long-term functional impairment in several areas (e.g., substance use and moods/emotions). Such problems likely will not respond to short-term or narrowly focused interventions. These youth likely require comprehensive services delivered over an extended period of time. Unfortunately, mental health services are not typically designed or funded to meet these needs.

Conclusion

Research suggests that incarcerated youth have difficulty functioning in society as they age. This study reveals that 3 years after detention, most youth struggle in one or more life domains, and one in five youth is severely impaired. Other studies have shown that fewer than 50 percent of youth find employment or return to school within 6 months of release from detention, and as many as two-thirds of youth are rearrested within 4.5 years of release (Benda, Flynn Corwyn, and Toombs, 2001; Bullis, Yovanoff, and Havel, 2004; Heilbrun et al., 2000; Wilson et al., 2001).

Juvenile justice organizations, community groups, law enforcement, and corrections agencies must invest in targeted, comprehensive strategies to give these youth a chance to experience productive and healthy lives.

For More Information

This bulletin was adapted from Abram, K.M., Choe, J.Y., Washburn, J.J., Romero, E.G., and Teplin, L.A. 2009. Functional impairment in youth three years after detention. Journal of Adolescent Health 44(6):528–535.

Endnotes

1. Youth ranged from 10–18 years at baseline. For these analyses, the authors adopted the following age groups: 10–13 years, 14–15 years, and 16–18 years.

2. For the “home” domain, incarcerated males were assessed regarding their behavior in the correctional facility. For example, the authors assessed whether males received disciplinary actions in prison for rule infractions.

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Teplin, L.A., Abram, K.M., McClelland, G.M., Washburn, J.J., and Pikus, A.K. 2005. Detecting mental disorder in juvenile detainees: Who receives services? American Journal of Public Health 95(10):1773–1780.

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Werner, E.E. 1992. The children of Kauai: Resiliency and recovery in adolescence and adulthood. Journal of Adolescent Health 13(4):262–268.

Wilson, J.J., Rojas, N., Haapanen, R., Duxbury, E., and Steiner, H. 2001. Substance abuse and criminal recidivism: A prospective study of adolescents. Child Psychiatry and Human Development 31(4):297–312.

Acknowledgments

Karen M. Abram, Ph.D., is Associate Professor and Associate Director, Health Disparities and Public Policy, in the Department of Psychiatry and Behavioral Sciences at the Feinberg School of Medicine, Northwestern University, Chicago, IL.

Jeanne Y. Choe, Ph.D., is a psychologist and Coordinator of Outreach/Prevention at Fordham University, Bronx, NY.

Jason J. Washburn, Ph.D., ABPP, is Assistant Professor and Director of Education and Clinical Training in the Division of Psychology, Department of Psychiatry and Behavioral Sciences at the Feinberg School of Medicine. He is also Director of the Center for Evidence-Based Practice at Alexian Brothers Behavioral Health Hospital, Hoffman Estates, IL.

Erin G. Romero, Ph.D., is a psychologist and team leader for the PTSD clinical team in the Veterans Administration Maryland Health Care System, Baltimore, MD.

Linda A. Teplin, Ph.D., is the Owen L. Coon Professor and Vice Chair for Research in the Department of Psychiatry and Behavioral Sciences at the Feinberg School of Medicine, as well as Director of the Department’s Program in Health Disparities and Public Policy.

Elena D. Bassett, M.S., is a doctoral candidate in the Division of Psychology, Department of Psychiatry and Behavioral Sciences at the Feinberg School of Medicine.

The authors thank all of their agencies for their collaborative spirit and steadfast support. They also thank the research participants for their time and willingness to participate as well as the Cook County Juvenile Temporary Detention Center, Cook County Department of Corrections, and Illinois Department of Corrections for their cooperation.

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The research described in this bulletin was supported in part by grants 1999–JE–FX–1001, 2005–JL–FX–0288, and 2008–JF–FX–0068 from the Office of Juvenile Justice and Delinquency Prevention (OJJDP), U.S. Department of Justice.

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NCJ 239996

Suicidal Thoughts and Behaviors Among Detained Youth

Karen M. Abram, Jeanne Y. Choe, Jason J. Washburn, Linda A. Teplin, Devon C. King, Mina K. Dulcan, and Elena D. Bassett

July 2014

Highlights

Incarcerated youth die by suicide at a rate two to three times higher than that of youth in the general population. In this bulletin, the authors examine suicidal thoughts and behaviors among 1,829 youth ages 10 to 18 in the Northwestern Juvenile Project—a longitudinal study of youth detained at the Cook County Juvenile Temporary Detention Center in Chicago, IL.

Key findings include the following:

• Approximately 1 in 10 juvenile detainees (10.3 percent) thought about suicide in the past 6 months, and 11 percent had attempted suicide.

• More than one-third of male juvenile detainees and nearly half of female juvenile detainees felt hopeless or thought a lot about death or dying in the 6 months prior to detention.

• Recent suicide attempts were most prevalent in female detainees and youth with anxiety disorders.

• Fewer than half of detainees with recent thoughts of suicide had told anyone about their suicidal thoughts.

At a rate of 10.5 per 100,000 adolescents measured in 2010, suicide is the third-leading cause of death in youth between 15 and 24 years old (Centers for Disease Control and Prevention, 2013). Youth suicide has nearly doubled since 1950, increasing at a faster rate than among adults age 25 and older (National Center for Health Statistics, 2004). National data suggest that incarcerated youth are at particularly greater risk for suicide; the prevalence rates of completed suicide for this group are between two and four times higher than those for youth in the general population (Gallagher and Dobrin, 2006; Memory, 1989).

A number of factors may play a role in juvenile detainees considering and attempting suicide more often than youth in the general population. Incarcerated youth often have characteristics commonly associated with increased risk for suicide (Hayes, 2004), such as high rates of psychiatric disorders (Teplin et al., 2002) and trauma (Abram et al., 2004; Shelton, 2000). Studies suggest that conditions associated with confinement, such as separation from loved ones (Pogrebin, 1985), crowding (Parent et al., 1994), sleeping in locked rooms (Gallagher and Dobrin, 2006), and solitary confinement (Marcus and Alcabes, 1993; Parent et al., 1994) may also increase the risk for suicide among detained youth.

Detention provides the juvenile justice system its first opportunity to systematically screen youth for risk of suicide. Screening for current and prior suicidal ideation (i.e., suicidal thoughts) and behaviors is critical for prevention. A national study of 79 suicides among incarcerated and detained youth found that more than two-thirds of the victims had made prior attempts, reported suicidal ideation, made suicidal threats, or physically harmed themselves (Hayes, 2004). Thus, corrections staff may be able to significantly reduce the rates of suicide in detention if they can identify youth at risk for suicide.

To investigate the thoughts, behaviors, and psychiatric disorders associated with suicide in juvenile detainees, researchers at Northwestern University conducted a longitudinal study of 1,829 detained juveniles between ages 10 and 18 at the Cook County Juvenile Temporary Detention Center in Chicago, IL. This bulletin presents the results of that research.

Literature Review

Although studies have examined suicidal behaviors in youth in long-term correctional facilities (Evans et al., 1996; Penn et al., 2003), youth in residential facilities (Holsinger and Holsinger, 2005), and youth formally processed by the juvenile justice system (Wasserman and McReynolds, 2006), few large-scale investigations have examined detained youth in the United States. Findings from previous studies of detained youth vary widely. Current prevalence rates of suicidal ideation in this population vary from 14.2 percent to 51 percent (Cauffman, 2004; Esposito and Clum, 1999; Goldstein et al., 2003; Morris et al., 1995; Rohde, Seeley, and Mace, 1997; Shelton, 2000). Racial/ethnic differences in suicidal ideation also vary across studies; some report higher rates of ideation in non-Hispanic whites than in African Americans and Hispanics (Cauffman, 2004; Morris et al., 1995), whereas others report no racial/ethnic differences (Esposito and Clum, 1999; Rohde, Seeley, and Mace, 1997; Sanislow et al., 2003). Similarly, some report higher prevalence rates of ideation in females than males (Cauffman, 2004; Morris et al., 1995; Rohde, Seeley, and Mace, 1997), whereas others found no differences between genders (Esposito and Clum, 2002; Sanislow et al., 2003).

Reasons for Variation in Study Results

In some cases, variations between studies may be due to differences in sampling. The largest study of detained youth examined 18,607 admissions to detention; however, youth may have been admitted more than once (Cauffman, 2004), which may bias estimates of suicidal ideation. The largest study of individual detainees sampled a combination of 451 youth held in detention and 1,350 youth incarcerated in long-term facilities (Morris et al., 1995). However, Morris and colleagues’ findings were not reported by type of facility, and combining the results for all youth is problematic because youth in detention and youth in prison have different patterns of suicidal behavior (Hayes, 2004). For example, 40 percent of completed juvenile suicides in detention occur within 3 days of admission. In contrast, for youth in long-term facilities, more than 72 percent of completed suicides occur after 3 months (Hayes, 2004).

Variation in prevalence rates also may be due to differences in measurement. Although all previous studies used questionnaires to assess suicidal ideation and behavior, some were self-administered (Cauffman, 2004; Esposito and Clum, 1999, 2002; Goldstein et al., 2003; Sanislow et al., 2003; Shelton, 2000) and others were group-administered (Morris et al., 1995), which may affect motivation to disclose.

Gaps in the Research Literature

There are several key omissions in the literature. First, many of the samples were too small or homogeneous for researchers to examine differences by race/ethnicity and gender (Goldstein et al., 2003; Rohde, Seeley, and Mace, 1997; Sanislow et al., 2003). Researchers must examine these differences because suicidal ideation and attempts vary by these characteristics in the general population (Flannery, Singer, and Wester, 2001; Gould et al., 2003; Kessler, Borges, and Walters, 1999; Lewinsohn, Rohde, and Seeley, 1996). Understanding demographic differences also helps researchers identify culturally relevant and gender-specific interventions for detained youth.

Second, research on suicide attempts is limited. Only three studies examined prevalence rates of suicide attempts in juvenile detainees (Esposito and Clum, 2002; Morris et al., 1995; Rohde, Seeley, and Mace, 1997). Due to differences in the methodologies that the researchers employed, the rates reported in these studies vary widely. Rohde, Mace, and Seeley report a lifetime attempt rate of 19.4 percent; Morris and colleagues report a past-year attempt rate of 15.5 percent; and Esposito and Clum report lifetime, past-year, and past-month attempt rates of 33 percent, 29 percent, and 26 percent, respectively. Past suicide attempts are powerful predictors of future attempts (Hayes, 2004) and should be studied more closely.

Finally, few studies of detained youth have examined the relationship between psychiatric diagnosis and suicide risk, and those that did relied on small samples (Rohde, Mace, and Seeley, 1997) or examined a limited range of disorders (Morris et al., 1995; Rohde, Seeley, and Mace, 1997). Psychopathology is consistently linked with risk for suicide in adolescents (Gould et al., 1998) and is prevalent in detainees (Teplin et al., 2002; Wasserman et al., 2002). Research has identified depression (Rohde, Mace, and Seeley, 1997; Wasserman and McReynolds, 2006), anxiety (Rohde, Mace, and Seeley, 1997), substance use (Morris et al., 1995; Wasserman and McReynolds, 2006), and behavioral disturbances in boys (Rohde, Mace, and Seeley, 1997) as correlates of past suicide attempts for youth involved in the justice system.

The research summarized in this bulletin represents the first large-scale epidemiological study of detained youth in the United States that uses a comprehensive, standardized interview to examine prevalence rates of suicidal ideation and behaviors, the relationship between recent suicide attempts and psychiatric disorders, and differences by gender and race/ethnicity.

Methods

The authors assessed suicidal ideation, suicide attempts, the lethality of suicide attempts, and a wide range of psychiatric disorders in detained youth. This section provides a brief overview of the authors’ methods. Additional, detailed information on the researchers’ methods and statistical analysis can be found in Abram et al. (2003) and Teplin et al. (2002).

Participants and Sampling Procedures

Participants were part of the Northwestern Juvenile Project, a longitudinal study of 1,829 youth (ages 10–18) arrested and detained between November 20, 1995, and June 14, 1998, at the Cook County Juvenile Temporary Detention Center (CCJTDC) in Chicago, IL. The random sample was stratified by gender, race/ethnicity (African American, non-Hispanic white, Hispanic, or other), age (10–13 years or 14 years and older), and legal status (processed in juvenile court or adult court) to obtain enough participants to examine key subgroups (e.g., females, Hispanics, younger children).

Like juvenile detainees nationwide, the majority of CCJTDC detainees are male and most belong to racial/ethnic minority groups (77.9 percent African American, 5.6 percent non-Hispanic white, 16 percent Hispanic, and 0.5 percent other racial/ethnic groups). The age and offense distributions of the CCJTDC detainees are also similar to detained juveniles nationwide (Snyder and Sickmund, 2006).

The authors chose the detention center in Cook County, which includes Chicago and surrounding suburbs, for three reasons:

• Nationwide, most juvenile detainees live in and are detained in urban areas (Pastore and Maguire, 2000).

• Cook County is ethnically diverse and has one of the largest Hispanic populations in the United States (U.S. Census Bureau, 2001). Studying this population is important because Hispanics are the largest minority group in the United States (U.S. Census Bureau, 2010).

• The detention center’s size (daily census of approximately 650 youth and intake of 20 youth per day) ensured that a large enough pool of participants would be available.

The final sample of 1,829 youth was composed of 1,172 males (64.1 percent) and 657 females (35.9 percent); 1,005 (54.9 percent) were African American, 524 (28.7 percent) were Hispanic, 296 (16.2 percent) were non-Hispanic white, and 4 (0.2 percent) were from other racial/ethnic groups. The mean age of participants was 14.9 years and the median age was 15 years.

Detainees were eligible to participate regardless of psychiatric morbidity, alcohol or other drug intoxication, or fitness to stand trial. Participants were interviewed privately for 2 to 3 hours, usually within 2 days of intake.

Measures

The researchers used version 2.3 of the Diagnostic Interview Schedule for Children (DISC) (Bravo et al., 1993; Shaffer et al., 1996) in English and Spanish. DISC 2.3 assesses the presence of the following disorders from the Diagnostic and Statistical Manual of Mental Disorders, Third Edition, Revised (DSM–III–R) in interviewees within the past 6 months: major depression, dysthymia, mania, hypomania, panic disorder, separation-anxiety disorder, overanxious disorder, generalized anxiety disorder, obsessive-compulsive disorder, psychotic disorder, attention-deficit/hyperactivity disorder, oppositional defiant disorder, conduct disorder, marijuana use disorder, alcohol use disorder, and other drug use disorder. DISC 2.3 also includes specific questions that assess thoughts of death, suicidal ideation, suicide plans, lifetime suicide attempts, number of suicide attempts, age at first suicide attempt, suicide attempts within the past 6 months, and method of suicide attempts. For analyses including psychiatric diagnoses, the researchers excluded items related to suicidal ideation and behavior from the diagnostic algorithms for major depression and dysthymia to avoid inflating the relationship between the two conditions.

Findings

Table 1 shows the prevalence rates of suicidal ideation and behavior by gender and race/ethnicity. Results are summarized by type of suicidal ideation and behavior and are described below.

Hopelessness. More than one-third of the juvenile detainees had at some point felt that life was hopeless. Significantly more females (44.2 percent) than males (35.6 percent) had ever felt that life was hopeless.

Thoughts about death and dying. More than one-third of the youth had thought a lot about death and dying in the 6 months prior to the interview. Significantly more Hispanics and African Americans than non-Hispanic white males had thoughts of death and dying. During the past 6 months, approximately one-fifth of the youth had thought about death and dying for at least 2 weeks.

Thoughts about suicide. Approximately 10 percent of the sample had thoughts about suicide in the past 6 months. Significantly more females (19.3 percent) than males (9.5 percent) had thought about suicide. More Hispanic than African American females had thought about suicide. Significantly more non-Hispanic white than African American males reported thoughts of suicide.

Nearly 4 percent of the sample had thought “a lot” about suicide for at least 2 weeks in the past 6 months, and significantly more females (8.3 percent) than males (3.3 percent) had such thoughts. Significantly more Hispanic than non-Hispanic white females had thought about killing themselves for 2 or more weeks. Significantly more non-Hispanic white than African American males had thoughts about suicide for 2 or more weeks.

Suicide plan. Nearly 6 percent of the youth developed a specific plan for suicide in the past 6 months. Significantly more females (10.5 percent) than males (5.1 percent) had a suicide plan.

Telling someone about suicidal thoughts. Among youth who had suicidal thoughts in the past 6 months, 46.1 percent had told someone about those thoughts (approximately 5 percent of the total sample). Significantly more females than males had told someone about their suicidal thoughts. Significantly more non-Hispanic white males (11.2 percent) than African American (4.3 percent) or Hispanic (2.5 percent) males had told someone that they were thinking about suicide.

Suicide attempts. Eleven percent of the youth had attempted suicide at least once. Those who had attempted suicide had made an average of two attempts. The average age at first suicide attempt was 12.7 years. Significantly more females than males had attempted suicide. Significantly more non-Hispanic white and Hispanic females than African American females had attempted suicide. Significantly more non-Hispanic white males than African American and Hispanic males had attempted suicide.

Three percent of the sample had attempted suicide in the past 6 months. Significantly more females (8.4 percent) than males (2.5 percent) made suicide attempts in the past 6 months.

Within their lifetimes, 283 participants had attempted suicide. The most common types of attempts included cutting (26.9 percent), drug overdose (23.8 percent), and jumping (20.7 percent) (see table 2). Less common methods included hanging, firearms, and ingestion (other than drugs). Approximately 14 percent used methods other than those that the DISC 2.3 specifically listed (e.g., running into traffic). Significantly more males than females jumped from a high place in their suicide attempt. Significantly more Hispanic males than African American males attempted suicide with firearms.

Psychiatric disorders that may increase the odds of suicide attempts. Controlling for gender, age, and race/ethnicity in separate analyses of individual disorders, most of the psychiatric disorders that the DISC assessed—including generalized anxiety disorder, overanxious disorder, major depression, oppositional defiant disorder, panic disorder, obsessive-compulsive disorder, psychotic disorder, separation-anxiety disorder, alcohol use disorder, conduct disorder, dysthymia, and other substance use disorder—were significantly associated with a recent suicide attempt.

In a separate analysis that included gender, age, and race/ethnicity along with all of the disorders that were individually associated with the suicide attempt, generalized anxiety disorder and overanxious disorder significantly increased the odds of having made a recent suicide attempt.

Discussion of Findings

One of every ten newly detained youth has a history of attempted suicide. Because past suicide attempts are a powerful predictor of future attempts (Hayes, 2004), detained youth are at greater risk than youth in the general population (Gould et al., 1998; Foley et al., 2006; Johnson et al., 2002; Kessler, Borges, and Walters, 1999; Lewinsohn, Rohde, and Seeley, 1996).

Demographic Characteristics and Suicide Risk

Suicide risk in this study varied by demographic characteristics. Females have a greater risk for attempting suicide than males, a finding consistent with prior studies of detained youth (Cauffman, 2004; Morris et al., 1995; Rohde, Mace, and Seeley, 1997) and a study of delinquency among youth in the general population (Thompson, Kingree, and Ho, 2006). The association with recent suicide attempts persists even after controlling for current psychiatric disorders, which also tend to be more prevalent among girls (Teplin et al., 2002).

The study also confirms and extends what is currently known about racial/ethnic differences among detained youth (Cauffman, 2004; Esposito and Clum, 2002; Morris et al., 1995; Rohde, Seeley, and Mace, 1997). Non-Hispanic whites generally have a greater risk for suicide compared to minority youth. However, this study notes a few exceptions. Hispanic females had more suicidal thoughts than females of other races/ethnicities. Studies of youth in the general population have also found that Hispanic females have higher prevalence rates of suicidal ideation and behavior than their non-Hispanic white (Roberts, Chen, and Roberts, 1997; Roberts and Chen, 1995; Tortolero and Roberts, 2001) and African American (Grunbaum et al., 2004; Sen, 2004) counterparts. Suicidal ideation and behavior appear to be most prevalent in U.S.-born Hispanic females from traditional Hispanic families, who may find it difficult to cope with contrasting social role expectations at home and among peers (Zayas et al., 2005; Zimmerman, 1991).

The authors also found that significantly more African American and Hispanic males had thoughts about death in the past 6 months than non-Hispanic whites. It is unclear whether and how concern about death among African American and Hispanic males is related to risk for suicide. Some studies suggest that such concern may result from a greater likelihood of having lost siblings and peers to violent death as compared to non-Hispanic white males (Crouch et al., 2000; Viboch, 2005). These findings also may reflect an awareness of a heightened risk of mortality. Among the Cook County sample, African American and Hispanic males had a substantially greater risk of an early violent death than non-Hispanic whites (Teplin et al., 2005).

The most common methods for recent suicide attempts reported in this study—cutting and drug overdose—are also the most common in the general population (Gould et al., 1998). A striking finding of this study was that Hispanic males who attempted suicide were more likely to use a firearm than African American or non-Hispanic white males. This finding is of particular concern because half of all completed suicides of young men in the general population involve firearms (Centers for Disease Control and Prevention, 2013).

Psychiatric Disorders and Suicide Risk

Most of the psychiatric disorders this study assessed were associated with respondents who had made a recent suicide attempt. At a minimum, detainees who are in any type of distress must be considered at risk for self-harm. Generalized anxiety disorder and overanxious disorder were most strongly associated with a recent suicide attempt. These disorders are often difficult for correctional staff to identify because affected youth tend to be compliant and cause little trouble.

Study Limitations

The study had a few limitations worth noting. Because the measure of suicidal ideation and behavior used in this study was part of a larger diagnostic module, data were not as comprehensive and detailed as clinical measures of suicidal ideation and behavior, such as the Suicidal Behaviors Interview (Reynolds, 1990), the Suicidal Ideation Questionnaire (Reynolds, 1988), and the Scale for Suicidal Ideation (Beck, Kovacs, and Weissman, 1979; Clum and Curtin, 1993). In addition, using an interview instead of a self-report questionnaire may underreport the prevalence of suicidal ideation because youth may be more hesitant to report symptoms to an interviewer than in a completely anonymous survey. In contrast, the turmoil of recent admission to detention may increase participants’ suicidal symptoms or their awareness of symptoms.

Although this study draws from a large and diverse sample, statistical power limited analyses of racial/ethnic differences for certain behaviors (e.g., method of suicide attempts) due to their lack of prevalence. Furthermore, correlational analyses do not infer causality—for example, although a youth has major depression, it does not mean that this dis- order necessarily is the cause of his or her suicide attempt.

Finally, findings may generalize only to juvenile detainees living in urban areas because the sample was based in Chicago. Despite these limitations, the findings presented here have important implications for research and for clinical services.

Directions for Future Research

The authors suggest that future research on juvenile suicides in detention should—

• Investigate the factors that underlie gender and racial/ethnic differences in suicidal ideation and behavior. Having thoughts of suicide may play a different role in suicide risk for youth of different races and ethnicities. For example, studies might investigate why suicidal ideation was most common in Hispanic females, yet non-Hispanic white females had the highest prevalence rate of suicide attempts. Further research is also needed to examine whether the disproportionate number of violent deaths among African American and Hispanic males (Teplin et al., 2005) reflects, in part, their underlying suicidal ideation. Suicidal behavior in these youth may manifest as self-destructive, reckless, or dangerous behavior, often referred to as victim-precipitated homicide or “suicide by cop” (Lindsay and Lester, 2004).

• Study the relationship between adverse life events and thoughts of death. Although having thoughts of death is a common risk factor for suicide in the general population, these thoughts may also reflect a greater exposure to violence, loss, and trauma among detained youth (Abram et al., 2004; Viboch, 2005). Studies are needed to examine whether having thoughts of death remains a useful marker for suicidal ideation and behavior in a population that routinely experiences loss and violence.

• Improve methods for assessing suicidal ideation. Research has not determined which methods best assess suicidal ideation. Some studies suggest that self-report questionnaires may yield higher prevalence rates of suicidal ideation than face-to-face interviews (Kaplan et al., 1994; Klimes-Dougan, 1998; Levine, Ancill, and Roberts, 1989). Another study suggests that a multipronged approach using both interviews and self-reports may produce the most accurate information (Klimes-Dougan, 1998). Future research should identify which methods of suicide assessment are most accurate, especially for high-risk youth.

Conclusion

The research discussed in this bulletin has two clinical implications. First, juvenile detention facilities must systematically screen for suicide risk. These detention centers often provide the first opportunity to screen youth for suicide risk and to provide interventions, yet most facilities do not perform adequate screening for emergent risk (Wasserman et al., 2003). One study found that facilities that screen all juveniles within 24 hours of arrival had lower prevalence rates of serious suicide attempts than those that screen only juveniles considered at risk for suicide (Gallagher and Dobrin, 2005). Problematically, fewer than half of the detainees with recent suicidal thoughts had shared their thoughts with someone else. Thus, juvenile facilities cannot rely on juvenile detainees to inform staff that they are contemplating suicide (Gallagher and Dobrin, 2005). Identifying youth at risk for suicide reliably helps prevent suicide, both in detention centers and after youth return to their communities.

Second, psychiatric services in detention facilities must be increased. The Office of Juvenile Justice and Delinquency Prevention’s biennial Juvenile Residential Facility Census reported that 43 percent of juvenile residential facilities do not assess all youth for mental health needs (Hockenberry, Sickmund, and Sladky, 2013). Youth with psychiatric disorders, especially anxiety, may be at particular risk for suicide attempts. Detention center staff should be trained to recognize anxiety disorders in detainees and should refer affected youth for psychiatric services. By competently assessing and treating psychiatric disorders in detained youth, facilities will prevent untimely deaths.

For More Information

This bulletin was adapted from Abram, K.M., Choe, J.Y., Washburn, J.J., Teplin, L.A., King, D.C., and Dulcan, M.K. 2008. Suicidal ideation and behaviors among youth in juvenile detention. Journal of the American Academy of Child & Adolescent Psychiatry 47(3):291–300.

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Acknowledgments

Karen M. Abram, Ph.D., is Associate Professor and Associate Director, Health Disparities and Public Policy, in the Department of Psychiatry and Behavioral Sciences at the Feinberg School of Medicine, Northwestern University, Chicago, IL.

Jeanne Y. Choe, Ph.D., is a psychologist affiliated with the Department of Psychiatry and Behavioral Sciences at the Feinberg School of Medicine.

Jason J. Washburn, Ph.D., ABPP, is Assistant Professor and Director of Education and Clinical Training in the Division of Psychology, Department of Psychiatry and Behavioral Sciences at the Feinberg School of Medicine. He is also Director of the Center for Evidence-Based Practice at Alexian Brothers Behavioral Health Hospital, Hoffman Estates, IL.

Linda A. Teplin, Ph.D., is the Owen L. Coon Professor and Vice Chair for Research in the Department of Psychiatry and Behavioral Sciences at the Feinberg School of Medicine, as well as Director of the Department’s Program in Health Disparities and Public Policy.

Devon C. King, Ph.D., is a psychologist practicing in Bethesda, MD, as well as Assistant Professor of Clinical Psychology at the Center for Professional Psychology, George Washington University.

Mina K. Dulcan, M.D., is a Professor in both the Department of Psychiatry and Behavioral Sciences and the Department of Pediatrics at the Feinberg School of Medicine. She is also the Head of the Department of Child and Adolescent Psychiatry at the Ann & Robert H. Lurie Children’s Hospital of Chicago.

Elena D. Bassett, Ph.D., is a psychology postdoctoral fellow in Psychosocial Rehabilitation & Recovery Oriented Services at the VA Palo Alto Healthcare System, Palo Alto, CA.

The authors thank all of their agencies for their collaborative spirit and steadfast support. They also thank the research participants for their time and willingness to participate as well as the Cook County Juvenile Temporary Detention Center, Cook County Department of Corrections, and Illinois Department of Corrections for their cooperation.

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The research described in this bulletin was supported in part by grants 1999–JE–FX–1001, 2005–JL–FX–0288, and 2008–JF–FX–0068 from the Office of Juvenile Justice and Delinquency Prevention (OJJDP), U.S. Department of Justice.

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NCJ 243891

Detained Youth Processed in Juvenile and Adult Court: Psychiatric Disorders and Mental Health Needs

Jason J. Washburn, Linda A. Teplin, Laurie S. Voss, Clarissa D. Simon, Karen M. Abram, Gary M. McClelland, and Nichole D. Olson

September 2015

Highlights

This bulletin presents results of a study of the prevalence of psychiatric disorders among youth transferred to adult criminal court compared with those processed in juvenile court. Key observations, findings, and recommendations include:

• Many youth are being transferred to adult criminal court, with males, African Americans, Hispanics, and older youth significantly more likely to be processed in adult criminal court than females, non-Hispanic whites, and younger youth (even after controlling for the current charge).

• The prevalence of one or more disorders among youth transferred to adult criminal court does not significantly differ from that among youth processed in juvenile court.

• Among youth processed in adult criminal court, those sentenced to prison had significantly greater odds than those who received a less severe sentence of having a disruptive behavior disorder, a substance use disorder, or co-occurring affective and anxiety disorders.

• Community and correctional systems must collaborate to identify and treat youth with psychiatric disorders who are transferred to adult criminal court. Youth who are transferred to adult criminal court and receive prison sentences should be considered a particularly high-risk group who are likely to require additional services.

All 50 states and the District of Columbia have legal mechanisms for trying juveniles as adults in criminal court (General Accounting Office, 1995; Griffin, 2003; OJJDP, 2012; Puzzanchera et al., 2003). Historically, most states transferred juveniles to adult criminal court primarily through judicial waiver. Juvenile court judges waived youth to criminal court on a case-by-case basis, considering both the charge and the characteristics of the individual youth (Griffin, 2003; Salekin, 2002; Snyder, Sickmund, and Poe-Yamagata, 2000). The number of youth transferred to the adult court through a judicial waiver nearly doubled from 1985 to 1994 (Puzzanchera and Kang, 2012), contributing to the 128-percent increase in the number of juveniles held in adult jails during that time period (Adams and Addie, 2010).

Today, more juveniles are transferred to the adult criminal court, using automatic transfers and prosecutorial direct-file procedures, than by judicial waiver (Griffin et al., 2011). Automatic transfers exclude juveniles from the jurisdiction of the juvenile court solely on the basis of the type of offense, criminal history, and age of the youth. Prosecutorial direct-file mechanisms allow prosecutors to determine when to file certain juvenile cases directly in criminal court. Juvenile court judges are precluded from exercising their discretion in both of these forms of transfer. By 2011, automatic transfers were available in 29 states and prosecutorial direct-file procedures were available in 15 states, accounting for 78.4 percent of transfers to adult criminal court (Griffin et al., 2011). The expansion of automatic transfers and prosecutorial direct-file mechanisms likely contributed to the 39-percent decline in the proportion of youth transferred to the adult court through the use of judicial waiver since its peak in 1994 (Adams and Addie, 2012). Given the substantial number of youth whose cases are filed in adult criminal court annually, accurate information on the prevalence of psychiatric disorders in this population is critical because youth with serious psychiatric disorders who are processed in adult criminal court have the right to receive treatment.

Recent studies indicate that a substantial proportion of juvenile detainees need mental health services (Cauffman, 2004) and that between one-half and two-thirds of these juveniles have one or more psychiatric disorders (Teplin et al., 2002; Wasserman et al., 2002). Another study using a screening instrument for mental health problems indicates that youth who are transferred to adult prison have higher rates of psychiatric symptoms than youth housed in juvenile facilities (Murrie et al., 2009). Yet, no study has examined how prevalent psychiatric disorders are among youth transferred to adult criminal court (referred to in this bulletin as “transferred youth”). Data on this topic is needed for several reasons.

Historically, transferred youth have disproportionately come from underserved sociodemographic groups, and numerous studies indicate that they are disproportionately male and from racial/ethnic minority groups (Austin, Johnson, and Gregoriou, 2000; Barnes and Franz, 1989; Bishop, 2000; Fagan, Forst, and Vivona, 1987; Hamparian et al., 1982; Kinder et al., 1995; Olson, 2005; Snyder, Sickmund, and Poe-Yamagata, 2000). Although these disparities have declined in the past decade, they persist (Adams and Addie, 2010). They are a significant concern because young men and adolescent youth from racial/ethnic minority groups are significantly less likely than female and non-Hispanic white youth to receive the mental health treatment they need, once they are detained (Teplin et al., 2005). Little is known, however, about racial/ethnic disparities in mental health needs among transferred youth.

A further disadvantage for transferred youth is that they often wait substantially longer for their cases to be adjudicated (that is, to receive a finding of guilt or innocence) than youth who remain in the juvenile system (Fagan, 1996; Myers, 2003; Rudman et al., 1986). They are also less likely to be released before adjudication than adults in the criminal court system (Rainville and Smith, 2003). Because they are incarcerated longer, transferred youth may be at greater risk for developing psychiatric problems than those held in juvenile detention for shorter periods. In particular, the conditions often associated with extended detention—separation from loved ones, crowding, and solitary confinement—may increase the risk of suicidal behavior among transferred youth (Gallagher and Dobrin, 2006; Marcus and Alcabes, 1993; Parent et al., 1994; Pogrebin, 1985).

In addition, findings from an experimental study suggest that, once in court, transferred youth face jurors who may be biased against them simply because they are being tried in an adult court. Where it exists, this bias increases the likelihood of a guilty verdict, boosts the jurors’ confidence in the youth’s guilt, and lowers the standard of proof for guilt (Tang and Nunez, 2003). Transferred youth are more likely to be convicted and to receive more stringent sentences than those processed in juvenile court (Myers, 2003; Podkopacz and Feld, 1996; Rainville and Smith, 2003; Strom, Smith, and Snyder, 1998). They are also more likely to receive more severe punishments than young adults facing similar charges in adult criminal court (Kurlychek and Johnson, 2004, 2010). Nearly 60 percent of all transferred youth charged with violent offenses are adjudicated to prison, compared with 26 percent of similarly charged young adults (Rainville and Smith, 2003). As a result, approximately 2,639 youth are housed in adult state prison facilities (Sabol and Couture, 2008), where they may not receive age-appropriate interventions (Woolard et al., 2005). Before age-appropriate interventions for youth in the adult correctional system can be developed and implemented, corrections personnel and treatment providers need to know which psychiatric disorders are most prevalent among these youth.

Despite the importance of this issue, the authors found only one study that examined psychiatric problems among transferred youth (Beyer, 2006). That study investigated only posttraumatic stress disorder (PTSD) and learning disorders, and it was based on one clinician’s coding of diagnoses from 50 of his case records.

Therefore, the Northwestern Juvenile Project study reported here is the first large-scale investigation of psychiatric disorders among transferred youth. Using data from the Northwestern Juvenile Project (Teplin et al., 2002), the authors compared transferred youth with those processed in juvenile court, addressing the following questions:

• Do the demographic characteristics of transferred youth differ from those of youth processed in juvenile court?

• Do the psychiatric needs of transferred youth differ from those of youth processed in juvenile court?

• Do the psychiatric needs of transferred youth who were sentenced to prison differ from those of transferred youth who received less severe sentences?

Methods

This section provides a brief overview of the authors’ methods. Additional detailed information on the methodology can be found in Abram et al. (2003) and Teplin et al. (2002).

Participants and Sampling Procedures

Participants were part of the Northwestern Juvenile Project (NJP), a longitudinal study of 1,829 youth (ages 10–18) arrested and detained between November 20, 1995, and June 14, 1998, at the Cook County Juvenile Temporary Detention Center (CCJTDC) in Chicago, IL. The random sample was stratified by gender, race/ethnicity (African American, non-Hispanic white, Hispanic, or other), age (10–13 years or 14 years and older), and legal status (processed in juvenile or adult court) to obtain enough participants to examine key subgroups (e.g., females, Hispanics, younger children).

The gender, age, and offense distributions of the CCJTDC detainees are similar to detained juveniles nationwide (Snyder and Sickmund, 2006). As in other urban facilities, most youth detained in the center belong to racial/ethnic minority groups. The CCJTDC population is 77.9 percent African American, 5.6 percent non-Hispanic white, 16 percent Hispanic, and 0.5 percent other racial/ethnic groups.

The authors chose the detention center in Cook County, which includes Chicago and surrounding suburbs, for three reasons:

• Nationwide, most juvenile detainees live in and are detained in urban areas (Pastore and Maguire, 2000).

• Cook County is ethnically diverse and has the third largest Hispanic population in the United States (U.S. Census Bureau, 2001). Studying this population is important because Hispanics are the largest minority group in the United States (U.S. Census Bureau, 2000).

• The detention center’s size (daily census of approximately 650 youth and intake of 20 youth per day) ensured that a large enough pool of participants would be available.

Detainees were eligible to be sampled regardless of any psychiatric diagnoses, their state of drug or alcohol intoxication, or their fitness to stand trial. The youth were interviewed in a private area, almost always within 2 days of intake. Most interviews lasted 2 to 3 hours, depending on how many symptoms were reported.

Transfer to Adult Criminal Court in Illinois

In Illinois, the minimum age at which a juvenile can be transferred to adult criminal court is 13 years. At the time the data were collected, the juvenile court had jurisdiction over all youth 16 years and younger, unless they were transferred to an adult criminal court (Illinois Juvenile Justice Commission, 2010). The Illinois statute at that time specified six felony offenses for which youth were automatically transferred to adult criminal court for processing. Four of these offenses are violent offenses (first-degree murder, aggravated criminal sexual assault, armed robbery with a firearm, or aggravated vehicular hijacking with a firearm); the other two offenses are not (unlawful use of a weapon on or within 1,000 feet of school property, and delivery of a controlled substance in or within 1,000 feet of a school or public housing).

Measures

To determine diagnoses, the authors used the English- and Spanish-language versions of the Diagnostic Interview Schedule for Children Version 2.3 (DISC–2.3) (Schwab-Stone et al., 1996), which was the most recent version available at the time of the study. The DISC–2.3 assesses the presence of disorders from the Diagnostic and Statistical Manual of Mental Disorders, Third Edition, Revised (DSM–III–R) in interviewees within the past 6 months. Data collection for PTSD began 13 months after the study began because PTSD was not included in the DISC–2.3. PTSD was measured with the DISC–4.0 (Shaffer et al., 2000), which provided 12-month rates using DSM–IV criteria for PTSD. Data on PTSD diagnoses were examined by using a subsample of 898 participants. The subsample was composed of 532 males (59 percent) and 366 females (41 percent). It included 490 African American youth (55 percent), 154 non-Hispanic white youth (17 percent), 252 Hispanic youth (28 percent), and 2 youth of other racial/ethnic groups (less than 1 percent).

The authors included the following disorders:

• Affective disorders (major depression, dysthymia, mania, and hypomania).

• Anxiety disorders (generalized anxiety disorder, separation anxiety disorder, obsessive-compulsive disorder, overanxious disorder, PTSD, and panic disorder).

• Psychotic disorders.

• Disruptive behavior disorders (conduct disorder, attention-deficit/hyperactivity disorder [ADHD], and oppositional defiant disorder).

• Substance use disorders (alcohol, marijuana, and drugs other than marijuana).

Details of the special procedures implemented for determining psychotic disorders and ADHD have been reported previously (Teplin et al., 2002).

Data on arrest charges were obtained from intake records at the Cook County Juvenile Temporary Detention Center.

Final Sample for Analyses

The final sample was restricted to participants 13 years and older (N = 1,715) because juveniles younger than 13 are not eligible for processing in adult criminal court in Illinois (see “Transfer to Adult Criminal Court in Illinois”). The PTSD subsample consisted of 840 participants 13 years and older. The final sample of transferred youth totaled 275; it included 21 females and 254 males, 199 African Americans, 69 Hispanics, and 7 non-Hispanic whites. The sample of youth processed in juvenile court totaled 1,440, including 616 females and 824 males, 727 African Americans, 429 Hispanics, 280 non-Hispanic whites, and 4 participants who self-identified as an “other” race or ethnicity. The unweighted M±SD (mean±standard deviation) age was 15.7±0.5 years for transferred youth and 15.0±1.2 years for youth processed in juvenile court.

Findings

Criminal Characteristics

Among the 275 transferred youth, 117 (43 percent) were charged with a violent felony, 213 (78 percent) were found guilty, and 139 (51 percent) were sentenced to prison. Among the 1,440 youth processed in the juvenile court, 281 (20 percent) were charged with a violent felony, 945 (65 percent) were “adjudicated delinquent” (the juvenile justice equivalent to being found guilty), and 8 (1 percent) were sentenced to prison. Compared with youth processed in juvenile court, significantly more transferred youth were charged with a violent felony, found guilty, and sentenced to prison.

Likelihood of Transfer to Criminal Court by Gender, Age, and Racial/Ethnic Subgroup

Table 1 presents the unweighted demographic characteristics of the sample and the weighted proportions of transferred youth compared with youth processed in juvenile court by gender, racial/ethnic subgroup, and specific age group. As shown in table 1, males, youth from racial/ethnic minority groups, and older youth had greater odds of being transferred to adult court than females, non-Hispanic whites, and younger youth. Furthermore, African American youth had greater odds of being transferred than Hispanic youth. When examining whether the results changed when the sample was controlled for those charged with a violent felony, the results did not change. Males, youth from racial/ethnic minority groups, and older youth still had significantly greater odds of being transferred to adult court than females, non-Hispanic whites, and younger youth.

Psychiatric Disorders Among Youth Processed in Juvenile Versus Criminal Court

Next, the study compared the prevalence of specific psychiatric disorders (table 2) and co-occurring psychiatric disorders (table 3) among transferred youth and youth processed in juvenile court. No significant differences in the prevalence of specific disorders were found between the two groups; both had high rates of disorders.

As shown in table 3, no differences were found for any combination of co-occurring psychiatric disorders. Furthermore, the authors found no differences between transferred youth and youth processed in juvenile court in the number of specific disorders or the number of types of psychiatric disorders.

Psychiatric Disorders Among Youth Processed in Adult Court Receiving a Prison Sentence or a Sentence Other Than Prison

Prevalence rates of psychiatric disorders among those who did and did not receive a prison sentence were compared among the 275 youth who were transferred. Table 4 shows the prevalence rates of specific psychiatric disorders. Transferred youth who received a prison sentence had significantly greater odds of having any disorder, any disorder except conduct disorder, any disruptive behavior disorder, oppositional defiant disorder, conduct disorder, any substance use disorder, alcohol use disorder, marijuana use disorder, and co-occurring alcohol and drug use disorders.

Table 5 shows the prevalence rates of co-occurring disorders among transferred youth by prison status (sentenced to prison or not). Transferred youth who received a prison sentence had significantly greater odds for having nearly all combinations of co-occurring disorders. Compared with transferred youth who did not receive a prison sentence, those who received a sentence had significantly greater odds of having two or more, three or more, and all four types of disorders. Finally, transferred youth who received a prison sentence had significantly greater numbers of specific disorders and significantly more types of disorders than those who did not receive a prison sentence.

Discussion of Findings

Diagnoses and Need for Psychiatric Treatment Among Transferred Youth Compared With Youth Processed in Juvenile Court and Adults in Detention

The study’s findings indicate that the prevalence of one or more psychiatric disorders is as high for transferred youth as for youth processed in juvenile court. These findings are consistent with the clinical data reported by Beyer (2006), who found no differences on a clinical assessment between transferred youth and youth processed in juvenile court. The study reported in this bulletin provides the first systematic empirical evidence that many transferred youth, like their peers processed in juvenile court, have a substantial need for psychiatric and substance abuse services.

These findings also suggest that transferred youth may have a greater need for psychiatric services than detained adults. Previous research indicates that less than 35 percent of detained adult males have a psychiatric disorder (excluding antisocial personality disorder) (Teplin, 1994); in contrast, 64 percent of transferred youth have a psychiatric disorder, even when conduct disorder is excluded. This study found that the 6-month prevalence rate of major depression for transferred youth (16 percent) was three times greater than the rate of depression over a lifetime as reported by adult male detainees (5 percent) (Teplin, 1994).

This study replicates previous findings that transferred youth are disproportionately male, African American, Hispanic, and older. Although these findings underscore the importance of addressing disproportionate confinement of individuals from minority groups (Hsia, Bridges, and McHale, 2004), the findings also have implications for psychiatric services. The sociodemographic factors associated with greater odds of being processed in adult criminal court are the same factors associated with lower odds of receiving psychiatric services, regardless of need (Teplin et al., 2005). This finding suggests that an urgent situation exists within the prison system; that is, the largest numbers of transferred youth who need psychiatric services are also the least likely to receive them.

The study also found that the odds of having a psychiatric disorder were greater among transferred youth sentenced to prison than those who received less severe sentences. The specific disorders associated with increased odds for a prison sentence were disruptive behavior and substance use disorders. Higher rates of disruptive behavior and substance use disorders may reasonably be expected among youth with more antisocial traits, assuming that a prison sentence is a proxy for more antisocial behavior. In other words, disruptive behavior and substance use disorders may reflect underlying antisocial traits. A parallel result has been found among adult male prisoners, of whom approximately half meet criteria for antisocial personality disorder (Fazel and Danesh, 2002).

The higher prevalence of co-occurring disorders found among prison-bound youth, however, is less easily explained by underlying antisocial traits. On average, transferred youth who were sentenced to prison had more than one psychiatric disorder, and 15 percent had all four major types of psychiatric disorders. Furthermore, the types of disorders were not limited to behavioral or substance use disorders; receiving a prison sentence was also associated with greater odds of having co-occurring affective and anxiety disorders. These findings suggest that transferred youth sentenced to prison have not only greater needs for behavioral rehabilitation to address disruptive behavior and substance use disorders than transferred youth who receive less severe sentences but also greater needs for psychiatric treatment of major affective and anxiety disorders.

Study Limitations

This study has several limitations. Because the findings are drawn from a single site, they may pertain only to detention centers with a demographic composition and legal mechanisms for transfer to adult criminal court that are similar to those at CCJTDC. For example, these findings may be generalized only to states that limit the juvenile court’s jurisdiction to youth ages 16 and younger; most states extend their juvenile court’s jurisdiction to age 18. Differences in the prevalence of disorders by transfer status may vary if diagnoses are based on later editions of the DSM than the DSM–III–R. Because it was not feasible to interview caretakers (few would have been available), the diagnostic data are also limited by the reliability and validity of youth’s reports of their own behavior. This may result in underreporting of some disorders, such as disruptive behavior disorders. In addition, the sample size for specific sociodemographic groups, such as non-Hispanic white females, may be too small for reliable comparisons with other states. The findings may apply less to areas with different mechanisms for transferring juveniles to adult criminal court.

Directions for Future Research

The following directions are suggested for future research.

Conduct Studies of Long-Term Functioning and Outcomes for Transferred Youth

Although several studies have examined recidivism among transferred youth (Bishop et al., 1996; Fagan, 1996; Myers, 2001; Podkopacz and Feld, 1996; Redding, 2010; Winner et al., 1997), little is known about the long-term effects for broader indications of functioning on individuals who have been processed in adult criminal court. Findings from this study suggest that youth processed in adult criminal court may experience worse long-term psychiatric outcomes than youth processed in juvenile court; however, few empirical studies are available. Longer stays in preadjudication detention and the stressors associated with processing in adult criminal court may increase the risk of psychiatric disorders and other adverse developmental, social, and functional consequences for transferred youth (Bishop and Frazier, 2000; Forst, Fagan, and Vivona, 1989; Penney and Moretti, 2005; Redding, 2003). Furthermore, previous studies have found that even within the juvenile court system, few youth receive the psychiatric services they need before they are adjudicated (Teplin et al., 2005), and the likelihood that transferred youth will receive the services they need after their adjudication is slim (Mulvey, Schubert, and Chung, 2007). With most transferred youth likely to complete their sentences and be released or to be returned to their communities on parole, data on the long-term psychiatric and overall functioning of this population are especially needed.

Conduct Studies of Competency To Stand Trial

Future studies should investigate the influence of psychiatric disorders on competency to stand trial among youth transferred to adult criminal court. Some states are beginning to recognize cognitive and developmental immaturity as a basis for incompetence similar to mental illness and mental retardation (Poythress et al., 2006). Although research indicates that adolescents as young as 16 years have, on average, abilities for judicial competency that are similar to those of adults (Bishop and Frazier, 2000; Poythress et al., 2006), more research is needed to understand how psychiatric disorders interact with the developmental stages that youth progress through and how they affect a youth’s ability to participate in adult legal proceedings.

Implications for the Juvenile Justice System

Provide Diagnosis and Treatment for Transferred Youth

Psychiatric services within correctional systems must address the needs and characteristics of transferred youth; however, correctional systems are not yet prepared to identify and treat transferred youth who have psychiatric disorders (Woolard et al., 2005). Assessment and treatment approaches developed for use with adults cannot be applied automatically to transferred youth (Woolard et al., 2005), so correctional psychiatric systems must use developmentally, culturally, and contextually appropriate assessment and treatment approaches (Penney and Moretti, 2005). Because little is known about the effectiveness of treatments delivered to youth in correctional facilities (Grisso, 2004), correctional systems cannot assume that assessment and treatment approaches used with youth in the general population will be effective with transferred youth (Woolard et al., 2005). It is essential to correctly identify and treat psychiatric disorders in correctional settings to better serve not only the transferred youth themselves but also the communities to which they will return after serving their sentences.

Determine Whether Psychiatric Disorders Should Play a Mitigating Role in Transfer Decisions

Judicial processing, particularly the decision to process youth as adults or juveniles, provides a critical opportunity to intervene in a juvenile’s life (Skowyra and Cocozza, 2007). Clinicians can advise the court about which youth may benefit from alternative sentencing options and which youth may be more likely or less likely to benefit from rehabilitation (Grisso, 2000). If alternative sentencing options are made available, prison sentences may become less common (Steiner, 2005). Clinicians and researchers must continue to refine juvenile assessment technology to help courts weigh mitigating psychiatric factors in transfer decisions (Brannen et al., 2006; Penney and Moretti, 2005). Unfortunately, although public opinion generally supports considering mitigating factors when making transfer decisions (Nunez et al., 2007), jurisdictions that have automatic transfer systems make this impossible.

Address Racial and Ethnic Disparities in the Transfer Process

The field must continue to address ongoing racial/ethnic disproportionality associated with the transfer process. According to the study’s findings and national statistics, more than 60 percent of transferred youth with psychiatric problems are from racial/ethnic minority groups (Sickmund, Sladky, and Kang, 2008); these youth are most likely to be underserved in detention and in the community (Teplin et al., 2005). The disproportionate transfer of African American youth to adult court is of particular concern.

More locally, this study revealed metrics for CCJTDC that clearly show that minority youth in Cook County are disproportionately transferred to adult criminal court—84 percent of transferred youth were African American, but only 26 percent of Cook County’s population is African American. Some states have already begun to address the influence of transfer processing on racial/ethnic disproportionality, and considerable gains have been made (Adams and Addie, 2010). For example, Illinois repealed two laws enacted in 1989 that required automatic transfer of youth older than 14 years to adult criminal court if they were charged with selling drugs within 1,000 feet of a designated “safe zone,” typically schools and public housing. Because of the dense concentration of both schools and public housing in urban areas where racial/ethnic minority groups make up a large portion of the population, 99 percent of the youth transferred to adult criminal court for a drug crime were from racial/ethnic minority groups (Kooy, 2001).

Conclusion

Male, African American, Hispanic, and older youth had greater odds of being processed in adult criminal court than female, non-Hispanic white, and younger youth, even after adjusting for felony-level violent crime. Among youth processed in adult criminal court, 66 percent had at least one psychiatric disorder and 43 percent had two or more disorders. The prevalence and number of co-occurring disorders for youth processed in adult criminal court were similar to those processed in juvenile court. Among youth processed in adult criminal court, those sentenced to prison had significantly greater odds than those receiving a less severe sentence of having a disruptive behavior disorder, a substance use disorder, or co-occurring affective and anxiety disorders.

The transfer of youth to adult criminal court should be reserved for the most serious, chronic, and violent offenders (Penney and Moretti, 2005). Clinicians can help to ensure this outcome by determining when and how mitigating psychiatric factors should be considered and which transferred youth may respond best to alternative sentencing. Correctional systems as well must provide psychiatric services to transferred youth, especially to youth sentenced to prison, and community health systems must continue services for these youth when they are released into the community. Whether part of the corrections or community systems, psychiatric service providers need to consider the disproportionate number of individuals from racial/ethnic minority groups who are transferred to adult criminal court when they are developing and implementing services.

For More Information

This bulletin was adapted from Washburn, J.J., Teplin, L.A., Voss, L.S., Simon, C.D., Abram, K.M., and McClelland, G.M. 2008. Psychiatric disorders among detained youths: A comparison of youths processed in juvenile court and adult criminal court. Psychiatric Services 59:965–973.

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Acknowledgments

Jason J. Washburn, Ph.D., ABPP, is Assistant Professor and Director of Education and Clinical Training in the Division of Psychology, Department of Psychiatry and Behavioral Sciences at the Feinberg School of Medicine, Northwestern University, Chicago, IL. He is also Director of the Center for Evidence-Based Practice at Alexian Brothers Behavioral Health Hospital, Hoffman Estates, IL.

Linda A. Teplin, Ph.D., is the Owen L. Coon Professor and Vice Chair for Research in the Department of Psychiatry and Behavioral Sciences at the Feinberg School of Medicine, Northwestern University, Chicago, IL, as well as Director of the Department’s Program in Health Disparities and Public Policy.

Laurie S. Voss, Ph.D., is Managing Principal and Global Lead Executive Coaching, Korn/Ferry International, Durango, CO.

Clarissa D. Simon, Ph.D., is an Adjunct Professor in the School of Education and Social Policy, Northwestern University, Evanston, IL. She is also a Research Consultant in the Department of Medical and Social Sciences at the Feinberg School of Medicine, Northwestern University, Chicago, IL.

Karen M. Abram, Ph.D., is Associate Professor and Associate Director, Health Disparities and Public Policy, in the Department of Psychiatry and Behavioral Sciences at the Feinberg School of Medicine, Northwestern University, Chicago, IL.

Gary M. McClelland, Ph.D., is Research Assistant Professor in Psychiatry and Behavioral Sciences, Feinberg School of Medicine, Northwestern University, Chicago, IL.

Nichole D. Olson, Ph.D., is a postdoctoral fellow in the Department of Psychiatry, Stanford School of Medicine, Stanford, CA.

The study on which this bulletin is based could not have been accomplished without the advice of Ann Hohmann, Ph.D., Kimberly Hoagwood, Ph.D., Heather Ringeisen, Ph.D., Grayson Norquist, M.D., and Delores Parron, Ph.D. The procedures used with the study’s participants were guided by Celia Fisher, Ph.D. Leah Welty, Ph.D., provided assistance on analytic issues. She is an Associate Professor in the Department of Preventive Medicine and the Department of Psychiatry and Behavioral Sciences and a biostatistician in the Biostatistics Collaboration Center, all at the Feinberg School of Medicine, Northwestern University. The authors also thank Eugene Griffin, Ph.D., for reviewing an earlier version of this article.

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NCJ 248283

Psychiatric Disorders in Youth After Detention

Linda A. Teplin, Leah J. Welty, Karen M. Abram, Mina K. Dulcan, Jason J. Washburn, Kathleen McCoy, and Marquita L. Stokes

September 2015

Highlights

This bulletin examines the results of the Northwestern Juvenile Project—a longitudinal study of youth detained at the Cook County Juvenile Temporary Detention Center in Chicago, IL. The authors discuss the findings related to the prevalence and persistence of psychiatric disorders in youth after detention.

Key findings include the following:

• Five years after the first interview, more than 45 percent of male juveniles and nearly 30 percent of female juveniles had one or more psychiatric disorders.

• Substance use disorders were the most common and most likely to persist. Males had higher prevalence rates of substance use disorders over time.

• As compared to African Americans, non-Hispanic whites and Hispanics had higher rates of substance use disorders.

• Females had higher rates of depression over time.

Psychiatric disorders are prevalent among incarcerated juveniles (Rohde, Mace, and Seeley, 1997; Timmons-Mitchell et al., 1997; Wasserman et al., 2002), a fact that a 2008 literature review, which concluded that psychiatric disorders are substantially more common in adolescents in detention than among adolescents in the general population, further confirms (Fazel, Doll, and Långström, 2008). The Northwestern Juvenile Project found that at intake to detention, even after excluding the most prevalent disorder found in detained populations—conduct disorder—more than 60 percent of juvenile detainees met the diagnostic criteria for one or more psychiatric disorders (Teplin et al., 2002). Among youth incarcerated for 9 months, Karnik and colleagues (2009) found even higher rates—approximately 90 percent of detainees had a psychiatric disorder other than conduct disorder or oppositional defiant disorder. Using only the lower rate mentioned above (Teplin et al., 2002), an estimated 36,800 of the 61,423 youth held in U.S. correctional facilities each day (Sickmund et al., 2013) have 1 or more psychiatric disorders.

For many of these juveniles, psychiatric disorders will persist as they become young adults because of their continual exposure to numerous risk factors—including maltreatment (Dixon, Howie, and Starling, 2004; Gover, 2004; Wareham and Dembo, 2007), dysfunctional families (Dembo et al., 2007; Dixon, Howie, and Starling, 2004), family substance abuse (Wareham and Dembo, 2007), and brain injury (Perron and Howard, 2008). With few protective factors to offset these risks, many delinquent youth are vulnerable to continued psychiatric morbidity as they age (Wareham and Dembo, 2007).

Despite their importance, few longitudinal studies have examined the prevalence and persistence of psychiatric disorders after youth leave detention. Instead, studies of delinquent youth have focused on the association between psychiatric disorders and criminal recidivism, antisocial behavior, or social functioning (Douglas, Epstein, and Poythress, 2008; Hiscoke et al., 2003; Randall et al., 1999). Harrington and colleagues (2005)—the only longitudinal study of the persistence and prevalence of psychiatric disorders in detained youth—found that 2 years after detention, many mental health problems persisted or worsened. However, their sample excluded females, was 80 percent white, and was too small (n = 97) to permit detailed analyses. Moreover, the study was conducted in the United Kingdom, limiting its applicability when generalized to juvenile detainees in the United States.

The related literature—longitudinal studies of high-risk youth—also provides little information. Youth with histories of detention have been included in studies of high-risk youth: homeless youth (Craig and Hodson, 2000; Meyer et al., 2009), youth living in impoverished or high-crime neighborhoods (Cohen et al., 2007; Fothergill et al., 2008; Mason et al., 2004), and the offspring of parents who have used substances or have psychiatric disorders themselves (Buu et al., 2009; King and Chassin, 2007, 2008; Nigg et al., 2006). Yet, none of these studies distinguished between youth with and without histories of detention.

In sum, the researchers do not know of any large-scale longitudinal study that has examined the prevalence and persistence of psychiatric disorders after youth leave detention. This omission is critical. Among detained juvenile offenders, only 28 percent of youth are in facilities 30 days or more (Snyder and Sickmund, 2006), which greatly limits any efforts to diagnose and treat them; therefore, they may pose problems in the community when they are released and may continue to burden society as they age. Epidemiologic studies are the first step to improving prevention and treatment in correctional facilities and in the community (U.S. Department of Health and Human Services, 2011). Data are also needed to address health disparities, a priority of Healthy People 2020 (U.S. Department of Health and Human Services, 2014) and the Institute of Medicine (Smedley, Stith, and Nelson, 2003). African Americans and Hispanics comprise one-third of the general population (see table 11 in U.S. Census Bureau, 2014) but make up nearly two-thirds of the approximately 500,000 incarcerated youth and young adults (age 24 and younger) (Sickmund et al., 2013; West, 2010).

In this bulletin, the authors examine changes in the prevalence and persistence of disorders during the 5 years after detention, focusing on gender and racial/ethnic differences.

Methods

This section provides a brief overview of the authors’ methods. Additional, detailed information on the authors’ methods, statistical analysis, and potential bias from attrition can be found in Teplin et al. (2012).

Participants and Sampling Procedures

Participants were part of the Northwestern Juvenile Project, a longitudinal study of 1,829 youth (ages 10–18) arrested and detained between November 20, 1995, and June 14, 1998, at the Cook County Juvenile Temporary Detention Center (CCJTDC) in Chicago, IL. The random sample was stratified by gender, race/ethnicity (African American, non-Hispanic white, Hispanic, or other), age (10–13 years or 14 years and older), and legal status (processed in juvenile or adult court) to obtain enough participants to examine key subgroups (e.g., females, Hispanics, younger children).

Like juvenile detainees nationwide, the majority of CCJTDC detainees are male and most belong to racial/ethnic minority groups (77.9 percent African American, 5.6 percent non-Hispanic white, 16 percent Hispanic, and 0.5 percent other racial/ethnic groups). The age and offense distributions of the CCJTDC detainees are also similar to detained juveniles nationwide (Snyder and Sickmund, 2006).

The authors chose the detention center in Cook County, which includes Chicago and surrounding suburbs, for three reasons:

• Nationwide, most juvenile detainees live in and are detained in urban areas (Pastore and Maguire, 2000).

• Cook County is ethnically diverse and has the third-largest Hispanic population in the United States (U.S. Census Bureau, 2001). Studying this population is important because Hispanics are the largest minority group in the United States (U.S. Census Bureau, 2000).

• The detention center’s size (daily census of approximately 650 youth and intake of 20 youth per day) ensured a large enough pool of participants would be available.

Baseline interviews. All detainees who were awaiting the adjudication or disposition of their case were eligible to participate in the study. Among them, 2,275 detainees were randomly selected; 4.2 percent (34 youth and 62 parents or guardians) refused to participate. There were no significant differences in refusal rates by gender, race/ethnicity, or age. The final sample size was 1,829: 1,172 males and 657 females; 1,005 African Americans, 296 non-Hispanic whites, 524 Hispanics, and 4 of other race/ethnicity; with an age range of 10 to 18 years (a mean of 14.9 years and a median of 15 years) (see table 1). Face-to-face structured interviews were conducted at the detention center in a private area, most within 2 days of intake.

Followup interviews. Participants were interviewed at various followup points. Followup interviews were scheduled at 3 years (time 1) and 4.5 years (time 2) after baseline interviews; two additional interviews were scheduled at 3.5 years and 4 years for a random subsample of 997 participants (600 males and 397 females). The median time between baseline and the time 1 interview was 3 years, with a range of 2.7 to 4.5 years. For simplicity, the time 1 interview is considered to occur approximately 3 years after baseline. The median time between baseline and the time 2 interview was 4.7 years, with a range of 4.3 to 6 years. For simplicity, the time 2 interview is considered to occur approximately 5 years after baseline. All interviews were used to examine gender and racial/ethnic differences and to identify changes over time. Teplin and colleagues (2012) contains more information about the statistical analyses.

Analyses

This section discusses methods used in the study.

Baseline interviews. The researchers used the Diagnostic Interview Schedule for Children (DISC), version 2.3 (Fisher et al., 1993; Shaffer et al., 1996), the most recent English and Spanish versions available at the time. This version, based on the Diagnostic and Statistical Manual of Mental Disorders (DSM–III–R; American Psychiatric Association [APA], 1987), assesses the presence of disorders in the past 6 months. It is highly structured, contains detailed symptom probes, has acceptable reliability and validity, and requires relatively brief training (Piacentini et al., 1993; Schwab-Stone et al., 1993, 1996; Shaffer et al., 1993, 1996). Because DISC 2.3 did not include posttraumatic stress disorder (PTSD), the researchers used the module from DISC–IV when it became available 13 months after the study began (Abram et al., 2004). Additional information about baseline diagnostic decisions can be found in other sources (Abram et al., 2003, 2004; Teplin et al., 2002).

Followup interviews. The researchers administered DISC–IV (child and young adult versions), based on DSM–IV (APA, 1994), to assess for schizophrenia, mood disorders, anxiety disorders, attention-deficit/hyperactivity disorder, and disruptive behavior disorders in the past year (Shaffer, Fisher, and Lucas, 2003; Shaffer et al., 2000). They defined impairment as moderate impairment in at least one area of functioning (Canino et al., 2004). The researchers present all analyses using the impairment criterion.

To assess substance use disorders and antisocial personality disorder (APD) at followup, researchers administered the Diagnostic Interview Schedule, version IV (DIS–IV)(Compton and Cottler, 2004; Robins et al., 1995). They used DIS–IV to assess substance use disorders because DISC–IV is not sufficiently detailed for the study population. APD was assessed for participants age 18 and older (who are no longer eligible for diagnoses of childhood disruptive behavior disorders). Disorders are assessed for the year prior to the interview. In accordance with the National Comorbidity Survey Replication (Kessler et al., 1994), participants who met criteria for substance use disorder or APD with “partial recovery” were scored as having the disorder.

Comparability of diagnoses over time. The diagnostic measures changed over time for three reasons: (1) the release of the DISC–IV (based on the DSM–IV criteria) midstudy, (2) some participants turned 18 years old and were therefore ineligible for childhood disruptive behavior disorders, and (3) the need to use a more comprehensive measure of substance use disorder (DIS–IV) for the followup interviews. Researchers analyzed measurement factors to ensure that they did not affect results.

Findings

This section discusses study findings.

Prevalence

Table 2 reports prevalence rates of disorders at baseline, time 1, and time 2 for males and females. Tables 3 and 4 show prevalence rates of disorders by race/ethnicity for males and females.

At time 2, more than 45 percent of males and nearly 30 percent of females had a disorder (with impairment). Even excluding disruptive behavior disorders, 37 percent of males and 25 percent of females had a disorder. Among males, 44 percent of African Americans, 50 percent of Hispanics, and 64 percent of non-Hispanic whites had a disorder at time 2. More than one-quarter of African American females and more than one-third of Hispanic and non-Hispanic white females had a disorder.

Mood disorders. Other than mania, the prevalence rates for mood disorders decreased as the participants aged. Over time, females had higher rates of any mood disorder than males. Figure 1 shows prevalence rates of major mood disorders over time by gender. The only significant racial/ethnic difference was for mania, which was more prevalent among minorities over time.

Anxiety disorders. The prevalence of panic disorder increased slightly overall. Figure 1 shows changes in prevalence rates over time by gender. Females had higher rates of any anxiety disorder. Compared with non-Hispanic whites, Hispanics were more likely to have an anxiety disorder and its subcategory, PTSD. Compared with African Americans, Hispanics were more likely to experience panic disorder. In addition, African Americans were more likely than non-Hispanic whites to have PTSD, although non-Hispanic whites were more likely than African Americans to have panic disorder.

Disruptive behavior disorders. The prevalence of any disruptive behavior disorder decreased over time, but the rate of this decrease depended on gender. Males and females did not have significantly different rates of disruptive behavior disorder at baseline, but the prevalence of these disorders decreased faster among females than among males. Figure 2 shows these differences over time. Three years after baseline, males were more likely to have a disruptive disorder; at 5 years, the disparity was even greater. Figure 2 shows that non-Hispanic whites had the highest rates of disruptive behavior disorder over time, followed by Hispanics.

Substance use disorders. Substance use disorders were the most prevalent disorders found in this juvenile population. The prevalence of substance use disorders generally decreased over time, but the rate of decrease depended on gender. Figure 2 illustrates gender and racial/ethnic differences over time. At baseline, compared with females, males had about one-third greater odds of having any substance use disorder and its subcategory, drug use disorder. Rates for alcohol use disorder were not significantly different. By the followup interviews, however, the disparities between males and females increased substantially because prevalence rates decreased faster for females than for males. Three years after baseline, compared with females, males were more likely to have a substance use disorder and its subcategories, drug use disorder and alcohol use disorder. Five years after baseline, the disparity was even larger, with males even more likely than females to have these disorders. Although the prevalence rates of most disorders decreased for males and females alike, 3 years after baseline, rates of alcohol use disorder were no longer decreasing among males.

Even after adjusting for time spent in correctional facilities, substance use disorders were more common among non-Hispanic whites and Hispanics than among African Americans. Compared with African Americans, non-Hispanic whites were more likely to have a substance use disorder and its subcategories, drug use disorder and alcohol use disorder. Hispanics also were more likely than African Americans to have a substance use disorder.

Substance use disorders among participants living in the community at time 2. Because substance use is restricted in jails and prisons, the researchers examined rates of substance use disorders only among participants who had lived in the community the entire year before time 2 (345 males and 479 females). These prevalence rates, and the demographic differences, were substantially similar to those in the entire sample.

Persistence

To assess persistence of disorders in diagnosed youth, the authors examined the proportion that still had the disorder at time 1 or time 2 (see table 5). For most disorders, rates of persistence were higher at time 1 than at time 2.

Gender differences. Approximately one in five participants (regardless of gender) had a mood disorder that persisted to time 2. Substance use disorders were among the most persistent disorders for both males and females, but were significantly more likely to persist among males than females. The existence of any disruptive behavior disorder was also among the most persistent disorders in males and, at time 2, was significantly more likely to persist in males than in females.

Racial/ethnic differences. There were no significant racial/ethnic differences in the persistence of disorders among males; however, there were several significant differences among females. At time 1, any substance use disorder and its subcategory, alcohol use disorder, were more likely to persist among non-Hispanic whites and Hispanics than among African Americans. At time 2, drug use disorders were also more likely to persist among non-Hispanic whites than among African Americans.

Discussion of Findings

Although the prevalence rates of most psychiatric disorders declined over time, a substantial proportion of delinquent youth continue to have disorders as they age. For some youth, detention may coincide with a period of crisis that subsequently abates. Many youth, however, continue to struggle: 5 years after detention, when participants were ages 14 to 24 years, nearly 50 percent of males and nearly 30 percent of females had one or more psychiatric disorders, with their associated impairments.

Substance use and disruptive behavior disorders continued to be the most common disorders. For many delinquent youth (especially males), externalizing disorders were not limited to adolescence. These disorders (such as conduct disorder and attention-deficit/hyperactivity disorder), which show up in the youth’s outward behavior, often continue into adulthood. Five years after baseline, males had two to three times the odds of having substance use and disruptive behavior disorders compared with females, a disparity that increased for males over time. Males were also more likely than females to persist with substance use disorders and disruptive behavior disorder.

The observed gender differences in externalizing disorders are consistent with those in the general population, where males are as many as 10 times more likely than females to continue antisocial behavior from childhood into adulthood (Moffitt et al., 2002). Males may fare worse than females for a number of reasons. First, delinquent males are less likely to receive mental health and substance abuse services than females, which may exacerbate these differences (Teplin et al., 2005). Second, they may have fewer opportunities to assume age-appropriate social roles (e.g., jobs, postsecondary schooling)—all turning points that might reduce problem behaviors (Sampson and Laub, 1992). Third, males are incarcerated more frequently and for longer periods of time than females, thus decreasing the amount of time available for building a stable life (Massoglia and Uggen, 2010). Finally, early entry into adult social roles, such as parenthood, may be associated with worse outcomes for males than for females (Hope, Wilder, and Watt, 2003; Kreager, Matsueda, and Erosheva, 2010; Thornberry et al., 2000).

As in the general population, females had higher rates of internalizing disorders (e.g., depression, panic disorder) than males. The persistence of mood disorders (about 20 percent) was similar for both genders.

Rates of substance use disorders and disruptive behavior disorders were lower in African Americans than in non-Hispanic whites. These findings may reflect underlying racial/ethnic disparities in the legal system (Minton, 2011; Sickmund, Sladky, and Kang, 2014; West, 2010) and the different pathways by which non-Hispanic whites and racial/ethnic minorities enter the juvenile detention system. The researchers found racial/ethnic differences in substance use disorders even after taking into account that African Americans spend more time in correctional facilities, where access to alcohol and drugs is restricted (Sickmund, Sladky, and Kang, 2014).

These findings add to the growing debate about how the “war on drugs” has affected the disproportionate incarceration of African Americans. The study findings are consistent with the views of many researchers—that disproportionate minority confinement for drug offenses is due, in part, to disparate enforcement of drug laws in African American communities rather than higher rates of drug use or dealing (Beckett, Nyrop, and Pfingst, 2006; Kakade et al., 2012; Moore and Elkavich, 2008).

Differences in the instruments used and in the sample’s demographics limit meaningful comparisons to most general population studies. The National Comorbidity Survey Replication (NCS–R) provides data that are most comparable to the time 2 interview. Although NCS–R used different (and often less stringent) criteria for impairment and did not assess the same disorders (e.g., antisocial personality disorder), it provides DSM–IV diagnoses for a sample of similar ages (18–24 years) (Harvard Medical School, 2005a, 2005b). The most marked discrepancies between the study findings and NCS–R were for drug use disorders, regardless of gender and race/ethnicity. For example, about 20 percent of males in the study had a drug use disorder, compared with about 7 percent in NCS–R; nearly 14 percent of Hispanic females and nearly 25 percent of Hispanic males had a drug use disorder, compared with less than 5 percent of Hispanics in NCS–R.

Changes in the prevalence of a disorder over time mirror those in the general population for most disorders. As summarized in the recent literature review by Costello, Copeland, and Angold (2011), many disorders in the general population decrease from adolescence to young adulthood except for panic disorders and substance use disorders, which increase (Jaffee et al., 2002; Kessler and Walters, 1998; Moffitt et al., 2007); findings on depression have been equivocal (Jaffee et al., 2002; Kessler and Walters, 1998; Moffitt et al., 2007). As mentioned previously, the youth studied here are most notably different from the general population regarding substance use disorders and the decreased rates over time. Perhaps substance abuse peaks earlier in delinquent youth, coinciding with the general course of delinquent behavior (Hirschi and Gottfredson, 1983; Moffitt, 1993). In contrast, youth in the general population may experience events that increase the likelihood of substance abuse as they age (Arnett, 2005; White and Jackson, 2004), including living in college dormitories, freedom from social controls, and delays in assuming adult responsibilities such as parenting—all events that delinquent youth are less likely to experience (Berzin and De Marco, 2010).

In terms of persistence, the most recent comparable investigation (Copeland et al., 2009) conducted in the United States using a sample of similar age and DSM-based criteria (albeit different measures) found lower rates of persistence of depression and disruptive behavior disorders than in the study sample. (Persistence of substance use disorders cannot be compared because the two studies’ definitions of this disorder differed; Copeland and colleagues used more liberal criteria to identify impairment and included nicotine use.)

Study Limitations

The data reported in this bulletin are subject to the limitations of self-reporting. Moreover, it was not feasible to study more than one jurisdiction and the prevalence of psychiatric disorders may vary across jurisdictions (Fazel and Danesh, 2002; Fazel, Doll, and Långström, 2008; Wasserman et al., 2010), limiting whether and how much the results can be generalized to apply to other areas of the country. Researchers do not know if psychiatric disorders increase the likelihood of arrest and detention, or vice versa. Findings might have been marginally different if identical measures and time frames had been used at the baseline and followup interviews. Rates would likely have been higher if the juveniles’ caretakers had been available for interviews at baseline (Teplin et al., 2002). When researchers conducted the followup interviews, it was not possible to interview many of the previous caretakers because the participants were older than age 17 or no longer living with a caretaker. Although retention rates were high, participants who missed interviews might be more likely to have had disorders than those who were located and thereby interviewed. The study findings also do not take into account mental health services that these youth and young adults might have received. Despite these limitations, the findings have implications for future research and mental health policy.

Directions for Future Research

Retain incarcerated persons in longitudinal studies of psychiatric disorders. Most large-scale longitudinal studies of the general population (such as the National Epidemiologic Survey on Alcohol and Related Conditions (Bridget Grant, National Institute on Alcohol Abuse and Alcoholism, personal communication, August 13, 2010)) do not retain persons who become incarcerated by the time followup is conducted or they reinterview too few subjects to allow for a proper analysis (such as the Epidemiologic Catchment Area Study; William Eaton, Johns Hopkins University, personal communication, August 11, 2010). Thus, these samples are biased; they systematically exclude persons who, as this study suggests, are likely to have psychiatric disorders and poor outcomes. Excluding incarcerated persons will bias prevalence rates, especially for African American males. At any given time, nearly one in nine African American males ages 25 to 34 are incarcerated (West, 2010). To address health disparities, researchers must include the correctional population, which was estimated to be 1.5 million people in 2012 (Carson and Golinelli, 2013).

Add variables on incarceration history to general population studies. Although many studies examine the prevalence of psychiatric disorders in incarcerated populations, few focus on the effect of incarceration on psychiatric disorders. The researchers suggest that epidemiologic surveys of the general population include the following variables: number of incarcerations, age at time of incarceration, length of incarcerations, and experiences in community corrections (parole, probation, and community supervision). This strategy would generate information regarding how disproportionate confinement of racial/ethnic minorities affects health disparities in psychiatric disorders and the outcomes of these disorders.

Include females in longitudinal studies of delinquents. Gender differences observed in the study underscore the fact that findings for males may not generalize to females. Yet, most longitudinal studies of delinquents exclude females or sample too few to analyze gender differences. Future studies must include females and collect data on pregnancy, childbirth, and childrearing. This will provide the requisite empirical foundation for improving gender-specific mental health services, which is especially important because females now make up an increasing proportion of juvenile arrests (29 percent) (Puzzanchera, 2013).

Examine variables that affect trajectories of disorder in high-risk youth. Few studies of high-risk youth examine the trajectories of disorders; still fewer examine how potentially modifiable risk and protective factors predict trajectories of disorder. Future studies should investigate how social, cognitive, and biological factors interact to affect these trajectories. For example, advances in neuroscience research provide unique opportunities for investigating how developmental differences in emotion regulation interact with “turning points” to alter these trajectories (Drabant et al., 2009; Feder, Nestler, and Charney, 2009; Wager et al., 2008).

Conclusion

Although prevalence rates of most psychiatric disorders decline as youth age, the study results show that disorders persist in a significant proportion of delinquent youth. To bolster youth’s chances of success upon reentry, the authors offer the following recommendations for mental health policy.

Focus on delinquent males. In recent years, innovative programs that the Office of Juvenile Justice and Delinquency Prevention has funded—such as the Girls Study Group (Zahn et al., 2008), GIRLS LINK (Schaffner, 2002), and Girl Scouts in Detention Centers—addressed the needs of delinquent females (Office of Juvenile Justice and Delinquency Prevention, 1998, 2010; Sherman, 2005). The mental health system must now improve services for males, who account for 71 percent of juvenile arrests and 85 percent of youth in correctional facilities (Puzzanchera, 2013; Sickmund et al., 2013). The study findings demonstrate that interventions for substance use and disruptive behavior disorders are especially needed. Comprehensive interventions, such as functional family therapy (Gordon et al., 1988), multidimensional treatment foster care (Chamberlain, Leve, and DeGarmo, 2007), and multisystemic therapy (Henggeler et al., 2002) can be effective. Continued development and dissemination of these programs can further reduce illegal behaviors and provide cost-effective alternatives to incarceration (Aos et al., 2001).

Assess and treat substance use disorders in correctional facilities and after release. Regardless of gender or race/ethnicity, alcohol and drug use disorders were among the most common and persistent disorders; the need for services far exceeds their availability. Approximately one-half of youth in juvenile correctional facilities (Mulvey, Schubert, and Chung, 2007; Sedlak and McPherson, 2010) and approximately three-quarters of youth in adult jails and prisons who need substance abuse treatment do not receive it (Mulvey, Schubert, and Chung, 2007). Incarcerated adults fare much worse—a study published in the Journal of the American Medical Association concluded that 80 to 85 percent of adult prisoners who needed treatment for drug abuse did not receive it (Chandler, Fletcher, and Volkow, 2009). When individuals reenter their communities after release, services may be difficult to obtain. The Substance Abuse and Mental Health Services Administration reports, for example, that fewer than 10 percent of juveniles and adults with an alcohol use problem received specialty services in the past year (Office of Applied Studies, 2010).

Despite the promise of the Patient Protection and Affordable Care Act and the healthcare reform it will bring, the law may not improve mental health services for persons such as those who participated in this study, who may frequently cycle through correctional facilities (Congressional Budget Office, 2012). Incarceration disrupts community treatment and Medicaid benefits (Freudenberg et al., 2008). Therefore, services must be improved both in correctional facilities and in the community, where the majority of detainees will eventually return.

For More Information

This bulletin was adapted from Teplin, L.A., Welty, L.J., Abram, K.M., Dulcan, M.K., and Washburn, J.J. 2012. Prevalence and persistence of psychiatric disorders in youth after detention: A prospective longitudinal study. Archives of General Psychiatry 69(10):1031–1043.

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Acknowledgments

Linda A. Teplin, Ph.D., is the Owen L. Coon Professor and Vice Chair for Research in the Department of Psychiatry and Behavioral Sciences at the Feinberg School of Medicine, Northwestern University, Chicago, IL, as well as Director of the Department’s Program in Health Disparities and Public Policy.

Leah J. Welty, Ph.D., is Associate Professor in the Department of Preventive Medicine and the Department of Psychiatry and Behavioral Sciences at the Feinberg School of Medicine.

Karen M. Abram, Ph.D., is Associate Professor and Associate Director, Health Disparities and Public Policy, in the Department of Psychiatry and Behavioral Sciences at the Feinberg School of Medicine.

Mina K. Dulcan, M.D., is a Professor in both the Department of Psychiatry and Behavioral Sciences and the Department of Pediatrics at the Feinberg School of Medicine. She is also the Head of the Department of Child and Adolescent Psychiatry at the Ann & Robert H. Lurie Children’s Hospital of Chicago.

Jason J. Washburn, Ph.D., ABPP, is Assistant Professor and Director of Education and Clinical Training in the Division of Psychology, Department of Psychiatry and Behavioral Sciences at the Feinberg School of Medicine. He is also Director of the Center for Evidence-Based Practice at Alexian Brothers Behavioral Health Hospital, Hoffman Estates, IL.

Kathleen McCoy was a postdoctoral psychology fellow in the Health Disparities and Public Policy Program in the Department of Psychiatry and Behavioral Sciences at the Feinberg School of Medicine.

Marquita L. Stokes, M.S., is a doctoral candidate in the Health Disparities and Public Policy Program in the Division of Psychology, Department of Psychiatry and Behavioral Sciences at the Feinberg School of Medicine. She is also a psychology extern at the Institute for Juvenile Research’s Pediatric Mood Disorders Program at the University of Illinois-Chicago.

The authors thank all of their agencies for their collaborative spirit and steadfast support. They also thank the research participants for their time and willingness to participate and the Cook County Juvenile Temporary Detention Center, Cook County Department of Corrections, and Illinois Department of Corrections for their cooperation.

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The research described in this bulletin was supported in part by grants 1999–JE–FX–1001, 2005–JL–FX–0288, and 2008–JF–FX–0068 from the Office of Juvenile Justice and Delinquency Prevention (OJJDP), U.S. Department of Justice.

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NCJ 246824

Perceived Barriers to Mental Health Services Among Detained Youth

Karen M. Abram, Leah D. Paskar, Jason J. Washburn, Linda A. Teplin, Naomi A. Zwecker, and Nicole M. Azores-Gococo

September 2015

Highlights

This bulletin is part of a series that presents the results of the Northwestern Juvenile Project—a longitudinal study of youth detained at the Cook County Juvenile Temporary Detention Center in Chicago, IL. The authors examine youth’s perceptions of barriers to mental health services, focusing on youth with alcohol, drug, and mental health disorders.

Findings include the following:

• Most frequently, youth did not receive services because they believed their problems would go away without outside help (56.5 percent).

• Nearly one-third of youth (31.7 percent) were not sure whom to contact or where to get help.

• Nearly one-fifth of the sample (19.1 percent) reported difficulty in obtaining help.

• African American and Hispanic detainees received significantly fewer services in the past compared with non-Hispanic white youth. Male detainees also received significantly fewer services in the past when compared with female detainees.

Perceived Barriers to Mental Health Services Among Detained Youth

Karen M. Abram, Leah D. Paskar, Jason J. Washburn, Linda A. Teplin, Naomi A. Zwecker, and Nicole M. Azores-Gococo

More than 2 million youth are arrested each year (Snyder, 2005), and more than 61, 000 juveniles were placed in custody on any given day in 2011 (Sickmund et al., 2013). Of the many youth involved in the juvenile justice system, most meet the criteria for psychiatric disorders that warrant mental health treatment (Teplin et al., 2002; Vermeiren, Jespers, and Moffit, 2006; Wasserman et al., 2002). Estimates indicate that nearly 70 percent of female detainees and 60 percent of male detainees have a psychiatric disorder other than a conduct disorder (Teplin et al., 2002) and that approximately half have two or more disorders (Abram et al., 2003). Rates of psychiatric disorder among youth in the juvenile justice system are substantially higher than rates in the general population (Teplin et al., 2002).

Jails are required to provide a minimum of psychiatric care to inmates (American Association of Correctional Psychology, 2000), yet reports issued by the Surgeon General (U.S. Department of Health and Human Services, 2000) and The President’s New Freedom Commission on Mental Health (2004) suggest that youth in custody are profoundly underserved.

This bulletin describes the results of a study that examined youth’s perceptions of barriers to mental health services. The authors interviewed 1,829 juveniles detained in Chicago to determine their need for, use of, and barriers to services.

Background

Although more than 70 percent of detention centers now screen for mental disorders (Goldstrom et al., 2000), research suggests that only 15.4 percent of detainees with major mental disorders receive treatment (Teplin et al., 2005). Males, older youth, and racial/ethnic minorities with major mental disorders are significantly less likely to receive treatment than females, younger detainees, and non-Hispanic whites with major mental disorders (Teplin et al., 2005).

Youth in the juvenile justice system have many of the characteristics associated with lower rates of service use: poverty and poor education (Buckner and Bassuk, 1997; Heflinger, Chatman, and Saunders, 2006; Pumariega et al., 1998), inadequate health insurance and ineligibility for Medicaid (Flores et al., 2002; Holl et al., 1995; Moffitt and Slade, 1997), racial/ethnic minority status (Heflinger, Chatman, and Saunders, 2006; McMiller and Weisz, 1996), a history of arrest (Rogers et al., 2001; Teplin et al., 2002), and a small social network (Harrison, McKay, and Bannon, 2004; McKay, McCadam, and Gonzales, 1996).

Although much is known about these external barriers to mental health service use, less is known about youth’s perceived barriers and attitudes toward service use. How youth think about services helps determine whether they cooperate with referrals or remain in treatment. To date, three studies have examined perceived barriers to substance abuse treatment among detained youth (Johnson et al., 2001; Kim and Fendrich, 2002; Lopez, 2003). Kim and Fendrich (2002) and Lopez (2003) found that a youth’s perceived need for treatment, regardless of his or her race or ethnicity, determined whether he or she sought services for substance abuse. Johnson and colleagues (2001) found that detainees who believed they could handle their own problems or that problems would simply go away had lower rates of service use. However, these studies only examined services for substance abuse. To the authors’ knowledge, no study until this point had investigated perceived barriers to mental health service use among juvenile detainees. The study described in this bulletin was designed to address this omission in the literature. Because prior evidence suggests that perceptions of services may differ across sociodemographic groups, the study also examines gender and racial/ethnic differences in perceived barriers (Diala et al., 2000, 2001; Gonzalez, Alegria, and Prihoda, 2005; Ojeda and Bergstresser, 2008).

Methods

This section provides a brief overview of the authors’ methods. Additional, detailed information on the methodology can be found in Abram et al. (2003) and Teplin et al. (2002).

Participants and Sampling Procedures

Participants were part of the Northwestern Juvenile Project (NJP), a longitudinal study of 1,829 youth (ages 10–18) arrested and detained between November 20, 1995, and June 14, 1998, at the Cook County Juvenile Temporary Detention Center (CCJTDC) in Chicago, IL. The random sample was stratified by gender, race/ethnicity (African American, non-Hispanic white, Hispanic), age (10–13 years, or older than 14 years), and legal status (processed as a juvenile or as an adult) to obtain enough participants to examine key subgroups (e.g., females, Hispanics, younger children).

Like juvenile detainees nationwide, the majority of CCJTDC detainees are male and most belong to racial/ethnic minority groups (77.9 percent African American, 5.6 percent non-Hispanic white, 16 percent Hispanic, and 0.5 percent other racial/ethnic groups). The age and offense distributions of the CCJTDC detainees are also similar to detained juveniles nationwide (Snyder and Sickmund, 2006).

The authors chose the detention center in Cook County (which includes Chicago and surrounding suburbs) for three reasons:

• Nationwide, most juvenile detainees live in and are detained in urban areas (Pastore and Maguire, 2000).

• Cook County is ethnically diverse and has one of the largest Hispanic populations in the United States. Studying this population is important because Hispanics are the largest minority group in the United States (U.S. Census Bureau, 2000, 2001).

• The detention center’s size (daily census of approximately 650 youth, intake of 20 youth per day) ensured that a large enough pool of participants would be available.

Detainees were sampled for the study regardless of their psychiatric morbidity, state of drug or alcohol intoxication, or fitness to stand trial. Participants received a face-to-face structured interview in a private area. The interviews typically took place within 2 days of intake and lasted approximately 2 to 3 hours.

Measures

The authors identified youth’s psychiatric diagnosis and measured their functional impairment to determine their need for mental health services. They used the Diagnostic Interview Schedule for Children, version 2.3 (DISC–2.3), based on the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, Third Edition, Revised (DSM–III–R; 1987) criteria, to measure alcohol, drug, and mental disorders (Bravo et al., 1993; Shaffer et al., 1996). These included affective disorders (major depression, dysthymia, mania, hypomania), anxiety disorders (panic, generalized anxiety, separation anxiety, obsessive-compulsive, overanxious), behavior disorders (conduct, attention-deficit/hyperactivity, oppositional), psychosis, and substance use disorders (alcohol, marijuana, and other substances). The authors then used the Children’s Global Assessment Scale (Shaffer et al., 1983) to measure functional impairment. This instrument allows the interviewer to determine the lowest level of the interviewee’s functioning at home, at school and/or work, and in other social environments. Scores range from 1 (most impaired) to 100 (healthiest). Scores of less than 61 indicate that children require services (Bird et al., 1990).

To assess service use and barriers to services, the authors used the Service Utilization and Risk Factors interview (Lahey et al., 1996). Interviewees were asked about services received for educational, behavioral, emotional, or substance use problems; types of services received (inpatient, outpatient, or residential); treatment providers; length of treatment; and their satisfaction with services.

The authors asked youth who were currently in treatment, or who had a history of using mental health services, why they stopped treatment or whether various factors made them think about stopping treatment. Of the youth who had been referred but had not received treatment, the authors asked why they had not gone for help. Of those who had never been referred nor received services, the authors asked which factors would impede them from getting help if they needed it. The specific barriers assessed were a belief that the problem would go away or could be solved on one’s own, being unsure of the right person or place to get help, difficulty in obtaining help, concern about what others would think, and worry about cost. The authors also asked participants if there were “other” barriers beyond those specifically listed that they would like to volunteer. Barriers were not mutually exclusive; participants could choose more than one. The results are summarized below; for more detailed information, see the table.

Results

Among participants with any alcohol, drug, or mental disorder, most reported at least one barrier to services received outside school. Most commonly, youth believed that the problem would go away or that they could solve the problem without help. The second most common barrier was that youth were not sure who to contact or where to go for help. Nearly one-fifth of the sample reported difficulty obtaining help. The authors found no significant differences in these barriers in relation to race, ethnicity, or gender.

More than one-fourth (27 percent) of the sample with alcohol, drug, or mental disorders volunteered “other” barriers to services, most commonly, denial that the problem exists, disinterest in treatment, and dissatisfaction with their therapist or treatment. The prevalence of these “other” barriers varied by gender and race/ethnicity. Among all participating youth with a disorder, significantly more males than females volunteered that they did not have a problem (31.8 percent versus 19.1 percent). Significantly more females than males volunteered that they were afraid of labeling or other negative consequences of treatment (17.3 percent versus 3.8 percent). Significantly more African American and Hispanic youth than non-Hispanic white youth volunteered that they did not have a problem (31.9 percent and 35.9 percent versus 11.7 percent). Finally, significantly more non-Hispanic white youth than Hispanic youth volunteered that they feared labeling or other consequences of treatment (7.7 percent versus 1.5 percent).

The authors then examined whether a history of service use influenced detainees’ perceptions of barriers to services if they had an alcohol, drug, or mental disorder. History of service use varied by gender and race/ethnicity. Significantly more females (70.0 percent) than males (49.1 percent) had received services outside school (e.g., medication, residential treatment, and professional outpatient services) before detention. Most non-Hispanic white males had received out-of-school services before detention (83.1 percent), in contrast to less than half of African American (48.4 percent) and Hispanic (40.0 percent) males. Among females, significantly more non-Hispanic whites received services outside school (87.0 percent) than African Americans (64.7 percent).

The table shows that significantly more females who had received services before detention, or who had been referred for services but had never received them, believed that their problems would go away than females who had never been referred nor received services. Compared with males who had received services, significantly more males who had never received services worried about the cost of services. Similarly, compared with females who had received services, significantly more females who had never received services or who had been referred but had not received services worried about the cost of services. Significantly more males who had never received services reported that they were concerned about what others might think of them receiving treatment compared with males who had received services. Significantly more males who had been referred but had never received services reported uncertainty about how to get help than males who had received services.

The authors also asked detainees with alcohol, drug, or mental disorders about their history of service use to examine the prevalence of other barriers to services. Among those who reported a barrier to treatment not listed in the survey, significantly more youth who had never received services before detention denied having a problem than those who had received past services (never referred, never received = 53.7 percent; referred, never received = 71.2 percent; received = 18.1 percent).

Discussion

Youth may decide not to seek services for mental health problems for many reasons. This study shows that most detained youth with alcohol, drug, or mental disorders report at least one perceived barrier to services. Most frequently, youth believe that problems will go away without outside help. This is the most common barrier regardless of gender, race/ethnicity, or (among females) previous experience with mental health services. Similarly, youth in the general population who have self-identified mental health needs (Samargia, Saewyc, and Elliott, 2006) and youth receiving substance use services (Johnson et al., 2001) often believe that their problems do not require treatment. Parents of children with mental illness also frequently report this barrier (Flisher et al., 1997), which indicates the possibility of an intergenerational pathway for this belief.

Despite meeting the criteria for a mental disorder, many youth stated that they did not have a mental health problem. Detained youth who do not recognize their mental health problems or feel that they can solve such problems independently are unlikely to cooperate with referrals. Youth must first understand that they need mental health services before they will seek them out (Kim and Fendrich, 2002; Lopez, 2003) and stay in treatment (Ortega and Alegria, 2005).

The common barriers that juvenile detainees in this study reported may reflect perceptions about the state of the mental health service system in the United States. Most youth said they know how to access services; however, a substantial minority (about one-third) did not, and nearly one in five felt that it was too difficult to access services. National reports substantiate difficulties in accessing services (U.S. Department of Health and Human Services, 1999, 2000). Fragmented systems of care likely contribute to confusion about where to seek needed services (Goldstrom et al., 2000; U.S. Department of Health and Human Services, 1999). They are often not based on continuity of care or long-term needs (Goldstrom et al., 2000). Moreover, the separation of service sectors for mental health and substance use from general healthcare providers limits the sharing of patient information to coordinate care between providers and often results in multiple “handoffs” of patients for different services (Institute of Medicine, 2006).

African American and Hispanic detainees had received significantly fewer services in the past than non-Hispanic white youth, which follows similar patterns in the general population and in public sectors of care (Angold et al., 2002; Cuffe et al., 2005; Garland et al., 2005; Hazen et al., 2004; Lopez-Williams et al., 2006). Male detainees also had received significantly fewer services in the past compared with female detainees.

Despite disparities in service use, detainees’ attitudes toward services were remarkably similar across gender and race. These findings suggest that individual perceptions and attitudes toward mental health services do not explain the disparities in service use. Instead, racial and ethnic disparities in service use may stem from external factors such as poverty, lack of sufficient minority service providers, and sociocultural barriers (U.S. Department of Health and Human Services, 2001). Disparities in service use between males and females may be due to greater help-seeking behaviors among females than among males (Garland and Zigler, 1994) and the higher likelihood that females will be referred to mental health services (Lopez-Williams et al., 2006).

Nearly three-fourths of youth had received services (including those received in school) before being detained. These rates are significantly higher among detained youth than among youth in the community (Kataoka, Zhang, and Wells, 2002; Leaf et al., 1996; Zahner and Daskalakis, 1997) and are comparable with rates of service use among youth in public service sectors (Garland et al., 2005; Hazen et al., 2004; Pumariega et al., 1999; Rosenblatt, Rosenblatt, and Biggs, 2000).

Moreover, youth who had never received services were more likely to be concerned about what others may think of them, uncertain about where to seek services, and unsure whether they could afford services than youth who had received services. These barriers are also common among untreated youth (Flisher et al., 1997) and adults (Wang, 2006) with mental health disorders in the general population. Youth who had received services in the past were more skeptical about using services in the future than those who had never received services. Youth who received services prior to detention were more likely than untreated youth to believe that problems would go away on their own. To best understand how to successfully deliver treatment, service providers should examine how past experiences influence youth’s willingness to accept referrals to treatment.

Study Limitations

The study’s findings are drawn from a single site and therefore may pertain only to youth in urban detention centers with a similar demographic composition. In addition, service rates might differ if diagnoses were based on DSM–IV (American Psychiatric Association, 1994) instead of DSM–III–R (1987) criteria.

Because it was not feasible to interview caretakers, the study’s data are subject to the reliability and validity of the youth’s self-reporting. Although the self-reporting instrument used may have included services that official records (e.g., nonreimbursed, informal services) did not capture, the turmoil of a recent detention, memory loss, different rates of service use over time, or omissions (Burns, Angold, and Costello, 1992) may affect self-report of use.

The authors asked adolescents who had neither received nor been referred to services in the past to “imagine” perceived barriers if they did have a problem. This type of abstraction may not correspond to how the adolescent would behave if confronted with an actual problem. Also, the Service Utilization and Risk Factors interview only asks about five barriers to services. Many of the participants reported additional barriers to treatment.

Finally, the authors were not able to assess the quality or appropriateness of services, so this study could not determine whether past treatment was appropriate for participants’ needs.

Conclusion

Findings from the study highlight areas for future research and point out ways in which clinical services and educational outreach might be improved.

Future Research

The authors recommend three areas for future research:

• Investigate the characteristics of mental health services that high-risk youth receive and why they are satisfied with these services. Why does past service use predict poor attitudes toward treatment among high-risk youth? How do characteristics of services—length of treatment, type of treatment, caregiver characteristics—affect perceptions of services?

• Investigate gender and racial/ethnic differences in service use. Disparities in service use are well known; however, the mechanisms by which service use varies by gender or race/ethnicity are less clear. The present study suggests that disparities are unlikely to originate from differences in perceived barriers to service use among youth.

• Study the role of social networks in youth’s attitudes toward services. As youth rarely are capable of seeking services on their own and may be resistant to seeking help (Boldero and Fallon, 1995; Samargia, Saewyc, and Elliott, 2006), researchers must work to understand the influence of social networks on service use. Social interactions may be the most important mechanism through which people recognize their problems and seek mental health services (Pescosolido, Gardner, and Lubell, 1998). Understanding how parents, extended family members, and other influential members of social networks facilitate or limit treatment-seeking behaviors will help service providers tailor outreach services to make them more acceptable to youth.

Implications for Clinical Services

The study’s findings have implications for clinical services. First, mental health staff must engage youth in the referral process. Findings from this study highlight the importance of understanding youth’s past experiences with mental health services before referring them to new services. These past experiences may contribute to youth’s negative perceptions of future services and decrease their willingness to seek help in the future. Candid exploration of past experiences allows youth to express negative perceptions and choose service options that will maximize their likelihood of engaging in treatment.

Second, the mental health and juvenile justice systems must provide educational outreach. To close the gap between service need and service delivery, these systems must collaborate to educate high-risk youth and their families about the nature of mental health problems, the myths of such problems and the stigma they carry, and available treatment options. Furthermore, education can improve juvenile detainees’ understanding of how to navigate the complex mental health system.

Despite the pervasive need for mental health services, findings from this study suggest that detained youth do not perceive the mental health system as an important or accessible resource. Improving service delivery to these high-risk youth must include finding ways to inspire their confidence.

For More Information

This bulletin was adapted from Abram, K.M., Paskar, L.D., Washburn, J.J., and Teplin, L.A. 2008. Perceived barriers to mental health services among youths in detention. Journal of the American Academy of Child and Adolescent Psychiatry 47(3):301–308.

Endnote

1. The racial/ethnic and gender disparities in perceived barriers were only among those youth who volunteered a barrier that was not listed in the survey; unfortunately, these disparities cannot be interpreted more broadly because not all participants were asked about these barriers.

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Acknowledgments

Karen M. Abram, Ph.D., is Associate Professor and Associate Director, Health Disparities and Public Policy, in the Department of Psychiatry and Behavioral Sciences at the Feinberg School of Medicine, Northwestern University, Chicago, IL.

Leah D. Paskar, Ph.D., is a psychologist at the Jesse Brown VA Medical Center, Chicago, IL.

Jason J. Washburn, Ph.D., ABPP, is Assistant Professor and Director of Education and Clinical Training in the Division of Psychology, Department of Psychiatry and Behavioral Sciences, at the Feinberg School of Medicine. He is also Director of the Center for Evidence-Based Practice at Alexian Brothers Behavioral Health Hospital, Hoffman Estates, IL.

Linda A. Teplin, Ph.D., is the Owen L. Coon Professor and Vice Chair for Research in the Department of Psychiatry and Behavioral Sciences at the Feinberg School of Medicine as well as Director of the Department’s Program in Health Disparities and Public Policy.

Naomi A. Zwecker, Ph.D., is a psychologist at the Houston OCD Program, Houston, TX.

Nicole M. Azores-Gococo, M.S., is a graduate student in the Division of Clinical Psychology of the Department of Psychiatry and Behavioral Sciences at the Feinberg School of Medicine.

The authors thank Ann Hohmann, Ph.D., Kimberly Hoagwood, Ph.D., and Heather Ringeisen, Ph.D., for indispensable advice, and Grayson Norquist, M.D., and Delores Parron, Ph.D., for their support. Celia Fisher, Ph.D., guided our human subject procedures. We thank project staff, especially Amy Mericle, Ph.D., Linda Carey, M.A., and our field interviewers. Without the cooperation of the Cook County and State of Illinois systems, this study would not have been possible. Finally, we thank the participants for their time and willingness to participate.

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NCJ 248522

Violent Death in Delinquent Youth After Detention

Linda A. Teplin, Gary M. McClelland, Karen M. Abram, Darinka Mileusnic-Polchan, Nichole D. Olson, and Anna J. Harrison

September 2015

Highlights

This bulletin examines the results of the Northwestern Juvenile Project—a longitudinal study of youth detained at the Cook County Juvenile Temporary Detention Center in Chicago, IL. Among the issues under examination, the authors looked at mortality rates among the youth enrolled in the project.

Some findings include the following:

• The standardized mortality rate for delinquent youth is more than four times the rate for youth in the general population.

• The mortality rate for delinquent female youth is nearly eight times the rate in the general population.

• The vast majority of deaths among delinquent youth were homicides from gunshot wounds.

• African American youth continue to experience the highest mortality rate.

Delinquent youth, who often are depicted as juvenile predators (U.S. Department of Health and Human Services, 2001), are also at great risk for injury (Laub and Vaillant, 2000; Lauritsen, Laub, and Sampson, 1992; Loeber, Kalb, and Huizinga, 2001; Menard, 2002) and early violent death (Lattimore, Linster, and MacDonald, 1997; Yeager and Lewis, 1990). Offending increases exposure to life-threatening situations (Huizinga and Jakob-Chien, 1998; Loeber et al., 1999; Menard, 2002). In their classic study of 500 white male delinquents sampled in the 1940s, Glueck and Glueck (1950) found that nearly 5 percent had died by age 32, compared with 2.2 percent of nondelinquent control subjects; by age 65, 13 percent had died unnatural deaths, compared with 6 percent of the nondelinquent control subjects (Laub and Vaillant, 2000). Another study of 118 delinquents found that 7 (5.9 percent) had died by age 25 (Yeager and Lewis, 1990). Similarly, death rates in two samples of male parolees were 3.6 percent (1,998 male subjects sampled in 1981–82 and tracked for 6 years) and 5.5 percent (1,997 male subjects sampled in 1986–87 and tracked for 11 years) (Lattimore, Linster, and MacDonald, 1997).

Previous studies do not reflect today’s delinquent youth. The Glueck and Glueck study (1950; Laub and Vaillant, 2000) in the 1940s did not include black or Hispanic youth (now more than two-thirds of juvenile detainees) (Sickmund et al., 2011) and, like the study by Lattimore, Linster, and MacDonald (1997), did not include female youth (now 30 percent of arrested youth (Puzzanchera, 2009) and nearly 15 percent of youth in residential placement (Sickmund et al., 2011)). Even studies that included female youth (Yeager and Lewis, 1990) included too few to allow the study researchers to analyze gender differences. The Cambridge Study in Delinquent Development recently examined early death among a sample of delinquent youth in the United Kingdom (Piquero et al., 2014). Although an excellent study, generalizability is limited because the prevalence and correlates of death in the United Kingdom are quite different than those in the United States. Finally, the most recent U.S. study was conducted in the 1980s and early 1990s (Lattimore, Linster, and MacDonald, 1997), when youth homicides were increasing to record high levels (Fox and Zawitz, 2002).

Studying mortality rates among delinquent youth is timely. Homicide, the second leading cause of death for youth ages 15–24 (4,678 homicides in 2010) (Centers for Disease Control and Prevention, 2013b), is one of the only causes of death in youth to increase in incidence in the past 10 years (Xu et al., 2010). Data that the Centers for Disease Control and Prevention published show that, among African American youth, homicide is the most common cause of death (48.77 cases per 100,000) (Centers for Disease Control and Prevention, 2010, 2012). The annual homicide rate among African American youth is 3.07 times that of Hispanic youth (15.89 per 100,000) and 13.47 times that of non-Hispanic white youth (3.62 per 100,000) (Centers for Disease Control and Prevention, 2012). The groups that are at greatest risk (racial and ethnic minorities, male youth, and urban youth) are all overrepresented in the juvenile justice system (Pastore and Maguire, 2002; Snyder and Sickmund, 2006).

In this bulletin, the researchers compare mortality rates for delinquent youth with those for the general population, controlling for differences in gender, race/ethnicity, and age.

Methods

This section provides a brief overview of the authors’ methods. Additional, detailed information on the methodology can be found in Teplin et al. (2002, 2005, 2012, 2013).

Participants and Sampling Procedures

Participants were part of the Northwestern Juvenile Project, a longitudinal study of 1,829 youth (ages 10–18) arrested and detained between November 20, 1995, and June 14, 1998, at the Cook County Juvenile Temporary Detention Center (CCJTDC) in Chicago, IL. The random sample was stratified by gender, race/ethnicity (African American, non-Hispanic white, Hispanic, or other), age (10–13 years or 14 years and older), and legal status (processed in juvenile or criminal court) to obtain enough participants to examine key subgroups (e.g., females, Hispanics, younger children). All detainees who were awaiting the adjudication or disposition of their case were eligible to participate in the study. Among these, 2,275 detainees were randomly selected; 4.2 percent (34 youth and 62 parents or guardians) refused to participate. There were no significant differences in refusal rates according to gender, race/ethnicity, or age. Twenty-seven youth left the detention center before an interview could be scheduled; 312 left CCJTDC while the authors attempted to locate their caretakers for consent. Eleven others were excluded from the sample because they were unable to complete the interview. Table 1 shows demographic characteristics of the final sample.

Like juvenile detainees nationwide, the majority of CCJTDC detainees are male and most belong to racial/ethnic minority groups (77.9 percent African American, 5.6 percent non-Hispanic white, 16 percent Hispanic, and 0.5 percent other racial/ethnic groups). The age and offense distributions of the CCJTDC detainees are also similar to detained juveniles nationwide (Snyder and Sickmund, 2006).

The authors chose the detention center in Cook County, which includes Chicago and surrounding suburbs, for three reasons:

• Nationwide, most juvenile detainees live in and are detained in urban areas (Pastore and Maguire, 2000).

• Cook County is ethnically diverse and has the third-largest Hispanic population in the United States (U.S. Census Bureau, 2001). Studying this population is important because Hispanics are the largest minority group in the United States (U.S. Census Bureau, 2000).

• The detention center’s size (daily census of approximately 650 youth and intake of 20 youth per day) ensured a large enough pool of participants would be available.

The researchers have been tracking the participants since they were enrolled in the study. To ensure comparability with other studies of mortality rates (National Center for Health Statistics, 1996; Singh and Yu, 1996), the researchers examined deaths that occurred in participants who were 15–24 years old. As of March 31, 2004, participants had been monitored for 0.5 to 8.4 years (mean: 7.1 years; median: 7.2 years); the aggregate exposure for all participants was 12,944 person-years (that is, the total number of years all participants were tracked).

Deaths were identified during contacts with participants’ friends, family members, and other acquaintances; by checking death records at the Cook County Medical Examiner’s office; and by submitting participants’ names to the National Death Index (Centers for Disease Control and Prevention, 2013a). All deaths were verified by obtaining copies of death certificates.

The comparison group included all persons in the general population of Cook County, IL, who were 15–24 years old (U.S. Census Bureau, n.d.). The researchers obtained counts of deaths in the comparison group using the most recent source available, the National Center for Health Statistics’ Multiple Cause-of-Death Public Use Files for 1996–2001 (National Center for Health Statistics, 2004).

Analyses

To compare mortality rates for delinquents with those in the general population, all data were weighted according to the racial/ethnic, gender, and age characteristics of the detention center’s youth population; these weighted, standardized populations were used to calculate reported percentages and mortality ratios. Mortality ratios were calculated by comparing the sample’s mortality with that for the general population of Cook County, controlling for differences in gender, race/ethnicity, and age.

The researchers used bootstrap methods for all inferential statistics. For a more detailed explanation, see Efron and Tibshirani (1993).

Findings

Sixty-five participants died during the followup period. Table 2 reports their gender, race/ethnicity, and age at death. Figure 1 shows that all died as a result of external causes (World Health Organization, 1977); 95.5 percent died as a result of homicide or legal intervention (90.1 percent homicide and 5.4 percent legal intervention), and 1.1 percent of all deaths were suicides. Ninety-three percent of homicides were from gunshot wounds.

Next, the researchers compared the mortality rate from external causes among delinquents with that for the general population, controlling for gender and race/ethnicity. Table 3 and figure 2 present standardized annual mortality rates per 100,000 person-years for the sample of delinquent youth and the general population, and standardized mortality ratios comparing the sample with the general population. Figure 2 also shows the crude mortality rate for 1996 to 2001 for the same age group (15–24 years old) in the general population (not corrected for gender, race/ethnicity, and age) (Arias et al., 2003; Hoyert et al., 2001; Hoyert, Kochanek, and Murphy, 1999; Minino et al., 2002; Murphy, 2000; Peters, Kochanek, and Murphy, 1998).

The standardized mortality rate for delinquent youth (806 deaths per 100,000 person-years) is approximately 4.4 times that for general-population youth (184 deaths per 100,000 person-years). Table 3 also shows that mortality ratios are substantially greater than 1 for male youth overall, for each racial/ethnic subgroup of male youth, for female youth overall, and for Hispanic female youth. Although the mortality ratios are greater in the detained population than in the community population for African American and non-Hispanic white females, these ratios are not significant. Both delinquent and general-population female youth had significantly lower mortality rates than their male counterparts. Delinquent African American male youth had the highest mortality rate (887 deaths per 100,000 person-years). However, African American male youth had the lowest mortality ratio (3.9) because their mortality rate in the general population was relatively high (228 deaths per 100,000 person-years). Test results for differences in mortality rates among racial/ethnic groups were not significant for either male or female youth, possibly because there were too few participants within racial/ethnic subgroups for detection of differences.

Discussion of Findings

Overall, the mortality rate among delinquent youth was more than four times higher than that in the standardized general population of Cook County. Of particular concern was the mortality rate for delinquent female youth, which was nearly eight times the general-population rate. More than 90 percent of deaths among delinquent youth were homicides, and more than 90 percent were from gunshot wounds (homicidal, accidental, or self-inflicted). To put the authors’ findings (806 deaths per 100,000) in perspective, the leading causes of death among youth in the general population are accidents (37.4 deaths per 100,000 person-years), homicide (13.1 deaths per 100,000 person-years), suicide (9.7 deaths per 100,000 person-years), and malignant neoplasms (3.9 deaths per 100,000 person years) (Xu et al., 2010).

Mortality rates in this sample appeared to be as much as three times higher than those among 11- to 32-year-old delinquents and former delinquents in the 1940s study by Glueck and Glueck (1950), which examined only non-Hispanic white male youth. Mortality rates in this sample also appeared to be higher than those reported by Lattimore and colleagues (1997), although their study included only male youth, all of whom were serious offenders, and was conducted when homicide rates were at an all-time high (Fox and Zawitz, 2002). The findings of Laub and Vaillant (2000) suggest that, as delinquent youth age, they will continue to have higher mortality rates than youth in the general population.

The overall mortality rate in the sample was similar to that in an Australian study of young offenders (Coffey et al., 2003). However, nearly one-half of deaths in the Australian sample were attributable to drug overdoses, compared with only three drug overdose deaths in this study’s sample. The small number of drug overdoses may be because few of the study participants used illegal drugs other than marijuana or alcohol (McClelland et al., 2004; McClelland, Teplin, and Abram, 2004). Nevertheless, many of the homicides in the sample might be drug related; nearly 97 percent of youth who die as a result of homicide have sold drugs (Howell and Decker, 1999).

The findings highlight several key public health issues. Even in the general U.S. population, youth are vulnerable to homicide. Although homicide rates have decreased since the early 1990s, they still represent 16.3 percent of all deaths among youth between the ages of 15 and 24 (Xu et al., 2010). More than one-third of homicide deaths in 2007 were persons younger than age 25 (Xu et al., 2010). On an average day in 2002, four youth younger than age 18 became victims of homicide (Snyder and Sickmund, 2006).

Study findings highlight the role of firearms in early violent death, especially homicides. Among youth ages 15–24 in the United States, nearly 20 percent of deaths are from firearms (Xu et al., 2010); in the sample, more than 90 percent of deaths were from firearms. In the United States, more than 80 percent of homicides among youth ages 15–24 are related to firearms (Centers for Disease Control and Prevention, 2012). Nationally, only the number of deaths from motor vehicle accidents exceeds the number of homicides from gunshot wounds among youth ages 15–24 (National Highway Traffic Safety Administration, 2001).

Deaths from firearms affect minority youth disproportionately, both in this sample and in the general U.S. population (Minino et al., 2002). Of general-population youth ages 15–24 who were killed by firearms in 2007, 66 percent were African American or Hispanic (Centers for Disease Control and Prevention, 2012), compared with almost 98 percent in this sample. Among general-population African American and Hispanic youth ages 15–24 who died in 2007, 35 percent of deaths were firearm related (Centers for Disease Control and Prevention, 2010, 2012), compared with more than 90 percent in this sample. Although homicide rates have decreased among all racial/ethnic groups and ages since the mid-1990s, African Americans (regardless of gender or age) still have the highest mortality rate by far (Fox and Zawitz, 2007).

Study Limitations

The study has several limitations. As in previous studies (Lattimore, Linster, and MacDonald, 1997; Laub and Vaillant, 2000), the researchers sampled from a detained population. Generalizability, therefore, is limited to urban youth who are apprehended and detained. Detained youth may engage in more serious delinquent acts than arrestees or youth whose delinquency is not detected. Furthermore, these findings may not be generalizable to jurisdictions outside Chicago with different patterns of firearm violence. Although this study shows a higher risk of death among formerly incarcerated youth, readers should not presume a causal relationship between the experience of incarceration and early violent death.

Although the mortality rate in this population is large compared with the death rate in the general population, there were still too few deaths in the sample to examine well-known correlates of early violent death, such as gang affiliation (Lattimore, Linster, and MacDonald, 1997), substance abuse (Valois et al., 1995), family disorganization (Caputo, 2002; Laub and Vaillant, 2000), and child physical abuse (Sabotta and Davis, 1992).

The available general-population data (1996 to 2001) are not precisely contemporaneous with deaths in the sample (June 1996 through March 2003). Bias is minimal, however, because homicide rates in the general population did not change appreciably between 2001 and 2003 (Fox and Zawitz, 2002; Snyder, 2003).

The true mortality ratios may be even greater than those observed for the following reasons:

• Because the researchers counted death only when they could obtain a death certificate, the true mortality rate in the sample might be underestimated.

• The groups (i.e., the sample and the standardized general population of Cook County) are not mutually exclusive because the comparison group (the general population) also includes youth who have been detained. Because African Americans are incarcerated at a higher rate than non-Hispanic whites (Sabol, Couture, and Harrison, 2007), findings may underestimate the increased risk of death especially in African Americans.

• Census data (the denominator with which risk is computed for the general population) undercount male subjects, minorities, youth, and persons living in central cities (Robinson, 2001; Schenker, 1993), which increases estimates of mortality rates for these groups and decreases the mortality ratio.

Overall, these limitations narrow the differences between the sample and the comparison group and reduce the power to detect them. Conversely, the true mortality ratios may be smaller than observed because 1.2 percent of deaths reported to the National Death Index do not list the cause of death (National Center for Health Statistics, 2004). Despite these limitations, the study has implications for research and for public health policy.

Directions for Future Research

The authors suggest the following directions for future research.

Longitudinal Studies of Violent Victimization

Longitudinal descriptive studies would provide information about resilience to violent victimization in high-risk groups, the risk factors that distinguish high-risk from low-risk groups, and the modifiable risk factors related to youth’s behavior whose reduction holds the greatest promise for preventing violent death among youth (e.g., fighting, carrying weapons, belonging to a gang). Longitudinal intervention studies could inform public health professionals about the effectiveness and persistence of prevention strategies, about which programs warrant investment and for which risk groups, and whether gender-specific and culturally specific interventions warrant the additional effort. It is important to study youth as they make the transition from adolescence into young adulthood, the period of greatest risk.

Studies of Delinquent Female Youth

Despite the relatively small numbers of female youth in the juvenile justice system (30 percent of arrested youth) (Puzzanchera, 2009), research on this group is needed. Compared with delinquent male youth, female youth are more likely to have histories of physical and sexual abuse and certain psychiatric disorders (Abram et al., 2003, 2004; Teplin et al., 2002, 2003). Intimate partner violence and pregnancy-associated homicide are particularly important areas for study (Abbott et al., 1995; Chang et al., 2005; Silverman et al., 2001). Even in the general population, female youth younger than age 24 are 10 times more likely than male youth to be killed by intimate partners (Greenfeld et al., 1998).

Suicidal Ideation and Risk Among Minority Youth

Suicide is now the third leading cause of death among African American youth ages 15–19 (Heron, 2010). The rate increased from 2.1 deaths per 100,000 person-years in 1980 (for youth ages 10–19) to 4.5 deaths per 100,000 person-years in 1995 (Centers for Disease Control and Prevention, 1998), and suicide is now nearly as common in minority youth as in nonminority youth (Gould et al., 2003). In the study sample, African American male youth had a significantly higher mortality rate than other groups; however, no deaths were recorded officially as suicide. The true suicide rate among minority youth may be much higher than indicated by the findings. Some studies (Gould et al., 2003; Joe and Kaplan, 2001; Poussaint and Alexander, 2000) suggested that African American youth may express suicidal intent by putting themselves at risk for homicide. Additional research is needed to examine the ways in which suicidality manifests itself as violent death among minority youth.

Implications for Public Health Policy

Medical, public health, and juvenile justice professionals must take the following steps:

First, early violent death should be addressed as aggressively as any other health disparity. Compared with non-Hispanic white youth, minority youth have a much greater risk of early violent death. Moreover, minorities are overrepresented in the justice system. One study found that more than one-fourth of low-income, urban, African American youth have been arrested by the time they were 18 years old (Reynolds, 1998). Nearly 1 in 9 African American males in their twenties and early thirties are incarcerated at any given time, compared with approximately 1 in 25 Hispanic and 1 in 60 non-Hispanic white males (West, 2010).

Second, delinquency-prevention and violence-prevention programs should be implemented. Attempts to reduce violence can begin by addressing common modifiable risk factors, such as physical fighting (reported by 33 percent of general-population youth in grades 9 through 12) (Centers for Disease Control and Prevention, 2004), carrying weapons (reported by 17.1 percent of youth) (Centers for Disease Control and Prevention, 2004), and gang membership (reported by 9 percent of youth) (Taylor et al., 2008). Delinquency prevention programs could reduce the number of offenders who also become victims (Loeber et al., 1999; Loeber, Kalb, and Huizinga, 2001). Interventions must be tailored to youth of widely varying social, economic, cultural, and ethnic backgrounds and should include parent training, mentoring, home visitation, and education (Thornton et al., 2002).

Third, violence-prevention interventions should be implemented in nontraditional settings. Community-based programs can augment school-based interventions. Public health, criminal justice, and educational experts must collaborate to develop interventions in nontraditional settings for youth who do not attend school regularly. For example, interventions in urban detention centers would reach youth who are at greatest risk: male youth, racial/ethnic minority youth, older teens, and urban youth. Moreover, these interventions would be more likely to reach high-risk youth who cycle through the juvenile justice system at some time during adolescence (Teplin et al., 2002, 2003). Referrals from juvenile courts to violence-prevention programs could impact youth involved in the 1.2 million delinquency cases per year (Hockenberry and Puzzanchera, 2014; Snyder and Sickmund, 2006).

Fourth, U.S. firearms policies should be evaluated in terms of national public health. In 2007, 31,224 persons of all ages died from firearms in the United States, and more than one-fifth of victims were 15–24 years old (Xu et al., 2010). A World Health Organization report on violence and health (Krug et al., 2002) shows that the rate of death from firearms in the United States is more than 3 times higher than that in Canada, more than 6 times higher than that in Australia, and nearly 38 times higher than that in the United Kingdom. Although the consequences of gun violence against youth are incalculable, the financial costs are estimated at $15 billion per year (Kizer et al., 1995; Cook and Ludwig, 2002).

Fifth, conditions correlated with early violent death should be improved. Many detained youth are poor (Dembo et al., 2000; Domalanta et al., 2003; McCabe et al., 2002). Since the 1970s, income segregation (in addition to racial/ethnic segregation) has resulted in increased concentration of poverty in U.S. cities (Jargowsky, 1996). Reducing poverty, segregation, and de facto racial/ethnic isolation, which are known correlates of illness, violence, death, and homicide, could also reduce violence among youth (Rosenberg, O’Carroll, and Powell, 1992).

Sixth, mental health services for high-risk youth should be improved. Nearly three-fourths of detained female youth and two-thirds of detained male youth have more than one psychiatric disorder (Abram et al., 2003; Teplin et al., 2002). The Surgeon General reports that, despite the need for mental health treatment, insufficient services are available for delinquent youth in detention centers and after they return to their communities (U.S. Public Health Service, 2000). Treating youth who have behavioral or substance use disorders may reduce the risk of victimization by curtailing high-risk lifestyles associated with these disorders (Loeber et al., 2004). Moreover, treating youth who have substance use or mood disorders may decrease suicidal risk (Shaffer et al., 1996).

Conclusion

Perhaps nothing underscores the failure to address mental health needs and to rehabilitate at-risk youth more than their vulnerability to an early and violent death. Ironically, mass shootings (144 deaths between 2010 and 2012; annotated table available from the authors), which comprise a small fraction of gun deaths in the United States (Bjelopera et al., 2013), have received far more media attention than have homicides of inner-city youth. Mass shootings capture the nation’s attention because of their drama and potential for contagion, but in 2010 alone, 11,078 people were murdered using firearms (Centers for Disease Control and Prevention, 2012). Health professionals must address the equally tragic, if less dramatic, daily violence that affects urban, delinquent youth.

For More Information

This bulletin was adapted from Teplin, L.A., McClelland, G.M., Abram, K.M., and Mileusnic, D. 2005. Early violent death among delinquent youth: A prospective longitudinal study. Pediatrics 115:1586–1593.

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Acknowledgments

Linda A. Teplin, Ph.D., is the Owen L. Coon Professor and Vice Chair for Research in the Department of Psychiatry and Behavioral Sciences at the Feinberg School of Medicine, Northwestern University, Chicago, IL, as well as Director of the Department’s Program in Health Disparities and Public Policy.

Gary M. McClelland, Ph.D., is a Research Assistant Professor and Director of Data Operations in the Mental Health Services and Public Policy Program, Department of Psychiatry and Behavioral Sciences at the Feinberg School of Medicine.

Karen M. Abram, Ph.D., is Associate Professor and Associate Director, Health Disparities and Public Policy, in the Department of Psychiatry and Behavioral Sciences at the Feinberg School of Medicine.

Darinka Mileusnic-Polchan, M.D., Ph.D., was formerly Assistant Medical Examiner at the Cook County Office of the Medical Examiner, Chicago, IL, and is currently Medical Examiner at the Knox County Office of the Medical Examiner, Knoxville, TN.

Nichole D. Olson, Ph.D., is a postdoctoral fellow at the Stanford University School of Medicine, Department of Psychiatry and Behavioral Sciences.

Anna J. Harrison, M.S., is a doctoral candidate in the Division of Psychology, Department of Psychiatry and Behavioral Sciences at the Feinberg School of Medicine.

The authors thank all of their agencies for their collaborative spirit and steadfast support. They also thank the research participants for their time and willingness to participate as well as the Cook County Juvenile Temporary Detention Center, Cook County Department of Corrections, and Illinois Department of Corrections for their cooperation.

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The research described in this bulletin was supported in part by grants 1999–JE–FX–1001, 2005–JL–FX–0288, and 2008–JF–FX–0068 from the Office of Juvenile Justice and Delinquency Prevention (OJJDP), U.S. Department of Justice.

Points of view or opinions expressed in this document are those of the authors and do not necessarily represent the official position or policies of OJJDP or the U.S. Department of Justice.

The Office of Juvenile Justice and Delinquency Prevention is a component of the Office of Justice Programs, which also includes the Bureau of Justice Assistance; the Bureau of Justice Statistics; the National Institute of Justice; the Office for Victims of Crime; and the Office of Sex Offender Sentencing, Monitoring, Apprehending, Registering, and Tracking.

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NCJ 248408