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Health Policy and Systems

The complexity of the emotional and behavioral problems yourth experience thwart efforts to develop integrated and coordinated systems of care for

children and adolescents. The difficulties of helping youthwith multiple problems are compounded when these youthexhibit behaviors that span the mental health system and thejuvenile justice system. To date, few systematic studies havebeen conducted in the United States (US) to address theproblem of detention and incarceration of youth withemotional disorders or mental illness.

Background

Many youth detained in juvenile justice systems in theUnited States suffer from emotional disorders. An estimated60% of youth in juvenile correctional facilities suffer fromemotional illnesses (Cocozza, 1991). Youth detained orcommitted in correctional facilities have levels ofpsychopathology similar to the levels of mental illness foundin psychiatric hospitals (Davis, Bean, Schumacher, & Stringer,1991; Pumariega, 1996). Other studies have shown thatyouth in the juvenile justice systems had high levels ofemotional and other problems. These youth had histories

Emotional Disorders in YoungOffendersDeborah Shelton

Problem: To estimate rates of emotional disorder in the Maryland Juvenile Justice system as aguide for planning and policy efforts.

Methods: In this cross-sectional study, psychopathology and level of functioning in a randomsample of 312 committed and detained youth (60 females, 252 males) were assessed. Youthdiagnostically classified met criteria for mental disorder using the Diagnostic InterviewSchedule for Children (DISC) combined with a cut-off score (60 or below) on the ChildGlobal Assessment Scale (CGAS), as established by the National Institute of Mental Health(NIMH).

Findings: Fifty-three percent were classified with diagnosable mental disorders on the DISC,but were above the cut-off scores on the CGAS. Forty-six percent met criteria for diagnosisand low functioning. Twenty-six percent of youth indicated need for immediate mentalhealth services. Fourteen percent with serious mental disorders and substantial functionalimpairment were in need of a highly restrictive environment as determined by the severityof their offenses.

Conclusions: The number of youth in the Maryland Juvenile Justice System in need of mentalhealth services indicates a need to examine treatment options that meet the requirementsfor security and treatment. The complexity of problems found in this sample indicates theneed for collaborative efforts between mental health and juvenile justice personnel in planningfor the immediate and future needs of these youth.

JOURNAL OF NURSING SCHOLARSHIP, 2001; 33:3, 259-263. ©2001 SIGMA THETA TAU INTERNATIONAL.

[Key words: mental health, juvenile justice system, young offenders, emotional disorders]

* * *

Deborah Shelton, RN, PhD, CNA, Pi, Associate Professor, Howard University,Division of Nursing, Washington, DC. This project was made possible with fundingby the Maryland Juvenile Justice Advisory Council and National Institute of MentalHealth Child Mental Health Training Grant (5 T32 MH 19545-05). Correspondenceto Dr. Shelton, 11934 Gold Needle Way, Columbia, MD 21044. E-mail:dashelton@howard.edu␣ ␣ Accepted for publication November 9, 2000.

for childhood abuse and substance abuse (Timmons-Mitchellet al., 1995), with the greatest number experiencing attentionproblems, anxiety, and depression (Breda, 1995). Breda(1995) found that higher levels of delinquency weresignificantly associated with higher levels of psychopathology.In a study about the characteristics of repeat offendersreferred for mental health services, youth referred for mentalhealth services included more young women than young menand more youth with serious violent offenses than without(Rogers, Powell, & Camp, 1996). In their conclusions, theresearchers stated that exposure to violence, particularly forethnic minorities, appeared to have a significant effect ontheir mental status and involvement in the juvenile justicesystem. Indications were that treatment modalities used with

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juvenile offenders who have emotional disturbances mustinclude treatments focused on both the delinquent behaviorand noncriminal clinical symptoms.

Delinquency and mental disorder have been shown to co-occur in general adolescent populations (Stoep, Evens, &Taub, 1997), and they have similar correlates. Negative familyand parental influences, patterns of family dysfunction, andparental health problems, such as substance abuse andemotional illness, appear to predispose youth for suchdifficulties (Breda, 1995). These difficulties, compounded bypoor academic experience, antisocial peers, and chaoticenvironments and neighborhoods that condone violentbehavior, contribute to delinquency (Hawkins & Catalano,1993). Individual biologic and emotional characteristics,such as intelligence, self-esteem, and social skills, are but afew of the factors that affect youth behavior and emotionalwell-being.

The fact that youth with mental illness are beingincarcerated at all has raised serious concerns about the failureof community services designed to prevent such outcomes(Aderibigbe, 1997). A lack of community-based, preventivemental health services allows many youth with emotionaldisorders to go undetected and untreated. As a result, theysuffer from disruptive behavioral symptoms and are oftenreferred to juvenile authorities and family courts (Pumariegaet al., 1995). Such outcomes may indicate service systembiases, cultural perceptions regarding preventive healthservices, and barriers to treatment.

Despite indications that large and increasing numbers ofyouth in juvenile justice systems across the nation suffer fromemotional disorders, few juvenile justice systems provideextensive mental health services (Cocozza & Skowyra, 2000).Young offenders with the pervasiveness of their problemschallenge the way in which services are developed, structured,and delivered. As Breda (1995) pointed out, “Programs withinmental health systems have traditionally been designed fortroubled youth, not troublesome youth.” The overlapbetween mental disorder and delinquency calls into questionthe criteria for placing youth in either the mental health orjuvenile justice system—a task made only more difficult bythe seriousness of the crimes they have committed. This studywas done to estimate the number of youth with mentaldisorders and the diagnostic classifications for purposes ofmaking policy decisions about placement and treatment ofyouth in the Maryland Juvenile Justice system.

Methods

This cross-sectional design was used to randomly sampleall youth in 15 detention and committed juvenile justicefacilities in Maryland over a 4-month period in 1996. Twenty-five percent of male youth in facilities during the time ofdata collection were randomly sampled. All female youth(n=60) were sampled because of their small number. This60%-40% split was consistent with proportions in the systembetween committed and detention programs.

Assessment of emotional disorder was based onclassification of symptoms using the Diagnostic InterviewSchedule for Children (DISC; Costello, Edelbrock, Dulcan,Kalas, & Klaric, 1984) and level of functioning determinedby a score of 60 or less on the Child Global Assessment Scale(CGAS; Shaffer et al., 1983). In addition to diagnosticinterviews, the Maryland Juvenile Justice criminal databaseand field records were used. Accuracy of the data was cross-validated among the interview information, the criminaldatabase, and field records.

Four categories of crime seriousness were based on theUniform Crime Index (UCI) ranging from “most serious” to“least serious” (Maryland Department of Juvenile Justice,1995). Offenses categorized as “most serious” includedviolent person-to-person crimes, serious drug offenses, andmajor property felonies. Offenses categorized in the “leastserious” category included malicious destruction orvandalism, and status offenses. Youth that committed the“most serious” offenses were assumed by the MarylandDepartment of Juvenile Justice Department to be in need ofmore restrictive environments for public safety reasons thanwere those who committed “less serious” offenses.

Findings

Demographic profileThe majority of the sample were male (81%), African

American (57%), and in late adolescence (82%). Twenty-sixpercent of youth were Caucasian; and youth of Hispanic,American Indian, Asian, and biracial cultures accounted for17% of the sample. Nearly 17% spoke English as a secondlanguage. The age range was 12 to 20 years, with 82%between 15-17 years. Eleven percent were identified as havinga learning disability and 37% in need of special educationservices.

Most youth and their families were below the poverty level.Only 16% were at or above the $46,000 state average forincome (Annie E. Casey Foundation, 1997). Fifty-threepercent had public medical insurance, 23% had privatemedical insurance, and 24% had no or unknown medicalinsurance.

Criminal Offense ActivityA total of 2,629 offenses were committed by the 312 youth

interviewed. Fifty-one percent of youth were adjudicated formore serious crimes, such as violent person-to person anddrug or property felony. Court dispositions for adjudicatedyouth were rarely waived to the adult system (3%) and theymost frequently resulted in commitment to the Departmentof Juvenile Justice (40%). Sixteen percent of cases were closedor dismissed, 21% were directed to community detention orprobation, and 20% of the cases were continued or referredout of the system. Ten percent of adjudicated youth remainedin detention waiting for placement.

Episodes of commitment or detention ranged from 1 to 27events. Youth with a high number of out-of-home juvenile

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justice placements were older, committed more serious crimes,and had more complex types of problems, resulting in theirfrequent return to these restrictive settings.

Diagnostic ClassificationDiagnostic classification of youth yielded 165 youth (53%)

classified for at least one AXIS I diagnosis by the DISC. Sixty-one youth (18.9%) were classified with an AXIS II diagnosis(learning disorders, 10.7%; personality disorders, 8.2%).Seventy-four percent of youth with a diagnosis were classifiedin more than one diagnostic category. The distributions ofthese classifications are listed in Table 1.

Patterns of Dual DiagnosisThe co-occurrences of disorders for this sample as classified

by the DISC are shown in Table 2. Substance abuse disorders,disruptive behavior disorders, and anxiety disorders co-occurwith other disorders most frequently. Dual diagnoses occurredat a slightly higher rate for youth in committed programs(24.9%) than in detention programs (22.4%). Youngestparticipants (12-14 years of age) who met criteria for morethan one diagnosis had significantly more serious criminalbehavior (t=1.29, p=.01) of substance use and abuse in thissample of youthful offenders was significant as a co-occurringdisorder (χ2= 9.20, p=.01).

Level of FunctioningA CGAS score of 60 or less (recommended by the National

Institutes of Mental Health) when combined with diagnosticclassification indicates a need for treatment for mental healthproblems. Forty-six percent of this sample scored below thecut-off score of 60, indicating difficulty in daily functioning.As shown in Table 3, 11% were very low functioning,indicating major impairment in ability to function and inneed of constant supervision. Thirty-five percent wereexperiencing moderate difficulty in more than one area offunctioning, such as school, home, or peer relationships.

Table 1. Psychiatric Disorders of Diagnostically ClassifiedYouth in the Maryland Juvenile Justice SystemDiagnostic classifications n percenta

Anxiety disorders 155 57.6Disruptive behavior disorders 107 39.8Schizophrenia or psychoses 86 32.0Misc. disorders (tics, eating) 47 17.5Affective disorders 45 16.7Substance abuse disorders 100 37.2

Note: total sample N=312, total sample classified N=165.aoverlapping categories

As shown in this table, 58% of youth classified wereexperiencing anxiety symptoms followed by behaviorproblems (40%) and substance abuse problems (38%). Otherresearchers studying mental disorders in minorities havesuggested that the subscale scores for schizophrenia andpsychoses were inflated and that affective disorders wereunderreported (Friedman, Katz-Leavy, Manderscheid, &Sandheimer, 1996). Re-examination of the raw data revealedcomments made by 80 youth about White and Black magicand mystical beliefs. Five youth discussed having contact withdead relatives or people they knew had suffered from a violentdeath. Three of these five were disturbed by these occurrences.Such reports may be misconstrued as “psychotic episodes”and are referred to as a “culture-bound syndrome” (AmericanPsychiatric Association [APA], 1994).

Chi-square analyses were used to explore individualcharacteristics of youth (age, gender, and race) by diagnosticclassification. For this sample, youth with anxiety disorderswere younger (12-14 years of age), female (χ2=4.64, p=.03)and African American (χ2=8.99, p=.02). Those youthclassified with disruptive behaviors were either the youngerAfrican American females (χ2=5.88, p=.04) or older (18-20years of age) of any race (χ2=6.80, p=.03).

Miscellaneous disorders such as tics, elimination disorders,or eating disorders were significant for African Americanyouth at any age (χ2=10.52, p=.03), and for the youngestCaucasian females (χ2=4.56, p=.04). Affective disorders weresignificant for older Caucasian youth of either gender(χ2=6.04, p=.04). Substance abuse disorders were significantfor female youth of any race (χ2=12.64, p=.001).

Table 2. Dual Diagnoses Among Detained and CommittedYouth (N= 312)

Diagnostic classification

Diagnostic Anxiety Disruptive Schiz./ Misc. Affective Substancecategory behavior psychotic disorders abuseAnxiety — n=86 n=64 n=43 n=43 n=78(n=155) 27.5% 20.5% 13.8% 13.8% 25.0%Disruptive — — n=44 n=26 n=27 n=58behavior 14.1% 8.3% 8.6% 18.6%(n=107)Psychoses — — — n=10 n=4 n=46(n=102) 3.2% 1.3% 14.7%Misc. (tics, — — — — n=16 n=23eating) 5.1% 7.4%(n=47)Affective — — — — — n=21(n=45) 6.7%Substance — — — — — —abuse(n=100)Note: Percentages indicate percentage of the total sample (N=312).

Table 3. Level of Functioning among DiagnosticallyClassified Young OffendersCGAS Percent (n)

High (CGAS>60) 53.7 (89)Low (CGAS≤40) 46.2 (76)

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Low-functioning youth were classified most frequently withanxiety disorder (n=87), disruptive behavior disorders (n=53)and substance abuse disorders (n=45). Low-level functioningfor diagnostically classified youth was significant for thosewith more than one diagnosis (t=1.45, p=.01), particularlyfor those with substance abuse as one of the co-occurringdiagnoses (χ2=9.20, p=.02).

Low-level functioning was also significant for youth whohad higher rates of recidivism in the juvenile justice system(χ2=20.29, p=.001). As Table 4 shows, youth experiencinggreater difficulty in daily functioning and classified withanxiety disorders, disruptive behavior disorders,miscellaneous disorders, or substance abuse disorders aremore likely than are their counterparts to have repeatedinvolvement with the juvenile justice system.

meeting those needs requires changes in the ways both themental health and juvenile justice systems operate. Treatmentand sanctions should be combined with a variety of otherservices, including but not limited to psychiatric assessment,psychotherapy, medication management, treatment planning,home-based treatment, case management, family supportservices, crisis intervention, and respite care. Although thecorrelation has not been clearly demonstrated in youth, manyof the causes and correlates of juvenile delinquency are similarto risk factors for developing mental health and substanceabuse disorders (Browning & Loeber, 1999).

Information from other states has indicated a shift towardprovision of mental health services within the juvenile system.This situation raises both concerns and hopes. One concernis another layering of stigmatizing labels and a return toinstitutionalization of youth with emotional disorders. A hopeis that these youth may finally receive the services they haveneeded but were unable or unwilling to obtain.

A California study showed that 22% of youth were referredfor mental health services within a juvenile detention facility;researchers said this rate was conservative (Rogers et al.,1996). A study of young offenders in South Carolina showed72% of youth with emotional disorders, 53% with seriousfunctional limitations (Pumariega et al., 1995). In this state,the decision was made to treat these youth through a“specialized mental health unit” within the mental healthsystem. The rates of emotional disorder estimated in this studyare somewhere between; 46% were experiencing difficultywith their level of functioning and 53% were diagnosticallyclassified. Twenty-six percent of this sample were in need ofimmediate mental health services. The decision in Marylandwas to treat those youth with emotional disorders and the“most serious” criminal behavior (14%) within the morerestrictive setting of the juvenile justice system. Those youngoffenders with emotional disorders and involved in “leastserious” crimes (10%) would be referred for treatment inthe less restrictive settings within the mental health system.The details of these services have yet to be worked out.

The most prominent profile in this sample is of minorityadolescent youth that demonstrate a high degree of anxietyand substance abuse despite their level of functioning or typeof offense. Because of the high rates of abuse and exposureto violence that occurred in this sample, one must considerhow the effects of the daily stressors of their often violentand chaotic environments are demonstrated through theirdisruptive and criminal behaviors (Myers, 1990). The effectof this factor may be more significant given individualpsychological predispositions, but further exploration isneeded.

Given that the majority of youth sampled, and in juvenilejustice systems nationally, are youth of color, culturalperspectives should be explored. Overrepresentation ofminorities is known to occur at every stage of the juvenilejustice process (Office of Juvenile Justice and DelinquencyPrevention [OJJDP], 1999). Nationally, many youth receivemental health services while under the care or supervision of

Restrictive EnvironmentsThose youth considered to be in need of mental health

services within the restrictive environment of the juvenilesystem were classified by the DISC and CGAS, and they alsohad been confined for more serious and violent crimes. Basedupon this definition, 45 of the 76 youth (14% of the totalsample) were likely to need a very restrictive setting. In thissample, these youth were most likely to be charged withserious and violent felonies related to a drug charge, or aviolation involving a deadly weapon. The remaining 31 youth(10% of the total sample) who committed the less seriouscrimes were evaluated as appropriately treated in a lessrestrictive mental health setting.

Discussion

Mental health problems are of critical importance in thelives of the approximately 1.8 million youth in the juvenilejustice system annually (Friedman, Katz-Leavy, Mandescheid,& Sandheimer, 1996). This study showed the rates and trendsof mental health problems and substance abuse disorders ina juvenile justice population, and shows that the needs ofemotionally disturbed youth in this juvenile justice systemwere similar to the needs of emotionally disturbed youth inthe general population. Treatment needs do not changebecause of involvement with the juvenile justice system, but

Table 4. Number of Out-of-Home Placements for YoungOffenders with Mental Disorders

Out-of-Home Placements

Diagnostic category 1-2 3-5 6-10 11+Anxiety disorder 5.7% 8.9% 25.3% 12.4%(p=.0005)Disruptive behavior 5% 7.6% 14.3% 17.6%disorder (p=.004)

Misc. disorders 5.9% 9.8% 9.8% 29.4%(p=.009)Substance abuse disorders 7.1% 8.9% 14.7% 17.8%(p=.006)

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an alternate agency such as juvenile justice systems (Centerfor Mental Health Services [CMHS], 1998). Mental healthtreatment may occur through the juvenile justice systembecause minority individuals were less likely to seekformalized services (Walker, 1996), were incorrectlydiagnosed (APA, 1994) and were referred for mental healthservices less frequently than were their White counterparts(CMHS, 1998). Limitations of the mental health system withregard to access and financing may result in “dumping” youthwith mental health problems into the juvenile justice system(Cocozza & Skowyra, 2000).

Criminal justice systems typically do not have theknowledge base or resources to appropriately treat, let alonerehabilitate. Confinement, by itself, does not facilitateimprovement in mental health, prevent relapse into substanceuse, or adoption of prosocial behaviors. On the other hand,traditional mental health care has been ineffective in treatingminority children and families in general, and AfricanAmericans in the juvenile justice system in particular. Futureefforts aimed at understanding the complex connectionsbetween emotional disturbance, substance abuse, delinquentbehavior, stressful life events, and strength of social supportsin children in different ethnic groups will enable developmentof a rational plan for appropriate responses.

Conclusions

The findings of this study are comparable to results ofstudies of emotional disorder in other juvenile justicepopulations, all of which show higher rates than exist in thegeneral population. Although methods vary, these studiesserve as a comparison of emotional disorders in youngoffenders and indicate the magnitude of the need for services.

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