- Email: [email protected]
Adolescent forensic psychiatry
Approaches to treatment
Adolescent forensic psychiatry
development of six medium secure in-patient units spread across England, operating within the National Health Service (NHS) and funded centrally by the National Commissioning Group (NCG). These units operate as part of a clinically managed network, taking referrals through a centralized system and admitting 12–17-year-old young people who have both displayed behaviour that creates serious risk for others and who are liable for detention under the Mental Health Act. This created an easier path to access to mental health services both for young people too difficult to manage in open adolescent units and for those detained in prison or appearing before the courts. Each unit has a multidisciplinary team, with clinicians from psychiatry, psychology, social work, occupational therapy, and nursing contributing to the care and management of the client group. All units also have specialized educational and occupational services so that the young people, who may be in hospital for a year or more, can continue to develop academic and work skills, and have at least part of their day that is as close as possible to that experienced by their peers in the community. All of the units provide assessment and treatment for those with serious and enduring mental illnesses such as schizophrenia and bipolar disorder. Some of the units, such as the Roycroft unit in Newcastle, also offer expertise in the management of emerging personality disorders, and further expansion is under way to provide services for those who also have learning difficulties.
Julie Withecomb
Abstract Adolescent forensic psychiatry merges understanding of the developmental trajectories of personality and behavioural traits with assessment of risk and treatment of mental disorder in young people who are offending or harming others. This article describes the various mental health services that have developed in England to provide help for these young people across health, social care, and criminal justice, including medium secure mental health services for adolescents. The different disorders and behaviours that commonly present to adolescent forensic services, including conduct disorder, psychopathy, and sexually harmful behaviour, are also reviewed. Risk assessment is described briefly, with reference to structured assessment tools that can be used with young people in the assessment of violence, psychopathy, and sexual offending.
Keywords adolescence; forensic; in-reach; medium secure; mental disorder; Mental Health Act; offending; personality disorder; risk; violence
‘Outreach’ and ‘inreach’ adolescent forensic services Not all young people in need of adolescent forensic services require admission and there is increasing provision of mental health services by teams that work from an NHS base into different kinds of non-NHS facility where young people are resident. Young people up to 18 years of age who are deemed to present a risk to themselves or others can be held for periods on Secure Accommodation Orders under the Children Act 1989 in local authority secure children’s homes (LASCHs), although those under 13 years require the permission of the Secretary of State. Those who have reached the age of 10 years (the age of criminal responsibility) and who have committed offences may be held on remand or serve custodial sentences in LASCHs, secure training centres (STCs) or young offender institutions (YOIs). There is a high prevalence of psychiatric morbidity in this group,1,2 with significant numbers – perhaps even the majority – displaying evidence of mental health problems, with substance misuse, conduct disorder, personality disorder and emotional disturbance being common. The kind of service that the young detainees can access is still highly variable across the country, with some institutions having access only to lone working mental health professionals, although an increasing number have full, highly specialist, multidisciplinary teams; those providing input to the Huntercombe YOI in Oxfordshire and Ashfield YOI in Bristol are regarded as examples of good practice.3
Adolescent forensic psychiatry is a relatively new field, but one with a growing number of practitioners from a range of professional backgrounds who provide services in many different kinds of setting from secure residential to the community, and from hospital to prison. It has roots in both child and forensic psychiatry, with a focus on the interplay between mental disorder, risk, and offending behaviour, and with assessment and management occurring in the context of the developmental and family background of the individual patient. This article will first describe the systems and settings within which adolescent forensic mental health is practised and then review current knowledge in the field.
The national adolescent medium secure network After it had been recognized that there was a population of young people who were best treated for their mental health problems in conditions of security, a process began that led to the eventual
Julie Withecomb MBBS MRCPsych is a Consultant Forensic Adolescent Psychiatrist who has worked with young people and their families in a range of residential and community settings including medium secure health and social service facilities, prisons, youth offending teams, and services for young people with substance misuse and sexual offending behaviours. She trained at Cambridge and at Guy’s and St Thomas’ Hospitals, London, UK. Her interests include stalking, and she has been widely involved in teaching and service development. Conflicts of interest: none.
PSYCHIATRY 7:9
Community forensic child and adolescent mental health services Young people under the care of child and adolescent mental health services (CAMHS) can present with risky and uncommon 395
© 2008 Published by Elsevier Ltd.
Approaches to treatment
symptoms or behaviours that cause clinicians concern, such as very severe self-harm, sexually harmful behaviours, and violent ruminations. For these young people, some CAMHS can now refer to community adolescent forensic teams (FCAMHS), whose members have particular expertise in risk assessment and management of the complex area of overlap between psychiatric and psychological symptoms and offending behaviour. For those whose behaviour has led them into formal contact with the criminal justice system, the Crime and Disorder Act 1998 set out a strategy for development of multi-agency youth offending teams (YOTs), and the Children’s National Service Framework (NSF), announced in 2001, set the aim of integrated services for those with complex needs. Through this legislation an expectation was created that health authorities, through CAMHS, would commit resources to young offenders with the aim of ensuring that the needs of those with complex problems would be met and consequently offending behaviour reduced. This work is sometimes helped and sometimes hindered by legislation such as Antisocial Behaviour Orders (ASBOs) and Parenting Orders, which make statutory requirements of young people and their families to attend programmes designed to change behaviour associated with offending. In practice, as with in-reach teams, provision is variable: some YOTs have only lone health workers who may not even have mental health training, whereas others have access to a full range of mental health professionals. The ASSET risk assessment tool developed by the Youth Justice Board, together with the Screening Interview for Adolescents (SIFA) and the Screening Questionnaire Interview for Adolescents (SQUIFA),4 have been developed to assist youth justice workers in the assessment of mental health problems and in signposting those most in need of help to the appropriate services.
Services that offending adolescents may encounter • Adolescent inpatient • Secure hospitals • Forensic CAMHS • Generalist CAMHS • Young offender institutions • Youth offending teams • Secure training centres • Specialist schools • Social service area teams • LASCHs • Voluntary sector • Adult mental health CAMHS, child and adolescent mental health services; LASCH, local authority secure children’s home
Table 1
adolescence is generally more difficult than in adulthood. It is recognized that a significant number of young people who initially appear to be developing conduct problems are later shown to have been developing schizophrenia with an insidious onset6 and there is now a well established literature setting out the association between conduct problems and schizophrenia.7 Symptoms suggestive of schizophrenia and bipolar disorder may co-occur, and the affected young person may also be using illicit drugs, the effects of which further complicate the presenting picture.
Conduct disorder, impulsivity, and delinquency The majority of offending, including persistent and serious offending, is not committed by those with serious mental disorders. The most commonly occurring psychiatric disorder in 5–15 year olds is conduct disorder (found in 5% of young people in Meltzer’s study8), defined by the presence of a ‘persistent pattern of behaviour in which the rights of other are violated’.9,10 Adolescent conduct problems have repeatedly been shown to predict later offending,11 with earlier onset and a wider range of antisocial behaviours increasing later risk. Conduct disorder has a significant co-morbidity, frequently occurring alongside hyperkinetic disorders and substance misuse, each of which also carries independent additional risks for offending.5,12 This group of disorders is often characterized by a particular pattern of distorted cognitions and affect that includes: • hostile attributions • a focus on aggressive cues • poor verbal problem-solving • labelling one’s own arousal as anger.13 Given this pattern, it is easy to see how those affected have high levels of offending, and this presentation is common in young people in contact with the criminal justice system and in those whom adolescent forensic psychiatrists are asked to assess. Conduct disorder is difficult to treat, often arising from a combination of inherent neurobiological deficits and early exposure to a chaotic, abusive and neglectful environment.
Pathways to care Although the different services that young people may encounter have been described separately above, any individual young person may move between these health services, as well as many others (Table 1), with decisions about where and how young people are looked after usually having little to do with need.
Gender differences Most young offenders are male, although the sex ratio is falling;5 it was approximately 6 : 1 In 2001, according to Home Office criminal statistics for 10–18 year olds. The full explanation for this has yet to be discovered, but certainly the conditions associated with offending, such as conduct disorder and hyperactivity, are more common in boys than in girls. Young women are referred less often to adolescent forensic psychiatry, and a significant proportion of those who are referred show repetitive self-harm rather than offending behaviour.
Serious mental illness As with adult forensic services, adolescent forensic psychiatry is concerned with the identification and treatment of conditions such as schizophrenia and bipolar disorder in those who have committed offences. However, diagnosis of these conditions in
PSYCHIATRY 7:9
396
© 2008 Published by Elsevier Ltd.
Approaches to treatment
ppropriate pharmacotherapy can alleviate symptoms, espeA cially when impulse control is a problem, and there is evidence that approaches such as multisystemic therapy may improve outcomes.14
groundbreaking services in Manchester and Newcastle. Although such services are developing independently of adolescent forensic services, substance misuse is a highly significant factor in adolescent offending, and YOTs have frequently chosen substance misuse workers as their health representatives.
Personality disorder and psychopathy Complexity in presentation
Certain personality traits, discernible in adolescence or even in childhood, are relatively stable and underlie a continuity between childhood and adult behavioural and social relationship problems. The traits of impulsivity and aggression associated with conduct disorder and delinquency, for example, are also associated with the development of antisocial personality disorder in adulthood, so that young people with conduct disorders are likely to continue to have contact with criminal justice and mental health services as they grow older. Dolan and Millington 15 have suggested that psychopathy is different from antisocial personality, and is characterized by additional deficits in empathy. Recently, scales have been developed to measure psychopathic traits in adolescents, for example the Psychopathy Checklist: Youth Version (PCL:YV).16 The predictive value of these scales is not yet clear, but it has been suggested that affected young people may be over-represented amongst those who commit serious violent and sexual offences. Apart from input into risk assessment and management, adolescent forensic psychiatry currently has little to offer to those with personality disorders, although it can be important to distinguish them from other conditions with similar presentations, such as autistic spectrum disorders.
In this article the different kinds of underlying problem have each been explored separately, but in practice it is common for young people presenting to adolescent forensic services to be adversely affected by multiple contributory factors (Table 2).
Assessment tools and risk Good risk assessment is now regarded as best grounded in clinical interpretation of material gathered and ordered by use of structured assessment tools. The Structured Assessment of Violence Risk in Youth (SAVRY)18 is a widely used tool focusing on a range of environmental and personal factors that have been shown to be associated with increased future risk of violence for those who have already committed a violent act. The Adolescent Intervention Model (AIM)19 is a structured approach for prediction of risk of sexual acting out and is helpfully organized in such a way as to describe potential strengths and weaknesses in the young person’s surrounding family and community, as well as considering aspects of the young person’s own behaviour and mental state that can contribute to higher risk. The PCL:YV, referred to above, is not strictly a risk assessment tool, but, as for those who register high scores with the adult version, it appears that adolescents with high PCL:YV scores may be at greater risk of re-offending and are more resistant to therapeutic input. Care does need to be taken, however, with the predictive capability of any of these approaches. These tools indicate only the overall risk for the group of those who posses a particular set of factors; any individual, even though they may closely fit the set of group-defining factors, may present a widely different risk from that of the group. In addition, risk assessment tools tend to put significant weight on historical and unchangeable (static) factors. This makes sense, given that the best predictors of future behaviours are past behaviours. However, especially for younger
Sexual offending Significant numbers of recorded sexual offences are committed by young people, and there is increasing recognition of the need for better understanding of this offender group and better services aimed at reducing their risk of re-offending. For many, committing a sexually harmful act is a single incident – perhaps the acting out of distress in the context of environmental pressure. In other cases, though, there is evidence that young men, and even young women, can already show patterns of entrenched distorted cognitions, including paedophilic sexual interest, that may be accompanied by evidence of developing personality disorder.17 Occasionally, such young people may suffer from diagnosable mental health problems, but it is far more likely that repeat and high-risk offenders show a pattern of learning difficulties and personality problems, and nearly all have at least been exposed to sexually inappropriate material themselves. There are woefully few services for such young people nationwide. A shortage of provision within YOIs means that the most serious offenders who receive custodial sentences have limited access to services. It is also difficult to identify services for special groups, such as young people with severe learning difficulties, and young women.
Underlying contributors in adolescent forensic patients • Trauma and abuse • Aggression • Substance misuse • Poor empathy and socialization • Mental illness • Learning and neurological problems • Inattention and impulsivity • Antisocial, delinquent, conduct disordered
Substance misuse Young people’s substance misuse services are now being developed in several parts of the country, following the lead of the
PSYCHIATRY 7:9
Table 2
397
© 2008 Published by Elsevier Ltd.
Approaches to treatment
people, there is hope of change, which may significantly reduce future risk but may not be reflected in formal risk assessment ‘scores’.
7 Dunedin Study. Institute of Psychiatry. Dunedin Multi-disciplinary Health and Development Study. http://www.iop.kcl.ac.uk/ departments/? locator=351 (accessed 29 July 2008). 8 Meltzer H, Gatward R, Goodman R, Ford T. The mental health of children and adolescents in Great Britain, London: ONS, 1999. 9 World Health Organization. The ICD-10 classification of mental and behavioural disorders: clinical descriptions and diagnostic guidelines, Geneva: World Health Oraganization, 1992. 10 Hill J. Conduct disorders. Psychiatry 2002; 1: 71–4. 11 Kratzer L, Hodgins S. Adult outcomes of child conduct problems: a cohort study. J Abnorm Child Psychol 1997; 25: 65–81. 12 Cohen P, Brook J. Family factors related to the persistence of psychopathology in childhood and adolescence. Psychiatry 1987; 50: 332–45. 13 Bailey S, Marshall R. Perspectives on substance misuse in young offenders. In: Crome I, Ghodse H, Gilvarry E, McArdle P, eds. Young people and substance misuse. London: Gaskell, 2004. 14 Henggeler S. Multisystemic therapy: an overview of clinical procedures, outcomes, and policy implications. Child Psychol Psychiatry Rev 1999; 4: 2–10. 15 Dolan M, Millington J. Personality dysfunction and disorders in childhood and adolescence. In: Bailey S, Dolan M, eds. Adolescent forensic psychiatry. London: Arnold, 2004. 16 Forth AE, Kosson DS, Hare RD. Hare psychopathy checklist: youth version (PCL:YV), Toronto: Multi-Health Systems, 2004. 17 Vizard E, French L, Hickey N, Bladon E. Severe personality disorder emerging in childhood: a proposal for a new developmental disorder. Crim Behav Ment Health 2004; 14: 17–28. 18 Borum R, Bartel P, Forth A. Structured assessment of violence risk in youth, London: Pearson, 2006. 19 Print B, Griffin H, Beech AR, et al. AIM2: an initial assessment model for young people who display sexually hamful behaviour, Manchester: The AIM Project, 2007.
Treatment The Mental Health Act 1983 is applicable, with a few minor exceptions, to those affected by mental disorder at any age, although in practice it is unusual to ‘section’ someone under the age of 11 years, and most detained in-patients in adolescent units are aged 14 years and above. This will not change when the new legislation of amendments to the Act comes into force. Although many medications are licensed for use only in those over 18 years of age, the full range of pharmacological treatments including antipsychotic and mood-stabilizing agents are used in the forensic adolescent population. Where available, therapeutic interventions are used alongside pharmacological treatments, often in combinations of individual work with group and/or family therapy.
Conclusion The ultimate aim of adolescent forensic psychiatry is to minimize harm from mental illness and other inherent and environmental factors in order that future risk to the young patients themselves, and to their potential victims, is reduced. Practitioners need to work in the context of an understanding of child development and the systems that can promote and alleviate psychological disturbance, and be prepared to try to offer help wherever their patients are able to accept it. ◆
Further reading Bailey S, Dolan M, eds. Adolescent forensic psychiatry. London: Arnold, 2004. (Comprehensive textbook with useful reviews of mental illness and personality disorder in young people, and their relation to different kinds of offending behaviour.) Rutter M, Giller H, Hagell A. Antisocial behavior by young people. Cambridge: Cambridge University Press, 1998. (Thorough and readable review of the evidence base relating to antisocial and delinquent behaviour.)
References 1 McCann JB, James A, Wilson S, Dunn F. Prevalence of psychiatric disorders in young people in the care system. Br Med J 1996; 313: 529–30. 2 Harrington R, Bailey S. Mental health needs and effectiveness of provision for young offenders in custody and in the community, London: Youth Justice Board, 2005. 3 Department of Health. Promoting mental health for children hold in secure settings: a framework for commissioning service, London: Department of Health, 2007. 4 ASSETT. Youth Justice Board. http://www.yjb.gov.uk/Publications/ Resources/Downloads/AssetSum.pdf (accessed 29 July 2008). 5 Rutter M, Giller H, Hagell A. Antisocial behavior by young people, Cambridge: Cambridge University Press, 1998. 6 James A. Schizophrenia. In: Bailey S, Dolan M, eds. Adolescent forensic psychiatry. London: Arnold, 2004.
PSYCHIATRY 7:9
Useful websites For information on youth justice, see: http://www.homeoffice.gov.uk/justice/sentencing/youthjustice/ http://www.homeoffice.gov.uk/docs/youjust.html http://www.homeoffice.gov.uk/docs/yotcirc.html
398
© 2008 Published by Elsevier Ltd.
Adolescent forensic psychiatry
development of six medium secure in-patient units spread across England, operating within the National Health Service (NHS) and funded centrally by the National Commissioning Group (NCG). These units operate as part of a clinically managed network, taking referrals through a centralized system and admitting 12–17-year-old young people who have both displayed behaviour that creates serious risk for others and who are liable for detention under the Mental Health Act. This created an easier path to access to mental health services both for young people too difficult to manage in open adolescent units and for those detained in prison or appearing before the courts. Each unit has a multidisciplinary team, with clinicians from psychiatry, psychology, social work, occupational therapy, and nursing contributing to the care and management of the client group. All units also have specialized educational and occupational services so that the young people, who may be in hospital for a year or more, can continue to develop academic and work skills, and have at least part of their day that is as close as possible to that experienced by their peers in the community. All of the units provide assessment and treatment for those with serious and enduring mental illnesses such as schizophrenia and bipolar disorder. Some of the units, such as the Roycroft unit in Newcastle, also offer expertise in the management of emerging personality disorders, and further expansion is under way to provide services for those who also have learning difficulties.
Julie Withecomb
Abstract Adolescent forensic psychiatry merges understanding of the developmental trajectories of personality and behavioural traits with assessment of risk and treatment of mental disorder in young people who are offending or harming others. This article describes the various mental health services that have developed in England to provide help for these young people across health, social care, and criminal justice, including medium secure mental health services for adolescents. The different disorders and behaviours that commonly present to adolescent forensic services, including conduct disorder, psychopathy, and sexually harmful behaviour, are also reviewed. Risk assessment is described briefly, with reference to structured assessment tools that can be used with young people in the assessment of violence, psychopathy, and sexual offending.
Keywords adolescence; forensic; in-reach; medium secure; mental disorder; Mental Health Act; offending; personality disorder; risk; violence
‘Outreach’ and ‘inreach’ adolescent forensic services Not all young people in need of adolescent forensic services require admission and there is increasing provision of mental health services by teams that work from an NHS base into different kinds of non-NHS facility where young people are resident. Young people up to 18 years of age who are deemed to present a risk to themselves or others can be held for periods on Secure Accommodation Orders under the Children Act 1989 in local authority secure children’s homes (LASCHs), although those under 13 years require the permission of the Secretary of State. Those who have reached the age of 10 years (the age of criminal responsibility) and who have committed offences may be held on remand or serve custodial sentences in LASCHs, secure training centres (STCs) or young offender institutions (YOIs). There is a high prevalence of psychiatric morbidity in this group,1,2 with significant numbers – perhaps even the majority – displaying evidence of mental health problems, with substance misuse, conduct disorder, personality disorder and emotional disturbance being common. The kind of service that the young detainees can access is still highly variable across the country, with some institutions having access only to lone working mental health professionals, although an increasing number have full, highly specialist, multidisciplinary teams; those providing input to the Huntercombe YOI in Oxfordshire and Ashfield YOI in Bristol are regarded as examples of good practice.3
Adolescent forensic psychiatry is a relatively new field, but one with a growing number of practitioners from a range of professional backgrounds who provide services in many different kinds of setting from secure residential to the community, and from hospital to prison. It has roots in both child and forensic psychiatry, with a focus on the interplay between mental disorder, risk, and offending behaviour, and with assessment and management occurring in the context of the developmental and family background of the individual patient. This article will first describe the systems and settings within which adolescent forensic mental health is practised and then review current knowledge in the field.
The national adolescent medium secure network After it had been recognized that there was a population of young people who were best treated for their mental health problems in conditions of security, a process began that led to the eventual
Julie Withecomb MBBS MRCPsych is a Consultant Forensic Adolescent Psychiatrist who has worked with young people and their families in a range of residential and community settings including medium secure health and social service facilities, prisons, youth offending teams, and services for young people with substance misuse and sexual offending behaviours. She trained at Cambridge and at Guy’s and St Thomas’ Hospitals, London, UK. Her interests include stalking, and she has been widely involved in teaching and service development. Conflicts of interest: none.
PSYCHIATRY 7:9
Community forensic child and adolescent mental health services Young people under the care of child and adolescent mental health services (CAMHS) can present with risky and uncommon 395
© 2008 Published by Elsevier Ltd.
Approaches to treatment
symptoms or behaviours that cause clinicians concern, such as very severe self-harm, sexually harmful behaviours, and violent ruminations. For these young people, some CAMHS can now refer to community adolescent forensic teams (FCAMHS), whose members have particular expertise in risk assessment and management of the complex area of overlap between psychiatric and psychological symptoms and offending behaviour. For those whose behaviour has led them into formal contact with the criminal justice system, the Crime and Disorder Act 1998 set out a strategy for development of multi-agency youth offending teams (YOTs), and the Children’s National Service Framework (NSF), announced in 2001, set the aim of integrated services for those with complex needs. Through this legislation an expectation was created that health authorities, through CAMHS, would commit resources to young offenders with the aim of ensuring that the needs of those with complex problems would be met and consequently offending behaviour reduced. This work is sometimes helped and sometimes hindered by legislation such as Antisocial Behaviour Orders (ASBOs) and Parenting Orders, which make statutory requirements of young people and their families to attend programmes designed to change behaviour associated with offending. In practice, as with in-reach teams, provision is variable: some YOTs have only lone health workers who may not even have mental health training, whereas others have access to a full range of mental health professionals. The ASSET risk assessment tool developed by the Youth Justice Board, together with the Screening Interview for Adolescents (SIFA) and the Screening Questionnaire Interview for Adolescents (SQUIFA),4 have been developed to assist youth justice workers in the assessment of mental health problems and in signposting those most in need of help to the appropriate services.
Services that offending adolescents may encounter • Adolescent inpatient • Secure hospitals • Forensic CAMHS • Generalist CAMHS • Young offender institutions • Youth offending teams • Secure training centres • Specialist schools • Social service area teams • LASCHs • Voluntary sector • Adult mental health CAMHS, child and adolescent mental health services; LASCH, local authority secure children’s home
Table 1
adolescence is generally more difficult than in adulthood. It is recognized that a significant number of young people who initially appear to be developing conduct problems are later shown to have been developing schizophrenia with an insidious onset6 and there is now a well established literature setting out the association between conduct problems and schizophrenia.7 Symptoms suggestive of schizophrenia and bipolar disorder may co-occur, and the affected young person may also be using illicit drugs, the effects of which further complicate the presenting picture.
Conduct disorder, impulsivity, and delinquency The majority of offending, including persistent and serious offending, is not committed by those with serious mental disorders. The most commonly occurring psychiatric disorder in 5–15 year olds is conduct disorder (found in 5% of young people in Meltzer’s study8), defined by the presence of a ‘persistent pattern of behaviour in which the rights of other are violated’.9,10 Adolescent conduct problems have repeatedly been shown to predict later offending,11 with earlier onset and a wider range of antisocial behaviours increasing later risk. Conduct disorder has a significant co-morbidity, frequently occurring alongside hyperkinetic disorders and substance misuse, each of which also carries independent additional risks for offending.5,12 This group of disorders is often characterized by a particular pattern of distorted cognitions and affect that includes: • hostile attributions • a focus on aggressive cues • poor verbal problem-solving • labelling one’s own arousal as anger.13 Given this pattern, it is easy to see how those affected have high levels of offending, and this presentation is common in young people in contact with the criminal justice system and in those whom adolescent forensic psychiatrists are asked to assess. Conduct disorder is difficult to treat, often arising from a combination of inherent neurobiological deficits and early exposure to a chaotic, abusive and neglectful environment.
Pathways to care Although the different services that young people may encounter have been described separately above, any individual young person may move between these health services, as well as many others (Table 1), with decisions about where and how young people are looked after usually having little to do with need.
Gender differences Most young offenders are male, although the sex ratio is falling;5 it was approximately 6 : 1 In 2001, according to Home Office criminal statistics for 10–18 year olds. The full explanation for this has yet to be discovered, but certainly the conditions associated with offending, such as conduct disorder and hyperactivity, are more common in boys than in girls. Young women are referred less often to adolescent forensic psychiatry, and a significant proportion of those who are referred show repetitive self-harm rather than offending behaviour.
Serious mental illness As with adult forensic services, adolescent forensic psychiatry is concerned with the identification and treatment of conditions such as schizophrenia and bipolar disorder in those who have committed offences. However, diagnosis of these conditions in
PSYCHIATRY 7:9
396
© 2008 Published by Elsevier Ltd.
Approaches to treatment
ppropriate pharmacotherapy can alleviate symptoms, espeA cially when impulse control is a problem, and there is evidence that approaches such as multisystemic therapy may improve outcomes.14
groundbreaking services in Manchester and Newcastle. Although such services are developing independently of adolescent forensic services, substance misuse is a highly significant factor in adolescent offending, and YOTs have frequently chosen substance misuse workers as their health representatives.
Personality disorder and psychopathy Complexity in presentation
Certain personality traits, discernible in adolescence or even in childhood, are relatively stable and underlie a continuity between childhood and adult behavioural and social relationship problems. The traits of impulsivity and aggression associated with conduct disorder and delinquency, for example, are also associated with the development of antisocial personality disorder in adulthood, so that young people with conduct disorders are likely to continue to have contact with criminal justice and mental health services as they grow older. Dolan and Millington 15 have suggested that psychopathy is different from antisocial personality, and is characterized by additional deficits in empathy. Recently, scales have been developed to measure psychopathic traits in adolescents, for example the Psychopathy Checklist: Youth Version (PCL:YV).16 The predictive value of these scales is not yet clear, but it has been suggested that affected young people may be over-represented amongst those who commit serious violent and sexual offences. Apart from input into risk assessment and management, adolescent forensic psychiatry currently has little to offer to those with personality disorders, although it can be important to distinguish them from other conditions with similar presentations, such as autistic spectrum disorders.
In this article the different kinds of underlying problem have each been explored separately, but in practice it is common for young people presenting to adolescent forensic services to be adversely affected by multiple contributory factors (Table 2).
Assessment tools and risk Good risk assessment is now regarded as best grounded in clinical interpretation of material gathered and ordered by use of structured assessment tools. The Structured Assessment of Violence Risk in Youth (SAVRY)18 is a widely used tool focusing on a range of environmental and personal factors that have been shown to be associated with increased future risk of violence for those who have already committed a violent act. The Adolescent Intervention Model (AIM)19 is a structured approach for prediction of risk of sexual acting out and is helpfully organized in such a way as to describe potential strengths and weaknesses in the young person’s surrounding family and community, as well as considering aspects of the young person’s own behaviour and mental state that can contribute to higher risk. The PCL:YV, referred to above, is not strictly a risk assessment tool, but, as for those who register high scores with the adult version, it appears that adolescents with high PCL:YV scores may be at greater risk of re-offending and are more resistant to therapeutic input. Care does need to be taken, however, with the predictive capability of any of these approaches. These tools indicate only the overall risk for the group of those who posses a particular set of factors; any individual, even though they may closely fit the set of group-defining factors, may present a widely different risk from that of the group. In addition, risk assessment tools tend to put significant weight on historical and unchangeable (static) factors. This makes sense, given that the best predictors of future behaviours are past behaviours. However, especially for younger
Sexual offending Significant numbers of recorded sexual offences are committed by young people, and there is increasing recognition of the need for better understanding of this offender group and better services aimed at reducing their risk of re-offending. For many, committing a sexually harmful act is a single incident – perhaps the acting out of distress in the context of environmental pressure. In other cases, though, there is evidence that young men, and even young women, can already show patterns of entrenched distorted cognitions, including paedophilic sexual interest, that may be accompanied by evidence of developing personality disorder.17 Occasionally, such young people may suffer from diagnosable mental health problems, but it is far more likely that repeat and high-risk offenders show a pattern of learning difficulties and personality problems, and nearly all have at least been exposed to sexually inappropriate material themselves. There are woefully few services for such young people nationwide. A shortage of provision within YOIs means that the most serious offenders who receive custodial sentences have limited access to services. It is also difficult to identify services for special groups, such as young people with severe learning difficulties, and young women.
Underlying contributors in adolescent forensic patients • Trauma and abuse • Aggression • Substance misuse • Poor empathy and socialization • Mental illness • Learning and neurological problems • Inattention and impulsivity • Antisocial, delinquent, conduct disordered
Substance misuse Young people’s substance misuse services are now being developed in several parts of the country, following the lead of the
PSYCHIATRY 7:9
Table 2
397
© 2008 Published by Elsevier Ltd.
Approaches to treatment
people, there is hope of change, which may significantly reduce future risk but may not be reflected in formal risk assessment ‘scores’.
7 Dunedin Study. Institute of Psychiatry. Dunedin Multi-disciplinary Health and Development Study. http://www.iop.kcl.ac.uk/ departments/? locator=351 (accessed 29 July 2008). 8 Meltzer H, Gatward R, Goodman R, Ford T. The mental health of children and adolescents in Great Britain, London: ONS, 1999. 9 World Health Organization. The ICD-10 classification of mental and behavioural disorders: clinical descriptions and diagnostic guidelines, Geneva: World Health Oraganization, 1992. 10 Hill J. Conduct disorders. Psychiatry 2002; 1: 71–4. 11 Kratzer L, Hodgins S. Adult outcomes of child conduct problems: a cohort study. J Abnorm Child Psychol 1997; 25: 65–81. 12 Cohen P, Brook J. Family factors related to the persistence of psychopathology in childhood and adolescence. Psychiatry 1987; 50: 332–45. 13 Bailey S, Marshall R. Perspectives on substance misuse in young offenders. In: Crome I, Ghodse H, Gilvarry E, McArdle P, eds. Young people and substance misuse. London: Gaskell, 2004. 14 Henggeler S. Multisystemic therapy: an overview of clinical procedures, outcomes, and policy implications. Child Psychol Psychiatry Rev 1999; 4: 2–10. 15 Dolan M, Millington J. Personality dysfunction and disorders in childhood and adolescence. In: Bailey S, Dolan M, eds. Adolescent forensic psychiatry. London: Arnold, 2004. 16 Forth AE, Kosson DS, Hare RD. Hare psychopathy checklist: youth version (PCL:YV), Toronto: Multi-Health Systems, 2004. 17 Vizard E, French L, Hickey N, Bladon E. Severe personality disorder emerging in childhood: a proposal for a new developmental disorder. Crim Behav Ment Health 2004; 14: 17–28. 18 Borum R, Bartel P, Forth A. Structured assessment of violence risk in youth, London: Pearson, 2006. 19 Print B, Griffin H, Beech AR, et al. AIM2: an initial assessment model for young people who display sexually hamful behaviour, Manchester: The AIM Project, 2007.
Treatment The Mental Health Act 1983 is applicable, with a few minor exceptions, to those affected by mental disorder at any age, although in practice it is unusual to ‘section’ someone under the age of 11 years, and most detained in-patients in adolescent units are aged 14 years and above. This will not change when the new legislation of amendments to the Act comes into force. Although many medications are licensed for use only in those over 18 years of age, the full range of pharmacological treatments including antipsychotic and mood-stabilizing agents are used in the forensic adolescent population. Where available, therapeutic interventions are used alongside pharmacological treatments, often in combinations of individual work with group and/or family therapy.
Conclusion The ultimate aim of adolescent forensic psychiatry is to minimize harm from mental illness and other inherent and environmental factors in order that future risk to the young patients themselves, and to their potential victims, is reduced. Practitioners need to work in the context of an understanding of child development and the systems that can promote and alleviate psychological disturbance, and be prepared to try to offer help wherever their patients are able to accept it. ◆
Further reading Bailey S, Dolan M, eds. Adolescent forensic psychiatry. London: Arnold, 2004. (Comprehensive textbook with useful reviews of mental illness and personality disorder in young people, and their relation to different kinds of offending behaviour.) Rutter M, Giller H, Hagell A. Antisocial behavior by young people. Cambridge: Cambridge University Press, 1998. (Thorough and readable review of the evidence base relating to antisocial and delinquent behaviour.)
References 1 McCann JB, James A, Wilson S, Dunn F. Prevalence of psychiatric disorders in young people in the care system. Br Med J 1996; 313: 529–30. 2 Harrington R, Bailey S. Mental health needs and effectiveness of provision for young offenders in custody and in the community, London: Youth Justice Board, 2005. 3 Department of Health. Promoting mental health for children hold in secure settings: a framework for commissioning service, London: Department of Health, 2007. 4 ASSETT. Youth Justice Board. http://www.yjb.gov.uk/Publications/ Resources/Downloads/AssetSum.pdf (accessed 29 July 2008). 5 Rutter M, Giller H, Hagell A. Antisocial behavior by young people, Cambridge: Cambridge University Press, 1998. 6 James A. Schizophrenia. In: Bailey S, Dolan M, eds. Adolescent forensic psychiatry. London: Arnold, 2004.
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Useful websites For information on youth justice, see: http://www.homeoffice.gov.uk/justice/sentencing/youthjustice/ http://www.homeoffice.gov.uk/docs/youjust.html http://www.homeoffice.gov.uk/docs/yotcirc.html
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