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Mental Health Problems and Service Use Among Female Juvenile Offenders: Their Relationship to Criminal History
Mental Health Problems and Service Use Among Female Juvenile Offenders: Their Relationship to Criminal History SHERYL H. KATAOKA, M.D., BONNIE T. ZIMA, M.D., M.P.H., DEIRDRE A. DUPRE, M.D., KATHLEEN A. MORENO, M.D., XIAOWEI YANG, PH.D., AND JAMES T. MCCRACKEN, M.D.
ABSTRACT Objective: To describe (1) the level of mental health problems and lifetime use of specialty mental health services and special education programs among incarcerated female juvenile offenders and (2) how these indices relate to their criminal history. Method: Between 1997 and 1998, fifty-four female youths incarcerated in California were interviewed on-site using standardized self-report measures of depression and anxiety symptoms and substance use problems. Results: Eighty percent of the youths had symptoms of an emotional disorder or substance use problem, and almost two thirds (63%) had a history of recidivism. Of those with emotional symptoms or a substance use problem, 51% had used specialty mental health services and 58% had been in a special education program during their lifetime. In addition, among recidivistic youths, 82% had a history of a substance use problem and 47% had used specialty mental health services during their lifetime. Conclusions: A substantial proportion of female juvenile offenders merit a mental health evaluation. Interventions for these high-risk youths should include an assessment for substance use disorders because of the association of recidivism and substance use problems in this population. J. Am. Acad. Child Adolesc. Psychiatry, 2001, 40(5):549–555. Key Words: mental health, substance use, recidivism, juvenile delinquent, female.
Amidst rising concerns about the level of untreated mental health problems among youths in the juvenile justice system (American Medical Association, 1990), little is known about the clinical profile of detained females, their use of specialty mental health services, and the relationship of these factors with their criminal history. Such information is necessary to guide the development of mental health interventions that take into account gender and legal history differences, such as Accepted December 19, 2000. Drs. Kataoka, Zima, and McCracken are with the Department of Psychiatry and Dr. Yang is with the Department of Biostatistics, University of California, Los Angeles; Dr. Dupre is with Ravenswood Community Mental Health Center, Chicago; and Dr. Moreno is with St. John’s Child and Family Development Center, Los Angeles. This study was supported by the Robert Wood Johnson Clinical Scholars Program, the American Academy of Child and Adolescent Psychiatry/Eli Lilly Pilot Research Award, and the APA PMRTP Program. The authors thank the probation department staff and Brett Johnson, Michelle Parra, Madeline Zwart, Stacey Dutkieweicz, Jessica Oifer, and Florence Sterni. Reprint requests to Dr. Kataoka, RWJ Clinical Scholars Program, UCLA, B-537 Factor Bldg., Box 951736, Los Angeles, CA 90095-1736. 0890-8567/01/4005-0549䉷2001 by the American Academy of Child and Adolescent Psychiatry.
recidivism and violent offenses, for this rapidly growing population (Snyder and Sickmund, 1999). Compared with males, the number of female youths entering the juvenile justice system, particularly for violent offenses, has increased disproportionately during the past two decades. The female arrest rate for violent crimes has risen 103% since 1981, representing an almost four-fold higher rate of increase compared with males. Furthermore, the need to design mental health interventions that are tailored to the potentially unique needs of female detained youths is underscored by the findings that these female youths often have substantial neuropsychological and social impairments in adulthood (Lewis et al., 1991). Earlier studies based on predominantly male samples suggest that juvenile offenders have significant mental health concerns warranting attention. The relationship between substance use and juvenile delinquency has been well established (Dembo et al., 1991; Farrow and French, 1986; Huizinga and Jakob-Chien, 1998; Johnson et al., 1991; Van Kammen et al., 1991). Compared with youths without a drug or alcohol problem,
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those with a history of substance abuse are significantly more likely to have histories of serious delinquency (Dembo et al., 1991; Van Kammen et al., 1991). In the National Youth Survey, substance-using delinquents comprised 30% of the sample but were responsible for committing 85% of the delinquencies (Johnson et al., 1991). Juvenile offenders with substance abuse problems also have significant comorbid disorders, such as attention deficit disorder and conduct disorder, compared with non–substance abusers (Milin et al., 1991). In addition to these problems, internalizing disorders may be of particular importance for female detained youths because depression (Kashani et al., 1987) and anxiety disorders (Werry, 1991) are clinically more common in female adolescents. In incarcerated samples of both males and females, 15% to 42% of detained youths were found to have major affective disorders, such as bipolar disorder and depression (McManus et al., 1984; Pliszka et al., 2000). In one of the few studies that examined gender differences in psychopathology in this population, Cauffman and colleagues (1998) found that female incarcerated offenders were twice as likely to have posttraumatic stress disorder as their male counterparts. Yet despite the potentially high level of mental health problems among detained youths, access to specialty mental health services is poor (Bilchik, 1998) and may be influenced by differences in case mix among youths entering the juvenile justice system. In a detained adolescent population, only 22% of youths who were given a substance abuse treatment referral reported receiving any such treatment during a 15-month follow-up period (Dembo et al., 1991). Earlier studies attributed poor access to the lack of on-site screening procedures and mental health services in many juvenile detention facilities (Anno, 1984; Barton, 1976). In addition, gender differences, but not disorder severity, have been found to be predictive of mental health service use in this population (Shanok and Lewis, 1977; Westendorp et al., 1986). Compared with males, female delinquent youths have higher mental health referral rates (Barnum et al., 1989; Dembo et al., 1993; Vander Stoep et al., 1997) and are more likely to have received psychiatric treatment prior to being incarcerated (Lewis et al., 1982; Thomas and Stubbe, 1996). In addition to gender differences, mental health service use may vary by a youth’s criminal history, but these relationships are less clear. Wierson and Forehand (1995) found that nonrecidivist youths were more likely to have a substance abuse disorder compared with those who
were rearrested within 21 months after their release from detention. Others have found that drug offenses, but not substance abuse, predict recidivism in male offenders (Dembo et al., 1995). This is in contrast to yet other studies that report an association between substance abuse and recidivism (Duncan et al., 1995; Niarhos and Routh, 1992). Furthermore, criminal history may differentiate those youths who receive and not receive a mental health referral. Youths who were first arrested at a younger age received significantly more mental health referrals than those without this history (Barnum et al., 1989). Being a repeat offender or having a history of more serious crimes also is related to a youth’s greater likelihood of being referred for mental health treatment (Sorensen, 1978; Vander Stoep et al., 1997). To build on these earlier findings, the objectives of this study are to describe the level of mental health problems and lifetime service use among incarcerated female juvenile offenders and to explore how these factors relate to their criminal history. We anticipate that emotional disorder symptoms and substance use problems will be prominent among these incarcerated female adolescents and that many will have had prior contact with specialty mental health services or special education programs. Also, we hypothesize that female detained youths with more extensive criminal histories will be more likely to have received mental health services.
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METHOD Subjects From December 1997 to July 1998, fifty-four incarcerated female offenders were interviewed at a secured juvenile probation camp in Los Angeles County. On average, this all-female facility housed 110 females daily during this 8-month period. Youths were eligible for the study if they were between the ages of 14 and 18 years and were available to participate at the time of the interview (i.e., not working off campus or being disciplined). Approximately five youths were excluded because of age or availability. Of the 61 eligible adolescents who were approached, 89% agreed to participate. Participants and nonparticipants did not vary by sociodemographic characteristics. Procedures Recruitment and on-site youth interviews were conducted following informed consent procedures approved by the UCLA Human Subjects Protection Committee and the Los Angeles County Probation Department. When youths were initially approached, they were given a verbal explanation of the study by one of the research staff. A ballot box methodology was used for those youths who were interested in learning more about participating in the study. The interested youths deposited an “interest card” with their name printed on the card in a “ballot box,” to minimize coercion of any noninterested youths. Research staff then met with the interested youths individually to further describe the study. During this discussion, the vol-
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untary nature of participation was emphasized. The youths were informed that the specific information collected would not be shared with the facility staff and that their participation would not have an impact on their length of stay at the facility. Written assent was obtained from each youth prior to her participation. Interviews were conducted in a private room with one of three trained interviewers who read the self-report questionnaires aloud to the adolescent. The survey included inquiries about the youth’s sociodemographic characteristics, criminal history, and lifetime mental health services and special education program use, as well as standardized screening measures of substance use, depressive symptoms, and anxiety. Participants received small gifts valued at $5.00 for completing the interview. The interviewers had a minimum of 4 years of college education and received 2 full days of training in general survey administration and use of mental health measures. Upon completion, surveys were proofread by a child and adolescent psychiatrist (S.H.K.) for completeness prior to data entry. The same child and adolescent psychiatrist supervised the interviewers during weekly group meetings. Measures Substance use was measured with the Drug Consumption Questionnaire, a 44-item self-report questionnaire that has been used in delinquent populations to evaluate both level of and problems due to substance use (Loeber et al., 1998). Each subject was asked about her use of specific substances. For each major category of substance use (alcohol, tobacco, marijuana, and other drugs), 10 problems related to substance use were asked, such as the following: have you “gotten into physical fights because of your use,” “had any accidents because of the use,” and “done anything illegal in order to get [the substance].” The youth was classified as having a substance use problem if she attributed at least one serious problem involving family, peers, school, community, or health to substance use during her lifetime. The level of depressive symptoms was assessed by the Children’s Depression Inventory (CDI) (Kovacs, 1992), a 27-item self-report measure. For each item, the subject chose one statement out of three that best described her feelings over the previous 2 weeks. The symptoms were scored from 0 to 2, with the higher number corresponding to increased severity of symptom. Youths who had a total T score greater than 60 were identified as screening positive for depressive symptoms, which has been found to correspond to clinically significant depressive symptoms in children and adolescents. In community and clinical populations, the reliability and validity of the CDI is well established (Kovacs, 1992), and significant age, gender, and race effects on validity have not been found (Doerfler et al., 1988). The presence of anxiety symptoms was determined by using the Revised Children’s Manifest Anxiety Scale (RCMAS), a 37-item selfreport instrument (Reynolds and Richmond, 1985). Subjects were asked to answer yes or no to statements about anxiety symptoms that had occurred during the previous 2 weeks. A total T score greater than 60 corresponded to clinically significant anxiety. The reliability (α = .62–.87) of the RCMAS among female adolescents from white and African-American backgrounds is very good (Reynolds and Richmond, 1985). Although the validity (r = 0.90–0.99) has been reported as excellent (Reynolds and Richmond, 1985), others have found that the RCMAS may not discriminate well between those with symptoms of anxiety disorders and attention-deficit hyperactivity disorder (Perrin and Last, 1992). The psychometric properties of the screening measures used in this study also have not been established for detained female juvenile offenders.
RESULTS Sample Characteristics and Level of Mental Health Problems
Sociodemographic characteristics, criminal history, mental health problems, and lifetime service use among detained female offenders are summarized in Table 1. The youths’ mean age was 16.1 years (SD = 1.2), and the majority (n = 51; 94%) were from minority backgrounds. On average, youths had been at the facility for 6.4 months (SD = 3.8) at the time of the interview. Almost 60% of the youths were violent offenders whose index offenses
TABLE 1 Characteristics of Incarcerated Female Juvenile Offenders (N = 54) Mean (SD) Age (yr) Race White African American Asian Latino Mixed Criminal history Age at first offense (yr) Length of offense history (yr) Incarcerated for violent offense a Previous camp detention Emotional symptoms Depressionb Anxiety c Any Substance use problem d Tobacco Alcohol Marijuana Other drugs e Any With comorbid emotional symptoms Lifetime service use Specialty mental health Special education
% (n)
16.1 (1.2) 6 48 2 37 7
(3) (26) (1) (20) (4)
13.8 (1.8) 2.3 (1.9) 59 (32) 63 (34) 28 (15) 28 (15) 37 (20) 38 52 52 37 71 29
(20) (27) (27) (20) (37) (15)
46 (25) 30 (16)
Analysis Bivariate analyses were conducted with the χ2 test of proportions for discrete variables and analysis of variance for continuous variables.
Note: Missing cases: tobacco = 1, alcohol = 2, marijuana = 2, any substance use problem = 2, any emotional disorder and substance use problem with comorbid emotional symptoms = 2, special education = 7. a Violent offenses include assault, robbery, kidnapping, and accessory to murder. b Clinically significant depressive symptoms defined as Children’s Depression Inventory T score >60. c Clinically significant anxiety symptoms defined as Revised Children’s Manifest Anxiety Scale total T score >60. d Substance use problem defined as lifetime substance use with at least one problem attributed to substance use. e Other drugs include amphetamines, cocaine, hallucinogens, inhalants, tranquilizers, codeine, barbiturates, and heroin.
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were assault, robbery, kidnapping, or accessory to murder. An additional 35% of the youths (n = 19) were incarcerated for other serious offenses, such as theft, car-jacking, drug-related crimes, and weapons violations. Overall, 80% of the youths (n = 43) had symptoms of an emotional disorder or substance use problem. The mean T scores on the CDI and RCMAS were 53.0 (SD = 13.0) and 52.6 (SD = 11.0), respectively. Comorbidity of mental health problems was common. Two thirds of the youths (10/15; 67%) who screened positive for depression reported anxiety symptoms in the clinical range. Compared with nondepressed youths, those with depressive symptoms were significantly more likely to report clinical anxiety (χ2 = 15.66, p < .001). In addition, 79% of the youths (15/19) with clinical symptoms of depression or anxiety had a substance use problem, and of the 71% of female detainees with a substance use problem, 41% (15/37) had symptoms of an emotional disorder. The most common substances used, for which problems were attributed, were alcohol and marijuana. The other drugs used by these adolescents were amphetamines (n = 21; 39%), cocaine (n = 18; 33%), hallucinogens (n = 15; 28%), inhalants (n = 12; 22%), tranquilizers (n = 8; 15%), codeine (n = 8; 15%), barbiturates (n = 6; 11%), and heroin (n = 2; 4%). Problems attributed to substance use stratified by drug type are described in Table 2. More than one half of the youths (n = 28/50; 56%) had three or more problems attributed
to their substance use, and 40% (n = 20/50) of the youths reported five or more problems associated with substance use. Legal problems, such as engaging in illegal activities to obtain the substance, were the most common type of problem attributed to substance use. Relationship Between Mental Health Problems and Service Use
More than one half of the detained female offenders (n = 31; 57%) had used specialty mental health or special education services during their lifetime. Of those youths with emotional disorder symptoms or a substance use problem, 51% (22/43) had a lifetime history of specialty mental health service use. Specifically, 55% of youths (n = 11/20) with emotional disorder symptoms and 51% (n = 19/37) with a substance use problem had at least one contact with specialty mental health services during their lifetime. Likewise, 58% of youths (21/36) with a mental health problem had a lifetime history of being enrolled in a special education program, such that 47% of those (8/17) with an emotional disorder and 47% (14/30) with a substance use problem had used such services. Emotional disorder symptoms were associated with lifetime use of either mental health or special education services (χ2 = 4.021, p = .045). However, when evaluated separately, neither use of past specialty mental health nor use of special education services was related to symptoms of depression, anxiety, or a substance use problem.
TABLE 2 Problems Attributed to Substance Use Among Incarcerated Female Juvenile Offenders Lifetime Substance Use: % (n) Problems Relational Trouble with friends Trouble with family Trouble at school Trouble with others in the community Any Health Physical Mental Accidents Any Legal Trouble with the police Physical fights Illegal activity Any
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Alcohol (n = 49)
Tobacco (n = 42)
29 12 14 18 41
12 14 7 7 24
(14) (6) (7) (9) (20)
Marijuana (n = 47)
Other (n = 28)
Any (n = 50)
(5) (6) (3) (3) (10)
26 23 30 19 40
(12) (11) (14) (9) (19)
39 43 18 21 57
(11) (12) (5) (6) (16)
44 34 36 28 60
(22) (17) (18) (14) (30)
14 (7) 12 (6) 8 (4) 24 (12)
12 (5) 0 2 (1) 14 (6)
13 15 6 26
(6) (7) (3) (12)
29 25 7 43
(8) (7) (2) (12)
30 26 8 44
(15) (13) (4) (22)
14 31 35 45
0 5 (2) 29 (12) 29 (12)
23 19 23 40
(11) (9) (11) (19)
39 39 36 61
(11) (11) (10) (17)
42 40 50 66
(21) (20) (25) (33)
(7) (15) (17) (22)
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Relationship Between Mental Health Problems and Service Use With Criminal History
Table 3 compares the level of mental health problems and service use between recidivist and nonrecidivist youths. The majority of youths (n = 30/43; 70%) with either emotional disorder symptoms or lifetime substance use problems had a history of prior incarceration at the probation camp. More than one half of youths who had received specialty mental health services or special education during their lifetime also had a history of recidivism. Recidivist females were more likely to have a substance use problem (χ2 = 5.0, p = .025), particularly with alcohol (χ2 = 7.9, p = .005), than females without a prior history of incarceration. The level of emotional disorder symptoms, substance use problems, and service use did not vary by ethnicity or other criminal history variables. DISCUSSION
Findings from this study suggest that a substantial proportion of incarcerated female youths (80%) merited a mental health evaluation for an emotional disorder or substance use problem. Compared with female adolescents in the general population (Offord et al., 1987), female juvenile offenders in this study were three times more likely to have clinical symptoms of depression or anxiety. In addiTABLE 3 Mental Health Problems and Lifetime Service Use Among Recidivist and Nonrecidivist Female Youths (n = 54) Recidivisma: % (n) Yes (n = 34) Emotional symptoms Depression Anxiety Any Substance use problem Alcohol Tobacco Marijuana Other drugs Any With comorbid emotional symptoms Lifetime service use Specialty mental health Special education
No (n = 20)
26 (9) 29 (10) 38 (13)
30 (6) 25 (5) 35 (7)
67 45 61 41 82 30
26 25 37 30 53 26
(22)** (15) (20) (14) (27)* (10)
47 (16) 59 (16)
(5) (5) (7) (6) (10) (5)
45 (9) 75 (15)
a Recidivism refers to a history of prior incarceration at the secured juvenile probation camp. * p < .05; ** p < .01.
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tion, the level of depressive symptoms among detained female youths studied was comparable with that found in other female incarcerated youth populations (McManus et al., 1984) but lower than that recently reported among a predominantly male detained youth sample (Pliszka et al., 2000). Unfortunately, because of the methodological differences between these studies, gender differences in depressive symptoms cannot be tested. Furthermore, substance use among the female youths studied was greater than that reported among the general adolescent population (Johnston et al., 2000), and the problems attributed to substance use were more severe. For example, among the general adolescent population, lack of involvement in school and sports activities were problems related to substance use (Zoccolillo et al., 1999). As hypothesized, lifetime contact with specialty mental health services or special education programs was relatively common among incarcerated female youths and related to having at least one mental health problem. Such findings thus suggest that prior service use in either of these care sectors may serve as an indication that a mental health evaluation is needed. The disproportionate contact with special education also is consistent with earlier observations that contact with care sectors outside specialty mental health in community-based samples is common among youths with mental health problems (Burns et al., 1995). Furthermore, the finding that the presence of a substance use problem was not related to prior specialty mental health service use merits further study. A temporal relationship between indicators of need for a mental health evaluation and service use cannot be assessed because of this study’s design. Nevertheless, these preliminary findings raise questions about underdetection of substance abuse and barriers to care for this population. For example, medical necessity criteria for publicly funded specialty mental health services in California do not include the diagnosis of solely substance abuse, potentially limiting access. In addition to clinical need, these findings also suggest that criminal history may be important characteristics that should be taken into account when assessing detained female youths. Of note, we found that a history of prior incarceration was associated with substance use problems, which is consistent with earlier findings in male juvenile delinquent populations (Duncan et al., 1995; Niarhos and Routh, 1992). Although the direction of this relationship cannot be established from this study’s cross-sectional design, these findings suggest that interventions for this 553
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population should include screening for substance use disorders, particularly given the association of worse criminal history and substance use problems.
cient number of female youths to explore gender differences in policy-relevant outcomes such as recidivism. REFERENCES
Limitations
Nevertheless, these preliminary findings suggest that detained female juvenile offenders represent a growing population of high-risk youths who merit a mental health and substance abuse evaluation. Future research with this population should use larger, representative samples as well as standardized measures of diagnoses and impairment to determine more accurately the need for mental health services. The relationship between criminal history indices and substance use problems also needs to be more fully understood. Such information can then be used to guide the delivery of mental health services for female juvenile offenders. Furthermore, future studies examining the effectiveness of mental health interventions for detained youths should include a suffi-
American Medical Association, Council on Scientific Affairs (1990), Health status of detained and incarcerated youths. JAMA 263:987–991 Anno B (1984), The availability of health services for juvenile offenders: preliminary results of a national survey. J Prison Jail Health 4:77–90 Barnum R, Famularo R, Bunshaft D, Fenton T, Bolduc S (1989), Clinical evaluation of juvenile delinquents: who gets court referred? Bull Am Acad Psychiatry Law 17:335–344 Barton W (1976), Discretionary decision-making in juvenile justice. Crime Delinquency 22:470–480 Bilchik S (1998), Mental Health Disorders and Substance Abuse Problems Among Juveniles. OJJDP Fact Sheet. Washington, DC: US Department of Justice Burns BJ, Costello EJ, Angold A et al. (1995), Children’s mental health service use across service sectors. Health Aff 14:147–159 Cauffman E, Feldman SS, Waterman J, Steiner H (1998), Posttraumatic stress disorder among female juvenile offenders. J Am Acad Child Adolesc Psychiatry 37:1209–1216 Dembo R, Turner G, Sue CC, Schmeidler J, Border P, Manning D (1995), Predictors of recidivism to a juvenile assessment center. Int J Addict 30:1425–1452 Dembo R, Williams L, Getreu A et al. (1991), A longitudinal study of the relationships among marijuana/hashish use, cocaine use, and delinquency in a cohort of high risk youths. J Drug Issues 21:271–312 Dembo R, Williams L, Schmeidler J (1993), Gender differences in mental health service needs among youths entering a juvenile detention center. J Prison Jail Health 12:73–101 Doerfler LA, Felner RD, Rowlison RT, Raley PA, Evans E (1988), Depression in children and adolescents: a comparative analysis of the utility and construct validity of two assessment measures. J Consult Clin Psychol 56:769–772 Duncan RD, Kennedy WA, Patrick CJ (1995), Four-factor model of recidivism in male juvenile offenders. J Clin Child Psychol 24:250–257 Farrow JA, French J (1986), The drug abuse–delinquency connection revisited. Adolescence 21:952–960 Huizinga D, Jakob-Chien C (1998), The contemporaneous co-occurrence of serious and violent juvenile offending and other problem behaviors. In: Serious and Violent Juvenile Offenders, Loeber R, Farrington DP, eds. Thousand Oaks, CA: Sage, pp 47–67 Johnson BD, Wish ED, Schmeidler J, Huizinga D (1991), Concentration of delinquent offending: serious drug involvement and high delinquency rates. J Drug Issues 21:205–229 Johnston LD, O’Malley PM, Bachman JG (2000), The Monitoring the Future National Survey Results on Adolescent Drug Use: Overview of Key Findings, 1999 (NIH Publication 00-4690). Rockville, MD: National Institute on Drug Abuse Kashani JH, Carlson GA, Beck NC et al. (1987), Depression, depressive symptoms, and depressed mood among a community sample of adolescents. Am J Psychiatry 144:931–934 Kovacs M (1992), Children’s Depression Inventory. New York: Multi-Health Systems Lewis DO, Shanok SS, Pincus JH (1982), A comparison of the neuropsychiatric status of female and male incarcerated delinquents: some evidence of sex and race bias. J Am Acad Child Psychiatry 21:190–196 Lewis DO, Yeager CA, Cobham-Portorreal CS, Klein N, Showalter C, Anthony A (1991), A follow-up of female delinquents: maternal contributions to the perpetuation of deviance. J Am Acad Child Adolesc Psychiatry 30:197–201 Loeber R, Farrington DP, Stouthamer-Loeber M, Van Kammen WB (1998), Antisocial Behavior and Mental Health Problems: Explanatory Factors in Childhood and Adolescence. Mahwah, NH: Erlbaum McManus M, Alessi NE, Grapentine WL, Brickman A (1984), Psychiatric disturbance in serious delinquents. J Am Acad Child Psychiatry 23:602–615 Milin R, Halikas JA, Meller JE, Morse C (1991), Psychopathology among substance abusing juvenile offenders. J Am Acad Child Adolesc Psychiatry 30:569–574
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This study has several limitations. The level of mental health problems and service use is based on a convenience sample using screening measures, and therefore these findings should not be interpreted as estimates of the prevalence of psychiatric disorders or level of unmet need for mental health services. Because of the study’s cross-sectional design, the temporal relationship between the onset of emotional symptoms and substance use problems also cannot be evaluated. Symptoms of depression or anxiety can occur during drug withdrawal. However, it is unlikely that the symptoms described in this study were solely a result of drug withdrawal because the average length of stay at the secured probation camp was approximately 6 months at the time that the interview was conducted. Also, whether or not the symptoms developed during the incarceration could not be determined from this study. Data were restricted to detained female youths in one facility, limiting the generalizability of these findings to youths in other juvenile justice settings or to male juvenile offenders. Furthermore, the sample consisted predominantly of minority youths, which may call into question the generalizability of this sample to other female offenders. However, it has been well documented that minorities are overrepresented in the juvenile justice population. In one report, 7 in 10 youths held in custody for a violent offense were from minority backgrounds (Snyder and Sickmund, 1999). Clinical Implications
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Niarhos FJ, Routh DK (1992), The role of clinical assessment in the juvenile court: predictors of juvenile dispositions and recidivism. J Clin Child Psychol 21:151–159 Offord DR, Boyle MH, Szatmari P et al. (1987), Ontario Child Health Study, II: six-month prevalence of disorder and rates of service utilization. Arch Gen Psychiatry 44:832–836 Perrin S, Last CG (1992), Do childhood anxiety measures measure anxiety? J Abnorm Child Psychol 20:567–578 Pliszka SR, Sherman JO, Barrow MV, Irick S (2000), Affective disorder in juvenile offenders: a preliminary study. Am J Psychiatry 157:130–132 Reynolds CR, Richmond BO (1985), Revised Children’s Manifest Anxiety Scale (RCMAS) Manual. Los Angeles: Western Psychological Services Shanok SS, Lewis DO (1977), Juvenile court versus child guidance referral: psychosocial and parental factors. Am J Psychiatry 134:1130–1133 Snyder HN, Sickmund M (1999), Juvenile offenders and victims: 1999 national report. Washington, DC: Office of Juvenile Justice and Delinquency Prevention Sorensen J (1978), Outcome evaluation of a referral system for juvenile offenders. Am J Community Psychol 6:381–388
Thomas WJ, Stubbe DE (1996), A comparison of correctional and mental health referrals in the juvenile court. J Psychiatry Law 24:379–400 Van Kammen WB, Loeber R, Stouthamer-Loeber M (1991), Substance use and its relationship to conduct problems and delinquency in young boys. J Youth Adolesc 20:399–413 Vander Stoep A, Evens CC, Taub J (1997), Risk of juvenile justice systems referral among children in a public mental health system. J Ment Health Adm 24:428–442 Werry JS (1991), Overanxious disorder: a review of its taxonomic properties. J Am Acad Child Adolesc Psychiatry 30:533–544 Westendorp F, Brink K, Roberson M, Ortiz I (1986), Variables which differentiate placement of adolescents into juvenile justice or mental health systems. Adolescence 21:23–37 Wierson M, Forehand R (1995), Predicting recidivism in juvenile delinquents: the role of mental health diagnoses and the qualification of conclusions by race. Behav Res Ther 33:63–67 Zoccolillo M, Vitaro F, Tremblay RE (1999), Problem drug and alcohol use in a community sample of adolescents. J Am Acad Child Adolesc Psychiatry 38:900–907
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ABSTRACT Objective: To describe (1) the level of mental health problems and lifetime use of specialty mental health services and special education programs among incarcerated female juvenile offenders and (2) how these indices relate to their criminal history. Method: Between 1997 and 1998, fifty-four female youths incarcerated in California were interviewed on-site using standardized self-report measures of depression and anxiety symptoms and substance use problems. Results: Eighty percent of the youths had symptoms of an emotional disorder or substance use problem, and almost two thirds (63%) had a history of recidivism. Of those with emotional symptoms or a substance use problem, 51% had used specialty mental health services and 58% had been in a special education program during their lifetime. In addition, among recidivistic youths, 82% had a history of a substance use problem and 47% had used specialty mental health services during their lifetime. Conclusions: A substantial proportion of female juvenile offenders merit a mental health evaluation. Interventions for these high-risk youths should include an assessment for substance use disorders because of the association of recidivism and substance use problems in this population. J. Am. Acad. Child Adolesc. Psychiatry, 2001, 40(5):549–555. Key Words: mental health, substance use, recidivism, juvenile delinquent, female.
Amidst rising concerns about the level of untreated mental health problems among youths in the juvenile justice system (American Medical Association, 1990), little is known about the clinical profile of detained females, their use of specialty mental health services, and the relationship of these factors with their criminal history. Such information is necessary to guide the development of mental health interventions that take into account gender and legal history differences, such as Accepted December 19, 2000. Drs. Kataoka, Zima, and McCracken are with the Department of Psychiatry and Dr. Yang is with the Department of Biostatistics, University of California, Los Angeles; Dr. Dupre is with Ravenswood Community Mental Health Center, Chicago; and Dr. Moreno is with St. John’s Child and Family Development Center, Los Angeles. This study was supported by the Robert Wood Johnson Clinical Scholars Program, the American Academy of Child and Adolescent Psychiatry/Eli Lilly Pilot Research Award, and the APA PMRTP Program. The authors thank the probation department staff and Brett Johnson, Michelle Parra, Madeline Zwart, Stacey Dutkieweicz, Jessica Oifer, and Florence Sterni. Reprint requests to Dr. Kataoka, RWJ Clinical Scholars Program, UCLA, B-537 Factor Bldg., Box 951736, Los Angeles, CA 90095-1736. 0890-8567/01/4005-0549䉷2001 by the American Academy of Child and Adolescent Psychiatry.
recidivism and violent offenses, for this rapidly growing population (Snyder and Sickmund, 1999). Compared with males, the number of female youths entering the juvenile justice system, particularly for violent offenses, has increased disproportionately during the past two decades. The female arrest rate for violent crimes has risen 103% since 1981, representing an almost four-fold higher rate of increase compared with males. Furthermore, the need to design mental health interventions that are tailored to the potentially unique needs of female detained youths is underscored by the findings that these female youths often have substantial neuropsychological and social impairments in adulthood (Lewis et al., 1991). Earlier studies based on predominantly male samples suggest that juvenile offenders have significant mental health concerns warranting attention. The relationship between substance use and juvenile delinquency has been well established (Dembo et al., 1991; Farrow and French, 1986; Huizinga and Jakob-Chien, 1998; Johnson et al., 1991; Van Kammen et al., 1991). Compared with youths without a drug or alcohol problem,
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those with a history of substance abuse are significantly more likely to have histories of serious delinquency (Dembo et al., 1991; Van Kammen et al., 1991). In the National Youth Survey, substance-using delinquents comprised 30% of the sample but were responsible for committing 85% of the delinquencies (Johnson et al., 1991). Juvenile offenders with substance abuse problems also have significant comorbid disorders, such as attention deficit disorder and conduct disorder, compared with non–substance abusers (Milin et al., 1991). In addition to these problems, internalizing disorders may be of particular importance for female detained youths because depression (Kashani et al., 1987) and anxiety disorders (Werry, 1991) are clinically more common in female adolescents. In incarcerated samples of both males and females, 15% to 42% of detained youths were found to have major affective disorders, such as bipolar disorder and depression (McManus et al., 1984; Pliszka et al., 2000). In one of the few studies that examined gender differences in psychopathology in this population, Cauffman and colleagues (1998) found that female incarcerated offenders were twice as likely to have posttraumatic stress disorder as their male counterparts. Yet despite the potentially high level of mental health problems among detained youths, access to specialty mental health services is poor (Bilchik, 1998) and may be influenced by differences in case mix among youths entering the juvenile justice system. In a detained adolescent population, only 22% of youths who were given a substance abuse treatment referral reported receiving any such treatment during a 15-month follow-up period (Dembo et al., 1991). Earlier studies attributed poor access to the lack of on-site screening procedures and mental health services in many juvenile detention facilities (Anno, 1984; Barton, 1976). In addition, gender differences, but not disorder severity, have been found to be predictive of mental health service use in this population (Shanok and Lewis, 1977; Westendorp et al., 1986). Compared with males, female delinquent youths have higher mental health referral rates (Barnum et al., 1989; Dembo et al., 1993; Vander Stoep et al., 1997) and are more likely to have received psychiatric treatment prior to being incarcerated (Lewis et al., 1982; Thomas and Stubbe, 1996). In addition to gender differences, mental health service use may vary by a youth’s criminal history, but these relationships are less clear. Wierson and Forehand (1995) found that nonrecidivist youths were more likely to have a substance abuse disorder compared with those who
were rearrested within 21 months after their release from detention. Others have found that drug offenses, but not substance abuse, predict recidivism in male offenders (Dembo et al., 1995). This is in contrast to yet other studies that report an association between substance abuse and recidivism (Duncan et al., 1995; Niarhos and Routh, 1992). Furthermore, criminal history may differentiate those youths who receive and not receive a mental health referral. Youths who were first arrested at a younger age received significantly more mental health referrals than those without this history (Barnum et al., 1989). Being a repeat offender or having a history of more serious crimes also is related to a youth’s greater likelihood of being referred for mental health treatment (Sorensen, 1978; Vander Stoep et al., 1997). To build on these earlier findings, the objectives of this study are to describe the level of mental health problems and lifetime service use among incarcerated female juvenile offenders and to explore how these factors relate to their criminal history. We anticipate that emotional disorder symptoms and substance use problems will be prominent among these incarcerated female adolescents and that many will have had prior contact with specialty mental health services or special education programs. Also, we hypothesize that female detained youths with more extensive criminal histories will be more likely to have received mental health services.
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METHOD Subjects From December 1997 to July 1998, fifty-four incarcerated female offenders were interviewed at a secured juvenile probation camp in Los Angeles County. On average, this all-female facility housed 110 females daily during this 8-month period. Youths were eligible for the study if they were between the ages of 14 and 18 years and were available to participate at the time of the interview (i.e., not working off campus or being disciplined). Approximately five youths were excluded because of age or availability. Of the 61 eligible adolescents who were approached, 89% agreed to participate. Participants and nonparticipants did not vary by sociodemographic characteristics. Procedures Recruitment and on-site youth interviews were conducted following informed consent procedures approved by the UCLA Human Subjects Protection Committee and the Los Angeles County Probation Department. When youths were initially approached, they were given a verbal explanation of the study by one of the research staff. A ballot box methodology was used for those youths who were interested in learning more about participating in the study. The interested youths deposited an “interest card” with their name printed on the card in a “ballot box,” to minimize coercion of any noninterested youths. Research staff then met with the interested youths individually to further describe the study. During this discussion, the vol-
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untary nature of participation was emphasized. The youths were informed that the specific information collected would not be shared with the facility staff and that their participation would not have an impact on their length of stay at the facility. Written assent was obtained from each youth prior to her participation. Interviews were conducted in a private room with one of three trained interviewers who read the self-report questionnaires aloud to the adolescent. The survey included inquiries about the youth’s sociodemographic characteristics, criminal history, and lifetime mental health services and special education program use, as well as standardized screening measures of substance use, depressive symptoms, and anxiety. Participants received small gifts valued at $5.00 for completing the interview. The interviewers had a minimum of 4 years of college education and received 2 full days of training in general survey administration and use of mental health measures. Upon completion, surveys were proofread by a child and adolescent psychiatrist (S.H.K.) for completeness prior to data entry. The same child and adolescent psychiatrist supervised the interviewers during weekly group meetings. Measures Substance use was measured with the Drug Consumption Questionnaire, a 44-item self-report questionnaire that has been used in delinquent populations to evaluate both level of and problems due to substance use (Loeber et al., 1998). Each subject was asked about her use of specific substances. For each major category of substance use (alcohol, tobacco, marijuana, and other drugs), 10 problems related to substance use were asked, such as the following: have you “gotten into physical fights because of your use,” “had any accidents because of the use,” and “done anything illegal in order to get [the substance].” The youth was classified as having a substance use problem if she attributed at least one serious problem involving family, peers, school, community, or health to substance use during her lifetime. The level of depressive symptoms was assessed by the Children’s Depression Inventory (CDI) (Kovacs, 1992), a 27-item self-report measure. For each item, the subject chose one statement out of three that best described her feelings over the previous 2 weeks. The symptoms were scored from 0 to 2, with the higher number corresponding to increased severity of symptom. Youths who had a total T score greater than 60 were identified as screening positive for depressive symptoms, which has been found to correspond to clinically significant depressive symptoms in children and adolescents. In community and clinical populations, the reliability and validity of the CDI is well established (Kovacs, 1992), and significant age, gender, and race effects on validity have not been found (Doerfler et al., 1988). The presence of anxiety symptoms was determined by using the Revised Children’s Manifest Anxiety Scale (RCMAS), a 37-item selfreport instrument (Reynolds and Richmond, 1985). Subjects were asked to answer yes or no to statements about anxiety symptoms that had occurred during the previous 2 weeks. A total T score greater than 60 corresponded to clinically significant anxiety. The reliability (α = .62–.87) of the RCMAS among female adolescents from white and African-American backgrounds is very good (Reynolds and Richmond, 1985). Although the validity (r = 0.90–0.99) has been reported as excellent (Reynolds and Richmond, 1985), others have found that the RCMAS may not discriminate well between those with symptoms of anxiety disorders and attention-deficit hyperactivity disorder (Perrin and Last, 1992). The psychometric properties of the screening measures used in this study also have not been established for detained female juvenile offenders.
RESULTS Sample Characteristics and Level of Mental Health Problems
Sociodemographic characteristics, criminal history, mental health problems, and lifetime service use among detained female offenders are summarized in Table 1. The youths’ mean age was 16.1 years (SD = 1.2), and the majority (n = 51; 94%) were from minority backgrounds. On average, youths had been at the facility for 6.4 months (SD = 3.8) at the time of the interview. Almost 60% of the youths were violent offenders whose index offenses
TABLE 1 Characteristics of Incarcerated Female Juvenile Offenders (N = 54) Mean (SD) Age (yr) Race White African American Asian Latino Mixed Criminal history Age at first offense (yr) Length of offense history (yr) Incarcerated for violent offense a Previous camp detention Emotional symptoms Depressionb Anxiety c Any Substance use problem d Tobacco Alcohol Marijuana Other drugs e Any With comorbid emotional symptoms Lifetime service use Specialty mental health Special education
% (n)
16.1 (1.2) 6 48 2 37 7
(3) (26) (1) (20) (4)
13.8 (1.8) 2.3 (1.9) 59 (32) 63 (34) 28 (15) 28 (15) 37 (20) 38 52 52 37 71 29
(20) (27) (27) (20) (37) (15)
46 (25) 30 (16)
Analysis Bivariate analyses were conducted with the χ2 test of proportions for discrete variables and analysis of variance for continuous variables.
Note: Missing cases: tobacco = 1, alcohol = 2, marijuana = 2, any substance use problem = 2, any emotional disorder and substance use problem with comorbid emotional symptoms = 2, special education = 7. a Violent offenses include assault, robbery, kidnapping, and accessory to murder. b Clinically significant depressive symptoms defined as Children’s Depression Inventory T score >60. c Clinically significant anxiety symptoms defined as Revised Children’s Manifest Anxiety Scale total T score >60. d Substance use problem defined as lifetime substance use with at least one problem attributed to substance use. e Other drugs include amphetamines, cocaine, hallucinogens, inhalants, tranquilizers, codeine, barbiturates, and heroin.
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were assault, robbery, kidnapping, or accessory to murder. An additional 35% of the youths (n = 19) were incarcerated for other serious offenses, such as theft, car-jacking, drug-related crimes, and weapons violations. Overall, 80% of the youths (n = 43) had symptoms of an emotional disorder or substance use problem. The mean T scores on the CDI and RCMAS were 53.0 (SD = 13.0) and 52.6 (SD = 11.0), respectively. Comorbidity of mental health problems was common. Two thirds of the youths (10/15; 67%) who screened positive for depression reported anxiety symptoms in the clinical range. Compared with nondepressed youths, those with depressive symptoms were significantly more likely to report clinical anxiety (χ2 = 15.66, p < .001). In addition, 79% of the youths (15/19) with clinical symptoms of depression or anxiety had a substance use problem, and of the 71% of female detainees with a substance use problem, 41% (15/37) had symptoms of an emotional disorder. The most common substances used, for which problems were attributed, were alcohol and marijuana. The other drugs used by these adolescents were amphetamines (n = 21; 39%), cocaine (n = 18; 33%), hallucinogens (n = 15; 28%), inhalants (n = 12; 22%), tranquilizers (n = 8; 15%), codeine (n = 8; 15%), barbiturates (n = 6; 11%), and heroin (n = 2; 4%). Problems attributed to substance use stratified by drug type are described in Table 2. More than one half of the youths (n = 28/50; 56%) had three or more problems attributed
to their substance use, and 40% (n = 20/50) of the youths reported five or more problems associated with substance use. Legal problems, such as engaging in illegal activities to obtain the substance, were the most common type of problem attributed to substance use. Relationship Between Mental Health Problems and Service Use
More than one half of the detained female offenders (n = 31; 57%) had used specialty mental health or special education services during their lifetime. Of those youths with emotional disorder symptoms or a substance use problem, 51% (22/43) had a lifetime history of specialty mental health service use. Specifically, 55% of youths (n = 11/20) with emotional disorder symptoms and 51% (n = 19/37) with a substance use problem had at least one contact with specialty mental health services during their lifetime. Likewise, 58% of youths (21/36) with a mental health problem had a lifetime history of being enrolled in a special education program, such that 47% of those (8/17) with an emotional disorder and 47% (14/30) with a substance use problem had used such services. Emotional disorder symptoms were associated with lifetime use of either mental health or special education services (χ2 = 4.021, p = .045). However, when evaluated separately, neither use of past specialty mental health nor use of special education services was related to symptoms of depression, anxiety, or a substance use problem.
TABLE 2 Problems Attributed to Substance Use Among Incarcerated Female Juvenile Offenders Lifetime Substance Use: % (n) Problems Relational Trouble with friends Trouble with family Trouble at school Trouble with others in the community Any Health Physical Mental Accidents Any Legal Trouble with the police Physical fights Illegal activity Any
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Alcohol (n = 49)
Tobacco (n = 42)
29 12 14 18 41
12 14 7 7 24
(14) (6) (7) (9) (20)
Marijuana (n = 47)
Other (n = 28)
Any (n = 50)
(5) (6) (3) (3) (10)
26 23 30 19 40
(12) (11) (14) (9) (19)
39 43 18 21 57
(11) (12) (5) (6) (16)
44 34 36 28 60
(22) (17) (18) (14) (30)
14 (7) 12 (6) 8 (4) 24 (12)
12 (5) 0 2 (1) 14 (6)
13 15 6 26
(6) (7) (3) (12)
29 25 7 43
(8) (7) (2) (12)
30 26 8 44
(15) (13) (4) (22)
14 31 35 45
0 5 (2) 29 (12) 29 (12)
23 19 23 40
(11) (9) (11) (19)
39 39 36 61
(11) (11) (10) (17)
42 40 50 66
(21) (20) (25) (33)
(7) (15) (17) (22)
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Relationship Between Mental Health Problems and Service Use With Criminal History
Table 3 compares the level of mental health problems and service use between recidivist and nonrecidivist youths. The majority of youths (n = 30/43; 70%) with either emotional disorder symptoms or lifetime substance use problems had a history of prior incarceration at the probation camp. More than one half of youths who had received specialty mental health services or special education during their lifetime also had a history of recidivism. Recidivist females were more likely to have a substance use problem (χ2 = 5.0, p = .025), particularly with alcohol (χ2 = 7.9, p = .005), than females without a prior history of incarceration. The level of emotional disorder symptoms, substance use problems, and service use did not vary by ethnicity or other criminal history variables. DISCUSSION
Findings from this study suggest that a substantial proportion of incarcerated female youths (80%) merited a mental health evaluation for an emotional disorder or substance use problem. Compared with female adolescents in the general population (Offord et al., 1987), female juvenile offenders in this study were three times more likely to have clinical symptoms of depression or anxiety. In addiTABLE 3 Mental Health Problems and Lifetime Service Use Among Recidivist and Nonrecidivist Female Youths (n = 54) Recidivisma: % (n) Yes (n = 34) Emotional symptoms Depression Anxiety Any Substance use problem Alcohol Tobacco Marijuana Other drugs Any With comorbid emotional symptoms Lifetime service use Specialty mental health Special education
No (n = 20)
26 (9) 29 (10) 38 (13)
30 (6) 25 (5) 35 (7)
67 45 61 41 82 30
26 25 37 30 53 26
(22)** (15) (20) (14) (27)* (10)
47 (16) 59 (16)
(5) (5) (7) (6) (10) (5)
45 (9) 75 (15)
a Recidivism refers to a history of prior incarceration at the secured juvenile probation camp. * p < .05; ** p < .01.
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tion, the level of depressive symptoms among detained female youths studied was comparable with that found in other female incarcerated youth populations (McManus et al., 1984) but lower than that recently reported among a predominantly male detained youth sample (Pliszka et al., 2000). Unfortunately, because of the methodological differences between these studies, gender differences in depressive symptoms cannot be tested. Furthermore, substance use among the female youths studied was greater than that reported among the general adolescent population (Johnston et al., 2000), and the problems attributed to substance use were more severe. For example, among the general adolescent population, lack of involvement in school and sports activities were problems related to substance use (Zoccolillo et al., 1999). As hypothesized, lifetime contact with specialty mental health services or special education programs was relatively common among incarcerated female youths and related to having at least one mental health problem. Such findings thus suggest that prior service use in either of these care sectors may serve as an indication that a mental health evaluation is needed. The disproportionate contact with special education also is consistent with earlier observations that contact with care sectors outside specialty mental health in community-based samples is common among youths with mental health problems (Burns et al., 1995). Furthermore, the finding that the presence of a substance use problem was not related to prior specialty mental health service use merits further study. A temporal relationship between indicators of need for a mental health evaluation and service use cannot be assessed because of this study’s design. Nevertheless, these preliminary findings raise questions about underdetection of substance abuse and barriers to care for this population. For example, medical necessity criteria for publicly funded specialty mental health services in California do not include the diagnosis of solely substance abuse, potentially limiting access. In addition to clinical need, these findings also suggest that criminal history may be important characteristics that should be taken into account when assessing detained female youths. Of note, we found that a history of prior incarceration was associated with substance use problems, which is consistent with earlier findings in male juvenile delinquent populations (Duncan et al., 1995; Niarhos and Routh, 1992). Although the direction of this relationship cannot be established from this study’s cross-sectional design, these findings suggest that interventions for this 553
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population should include screening for substance use disorders, particularly given the association of worse criminal history and substance use problems.
cient number of female youths to explore gender differences in policy-relevant outcomes such as recidivism. REFERENCES
Limitations
Nevertheless, these preliminary findings suggest that detained female juvenile offenders represent a growing population of high-risk youths who merit a mental health and substance abuse evaluation. Future research with this population should use larger, representative samples as well as standardized measures of diagnoses and impairment to determine more accurately the need for mental health services. The relationship between criminal history indices and substance use problems also needs to be more fully understood. Such information can then be used to guide the delivery of mental health services for female juvenile offenders. Furthermore, future studies examining the effectiveness of mental health interventions for detained youths should include a suffi-
American Medical Association, Council on Scientific Affairs (1990), Health status of detained and incarcerated youths. JAMA 263:987–991 Anno B (1984), The availability of health services for juvenile offenders: preliminary results of a national survey. J Prison Jail Health 4:77–90 Barnum R, Famularo R, Bunshaft D, Fenton T, Bolduc S (1989), Clinical evaluation of juvenile delinquents: who gets court referred? Bull Am Acad Psychiatry Law 17:335–344 Barton W (1976), Discretionary decision-making in juvenile justice. Crime Delinquency 22:470–480 Bilchik S (1998), Mental Health Disorders and Substance Abuse Problems Among Juveniles. OJJDP Fact Sheet. Washington, DC: US Department of Justice Burns BJ, Costello EJ, Angold A et al. (1995), Children’s mental health service use across service sectors. Health Aff 14:147–159 Cauffman E, Feldman SS, Waterman J, Steiner H (1998), Posttraumatic stress disorder among female juvenile offenders. J Am Acad Child Adolesc Psychiatry 37:1209–1216 Dembo R, Turner G, Sue CC, Schmeidler J, Border P, Manning D (1995), Predictors of recidivism to a juvenile assessment center. Int J Addict 30:1425–1452 Dembo R, Williams L, Getreu A et al. (1991), A longitudinal study of the relationships among marijuana/hashish use, cocaine use, and delinquency in a cohort of high risk youths. J Drug Issues 21:271–312 Dembo R, Williams L, Schmeidler J (1993), Gender differences in mental health service needs among youths entering a juvenile detention center. J Prison Jail Health 12:73–101 Doerfler LA, Felner RD, Rowlison RT, Raley PA, Evans E (1988), Depression in children and adolescents: a comparative analysis of the utility and construct validity of two assessment measures. J Consult Clin Psychol 56:769–772 Duncan RD, Kennedy WA, Patrick CJ (1995), Four-factor model of recidivism in male juvenile offenders. J Clin Child Psychol 24:250–257 Farrow JA, French J (1986), The drug abuse–delinquency connection revisited. Adolescence 21:952–960 Huizinga D, Jakob-Chien C (1998), The contemporaneous co-occurrence of serious and violent juvenile offending and other problem behaviors. In: Serious and Violent Juvenile Offenders, Loeber R, Farrington DP, eds. Thousand Oaks, CA: Sage, pp 47–67 Johnson BD, Wish ED, Schmeidler J, Huizinga D (1991), Concentration of delinquent offending: serious drug involvement and high delinquency rates. J Drug Issues 21:205–229 Johnston LD, O’Malley PM, Bachman JG (2000), The Monitoring the Future National Survey Results on Adolescent Drug Use: Overview of Key Findings, 1999 (NIH Publication 00-4690). Rockville, MD: National Institute on Drug Abuse Kashani JH, Carlson GA, Beck NC et al. (1987), Depression, depressive symptoms, and depressed mood among a community sample of adolescents. Am J Psychiatry 144:931–934 Kovacs M (1992), Children’s Depression Inventory. New York: Multi-Health Systems Lewis DO, Shanok SS, Pincus JH (1982), A comparison of the neuropsychiatric status of female and male incarcerated delinquents: some evidence of sex and race bias. J Am Acad Child Psychiatry 21:190–196 Lewis DO, Yeager CA, Cobham-Portorreal CS, Klein N, Showalter C, Anthony A (1991), A follow-up of female delinquents: maternal contributions to the perpetuation of deviance. J Am Acad Child Adolesc Psychiatry 30:197–201 Loeber R, Farrington DP, Stouthamer-Loeber M, Van Kammen WB (1998), Antisocial Behavior and Mental Health Problems: Explanatory Factors in Childhood and Adolescence. Mahwah, NH: Erlbaum McManus M, Alessi NE, Grapentine WL, Brickman A (1984), Psychiatric disturbance in serious delinquents. J Am Acad Child Psychiatry 23:602–615 Milin R, Halikas JA, Meller JE, Morse C (1991), Psychopathology among substance abusing juvenile offenders. J Am Acad Child Adolesc Psychiatry 30:569–574
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This study has several limitations. The level of mental health problems and service use is based on a convenience sample using screening measures, and therefore these findings should not be interpreted as estimates of the prevalence of psychiatric disorders or level of unmet need for mental health services. Because of the study’s cross-sectional design, the temporal relationship between the onset of emotional symptoms and substance use problems also cannot be evaluated. Symptoms of depression or anxiety can occur during drug withdrawal. However, it is unlikely that the symptoms described in this study were solely a result of drug withdrawal because the average length of stay at the secured probation camp was approximately 6 months at the time that the interview was conducted. Also, whether or not the symptoms developed during the incarceration could not be determined from this study. Data were restricted to detained female youths in one facility, limiting the generalizability of these findings to youths in other juvenile justice settings or to male juvenile offenders. Furthermore, the sample consisted predominantly of minority youths, which may call into question the generalizability of this sample to other female offenders. However, it has been well documented that minorities are overrepresented in the juvenile justice population. In one report, 7 in 10 youths held in custody for a violent offense were from minority backgrounds (Snyder and Sickmund, 1999). Clinical Implications
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Niarhos FJ, Routh DK (1992), The role of clinical assessment in the juvenile court: predictors of juvenile dispositions and recidivism. J Clin Child Psychol 21:151–159 Offord DR, Boyle MH, Szatmari P et al. (1987), Ontario Child Health Study, II: six-month prevalence of disorder and rates of service utilization. Arch Gen Psychiatry 44:832–836 Perrin S, Last CG (1992), Do childhood anxiety measures measure anxiety? J Abnorm Child Psychol 20:567–578 Pliszka SR, Sherman JO, Barrow MV, Irick S (2000), Affective disorder in juvenile offenders: a preliminary study. Am J Psychiatry 157:130–132 Reynolds CR, Richmond BO (1985), Revised Children’s Manifest Anxiety Scale (RCMAS) Manual. Los Angeles: Western Psychological Services Shanok SS, Lewis DO (1977), Juvenile court versus child guidance referral: psychosocial and parental factors. Am J Psychiatry 134:1130–1133 Snyder HN, Sickmund M (1999), Juvenile offenders and victims: 1999 national report. Washington, DC: Office of Juvenile Justice and Delinquency Prevention Sorensen J (1978), Outcome evaluation of a referral system for juvenile offenders. Am J Community Psychol 6:381–388
Thomas WJ, Stubbe DE (1996), A comparison of correctional and mental health referrals in the juvenile court. J Psychiatry Law 24:379–400 Van Kammen WB, Loeber R, Stouthamer-Loeber M (1991), Substance use and its relationship to conduct problems and delinquency in young boys. J Youth Adolesc 20:399–413 Vander Stoep A, Evens CC, Taub J (1997), Risk of juvenile justice systems referral among children in a public mental health system. J Ment Health Adm 24:428–442 Werry JS (1991), Overanxious disorder: a review of its taxonomic properties. J Am Acad Child Adolesc Psychiatry 30:533–544 Westendorp F, Brink K, Roberson M, Ortiz I (1986), Variables which differentiate placement of adolescents into juvenile justice or mental health systems. Adolescence 21:23–37 Wierson M, Forehand R (1995), Predicting recidivism in juvenile delinquents: the role of mental health diagnoses and the qualification of conclusions by race. Behav Res Ther 33:63–67 Zoccolillo M, Vitaro F, Tremblay RE (1999), Problem drug and alcohol use in a community sample of adolescents. J Am Acad Child Adolesc Psychiatry 38:900–907
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