In the twenty-first-century world of juvenile justice policy and practice, nearly everyone agrees that one of the most pressing issues facing the nation's juvenile courts is their proper response to delinquent youths with mental disorders. Recent research indicates that about two-thirds of adolescent offenders in juvenile justice facilities meet the criteria for one or more mental disorders. What are the obligations of our juvenile justice system, then, as the caretaker for delinquent youth with such disabilities? How do issues of adolescent development create special challenges in determining the court's proper response to delinquents with special mental health needs? Thomas Grisso considers these questions while offering new information to assist the juvenile justice system in its responses to the needs of our children.
Double Jeopardy considers the newest data on the nature of youths' mental disorders—their relationships to delinquency, the values and limits of methods to treat them, and the common patterns of adolescent offending. That information is used to chart a rational course for fulfilling the juvenile justice system's duty—as a custodian of children in need of health care, as a legal system promoting fairness in youth adjudication, and as a protector of public safety—to respond to delinquent youths' mental disorders. Moreover, Double Jeopardy provides a scientific yet practical foundation for lawmakers, judges, attorneys, and mental health care professionals, as well as researchers who must fill the knowledge gaps that limit the juvenile justice system's abilities to meet youths' mental health needs.
About the Author
Thomas Grisso, a clinical psychologist, is a professor of psychiatry and coordinator of the Law and Psychiatry Program at the University of Massachusetts Medical School. He is the author or co-editor of several books. Among these is Youth on Trial, also published by the University of Chicago Press.
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Adolescent Offenders with Mental Disorders
By Thomas Grisso
The University of Chicago Press
Copyright © 2004 The University of Chicago
All right reserved.
Reasons for Concern about Mental Disorders of Adolescent Offenders
Many agencies and advocates recently have urged that greater attention be given to the mental health needs of youths in the juvenile justice system (e.g., after an early warning by Cocozza, 1992: American Bar Association, 2001; Office of Juvenile Justice and Delinquency Prevention, 2000; National Council of Juvenile and Family Court Judges, 2000; National Mental Health Association, 2000; U.S. Surgeon General, 1999). They have pointed with alarm at an apparent increase in the proportion of youths with mental disorders in detention centers and juvenile correctional facilities, pressing the juvenile justice system to meet its obligation to provide them treatment.
This volume explores the basis for our obligations to identify and respond to adolescent offenders' mental disorders, examines the state of our knowledge about youths' mental disorders and their consequences, and charts a rational course for the juvenile justice system's response to the mental health needs of those who are in its custody. To set the stage, this chapter identifies why the question regarding mental health needs of juvenile offenders has arisen in recent years, the scope of the problem, and a foundation for examining the juvenile justice system's obligation to respond to youths' mental disorders.
How Delinquent Youths' Mental Disorders Got Our Attention
The juvenile justice system, now a little more than a century old, has weathered many storms in its first century. But it will probably require another two decades for it to recover from the tempests of the 1990s.
The barometer began to fall around 1987, when headlines and then Justice Department statistics reported an increase in lethal violence by youth. The gathering clouds soon erupted and produced a growing flood of homicides and aggravated assaults committed by youths ages thirteen to seventeen, increasing year by year until the rates had more than doubled by 1994 (U.S. Department of Justice, 1980-1993, 1994, 1995-1996). Explanations ranged from notions that our country had spawned a generation of "super-predators" (DiIulio, 1995; Fox, 1996) to more reasonable interpretations of the confluence of changes in the drug market and the availability and use of guns by adolescents, especially in the cities (e.g., Blumstein, 1995; Zimring, 1998). Compounding the effect was an increase in school violence in suburbs and small towns nationwide, which, although contributing little to the crime rate, kindled intense public feelings of grief and vulnerability.
Out of the alarming words and images created by these events grew a "moral panic ... an exaggerated perception of the seriousness of the threat and the number of offenders, and collective hostility toward the offenders, who [were] perceived as outsiders threatening the community" (Scott & Steinberg, 2003, p. 807). Reacting swiftly, legislators erected what were meant to be bulwarks against the rising flood of juvenile crime. Virtually every state modified its laws pertaining to juveniles in ways that resulted in more punitive sanctions for serious violent offenses by youths (U.S. General Accounting Office, 1995; Torbet et al., 1996; Snyder & Sickmund, 1999; Grisso, 1996). They lowered the age and broadened the offense criteria for trying adolescents in criminal court rather than juvenile court, more often required a transfer to criminal court for young people charged with serious offenses (reducing judicial discretion), and increased the penalties that were legally available or required for cases retained in juvenile court. Many states' legislatures made it clear that these changes constituted a fundamental reform in the purposes of the juvenile justice system, simultaneously revising the "purpose clause" of their juvenile codes to reflect a primary emphasis on public safety and only secondarily on rehabilitation (Grisso, 1996; Snyder & Sickmund, 1999). Momentum carried this trend in legal reform through the late 1990s, well beyond 1995 when Justice Department statistics began reporting a decrease in the volume of youths' violent offenses (Blumstein & Wallman, 2000). The bulwarks still stand; there has been little subsequent change to the more punitive sanctions that were put in place during those stormy years.
Concurrent with these events, juvenile justice personnel in the early 1990s began to report what they thought was an increasing proportion of youths with mental disorders entering the juvenile justice system (Cocozza, 1992). In fact, reviews of epidemiologic studies seem to indicate that rates of mental disorders among adolescents in general (in the United States and European countries) were increasing during the past few decades compared to the first three-quarters of the twentieth century (e.g., Fombonne, 1998), possibly due to modern changes in the social context of adolescent development (Rutter & Smith, 1995). If the rates of mental disorder among youths in the juvenile justice system increased beyond that already-heightened base rate, there are several plausible explanations:
The increase in youth violence itself produced traumatizing conditions in neighborhoods, elevating the prevalence of symptoms of mental disorders among youths in those neighborhoods.
New laws reducing judicial discretion and assigning penalties based primarily on a youth's offense worked to decrease "screening" and "diversion" of mentally disordered youths from juvenile justice processing, allowing more of them to penetrate the juvenile justice system than had formerly been the case.
Simultaneous with changes in crime rates and legal reforms, public mental health services for children were deteriorating in many states due to complex financial circumstances, creating a functional "diversion" of mentally disordered youths into juvenile justice facilities.
There is substantial evidence for the last of these explanations. During the 1990s, state after state experienced the collapse of public mental health services for children and adolescents (e.g., New York Times, 2001) and the closing of many-in some states, all-of their residential facilities for seriously disturbed youths (e.g., Arizona Daily Star, 2000; Columbus Dispatch, 2001). The juvenile justice system soon became the primary referral for youths with mental disorders. In California, the Los Angeles Times (November 21, 2000) reported that "absent adequate mental health services, the cop has become the clinician ... the jail has become a crisis center," and quoted the chief of correctional services of the Los Angeles County Sheriff's Department as acknowledging that the Los Angeles County Jail was now the largest de facto mental health facility in the nation. Cases mounted in which parents gave up custody of their children to the juvenile justice system, or managed to have their children arrested, in order to obtain mental health services that they could no longer find in their communities (e.g., Columbus Dispatch, 2002; Progressive, 2001; Omaha World-Herald, 2002).
As the storm clouds of juvenile violence began to clear late in the 1990s, some surveyors of the wreckage-cited at the beginning of this chapter-began to call attention to the problem. They pointed to what appeared to be an alarming number of adolescents with mental disorders in juvenile justice custody, and they asserted the juvenile justice system's responsibility to identify them and to provide appropriate treatment.
But how big is the problem today? What is the nature of mental disorders among delinquent youths, and of what relevance are they for our nation's objectives for the juvenile justice system? Can we identify the young people about whom we are concerned? And above all, what types of intervention are needed? Can we chart a rational course for responding to their needs? The first step in answering these questions is to take a closer look at the scope of the problem, as described in studies of the prevalence of mental disorders among adolescent offenders in juvenile justice custody.
How Big Is the Problem?
We have no reliable data on the prevalence of mental disorders among juvenile justice youths prior to the 1990s (Otto et al., 1992). Therefore, an empirical estimate of the increase in prevalence does not exist. Nevertheless, the perception in the mid-1990s that the proportion was growing resulted in significant efforts by government agencies and social researchers to identify the prevalence of mental disorders among youths in juvenile detention and correction settings.
Studies of Prevalence in Juvenile Justice Settings
Several studies have identified a significant overlap between the populations of youths served by community public health agencies and youths in contact with a community's juvenile court (e.g., Rosenblatt, Rosenblatt, & Biggs, 2000; Vander Stoep, Evans, & Taub, 1997; Westendorp et al., 1986). In addition, some studies indicate that the prevalence of mental disorders among juvenile justice youths is higher than that among youths in other public health or educational settings (Stiffman et al., 1997), but about the same as those found among adolescents receiving services in community mental health programs and lower than those found in inpatient clinical services for youths (Atkins, Pumariega, & Rogers, 1999).
The specific scope of the problem, however, has been difficult to discern because of wide variations in estimates from study to study. (For a review of all such studies reported through 2002, see Cocozza & Skowyra, in press.) Research during the 1990s reported prevalence estimates for mental disorders in delinquent samples that varied from 50 to 100 percent. For example, prevalence for mental disorders among juvenile justice youth was reported as 53 percent in Maryland (Faenza, Siegfried, & Wood, 2000), about 60-70 percent for youths in Chicago (Teplin et al., 2002), 61 percent for youths in Georgia (Marsteller et al., 1997), and 76 percent in Texas (Pliszka et al., 2000). At the highest end of the spectrum, the prevalence of mental disorders for juvenile justice samples was reported to be 85 percent in Mississippi (Robertson & Husain, 2001) and 100 percent for youths in Ohio's juvenile justice facilities (Timmons-Mitchell et al., 1997).
The variability among these studies is considerable, but it is especially marked when one examines their reported prevalence rates for specific disorders. For example, a number of studies reported a prevalence of psychotic-spectrum disorders (e.g., schizophrenia) ranging from about 1 percent (Teplin et al., 2002) to 16 percent (Timmons-Mitchell et al., 1997) to 45 percent (Atkins, Pumariega, & Rogers, 1999). Mood disorders were listed as 10 percent (Wasserman et al., 2002), about 20 percent (Teplin et al., 2002), and 72 percent (Timmons-Mitchell et al., 1997); and anxiety disorders at 8 percent (Garland et al., 2001), 19 percent (Wasserman et al., 2002), 20-30 percent (Teplin et al, 2002), and 52 percent (Timmons-Mitchell et al., 1997). Attention-deficit/hyperactivity disorder (ADHD) was reported as low as 2 percent (Wasserman et al., 2002) and 18 percent (Pliszka et al., 2000) and as high as 76 percent (Timmons-Mitchell et al., 1997).
This troublesome variability may be related to many potential differences among studies in terms of their scope, framework, and measurement parameters. Moreover, often it is difficult to identify some of these study characteristics from their published reports. Generally, variation among studies has been along the following lines:
Which mental disorders were included
How "disorder" was defined (e.g., presence of symptoms versus a combination of their presence and their severity)
Time frame for the presence of symptoms associated with the diagnosis (e.g., current, or past six or twelve months, or life-time prevalence)
General methods for measuring disorders (e.g., unstructured clinical interviews, structured diagnostic interviews, paper-and-pencil measures, self-report, or multiple external sources of data)
Use of criteria requiring a particular severity of disorder in order to qualify as a positive case
Quality of the measures used
Sample sizes (some being small)
Contexts of youths' self-reports of symptoms (e.g., whether in the context of clinical care, the legal process, or research anonymity-which might influence youths' expectancies regarding use of the information and, thus, their motivations for reporting or concealing their symptoms)
Types of facilities surveyed and thus the nature of the sample (e.g., youths on probation, in pretrial detention centers, or in postadjudication correctional facilities)
Communities' uses of juvenile justice facilities (e.g., greater or lesser police diversion)
Population characteristics, especially age, gender, and cultural or ethnic characteristics
Given the many ways studies can vary, it is not possible to sort out whether the differences in their results are due to actual differences in youths' characteristics from one study to another or due to methodological variation. The best we can do at present is examine a smaller set of studies that did have several methodological factors in common.
The DISC Studies
Three recent studies-Atkins, Pumariega, & Rogers (1999), Teplin et al. (2002), and Wasserman et al. (2002)-examined large samples of youths in secure juvenile justice facilities (with the proportions of youths by ethnicity being representative of the facilities) and used the Diagnostic Interview Schedule for Children (DISC) as their measure. As described in chapter 3, the DISC provides psychiatric diagnoses according to criteria established by the Diagnostic and Statistical Manual of Mental Disorders (DSM) (American Psychiatric Association, 1987, 1994). In addition, all three studies provided data for four major types of disorders, as well as overall prevalence (meeting criteria for one or more disorders). Prevalence was expressed two ways: youths meeting basic diagnostic criteria, and youths meeting those criteria as well as exceeding a level of impairment suggesting clinical significance. (This distinction is discussed in chapter 2.)
Table 1 compares the prevalence figures provided by these studies for boys (because not all studies included girls). The glass is half empty and half full; there are some differences between studies, but overall, there are remarkable general similarities. The Wasserman et al. figures for specific disorders are somewhat lower than those of Teplin et al., which in turn are somewhat lower than those of Atkins, Pumariega, & Rogers. Wasserman et al. (2002) made this same comparison, noting that some of the discrepancies may be due to methodological differences between the studies:
Wasserman used a newer version of the DISC (the DISC-IV) with somewhat different criteria than the one used by Teplin and Atkins (DISC-2.3) (described in chapter 3), and youths responded to questions via computer in Wasserman's administration in contrast to Teplin's and Atkin's use of interviewers.
Wasserman's youths were in secure correctional facilities, while Teplin's were in a pretrial detention center. One might expect greater symptom severity for some psychological conditions among youths recently admitted to detention centers than among youths who have had time to "adjust" to confinement. Differences between results in these settings are also possible because of differences in their willingness to report symptoms depending on their expectancies about people's responses to them.
Wasserman measured current symptoms within the past month, while Teplin and Atkins measured symptoms during the past six months.
The three studies used somewhat different measures of degree of impairment.
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Table of Contents
Part I: Examining Realities
1. Reasons for Concern about Mental Disorders of Adolescent Offenders
2. Defining Mental Disorders in Adolescents
3. Assessing Mental Disorders in Adolescents
4. The Consequences of Mental Disorders in Adolescents
Part II: Discovering the Obligations
5. Refining the Custodial Obligation to Provide Treatment
6. Locating the Due Process Obligation
7. Fulfilling the Public Safety Obligation