Juvenile delinquency and serious antisocial behaviour
Susan Bailey
Introduction
Juvenile crime and delinquency represent a significant social and public health concern. Both rates of mental disorders and offending are high during adolescence. This chapter reviews prevalence rates of mental disorders in young offenders, screening, and assessment of juveniles, principles of interventions with young offenders before describing principles of forensic mental health, policy and practice, how mental disorders in adolescence can impact on offending and antisocial behaviour, how policy is shaping practice in this field and how mental health practitioners may be involved in meeting mental health needs and undertaking medico-legal assessments
Delinquency, conduct problems, and aggression all refer to antisocial behaviours that reflect a failure of the individual to conform his or her behaviour to the expectations of some authority figure, to societal norms, or to respect the rights of other people. The ‘behaviours’ can range from mild conflicts with authority figures, to major violation of societal norms, to serious violations of the rights of others.(1) The term ‘delinquency’ implies that the acts could result in conviction, although most do not do so. The term ‘juvenile’ usually applies to the age range, extending from a lower age set by age of criminal responsibility to an upper age when a young person can be dealt with in courts for adult crimes. These ages vary between, and indeed within, countries and are not the same for all offences.(2,3)
Adolescence as a context
The adolescent population in the UK constitutes half of the child population with around 7.5 million young people in the transitional stage between childhood and adulthood, (age 10-19).(4) Adolescence is a transitional stage of development between childhood and adulthood—a stage of possibility and of promises and worries that attend this possibility. The developmental tasks of adolescence centre on autonomy and connection with others, rebellion and the development of independence, development of identity and distinction from and continuity with others. The physical changes of puberty are generally seen as the starting point of adolescence whilst the end is less clearly delineated. Adolescence ends with attainment of ‘full maturity’. A range of social and cultural influences including the legal age of majority, may influence the definition of maturity.(5)
Mortality among adolescents, in contrast to almost all other age groups, did not fall during the second half of the twentieth century, the main causes being accidents and self-harm.(4). Health needs are greater in this age band than in children in middle childhood (5 to 12 years) or of young adults, and arises out of mainly chronic illness and mental health problems. The main concerns of young people, in relation to health, focus on issues of immediacy that impact on their relations with peers and include problems with skin, weight, appearance, emotions, and sexual health including contraception.
The principal aim of the Youth Justice System (YJS) is to prevent offending by children and young people under 18 years of age. There are 157 Youth Offending Teams in England and Wales. The YJB commissions some 3000 custodial places at any one time for young people under the age of 18 years in 18 Prison Service Young Offenders Institutions, 15 Local Authority Secure Children’s Home and 4 private sector Secure Training Centres. In 2005-2006 there were 301,860 recorded offences the 4 highest recorded offences being theft and handling 18.5 per cent, violence against the person 18.1 per cent, motoring offences 16.6 per cent, criminal damage 12.9 per cent. 16 and 17 year old were responsible for 49.6 per cent of offences with males responsible for 80.6 per cent and females 19.4 per cent of all offences resulting in a disposal. Offences by ethnicity were white 85.2 per cent and Black and Ethnic Minority 14.8 per cent. Of the 2 12, 242 disposals 80 per cent received precourt of first tier disposals with 17 per cent receiving a community sentence and 3 per cent a custodial sentence.(6)
Risk factors for, and pathways to antisocial behaviour are summarized in Tables 11.7.1 and 11.7.2 respectively. There is a significant overlap between the risk factors for offending, poor mental health and substance misuse and the number of assessed risk factors increases as a young person moves further into the Youth Justice System.(7) Many young offenders are not engaged in mainstream education and health services. It is critical that these young people are supported to access the mainstream and specialist services they require while under the supervision of the YOT or in custody. Otherwise, once their sentence ends they can become detached from services and their circumstances are likely to deteriorate, leading to more offending and greater demands on specialist services as they get older.
In the UK, the Children’s National Service Framework for Children, Young People and Maternity Services (NSF) set out a vision of a comprehensive child and adolescent mental health service.(8)
A young person in contact with the criminal justice system, whether in custody, or in the community, should have the same access to this comprehensive service as any other child or young person within the general population. Treatment options should not be affected by a young offender’s status within the criminal justice system. The Change for Children Programme has the aim of improving outcomes for all children in the following 5 areas: being healthy, staying safe; enjoying and achieving; making a positive contribution; and achieving economic well-being, and to narrow the gap in outcomes between those who do well and those who do not. If we do not address the mental health needs of young offenders then they are excluded from the opportunity to participate in improvements in these 5 outcomes and ultimately from the ability to achieve their full potential.
A young person in contact with the criminal justice system, whether in custody, or in the community, should have the same access to this comprehensive service as any other child or young person within the general population. Treatment options should not be affected by a young offender’s status within the criminal justice system. The Change for Children Programme has the aim of improving outcomes for all children in the following 5 areas: being healthy, staying safe; enjoying and achieving; making a positive contribution; and achieving economic well-being, and to narrow the gap in outcomes between those who do well and those who do not. If we do not address the mental health needs of young offenders then they are excluded from the opportunity to participate in improvements in these 5 outcomes and ultimately from the ability to achieve their full potential.
Table 11.7.1 Major risk areas in children and adolescents with persistent antisocial behaviour(35) | |||||||||||||||||||||
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Table 11.7.2 Critical pathway to serious antisocial behaviour(64) | ||||||||||||||||||
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There is a high prevalence of mental health problems among young people in custody.(9) YJB research published in 2005 reported the following findings.(10)
31 per cent had mental health problems
18 per cent had problems with depression
10 per cent suffered from anxiety
9 per cent reported a history of self-harm in the preceding month
9 per cent suffered from post-traumatic stress disorder
7 per cent had problems with hyperactivity
5 per cent reported psychotic-like symptoms
One in five young offenders were identified as having intellectual disability IQ<70. Additionally, needs were identified across education 48 per cent and social relationships 36 per cent. Needs were unmet because they were not recognized.
Research consistently reveals high levels of psychiatric disorders among detained juveniles, although rates vary widely by study, ranging from more than 50 per cent to 100 per cent.(11,12,13,14,15,16,17,18,19,20,21) The variations between the studies may reflect methodological differences or true variations between countries and samples. Advances in developmental psychopathology and increased understanding of the continuities between child and adult life(27) demonstrating that many childhood disorders once thought to resolve with age cast long shadows over later development.
There are several reasons why high rates of mental disorders may be expected in youth in contact with juvenile justice. First, prevalence rates of psychiatric disorders in community samples were shown to be around 15 per cent.(22) Also, severe delinquency is common in the adolescent population, with about 5 per cent showing an early-onset and persistent pattern of antisocial behaviour.(23) A substantial number of adolescents will show offending behaviour and will have a mental health disorder simply because of coincidental overlap between both conditions. Second, because delinquent and antisocial behaviour reaches high levels among juvenile justice populations, a diagnosis of conduct disorder (CD) will often be made. Because CD shows high comorbidity rates with several other psychiatric disorders,(24) increased levels of many types of disorder may be expected. Third, risk factors for youthful offending overlap substantially with those for several types of non-disruptive child psychiatric disorders, therefore identical risk factors may underlie both antisocial behaviour and emotional or developmental problems. Disorders for which mental health interventions are provided, such as substance use disorders (SUD’s), may also lead to judicial involvement. Also, because of the prevalence of complex comorbidity, treatment in a regular mental health care programme may be intricate and often is not possible, thus increasing the likelihood of judicial involvement. In addition, severely disordered persons may be less likely to have the personal capability and have adequate resources to defend themselves and to avoid more drastic legal interventions.
Grisso and Zimring listed three principal reasons for concern regarding mental disorders in youthful offenders: a) the obligation to respond to mental health needs in those in custody, b) assurance of due process in adjudicative proceedings, and c) public safety.(25)
Mental health treatment within the juvenile justice system is often inadequate. It has been reported that only about 20 per cent of incarcerated youth with depressive disorders, 10 per cent with other mental disorders, and less than half with SUD receive intervention.(26,27). Much more research is needed into the treatment needs of this population.
Risk and protective factors
Understanding is growing of how risk factors combine to both precipitate and maintain antisocial behaviour. Several environmental and individual risk factors including psychiatric pathology in childhood have been identified.(28) Not all risk factors need to be present in a single individual but multiple risk factors greatly increases the risk of a serious and long-term negative development.(29) Positive characteristics or experiences may act protectively. These protective factors may be specific interventions or experienced within the natural contact of development. When protective factors are present, young people may show positive social development despite high risk of antisocial behaviour, or they may abandon their problem behaviour after a difficult phase. Such trajectories are less well investigated than the risks.(30,31,32,33) It is also more difficult to implement adequate research designs in this field.(34) It could be assumed that the opposite to the risk value of the variables listed in Table 11.7.1 may promote positive development. However, truly protective effects need to compensate for a given high-risk constellation (moderator approach). The available research suggests a number of factors that may protect from the risks of antisocial behaviour. Table 11.7.3 reports a selection of such personal and social resources that have already been proven or may be promising (for a detailed review see(33)).
Pathways of care and the juvenile justice system
Juvenile justice is a high-volume system, which makes clear logistics and a clear pathway of care necessary. Early identification of mental health needs may result in diversion from custody by using community services rather than adjudication and derive economic benefit by affording non-custodial disposal. Nonetheless a significant number of young persons progress to pre-trial assessment, albeit from the home or a residential care setting.
Preadjudication dispositions should be informed therefore by best available screening and assessment processes. In this context specific tools may be used to derive markers of psychopathology and of ongoing risk to self and others as well as to address medico-legal questions posed by the criminal justice system including assessment on disposition, matters of public protection, treatment for mental disorders, and need for security and likelihood of recidivism.
For those detained in prison, screening must determine if urgent problems (such as suicidal intent or consequences of substance use) require immediate attention; a detailed diagnostic assessment of the young person may take a longer period of time and continue as the youngster moves from one institution to another. Later critical transitions, for which an additional screening may be useful, include re-entry into the community, assessment of readiness for re-entry, mental health planning for integrated continuing care post detention as part of a multiagency re-entry strategy, and, where necessary, community residential programmes monitoring emotion or reactions, especially where the young person is returning to stressful conditions such as a troublesome family.
Table 11.7.3 Multilevel examples for protective factors against serious antisocial behaviour(35) | |||||||||||||||||||||||||||||||||
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General principles of assessment
Standard clinical assessment tools used in child and adolescent psychiatry cover many of the areas considered in forensic child and adolescent risk assessments.(36) This is especially important as juvenile justice systems in particular are not always equitable. In choosing between the many scales available it is important to question not just their proven scientific properties but also their feasibility for practitioners to use.
It is important to consider the purpose for which the scale is to be used (see table below). Scales that measure psychopathology may not be good ways of assessing the risk that the psychopathology poses. Measures used to map out types of symptom must have good content validity. An instrument required to pick out one group of symptomatic people from the rest of the community (e.g. mental health screening of young people in custody) needs to have
good criterion validity. A related issue is the extent to which the scale is intended to measure change.
good criterion validity. A related issue is the extent to which the scale is intended to measure change.
Grid for specifying requirements of a structured scale in a juvenile forensic population
Assessment required (yes / no)
Purpose of assessment | Psychopathology | Need | Risk |
Screening of all juveniles coming into contact with an agency | |||
Detailed assessment e.g. for sentencing, planning treatment | |||
Measuring change e.g. during treatment or sentence |
Child psychiatry uses multi-axial and developmental concepts of child psychopathology. Specific and general intellectual delays are very common among young people in the juvenile justice system(10) as is co-morbidity of disorders. Broad-band interviews, however, offer only poor coverage of rare conditions such as pervasive developmental disorders.
Needs assessment
Needs assessment may have advantages over more traditional ways of diagnosing disorders, mainly because this method also indicates whether specific conditions need attention and intervention. Especially in delinquent youth characterized by multiple problems, such an approach may carry substantial advantage. A health care need should be distinguished from a general need. One commonly used definition of a health care need is ‘the ability to benefit in some way from (health) care’.(37)
Needs and risk assessment are two separate but intertwined processes essential for clinical management (see Fig. 11.7.1). Assessment of danger to others and the need to address this problem is at the centre of legislative and policy decision-making. The attention of the public and media are focussed on this area. Needs assessment may both inform and be a response to the risk-assessment process.(38) The reciprocal process can be termed ‘risk management’ when accurate information about the risk assessment, combined with recurrent needs assessment, leads to risk-management procedures. A recurrent needs-assessment and risk-assessment process should identify changes in problem areas, thus leading to monitoring or intervention as part of risk management. Core to this assessment are appropriate mental health screening tools and processes that are available to the young person at any point in the system.(39)
Risk assessment
Risk assessment combines statistical data with clinical information in a way that integrates historical variables, current crucial variables, and the contextual or environmental factors. Structured risk assessment instruments have been developed that aim to increase the validity of clinical prediction. These scales typically contain a number of risk items selected from reviews of research, crime theories, and clinical considerations.(41,42) Items are summed to form a total risk score and may also reveal specific risk patterns (e.g. mainly family or child factors). Such instruments are used for screening, in-depth assessment and related risk management (e.g. for decisions on the child’s placement or specific interventions). They can also be applied in differentiated evaluations of intervention programmes. Instruments vary with respect to the age and gender for their clients, problem intensity in the target groups, theoretical and empirical foundations, the number and domains of risk included, scoring procedures, time required for assessment, information sources, institutional contexts of administration and other issues.(43,44) Many instruments have been designed for application in the juvenile justice system.(43,45,46) Most instruments contain factors from various areas of risk (e.g. individual, family, neighbourhood).
Mental disorders and offending
Current concepts focus on a developmental approach to psychopathology in child and adolescent psychiatry and psychology. Physical aggression peaks at around the second year of life and subsequently shows distinct developmental trajectories.(47,48) Attachment enables the mastery of aggression, self-control being developed through the efficient exercise of attritional mechanisms and symbolization. Fonagy has suggested a primary developmental role for early attachment in the development of mentalization (the capacity to understand others’ subjective experience). He suggests that impaired mentalization leads to later violence.(49) Threats to self-esteem trigger violence in individuals whose self-appraisal is ‘on shaky ground’ and are unable to see behind the threats to what is in the mind of the person threatening them. These processes are played out in the complex and toxic co-morbidities seen so much more frequently in child and adolescent than in adult mental health practice.
Oppositional disorders, conduct disorder, and ADHD
Substantially higher rates of physically aggressive behaviour are found in children and adolescents with attention deficit hyperactivity disorder, with those who meet the criteria for ADHD and conduct disorder having substantially greater risks of delinquent acts in adolescence, harmful acts in later adolescence and continued violence and offending into adulthood.(50) Children with hyperactivity, impulsivity, attention deficits and serious conduct problems may also be at risk for developing psychopathy.(51)
Distorted or biased thought processes have over time been implicated in the development of violence. Psychological treatments aimed at reducing violent behaviour in adolescents and young adults traditionally centre on violence as learned behaviour. Patterns of violence and criminal behaviour are seen as embedded in habits of thinking.(52) In juvenile delinquents significant cognitive attributional bias has been shown in aggressive children and youths. They are more likely to perceive neutral acts by others as hostile, and more likely to believe conflicts can be satisfactorily resolved by aggression. In the social context, as the young individual becomes more disliked and rejected by peers, the opportunity for viewing the world this way increases.(53) By their late teens they can hold highly suspicious attitudes and be quick to perceive disrespect from others. In the social context of juvenile incarceration,
being ‘para’(54) can become in peer group interactions the shared norm.(55)
being ‘para’(54) can become in peer group interactions the shared norm.(55)
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