Juvenile Justice

The Need For Psychiatric Infrastructure

By Carl C. Bell, M.D., F.A.P.A., F.A.C. and
Johnny Williamson, M.D.

Introduction
Violence perpetrated by juveniles in this country has reached epidemic proportions,1 so the juvenile justice system has rapidly expanded. The juvenile justice system was created in Chicago over a hundred years ago because it was recognized that youthful offenders needed to be managed differently from adults. They were to receive rehabilitation services instead of punishment and retribution.

Juvenile court began to move from rehabilitation to retribution after the 1967 Gault case.2 Gerald Gault was a 15-year-old boy who was adjudicated a delinquent by an Arizona juvenile court for making "lewd" phone calls. As a result, he was committed to the Arizona State Industrial School until his 21st birthday. As was typical of juvenile court in those days, he was not afforded counsel or opportunity to confront or cross-examine his accuser. In addition, he was not offered privilege against self-incrimination. After the hearing, he was afforded no right to appeal to a higher court, yet the case finally reached the Supreme Court. The maximum penalty Gault could have received if he were an adult was a $5-$50 fine or no longer than two months in jail, and, at 18, he would have had substantial constitutional and state statutory rights. The Supreme Court chided the juvenile court for its pretension of paternalism and blasted the juvenile court model as inadequate for the dispensation of justice.

Because of the Gault decision, juveniles began to be given their Miranda rights and access to counsel. Thus, the juvenile court began to move away from a system of rehabilitation to a system of due process with resultant criminalization of delinquent juvenile behavior. Beyond the Gault decision, public pressure has demanded protection of society, while the upsurge in violent juvenile offenders has challenged rehabilitation over punishment. "Dangerous" juveniles are increasingly transferred to the adult criminal justice system, where consequences are much harsher. Expansion of this segment of confined population has revealed that spread of juvenile violence, issues of juvenile competency, healthcare needs and prevention strategies are areas in need of immediate attention.

Spread of Juvenile Violence
Recently, juvenile homicide has become a serious problem in the United States, despite decreases in the arrest rate of juveniles for murder. The Columbine mass murder-suicide has drawn national attention to violent juvenile crime. Particularly, this mass school killing with suicide seems to be almost contagious among American youth.

Conceptualizing the spread of juvenile violence as an epidemic provides a model to study its patterns and progression. We know epidemics spread in various patterns, such as HIV, which is an epidemic that shifted between gender orientations. Polio, tuberculosis and drug abuse all started as epidemics in the under-class and spread to the middle- and upper-classes. Hepatitis C and drug-resistant tuberculosis are widespread in prisons and beginning to shift into society. No one is safe from epidemics occurring in other segments of society, and no one is safe from the epidemic of juvenile violence.

Issues of Competency
Since children are not legally competent adults, as more juvenile offenders enter the justice system, we have to determine juveniles' competency to understand and participate in their own defense. Although findings suggest that most youths do not have sufficient understanding for meaningful participation in trials, this consideration has not been uniformly addressed across the country. In some states, juvenile justice reforms have lowered waiver to criminal court from 18 to age 14, and, in other states, to ages 12 or 13 with a few states having no age limit for exclusion in certain serious offenses.3 Approximately one-third of the states recognize that youths must be competent to stand trial in delinquency proceedings. According to Grisso,4 current research suggests that by age 13 or 14, the average youth often has a basic idea of the roles of persons in the trial process and that defendants are charged with offenses with punitive consequences. To determine their understanding of Miranda (the right to remain silent), a study of 400 delinquent youths found that only 25 percent of 14- to 16-year-old delinquents described a right connoting entitlement, Grisso.5 Thus, when asked what is meant by, "You do not have to make a statement and have the right to remain silent," many youths interpreted this to mean, "You can be silent unless you are told to talk," or "You have to be quiet unless you are spoken to." Furthermore, delinquent youths ages 15 to 17 with low intelligence quotient (IQ) scores showed significantly poorer understanding than the average 12-year-old child.

Unfortunately, delinquent youths of this country are handled by varying standards with respect to competency. This begs the question of whether we can determine the competency of a juvenile defendant and how we can satisfy the basic legal tenet that all defendants be competent to stand trial and participate in their defense. A better grasp of juvenile delinquents' ability to understand their rights and the procedures of the court is warranted. Youths need psychiatric/psychological reviews from a forensic perspective to address this problem.

Healthcare Needs
Violent crime is often addressed from a judicial perspective without regard to underlying problems. For troubled youths and their families, there is little or no access to healthcare, especially mental healthcare. Public defenders of juvenile detention clients are targeting lawsuits at juvenile detention and confinement centers to get their clients adequate general and mental healthcare. Perhaps these efforts will use state laws on childhood education by maintaining that unless children are provided with treatment for mental illness, they cannot be adequately educated. This has already been successful in some states, showing that juvenile justice systems must become proactive and begin developing healthcare infrastructures now.

Currently, there are about 1,300 juvenile detention and confinement facilities in the United States. The

National Commission on Correctional Health Care accredits 37,6 all of whom have excellent facilities for healthcare. This commission discovered a pressing need for psychiatric/psychological reviews that are useful from a case finding and treatment perspective of youths. Mental illness and disordered behavior have a dramatic presence in our prisons and jails. The prevalence of major depression, schizophrenia and mania in the adult community population is 1.8 percent while the prevalence of these disorders in an adult jail population is 12.3 percent in females and 6.1 percent in males.7

The prevalence of mental disorders among juvenile delinquent offenders is unknown. In a personal communication, Dr. Leventhal of the University of Chicago estimates that at least one-third of male juvenile delinquents have an impairing mental disorder (excluding conduct disorder) that has not been adequately treated, if treated at all. He suggests that two of the more common mental disorders among children with early-onset, serious delinquency (attention deficit/hyperactivity disorder and depression) are treatable. Many of these children have a comorbid substance-use disorder. Dr. Leventhal also estimates that 75-90 percent of confined females have a serious, but treatable disorder.

According to Joseph Cocozza, the rates of mental illness in kids in juvenile justice is two to three times higher than in the general population, and 20 percent of these children have a serious mental disorder. He also asserts that there is a high degree of co-occurring mental health and substance-abuse disorders.

Further, by clustering juvenile offenders in detention centers, some of which have histories of violence; we are aggregating a group of children that may be at high risk for exposure to multiple types of trauma. Burton et al8 found the prevalence rate of posttraumatic stress disorder in juvenile offenders to be 24 percent. Suicide prevention is another large concern as we continue to place immature adolescents in adult jails and prisons. One study9 has shown an increased rate of suicide among youth placed in adult facilities compared with those in juvenile facilities.

These facts show that mental illness is a serious problem within the juvenile justice system. The fact that many of these disorders are treatable compels us to design a system that identifies at-risk persons, accurately diagnoses disorders and implements corrective action. Within the juvenile justice system, special housing units and programs for the mentally ill, designed to address mental health needs has been considered as one means to address this need. Independent of the form of the treatment intervention, it is imperative to include comprehensive assessment and care, continuity of care and specific health education.

Prevention Strategies
Having established that many incarcerated youth with mental illness and/or aberrant behaviors are treatable, we now turn our attention to the prospect of prevention. Youth violence is a major public health problem for which there are treatable predictors of recidivism. Implementing effective prevention and treatment programs remains the greatest challenge. To reduce the morbidity and mortality related to such conditions, parenting behaviors have been shown effective. Parenting practices are the goal-directed behaviors through which parents perform their parental duties designed to control and socialize their children.10 Lack of parental monitoring represented at its extreme by neglect, poor discipline and conflict about discipline, has been related to participation in delinquent and violent behavior for a range of populations.11-13 Similarly, low levels of parental warmth, acceptance, affection and cohesion along with high levels of conflict and hostility have been associated with delinquent and violent behavior.11,14,15

Improving parenting practices can positively influence and prevent violent and delinquent behavior. Effective parenting practices include: the use of positive parenting, increasing the effectiveness of discipline and minimizing avoidance of discipline. Maximizing involvement of the parents can enhance parental monitoring and supervision in the life of the child while strengthening their knowledge of the child's activities and whereabouts. The strongest evidence and most consistent support of effective prevention strategies are those that focus on family processes, especially parenting.14,16 Family relationship processes refer to the characteristics of the family as a system and include beliefs and values held by the family, emotional warmth between family members, support provided by family members as well as organization and communication among family members.14 Family-oriented intervention is directed at changing parenting style and practices to increase predictability and parental monitoring of children and decrease negative parenting methods. Goals of this strategy aim toward improvement in intra-family relations via a focus on closeness, positive statements, communication and emotional cohesion. These interventions have been shown to reduce risk for serious antisocial behavior and violence.17 All successful family interventions have combined behavioral parent-training techniques with other interventions based on family systems theory designed to improve family relations. 10

There is also evidence that school-based interventions that change management of high-risk children and /or increase parental involvement at school and collaboration with school personnel can reduce risk, particularly for in-school violence. Community organization efforts are producing promising results, although conducting experiments that permit traditional scientific criteria to be applied is difficult.18

Future Directions
Neuropsychiatric disorders may predispose individuals to violence,19,20 demanding treatment for such disorders to promote health behavior change. As the field of neuropsychiatry develops, psychiatric diagnosis and treatment of some causes of violent behavior will become more specific, with recent developments toward this end. A study by Klein et al21 emonstrated significant diminution of antisocial behavior with methylphenidate. More important, the reductions were substantial and clinically meaningful, demonstrating clear treatment effects on specific symptoms of conduct disorder, including cheating and stealing. Teachers indicated broad and marked amelioration in children who received methylphenidate but little alteration for those taking a placebo (a sugar pill). There also appears to be an independent influence of methylphenidate on provocative, aggressive and mean behaviors. The development of more effective treatments for drug addiction will significantly impact this problem as well.

The difficulty lies with implementing new developments in the juvenile justice system. We must be able to identify and appropriately divert mentally disturbed youth offenders from the juvenile justice system into the care of competent mental health professionals. We need a system in place designed to facilitate this with improved arrangements for psychiatric assessments. Without developing the infrastructure to provide more sophisticated services, juvenile justice will be the last to receive appropriate healthcare that can prevent some causes of risky health behaviors.

Dr. Carl C. Bell is President/CEO, Community Mental Health Council and Foundation, Inc., Director of Public and Community Psychiatry and Professor of Clinical Psychiatry & Clinical Public Health, University of Illinois. During 30 years, Dr. Bell has authored, co-authored and published over 200 articles on mental health as well as being editor of Psychiatric Perspectives on Violence: Understanding Causes and Issues in Prevention and Treatment. Dr. Bell was the E.Y. Williams Distinguished Senior Clinical Scholar Award of the Section on Psychiatry of the National Medical Association in 1992. He received the American Psychiatric Association President's Commendation - Violence in 1997. He was appointed to the Violence Against Women Advisory Council by Janet Reno, the Attorney General, Department of Justice and Donna Shalala, Secretary, Department of Health and Human Services, 1995-2000 and was a participant in the White House's Strategy Session on Children, Violence and Responsibility. He was appointed to the working group for Dr. Satcher's Surgeon General's Report on Mental Health, Culture, Race and Ethnicity, and appointed to the Planning Board for the Surgeon General's Report on Youth Violence. You may contact Dr. Bell by e-mail at: carlcbell@pol.net.

Dr. Johnny Williamson is a fourth year psychiatry resident at the University of Illinois at Chicago, Department of Psychiatry. He currently serves as Chief Resident for this program and also works at the Community Mental Health Council and Foundation, Inc. Dr. Williamson is a Minority Research Training Program Fellow as well as being a National Health Service Scholar. Some accomplishments throughout his training include the Meharry Medical College Scholarship, the Presidential Award Program Scholarship, the Phi Eta Sigma National Honor Society and the Alpha Lambda Delta National Academic Honor Society. You may contact Dr. Williamson by e-mail at: johnnyiv@hotmail.com.

References

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