Northwestern Juvenile Project Juvenile Detainee Mental Health 2013
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U.S. Department of Justice Office of Justice Programs Office of Juvenile Justice and Delinquency Prevention Melodee Hanes, Acting Administrator February 2013 Beyond Detention Even though research indicates that the majority of youth in the juvenile justice system have been diagnosed with psychiatric disorders, reports issued by the Surgeon General and the President’s New Freedom Commission on Mental Health show that juvenile detainees often do not receive the treatment and services they need. This bulletin series presents the results of the Northwestern Juvenile Project, the first large-scale, prospective longitudinal study of drug, alcohol, and psychiatric disorders in a diverse sample of juvenile detainees. Individual bulletins examine topics such as suicidal behaviors in youth in detention, posttraumatic stress disorder and trauma among this population, functional impairment in youth after detention, and barriers for youth who need to receive mental health services. Nearly all detained youth eventually return to their communities and the findings presented in this series provide empirical evidence that can be used to better understand how to meet youth’s mental health needs and provide appropriate services while in detention and after their release. The Office of Juvenile Justice and Delinquency Prevention hopes this knowledge will help guide innovative juvenile justice policy and create a better future for youth with psychiatric disorders in the justice system. The Northwestern Juvenile Project: Overview Linda A. Teplin, Karen M. Abram, Jason J. Washburn, Leah J. Welty, Jennifer A. Hershfield, and Mina K. Dulcan Highlights The Northwestern Juvenile Project (NJP) studies a randomly selected sample of 1,829 youth who were arrested and detained in Cook County, IL, between 1995 and 1998. This bulletin provides an overview of NJP and presents the following information about the project: • NJP is a longitudinal study that investigates the mental health needs and long-term outcomes of youth detained in the juvenile justice system. • This study addresses a key omission in the delinquency literature. Many studies examine the connection between risk factors and the onset of delinquency. Far fewer investigations follow youth after they are arrested and detained. • The mental health needs of youth detained in the juvenile justice system are far greater than those in the general population. • The mental health needs of youth in detention are largely untreated. Among detainees with major psychiatric disorders and functional impairment, only 15 percent had been treated in the detention center before release. Office of Juvenile Justice and Delinquency Prevention ojjdp.gov February 2013 The Northwestern Juvenile Project: Overview Linda A. Teplin, Karen M. Abram, Jason J. Washburn, Leah J. Welty, Jennifer A. Hershfield, and Mina K. Dulcan The Northwestern Juvenile Project (NJP) is the first large-scale, prospective longitudinal study of mental health needs and outcomes of juvenile detainees. The Office of Juvenile Justice and Delinquency Prevention (OJJDP) and a consortium of eight other federal agencies and five pri vate foundations have funded NJP. Data from large-scale studies such as NJP provide an empirical basis for decisionmaking in the juvenile justice system. NJP includes a diverse sample of 1,829 youth who were arrested and detained between 1995 and 1998 in Cook County, IL, the metropolitan area that includes Chicago and its surrounding suburbs. At baseline, the participants were between 10 and 18 years old. NJP continuously tracks and reinterviews participants. Following participants over time allows for the study of patterns and sequences of disorders, the impact of these disorders on functioning, and the important risk and protective factors in this population. Researchers inter view participants where they are living (either in their communities or in correctional facilities). In addition to conducting face-to-face inter views with participants, NJP also obtains records from 16 correctional and ser vice agen cies to cross-validate self-reported data on criminal justice involvement and to confirm the use of mental health and substance use services. About this series Studies in this series describe the results of statistical analyses of the Northwestern Juvenile Project, a longitu dinal study of youth detained at the Cook County Juvenile Temporary Detention Center in Chicago, IL, between 1995 and 1998. The sample included 1,829 male and female detainees between ages 10 and 18. The data come from structured interviews with the youth. Topics covered in the series include the prevalence of suicidal thoughts and behaviors among juvenile detain ees, posttraumatic stress disorder and trauma within this population, functional impairment after detention (at work, at school, at home, or in the community), psychiatric disor ders in youth processed in juvenile or adult court, barriers to mental health services, violent death among delinquent youth, and the prevalence of psychiatric disorders in youth after detention. The bulletins can be accessed from the Office of Juvenile Justice and Delinquency Prevention’s (OJJDP’s) Web site, ojjdp.gov. 2 Juvenile Justice Bulletin In addition to the funding that OJJDP provided, the research also was supported by the National Institute on Drug Abuse, the National Institute of Mental Health, the National Institute on Alcohol Abuse and Alcoholism, the Substance Abuse and Mental Health Services Administra tion (Center for Mental Health Services, Center for Sub stance Abuse Prevention, and Center for Substance Abuse Treatment), the Centers for Disease Control and Preven tion (National Center for Injury Prevention and Control and National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention), the National Institutes of Health Office of Research on Women’s Health, the National Institute on Minority Health and Health Disparities, the Office of Rare Diseases, the Office of Behavioral and Social Sciences Research, the U.S. Departments of Labor and Housing and Urban Development, the William T. Grant Foundation, and the Robert Wood Johnson Foundation. The John D. and Catherine T. MacArthur Foundation, the Open Society Foundations, and the Chicago Community Trust provided additional funds. background A significant proportion of the nation’s youth are involved in the juvenile justice system. In 2009, approximately 1.9 million arrests were made of persons younger than age 18; juveniles accounted for 12 percent of all Violent Crime Index arrests and 17 percent of all Property Crime Index arrests nationwide (Puzzanchera and Adams, 2011). In 2010, nearly 71,000 juveniles were in custody on an average day (Sickmund et al., 2011). Because of the large number of juvenile detainees, it is important to gather accurate epidemiologic data on psychiatric disorders. Comprehensive, accurate, and reliable data are needed to guide the development of innovative juvenile justice policy. NJP provides empirical evidence that communities can use to develop and provide appropriate services within detention centers. Because the study is longitudinal, it also provides information about the long-term outcomes of these youth after they leave detention. Findings from NJP, to be presented briefly in this bulletin and in greater detail in subsequent bulletins, provide important information on how to facilitate successful reentry into the community and successful transition to adulthood for youth in the juvenile justice system. Lewis et al., 1987; McCabe et al., 2002; Steiner, Garcia, and Mathews, 1997; Timmons-Mitchell et al., 1997). Far fewer studies, however, have examined how youth fare after they leave detention. Only two large-scale longitudi nal studies of juvenile detainees, in addition to NJP, have examined psychiatric disorders among youth in the juve nile justice system. Table 1 lists key characteristics of these longitudinal studies and NJP. The Youth Support Project (Dembo et al., 2000), an intervention study, reported on substance use, not substance use disorder or other psychi atric disorders. The Pathways to Desistance study (Mulvey, 2004) (also funded by OJJDP) sampled only serious of fenders; that is, those who were adjudicated delinquent for felonies or serious misdemeanors. Thus, the Pathways to Desistance study provides data on an important subgroup, but one that comprises a relatively small fraction of youth in the juvenile justice system (Stahl, 2003; Puzzanchera and Kang, 2011). NJP’s overall Approach and Goals NJP was designed to investigate the mental health needs and long-term outcomes of youth in the juvenile justice system. NJP has three primar y goals: 1. Assess the prevalence, development, and persistence of psychiatric disorders as youth in the juvenile justice system become adults. As part of this goal, the researchers do the following: Differences between NJP and other Longitudinal studies of Psychiatric Disorder Among Detained Youth Many excellent cross-sectional studies have examined men tal disorders among detained youth (Atkins et al., 1999; • Assess affective, anxiety, psychotic, disruptive be havior, and substance use disorders; and patterns of comorbid disorders. Table 1. Longitudinal Studies of Youth in the Juvenile Justice System1 Sample2 Race/Ethnicity3 Study Name and Location Type N Age Female W A H O Years Followed Northwestern Juvenile Project (Chicago, IL) (Teplin et al., 2002) Detainees 1,829 10–18 36% 16% 55% 29% 0.2% 16 Pathways to Desistance study (Philadelphia, PA, and Phoenix, AZ) (Mulvey, 2004) Serious adjudicated offenders4 1,354 14–18 14% 25% 44% 29% 2% 7 Youth support Project (Tampa, FL) (Dembo et al., 2000) Arrestees entering an intervention program 164 10–18 39% 59% 39% 30% 0% 3 1 This table includes studies that (1) were conducted in the United States, (2) had at least a 3-year followup period, (3) had a sample size of at least 100, (4) examined psychiatric disorder or substance use at two or more points in time, and (5) had one or more publications in a peer-reviewed journal. 2 Demographic characteristics are based on the baseline sample. The sample size at followup(s) may be smaller. Percentages are rounded to the nearest whole number and may not add to 100 percent. 3 W = Non-Hispanic white, A = African American, H = Hispanic, O = Other racial/ethnic group(s). 4 Participants were predominantly adjudicated of felonies. Juvenile Justice Bulletin 3 • Examine how incarceration during adolescence af fects subsequent psychiatric disorders, gang involve ment, criminal behaviors, involvement in the drug trade, violent perpetration and victimization, and mortality. • Study the consequences of incarceration on adult social role performance, as defined in goal 2 above. • Examine how factors in adolescence and young adult hood influence disproportionate minority contact with the justice system in adulthood. sampling and interview Methods • Examine functional impairment and outcomes associ ated with these disorders. • Focus on gender and racial/ethnic disparities in psychi atric and substance use disorders. • Examine how well community mental health and justice systems respond to the needs of these youth. 2. Examine the dynamic relationships among patterns of psychiatric disorders, risky behaviors, mortality, and other long-term outcomes in adulthood. As part of this goal, the researchers do the following: • Examine the development and persistence of risky behaviors such as gang involvement, criminal activity, risk behaviors related to sexual activity and drug use, involvement in the drug trade, and perpetration of violent crimes. • Focus on the antecedents of these risky behaviors (e.g., exposure to violence, abuse, and neglect) and how different types of risky behaviors are interrelated. • Determine the consequences of these behaviors on adult social role performance: educational attain ment, employment, residential independence, inti mate relationships, parenting, and desistance from crime. 3. Examine how patterns of incarceration during ado lescence and adulthood affect long-term outcomes in adulthood. As part of this goal, the researchers do the following: • Collect data on age at incarceration, number of incarcerations and releases, length of incarcerations, time spent in the community between incarcerations, terms of release, and experiences with community corrections (parole, probation, and community supervision). 4 Juvenile Justice Bulletin The following section discusses how the researchers carried out the study, including the demographic characteristics of the sample, the interview design, and the methods they used to track and retain sample participants. Demographic Characteristics of the Sample NJP recruited a stratified random sample of 1,829 youth at intake to the Cook County Juvenile Temporary Detention Center (CCJTDC) in Chicago, IL, between November 20, 1995, and June 14, 1998. CCJTDC is used for pretrial detention and for offenders sentenced for fewer than 30 days. To ensure adequate representation of key sub groups, researchers stratified the sample by gender, race/ ethnicity (African American, non-Hispanic white, His panic, or other), age (10–13 years or 14 years and older), and legal status (processed in juvenile or adult court). All detainees awaiting the adjudication or disposition of their case were eligible to participate in the study. Among them, the researchers randomly selected 2,275 detainees; 4.2 percent (34 youth and 62 parents or guardians) re fused to participate. There were no significant differences in refusal rates by gender, race/ethnicity, or age. Twentyseven youth left the detention center before an interview could be scheduled, 312 left while the researchers attempt ed to locate their caretakers for consent, and 11 others were excluded from the sample because they were unable to complete the interview. The final sample size was 1,829. It was composed of 1,172 males and 657 females; the ethnic breakdown was 1,005 African Americans, 296 non-Hispanic whites, 524 Hispanics, and 4 “other race/ethnicity.” The age range was 10 to 18 years old with a mean of 14.9 years and a median of 15 years. Sample weights are used in statistical analyses; therefore, findings reflect CCJTDC’s population rather than the stratified sample. Table 2 pres ents unweighted sample characteristics and figure 1 (page 6) presents information about sample stratification. • Inclusion of youth processed in juvenile and adult court. The sample includes youth processed as juveniles and oversampled those who were transferred to adult court. The sample has several strengths: • Size. The sample is large enough to investigate uncom mon risk factors and outcomes. • Large subsample of females. There are enough females (657, more than one-third of the sample) to examine gender differences. It is critical to study females because they comprise a substantial proportion of persons in the juvenile and adult justice systems: 30 percent of juvenile arrests, 14 percent of juveniles in residential placement, 25 percent of adult arrests, and 9 percent of incarcerated adults (Puzzanchera, 2009; Snyder, 2011; Sickmund et al., 2011; Glaze, 2010). Interviews Baseline interviews began in November 1995; 13 waves of followup interviews, spanning 16 years, began in Novem ber 1998 and are ongoing. Researchers conduct followup inter views with participants where they are living when their interview is due (in the community or in a correctional facility). A small propor tion of participants are interviewed by telephone if face to-face inter views are not feasible. • Racial/ethnic diversity. The sample is racially and eth nically diverse; it is composed of 1,005 African Ameri cans (54.9 percent), 524 Hispanics (28.7 percent), 296 non-Hispanic whites (16.2 percent), and 4 from other racial/ethnic groups (0.2 percent). Sample Retention Sample retention is critical to the integrity of longitudi nal data. NJP participants are highly mobile and can be difficult to locate. The researchers developed an extensive tracking system to maintain the sample. Participants re ceive thank-you notes, birthday cards, and routine mail ings with gifts throughout the year. All mailings include • Wide age range. At baseline, the age range was 10 to 18 years old (a mean of 14.9 years). Youth 10 to 13 years old were oversampled to provide adequate num bers to examine age differences. Table 2. Unweighted Sample Characteristics of Study Participants Northwestern Juvenile Project (NJP) Characteristic National Residential Placement (1997)3 Sample Size Percentage of Participants1 CCJTDC Population2 1,172 64.1% 93.4% 86.4% 657 35.9% 6.6% 13.6% 1,005 54.9% 82.7% 39.9% Hispanic 524 28.7% 11.2% 18.4% Non-Hispanic White 296 16.2% 5.6% 37.5% 4 0.2% 0.5% 4.2% 372 20.3% 8.6%4 6.5% 1,457 79.7% 91.4% 1,554 85.0% 93.1%5 275 15.0% 6.9%5 Gender Male Female race/ethnicity African American Other Age 10–13 14 and older Mean 14.9 Median 15 Mode 16 Legal status Juvenile court Adult court 4 93.5% CCJTDC = Cook County Juvenile Temporary Detention Center 1 Percentages may not add to 100 percent due to rounding. 2 Jail breakdown as calculated by NJP. 3 Sickmund et al., 2011. 4 Data were available for males only due to stratification. 5 Data were available for males ages 14 and older only. Juvenile Justice Bulletin 5 Figure 1. Sample Stratification for the Northwestern Juvenile Project racial/ethnic Characteristics of Participants (n = 1,829) Non-Hispanic whites in detention center (5.5%) 100 80 80 60 60 Percent Percent 100 Gender of Participants (n = 1,829) Males in detention center (92.7%) 40 20 40 20 0 Non-Hispanic white (n = 296) Hispanic (n = 524) 0 African American (n = 1,005) Age of Participants (n = 1,829) 100 Sample mean = 14.9 years Sample median = 15 years 80 60 Percent Percent Mean age in detention center (15.2) Detention center youth processed in adult court (6.4%) 20 10 11 12 13 14 15 16 17 18 Age (years) change of address cards. Returned mail indicates the participant has been lost to followup and more extensive tracking procedures are required. Inter viewers update con tact information at ever y inter view. To track participants, researchers use the telephone, Internet, agency contacts, and contacts the participant has previously provided; they also visit last-known addresses. Table 3 shows participation rates (82–97 percent). Considerations for Measurement The following goals have guided the choice of measures. Ensure comprehensiveness. Content areas reflect prior empirical studies of psychiatric and substance use disor ders, criminal recidivism, and risk and protective factors. 6 60 40 40 0 Male (n = 1,172) Legal status of Participants (n = 1,829) 100 80 Female (n = 657) Juvenile Justice Bulletin 20 0 Adult court (n = 275) Juvenile court (n = 1,554) Maximize sensitivity. Because many of the participants’ responses score at the extremes of conventional measures (e.g., very low on cognitive assessments and very high on many behavioral assessments), the researchers selected instruments that are sensitive in extreme ranges (Dowling, Johnson, and Fisher, 1994; Hawkins et al., 2003; Needle et al., 1995; Weatherby, Needle, and Cesari, 1994). When ever possible, the researchers chose instruments designed for high-risk populations who, on average, have more verbal deficits than general population youth. As needed, the research team refined the coding to capture smaller gradations of symptoms, behaviors, and attitudes. Minimize cultural bias. Standardized measures in some areas—demographics, family structure, and family functioning—are inappropriate for many delinquent youth because they often do not live in traditional families. It is common for these youth to live in single-parent house holds, move frequently, or be cared for by siblings or extended family. The researchers revised standard instru ments to capture variations in these family systems. Maximize comparability to the researchers’ baseline data. In some cases, the research team developed new in struments that were superior to those used in the baseline assessments or that better addressed participants’ evolving developmental stages. Where they used new instruments, researchers maximized their comparability to the instru ments used at earlier waves. Maximize efficiency. To complete inter views within the limits of most participants’ attention span and motivation, the researchers combined some instruments and con densed others, with advice from authors or experts in the field. Researchers worked with participants to construct a timeline of events since their last inter view, in the past year, and in the past 3 months to help them recall the timing of behaviors throughout the interview. Interviewers con ducted reliability checks with mock participants following training and annually thereafter to maintain consistency. Maximize comparability to other studies. Whenever possible, the research team selected commonly used in struments to maximize the likelihood that these data could be compared with other large studies of adolescents and at-risk populations. NJP draws questions from the Nation al Institute of Mental Health’s Methods for the Epide miology of Child and Adolescent Mental Disorders study (Goodman et al., 1998); the National Survey on Drug Use and Health (Substance Abuse and Mental Health Ser vices Administration, 2004); the National Institute on Drug Abuse’s Risk Behavior Assessment (Dowling, Johnson, and Fisher, 1994; Needle et al., 1995; Weath erby, Needle, and Cesari, 1994); the Denver Youth Survey (Institute of Behavioral Science, 1991); the Seattle Social Development Project (Hawkins et al., 2003); the Wash ington, DC, Metropolitan Area Drug Study of Juveniles (National Institute on Drug Abuse, 1995); the Child and Adolescent Functional Assessment Scale (Hodges, 1994); and the Child and Adolescent Ser vices Assessment– Modified (Burns et al., 1994). Statistical Manual for Mental Disorders (DSM–III–R)), which was the most recent version available (in both Eng lish and Spanish) at the time of those assessments (Bravo et al., 1993; Shaffer et al., 1996). The DISC is a highly structured diagnostic interview that contains detailed probes into symptoms. For followup interviews, the research team modified diag nostic assessments in accordance with improvements in di agnostic technology and the age of participants. The team administered the DISC version 4.0 (DISC–IV, which is based on the DSM–IV), which its authors modified for use with young adults, at the followup inter views (Fisher et al., 1997; Shaffer et al., 2000). In addition, the team used the Diagnostic Inter view Schedule, version IV (DIS–IV, which is based on the DSM–IV) to assess disorders that either were not assessed or that the DISC–IV did not adequately assess, including substance use disorders, schizophrenia, cognitive impairment, and antisocial personality disorder (Shaffer et al., 2000). By 2002, most of the participants in the sample were 18 years old or older, at which time NJP stopped using diagnostic tools designed for children and adolescents and began administering the World Mental Health– Composite International Diagnostic Inter view (WMH– CIDI) for adults. The researchers use the WMH–CIDI to assess the following DSM–IV disorders: depression, mania, panic, generalized anxiety, and posttraumatic stress disorder (PTSD), as well as suicidality (Kessler and Üstün, 2004). The WMH–CIDI is a comprehensive measure that Table 3. Participation Rates Followup Interview1 (years) 3 Diagnostic Measures NJP employs standardized diagnostic instruments that are appropriate for the developmental stage of the participants at each wave. The baseline assessments used the Diagnos tic Inter view Schedule for Children (DISC), version 2.3 (based on the revised third edition of the Diagnostic and Type Full Interviews Completed N N Percent3 1,829 1,751 97.5% 3.5 Subsample 997 942 95.5% 4 Subsample 997 914 93.1% Full 1,829 1,625 91.5% Full 1,829 1,489 84.2% Full 1,829 4.5 6 8 The sidebar “Northwestern Juvenile Project: Key Areas of Measurement” (pages 8–9) lists key variables that NJP assesses. Planned Sample2 4 4 1,442 82.3% 10 5 Subsample 800 655 85.5% 11 Subsample5 800 667 87.4% 12 Full 1,829 1,520 87.7% 1 The 13- to 16-year followup interviews are ongoing; participation rates are not yet available. 2 Number of interviews planned for the followup. Number of interviews completed divided by the number of participants still living at the close of the followup. Some participants completed interviews beyond the interview window. 3 4 The 3.5- and 4-year followup interviews include only a random subsample of participants (n = 997). 5 The 10- and 11-year followup interviews include only participants who had received the HIV/AIDS assessment at baseline (n = 800). Juvenile Justice Bulletin 7 NorthwesterN JuveNiLe ProJeCt: KeY AreAs of MeAsureMeNt Sociodemographic Characteristics Educational performance and attainment Employment Characteristics of employment Employment stability Compensation Attitudes and satisfaction Perceived barriers to securing employment Income Legal vs. illegal source Allocation of resources Public assistance status Other financial assistance (e.g., benefits, resources) Residential stability and living situation Type of residence Homelessness Marital status Acculturation (Hispanic participants) Psychiatric Disorders Psychotic disorders Psychosis Schizophrenia Affective disorders Gambling disorder Substance use disorders Alcohol abuse and dependence disorder Marijuana use and dependence disorder Other drug use and dependence disorders Substance Use Type of substance Recency of use Mode of use Use during pregnancy Context of use Inhibition Habitual use Readiness for change Criminal Activity Onset Type Frequency Recency Context Relationship to victim Working alone or with others Major depressive disorder Arrest history Dysthymic disorder Access to and use of guns Mania Hypomania Suicidality Anxiety disorders Separation anxiety disorder Overanxious disorder Generalized anxiety disorder Incarceration History Stays in correctional facilities Age at incarceration(s) Length of stay Type of facility Reentry from incarceration Panic disorder Number of release(s) into the community Posttraumatic stress disorder Resources at release Attentional/disruptive behavioral disorders Living arrangement after release Attention-deficit/hyperactivity disorder Employment after release Oppositional defiant disorder Relationship with community corrections (e.g., parole, probation) Conduct disorder 8 Antisocial personality disorder Juvenile Justice Bulletin Health and Impairment Functional impairment Global impairment Domain-specific impairment Physical functioning Infection, disease Injury Chronic pain Sexually transmitted infections Sex risk behaviors Drug risk behaviors Global health and exercise Cognitive functioning Intellectual functioning (composite IQ, verbal, nonverbal) Academic achievement (reading, arithmetic) Quality of life Mortality Life Events Milestones Future orientation Attitudes toward deviance and risky behavior Service Utilization Mental health and substance use services Provider Level of care Community-based services Inpatient services Correctional services Characteristics of services Satisfaction with services Payment for services Perceived barriers to mental health and substance use services Physical healthcare utilization Interpersonal and Community Characteristics Family of origin characteristics Household composition Biological parental contact Parental monitoring and disciplinary practices Marriage Primary caretaker(s) during childhood Childbirth Caretaker risk factors Educational attainment Substance use Employment Psychiatric problems Adverse life events Childhood maltreatment Physical abuse Sexual abuse Neglect Loss of intimates Trauma and exposure to violence Criminal involvement Marital and intimate relationships Quality of relationship Behaviors and employment of partner Parenting practices and attitudes Social support Deviant and peer associations Victimization Peer criminal activity Sexual Peer substance use Domestic Gang involvement Criminal Gang pressure toward deviance Attitudes and Beliefs Self-esteem Structure and function of social support network Sense of “mattering” to other(s) Neighborhood characteristics Self-efficacy Neighborhood safety Religiosity Ease of obtaining drugs Perceived violence Juvenile Justice Bulletin 9 provides information on both prevalence and severity of these disorders. It builds on earlier versions of the CIDI and DIS–IV (Kessler and Üstün, 2004). overview of selected findings from NJP NJP continues to use sections of the DIS–IV to assess (1) antisocial personality disorder because it is not in cluded in WMH–CIDI 2000, (2) substance use disorders because the WMH–CIDI collapses many types of drugs into an “other” categor y rather than identifying specific drugs abused, and (3) schizophrenia because the WMH– CIDI screens for psychosis only. Published data from NJP have been cited in the Report of the Surgeon General’s Conference on Children’s Mental Health (U.S. Department of Health and Human Services, 2000), by national advocacy groups, and in reports to Congress. Analy ses of data from NJP are ongoing. To date, articles have been published in the Archives of General Psychiatry, Ameri can Journal of Public Health, Journal of Adolescent Health, Journal of the American Academy of Child and Adolescent Psychiatry, Journal of Consulting and Clinical Psychology, Pediatrics, and Psychiatric Services. A brief summar y of some key findings follows (also see the sidebar, “Overview of Se lected Findings From the Northwestern Juvenile Project”). Other Measures More information about the measures used to assess other variables listed in the sidebar on pages 8–9 will be pro vided in subsequent bulletins. overview of seLeCteD fiNDiNGs froM the NorthwesterN JuveNiLe ProJeCt Characteristics of Youth in Detention trauma and Posttraumatic stress Disorder Prevalence of Psychiatric Disorders • Ninety-three percent of participants had been exposed to one or more traumas prior to baseline. • Psychiatric disorders are prevalent: 66 percent of males and 74 percent of females met the criteria for at least one disorder at the baseline interview in detention. • Significantly more males than females reported at least one trauma. • Substance use disorders are the most common: 51 percent of males and 47 percent of females met diagnostic criteria at baseline. • Eleven percent of the sample met diagnostic criteria for posttraumatic stress disorder (PTSD) in the past year; more than half of participants with PTSD reported witnessing violence as the precipitating trauma. • Rates of many disorders were greater among females and non-Hispanic whites. Multiple Disorders • Having more than one disorder is common: 46 percent of males and 57 percent of females had two or more disor ders at baseline. • Compared with participants who did not have a major men tal disorder (MMD), those with an MMD had significantly greater odds of also having a substance use disorder. • Multiple substance use disorders are also common: Among participants with an alcohol disorder, four out of five also had one or more drug disorders. Prevalence of Psychiatric Disorders Among Youth Processed as Adults • Rates of psychiatric disorder among youth processed in adult criminal courts are similar to the rates for youth processed in juvenile courts: 66 percent had at least one psychiatric disorder and 43 percent had two or more psy chiatric disorders. 10 Juvenile Justice Bulletin • Among participants with PTSD, 93 percent also met diagnostic criteria for at least one comorbid psychiatric disorder. suicidality • More than one in three juvenile detainees (and nearly half of female detainees) had felt hopeless or thought about death in the 6 months prior to detention. • One in ten juvenile detainees reported thinking about committing suicide in the past 6 months; 1 in 10 had ever attempted suicide. • Recent suicide attempts were most common in females and in youth with major depression and generalized anxiety disorder. • Less than 50 percent of detainees with recent thoughts of suicide had told anyone about their ideation. Child Maltreatment • Four out of five juvenile detainees reported ever having been physically abused. Characteristics of Youth in Detention This section discusses characteristics of the youth who were sampled at detention. Prevalence of psychiatric disorders. Psychiatric disorders are prevalent among juvenile detainees; in NJP, almost three-quarters of females and two-thirds of males in de tention had one or more psychiatric disorders. The rates of disorder remained high even after excluding conduct disorder. Substance use disorders, the most common type of disorder, affected more than 50 percent of males and 47 percent of females (Teplin et al., 2002, 2006). Overall, females were significantly more likely than males to have a psychiatric disorder. Non-Hispanic whites were also • Official records underestimate the prevalence of childhood maltreatment; only 17 percent of participants who reported any physical abuse, 22 percent who reported the great est level of abuse, and 25 percent who required medical attention as a result of abuse had a court record for this maltreatment. Prevalence of hiv/AiDs risk behaviors • Ninety-five percent of the sample engaged in 3 or more HIV/AIDS risk behaviors; 65 percent engaged in 10 or more risk behaviors. • Participants with substance use disorders were more likely to engage in HIV/AIDS risk behaviors. • HIV/AIDS risk behaviors are persistent: More than twothirds of youth who engaged in 10 or more risk behaviors at baseline persisted with at least 10 risk behaviors 3 years later. significantly more likely than African Americans or Hispan ics to have any disorder. Multiple disorders. Many youth have more than one dis order; 57 percent of females and 46 percent of males met diagnostic criteria for two or more disorders at baseline. Detained youth were more likely to have substance use disorders comorbid with attention-deficit/hyperactivity disorder or other behavioral disorders than any other com bination of disorders. Participants with a major psychi atric disorder (e.g., major depression, mania, psychosis) were significantly more likely to also have a substance use disorder than were those without major psychiatric dis orders (Abram et al., 2003; Teplin et al., 2006). Multiple substance use disorders are also common; more than 21 • The likelihood of detection and treatment was greater among youth with a current major psychiatric disorder or a history of receiving treatment, or among youth who reported suicidality. • The likelihood of detection and treatment was lower among racial/ethnic minorities, males, older detainees, and youth transferred to adult court. functional impairment • Twenty-two percent of youth had marked global impair ment that required intensive interventions from multiple sources of care. • Only 8 percent of the sample had no noteworthy impairment. Development of Antisocial Personality Disorder Perceived barriers to Accessing Mental health services • Three years after the baseline interview, 17 percent of de tained youth had developed antisocial personality disorder (APD). • Eighty-five percent of youth with psychiatric disorders re ported at least one perceived barrier to accessing services. • Significantly more males than females developed APD. • The most common barriers were the belief that the problem would go away or could be solved on its own, uncertainty about the appropriate place to get help, and difficulty ob taining help. Outcomes of Juvenile Delinquents Detecting and treating Psychiatric Disorders • Among detainees with major psychiatric disorders and functional impairment, 15 percent received treatment in the detention center and 8 percent received treatment in the community by the time of case disposition or 6 months after detention. Mortality • The overall mortality rate of juvenile detainees an average of 7.1 years after they were detained was more than four times as large as the rate in the general population. • The mortality rate of female detainees was nearly eight times the rate in the general population. • Ninety-six percent of deaths were homicides or legal interventions (e.g., the youth was killed by police); among homicides, 93 percent resulted from gunshot wounds. Juvenile Justice Bulletin 11 disorder. Fewer than half of detainees with recent thoughts of suicide had told anyone about their ideation (Abram, Choe et al., 2008). percent of participants had two or more substance use disorders. The most prevalent combination of substance use disorders was alcohol and marijuana. Among partici pants with an alcohol disorder, four out of five detainees also had one or more drug use disorders (McClelland et al., 2004). Prevalence of psychiatric disorders among youth pro cessed as adults. Youth processed in adult criminal court had rates of psychiatric disorder similar to those among youth processed in juvenile court; 66 percent of youth processed in criminal court had at least one psychiatric dis order and 43 percent had two or more types of disorder. Among youth transferred to criminal court, those sen tenced to prison had significantly greater odds of having a disruptive behavior disorder, a substance use disorder, or comorbid affective and anxiety disorders (Washburn et al., 2008). Child maltreatment. Child maltreatment is common among detained youth; 83 percent of detainees reported physical abuse received from parents, stepparents, foster parents, or other caretakers. Despite the high rates of selfreported physical abuse, a small proportion of all incidents of maltreatment come to the attention of authorities: Only 17 percent of those who reported any type of physical abuse, 22 percent of those who reported the most se vere level of physical abuse, and 25 percent of those who reported needing medical attention as a result of physical abuse had a court record of abuse or neglect (Swahn et al., 2006). Trauma and PTSD. Exposure to trauma is common among juvenile detainees; nearly all of the NJP participants (93 percent) experienced one or more traumas in their lifetime at baseline. Significantly more males than females reported having experienced a traumatic event (Abram et al., 2004). More than 1 in 10 detainees met diagnostic criteria for PTSD during the year prior to the baseline in ter view. Of those participants who met these criteria, more than half reported witnessing violence as the precipitating trauma. Among participants with PTSD, 93 percent also met criteria for at least one comorbid psychiatric disorder (Abram et al., 2007). Prevalence of HIV/AIDS risk behaviors. Risk for HIV/ AIDS infection is high among detained youth, regard less of gender, race/ethnicity, or age. Approximately 95 percent of detained youth engaged in 3 or more HIV/ AIDS risk behaviors, and 65 percent engaged in 10 or more HIV/AIDS risk behaviors. Significantly more African Americans than non-Hispanic whites engaged in sexual risk behaviors, while significantly more nonHispanic whites than African Americans engaged in drug risk behaviors (Teplin et al., 2003). Detained youth with substance use disorders, either with or without comorbid major psychiatric disorders, were more likely to engage in HIV/AIDS risk behaviors (Teplin, Elkington et al., 2005). Youth continue to engage in HIV/AIDS risk behaviors over time; more than two-thirds of youth who engaged in at least 10 risk behaviors at their baseline interviews persisted in at least 10 risk behaviors 3 years later (Romero et al., 2007). Suicidality. More than one-third of juvenile detainees felt hopeless or thought about death in the 6 months before detention. Approximately 1 in 10 juvenile detainees (10.3 percent) reported thinking about committing suicide in the past 6 months, and 11 percent had attempted suicide at some point in their lives. Recent suicide attempts were most prevalent among females and among youth who experienced major depression and generalized anxiety Perceived barriers to accessing mental health services. Approximately 85 percent of detained youth with psy chiatric disorders reported at least one perceived barrier to accessing ser vices. The most common barrier was the belief that problems would go away without help or that the individual could solve problems independently. Youth also reported that they were unsure of where or how to obtain help and that help was too difficult to obtain. Many 12 Juvenile Justice Bulletin “Three years after detention, African American and Hispanic males living in the community were more likely to be impaired than non-Hispanic whites and females.” participants denied having a problem; detained youth who do not recognize their mental health needs or who feel that they can resolve their problems alone are unlikely to seek ser vices or cooperate with services when they receive them (Abram, Paskar et al., 2008). Key Outcomes of Study Participants This section presents some of the outcomes of the youth who participated in NJP. Detecting and treating psychiatric disorders. Among detainees who had major psychiatric disorders and associ ated functional impairments, records showed that only 15 percent had been treated in the detention center before release and that even fewer (8 percent) had been treated in the community during the 6 months following their interview in detention (Teplin, Abram et al., 2005). The likelihood that disorders would be detected or treated was greater among youth who had a current major psychiatric disorder, a history of receiving treatment, or who reported suicidality at intake, whereas the likelihood was lower among racial/ethnic minorities, males, older detainees, and detainees transferred to adult court for legal process ing (Teplin, Abram et al., 2005). Functional impairment. Three years after detention, most participants continue to struggle in one or more major life domains; more than one in five participants had markedly impaired functioning that required intensive intervention. These youth failed to meet age-appropriate social, occupational, and interpersonal indicators. Only 8 percent of the entire sample demonstrated no noteworthy impairment (Abram et al., 2009). Development of antisocial personality disorder. Nearly one-fi fth (17 percent) of male juvenile detainees devel oped antisocial personality disorder (APD) approximately 3 years after detention. Significantly more males than females developed APD, but no differences were found by race/ethnicity. A diagnosis of conduct disorder (CD) and the number of CD symptoms endorsed were significantly associated with developing modified APD (M–APD; i.e., APD without the CD requirement). Subsequent analyses, however, indicated that the number of CD symptoms affects risk for M–APD: Participants with five or more CD symptoms were significantly more likely to develop M–APD than those with fewer than five symptoms. Analyses also indicated that several other disorders were significantly associated with developing M–APD, including dysthymia, alcohol use disorder, and generalized anxiety disorder (Washburn et al., 2007). Mortality. Based on the total number of deaths of 15- to 24-year-old participants that occurred an average of 7.1 years after baseline, standardized mortality rates among ju venile delinquents were more than four times greater than rates in the general population. Mortality among females was nearly eight times greater than in the general popula tion. For both males and females, all deaths resulted from external causes; 96 percent of the deaths were the result of homicide or legal inter vention (e.g., the study participant was killed by police). Gunshot wounds were the primary means of death (93 percent of the homicides) (Teplin, McClelland et al., 2005). summary As the first large-scale, prospective longitudinal study of drug, alcohol, and psychiatric disorders in juvenile detain ees, the Northwestern Juvenile Project provides muchneeded insight into the types of services and treatment that youth in the juvenile justice system most require. Findings from the study have been published in peerreviewed journals, cited in the Surgeon General’s Report on Children’s Mental Health and in reports to Congress, and used by national advocacy groups. The findings presented in this and future bulletins will help build the empirical foundation on which practition ers will develop and implement appropriate ser vices to facilitate youth’s successful reentry into the community. Analyses and data collection are ongoing. Juvenile Justice Bulletin 13 references Abram, K.M., Choe, J.Y., Washburn, J.J., Romero, E.G., and Teplin, L.A. 2009. 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Psychiatric Services 59(9):965–973. Weatherby, N.L., Needle, R., and Cesari, H. 1994. Validity of self-reported drug use among injection drug users and crack cocaine users recruited through street outreach. Evaluation and Program Planning 17:347–355. Juvenile Justice Bulletin 15 U.S. Department of Justice Office of Justice Programs Office of Juvenile Justice and Delinquency Prevention *NCJ~234522* PRESORTED STANDARD POSTAGE & FEES PAID DOJ/OJJDP Permit No. G–91 Washington, DC 20531 Official Business Penalty for Private Use $300 Acknowledgments Linda A. Teplin, Ph.D., is the Owen L. Coon Professor and Vice Chair for Research in the Department of Psychiatry and Behavioral Sciences at the Feinberg School of Medicine, Northwestern University, Chicago, IL, as well as Director of the Department’s Program in Health Disparities and Public Policy. Karen M. Abram, Ph.D., is Associate Professor and Associate Director, Health Disparities and Public Policy, in the Department of Psychiatry and Behavioral Sciences at the Feinberg School of Medicine. Jason J. Washburn, Ph.D., ABPP, is Assistant Professor and Director of Education and Clinical Training in the Division of Psychology, Department of Psychiatry and Behavioral Sciences at the Feinberg School of Medicine. He is also Director of the Center for Evidence-Based Practice at Alexian Brothers Behavioral Health Hospital, Hoffman Estates, IL. Leah J. Welty, Ph.D., is Assistant Professor in the Department of Preventive Medicine and the Department of Psychiatry and Behavioral Sciences at the Feinberg School of Medicine. She is also a biostatistician in the Biostatistics Collaboration Center at the Feinberg School of Medicine. Jennifer A. Hershfield, M.A., is a doctoral candidate in the Division of Psychology, Department of Psychiatry and Behavioral Sciences at the Feinberg School of Medicine. Mina K. Dulcan, M.D., is a Professor in both the Department of Psychiatry and Behavioral Sciences and the Department of Pediatrics at the Feinberg School of Medicine. She is also the Head of the Department of Child and Adolescent Psychiatry at the Ann & Robert H. Lurie Children’s Hospital of Chicago. The authors thank all of their agencies for their collaborative spirit and steadfast support. They also thank the research participants for their time and willingness to participate as well as the Cook County Juvenile Temporary Detention Center, Cook County Department of Corrections, and Illinois Department of Corrections for their cooperation. The research described in this bulletin was supported in part by grants 1999–JE– FX–1001, 2005–JL–FX–0288, and 2008–JF– FX–0068 from the Office of Juvenile Justice and Delinquency Prevention (OJJDP), U.S. Department of Justice. Points of view or opinions expressed in this document are those of the authors and do not necessarily represent the official position or policies of OJJDP or the U.S. Department of Justice. The Office of Juvenile Justice and Delinquency Prevention is a component of the Office of Justice Programs, which also includes the Bureau of Justice Assistance; the Bureau of Justice Statistics; the National Institute of Justice; the Office for Victims of Crime; and the Office of Sex Offender Sentencing, Monitoring, Apprehending, Registering, and Tracking. NCJ 234522