Abstract
Despite only constituting 9.9% of the population, juveniles aged between 10 and 16 accounted for about 25% of the total offender population in Australia in 2000–2001 [1]. Compared with adults, juveniles were less likely to commit violent crimes such as homicide, assault and sexual assault, but more likely to commit other crimes such as robbery, unlawful entry with intent and motor vehicle theft [2].
Adolescents who commit serious offences experience a broad range of psychosocial problems, as well as reduced educational, occupational and social opportunities [3]. The mental health needs of adolescents in juvenile care should therefore cause the public great concern, due to the risk that these young people pose for themselves through deliberate self-harm, suicide and substance abuse, and to the community through the cost of unemployment, lost opportunities and recidivism. Despite this, those working in the juvenile justice context may still have difficulty making a link between mental health issues and the origin and maintenance of serious and repeat juvenile offending [4].
A greater understanding of the prevalence of the mental health problems of juveniles in detention is therefore needed in order that resources may be correctly targeted to those most at need. A number of American and European studies have consistently reported a high prevalence of mental health problems in young people within the juvenile justice system [5–8]. Those Australian studies that have examined the level of mental illness of young people in juvenile detention, have also found disturbingly high rates of substance abuse and a wide range of psychiatric illness, including major depression, chronic dysthymia, anxiety disorders and posttraumatic stress [9–13]. More importantly, young people involved in the juvenile justice system frequently have one or more co-occurring mental disorders. As a result, correct diagnosis and treatment has become not only complex, but critical, with up to 52% of the sample population reported as suffering from three or more mental health problems, excluding conduct disorder [11].
To date, responses to the complex needs of adolescent forensic mental health (AFMH) have frequently been based on initiatives developed in the US. While much literature continues to be published in America concerning AFMH, what works there may not be transferable in Australia. A number of critical differences exist within the culture and characteristics of the US population that create issues which may not be relevant to the Australian forensic youth population. The American ‘gun culture’, which generates significant social and political debate in that country is not entrenched in Australian society. It has been reported that although percentages have decreased, over 18% of American high school students still carry a concealed weapon, while almost 6% have carried a gun to school over the previous 12 months [14], [15]. One cross-sectional elementary school study found that one in 12 American fourth and fifth-grade students reported carrying a weapon to school during the past 30 days [16]. Within the US, there is a growing and widespread perception that juvenile crime is therefore inevitable, a fact of life in an increasingly violent society. The philosophy of a ‘rehabilitative approach to juvenile justice’ has all but disappeared in the US [17]. On the other hand, there has been a backlash in the US in some jurisdictions regarding the failure of government to assist offenders. As a consequence of this, offender groups have taken successful class-action suits against government for failing to address problems they were able to prove related to their propensity to reoffend [4]. Such an ethos has not yet, thankfully, become established here in Australia.
A further critical difference between Australia and the US is the racial distribution of juveniles in detention. Indigenous young people are over-represented in juvenile detention centres in every state and territory in Australia. It is reported that indigenous young people were 21 times more likely to be in detention centres than non-indigenous juveniles Australia-wide, with the over-representation population ratio as high as 41 in Queensland and 31 in Western Australia [18]. In the US, comparatively few young people in detention are indigenous, with African-American forming the majority of detainees [5]. While both cohorts of young people come from communities that are often characterized by poverty, unemployment and social disadvantage, it would be reductionistic to attempt to equate the two.
Finally, in the US, both public and private health systems have increasingly been dominated by managed care [19–21]. Disorders that are commonly seen in the juvenile justice population, such as oppositional defiant disorder and conduct disorder, attention deficit hyperactive disorder and substance abuse disorders, may be constrained by narrow guidelines that restrict treatment within the managed care system [22], or result in the failure of such young people being seen due to a reduction to services in public health [23]. Outcome measures formulated in American settings may therefore not be applicable in an Australian context, though they could still be incorporated into broad system reform. The challenge is now to identify best-practice methods of adolescent forensic mental health assessment, management and service delivery in Australia.
Need for system reform
Changes in systems of mental health care have evolved over time to reflect the changing nature of societal norms and known or available treatments for mental illness. The restructuring of mental health services has occurred throughout Australia in the context of the continuing implementation of the National Mental Health Policy [24], the First National Mental Health Plan [25] and Second National Mental Health Plan [26]. Unfortunately, young people who are more likely to fall into the juvenile justice system, including those who are indigenous, homeless, from lower socio-economic backgrounds and single parent or broken families, have been identified as not receiving the benefits of this system reform [27]. Proposed strategies to meet the mental health needs of these young people within the juvenile justice system include comprehensive mental health assessments while in detention, the development of supports for community child and youth health services upon referral of such patients, and improved linkages between mental health services and youth sector agencies to ensure that mentally ill offenders are provided with an appropriate and accessible continuum of care [27].
The high prevalence of comorbidity between mental health and substance abuse has been recognized at a national level, with the National Standards for Mental Health Services [28] and the National Drug Strategic Framework [29] each identifying the need for specialized services for adults within the criminal justice system. There is also a growing body of evidence showing that significant comorbidity exists between mental health problems and drug and alcohol abuse within AFMH [30–32]. In a recent American study, Teplin reported approximately 50% of young people in detention met the diagnostic criteria for a substance abuse disorder [5], while Lennings and Pritchard found 90% of young people in Queensland detention centres had some degree of alcohol or drug abuse [30]. Appropriately targeted and co-ordinated mental health and substance abuse services should therefore be offered to all juveniles referred for mental health problems within the detention centre. The rise in substance abuse, particularly volatile substance abuse (chroming), is of increasingly concern, particularly within indigenous communities [33], [34]. The media's representation of volatile substance inhalation has significant implications for policy development, with welfare agencies in Victoria warning that recent political controversy over the issue of supervised chroming is beginning to force the problem underground [35]. Although there is scant data about managing the needs of young people with chronic problems related to inhalants and chroming, the Victorian Alcohol and Drug Association has recommended that young people engaged in volatile substance abuse should have access to a broad range of intervention and supports, including mental health and community health, family support, employment and education [36]. It was noted that at present these comprehensive interventions are not readily accessible or available to at-risk young people. Psychiatrists working within the field of AFMH should therefore take a prominent position in the debate and be involved in creating measures to assist in reducing the prevalence of chroming and other substance abuse in this population.
A broad range of factors, including low self-esteem and a difficult temperament [37], [38], poor academic achievement [39], [40], high peer tolerance for deviancy [41] and adverse familial events such as parental unemployment or separation [42], [43], poor parent–child communication [39], poor parenting skills [44], [45] and supervision [46] and low parental empathy [41], have been associated with adjustment difficulties that may lead to an increased risk of delinquent behaviour and mental health problems. As issues of risk assessment are closely linked to both prevention and treatment, a comprehensive family history should move beyond a mere psychiatric diagnosis to consider possible environmental and social issues that may be contributing to current delinquent behaviour and social functioning [47]. One of the general principles in the assessment of risk in adolescents is therefore the ability to gather accurate information from several sources. However, given that young people within the juvenile justice system commonly report fewer externalizing symptoms than parents or teachers [48], inaccurately report their own level of impairment and have limited insight and judgement regarding the impact their social disadvantage, family dysfunction and individual issues have on their forensic activities and mental health problems [49], conducting a comprehensive psychiatric assessment on young people within detention is challenging, due to the frequent unavailability of parental, teacher or other collateral history and lack of comprehensive patient charts. The ability to obtain this collateral history from other agencies may be of critical importance in the development of a comprehensive diagnostic formulation and management plan.
Policy makers, community leaders, funding agencies and stakeholders are now recognizing AFMH as a complex social and public health issue, with the need for adequate assessment and treatment of mental health problems, and drug and alcohol dependencies being integral in the management of juveniles within the juvenile justice system. The theme of a national youth justice conference, ‘Making the Youth Justice System Work Better’, was chosen to reflect a growing commitment to improving the quality of services available to young people within the justice system. The aims of the conference were to showcase ‘best practice programs in working with young people within the justice system, identify improvement in the operation of the system, and establish strategic alliances between professionals working within the system’ [50]. Mental health and disability, and drug use were identified as two of the four main streams of the conference, reflecting the increasing awareness of the importance of mental health issues in these young people. Of the 10 ‘best practice’ programs showcased between these two streams, only half were co-ordinated by medical or allied health professionals, which may reflect a belief that the management of such issues is no longer the sole domain of professional mental health workers.
A transdisciplinary approach
Although it may be argued that a holistic approach to mental health is no longer the sole domain of psychiatry, psychiatrists have a long tradition of systemic analysis which places the formulation of a patient's problems within the context of their psychosocial environment, including the peer group, school, family, community and physical and cultural surroundings. Within community-based mental health clinics, multidisciplinary teams with psychiatric input are frequently used to treat adolescents with mental illness. Such an approach draws on the varied skills and training that different professions bring into the clinic. Likewise, within the juvenile justice system, a co-ordinated system of referral, assessment and treatment of young people with mental illness needs to occur within the detention centre and beyond. Recognizing the broad systemic needs of these delinquent young people, a ‘transdisciplinary approach’ is required. A transdisciplinary approach may be defined as an integrated system of care, including mental health, community health, drug and alcohol and non-medical services, that functions as a co-ordinated network to meet the diverse and changing needs of young people within the juvenile justice system. Such a system of care goes beyond the multidisciplinary approach offered in community clinics. Interagency task forces, spanning not only mental health and drug and alcohol rehabilitation services, but also incorporating key workers across different departments who understand the limitation of available resources, collaborate to form co-ordinated bodies that formulate treatment plans to meet the systemic needs of these youth, reduce the risk of recidivism, avoid departmental duplication, facilitate transfer back into the community and promote both positive wellbeing and lifestyle.
A guiding principle of such a system of care is the recognition that young people and their families within the juvenile justice system have multiple needs that cross the boundaries of traditional mental health service delivery. However, it is not uncommon for agencies to resist collaboration, confusing shared goals with their differing individual modus operandi. To oversimplify some of the complexity, government departments of families and child welfare use ‘protective interventions’, the Departments of Justice use ‘corrective interventions’, while within mental health there is a focus on ‘treatment interventions’ [51]. Despite differences in preferred interventions, a system of care that supports a comprehensive continuum of services needs to be established in order to create room for all involved in a juvenile's care. The need is for the development of a system of care that addresses the mental health, physical health, drug and alcohol problems which frequently present in these young people but are traditionally managed by different agencies that don't work easily together. The challenge is to identify a preferred system of holistic care which allows for a seamless transfer of the young person from the detention centre to the community in a supported fashion that encourages ongoing mental health follow-up, reduces substance abuse, strengthens family and community supports and decreases the risk of recidivism.
The mental health care system provided to young people in detention must at the very least be developed within a framework that integrates the different service agencies dealing with these young people and their families. Agencies are frequently unable to provide effective services to juveniles within the juvenile justice system in the piece-meal, stop gap measures that currently exist. Restricted access to services, duplication of effort, missed opportunities to identify youth in need and philosophical or ‘turf’ barriers, must be replaced by co-operative endeavours that promote a common understanding between agencies and assist in consolidating scarce resources. Fragmented resources need to be integrated in a fashion that encourages collaboration between agencies, families and the community in order to meet the needs of these ‘trans-systemic’ youth.
Mental health professionals should ensure that services offered within detention must be transferable and at a comparable level to that offered in the community. It makes little sense to pour a great deal of resources into a young person's life during their time in detention, only to return them to the same sub-optimal environment on release without an adequate support system. Such support systems need to be co-ordinated with community mental health clinics, drug and alcohol services, indigenous services and other human service sectors. The involvement of the young person's family, peer group and partner should be included in service planning and delivery, especially in those areas sensitive to their ethnic and cultural values. Specialized ‘bridging’ services should be offered that allow the review of mental health management plans, established while the patient was in detention, give advice to community clinicians concerning AFMH issues and provide opportunities for joint assessments and a provision for shared intervention.
Although increasing studies have demonstrated the high prevalence of psychiatric illness within this population, few studies have examined the effectiveness of treatment-demonstrated outcome measures [52]. Recently, the Consensus Conference published wide-ranging recommendations aimed at addressing deficits in the management of juveniles with mental health problems within the youth justice setting in the US [49]. Guidelines included the provision for early evidence-based mental health screening of all young people following arrival in detention and prior to release back into the community, the provision for mental health assessment using wideranging collateral information from parents, teachers and other service providers, and the importance of ongoing staff training. This is important, as better co-ordination of existing services within community clinics alone does not necessarily lead to better outcomes [53–55]. European authors have made similar recommendations [7], [8]. Given the limited number of mental health professionals trained in AFMH, it was viewed as unreasonable to assume that all juveniles would receive comprehensive mental health screening or assessment. Other professionals, including those within the departments of juvenile justice, education and child welfare, would be required to function as ‘gatekeepers’ in the referral process [49]. A transdisciplinary approach, with its emphasis on interagency dialogue and collaboration, is well-placed to incorporate these recommendations into its service delivery.
A process to demonstrate what actually works within AFMH is required. High quality, evidence-based and locally co-ordinated services which allow for the monitoring and evaluation of service delivery that reflects a young person's ever-changing needs are needed. ‘Need’ should not be designated as simply a high score on a psychological questionnaire, or by the presence of psychiatric diagnoses according to the guidelines of DSM-IV or ICD-10. Such definitions are of limited use when planning services to young people within the juvenile justice system, as they do not take into account the complex social environment of this marginalized group.
Steps to system reform
In order to improve the effectiveness of our responses to AFMH, quality Australian initiatives stemming from quality Australian studies are required which address the unique needs of this population. Such a process could include three distinct steps. The first step would include collaborative, multi-site studies of the prevalence of psychiatric problems of young people in detention. Consistent nationwide policies regarding the appropriate assessment and management of young people with mental health problems within detention could then be developed. For instance, deliberate self-harming behaviour and suicide attempts frequently occur in young people within the youth justice system. The development of clear national guidelines regarding suicide prevention might be an appropriate task for the Faculty of Child and Adolescent Psychiatry, Royal Australian and New Zealand College of Psychiatrists. ‘At risk’ young people could then be recognized and appropriately referred for treatment.
A set of consistent guidelines is not all that is required. Step two would include ensuring that co-ordinated services, including screening and management of mental health and substance abuse problems, are available for young people both within detention and upon release back into the community. This would involve the identification of best-practices and programs for providing mental health services to youth at all points in the continuum of the juvenile justice process. The multisystemic therapy (MST) model, developed in response to the lack of scientifically validated, cost-effective treatment options, has proven effective in reducing conduct-disordered behaviour among diverse populations of antisocial youth [56], [57]. Although organizations within New Zealand have adopted such an approach, such programs remain in their infancy in Australia.
The third step would include a formative process which encourages the dissemination of information and identifies gaps in knowledge and the direction for future work. Critical to such a transdisciplinary approach is the formation of coalitions comprised of representatives from mental and general health, law enforcement, social services, court systems, education, consumers and the general public. Such a system would allow solutions to emerge that reflect a young person's complex level of need.
Conclusion
Transdisciplinary networks need to be established which are flexible, family and community-centred and are matched to the local needs of juveniles. This is not the traditional paradigm in adolescent forensic health service development. In Australia, psychiatrists have been at the forefront of advocacy efforts for public mental health policies and initiatives that focus on the needs of children and young families. They have promoted awareness that successful childhood programs may lead to improved outcomes in multiple domains throughout life, ranging from enhanced learning and academic performance, to better social skills and more successful relationships later in life. With increasing interest in reducing juvenile recidivism from both federal, state and local government sources, the current challenge is to encourage new ways of conceptualizing treatment of juveniles with mental health problems within the juvenile justice system, preferably informed by evidence-based practice.
A transdisciplinary approach, defined as an integrated system of care that includes mental health, drug and alcohol and non-medical services, is required to meet the diverse and changing needs of young people within the juvenile justice system. A guiding principle of such a system of care is the recognition that young people and their families have multiple needs that cross traditional agency boundaries and collaboration among agencies is therefore essential at both the policy and practical levels to maximize effective follow-up. Such a marginalized group of young people deserves nothing less.