Juvenile Justice

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Juvenile Justice Mental Health Paths to Care

• J. Scott Hickey, Ph.D.
• MHMRA of Harris County, Texas
• Pam Boveland, Ph.D., Diana Quintana, Ph.D.,
  Matthew Shelton, Ph.D.,
• Harris County Juvenile Probation Department,
• William Schnapp, Ph.D.
• University of Texas Mental Sciences Institute,.
• Keith Burau, Ph.D., Charles Begley, Ph.D.,
• University of Texas School of Public Health
• Rebecca DaCamera, J.D.
• Mental Health Association of Greater Houston
• Philip Emmite, Ph.D.
• Houston Independent School District

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Paper first presented to the Joint National
Conference on Mental Health Statistics Center
for Mental Health Services Washington, D.C.,
June 1, 2006
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Greater Houston Health Services Research
Collaborative

• Initiative of the Houston Endowment
• Funded through UT School of Public Health
• Goal Increase collaboration between academic and
  public sector researchers
• Purpose Improve the quality of research relating
  to public health care
• We are pleased to show the first product of the
  collaborative

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Why Does It Matter?

• That our jails have become the primary
  institutions for the care of the mentally ill is
  a sad but well-described phenomenon. Fewer than
  55,000 Americans currently receive treatment in
  psychiatric hospitals. Meanwhile, almost 10 times
  that number -- nearly 500,000 -- mentally ill men
  and women are serving time in U.S. jails and
  prisons. As sheriffs and prison wardens become
  the unexpected and often ill-equipped caretakers
  of this burgeoning population, they raise a
  troubling new concern Have America's jails and
  prisons become its new asylums?1
• 1 Public Broadcasting System, 2005,
  Frontline The New Asylums, http//www.pbs.org/wgb
  h/pages/frontline/shows/asylums/view/

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Headline U.S. leads in mental illness, lags in
treatment

• Washington Post June 6, 2005
• National Comorbidity Replication Study
• ¼ of all Americans met criteria for having a
  mental illness some time last year
• ¼ of those had symptoms severe enough to disrupt
  their day-today functioning

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National Comorbidity Replication Study, p. 2
Prevalence

• Half of all Americans will have a mental disorder
  at some time in their lives
• Against Pretty soon well have a syndrome for
  short fat Irish guys with a Boston accent, and
  Ill be mentally ill
• Dr. Paul McHugh, Professor of Psychiatry, Johns
  Hopkins University
• For If I told you that 99 of Americans had a
  physical illness, you wouldnt blink an eye.
• Dr. Ronald Kessler, Professor of Health Care
  Policy, Harvard Medical School

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National Comorbidity Replication Study, p. 3

• Good news
• Rates are flat over the past ten years
• Previous decades showed rising rates
• Bad news
• Less than half get treatment
• They have often suffered and delayed treatment
  for ten years
• During those ten years they develop additional
  problems
• When they get treatment, its inadequate
• Young are overlooked
• 50 of those diagnosed showed signs by age 14
• 75 by age 24
• Mental disorders are the chronic illnesses of
  youth.
• -Dr. Thomas Insel, Director, NIMH

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Statistics in Context

• Baseball fans use statistics like a drunk uses a
  lamppost, more for support than for
  illumination.
• Vin Scully

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Mental Disorders in the Juvenile Justice System

•  
• From 70 to 100, have a diagnosable mental
  disorder. (2-3 times higher than other youth)
• Approximately one out of five (20) has a serious
  mental disorder.
• These rates remain high even when you eliminate
  conduct disorder from the identified disorders-
• 60 of boys and 70 of girls still meet criteria
  for some other psychiatric disorder.
• Rates of mental disorder are consistently higher
  for girls than for boys,
• especially for affective and anxiety disorders.

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National Center for Mental Health Juvenile
Justice

• Increasing sense of awareness and crisis
  surrounding the care and treatment of youth with
  mental disorders in the juvenile justice system.
• population of youth whose mental health needs
  have been neglected for a long time.
• Growing concern over the criminalization of
  mental illness.
• Increasing attention by the media, advocacy
  organizations (NAMI, NMHA, Federation of
  Families), and funding organizations (private
  foundations like MacArthur and Casey, as well as
  federal agencies such as SAMHSA and OJJDP).
• DOJ investigations into the conditions of
  confinement of youth in juvenile detention and
  correctional facilities across the country.
• These investigations have consistently
  highlighted the lack of appropriate screening,
  assessment and treatment available to
  youth..(DOJ, 2003)

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Research Question To what degree do the public
mental health and juvenile justice systems serve
the same children and adolescents?

• Method Probabilistic data matching
• See CMHS IDBSE website for a report on the method
  and for SAS routines to perform the match

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The Two Databases to be Matched

• 99,371 Harris County Juvenile Probation
  Department Records gathered from 1990 forward
• Records of all children and adolescents referred
  to Juvenile Probation
• 294,020 Mental Health records obtained between
  1992 and 2006
• Records of all persons receiving public mental
  health or retardation services
• Entire contents of both databases

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Probabilistic Method

• Matched on
• Soundex phonetic name translations
• SS
• DOB
• Gender
• Race
• Zip Code

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Results About one in four overlap

• 24,668 matches
• 24.8 of individuals present in the juvenile
  justice database were also present in the mental
  health database
• When one considers research indicating 50-75
  incidence of mental disorder among juvenile
  offenders, the match rate is disappointingly low

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Conclusions

• Very significant overlap, but
• Low rate compared to rates of mental disorder in
  published probation samples
• Raises question Why do children with mental
  disorders fail to receive services?

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Question 2 Do matched cases differ from the
usual child mental health caseload?

• Method Comparison of characteristics of the
  matched sample to those of a mental health
  service only sample

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Matched vs. Mental Health Samples

• Comparison sample all cases served in the mental
  health system in 2005
• 4500 cases
• Some overlap in this sample
• 2133 cases remain if matched cases are removed
  from the MH Only sample

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Gender Baseball 1866 Vassar Womens Team
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The mental health only sample is..predominantly
(2/3) male
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African-American Hispanic
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..English-speaking
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.age at onset (system entry)
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In contrast, the matched sample
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.whiter
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.more English-speaking
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.. Young (17 year-old rookie)
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older
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How Old Would You Be If..
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Diagnostic Group Less Affective Less
Distractible
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Two Groups within Matched Sample
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Conclusions

• Younger children enter the system through the
  mental health portal
• Mental health case openings peak at age eight,
  and gradually decline
• Children with Affective Disorders (Depression
  Bipolar Disorders) make up a larger proportion of
  the mental health sample
• Children with ADHD also form a larger part of the
  mental health group
• Biologically-based disorders are apparently
  more frequently steered to mental health services
• Behavioral Disorders are more frequent among the
  matched group

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More Conclusions

• The system is male-oriented
• The public mental health system has a relative
  under-representation of White child consumers
  while the probation system does not

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Ray Chapman The only major league baseball
player killed while playing the game
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Question Do Adolescents differ according to
portal of entry?

• Are there detectable differences among members of
  the matched sample depending on the door (mental
  health or probation) through which they entered
  the system?

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The two paths 70/30 10 (2,500) cases had no
information regarding program of first mental
health episode
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Gender x Portal
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Ethnicity x Portal
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Diagnostic Group x Portal
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Mental Health Portal DX x Gender
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Probation Portal DX Group x Gender
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Age at Onset by Portal
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Age at Onset x Diagnostic Group
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Behavior Disorders Secondary Axis I Diagnoses
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Conclusions

• Entry through the Probation Portal is twice as
  likely
• Entry through the mental health vs. probation
  portal is associated with
• Proportionately more Females
• Proportionately fewer Whites, more Hispanics
• Younger Age at Onset
• Greater likelihood of Affective Disorder and ADHD
  lower likelihood of Behavioral Disorder

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More Conclusions

• Females using either portal are more frequently
  suffering from affective disorders
• Males entering through either portal are more
  likely diagnosed as behavior disorders

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Steroids Baseball
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What to do.?
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Question Is portal of entry associated with
differences in juvenile justice outcome?

• Is offense severity related to portal?
• Is probation history associated with portals?

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Frequency of Probation Activity

• Does portal of entry relate to probation file
  thickness?
• One-way analysis of variance
• Dependent variables
• of Referrals to Probation Dept.
• of Referrals Rsulting in Court Disposition
• of Dispositions to Probation

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Probation Activity x Diagnostic Group
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Analyses of Variance Groups Differ Significantly
(Portal of Entry Matters)
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Portal of Entry and File Thickness

• Although individuals enter the mental health
  portal at younger ages than those entering
  through the probation portal, their subsequent
  juvenile justice activity is thinner

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Portal of Entry and Severity

• Entering through the mental health portal is
  associated with fewer charges whether less severe
  (misdemeanors) or more serious felonies.

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Number of Felonies, Misdemeanors
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Cumulative Ratings as Severity Indicators

• Each offense can be rated on a locally developed
  nine-point severity scale ranging from level one,
  Class C (mild) Misdemeanor to level nine, Capital
  Murder
• For cumulative index, sum across individual
  history to get total lifetime severity
• Play a little loose and treat ordinal data as if
  it were continuous

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Lifetime Severity x Portal
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Conclusions

• Entering through the mental health portal is
  associated with lower cumulative, lifetime
  severity of offenses

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Looming Questions

• Is mental health treatment responsible for
  improved outcomes?
• Or
• Are different types of individuals entering
  through these two portals?

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Next Steps

• Follow a sample of individuals following an index
  offense
• Examine the impact of mental health service type,
  quantity and duration on juvenile justice
  re-referrals
• With adults we have demonstrated enduring effects
  for specific treatment types

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Propensity Groups

• Collaborating with public health types
• Lacking true control groups, plan to construct a
  matched sample
• matched on propensity scores, single indices
  quantifying multiple predictors

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Grand conclusion

• Results of recently released National Comorbidity
  Study indicate that a majority of persons who
  develop mental disorders as adults have shown
  signs of distress at age fourteen or earlier
• Current results tend to support conclusion that
  there are benefits to entering the system through
  the mental health rather than juvenile justice
  system
• Provide additonal support for policies aimed at
  early detection of mental disorder, and for
  mental health diversion from criminal justice

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Where the rubber meets the road

• Added impetus to our Juvenile Justice systems
  efforts to allocate more resources to screening
  and assessment
• Added emphasis to MHMRA Boards legislative
  agenda addressing criminalization of mental
  illness
• Contributed to current legislative lobbying
  efforts to accurately assess the prevalence of
  mental retardation in the criminal justice
  systems
• Provided a model of the value of needs assessment
  provided by this data matching other major
  providers to juveniles are interested in
  supporting similar research describing the mental
  health needs of the children they serve.
• Served as the basis for discussions among service
  providers to create specialty mental health
  clinics for these children.

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A solution to the unsanitary pitch

• Grandfathered Spitballers
• The 17 spitball pitchers designated after the
  1920 season were
• National League
• Bill Doak
• Phil Douglas
• Dana Fillingim
• Ray Fisher
• Marv Goodwin
• Burleigh Grimes
• Clarence Mitchell
• Dick Rudolph
• American League
• Doc Ayers
• Ray Caldwell
• Stan Coveleski
• Red Faber
• Dutch Leonard
• Jack Quinn
• Allan Russell

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Grandfathered steroid users?