Juvenile Justice & Mental Health: Paths to Care

1. 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

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

3. 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

4. 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/wgbh/pages/frontline/shows/asylums/view/

5. 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

6. National Comorbidity Replication Study, p. 2Prevalence • Half of all Americans will have a mental disorder at some time in their lives • Against: “Pretty soon we’ll have a syndrome for short fat Irish guys with a Boston accent, and I’ll 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 wouldn’t blink an eye.” • Dr. Ronald Kessler, Professor of Health Care Policy, Harvard Medical School

7. 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, it’s 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

8. Statistics in Context • “Baseball fans use statistics like a drunk uses a lamppost, more for support than for illumination.” • Vin Scully

9. 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.

10. 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)

11. 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

12. 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

13. Probabilistic Method • Matched on: • Soundex phonetic name translations • SS# • DOB • Gender • Race • Zip Code

14. 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

15. 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?

16. 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

17. 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

18. Gender & Baseball: 1866 Vassar Women’s Team

19. The mental health only sample is…..predominantly (2/3) male

20. ……African-American & Hispanic

21. …..English-speaking

22. ….age at onset (system entry)

23. In contrast, the “matched sample”…

24. ….whiter

25. ….more English-speaking

26. ….. Young (17 year-old rookie)

27. …older

28. “How Old Would You Be If…..”

29. Diagnostic Group: Less Affective & Less Distractible

30. Two Groups within Matched Sample

31. 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

32. 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

33. Ray Chapman: The only major league baseball player killed while playing the game

34. 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?

35. The two paths: 70/30 {10% (~=2,500) cases had no information regarding program of first mental health episode}

36. Gender x Portal

37. Ethnicity x Portal

38. Diagnostic Group x Portal

39. Mental Health Portal: DX x Gender

40. Probation Portal: DX Group x Gender

41. Age at Onset by Portal

42. Age at Onset x Diagnostic Group

43. Behavior Disorders: Secondary Axis I Diagnoses

44. 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

45. 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

46. Steroids & Baseball

47. What to do….?

48. Question: Is portal of entry associated with differences in juvenile justice outcome? • Is offense severity related to portal? • Is probation history associated with portals?

49. 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

50. Probation Activity x Diagnostic Group