MHYO Project Volume I
Mental Health resources and Young Offenders:
State of art, challenges and good practices
‘Mental Health Resources and Young Offenders: State of art, challenges and good practices’ is a unique document containing the analysis of the current status of mental health of young offenders, conducted in eight different European countries including: Belgium, France, Italy, the Netherlands, Poland, Portugal, Spain and the United Kingdom. In addition, Volume I includes the contributions of Brazil and the continent of Africa which allows for a comparative insight into the situation of mentally ill young offenders.
Each national report gives an insight into the difficult situation faced by young offenders with serious mental health issues. Each country follows the same structure and describes the profile and background of young offenders; the penal and child care regulations (including principles of access to appropriate services); the role of professionals and the development of their skills; intervention approaches (what is working and what is not), and recommendations and concrete proposals for good practices.
The authors of the Belgian article highlight and review the literature concerning Juvenile delinquency and psychiatric disturbances in Belgium and provide an analysis of the justice and therapeutic systems for young offenders. They describe an innovative model that has been developed since 2003, which creates forensic psychiatric units for adolescent delinquents, and more recent creation of a network of cross-sector care (health, education, and disability) at the institutional level based on a strong will of fostering coordination. The authors report that Belgium is at the forefront of research into psychiatric problems in this subsection of the population, owing to their programmes providing specific care and education, being developed collaboratively among the judicial, health and youth authorities.
The authors of the French report start their study by defining the different states of mental development of adolescents in conflict with the law, the impact of transition from childhood to adulthood and the process of development of their psychological progress thanks to specific programs for young offenders with mental health issues. Furthermore on a more political perspective, they provide a clear analysis of the ideological influences of the different institutional approaches, mainly divided between health and justice systems. The report also describes different programmes and procedures to identify possible models of youth justice practices for young people suffering from mental health issues. Moreover, a detailed description is provided of several care institutions for children and adolescents.
The authors of the Italian report begin by providing prevalence statistics for specific mental health problems in the Italian young offender population; based on the joint work from the Italian Juvenile Justice Department and the Don Calabria Institute, as there are no national empirical studies available. The evidence indicates the high prevalence of several mental health disturbances including mood disorders, anxiety disorders, disruptive disorders, substance abuse and thought disorders. The data also shows the increasing drug use among young people in contact with the Italian justice system and that 50% of young people in the juvenile justice system are non-Italian nationals.
The legal framework of youth justice is described to be under-pinned by principles of simplicity of process to ensure a minimum disruption the young person’s educational development. Young people in detention can be subjected to tailored educational programmes which may assist them in a number of dimensions of their life including psychological intervention. The provision of mental health services to juveniles in the criminal justice system is the responsibility of the National Health Service since 2008. While all juvenile offenders are assessed by a general medical practitioner who may seek further assessment from other specialists, there is no standardized screening system or tool to establish mental health status. Other shortcomings include the lack of specialist training of professionals within the juvenile justice or mental health system.
The report concludes with recommendations for good practice. It does so through a series of interviews with key stakeholders in the Italian juvenile justice and mental health system. They make a number of key recommendations regarding the availability of adequate services for young people involved in crime with mental health difficulties and the need for structured approaches to the assessment of mental health difficulties in these young people.
The author of the Dutch report begins by providing the rates of mental health difficulty in the Dutch population of young offenders. From this data it is clear that the rates of mental health difficulty among young offenders are 6-7 times higher than among non-offending youth; that some types of mental health difficulty are particularly prevalent such as externalizing disorders, affective disorders, substance abuse disorders, and personality disorders; that intellectual disability is also more common, and that the family life of young offenders is characterized by adversity and disadvantage. The author also notes that many young people simultaneously experience more than one mental health difficulty.
The report describes the current youth care system in the Netherlands as child and family centered and characterized by easy access, integration of services and designed to meet the needs of clients. The system is oriented towards helping a young person change their criminal behavior so as not to re-offend rather than to punish the young person by offering a continuum of response from referral to appropriate youth support services, to diversion from the youth justice system to organized restorative activities, to alternative sanctions such as community service, to detention. The report also delineates the training and experience of the various professionals who come into contact with juveniles and outlines suggestions for training that would further enhance their practice. It also identifies practical obstacles to inter-professional co-operation.
The author provides some examples of best practice and describes impressive wide-scale programmes designed to assess and tackle problematic behavior in young children that may leave them vulnerable to the development of criminal behavior. With regard to intervention, an emphasis is placed on evidence based programmes and several very effective examples developed in the Netherlands are described in the areas of parent training, the promotion of positive behavior in children, and functional family therapy. The report concludes with recommendations regarding the need for greater number of professionals with specialized training in the juvenile justice and health care systems as well as the further integration of these two systems.
The author of the Polish report begins by indicating that there are no official research studies and consequently their description of the mental health status of young people involved in juvenile crime is based on interviews with professionals working in this area and reports from centers of detention. The collected data indicates that 93% of young people in detention in Poland experience some form of mental health difficulty; that intellectual disability is about four-five times higher than in the general population and that young people in custody all experience significant family dysfunction. The author particularly identifies the developmental vulnerability towards violence and criminality among those children coming from over-crowded and poorly staffed orphanages.
In Poland, juveniles are defined as aged between 13 and 18 years for the purpose of criminal proceedings and up to the age of 21 for educational and reformatory measures. Family courts may order a range of measures which include required participation in restorative or educational classes, the appointment of a supervising professional, placement with a foster family or placement in a detention centre - being the most severe judicial response. The author describes a centralized service with some regional organizations available to assist young people in the court system who have mental health assessment and intervention needs.
The report concludes with a number of recommendations including the need for greater provision of regular juvenile mental health care across many currently un-serviced regions of Poland, the need for more professionals qualified to work in the area of juvenile mental health and specialized training of these professionals, the greater inclusion of family in interventions, and the development of preventative programmes.
The author of the report from Portugal indicates that there are no research data on the extent of mental health problems in children and adolescents in the general or criminal populations; however, a Portuguese Directorate General of Social Reintegration survey in 2008 reports that 54% of young people in detention centers met the diagnostic criteria for one or more psychiatric disorders under the DSM or ICD classification system. The juvenile detention system in Portugal is described as providing for the mental health needs of young people through accessing private care or accessing the local public health system. The pre-sentencing assessment of all young people for whom detention at an educational centre is being considered is mandatory in Portugal.
The age of criminal responsibility is 16 and those aged between 12 and 16 years who commit a crime are subject to educational intervention which can range from receiving a verbal warning, to community work, to supervision, to detention in an educational centre. Nevertheless, the author reports that at present there are no specific residential centers designed to meet the mental health needs of the juvenile offender population with personality disorders or serious addictions. The report also identifies the lack of coordination of staff and agencies and the lack of specialist training for professionals working with mentally ill juvenile offenders.
The Portuguese report concludes with a number of recommendations. These include the need for special training of professionals, national research to establish the extent of the mental health difficulties of young people who engage in criminal behavior, the need for early and community based preventative programmes, and the need for greater inter-agency and inter-professional co-operation.
The authors of the Spanish report also begin by stating that national research studies of the rate of mental health difficulties for young people engaging in criminal behavior are not available. Consequently, the Spanish report provides evidence from a Youth Rehabilitation Therapeutic Centre (Pi Margall) which indicates that young detainees in Spain experience mental health difficulties most frequently in the areas of disruptive disorders, substance abuse, difficulties associated with experiences of family violence, neglect and sexual abuse. Juvenile courts have the discretion to take mitigating effects of mental health difficulties into account and direct young people to appropriate services. Nonetheless, the authors highlight the lack of standardized system or protocol used for assessing the mental health needs of young offenders. The medical staff of detention centers can, however, access information about previous diagnoses retained during former contacts with mental health services by young people.
The mental health needs of young offenders is the responsibility of the national public health system, however, there is no specialty for child and adolescent psychiatry and hence no specialized training of professionals, only special units providing general mental health services to children and their families. The provision of special residential and community based services are reported to be very limited. With regard to suitable intervention programmes, they build on cognitive-behavioral models instead of punitive approaches. The Pi Margall center’s approach is described as an example of good practice in Spain as it blends individual therapy with family therapy and group work.
The Spanish team makes a number of recommendations including the need for early diagnosis of young people at risk and suitable preventative intervention programmes for them; the need for the development of the specialty of child and adolescent psychiatry along with the appropriate training of professionals. They also recommend research to better understand the mental health needs of the general and ‘criminal’ youth population in Spain. Finally, they recommend the need for coordinated plans and action to meet the mental health needs of young people who offend between Government Ministries of Social Welfare, Education, Health and Justice along with the different public and private institutions involved.
The authors of the UK report begin by drawing on a number of national studies which clearly illustrate that young people who engage in serious criminal behavior have significant mental health problems, with 43% of young offenders on community sanctions having a diagnosable mental health disorder compared with 10% of children (5-16 years) in the general population. Learning difficulties and experiences of abuse and neglect are also more common. The authors acknowledge that the criminal behavior of these young people requires not simply a judicial response but also an appropriate and evidence based response to their mental health needs.
The UK report describes examples of good practices; in particular the potential benefit of a “reach-in” system by local Child and Adolescent Mental Health Services (CAMHS). Within this system young people in offender institutions receive assessment and intervention offered by their local CAMHS team as a normal part of their custody. However, the provision of this system depends on the resources available for youth mental health in different locations. They also describe some of the effective intervention strategies for mentally ill youth engaging in criminal behavior including multi-systemic therapy, cognitive behavioral therapy and parenting programmes. The authors give an emphasis to interventions informed by the principles of attachment theory.
The authors identify several shortcomings in the system and highlight the need for continuity of care as young people transition back into their communities after a period of detention, and the need for professionals to have suitable training and qualification in mental health in order to appropriately assess and intervene to meet the needs of young detainees. Finally, the authors conclude that examples of good practice integrating criminal justice and mental health services do exist in the UK but these are to the credit of local agencies and local personnel. They require structured global support to ensure all young people who need to benefit from them do so.
The author of the African article begins by analyzing the prevalence of mental illness or mental disability in this continent. The report notes that children with mental illness or intellectual disabilities often come into conflict with the law for reasons either directly related to the disability or not. Consequently, the analysis is described in the contextual reality and the legal framework of justice for young offenders with mental illness in Africa. In addition to this, the author of the African article states that this region is large and wide in range, and it is hard in a short paper to develop in detail the various national circumstances and legislation in African countries. However, the author gives a broad perspective on this issue and a general overview of the legal framework on the rights of children with mental health problems or disabilities in the African context.
The author of the Brazilian report indicates that the relatively recent democratization of his nation has resulted in the recognition that children and adolescents are citizens with full and equal rights. This has led to an important shift from an orientation that promoted the exclusion and punishment of young people in conflict with the law to one which also recognizes their rights as citizens. As such the Brazilian Statute of Children and Adolescents makes special provision for young people who engage in criminal behavior who have mental health problems stipulating they require mental health services in an appropriate setting.
The provision of these services is the responsibility of the regular state health service and therefore a national agency has been established (SINASE) to oversee standards of care for the mental health needs of young detainees. Brazil simultaneously underwent a revision of its mental health system moving away from an institutionally based approach to one of care in the community. However, the author describes the experience of youth in the juvenile justice system as one where mistreatment and torture are still present as the actions of state institutions still solely focus on the punishment, and detention juvenile offenders.
The author reports that the profile of mental health needs of young people in conflict with the law in Brazil is still unknown. Regarding mental health provision to juvenile offenders, a 2008 survey of the practices of 272 detention centers indicated high levels of psychiatric medication use, high levels of use of restraint and isolation, and a lack of cooperation between detention centers and the public health service. The author also gives consideration to how the concept of dangerousness linked to psychopathology can be misused to undermine the development of adolescents. The author concludes by describing two pilot schemes which represent a positive way forward for managing the mental health needs of young people who engage in criminal behavior while respecting their rights as individual citizens.
Some general conclusions can be drawn from the nations described in detail in this volume. The available data indicates that in all nations evidence is found whether through formal research, or review of the records of detention centers, that juvenile offending and mental health difficulties go hand in hand. Furthermore, the level of involvement of a young person within the criminal justice system correlates with greater rates of mental health difficulty. Higher rates of mental health difficulty are found in juvenile offenders on community sanctions compared with non-offending youth in the general community, and higher rates again are found among young people in detention.
The types of mental health difficulties identified are also consistent across nations. Offending juveniles often exhibit externalizing and internalizing behavioral problems, such as Conduct Disorder and Mood disorders (depression, anxiety). Alcohol and/or drug addiction as well as suicidal ideation are also identified at higher rates. Other forms of problematic behaviors linked to mental health status and associated with traumatic and socially disadvantaged personal backgrounds will include risky sexual behavior, aggression, and violence. Specific learning difficulties and intellectual disability will also be more common. These are without a doubt complex mental health and psycho-social problems which are likely to be exacerbated by experiences of detention.
The nations described universally recognize that young people in conflict with the law require a response from the criminal justice system that is not simply punitive but which also strives to restore wellbeing in society by redirecting their development. The mental health needs of young people are seen as best met within the regular national health services rather than in specialist health services within centers of detention. Although this principal is endorsed by all, the reality in most nations is that the availability of good quality mental health services for young people in conflict with the law is limited. This is partly due to the lack of integration between juvenile justice, health and educational services. Each national report in this volume clearly indicates that training for staff is a key ingredient in this successful integration of these arms of government. A need for training of existing staff is identified; particularly training that supports legal professionals in understanding mental health issues, and mental health professionals in understanding the legal system of their respective nation.
A practice of screening the mental health status of all young people within the juvenile justice system, particularly those in detention is recommended. While this might not yet be the standard practice in many countries, we do have effective approaches that allow us to appropriately screen, assess, formulate and intervene when young people experience mental health difficulties. There are structured clinical tools available to screen and evidence-based interventions to intervene in the criminal career of juveniles, characterized by multi-systemic approaches which include family work, parent training, and individual treatments designed to target the many forms of behavioral problems. It is also clear from the report that many young people who find themselves in conflict with the law may be assisted prior to their involvement in crime. That is, within their homes, schools and communities effective preventative work may be valuable in assisting their development.
Volume I also reminds us that international law and standards require nations to deal appropriately and effectively with young people in the criminal justice system to ensure that their mental health status is identified and where indicated that they receive appropriate care. In order to achieve this, we need to bring to maturity the human rights principal of supporting the development of a young person vulnerable to a life of crime, by restoring the young person to a developmental pathway that leads away from criminality and towards responsible, crime free citizenry. It would appear that to do so require us to find a mechanism where aspects of the judicial, educational, and health systems combine to work co-operatively and effectively together for the good of all citizens. In most nations, this would appear to be something these systems have rarely succeeded in previously. However, it is possible and will bring benefits to all.