Detained Adolescents: Mental Health Needs, Treatment Use, and Recidivism

Mental Health Needs

Consistent with previous research in detained youths completing the MAYSI-2,^3,6,11,54 we found high rates of mental health needs. More than 80 percent of the total sample endorsed mental health problems or substance use that warranted clinical attention and follow-up. Clearly, DAs are a very vulnerable group at high risk for mental health problems.^6,10,37 Of note, the female DAs in this study reported significantly higher mental health needs than the male DAs. Such results are consistent with previous findings of greater severity and frequency of mental illness symptoms,^6,11,60 higher rates of psychiatric disorders,^4,8,39 and lower overall functioning among detained female adolescents than among male adolescents.^43,61 Such gender discrepancies may arise because female DAs are more likely than male DAs to identify and endorse mental health problems.¹¹ In addition, the differential treatment of male and female adolescents within the legal system may also contribute to the gender differences found in this study.⁶ Specifically, female adolescents are less likely to be arrested than are male adolescents;⁶¹ 3 in 100 female adolescents were arrested in 2010, compared with 8 in 100 male adolescents.¹ Judges are also less likely to incarcerate female offenders and more likely to assign them to probation or other diversion programs.^6,61 This fact may be due to female DAs evidencing increased mental health problems when compared to male DAs.^6,60

White DAs in this study reported significantly higher mental health concerns than did black DAs on four of the seven MAYSI-2 scales. In addition, the prevalence of white DAs who scored within the warning range on most scales was notably higher than black DAs. These results replicate those in some prior studies, which indicated that white DAs report significantly higher mental health needs^11,40 and are more likely than black or Hispanic DAs to meet criteria for one or more mental disorders.^48,62 However, not all studies of incarcerated youths support these conclusions; some studies show that racial/ethnic minorities have higher mental health needs^45,63 and others have failed to find significant racial differences in mental health concerns.⁷ Although current results may reflect true racial differences in mental health status between white and black DAs, it is also likely that racial differences are due to systematic biases in the legal system, in which minority youths are disproportionately involved in the juvenile justice system,^7,12,14 as well as biases in the self-report of mental health needs. Just as male adolescents are less likely to endorse mental health concerns than are female adolescents,^3,11 black adolescents may be less aware of or willing to endorse mental health problems,^11,25,64 perhaps because of a fear of being stigmatized or labeled as having a mental health problem. Thus, the minority DAs in the current study may have experienced similar mental health concerns to white DAs, they were less likely to endorse these concerns.

Mental Health Treatment Utilization

Despite current findings that most DAs had elevated mental health needs, only about 16 percent of the sample used mental health services after leaving detention. This prevalence rate is quite low, suggesting that DAs represent a poorly served population with unmet treatment needs.^{14,25,37,40,42} Unfortunately, this service utilization rate is fairly consistent with that found in prior work. It is slightly higher than some study estimates that showed that 8.1,³⁹ 13.6,³⁷ and 14.1 percent²⁴ of DAs obtain postdetention services, but lower than other study estimates that showed that 20.5 percent²¹ to 45.5 percent⁴¹ of DAs engage in postdetention services. Given that more than 80 percent of the sample scored in the caution range for at least one MAYSI-2 scale, current findings highlight a large discrepancy between mental health concerns and actual treatment use for this population. Moreover, the results showed that higher self-reported mental health needs did not consistently predict the use of mental health treatment, except for the angry–irritable score. Theoretically, greater mental health needs should have been associated with higher likelihood of treatment use, but results failed to support this relationship.

In trying to understand the study's findings, it should be noted that many mental health providers are available in the city of this study and about half the DAs who obtained services did not have insurance coverage, so lack of available services and lack of providers who accept noninsured youths do not appear to explain the results. At the same time, insurance status emerged as a particularly strong predictor of treatment use, in that DAs covered by Medicaid or private insurance were significantly more likely to obtain mental health treatment than were DAs with no insurance. Such findings make sense, given the low socioeconomic status within the DA population^8,42 and evidence that the financial costs of treatment or lack of insurance often serve as treatment barriers that prevent adolescents from obtaining needed treatment.^42,65

In addition to insurance status, findings indicate that receiving services may be strongly tied to demographic variables. As found in prior epidemiological studies,^37,40,42,45 male, minority, and older youths were significantly less likely to obtain services, regardless of mental health needs. Such results highlight treatment disparities related to gender, race, and age that may be due to several factors, including that male, minority, and older DAs engage in less treatment seeking,^25,42 lack financial resources and transportation to obtain treatment,^42,46 are less likely to be referred and connected to services by providers,^7,40 or are more likely to be re-arrested and detained in correctional facilities instead of mental health facilities.^27,47 In considering insurance status and demographic variables together, this study shows a strong bias against male DAs; they were significantly more likely than female DAs to have insurance but were still less likely to obtain treatment. Overall, findings suggest a two-tiered approach within the juvenile justice system, in which female, white, and younger offenders are more often placed on a rehabilitation-focused track, whereas male, black, and older offenders are more often placed on a punitive incarceration track.⁴⁷

Across the seven MAYSI-2 scales, the angry–irritable scale had the highest mean score. Such results seem reasonable, because anger and irritability are characteristics of behavior disorders, such as conduct disorder, oppositional defiant disorder, and attention deficit/hyperactivity disorder,⁶⁶ which are commonly found among juvenile offenders.^5,8,10 The proportion of DAs falling in the caution and warning ranges for the angry–irritable scale was not notably larger than that of other scales, yet the scale emerged as one of only two significant mental health predictors of service utilization, with higher scores linked to higher likelihood of receiving treatment. This scale has been associated with impulsivity and sensation seeking,⁵² as well as rules violations, aggression toward peers and staff, and need for intensive supervision.⁶⁷ Thus, DAs with high scores on the angry–irritable scale tend to exhibit increased behavioral problems and infractions, which may result in heightened attention of providers/staff, probation officers, and court officials who refer or order these youths to obtain treatment, thereby resulting in a relationship between higher angry–irritable scores and higher likelihood of treatment.

Recidivism

More than one-third of the sample had at least one recidivism event within six months of leaving detention, meaning that twice as many adolescents reoffended than received mental health treatment. Higher scores on the alcohol and drug use scale were associated with an increased likelihood of recidivism. Several factors may contribute to this relationship: adolescents with substance-related problems are more likely to engage in antisocial behavior while under the influence, to be arrested for possession of drugs or drug paraphernalia, and to be involved in drug-related activity (e.g., theft and gang involvement),^{15,28,68,–,70} resulting in more opportunities and risks for recidivism. In addition to alcohol and drug use, race was related to recidivism. As found in prior research,^12,15,16 black DAs were significantly more likely than white DAs to reoffend upon community re-entry. Although it is difficult to determine the exact reason for such findings, discrimination among law enforcement officers who disproportionately target black youths may partially account for the higher likelihood of arrest of black adolescents in the community.^48,49,71 In fact, the bias against black adolescents is quite apparent when considering alcohol and drug use and race together. White DAs reported higher alcohol and drug use than black DAs and higher alcohol and drug use was associated with an increased risk of recidivism, but black DAs still faced a higher risk of recidivism than white DAs.

Traumatic Experiences

Consistent with other studies of juvenile-justice–involved youths,^54,72,–,74 traumatic experiences were common among the study sample, with more than 80 percent of DAs reporting at least one traumatic event. DAs who reported a higher number of traumatic experiences were less likely to obtain mental health treatment within 60 days and to reoffend within 6 months. Several reasons may explain such findings. First, compared with youths with no trauma history, adolescents who experience trauma exhibit higher rates of both externalizing and internalizing problems after the occurrence of the traumatic event.⁷² Thus, adolescents with severe trauma histories may present with numerous problems, including delinquency and aggression, emotional dysregulation, abnormal eating, and lack of coping resources.^72,74 Given such concerns, it is possible that these adolescents are more likely to be placed in long-term residential treatment facilities after release from detention, thereby eliminating any opportunities for outpatient treatment (as measured in this study) and recidivism in the community. Alternatively, youths with traumatic experiences often develop psychological disorders such as posttraumatic stress, major depression, and anxiety.^73,74 Common symptoms and coping strategies associated with these disorders include behavioral inhibition, social withdrawal, and avoidance of others, places, and situations,⁶⁶ which may decrease the likelihood that these adolescents actively seek treatment or spend time with delinquent peers who engage in delinquent acts in the community, resulting in a reduced likelihood of treatment utilization and recidivism.

Effectiveness of Mental Health Treatment Utilization

The final regression model for this study indicated that mental health treatment services were associated with an increased likelihood of recidivism. Given studies demonstrating that mental health services can successfully improve psychiatric symptoms, decrease delinquent behavior, and teach coping skills to prevent recidivism,^29,30,75 the results are somewhat discouraging and counter to the purpose of mental health treatment. Several possibilities may explain the relationship between treatment utilization and higher likelihood of recidivism. First, treatment utilization may serve as a proxy measure of mental health needs, particularly alcohol and drug use. As mentioned previously, detained youths with serious substance-related problems are more likely to have a recidivism event (e.g., drug-related arrests and drug-related probation violations)^13,20,28,70 and may also be more likely to be court-ordered to receive treatment. Hence, adolescents' alcohol and drug use may moderate the relationship between mental health treatment and recidivism, but an examination of moderation was outside the scope of this study. Alternatively, DAs may have experienced treatment barriers,^22,40,–,42 such as lack of transportation, poor family and social support, negative beliefs about treatment, no interest in treatment, or the social stigma of seeking care, which prompted early termination of treatment. Unfortunately, because of limitations in data collection, we were unable to examine specifically the impact of discontinued treatment on recidivism or to compare recidivism outcomes for DAs who attended a single treatment session versus multiple sessions. Additional research is needed to test the relationship between treatment quantity and duration and recidivism.

Several other factors may also partially explain the positive relationship between treatment utilization and recidivism. Specifically, we measured treatment utilization within 60 days, which may not have been enough time for DAs to experience significant treatment benefits, such as improved behavior and reduced risk of recidivism. In addition, findings may be related to low-quality, non–evidence-based treatment. Reviews of different treatments for juvenile-justice–involved youths indicate that non–evidence-based treatment (e.g., poorly implemented, low fidelity) fail to prevent recidivism and can result in negative outcomes.^13,29,33 The DAs in this present study were unlikely to have participated in such high-quality, evidence-based treatments as MST or FFT; instead, they probably received low-quality treatment and episodes of recidivism were not reduced. Unfortunately, such conclusions are difficult to make because we examined only the use of mental health treatment and not key treatment elements (e.g., treatment strategies, family involvement, multiple services, duration of services, and treatment implementation/model fidelity) that promote the effectiveness of mental health treatment.^30,35,75 Future research should examine how these elements influence the effectiveness of mental health services on reducing recidivism.

Limitations

Several limitations of the study should be acknowledged. First, all data were abstracted from electronic records, so the rates of treatment utilization and recidivism may be inaccurate because of missing or inaccurately reported data. Further, treatment utilization rates are limited to Medicaid claims and medical records from a single hospital and its affiliated clinics. The number of adolescents who received services outside of Medicaid and this hospital system, participated in informal, nondocumented treatment (e.g., religious counseling and support groups), or moved out of state is not known, so the treatment utilization rates may underestimate the true rates. However, the hospital in which medical records were gathered is the primary care provider for indigent care and the largest provider of mental health services to individuals without insurance in the city. Provided that most noninsured adolescents in the sample would have used services at this hospital and that treatment data for all adolescents with Medicaid were collected, treatment estimates are likely to be generally accurate. Another potential limitation is that the study assessed only whether adolescents sought mental health services. Future research is needed with more detailed treatment information, particularly receipt of referrals, frequency of treatment sessions and withdrawals, treatment type, and treatment quality. These details are crucial to drawing firm conclusions about postdetention treatment services, treatment gaps and disparities, and the impact of treatment on recidivism. However, despite the study's limitations in the measurement of mental health treatment, the findings are important in showing that mere contact or connection with mental health services is not enough to reduce recidivism. Further, the study highlights the gap between youths who demonstrate the need for treatment and those who actually connect with services and emphasizes the need for effective mental health screening in the juvenile justice system.

As a final limitation, the sample consisted of adolescents detained in a single detention facility in Indiana, and thus there is the potential for generalizability concerns. This limitation is minimal, given that the sample was large and the demographic distribution matches the overall detained adolescent population.^1,76 Thus, results should have good generalizability and applicability to juvenile-justice–involved youths in other states.

Implications and Recommendations

Based on the literature and current study findings, the authors offer the following recommendations.

Programs are needed within the juvenile justice system that identify DAs with mental health concerns and treatment needs, so that these adolescents can be connected to appropriate, evidence-based treatment services upon community re-entry. Specifically, we recommend that juvenile justice facilities employ validated, reliable mental health screenings for all adolescents during intake.^4,11,13 Ideally, the results of an adolescent's mental health screening should help determine whether a comprehensive psychological evaluation is needed, and serve as a guide for assessing mental health treatment needs and appropriate mental health services.^12,43

Consistent with the literature, the current study found prominent mental health and substance use concerns among DAs, but low rates of service utilization in the community. Research examining the use of mental health treatment upon community re-entry is limited,^24,39,41 and therefore future research should focus on identifying and understanding postdetention treatment utilization, particularly prevalence rates, types of services used, quantity and duration of services, facilitators and barriers to treatment, and the discrepancy between low rates of service use and high rates of mental health problems. We recommend that future research also examine why demographic factors (e.g., race, gender, and age) appear to be more strongly tied to mental health treatment than to actual mental health concerns and treatment needs.

Reviews of mental health treatments for juvenile offenders indicate that certain interventions (e.g., MST, FFT) are effective in reducing recidivism,^32,34,36 whereas other treatments yield mixed support.^29,33,35 In the current study, we found that basic treatment use was associated with increased likelihood of recidivism, which calls into question the types of services that DAs are receiving. Researchers are advised to advance the development, implementation, and dissemination of evidenced-based treatments that not only address the mental health concerns regrading DAs, but also promote reductions in rates of recidivism.