ACEs and the Possibility of Preventing the Past
===============================================

* Merrill Rotter
* Zoe Feingold

## Abstract

Ashekun and colleagues’ study of the association between adverse childhood experiences (ACEs) and arrests in persons with serious mental illness (SMI) provides more evidence for the importance of addressing the broader needs (beyond narrowly defined symptoms of mental illness) of clients with SMI and criminal legal contact. Furthermore, the article supports the need to appreciate fully the intersection of behavioral health and criminal justice and the intersectionality of mental health and race (i.e., the additive adversities experienced by individuals with SMI who also face race-based inequities). In this commentary, we apply this public health framing of criminal legal involvement among individuals with SMI, expanding on the social adversities, including ACEs, that contribute to adverse health and legal outcomes. We support the relevance of prevention approaches and note areas for further inquiry. In so doing, we aim to reinforce a role for forensic practitioners in addressing these challenges.

*   adverse childhood experiences
*   criminal-legal contact
*   intersectionality
*   prevention
*   social determinants

In 1998, Ezra Griffith exhorted AAPL members to seek “both psychological and sociocultural truth” in our evaluation and treatment of clients with criminal justice involvement and to recognize the structural unfairness that is inherent to our society and legal system (Ref. 1, p 181). Twenty-five years later, we have seen further calls for a forensic psychiatric role that includes recognition of and working to ameliorate societal inequities2,3 and to find ways to incorporate compassion for the individuals we see and serve.4 In parallel fashion, forensic literature has stressed the more complicated relationship between serious mental illness and criminal behavior than presumed by the early versions of the criminalization hypothesis, often highlighting the social factors that bring individuals with serious mental illness into the criminal legal system.5,6 With a focus on the relevance of adverse childhood experiences (ACEs) in predicting arrests in persons with serious mental illness, Ashekun and colleagues7 provide more evidence for the importance of addressing the broader needs of clients with criminal legal contact. Ashekun’s article also supports the need to appreciate fully the intersection of behavioral health and criminal justice as well as the intersectionality of mental health and race (i.e., the additive adversities experienced by individuals with serious mental illness who also face race-based inequities). Ashekun and colleagues’ findings contribute to the conversation about how we might ameliorate these challenges, even when the damage may already have occurred.

## ACEs, RNR, and Social Determinants

Although not controlling for serious mental illness or symptoms thereof specifically, the authors demonstrate a relationship between higher ACEs scores and arrest history, along with the specific identification of lower educational achievement as a predictor of arrest history. As the authors note, these findings are consistent with both the “risk-needs-responsivity” (RNR) literature on criminal recidivism and the literature on social determinants of health.5,8,9

The RNR literature consistently shows that individuals with mental illness exhibit the same general risk factors for reoffending (e.g., educational and employment deficits, substance use problems, association with criminally involved peers) as individuals without mental illness, and that these general risk factors for criminal behavior are more predictive of reoffending than mental health–specific or clinical characteristics.6,9,10 Most individuals with mental illness become involved in the criminal legal system for many of the same reasons that all individuals do, and many of the well-researched risk factors for criminal offending overlap with social determinants of health and known risk factors for mental illness. For instance, youth who experience social disadvantages such as poverty, residential instability, or poor access to community supports and recreational activities also experience greater risk of mental illness along with heightened risk of arrest and incarceration in young adulthood.11,–,14 These social disadvantages also co-occur with the ACEs measured by Ashekun and colleagues.7 In turn, these ACEs may independently increase the risk of adulthood mental health problems and criminal legal involvement.13,15,16

Although the underlying risk factors for criminal legal involvement are likely to be similar among individuals with or without mental illness,17 individuals with mental illness may experience exacerbated and compounded risk over the life course, leaving them susceptible to repeated and cyclical patterns of criminal legal involvement.18,–,20 Indeed, incarcerated adults with mental illness tend to score higher on RNR assessments of the “central 8” criminogenic risk factors for reoffending when compared with their counterparts without mental illness.9,21 These same individuals also report disproportionately high rates of social and structural disadvantages, such as unstable housing, limited formal education, unemployment or under-employment, and low income.22,–,24 Thus, mental illness may be only one piece of a more complex puzzle contributing to negative socioeconomic, criminal, and health-related outcomes. Such findings make a clear case for broadening the scope of our interventions aimed to mitigate risk among individuals with mental illness and criminal legal involvement.

Ashekun and colleagues7 also note the disparity in arrest history among Black participants in their samples relative to White participants. These findings mirror the national statistics on incarcerated individuals with mental health disorders, wherein Black individuals make up a disproportionate percentage of inmates with a mental health condition relative to their share of the general population with mental illness (i.e., 27% of jail inmates with a mental health disorder are Black versus 10% of all U.S. adults with a mental illness).22,25 Were mental illness alone responsible for the overrepresentation of persons with mental illness in the criminal legal system, one would expect the racial makeup of persons with mental illness in jails and prisons to mirror that of individuals with mental illness in the general population. These racial disparities further support the notion that broader sociopolitical forces are responsible for the high rates of criminal legal involvement among individuals with mental illness. That is, the relationship between mental illness and criminal legal contact is exacerbated by raced-based inequities that make it more likely that Black individuals with a mental illness will be arrested or incarcerated than White individuals with a mental illness.

Although the higher risk of arrest and incarceration for people of color is often directly accounted for by racialized criminal justice polices (e.g., over-policing in Black neighborhoods, laws that inequitably target Black communities), what this study supports is that the higher risk of criminal legal contact is also undergirded by racialized social and structural factors, some of which are captured by or associated with ACE items (e.g., education and employment challenges). Although total ACEs scores were not significantly higher among Blacks compared with Whites, the Ashekun *et al.*7 subjects were all individuals with an arrest history. In general population studies, ACEs scores have been found to be higher in communities of color.26,27 Therefore, the relationship demonstrated in this study between ACEs and arrest history has an even greater significance for people of color. In addition to ACEs items, the other social and structural disadvantages that increase the likelihood of arrest and incarceration, described above in the context of serious mental illness, are also more common in the Black community.28,29

## Prevention Perspectives

A study about the impact of childhood traumas may appear discouraging, because the childhood trauma captured by the ACEs tool is a static feature of an individual’s past and may be the beginning of a tragic trajectory, anchored in daunting social structures. But the Ashekun *et al.*7 study is also an example of highlighting a more hopeful public health reframing of criminal legal contact, one that allows for intentional and creative preventive thinking.30 What’s more, the three types of prevention (primary, secondary, and tertiary) are connected to one another.

The criminal legal system is, in theory at least, a tertiary response. The specific deterrence purpose of punishment aims to improve prognosis by motivating more prosocial behavior among individuals who already present with the identified negative outcome (i.e., arrest).30 Over the past three decades, the literature has been increasingly supportive of addressing the problems underlying criminal legal contact rather than relying on deterrence alone. As described above, the adult-focused RNR approach advocates addressing both criminogenic needs (the direct drivers of criminal recidivism) and the indirect contributors or so-called “responsivity” factors.31 These needs and factors are also among the adverse outcomes associated with ACEs, including, but not limited to, educational and employment challenges, substance use, mental illness, interpersonal violence, and, of course, incarceration.32,33 In this way, RNR represents a prognosis-improving, tertiary prevention approach.

Successfully targeting these risk factors in the adult population also contributes to an intergenerational secondary prevention strategy (i.e., addressing problems when individuals are at risk but have not experienced the untoward health, behavioral health, or criminal–legal consequences). Mental illness, substance use, interpersonal violence, parental incarceration, and family instability (each of which is either a criminogenic need or responsivity factor) are items captured by ACEs. Ameliorating these outcomes in adults will, therefore, decrease exposure to these adverse experiences for the at-risk children in their lives.

Finally, from a primary prevention perspective, these outcomes also represent the downstream effects of the societal norms, public policies, and legislation that underpin the social determinants of health, behavioral health, and criminal legal contact.5,34 A primary prevention strategy is one in which intervention occurs upstream, at the level of norms, policies, and legislation. Discriminatory housing regulations, lack of health care access, inequitable educational and employment opportunities, and poverty are structural challenges for which we, as psychiatrists, might not have the solutions but about which we can advocate increased attention.3 Hansen *et al.* have also described ways in which a structural competence focus can support individual treatment as well, for example by helping clients identify opportunities to participate in advocacy communities.35

## Conclusion

Ashekun and colleagues’ ACEs study, with its focus on macro-level influences on mental health and criminal behavior, is not a novel perspective, but ACEs and related social and environmental factors have often been neglected in favor of a more simplistic focus on psychiatric symptoms and criminogenic risk factors.28,31,36 As a consequence, perhaps, interventions that take a narrow or primarily clinical approach to reducing the risk of legal system involvement among individuals with mental illness have frequently fallen short.37,38

The interplay of social determinants, mental illness, and race, especially, in leading to repeated criminal legal contact echoes Kimberly Crenshaw’s writings on intersectionality. Crenshaw focused on the multiplicative effects of co-occurring sources of discrimination or disadvantage, such as the experience of being both Black and female.39 One can apply a similar approach to understanding the experience of being both Black and having a serious mental illness, characteristics which individually and in combination are associated with higher risk of criminal legal contact.

This application of intersectionality, in turn, echoes the traditional psychiatric description of behavior as “overdetermined,” the idea that several factors have come together to lead to a particular outcome. Many articles support the association between criminal legal outcomes, ACEs, and other social determinants. Given the multiplicity of factors and the different kinds of criminal legal outcomes, however, it is not surprising that the relationships among these vulnerabilities and outcomes are complicated and nuanced.40 For example, Ashekun *et al.* identify a relationship between education, arrest, and ACEs. The pathway from educational challenges to arrest, though, is not necessarily straightforward. It may be mediated by, among other factors, associated challenges in employment, lack of prosocial associates, and program completion.20,41-43

Further research would help us to understand better the pathways to criminal legal contact, as well as the relationships among and the relative contribution of each factor, including individual ACEs items. Such a broader and deeper understanding of these contributions, accompanied by a particular awareness of the relevance of race-based inequities to the development of these risk factors and the associated criminal legal outcomes, would help operationalize the ethical and compassionate approaches with which we have been charged.

## Footnotes

*   Disclosures of financial or other potential conflicts of interest: None.

*   © 2023 American Academy of Psychiatry and the Law

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