Abstract
This mixed methods study examined initial and reevaluation reports of youth opined incompetent to proceed to investigate the impact of community interventions on changes in functional abilities. Using a structured quantitative chart review and an inductive and deductive qualitative coding scheme, we coded court-ordered, juvenile competence reports for 73 youth (85% male; ages 9-19, Mage = 14.07, SD = 2.36) opined incompetent. Upon reevaluation, 51 youth were opined to remain incompetent, and 22 were opined competent by the evaluator. No age differences were observed between youth who remained incompetent and those who were remediated. Higher IQ scores were associated with successful remediation of understanding, appreciation, decision-making, and assisting counsel. Thematic analysis suggested that stabilization in place of residence and family functioning were often noted for remediated youth. School functioning and mental status at the time of the evaluation may be indicative of competence abilities and highlight existing skill deficits. Results highlight the complexity of factors influencing juvenile adjudicative competence and how stabilization of placement, school, and family functioning may be useful points of intervention, particularly when focused remediation efforts are not available.
Although due process rights were extended to juveniles in Kent v. United States (1966),1 it was not until reforms of the 1990s increased punitive sanctions that juvenile adjudicative competence was regularly questioned in court.2 The majority of states applied the standard from Dusky v. United States (1960)3 to their juvenile courts when determining competency. Most states have adopted statutes specific to juvenile adjudicative competence, but they vary widely in their specificity and their application of developmental science and best practices.4,–,6 Although adult competence evaluations are the most frequent type of forensic mental health evaluation, with an estimated 130,000 conducted annually in the United States,7 estimates for the juvenile courts do not exist.8 Few studies have examined the prevalence of incompetence findings in youth. Those available suggest an increase in rates of incompetence opinions.9,–,14 Together, the limited available evidence indicates a notable number of youth referred for an evaluation may be opined incompetent to proceed (ITP) in jurisdictions across the country each year.
Research examining predictors of initial adjudicative competence opinions suggest some factors that might influence the success of remediation efforts. Age and IQ are consistently related to competence to proceed abilities; older youth and those with higher IQ scores were more likely to be opined competent.12,13,15,16 Conversely, youth with lower IQs or documented intellectual disabilities exhibited greater competence-related deficits.10,–,13,17,–,19 In addition, older youth were more likely to demonstrate the specific functional abilities20 required to be competent compared with their younger counterparts,17 highlighting the important role of normal adolescent cognitive development. Unlike in evaluations of adults, mental health diagnostic categories, aside from intellectual disabilities, were not consistently associated with competence-related deficits.21
Remediation of Incompetence to Proceed
When youth are found ITP, best practice requires evaluators to opine on how observed functional deficits may be remediated and in what timeframe. Scholars suggest remediation-specific services should be “individualized, community-based, integrative, and developmentally and culturally appropriate” (Ref. 22, p 57), addressing treatment needs and specific competence deficits.5 Remediation recommendations should be evidence-based and tailored to observed deficits and symptoms,23 yet data are not available to guide recommendations. The few studies measuring change in juvenile competence over time have examined individual factors (e.g., age, IQ, mental health diagnoses) but have not examined more dynamic factors, such as services provided or educational setting.19,24 Most states and jurisdictions do not have remediation services focused specifically on youth,9 and those that do vary in quality and availability. Courts without established remediation-specific programs may allow service provision (i.e., psychiatric or mental health services) through child welfare or protection mechanisms25 or allow time for the youth to stabilize or mature before the adjudication process continues,2 but little is known about how either approach affects juvenile adjudicative competence abilities. This study examines the effect of non-remediation-specific interventions and supports on competence-related abilities.
Current Study
As part of a larger study of functional deficits in juvenile adjudicative competence,21 we gathered a sample of reports of youth in Massachusetts who were opined ITP at their first court-ordered evaluation of adjudicative competence. We examined their functional deficits relevant to ITP, as well as their current situational (e.g., place of residence) and clinical factors (including participation in treatment and other interventions) at both their first and last evaluations during the five-year study period. Evaluator opinions on competence to proceed (CTP) were used as the presumed final outcome of adjudicate competence. Previous research has shown high agreement between evaluator opinions and judicial determinations.8,12,26 Massachusetts was uniquely suited for the study goals because of its court clinic model and state regulations requiring evaluators to complete specific training and a committee review process. Like many other states, Massachusetts recognized the ability to evaluate juvenile competency in statute27 (and developmental immaturity in case law28) but does not have a juvenile-specific statute to guide evaluation of juveniles nor remediation of incompetence in juveniles. It has not established statewide remediation-specific services for juveniles. Reevaluations occur periodically, providing unique information on the changes in youths’ adjudicative deficits over time. Without established remediation-specific services, the jurisdiction had only typical mental health, school, and social services resources available to address youths’ competence-related deficits. Available evidence suggests Massachusetts is typical of many states across the United States that do not have remediation-specific services in place.19 In Massachusetts, services were recommended by an evaluator or put in place by child protective services for youth in their custody but were not mandated by the court.
Using a pragmatic approach,29 this study employed a sequential explanatory mixed methods design30 to examine which factors and non-remediation-specific services were associated with an evaluator’s opining that a youth’s competence abilities were remediated at the time of reevaluation. We examined how the individual’s behavior, functioning, and related competence abilities might be influenced by community-based services directly in contact with the youth (e.g., psychiatric, family, school) and the interaction between those systems through services like case management.31,32
Across analyses, our goal was to examine whether non-remediation-specific, community-based treatments and interventions (i.e., services not specifically intended to address remediation of competence deficits) affected competence abilities. Quantitative analyses focused on variables established in previous research as being related to competence abilities.9,–,13,15,19,21 We hypothesized that older youth and those with higher IQ scores, current mental health treatment, and no history of special education placement would be more likely to be opined competent at final evaluation.
Our second goal was to examine whether the evidence supports theory and common practice in the real-world context of adjudicative competence remediation. First, the cognitive complexity model notes that rational abilities are more cognitively complex and demanding than factual abilities.33 If this is the case, factual understanding should be more easily remediated than rational appreciation. We examined whether remediation of factual abilities was differently associated with time and age than remediation of rational abilities.
Secondly, evaluator recommendations and court practices sometimes allow time for an incompetent youth to age or mature as one way to remediate deficits that may be related to developmental immaturity. This assumption that time to mature could remediate noted deficits in youth has not been empirically tested. We hypothesized that the passage of time might allow for maturation and resolution of some competence deficits but that longer time periods would not be associated with greater remediation of functional abilities.
We then conducted a qualitative chart review of the information contained within the last competence reports to explore factors at the direct (e.g., mental health treatment) and interactional (e.g., case management between systems) level that may be associated with remediation. This method could consider more complex combinations of factors and patterns of events than would be possible statistically in this small but novel sample. Qualitative methods34 were used to gather further information about the family, social, educational, and clinical factors as well as individual symptoms that may be associated with successful remediation of deficits in adjudicative competence.
We hypothesized the interactional factor conceptualized as stability, which is a state of reduced stressors or improvement in factors causing stress or inconsistency in the youths’ lives (e.g., stable housing and caregivers after shelter placements), would play a key role for youth in the remediation of functional deficits. This hypothesis was based on neuropsychological evidence that stress can affect abilities relevant to competence in healthy adults, including working memory35 and use of executive functioning skills.36
Methods
Sample
This study examined the deidentified, court-ordered, court clinic reports of juvenile adjudicative competence for 73 youth. All reports were gathered from the two Massachusetts counties with the most referrals for juvenile adjudicative competence during the five-year study period. An initial pool of 371 reports, representing 93 percent of ordered juvenile adjudicative competence evaluations in the two counties during that period, was identified.21 The current study included only youth who were opined ITP at the time of their first evaluation and had a subsequent reevaluation for the same charges during the study time period, 2009 to 2014. This allowed us to examine changes over time and code key variables from both the initial and last evaluations.
Table 1 provides demographic information for the 73 youth who were opined ITP by the forensic evaluator and later reevaluated during the study period. The sample was majority male, and information on race and ethnicity was rarely reported in the written report (see Refs. 21 and 37 for more information). Race and ethnicity were coded as two separate variables (i.e., a youth described as a “Black Hispanic female” was coded as Black for race and Latino or Hispanic for ethnicity). The youths’ most serious open charges ranged in severity from attempted murder to miscellaneous offenses (e.g., disorderly person, delinquent trespassing). The most common charges involved assault or assault and battery.
Demographic Information
For the present study, a youth’s first evaluation (“initial”) and most recent evaluation (“last”) during the study period were examined. At the time of initial evaluation, youth ranged from ages 9 to 19 years (see Table 1). Massachusetts juvenile court jurisdiction is, with very limited exceptions, determined by the age of the youth at the time of their alleged offense; youth over 18 remained in the jurisdiction of the juvenile court because their offense was committed before their 18th birthday. Most youth resided with primary caregivers at the time of both evaluations, and the time between evaluations varied from as little as four months to nearly five years. At the time of last evaluation, 30 percent of youth were opined competent and 70 percent remained ITP. Records of official court dispositions were not available, and evaluators’ opinions (both ultimate issue opinions and penultimate statements) were used as the measure of adjudicative competence.
Reports were written by a total of 17 evaluators who completed a range of 1 to 13 reports in the sample. Of the 73 youth, 39 youth had the same evaluator at initial and last evaluation, whereas 34 youth had a different evaluator for the last evaluation. Reports were completed by evaluators holding a PhD (n = 7), PsyD (n = 7), or an MD (n = 3).
Procedures
Quantitative Coding
A team of nine trained raters (graduate and undergraduate students) who were blind to study hypotheses coded the initial and last evaluations. This quantitative coding scheme included the item or factor to be coded, categorical codes, and definitions. Prior to coding, the scheme was reviewed by a panel of national experts in forensic evaluation and research with youth in the legal system and updated with expert feedback before coder training began. All coders were trained by the first author and coded multiple reports together to develop consensus and create a coding manual with detailed instructions for each item. One of every four reports was double-coded by two independent raters with fair to excellent inter-rater reliability observed (see Ref. 21).
Quantitative coding included data retrieval to pull information from the lengthy narrative reports and data coding to categorize and describe information provided in the report. The description from the report was coded into nominal categories (see Ref. 21 for more information on the quantitative coding scheme). To capture any remediation-specific services, all supportive services or interventions throughout the report were coded. Evaluator opinions on competence to proceed were coded as well as opinions on each of the component functional abilities: factual understanding, rational appreciation, ability to assist counsel, and decision-making. For quantitative analyses examining changes in functional abilities, any functional ability was coded as changed if it had been opined as inadequate or mixed in the initial evaluation and opined adequate in the last evaluation.
Qualitative Coding and Thematic Analysis
A structured inductive and deductive coding scheme was designed and piloted by the authors of the study to systematically pull data from each deidentified report. All qualitative coding was completed by the authors, all of whom were trained in the literature and procedures of juvenile adjudicative competence evaluations. Reports were coded online through Dedoose,38 a platform designed for qualitative and mixed methods research. For the first one-quarter (24%) of reports, the authors individually reviewed the same reports and coded data individually before meeting to review and reach consensus on coded data.39 Differences were discussed until consensus was reached, at which point the coding scheme was modified.40 After reaching consensus, the authors coded the remaining reports individually (approximately 14 each), with two additional reports coded by all raters to check and maintain consensus.
The coding matrix was initially developed through a deductive coding framework based on the four capacities model2 that organizes the abilities required for CTP into the categories of factual understanding, rational appreciation, ability to consult with and assist counsel, and decisional capacity. The initial framework was based on sections typically included in reports (e.g., mental status, an individual factor) and factors associated with adjudicative competence in previous research (e.g., psychiatric medication, a microsystem influence). An inductive coding framework was then utilized to assign codes to emerging trends that presented during consensus coding.41,42 Inductive coding was primarily utilized to code common trends within youths’ biopsychosocial history (e.g., developmental maturity).
The resulting structured coding scheme, as shown in Table 2, included qualitative coding that maps onto and expands the variables examined quantitatively. Qualitative coding took place in the second phase of the study, after quantitative analysis was complete. Table 2 also reports the percentage of reports with codable information in each domain. The study was approved by the administrative office of the juvenile court and the supervising Institutional Review Boards (IRBs) for both the court clinic and Wheaton College.
Quantitative and Qualitative Coding Variables and Percentage of Report with Codable Information
Results
Quantitative Analyses
Youth opined to remain incompetent at their last evaluation had a significantly longer time period between evaluations than peers opined competent at last evaluation (see Table 1). Similarly, when only youth ages 14 and below were examined, there was a significantly longer time period between evaluations for youth opined to remain incompetent (M = 93.78 weeks, SD = 53.34) than peers opined competent at last evaluation (M = 59.70 weeks, SD = 45.97), t(38) = 2.01, p = .023, d = .67. There was no association between evaluator (same or different as at initial evaluation) and competence opinion at reevaluation, χ2 (1, N = 73) = 1.32, p = .25, V = .13.
There was no significant difference in age at the time of last evaluation between youth opined competent and those who were not (see Table 1). No age differences in changes to functional abilities were observed.
Chi-square analyses were used to examine whether certain individual factors (e.g., mental health treatment, removal from home, trauma history, special education placement) were associated with changes in evaluator opinion of competence or its component functional abilities at the time of the last evaluation. The only significant association was between mental health treatment at the time of last evaluation and change in factual understanding, χ2 (1, N = 48) = 8.56, p = .003, V = .42. All youth whose factual understanding became adequate at the last evaluation were in some form of mental health treatment at the time of that last evaluation, and 63 percent of those whose factual understanding did not improve were in treatment at the time of their last evaluation. Notably, 89 percent of the youth whose factual understanding became competent were already in treatment of some type at the time of their first evaluation, as were 80 percent of youth whose factual understanding did not improve. Youth in mental health treatment were significantly younger (Mage = 15.14, SD = 2.12) than youth not in treatment (Mage = 16.43, SD = 2.24), t(69) = 2.25, p = .028, d = .60. Formal or informal remediation-specific services were not reported for any youth.
IQ scores were significantly higher in youth opined competent at last evaluation than in youth opined to remain incompetent (see Table 1). This pattern was consistent across functional domains, and significantly higher IQ scores were observed for youth whose factual understanding, t(30) = −2.64, p = .013, d = −.96; rational appreciation, t(27) = –2.68, p = .012, d = –1.16; and ability to assist counsel, t(22) = −3.12, p = .005, d = −1.47, had been opined adequate at last evaluation. In the current sample, only five youth were diagnosed with an intellectual developmental disability (IDD) and none were remediated and opined competent (compared with 32% of youth without an IDD diagnosis). No further analysis was conducted given the small number of cases.
Qualitative Chart Review
Biopsychosocial Data
Place of residence.
The study focused on changes in residency or placement, with 37 percent of reevaluation reports indicating a change in placement since the last evaluation. For youth who remained opined as incompetent, information on placement changes were included in 31 percent of these reports. For youth opined competent, information on placement was available in 50 percent of reports. Approximately half of all placement mentions were neutral statements that described place of residence without reporting the impact of placement changes on the youth’s functioning. The proportions of neutral placement descriptions were equivalent across youth opined competent and incompetent (for representative quotes in each area, see Table 3). For both youth opined competent and incompetent, the remaining descriptions of placement changes added context of either positive or negative impact of the change. For youth opined competent, the placement change was described with positive impact (e.g., better housing, safer neighborhood). For youth opined incompetent, the themes more often included negative impact or problems and described undesirable and potentially stressful impact, such as losing housing or being “kicked out” of a living situation.
Representative Quotes from Juvenile Competence to Proceed Evaluations
School functioning.
Half of all reports described changes in school placement or programming during the period between evaluations. For youth opined competent, 45 percent of reports noted school changes and none described worsening functioning at school. In most cases, stability or improvement were noted for youth opined competent. Changes in school were noted for 53 percent of youth opined incompetent, and half of those also noted improvements. In many reports, descriptions of behavior at school did not clearly identify how current functioning compared with other time points, but reports noted more negative themes around current problem behaviors.
Emerging themes in maturity and family.
Only 19 percent of all reports noted any data on the youths’ maturity. This information was often described in the summary sections of the analysis section, and most referenced the youth’s social functioning with peers as part of the evaluator’s conceptualization of maturity. A lack of maturity was described for 18 percent of youth opined incompetent. Improvements in maturity were also noted for two youth opined incompetent and two youth opined competent.
Almost half of reports included description of changes in family functioning, and some unique themes were noted in the few reports with girls (n = 6). For girls who were opined competent, positive changes in family functioning were noted. For girls who were opined to remain incompetent, problems in family relationship dynamics were noted as well as chaotic home environments. For boys opined to remain incompetent, half of reports provided description of events or information about family functioning but without information about their impact on the youth’s functioning or symptoms. Among boys opined competent, about half noted improvement in family functioning. No clear themes emerged about what aspects of family functioning affected these boys. In this small sample of female evaluees, family functioning was the only factor in which gender differences were observed in themes.
Other data sections.
In several additional areas, we examined patterns associated with remediation; however, no clear themes emerged. Changes in mental health symptoms were noted for 67 percent of youth but tended to focus on externalizing disorder symptoms, including changes in aggression, attention, and impulsivity. There was very little reference to internalizing symptoms such as depression and anxiety or psychotic symptoms. Many reports included statements that the youth was in treatment without information on whether or how mental health functioning had been affected.
The use or impact of psychiatric medication was included in only 37 percent of reports, and no themes emerged about the impact of medication for youth opined either competent or incompetent. Substance use was more rarely noted, in eight percent of evaluations, and no themes emerged. Similarly, involvement with child protective services was also rarely noted at the time of reevaluation, with changes described for only 10 percent of youth, with descriptions that ranged from unsupported allegations to closure of child protective supervision. No themes emerged in the impact on adjudicative competence.
Mental Status
Almost all reports, 97 percent, included description of the youth’s mental status at the time of the evaluation. Most reports with youth opined incompetent (53%) described more symptoms in speech (e.g., tone, expressive, or receptive language), development (e.g., concrete reasoning, desire to please adults), and mood and arousal (e.g., irritability, inattention). Of note, 18 percent of youth opined incompetent had nonremarkable and generally positive mental status descriptions. For youth opined competent, reports tended to note improvements in aspects of mental status (48%). If symptoms or deficits were noted in this section, they were placed in the context of other skills or aspects of mental status that might balance deficits. The evaluators compared current functioning with that observed during previous evaluations only in rare cases.
Competence to Proceed Sections
Functional abilities were described broadly in most reevaluations without reference to prior functioning. Only a few reports compared current abilities with those observed in previous evaluations. Almost all reevaluation reports included opinions on factual understanding (96%), but fewer reports included information on rational appreciation for both youth opined competent (64%) and incompetent (66%). Most statements on rational appreciation were broad and conclusory without using supporting information from the data section of the report (e.g., “continues to have deficits in his rational abilities”), although a few provided more specific information on the rational abilities affected that could be helpful for remediation planning (e.g., “limited factual understanding leaves him unable to form a rational understanding of how the court process unfolds…or how to make decision relevant to his case”). Information on decision-making (82%) and ability to assist the attorney (89%) were included more consistently. All reports on youth opined competent noted the youth’s ability to assist counsel. Most reports on youths who were opined to remain incompetent (84%) also addressed this functional ability. Evaluators only noted observed behaviors and abilities and did not refer to any information obtained from defense attorneys.
Ability to maintain appropriate courtroom behavior was noted in far fewer reports: 45 percent of reports for youth opined competent and only 16 percent of reports for youth opined incompetent. Opinions tended to rely on observed behavior during the evaluation and compared those observations with previously documented symptoms or presentations.
Discussion
The current study examined forensic evaluation reports of youth whose competence was reevaluated after an initial opinion of ITP, using a combination of quantitative and qualitative chart review methods. As expected, youth who continued to be opined ITP after reevaluation had a longer period between evaluations than youth who were opined competent.
Consistent with previous research,24 youth who were opined competent at reevaluation had higher IQ scores, likely reflecting greater verbal skills and cognitive capacities to draw on when learning and considering competence-related information. Higher IQ scores were observed in youths who improved in each functional area. The only other factor related to factual understanding was involvement in mental health treatment at reevaluation, although the relationship remains unclear. Most youth in treatment at the time of the last evaluation were also in treatment at the time of their initial evaluation. Improvements in emotion regulation and functioning from mental health treatment could help youth focus, learn, and retain competence-related information over time. It is unclear whether, in the current sample, treatment affected factual understanding or if differences reflect the observed age difference in youth who were and were not in treatment at the time of the last evaluation.
The current findings further emphasize the significant influence of IQ on both competence abilities and remediation. Youth with higher IQ scores appear better able to learn and demonstrate functional abilities relevant to competence. Age, however, shows a less clear relationship with remediation. Youth whose factual understanding improved by their last evaluation were younger, on average, than those whose factual understanding remained inadequate, but this difference was not significant and the passage of time was not associated with changes in overall CTP. Previous research has shown that age and IQ interact in relation to competence abilities, placing younger youth with low IQ at particular risk for deficits.17,18,21 Younger youth with high IQs may benefit from time, whereas older youth with lower IQs may not. The current study was limited to the five-year window of data collection. More time, including time for further brain development into the early 20s, could be associated with remediation of deficits. Courts will need to consider how much time is reasonable and consistent with legal reasoning.42 The current study did not find evidence of significant impact of the passage of time or individual-level factors, such as special education placement, on competence abilities at reevaluation.
Regarding the cognitive complexity of various aspects of competence-relevant abilities, it is notable that, when associations were observed with age and individual-level factors, they were associated with the less cognitively complex aspects of competence (e.g., mental health treatment was associated with changes in factual understanding, but not with the more cognitively complex area of rational appreciation). Further research will be needed to clarify whether this reflects cognitive complexity and thus the relative difficulty of remediating deficits in appreciation or the large number of reports in the current sample that did not describe rational appreciation (see further discussion below).
Impact of Non-Remediation-Specific Services
Thematic analysis of the last competence report content revealed a complex combination of factors and patterns that may inform competence reevaluation reports and future remediation efforts. One theme that emerged was the role of stabilizing or positive changes in youths’ places of residence. Stability, improvement, or positive changes in placement (e.g., a residence that fits the needs of this youth at the time) may allow youth to function at their best and demonstrate their full functional abilities, including complex memory and reasoning skills. How this stability promotes relevant functional abilities is not yet clear. Stability may reduce stress and allow youth to utilize the full capacity of their working memory, executive functioning, and reasoning skills needed for competence. Some literature has conceptualized this effect as a function of resources or bandwidth.44 Ecological System Theory31 would suggest this factor we conceptualized as stability may capture an important interactional variable that is not just an individual characteristic (e.g., IQ or mental health symptoms) or a targeted intervention (e.g., school placement), but the interdependent relationship of the right intervention for the unique characteristics of the youth and situation. Results suggest evaluators may need to consider and make recommendations regarding ways to stabilize or better support youth in their place of residence. This is not to suggest that youth require detention for stabilization. Detention has been associated with a host of negative impacts and poor outcomes for youth.45 Instead, findings suggest that a stable place of residence (usually, a community-based placement, often with family) that meets the youths’ current social, developmental, and mental health needs may be helpful to remediation efforts. This is consistent with findings in the adult restoration literature that show high restoration rates in outpatient competence restoration programs that provide case management and other services to promote stability for individuals in the community.46 It is also consistent with research highlighting how unmet basic needs and associated stress affect mental health functioning generally.47
Emerging themes around family functioning also highlighted the potential importance of stabilization. Improved and positive family functioning was noted more often in descriptions of youth opined competent, indicating that increased stability and decreased stress in the family may be another relevant target for recommendations. Although the number of girls in the sample was small, it was striking how consistently consideration of family functioning was incorporated in reports, whereas reports on boys varied considerably in their inclusion and consideration of this information. This variation may reflect societal standards for girls48 or the higher rates of crimes committed within families seen more frequently in girls.49 Barring evidence that family functioning affects girls more than boys, this may be an area to monitor for gender bias to ensure important information on family stability is not overlooked for boys.
Themes also emerged regarding school functioning and mental status at the time of the evaluation, the two areas most consistently included in reports. Competent youth were reported to have fewer negative school interactions as well as improvements in school functioning, often after changes in placement or programming that better fit their needs. Similarly, mental status reports on youth opined competent noted minimal mental health symptoms and when noted were often in the context of compensatory strengths. Reports on youth opined incompetent noted more interference of symptoms across domains, including speech, development, and mood. School functioning and mental status may serve as proxy measures of the severity and impact of current mental health symptoms on functioning. Both school and the competence evaluation process are, much like the adjudicatory process, highly verbal and require a range of cognitive skills as well as regulation of mood and impulses to navigate successfully. Both may serve as real-world tests of youths’ abilities and evidence of their capacity to exhibit similar skills in the adjudication process. Notably, both environments can differ from adjudication in important ways. Particularly supportive (e.g., a supportive teacher) or fraught (e.g., a bully or abrasive adult) relationships in either environment could make that functioning less indicative of adjudicative abilities. In this sample, many youth with improved school functioning were not opined competent. Nonetheless, themes found in report descriptions of mental status and school functioning may highlight a fruitful avenue for remediation recommendations. In jurisdictions without remediation-specific programs, evaluators may focus on functioning (both strengths and challenges) in these areas and recommend services to promote skill development (e.g., emotion regulation strategies for a youth who becomes explosive when frustrated by complex information). Skill-building and stability may help youth to demonstrate their maximal functional capacities. Focused remediation programs could examine disruptive and challenging situations at school to identify lagging skills (e.g., problem-solving, considering complex information) that could be addressed by remediation services.
Missing Information in Reevaluation Reports
Perhaps more striking than what we observed was what we did not see. Few common threads or themes emerged across youth whose competence deficits were remediated. Our findings highlight the complex nature of adjudicative competence in juveniles that reflects an interaction of functional abilities, complex situational factors, and the ever-evolving process of development. Contrary to findings in adults,46,50 in this sample of juveniles reevaluated for adjudicative competence, neither formal mental health disorders nor medication were a focus, and no themes emerged around mental health disorders associated with competence or medication use associated with remediation. The unique nature of adjudicative competence in juveniles, involving an interaction between mental illness, intellectual ability, and developmental immaturity,51 is well recognized as a complex challenge for evaluators2 and those seeking to remediate youths’ deficits.19 Results from this study highlight the complex and highly individualized nature of juvenile adjudicative competence.
As we looked for patterns associated with competence, what stood out most were patterns in information missing from reports. Although developmental maturity is widely recognized in the literature,5 developmental immaturity was only rarely noted in reports and, when noted, was typically only in conclusory statements without supporting evidence. Additionally, many reports lacked description of the youths’ rational appreciation. Although various models for adjudicative competence exist,2 all include both factual understanding and some form of rational capacity to appreciate, as defined in Dusky v. United States.3 Nonetheless, one-third of reports lacked information or provided only conclusory statements on rational appreciation.
Finally, we noted a consistent pattern in how data were reported, but not interpreted or connected to the psycholegal question. Reports frequently noted impactful events (e.g., death of a caregiver or transition to foster care) without reporting how these events affected the youth’s functioning. Although many youth participated in treatment, reports did not describe whether any changes had been observed in symptom severity or general functioning.
Limitations and Future Research
The current study used a sample of youth who, after being opined incompetent at their first evaluation during the study, had an additional reevaluation during the five-year study period. These reports from Massachusetts, a state without a juvenile-specific adjudicative competence statute, represent one end of the continuum where a statute has minimal specifications about what the report should include. At the other end of that continuum are juvenile competence statutes like those in Michigan52 that specify several areas where the evaluator must provide information; evaluators are responsible for adhering to these statutory requirements. Their reporting should comply with statute and best-practice recommendations; thus, the information included in reports will vary across jurisdictions, and the current sample represents just one type of report.
In the current study, because reports were the first and last for the youth within the study period, it is possible that youth had evaluations before and after the study period. It is also possible that youth whose adjudicative competence is reevaluated may differ from their peers who were not competent after initial evaluation but were not reevaluated for reasons ranging from dismissal of charges to the severity of observed deficits. Youth with the most profound deficits (e.g., severely impaired cognitive functioning) may be more likely to have their charges dismissed or informally handled. The current sample had notably lower rates of intellectual disability (7%) than previous studies examining remediation. Notably, the current sample also had much lower rates (30%) of successful remediation than previous studies (e.g., 76%19 and 69%24). This lower rate is likely influenced by the lack of focused remediation services in Massachusetts. It may also reflect differences in the seriousness of charges and severity of deficits found in youth whose cases remain on hold for ongoing evaluation of adjudicative competence in this jurisdiction. Although no reports mentioned any remediation-specific services, it is possible that such interventions took place for some youth but were not referenced in the written reevaluation report, which is a limitation of the available data.
Although aspects of the current sample limit comparison with previous research, it provides a unique opportunity to examine changes in response to non-remediation-specific mental health treatment, changes in the youth’s environment, and the maturation and symptom changes that may take place over the passage of time and relate to competence remediation efforts. Although there has been increased attention to juvenile competence and remediation, many states still lack remediation-specific services. As in Massachusetts, these jurisdictions have only general education, mental health, and social service resources to address youths’ competence-related deficits. Evaluators in these jurisdictions are still asked to opine on the likelihood and timeframe required for remediation, and the current study was designed to provide some evidence upon which to base recommendations. Furthermore, the written reports for the court provide a useful source of information for considering juvenile adjudicative competence. The youth whose reports were studied were in the midst of the real-world stressors and demands of adjudication. Although reports cannot reflect everything that was asked or considered by evaluators, they do reflect the information that was shared with the court and relied on by the trier of fact in decisions about adjudicative competence. In that way, they provide key sources of information on how remediation evaluations are conducted for the courts in jurisdictions with limited remediation options.
Future research should further examine the effect of remediation on rational appreciation and clarify how stabilizing interventions can be used effectively to support youth in remediation. In particular, research using prospective collection of data would allow researchers to gather comprehensive data, including variables, such as the specific nature and dosage of any provided treatments, that are important for understanding remediation of competence deficits but may not be relevant for inclusion in a written report. Court clinics or other systems that consistently provide competence evaluations for the courts may be uniquely suited to gather this type of information on youth whose competence has been questioned. The current study also highlighted patterns in the types of information included in written reevaluation reports, including the limited information on rational appreciation. The field would benefit from careful consideration of what information is most useful to the court in a reevaluation and how to communicate reevaluation findings most effectively.
Conclusions
Findings suggest that, in addition to the individual characteristics that have typically been the focus of competence-related research, consideration of the systems that affect and interact with the youth may provide additional targets for stability and remediation efforts, particularly when focused remediation efforts are unavailable. Specifically, general stabilization, including in family functioning, may allow youth to demonstrate their maximal functional abilities. Challenges observed in school functioning and general mental status may also indicate areas for intervention that could benefit competence-related abilities.
Footnotes
Disclosures of financial or other potential conflicts of interest: None.
- © 2025 American Academy of Psychiatry and the Law
