Mental Health and Incarcerated Youth. I: Prevalence and Nature of Psychopathology

The incarceration of mentally ill youth is a serious problem not receiving the same attention as in adults. In this study, we examine the prevalence of psychopathology and level of behavioral symptomatology in incarcerated youth versus youth receiving community mental health services or hospitalization. We randomly recruited youth from middle South Carolina served by a local CMHC (n = 60), youth served by the state adolescent inpatient program (n = 50), and youth in the S.C. Dept. of Juvenile Justice facilities from the same region (n = 75). We used the DISC-PC 2.3 to evaluate DSM-III-R diagnoses and the CBCL and YSR to evaluate behavioral symptomatology. On the DISC, incarcerated youth had significantly higher mean number of diagnoses and symptoms than CMHC youth, but lower numbers than hospitalized youth. Level of caseness (at least one diagnosis) was 86% in hospital youth, 72% in incarcerated youth, and 60% in CMHC youth. The groups differed in CBCL mean total T, internalizing T, and externalizing T scores as well as mean YSR internalizing T scores. Our results indicate the comparability in level of psychopathology in incarcerated and community-treated populations of youth, and the need to develop diversionary programs to prevent the entry of such youth into the juvenile justice system.     

Addressing the Challenge of Community Reentry Among Released Inmates with Serious Mental Illness

The purpose of the paper is to discuss the formidable challenges to community reentry and reintegration faced by U.S. prison inmates with serious mental illness and to describe various strategies for improving transitional services for these individuals. We review epidemiologic data supporting the high prevalence of severe mental illness in U.S. prisons as well as the historical factors underlying the criminalization of the mentally ill. The importance and challenges of providing adequate psychiatric care for mentally ill prisoners during their incarceration are discussed. We also review the numerous psychosocial and economic challenges confronting these individuals upon their release from prison, such as unemployment and vulnerability to homelessness, as well as specific barriers they may encounter in attempting to access community-based mental health services. We follow with a discussion of some of the more promising strategies for improving the transition of the mentally ill from prison to the community. In the final sections, we review the evidence for a relationship between serious mental illness and recidivism and briefly discuss emerging alternatives to incarceration of the mentally ill.     

Intensive Home Based Services Within a Comprehensive System of Care for Youth

Within a comprehensive mental health service array for youth, Intensive Home Based Services (IHBS) are designed to meet the needs of youth with significant emotional and behavioral problems in their home communities, avoiding the need for out-of-home services, particularly residential care. We examined youth receiving IHBS as their first service in the state of Hawaii system of care (N = 163) to determine how successful IHBS were in preventing the need for more restrictive services within 12 months of intake. Subsequently, we investigated characteristics that might be predictive of a youth’s need for service intensification within 12 months. Logistic regression analyses found that greater age, level of service need, and functional impairment at intake predicted use of more restrictive services within 12 months of intake, whereas gender, ethnicity, diagnosis, service intensity, and clinician credentials did not. Overall, our findings suggested that IHBS were reasonably successful in preventing residential placements, and provided some basis for determining characteristics of youth likely to require more restrictive placements within a one year period.     

Parental Incarceration Among Adolescents Receiving Mental Health Services

The Bureau of Justice Statistics estimates that approximately 1 in every 50 youth in the U.S. had a parent in State or Federal prison in 1999. Studies of children of incarcerated parents suggest that these youth are at risk for experiencing emotional and behavioral problems. Using a sample of 258 adolescents receiving routine mental health services, this study explored: (1) differences in demographic characteristics, lifetime exposure to risk factors, recent stressful life experiences, and clinical profiles of adolescents with and without a history of parental incarceration; and (2) the effect of parental incarceration relative to other risk factors on levels of emotional and behavioral problems and treatment outcomes. Nearly half (43%) of the youth studied had experienced the incarceration of one or both parents. Youth who experienced parental incarceration had been exposed to significantly more risk factors during their lifetimes including parental substance abuse, extreme poverty, and abuse or neglect. They were more likely than other treated youth to present with attention-deficit/hyperactivity and conduct disorders and less likely to have major depression. Findings provide preliminary evidence that parental incarceration may have a discrete negative effect on certain outcomes of treatment.     

Multisystemic therapy treatment of substance abusing or dependent adolescent offenders: Costs of reducing incarceration,inpatient, and residential placement

The development of more effective and less costly family- and community-based services to serve as alternatives to out-of-home placements of children is an important priority in the reform of mental health services for children and adolescents. Within the context of a randomized trial with 118 substance abusing or dependent juvenile offenders, we examined the incremental costs of multisystemic therapy (MST) and related these costs to observed reductions in days of incarceration, hospitalization, and residential treatment at approximately 1 year postreferral. Results showed that the incremental costs of MST were nearly offset by the savings incurred as a result of reductions in days of out-of-home placement during the year. The need to validate effective treatments for youth with serious clinical problems and to link the costs of treatment     

Women's Perceptions of the Prison Environment: When Prison is "the safest place i've ever been"

Incarcerated women's perceptions of the prison environment were explored with respect to relative level of safety from interpersonal abuse in prison as compared to before incarceration. Perceived levels of safety were analyzed based on reported past experiences of interpersonal violence. Participants were 65 women incarcerated in a medium security prison for women with mental and physical health problems. Women's perceptions of safety were evaluated using close–ended quantitative and open–ended qualitative self–report questions. The results suggest that, for some women, prison may be a relatively safe environment and that perceived level of safety may vary with the extent of previous experience of interpersonal violence in childhood and adulthood. Given that the structure of correctional institutions often incorporates abusive dynamics, the directionality of the findings is theoretically and socially important. The patterns apparent in these data are also consistent with other research and theory on the experiences of incarcerated women.     

Identification with arts‐based groups improves mental wellbeing in adults with chronic mental health conditions

People experiencing chronic mental health conditions (CMHC) often report feeling socially marginalised. There is emerging evidence that social and mental wellbeing can be enhanced through participation in arts‐based programmes. In this paper, a social identity theoretical approach was applied to explore how participation in the arts may improve mental health in a longitudinal study. A one‐year prospective study of 34 choir members and 25 creative writing group members (M_age = 46, 51% female) with CMHC, involved three assessments of participants’ group identification and mental wellbeing, measured by the Warwick Edinburgh Mental Wellbeing Scale. The programmes were community‐based and facilitated by arts professionals. Multilevel modelling analyses demonstrated that participants’ mental wellbeing significantly improved over time. Greater identification with their arts‐based group (ABG) was significantly related to an increased rate of improvement in mental wellbeing. The trajectory of improvement in mental wellbeing did not differ between participants partaking in the choir or creative writing group. This study demonstrates that participation in ABGs can be effective in improving mental wellbeing in adults with chronic mental health problems, particularly for those who strongly identify with the group. This study supports ABG participation as an accessible component of mental health services.     

Use of Out-of-Home Care Among a Statewide Population of Children and Youth Enrolled in Medicaid

System-wide research on the use of out-of-home care among children and youth is needed to inform the development of policies and services. We used Medicaid claims from North Carolina to examine patterns of out-of-home care, identify demographic and diagnostic differences between those who received care in residential treatment, psychiatric hospitals, or general hospitals, and determine whether demographic or diagnostic characteristics were associated with having more than one out-of-home stay during the year. Among those who received out-of-home care during a 1 year period, 36% received care in residential treatment only, 32.4% in general hospitals only, and 17.6% in psychiatric hospitals only, while 14.0% used more than one sector of out-of-home care. Boys, teenagers, and youth in foster care or diagnosed with emotional disturbance or hyperkinetic syndrome had higher odds of receiving care in residential treatment only whereas girls, youth age 19–21, and those with depressive and stress and adjustment disorders had higher odds of receiving care from hospitals only. Teenagers and youth in foster care had higher odds of having more than one stay. Among those with more than one stay, there were 300 patterns of care and nearly half received care from more than one service sector. The implications for services and policy are discussed. Further research is needed to understand patterns of out-of-home care and the factors that influence placement decisions.     

Engaging Australian Aboriginal youth in mental health services

It is currently estimated that up to 40% of Aboriginal youth (aged 13–17) will experience some form of mental health problem within their lifetime. Of greater concern is the evidence that indicates that Aboriginal youth fail to access mental health services commensurate with this need. This is due, in part, to the characteristically monocultural nature of service delivery of existing services. This paper overviews a model that has been developed specifically for the engagement of Aboriginal youth (aged 13–17 years) in mental health settings. Importantly, a mix of urban (N = 43) and rural (N = 68) Aboriginal youth were represented within the sample to determine its efficacy across different language and tribal groups. The model proved to be effective in engaging 97% of Aboriginal youth (n = 108), with only a small number not effectively engaged (n = 3). The model provides a foundation for the further development of evidence‐based models of best practice that have so far provided to be elusive within this complex field.     

An Exploration of Factors Reducing Recidivism Rates of Formerly Incarcerated Youth with Disabilities Participating in a Re-Entry Intervention

Juvenile offenders are costly to our society in terms of the monetary and social expenditures from the legal system, victims’ person costs, and incarceration. The re-entry and community reintegration outcomes for formerly incarcerated youth with a disabling condition are bleak compared to peers without disabilities. In this study, we examined the factors––both static and intervention-related––that reduce recidivism rates for project participants possessing a mental health and/or special education diagnosis and were served by a facility-to-community re-entry intervention. Our sample was comprised of a total of 320 youth formerly incarcerated who received project services between August of 1999 through June of 2004. Project services include a transition specialist whose role is service coordination to youth from the facility to the community. Kaplan–Meier survival functions were calculated for participants on the outcome measure of the rates of recidivism. Additionally, Cox regression modeling was used to identify factors for the prediction of time to recidivate. Our findings indicate that the intervention may contribute to reduced recidivism rates but that a set of static demographic and pre-incarceration risks contribute more to the prediction of recidivism than community adjustment factors (e.g., employment or enrollment). With these findings, the intervention seems promising yet it remains unclear about which programmatic features contribute to reduced recidivism rates. Implications for research and practice are shared.     

Residential and community treatment services utilized by a sample of youth with severe emotional disturbances

Analyzed case records to determine the costs and service usage patterns for a group of 25 youth randomly selected from the case load of a regional mental health agency. Study participants had extensive histories of publicly supported psychiatric hospitalizations. An average of 36.2 contacts per youth (905 total contacts) with human services providers were documented. Approximately 2 out of every 5 contacts resulted in out-of-home placements. The estimated cost of providing services to the 25 youth exceeded 3 million dollars. The types and costs of treatment services provided to study participants are discussed.     

Counseling Older Adults with Dementia: A Survey of Therapists in Massachusetts

Although much has been written about therapeutic interventions with caregivers, little is known about the counseling services that are available for victims of dementia. The present study was designed to explore community mental health center (CMHC) services and therapists' experiences in providing psychotherapy to this population in Massachusetts. Only 27 of the 36 CMHCs in the state reported providing mental health services to older adults with a dementing illness. A survey of therapists who specialized in working with older adults found that the percentage of older adult clients estimated to have dementia averaged about half of their caseload. Older persons in the early phase of a dementing illness were most frequently referred for depression and anxiety, whereas those with moderate decline were most frequently referred for management of disruptive behavior. The most common services provided to clients with dementia consisted of assessment and individual counseling. The latter finding indicates a discrepancy between what is practiced and the professional literature. Most of the psychotherapy described in the literature concerns group interventions, which were rarely provided by the mental health centers in Massachusetts. The centers tended to offer individual counseling; however, little information on how to provide this form of treatment can be found.     

Demon or disorder: A survey of attitudes toward mental illness in the Christian church

The present study assessed the attitudes and beliefs that mentally ill Christians encountered when they seek counsel from the church. Participants (n?=?293) completed an anonymous online survey in relation to their interactions with the church. Analysis of the results found that while a majority of the mentally ill participants were accepted by the church, approximately 30% reported a negative interaction. Negative interactions included abandonment by the church, equating mental illness with the work of demons, and suggesting that the mental disorder was the result of personal sin. Analysis of the data by gender found that women were significantly more likely than men to have their mental illness dismissed by the church and/or be told not to take psychiatric medication. Given that a religious support system can play a vital role in recovery from serious mental disorders, these results suggest that continued education is needed to bring the Christian and mental health communities together.     

Children's antisocial behavior, mental health, drug use, and educational performance after parental incarceration: a systematic review and meta-analysis

Unprecedented numbers of children experience parental incarceration worldwide. Families and children of prisoners can experience multiple difficulties after parental incarceration, including traumatic separation, loneliness, stigma, confused explanations to children, unstable childcare arrangements, strained parenting, reduced income, and home, school, and neighborhood moves. Children of incarcerated parents often have multiple, stressful life events before parental incarceration. Theoretically, children with incarcerated parents may be at risk for a range of adverse behavioral outcomes. A systematic review was conducted to synthesize empirical evidence on associations between parental incarceration and children's later antisocial behavior, mental health problems, drug use, and educational performance. Results from 40 studies (including 7,374 children with incarcerated parents and 37,325 comparison children in 50 samples) were pooled in a meta-analysis. The most rigorous studies showed that parental incarceration is associated with higher risk for children's antisocial behavior, but not for mental health problems, drug use, or poor educational performance. Studies that controlled for parental criminality or children's antisocial behavior before parental incarceration had a pooled effect size of OR = 1.4 (p < .01), corresponding to about 10% increased risk for antisocial behavior among children with incarcerated parents, compared with peers. Effect sizes did not decrease with number of covariates controlled. However, the methodological quality of many studies was poor. More rigorous tests of the causal effects of parental incarceration are needed, using randomized designs and prospective longitudinal studies. Criminal justice reforms and national support systems might be needed to prevent harmful consequences of parental incarceration for children.     

Children with ADHD in Residential Care

Little is known about the characteristics or functioning of children with ADHD in residential care as compared to their non-ADHD peers. This study evaluated data on 538 children with (n = 125) and without (n = 413) ADHD in residential care to determine demographic, mental health, behavioral, and treatment (i.e., medication use) characteristics. Results revealed that both groups presented elevated risks, however, scores for children with ADHD indicated even greater levels of need. Specifically, differences were found between the two groups on demographics (e.g., family reunification status, restrictiveness of prior out-of-home placements), behavior (e.g., attention problems, rule-breaking and aggressive behaviors) and medication status. Findings suggest there is a need for aftercare services to help support families as children transition from care, interventions to address behavior, and medication management through assessment and monitoring.     

Community-Based Interventions: A Return to Community Mental Health Centers' Origins

Consultation services offered by community mental health centers (CMHC) have gone through several significant changes since the signing of the Community Mental Health Center Act of 1963 (The President's Commission on Mental Health, 1978). Initially, consultation and education services were an integral part of the CMHC mission. With the passage of additional legislation that promoted a shift in focus, consultation services declined. By 1981, with the passage of the Omnibus Budget Reconciliation Act (Cutler, 1992) national mental health policy was adrift. Consultation and education were no longer seen as central components of mental health services, which increasingly were tied to acute care hospitalization. With a renewed focus on consultation and education, a coherent mental health policy can be reintroduced at the community level.     

Police perspectives on responding to mentally ill people in crisis: perceptions of program effectiveness

In this study, we sampled sworn police officers from three law enforcement agencies (n=452), each of which had different system responses to mentally ill people in crisis. One department relies on field assistance from a mobile mental health crisis team, a second has a team of officers specially trained in crisis intervention and management of mentally ill people in crisis, and a third has a team of in-house social workers to assist in responding to calls. Calls involving mentally ill people in crisis appear to be frequent and are perceived by most of the officers to pose a significant problem for the department; however, most officers reported feeling well prepared to handle these calls. Generally, officers from the jurisdiction with a specialized team of officers rated their program as being highly effective in meeting the needs of mentally ill people in crisis, keeping mentally ill people out of jail, minimizing the amount of time officers spend on these calls, and maintaining community safety. Officers from departments relying on a mobile crisis unit (MCU) and on police-based social workers both rated their programs as being moderately effective on each of these dimensions except for minimizing officer time on these calls where the MCU had significantly lower ratings. © 1998 John Wiley & Sons, Ltd.     

Outpatient Psychotropic Medication Use in the US: A Comparison Based on Foster Care Status

Using data from the Client/Patient Sample Survey, a nationally representative study of outpatient mental health service utilization, the prevalence and correlates of psychotropic medication receipt for youth who live with families and in foster care are compared. The medication rate is similar for both groups, with slightly more than one-third of youth treated with medication. Additionally, when medication is prescribed, it is the sole intervention provided for close to one half of each group, and the distribution of other services received (such as clinical case management and collateral services) is similar, regardless of living situation. However, the predictors of medication use differ for the two groups. Among foster care youth, only presenting problems of depressed mood, being withdrawn, and suicidality significantly increase the odds of medication; among youth with families, sociodemographic characteristics (male gender), and a range of clinical factors (disruptive behavior disorder, presenting problems of hyperactivity and sleep disturbance, prior mental health service receipt, and inpatient or residential care referral sources) increase the likelihood of medication. The conclusion that distinct sets of factors predict medication for the two groups was reinforced by results of multivariate analyses; foster care status moderates the association between medication receipt and only one of the correlates examined (gender). Implications, limitations, and areas for future research are presented.     

Benchmarking Treatment Effectiveness of Community‐Delivered Trauma‐Focused Cognitive Behavioral Therapy

It is critical for urban youth with post‐traumatic stress disorder (PTSD) living in poverty to have access to evidence‐based interventions for their traumatic stress. However, there is limited research on the effectiveness of these interventions when provided in urban, community settings. The objectives of the current study are to (a) evaluate the effectiveness of trauma‐focused cognitive behavioral therapy delivered from 2013 to 2016 in 15 behavioral health agencies on youth (N = 114) PTSD as well as  general mental health symptoms and  functioning, and (b) benchmark these clinical outcomes against other published efficacy and effectiveness trials. Effectiveness data are from the Philadelphia County Community Behavioral Health System, a system that has invested significantly in the training and ongoing support of clinicians providing high‐quality trauma services to youth since 2012. From baseline to last assessment, youth PTSD symptom severity (d = 0.34), PTSD functional impairment (d = 0.38), and overall mental health problem severity (d = 0.29) improved. The effect sizes of  improvements were smaller than effect sizes observed in efficacy and effectiveness studies. This study is the first benchmarking study of TF‐CBT and provides preliminary findings with regard to the effectiveness, and transportability, of TF‐CBT to urban community settings that serve youth in poverty.