Characteristics of children and adolescents in a psychiatric hospital and a corrections facility

Sex differences in youth with mental health problems in inpatient, outpatient and youth justice settings

BACKGROUND

Approximately 40-70% of justice-involved youth have untreated mental health problems. There is no current research that directly compares the mental health profiles of youth involved in the justice system to that of inpatients and outpatients. The research reported is significant because it directly compares the needs of these population by use of the same suite of standardized assessment tools.

METHODS

The sample consisted of 755 youth aged 16-19 years recruited from youth justice and mental health facilities in Ontario, Canada. Participants completed semi-structured assessment interviews using the interRAI child and youth suite of instruments to assess for internalizing and externalizing concerns as well as exposure to traumatic life events.

RESULTS

Findings indicated that justice-involved youth experienced higher levels of certain types of trauma. Analyses examining sex differences indicated that, controlling for age, males in the youth justice group reported higher cumulative trauma compared to male outpatients but not inpatients. Females in the youth justice group reported experiencing higher cumulative trauma compared to female outpatients and inpatients. In addition, controlling for sex and age, the youth justice group reported lower internalizing symptoms scores than inpatients and outpatients. Finally, males in the youth justice group scored lower than inpatients in externalizing symptoms, whereas females within the youth justice group scored higher in externalizing symptoms compared to inpatients and outpatients.

CONCLUSIONS

Results indicated that youth who are involved with the justice system exhibit significant psychosocial issues that represent complex service needs which require unique interventions in order to be addressed appropriately.

History of parenting instability and lifetime suicidal behavior in people who inject drugs

Despite high rates of suicide in people who inject drugs, little is known about the risk factors for suicide related to childhood and family history in this population. We aimed to explore the relationship between the history of out-of-home care (OHC) and lifetime suicide attempts among people who inject opioids. Participants (N = 202) were current injection opioid users with at least one previous episode of opioid maintenance treatment. They were recruited into a double-blind randomized controlled trial for opioid substitution treatment. Secondary analysis of baseline data was conducted from the European Addiction Severity Index and basic demographics questionnaires. A total of 81 (40%) participants reported a history of living in OHC and 27% reported attempting suicide. Participants who reported living in OHC were more likely to report lifetime suicide attempts compared to those who did not live in OHC. History of OHC and suicidal ideation were significant risk factors for suicide attempts adjusting for depression and anxiety. Highest rates of lifetime attempts were among participants who lived in a group home, foster care, and/or psychiatric facility. Living in OHC during childhood was significantly associated with higher rates of suicide attempts in our sample. Greater efforts should be made to provide children from vulnerable families with environments where stable one-to-one relationships can be cultivated.

Psychiatric medication refill practices of juvenile detainees

To examine the psychiatric medication fill rates of adolescents after release from juvenile detention. The team reviewed 177 charts. A fill was defined as a psychiatric medication charge to Medicaid 30- or 90-days after release. Differences in demographic characteristics were compared among individuals with fills at 30- or 90-days and those with no medication fills. Forty-five percent of patients were on at least one psychiatric medication. Among detainees on a psychiatric medication, 62 % had a fill by 30 days after release, and 78 % by 90 days. At least 50 % of the adolescents on a psychiatric medication were on an atypical antipsychotic. There was no significant relationship between medication fill and race, age, or sex. Despite the known associations between mental health diagnosis and treatment-seeking with age, sex, and race, it appears that psychiatric medication fill patterns after release from detention are not associated with these factors.

The effect of client ethnicity on clinical interpretation of the MMPI-2

Client ethnicity has been shown to affect clinicians' diagnostic impressions. However, it is not known whether interpretation of the Minnesota Multiphasic Personality Inventory-2 (MMPI-2) clinical scales is affected by ethnic bias. In this study, clinicians (82 males, 60 females) provided severity ratings for six symptoms based on three MMPI-2 profiles (representing the 27/72, 49/94, and 68/86 code-types) with the ethnicity of the client randomly assigned as either African American or Caucasian. To determine whether symptom severity ratings based on MMPI-2 profiles were affected by ethnicity, a 3 (code-type) × 2 (ethnicity) MANOVA was performed. Neither the main effect for ethnicity nor the ethnicity × code-type interaction was significant. These results indicated that the symptom severity ratings based on the MMPI-2 clinical scales were not affected by the client's identification as African American or Caucasian. Future studies are needed to explore the interpretation of profiles from clients representing other ethnic groups and for female clients.

Psychopathology of adolescent detained versus psychiatric inpatient females

Several studies have shown high rates of psychopathology among female adolescents in detention. Although rates of mental health problems have been called alarming, it is unknown whether mental health needs in females in juvenile justice differ substantially from those of females in mental health care. Therefore, this study compared adolescent females in detention with inpatient adolescent females. For this purpose, a sample of 256 detained females (mean age 15.4 ± 1.3) was compared to 45 psychiatric inpatient females (mean age 15.8 ±1.4). Socio-demographic characteristics, mental health history and psychiatric problems were investigated using file-information and self-report questionnaires. Compared to detained females, inpatients more often showed internalizing problems and dissociation, whereas externalizing problems prevailed in girls in detention centers. Females in detention more often came from an ethnic minority group, while females in mental healthcare more often received mental healthcare previously and had parents with higher employment. This study confirms that mental health needs of girls in mental healthcare and in detention are high. However, non-mental health related factors were different as well - i.e. socio-economic factors - and are likely to influence the involvement with either service sector.

Treatment of culturally diverse children and adolescents with depression

This article is written for the practitioners treating depression in ethnic minority youth. It will review the context in which services are delivered to these youth: Researchers have recognized persistent ethnic differences in terms of utilization of services and unmet need. Furthermore, when ethnic minority youth do receive pediatric mental health care, the services that they receive may differ from those given to White patients. The reasons for these discrepancies have been examined in numerous studies, and have included contextual variables (economics, availability, and accessibility of services), patient variables (differences in prevalence or manifestation of the disorder, cultural beliefs and attitudes, preferential use of alternative or informal services, health literacy, and adherence), and provider variables (referral bias and patient-provider communication). Information about the differences between White and minority youth in the pharmacodynamics and pharmacokinetics of the antidepressant response is still limited. There are significant challenges for developing evidence-based guidelines that inform practice with these youth, hinging on both the underrepresentation of ethnic minority groups in clinical trials, and the great variability in biological and cultural characteristics of individuals in ethnic minority categories. Awareness on the part of the practitioner of the cultural variables that influence help-seeking and ongoing utilization of mental health services may aid in the engagement, effective treatment, and retention of ethnic minority children and adolescents with depression. However, given the great heterogeneity that exists within any cultural grouping, clinicians will need to integrate information about cultural patterns with that obtained from the individual patient and family to inform optimal practices for each patient. This article is written to enhance awareness on the part of the practitioner as to the variables that influence psychiatric care for depression in culturally diverse youth. The mental health needs of minority youth are not well served: They are treated less frequently, and when they are treated, the services they receive are less frequently adequate. The reasons that have been proposed for the disparities in their care, particularly with regard to diagnosis and treatment for depression, will be reviewed. They include contextual factors (such as economics, insurance, and other variables affecting the availability of services) patient and family factors (such as prevalence, symptom presentation, and values and beliefs that influence whether patients are referred to and avail themselves of services), and provider factors (such as referral bias and patient-provider communication, which affect whether patients engage and stay in treatment). The implications for the practitioner treating ethnic minority youth with depression will be discussed. Culture, as used in this article, refers to the common values, beliefs, and social behaviors of individuals with a shared heritage. Some aspects of culture that are likely to influence service utilization include health beliefs, particularly regarding models of mental illness, and level of stigma toward mental health treatment, which are frequently shared by individuals in a cultural group. However, some caveats for the explanatory potential of "culture" should be kept in mind. Conventions for naming groups vary between investigators and over time (e.g., the restriction of the category "White" into "White NonHispanic," is quite recent). Although heterogeneity is assumed within a named cultural or racial group, the terms Hispanic, Asian, and African-American incorporate subgroups can be very different in linguistic, historical, and geographical ancestry (e.g., Stewart 2008 ), and each group incorporates individuals who may not share any components of their historical heritage. Even among those with historical ties, values, beliefs, and social behaviors can vary according to the extent to which they identify with the mainstream culture. Social class frequently creates a "culture" of its own, with individuals in the same social class across traditional cultural groupings sharing disparities in care, and many beliefs and values. Individuals are likely to belong to numerous "cultures," and may not share specific typical behaviors or beliefs with any of them.

Adolescent psychiatric patients and their parents: comparison with a non-clinical cohort

The study compared the psychiatric symptoms, coping skills, and family functioning of adolescent psychiatric inpatients and their primary caretakers with a non-clinical comparison group of adolescents and their primary caretakers. Participants completed measures of psychiatric symptoms, life experiences, problem-solving ability, family functioning, and anger. MANOVAs compared the adolescents and caretakers across the normative and clinical samples. A discriminate function analysis predicted membership in the clinical and non-clinical sample. Primary caretakers for the hospitalized adolescents reported significant differences in self-reported family functioning, life stress, psychiatric symptoms, and ratings of adolescent problem behaviors. These variables successfully classified 78% of the sample as inpatient or non-clinical comparison subjects. Adolescents hospitalized for psychiatric reasons did not differ from their non-clinical counterparts on self-report measures of psychiatric symptoms, distress, problem behaviors, problem solving, or trait anger. Independent of psychiatric status, adolescent self-reported family functioning and adolescent problem solving skills predicted the number of problems adolescents endorsed, the number of symptoms adolescents endorsed, and adolescent levels of trait anger. Although a brief psychiatric hospitalization seemed effective in treating adolescent mental health patients, the primary caretakers remained more symptomatic than a non-clinical cohort. Continuing to focus on the development of health care policies that are sensitive to needs of the primary caretakers will likely enhance long-term outcomes.

Posttraumatic stress as a mediator of the relationship between trauma and mental health problems among juvenile delinquents

This study investigated the interrelationships among trauma exposure, PTSD, and mental health problems in a sample of 289 adolescents (199 male, 90 female) detained in a juvenile correctional facility. Mean differences were found in that females scored higher than males on measures of interpersonal trauma exposure and symptoms of both simple and complex PTSD. Females also endorsed more mental health problems in the areas of depression/anxiety, somatic complaints, and suicidal ideation. For all youth, trauma exposure, PTSD, and mental health problems were correlated. Results of structural equation modeling were consistent with the hypothesis that PTSD mediates the relationship between interpersonal trauma and mental health problems for all youth, although the results were stronger for females.

Mental disorders among adolescents in juvenile detention and correctional facilities: a systematic review and metaregression analysis of 25 surveys

OBJECTIVE

To systematically review and perform a meta-analysis of the research literature on the prevalence of mental disorders in adolescents in juvenile detention and correctional facilities.

METHOD

Surveys of psychiatric morbidity based on interviews of unselected populations of detained children and adolescents were identified by computer-assisted searches, scanning of reference lists, hand-searching of journals, and correspondence with authors of relevant reports. The sex-specific prevalence of mental disorders (psychotic illness, major depression, attention-deficit/hyperactivity disorder [ADHD], and conduct disorder) together with potentially moderating study characteristics were abstracted from publications. Statistical analysis involved metaregression to identify possible causes of differences in disorder prevalence across surveys.

RESULTS

Twenty-five surveys involving 13,778 boys and 2,972 girls (mean age 15.6 years, range 10-19 years) met inclusion criteria. Among boys, 3.3% (95% confidence interval [CI] 3.0%-3.6%) were diagnosed with psychotic illness, 10.6% (7.3%-13.9%) with major depression, 11.7% (4.1%-19.2%) with ADHD, and 52.8% (40.9%-64.7%) with conduct disorder. Among girls, 2.7% (2.0%-3.4%) were diagnosed with psychotic illness, 29.2% (21.9%-36.5%) with major depression, 18.5% (9.3%-27.7%) with ADHD, and 52.8% (32.4%-73.2%) with conduct disorder. Metaregression suggested that surveys using the Diagnostic Interview Schedule for Children yielded lower prevalence estimates for depression, ADHD, and conduct disorder, whereas studies with psychiatrists acting as interviewers had lower prevalence estimates only of depression.

CONCLUSIONS

Adolescents in detention and correctional facilities were about 10 times more likely to suffer from psychosis than the general adolescent population. Girls were more often diagnosed with major depression than were boys, contrary to findings from adult prisoners and general population surveys. The findings have implications for the provision of psychiatric services for adolescents in detention.

Judging mental disorder in youths: Effects of client, clinician, and contextual differences

Using a vignette-based, mailed survey of 1,401 experienced psychologists, psychiatrists, and social workers, the authors examined how clients' race/ethnicity and clinicians' professional and social characteristics affect their judgment of mental disorder among antisocially behaving youths. Vignettes described problematic behaviors meeting the Diagnostic and Statistical Manual of Mental Disorders (4th ed.; DSM-IV; American Psychiatric Association, 1994) criteria for conduct disorder but contained contextual information suggesting either disorder or nondisorder, following DSM-IV guidelines. Clinicians depended on contextual information to decide whether a mental disorder existed, and they judged White youths to have a disorder more frequently than Black or Hispanic youths. Clinicians' occupation, theoretical orientation, and age also were associated with disorder judgments, whereas their gender, race, and experience were not. Research and training implications of these variations in clinical judgments are discussed.

Ethnic variation of self-reported psychopathology among incarcerated youth

Research on ethnic minority populations has shown them to be undertreated, underdiagnosed and perceived as more psychopathological in comparison to the Caucasian population. This study aimed to assess ethnic variation of self-perceived psychopathology in a population of incarcerated youths. The Youth Self-Report (YSR) was completed by 5964 incarcerated adolescents (95% male; mean age = 16.5) in the California Youth Authority (CYA) system. Overall, ethnic minorities (African-Americans and Hispanics) self-report lower levels of psychiatric problems than Caucasians. These differences were more pronounced in males than females. Further research is needed to better ascertain the reasons for these differences.

Conditions associated with identification of mentally ill youths in juvenile detention

The current study examines the prevalence and severity of psychiatric symptoms in incarcerated youth. A random sample of youth ages 13-17 who were referred for mental health services (n=120) and not referred for services (n=120) at a juvenile detention facility were studied. Psychopathology was evaluated using the Diagnostic Interview Schedule for Children and the Child Behavior Checklist. Ninety-six percent of referred youth and 69% of non-referred youth had one or more psychiatric diagnoses. Co-morbidity was common in both groups. The findings suggest that youths in the juvenile justice system have noteworthy psychopathology that often remains unidentified.

Detecting mental disorder in juvenile detainees: who receives services

OBJECTIVES

We determined whether or not juvenile detainees with major mental disorders received treatment, and the variables that predicted who received services.

METHODS

Our sample was 1829 randomly selected juvenile detainees taking part in the Northwestern Juvenile Project. To determine need for mental health services, independent interviewers administered the Diagnostic Interview Schedule for Children and rated functional impairment using the Child Global Assessment Scale. Records on service provision were obtained from the juvenile justice and public health systems.

RESULTS

Among detainees who had major mental disorders and associated functional impairments, 15.4% received treatment in the detention center and 8.1% received treatment in the community by the time of case disposition or 6 months, whichever came first. Significantly more girls than boys were detected and treated. Receiving treatment was predicted by clinical variables (having a major mental disorder or reported treatment history or suicidal behavior) and demographic variables.

CONCLUSIONS

The challenge to public health is to provide accessible, innovative, and effective treatments to juvenile detainees, a population that is often beyond the reach of traditional services.

A statewide screening of mental health symptoms among juvenile offenders in detention

OBJECTIVE

As awareness of the high prevalence of mental health problems among juvenile offenders has grown, researchers and practitioners have recognized the need for reliable and efficient methods of assessing such problems among large numbers of offenders to ensure that limited treatment resources are applied to those with the greatest need.

METHOD

Between May 2000 and October 2002, 18,607 admissions were administered the computerized version of the Massachusetts Youth Screening Instrument Version 2 (MAYSI-2) 24 to 48 hours after their arrival at detention centers throughout Pennsylvania.

RESULTS

Approximately 70% of the males and 81% of the females scored above the clinical cutoff on at least one of the following five MAYSI-2 scales: Alcohol/Drug Use, Angry-Irritable, Depressed-Anxious, Somatic Complaints, and/or Suicide Ideation. Girls were more likely than boys to exhibit internalizing as well as externalizing problems. Mental health problems were most prevalent among white youths and least prevalent among African American youths. When youths repeated the screen upon subsequent visits to detention, their scores generally remained stable.

CONCLUSIONS

The findings suggest that the MAYSI-2 is a promising triage tool for emergent risk. The use of such a screen may reduce bias in allocation of treatment resources and improves our understanding of the nature of mental health problems in delinquent populations.

Comorbid psychiatric disorders in youth in juvenile detention

OBJECTIVE

To estimate 6-month prevalence of comorbid psychiatric disorders among juvenile detainees by demographic subgroups (sex, race/ethnicity, and age).

DESIGN

Epidemiologic study of juvenile detainees. Master's level clinical research interviewers administered the Diagnostic Interview Schedule for Children Version 2.3 to randomly selected detainees.

SETTING

A large temporary detention center for juveniles in Cook County, Illinois (which includes Chicago and surrounding suburbs).

PARTICIPANTS

Randomly selected, stratified sample of 1829 African American, non-Hispanic white, and Hispanic youth (1172 males, 657 females, aged 10-18 years) arrested and newly detained.

MAIN OUTCOME MEASURE

Diagnostic Interview Schedule for Children.

RESULTS

Significantly more females (56.5%) than males (45.9%) met criteria for 2 or more of the following disorders: major depressive, dysthymic, manic, psychotic, panic, separation anxiety, overanxious, generalized anxiety, obsessive-compulsive, attention-deficit/hyperactivity, conduct, oppositional defiant, alcohol, marijuana, and other substance; 17.3% of females and 20.4% of males had only one disorder. We also examined types of disorder: affective, anxiety, substance use, and attention-deficit/hyperactivity or behavioral. The odds of having comorbid disorders were higher than expected by chance for most demographic subgroups, except when base rates of disorders were already high or when cell sizes were small. Nearly 14% of females and 11% of males had both a major mental disorder (psychosis, manic episode, or major depressive episode) and a substance use disorder. Compared with participants with no major mental disorder (the residual category), those with a major mental disorder had significantly greater odds (1.8-4.1) of having substance use disorders. Nearly 30% of females and more than 20% of males with substance use disorders had major mental disorders. Rates of some types of comorbidity were higher among non-Hispanic whites and older adolescents.

CONCLUSIONS

Comorbid psychiatric disorders are a major health problem among detained youth. We recommend directions for research and discuss how to improve treatment and reduce health disparities in the juvenile justice and mental health systems.

Validity of the pediatric inpatient behavior scale in an inpatient psychiatric setting

Standardized assessment of children's behavior during psychiatric hospitalization is increasingly important for evaluation, chart documentation, treatment planning, and outcome monitoring, yet little research has been done to validate the use of behavior checklists developed specifically to assess in-hospital behavior. The Pediatric Inpatient Behavior Scale (PIBS) was evaluated for its validity as a measure of behavior of children hospitalized on a psychiatric unit. Nurses completed the PIBS for 41 children, based on behavior observed during the first week of hospitalization. DSM-IV diagnoses and major symptoms were coded based on chart review, and children completed self-report measures of depression and anxiety. The Pediatric Inpatient Behavior Scale subscale scores were related significantly to diagnosis, as well as to major symptoms, correctly classifying 75 to 85% of cases. The Pediatric Inpatient Behavior Scale subscale scores also significantly correlated with self-reported symptoms of depression, but not symptoms of state anxiety. Results support the use of the PIBS as a behavioral instrument for hospitalized children with severe psychopathology.

Determinants of service placements for youth with serious emotional and behavioral disturbances

This paper examines the association between race and type of service placement for youth with serious emotional and behavioral disturbances. Placements were reviewed for 2,803 black and white youth served in the community mental health system. Differences were found between black and white youth in the type of out-of-home placements they received after controlling for sociodemographic variables and presenting problems. Black youth were more likely than whites to be placed in correctional facilities and foster care while white youth were more likely than blacks to be hospitalized (p < .001). This variation in placement may not be clinically warranted. Placement criteria and outcome assessments are needed.

Police reporting and professional help seeking for child crime victims: a review

Most crimes with child victims are not reported to police, nor do child victims access other professional victim services, despite evidence that these yield positive outcomes. This article develops a conceptual framework about the barriers to such access: (a) the reluctance to define the crime episodes or their consequences as serious, criminal, harmful, or warranting intervention; (b) the extra authorities, including parents and schools, who mediate between victims and police or services; (c) developmental issues, such as concerns about autonomy; (d) attitudinal and emotional obstacles; and (e) time and expense factors. This article suggests the need for initiatives to stimulate reporting and help seeking, such as more publicity about the seriousness of juvenile victimization, more justice-system involvement with schools, more child and family friendly police services, and an emphasis on attractive outcomes such as justice and empowerment.

Criminal behavior and emotional disorder: comparing youth served by the mental health and juvenile justice systems

This study explored whether youth involved in joint service systems differed from single-agency users in terms of types of crimes committed and clinical functioning. Data from 4,924 youth involved in one county's public mental health and juvenile justice service systems were examined. Twenty percent of those youth receiving mental health services had recent arrest records, and 30% of youth arrested received mental health services. Of all youth arrested in the county, mental health service users had more arrests than non-mental health service users. A subsample of 94 mental health service users with arrests was matched on demographics with 94 mental health service users without arrests. Youth with arrests had a higher frequency of conduct disorder, higher Child Behavior Checklist Externalizing and Total Problem Scale scores, and more functional impairment on the Child and Adolescent Functional Assessment Scale as compared to youth without arrests. Implications for behavioral health service delivery were discussed.

Patient race and ethnicity in primary care management of child behavior problems: a report from PROS and ASPN. Pediatric Research in Office Settings. Ambulatory Sentinel Practice Network

BACKGROUND

Minority persons have less access to many specialty treatments and services, possibly because of clinician biases. It is not clear whether any such biases exist in primary care settings, especially for children with psychosocial problems.

OBJECTIVES

The objective was to compare primary care recognition and treatment of pediatric psychosocial problems among African American, Hispanic American and European American patients.

DESIGN

A survey was made of parents and respective clinicians in primary care offices in two large practice-based research networks (PROS and ASPN) from 44 states, Canada, and Puerto Rico. Mixed regression analyses were employed to control for patient, clinician, and practice effects.

SUBJECTS

The subjects were 14,910 children aged 4 to 15 years seen consecutively for non-emergent care by 286 primary care clinicians in office-based practice.

MEASURES

Measures were parents' report for sociodemographics and behavioral symptoms using the Pediatric Symptom Checklist, and clinicians' report of psychosocial problems, type, management, and severity.

RESULTS

Of the sample, 8.0% were African American youth, 9.5% were Hispanic American youth, and 82.5% were European American youth. After controlling for other factors, race and ethnicity were not associated with any differences in psychotropic drug prescribing, counseling, referral, or recognition of psychosocial problems. Clinicians reported spending slightly more time with minority patients.

CONCLUSION

Race and ethnic status were not related to receipt of mental health services for children in primary care offices, suggesting that clinician biases may not be the primary cause of the racial differences in services noted earlier research. Improving services for minority youth may require increasing access to office-based primary care.

The contribution of treatment outcome research to the reform of children's mental health services: multisystemic therapy as an example

Service system reforms of the past decade have yielded innovations in type, accessibility, and cost of services provided for some children and families with serious problems, but few of the treatments delivered have been empirically evaluated. Rigorous tests of well-conceived treatments are needed to provide a solid foundation for continued reform. Multisystemic therapy has demonstrated efficacy in treating serious clinical problems in adolescents and their multineed families and is an example of the successful blending of rigorous treatment outcome research and service system innovation.

Social class, ethnicity, and mental illness: the importance of being more than earnest

This paper revisits a landmark study of the prevalence of mental illness in the state of Massachusetts conducted by Edward Jarvis in the 19th century. Jarvis drew an improper conclusion about the relationship between social class, ethnicity, and insanity, asserting that the Irish foreign-born had a higher prevalence of insanity in each social stratum. A reanalysis of Jarvis' data shows that in both the pauper and independent social classes in Massachusetts, the prevalence of insanity was significantly lower among foreign-born persons than among native-born persons. On the basis of his misperception, Jarvis constructed elaborate etiological theories. These theories made a strong impact on the mental health service policies of his day. The effects of incomplete examination of data on etiological theories and mental health policy in current times are highlighted in this article.

Administrative update: utilization of services. II. Utilization of mental health services in a tri-ethnic sample of adolescents

In our study of a tri-ethnic sample of 2528 junior and high school students, we examined utilization of outpatient mental health services in relation to a number of variables cited in the literature as leading to potential biases and barriers to care. These include: age, gender, ethnicity, socioeconomic status, family size and composition, and linguistic fluency in Hispanic youth. The impact of service availability was examined through differences between the two regions studied: a well-served region of coastal southeast Texas and the markedly under served lower Rio Grande Valley. The impact of symptomatology was evaluated using the total problem score on the Youth Self Report by Achenbach. Hispanic youth had significantly lower mean service utilization than non-Hispanic whites. Multiple regression analyses demonstrated that socioeconomic status and family composition had a greater relative impact on utilization than all other non-clinical factors, both for the total sample as well as for the Hispanic sample. Ethnicity may play a significant role in child mental health services utilization through its close association to socioeconomic status.

The nature and characteristics of psychiatric comorbidity in incarcerated adolescents

OBJECTIVES

To determine the prevalence of psychiatric disorders, the degree of psychiatric comorbidity, and the relationship between these and sociodemographic variables in a sample of incarcerated adolescents. A comparison with an age- and sex-matched community sample was conducted.

METHOD

Age- and sex-matched samples of 49 incarcerated adolescents and 49 nondelinquents were compared for psychiatric morbidity and psychosocial characteristics. Psychiatric diagnoses were determined using the Diagnostic Interview for Children and Adolescents-Revised (DICA-R). Additional information on psychosocial, family, and offence characteristics was obtained using a semistructured interview designed specifically for this study. The prevalence of single and comorbid psychiatric disorders was determined.

RESULTS

Approximately 63.3% of incarcerated adolescents had 2 or more psychiatric disorders. The degree of psychiatric morbidity was directly related to indicators of family adversity, physical abuse, other psychosocial variables, or polysubstance abuse. Psychiatric comorbidity was more frequent in females. Incarcerated adolescents were more likely to endorse symptoms of thought disorder.

CONCLUSIONS

Findings identify preventive intervention foci for policy makers and planners in the area of adolescent corrections. Implications for education and training of nonclinical custodial staff are discussed as is the need for a more therapeutic orientation in correctional facilities.

Risk factors for juvenile justice system referral among children in a public mental health system

The objective of this study is to identify, through the use of secondary data, risk factors for juvenile justice system involvement among children entering a public mental health system. Data-sharing agreements between juvenile justice and mental health systems enabled investigators to examine criminal referrals among 645 children between the ages of 10 to 17 who entered community-based public mental health programs in King County, Washington, over the course of a single year. Univariate and logistic regression analyses were performed. Adjusting for age, gender, and ethnicity, children involved in the public mental health system who had juvenile justice referrals were more likely than children involved in the mental health system without juvenile justice referrals to have parents with a history of incarceration, to abuse drugs and/or alcohol, and to have experienced physical abuse. The study shows that some children who receive public mental health services are at particular risk of having an encounter with the juvenile justice system. Understanding the characteristics and experiences of youth who use multiple service systems has important implications for children's mental health services delivery.

Practice parameters for the assessment and treatment of children and adolescents with conduct disorder. American Academy of Child and Adolescent Psychiatry

These practice parameters address the diagnosis, treatment, and prevention of conduct disorder in children and adolescents. Voluminous literature addresses the problem from a developmental, epidemiological, and criminological perspective. Properly designed treatment outcome studies of modern psychiatric modalities are rare. Ethnic issues are mentioned but not fully addressed from a clinical perspective. Clinical features of youth with conduct disorder include predominance in males, low socioeconomic status, and familial aggregation. Important continuities to oppositional defiant disorder and antisocial personality disorder have been documented. Extensive comorbidity, especially with other externalizing disorders, depression, and substance abuse, has been documented and has significance for prognosis. Clinically significant subtypes exist according to age of onset, overt or covert conduct problems, and levels of restraint exhibited under stress. To be effective, treatment must be multimodal, address multiple foci, and continue over extensive periods of time. Early treatment and prevention seem to be more effective than later intervention.

Race and gender differences in the treatment of psychiatric disorders in young adolescents

OBJECTIVE

Most children and adolescents with mental illness remain untreated. Evidence suggests that race is a factor in the referral of children for treatment. This study examines race and gender differences in treatment of adolescent psychiatric disorders.

METHOD

During a two-stage, school-based, epidemiological study of depression, data were collected on 478 adolescents. Instruments included the Schedule for Affective Disorders and Schizophrenia for School-Age Children and the Children's Global Assessment Scale.

RESULTS

Twenty-two percent of the sample had contact with professionals during the prior year, including 56% of adolescents with a psychiatric diagnosis. Significant odds ratios (ORs) were found between all diagnoses and treatment. Trends for undertreatment of females and African-Americans were evident in univariable and multivariable models. The OR (0.34) for African-American females was significant in the multivariable model. African-Americans were significantly more likely to receive only one or two treatment contacts.

CONCLUSION

Data suggest race and gender differences in the treatment of adolescent psychiatric disorders. Possible explanations include referral bias, low cultural competence of mental health professionals, and cultural differences in the expression and tolerance of symptoms and help-seeking behaviors. Further study of factors influencing treatment decisions is needed.

Influence of race on diagnosis in adolescent psychiatric inpatients

OBJECTIVE

To examine racial differences in 352 psychiatric inpatients, aged 12 to 18 years, at a state hospital facility that accepted admissions from throughout South Carolina. These were all the adolescent admissions during an entire calendar year (1988). There were 101 African-American and 251 white subjects.

METHOD

The data were abstracted from patients' hospital medical records and nursing incident reports. DSM-III-R discharge diagnoses were assigned to five non-mutually exclusive groupings (organic/psychotic, mood/anxiety, disruptive, personality, substance abuse). Racial differences were analyzed using chi 2, logistic regression, and T statistics.

RESULTS

African-Americans were more likely to be involuntarily committed at the time of admission (p = .010). Organic/psychotic diagnoses were much more frequent in African-Americans (odds ratio = 3.15, p < .003). Whites (p = .0347) were almost two times more likely to receive mood/anxiety diagnoses even when controlling for gender, type of admission, and comorbid diagnoses. Substance abuse was more often diagnosed in whites (odds ratio = 5.46, p < .0001).

CONCLUSIONS

This study identifies significant racial differences in the discharge diagnoses of psychiatrically hospitalized adolescents. African-Americans have fewer mood/anxiety and substance abuse diagnoses but significantly more organic/psychotic diagnoses. Some of these differences may reflect ethnocentric clinician bias in the diagnostic assessment of youth from differing cultural/racial backgrounds.