Mental health needs of community based young offenders in a city setting.
Psychiatric morbidity among young offenders is increasingly recognised as a key area. Several studies have demonstrated the high prevalence of psychological disorders. Kessler (2007) identified that the mental health, educational and social needs of young offenders are often inadequately assessed or met, possibly exacerbating recidivism due to insufficient care pathways to facilitate rehabilitation. Furthermore, young offenders are noted to have significantly increased mortality rates highlighting the importance of addressing their mental health needs (Coffey, Veit, Wolfe, Cini and Patton, 2003).
The International Classification of Diseases--Version 10 uses the concept of a multiaxial diagnosis, encouraging the clinician to identify the impact of migration, discrimination and family turmoil. In this context, the Youth Justice Board report Differences or Discrimination (2004) is of note, it identified higher rates of prosecution among Black males and higher rates of detention for Black, Asian and mixed parentage young people within the criminal justice system. This suggests that we are examining a demographic that can alter a young person's experience of the world around them. This report uses the terms 'Black', 'White' and 'Asian' and these are the terms used in this paper. We acknowledge the limitations of this system of description, and are mindful of the British Medical Journal guidance; 'Try to use accurate descriptions of race, ethnicity, and culture rather than catch all terms in common use. In the methods section of research articles describe the logic behind any ethnic groupings used.'
The 2001 United Kingdom (UK) census identified over 5.3 million people aged between 16 - 24, representing 11% of the population. In this city setting, 16-24 year olds comprised 18% of the population. Overall 13.5 % of young people in the UK are of Black or ethnic minority origin, however in this urban setting, 21.8% of people aged 16-24 are of Black or ethnic minority origin. Thus there is a need to understand the mental health needs of this youthful and diverse city population. Furthermore, Green, McGinnity, Meltzer, Ford, Goodman (2004) identified that approximately 12% of young people between 11-16 had a mental health need. A recent study conducted by Hackett, Theodosiou, Blackburn, Lever and Spicer (2011) found that 18% of 11-16 year olds scored abnormally on the Strengths and Difficulties Questionnaire (SDQ). The SDQ has been used in a range of studies both nationally (Green et al., 2004) and in local settings (Hackett et al., 2011). This 25 item questionnaire is available to be downloaded freely in a range of languages, normative data is available on the website. The answers can be scored using a free online system or a scoring sheet can be downloaded. The results are clustered in five symptom subheadings; Emotional, Conduct, Hyperactivity, Peer and Prosocial. Adding together the first four produces a summative score of need. A final section asks the person completing the tool to score the impact of the symptoms on the young person. All seven categories are scored as normal, borderline and abnormal.
The Conners Questionnaire (Conners, Wells, Parker, Sitarenios, Diamond and Powell, 1997) is a widely used screening tool for Attention Deficit Hyperactivity Disorder (Kumar and Steer, 2003). Results are clustered into four subheadings; conduct problems, inattention, hyperactivity and 'at risk' of Attention Deficit Hyperactivity Disorder (ADHD).
Teplin, Abram, McClelland, Mericle, Dulcan, Washburn and Shiraz (2007) reported that half of a sample of young offenders in custody assessed displayed an affective or anxiety disorder. Young people were more likely to have ADHD or behavioural disorders comorbid with substance misuse than any other combination of disorder. Furthermore, among adolescent substance users disorders such as anxiety are generally associated with more severe substance use (Whitmore, Mikulich, Thompson, Riggs, Aarons and Crowley, 1997), although if this is recognised these young offenders tend to have better treatment outcomes (Randall, Henggeler, Pickrel and Brondino, 1999).
Chitsabesan, Kroll, Bailey, Kenning, Sneider, MacDonald and Theodosiou (2006) examined the mental health and psychosocial needs of juvenile offenders in England and Wales. Almost a third of the sample had an unmet mental health need, for example self harm within the past month was reported by approximately 10% of the sample. The majority of these needs remained unmet with few young people having received any type of intervention for their needs.
In 2007, the National Institute for Health and Clinical Excellence (NICE) identified groups of vulnerable and disadvantaged young people as being at risk from substance misuse, among these were youth offenders. NICE strongly recommended that local agencies should develop and implement a strategy to reduce substance misuse. Their advice that the strategy should be based on a local profile of the target population further illustrates the importance of understanding the needs of inner city populations.
To understand the mental health problems and needs of young offenders.
To compare the demographics of the Youth Offending Service (YOS) users and the general population, looking particularly at ethnicity. To provide information for the Commissioners of Child and Adolescent Mental Health Services.
Prior to study commencement, ethical approval was obtained from Oldham Research Ethics Committee. All 180 cases open to YOS at the beginning of the study period were invited to participate. The study ran for 6 weeks with an opt-out consent method. For adolescents under 16, opt-out letters and information sheets were sent to parents and guardians. Young people over 16 received an opt-out form and information sheet directly. Confidentiality was strictly maintained; the YOS had a list of young people invited to participate. The researchers had no access to this information and each young person was allocated a unique randomised identification number.
Once opt-outs had been processed, workers and young people received a questionnaire pack. This questionnaire pack contained the SDQ, the abbreviated Conners and a qualitative tool designed for the study. The latter recorded demographic data such as ethnicity and also attempted to elucidate the perceived needs of the young people e.g. have they ever accessed healthcare, do they have unmet healthcare needs. The tool also asked if adolescents were using illegal substances, and if so which ones. All the questionnaires had a young person version and a key worker version. Packs were given to workers with a young person and a worker version sharing the same case number, in the hope that this would allow the two sets of data to be compared. Anonymised data was examined in the secure premises of a Child and Adolescent Mental Health Service (CAMHS). Analysis was undertaken using SPSS.
Under the conditions specified by ethics, the research team did not have any access to the names and addresses of the young offenders. After opt-outs and case closures, 150 adolescents were eligible and 83 worker questionnaires were returned with a gender ratio for young offenders of 72 males and 11 females. The mean age of the sample was 15.8 years, ranging from 11 to 18 years. Only 50 questionnaires were returned by young people, thus worker and young person data could not be directly compared. The youth offending service were asked to keep a list of all young people invited to participate. Unfortunately this information was not kept, thus the gender balance of the initial group invited to participate is not known.
Information from YOS workers
The workers identified 45% of the sample as being White, the age equivalent sample in the general city population comprises 81%. Black and mixed parentage young people were most prominent amongst the young offenders sample, 22% compared to 5%, furthermore Asian groups represented 16% of the youth offending sample and 9% of the city population.
As displayed in Table 1, there were differences between responses from YOS workers and young people. The workers' Conners results placed 34% of adolescents in the at risk range for ADHD symptoms. Furthermore, from the worker rated SDQ, 36% of young people scored abnormally on the summative scale indicating mental health needs. The Conduct subscale yielded the highest abnormal score at 40%. The hyperactivity subscale indicates that 24% scored abnormally, while 30% scored abnormally on the Prosocial behaviour subscale. On the scale indicating the impact of identified problems, 44% of young people scored abnormally.
YOS workers identified increased mental health needs for White adolescents within the domains of Conduct, Peer problems and Impact of problems. For Conduct problems, 58% scored abnormally and similarly 54% scored abnormally on the Impact score. Rates of abnormal scores on the Hyperactivity and Prosocial behaviour scales were also high within White groups (30% and 32% respectively).
Abnormal scores on the Prosocial scales were found to be highest amongst Black young people, at 39% as rated by workers. Additionally, in one third of cases, workers reported high levels of Conduct symptoms in Black young people. Similarly, Asian groups displayed significant abnormalities within the Prosocial and Impact domains (31% and 46%) and abnormal Conduct scores were prevalent and were reported by almost a quarter of workers. Finally, Conners tools scored by workers were found to be at risk of ADHD in almost half of young White people (49%) followed by Asian (31%) and Black (22%) groups.
Cannabis was the most frequently used substance, workers reported that 66% of young offenders had used cannabis. Alcohol and nicotine were the next highest substances used (31% and 23% respectively). Only two people had required medical attention, but YOS workers considered 17% of the population to be using drugs in a dangerous fashion. Logistical regression analysis was conducted to assess whether high scores on the questionnaires had any value in predicting certain drug use. High scores on the worker rated Conners questionnaire and the worker rated SDQ total score were able to predict cannabis use, B=1.514 (1) p=0.003 and B=1.057 (1) p=0.055 respectively. Additionally, high scores on the worker rated Conners questionnaire also predicted nicotine use B=0.125 (1) p=0.026.
Finally, White adolescents were the most likely to need professional input (68.6%) and the most likely to receive it (54%). However Black adolescents also had high levels of need (41%) as did Asian groups (39%) both of which were largely unmet.
Information from young people
Conners questionnaires from young people indicated that 8% scored as at risk for ADHD symptoms. While 28% of young people scored abnormally on the SDQ Conduct subscale and18% of young people scored abnormally on the hyperactivity subscale. However it is of note that from the SDQ Impact questions, 26% of young people scored abnormally. A large proportion of young people reported using substances; 66% of the sample was using cannabis, 32% had used alcohol and 25% of the sample had used nicotine. In addition, 11% of the sample had tried or was currently using cocaine and 6% of the sample had tried or was using ecstasy and amphetamines.
Looking at both the SDQ and the Conners questionnaires completed by workers, mental health needs were found to be much higher than the general population. However, the self report measures tended to be much lower than the worker rated questionnaires. Goodman (1998) has acknowledged that self reporting may lead to psychiatric cases being unrecognised and that additional informant data can help identify those young people in need of mental health intervention. Moreover, Goodman (1997) proposed that the supplementary Impact questionnaires on the SDQ holds more validity than symptomatic questions at discriminating psychiatric patients from a community sample. It is of note that high numbers of both worker and young person rated scores reached abnormality on this index, 44% and 28% respectively. Rajmil, Estrada, Herdman, Serra-Sutton, Tebe, Izaguirre, Alda, Alonso, Riley, Forrest, Starfield (2009) note that children with ADHD rate their symptoms at around the same level as their peers while their parents scored far higher. Goodman (2000) reports that the teacher version, used here with YOS workers is better at picking up disorders such as ADHD. Goodman notes that teacher and parent versions should be used in preference to the self-report. This may suggest that the model of child and family services offers significant potential to older adolescents.
Hackett (2011) identified that 18% of 11-16 year olds scored abnormally on the SDQ. However, abnormal SDQ results were reported in 35% of the youth offending sample. Furthermore, ethnic minority groups were overrepresented in this sample compared to the general population. Although the emotional scores reported by the young offenders themselves are lower than those reported in other comparable samples, it is of note that they are significantly higher than the normative population data from the SDQ website.
It has been hypothesised that needs between different ethnic groups may vary with behavioural and educational needs being higher among White groups. This is supported by research from the Office of National Statistics which identified higher rates of conduct and hyperactivity problems in White young people. Chitsabesan et al. (2006) found that White groups tended to have higher educational needs compared to minority groups. In the present study learning needs, ADHD and conduct problems were most prevalent amongst White ethnic groups. The question as to whether this group is developmentally different, for example with higher rates of ADHD needs to be elucidated.
Lord Bradley (2008) highlighted that socially excluded groups such as young offenders are known to be poor at accessing services. A recent paper 'Our Health, Our Care, Our Say' sets out a challenge to service commissioners and providers to ensure that community approaches are developed and tailored to meet the needs of excluded groups more successfully.
Dual Diagnosis is increasingly recognised as a major mental health problem for the youth offending population. Shaw et al. (2008) suggested that dual diagnosis should be regarded as the norm rather than the exception. Khantzian (1985) proposed a model of self medication in the initiation of substance use and further abuse. The model proposes that psychotropic drug effects interact with psychiatric disturbances which then lead to further addictive behaviours and explains why adolescents with unmet mental health needs often become addicted to both legal and illegal substances in an attempt to aid their psychological well being. It is of note that high scores on the workers' Connerstools predicted nicotine use, suggesting the lifespan physical health problems that young offenders, particularly those with ADHD can be vulnerable to.
The fact that we do not have the ethnicity and gender data from the original 150 young people is a clear weakness. However the data still demonstrates a high level of need and an overrepresentation of ethnic minorities. The principles of CAPA (choice and partnership approach) emphasise the need to involve young people and families. The fact that 26% of young people feel that their behaviour is having a negative impact on their lives suggests that these young people need a service. More work is needed to see where these young people would like this service to be offered. We are mindful that the 2005 Young Minds report addressing ethnic minority groups provides feedback from young people, they felt that ease of access to CAMHS would be enhanced by drop-in, a self-referral route and a greater choice of appointment venues. Workers noted that ethnic minority groups in this study were the least likely to have been offered CAMHS. Thus we suggest that our study elucidates a group whose mental health needs are currently unmet. Domain 4 of the NHS Outcomes Framework (2010) 'Ensuring that people have a positive experience of care' emphasises the importance of offering young people services where they want them in a way they will experience as beneficial. The authors plan to increase the mental health training to youth offending staff, and ensure that mental health staff are aware of the additional needs of young offenders. The venue of appointments for young offenders will be discussed with service providers and commissioners.
Effective use of mental health resource is particularly key at the present time. Principles of screening and early intervention highlight the need to make best use of a mental health workforce whose capacity may in some places be forcibly cut and in other places being asked to take on additional responsibility. An additional challenge is the way in which services across the lifespan are offered by different providers, often with completely different structures and funding. Older adolescents can be particularly vulnerable to this; Singh, Paul, Ford, Kramer and Weaver (2008) refer to the gaps in services that adolescents fall into. Highlighting the unmet mental health needs of older adolescents is an important theme for service providers and commissioners. This theme of gaps is echoed in the coalition government document 'Neighbourhood by neighbourhood: local action to reduce re-offending' which refers to gaps in the provision of the criminal justice system, and gaps in the multi-agency system around offenders, including housing, education, employment opportunities, healthcare and drug treatment. This study has demonstrated unmet needs in many of these areas, particularly for ethnic minority groups, and the need to involve families, communities and partnership agencies has been reinforced. Commissioners and local CAMHS have been informed of this study, as have the YOS and the young offenders. Workers based between YOS and CAMHS have been introduced, and we plan to audit the number of young offenders using local services. Fifty young people took the time to respond to our study we are grateful for their participation and recognise their contribution.
Bradley (2009) The Bradley Report-Review of people with mental health problems or learning disabilities in the criminal justice system. Department of Health. http://www.dh.gov.uk/ en/Publicationsandstatistics/Publications/ PublicationsPolicyAndGuidance/DH_098694 accessed 7.11.11.
British Medical Journal Defining ethnicity http://resources.bmj.com/bmj/authors/bmj-house-style/defining-ethnicity
Chitsabesan, P., Kroll, L., Bailey, S., Kenning, C., MacDonald, W., Theodosiou, L. (2006) Mental health needs of young offenders in custody and the community. The British Journal of Psychiatry 188: 534-540.
Coffey, C., Veit, F., Wolfe, R., Cini, E., Patton, G. (2003) Mortality in young offenders: retrospective cohort study. British Medical Journal. 326(7398): 1064.
Department of Health (2004) The mental and psychological well-being of children and young people--national service framework for children, young people and maternity services. http://www.dh.gov. uk/en/Publicationsandstatistics/ Publications/PublicationsPolicyAndGuidance/DH_4089114 accessed 7.11.11.
Feilzer, M. and Hood, R. (2004) Differences or Discrimination? Youth Justice Board. http://www.yjb.gov.uk/publications/ Resources/Downloads/Differences% 20or%20Discrimination%20-%20Summary.pdf accessed 7.11.11.
Goodman, R. (1997) The Strengths and Difficulties Questionnaire: a research note. Journal of Child Psychology and Psychiatry, 38: 581-586.
Goodman, R., Meltzer, H., Bailey, V. (1998) The strengths and difficulties questionnaire: A pilot study on the validity of the self-report version. European Child and Adolescent Psychiatry 7: 125-130.
Goodman, R., Ford, T., Simmons, H., Gatward, R., Meltzer, H. (2000) Using the Strengths and Difficulties Questionnaire (SDQ) to screen for child psychiatric disorders in a community sample. British Journal of Psychiatry, 177, 534-539.
Green. H., McGinnity, A., Meltzer, H., Ford, T., Goodman, R. (2004) Mental health of children and young people in Great Britain in 2004 Office of National Statistics http://www.dh.gov.uk/en/ Publicationsandstatistics/Publications/PublicationsStatistics/DH_4118332 accessed 7.11.11
Hackett, L., Theodosiou, L., Blackburn, C., Lever, R., Spicer, F. (2011) Understanding the mental health needs of secondary school children in Manchester, Mental Health in Family Medicine--Accepted.
ICD 10 classification of Mental and behavioural disorders in Children and Adolescents--Multiaxial classification of Child and Adolescent Psychiatric disorders World health organisation. Cambridge University press ISBN 0 521 58133-8.
Kessler, C. (2007) The mental health needs of young offenders. Forging paths towards reintegration and rehabilitation. Cambridge University Press. Cambridge
Khantzian, E. J. (1985). The self-medication hypothesis of addictive disorders: Focus on heroin and cocaine dependence. The American Journal of Psychiatry, 142, 1259-1264.
Kumar, G. and Steer, RA. (2003) Factorial validity of the Conners Parent Rating Scale-revised: short form with psychiatric outpatients. Journal of Personality Assessment; 80(3):252-9.
National Institute for Health and Clinical Excellence (2007) Community-based interventions to reduce substance misuse among vulnerable and disadvantaged children and young people. London (UK): National Institute for Health and Clinical Excellence. http://www.nice.org. uk/nicemedia/pdf/PHI004guidance.pdf accessed 7.11.11.
Our Health, Our Care, Our Say www.behfuture.nhs.uk/archive/docs/appendix_2.pdf Accessed 7.11.11.
Rajmil, L., Estrada, M.D., Herdman, M., Serra-Sutton, V., Tebe, C., Izaguirre, J., Alda, J.A., Alonso, J., Riley, A.W., Forrest, C.B., Starfield, B. (2009) [Parent-child agreement in the health related quality of life (HRQOL) of children with attention-deficit/hyperactivity disorder (ADHD): a longitudinal study] Anales de pediatrla; 70(6):553-61.
Randall, J., Henggeler, S.W., Pickrel, S.G., Brondino, M.J. (1999) Psychiatric comorbidity and the 16-month trajectory of substance-abusing and substance-dependent juvenile offenders. Journal of the American Academy of Child and Adolescent Psychiatry 38:1118-1124.
http://www.sdqinfo.com/ accessed 7.11.11.
Shaw J, Senior J, Lowthian C, Foster K, Clayton R, Coxon N, King C and Hassan L (2008) A national evaluation of prison mental health in-reach services http://www.ohrn.nhs.uk/ resource/Research/Inreach.pdf accessed 7.11.11.
Singh, S., Paul, M., Ford, T., Kramer, T., Weaver, T. (2008) Transitions of Care from Child and Adolescent Mental Health Services to Adult Mental Health Services (TRACK Study): A study of protocols in Greater London BMC Health Serv Res. 8: 135.
Social Exclusion Unit (2002) Reducing re-offending by ex-prisoners http://www.voluntaryarts.org/uploaded/ map983.pdf--accessed 22.5.10.
Street, C., Stapelkamp, C., Taylor, E., Malek, M., Kurtz, Z. (2005) Minority voices--research into the access and acceptability of services for the mental health of young people from the Black and minority ethnic groups. Young minds. http://www.youngminds.org.uk/publications/ all-publications/minority-voices accessed 7.11.11.
Teplin, L., Abram, K., McClelland, G., Mericle, A., Dulcan, M., Washburn, J., Shiraz, B. Psychiatric disorders of youth in detention in The Mental health needs of young offenders: forging paths between reintegration and rehabilitation (2007) eds Kessler C and Kraus L. Cambridge University Press. Cambridge.
The NHS Outcomes Framework 2011/12 http://www.dh.gov.uk/dr_consum_dh/groups/ dh_digitalassets/@dh/@en/@ps/documents/digitalasset/dh_123138.pdf accessed 8.11.11.
Whitmore, EA., Mikulich, SK., Thompson, LL., Riggs, PD., Aarons, GA., Crowley, TJ. (1997) Influences on adolescent substance dependence: conduct disorder, depression, attention deficit hyperactivity disorder, and gender. Drug Alcohol Depend. 47: 87-97
Ruth Marshall, Consultant Child and Adolescent Psychiatrist, The Winnicott Centre; Louise Theodosiou, Consultant Child and Adolescent Psychiatrist, Emerge; Benedict Pease, Medical Student, Manchester University; Natalie Kirby, Medical Student, Manchester University; and Jade Ark, Research Assistant, The Winnicott Centre
Table 1: SDQ scores in a control population available on the SDQ website and a young offending population Control (4228 cases) 11-15 years Teacher SDQ Normal % Borderline % Abnormal % Total SDQ 81.3 9.1 9.6 Emotional symptoms 91.4 3.8 4.7 Conduct problems 86.9 4.8 8.3 Hyperactivity-inattention 82.5 4.8 12.7 Peer problems 87.9 5.1 7.1 Pro-social 73.6 13.3 13.1 Impact 79.3 9.9 10.8 Self report SDQ Control (4228 cases) 11-15 years Total SDQ 83.5 11.3 5.2 Emotional symptoms 88.8 6.1 5.1 Conduct problems 79.0 10.4 10.6 Hyperactivity-inattention 79.0 9.5 11.5 Peer problems 90.8 7.7 1.5 Pro-social 91.4 6.8 1.8 Impact 86.8 7.3 5.8 YOS worker (83 cases) 11-18 years Teacher SDQ Normal % Borderline % Abnormal % Total SDQ 42.7 (35) 22.0 (18) 35.4 (29) Emotional symptoms 86.6 (71) 7.3 (6) 6.1 (5) Conduct problems 42.7 (35) 17.1 (14) 40.2 (33) Hyperactivity-inattention 62.2 (51) 12.2(10) 25.6 (21) Peer problems 74.4 (61) 11.0 (9) 14.6 (12) Pro-social 41.5 (34) 26.8 (22) 31.7 (26) Impact 48.8 (40) 7.3 (6) 43.9 (36) Self report SDQ Study (50 cases) 11-18 years Total SDQ 70.0 (35) 24.0 (12) 6.0 (3) Emotional symptoms 90.0 (45) 8.0 (4) 2.0 (1) Conduct problems 56.0 (28) 16.0 (8) 28.0 (14) Hyperactivity-inattention 76.0 (38) 6.0 (3) 18.0 (9) Peer problems 80.0 (40) 14.0 (7) 6.0 (3) Pro-social 80.0 (40) 14.0 (7) 6.0 (3) Impact 66.0 (33) 8.0 (4) 26.0 (13)