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Mental Health Courts and Adult Offenders with Developmental Disabilities and Co-occuring Diagnoses.

The emergence of mental health courts (MHCs) in North America, particularly in the United States, was the result of a paradigm shift as court personnel became increasingly sensitive to the state of mind of offenders charged with criminal offenses, specifically defendants with developmental disabilities and mental health diagnoses. Ennis, McLeod, Watt, Campbell, and Adams-Quackenbush (2016) acknowledged that MHCs emerged across North America in an effort to address the criminalization of persons with mental illness. The evolving statistics on these individuals were alarming: a 1999 study (Ditton, 1999) reported that, in prisons and jails in the United States, there were 283,800 offenders with mental illness experiencing co-occurring diagnoses including 10 percent with a mental or emotional condition. Among these offenders 10 percent reported staying overnight in a hospital or mental health program, 53 percent were incarcerated for violent offenses, and 13 percent for drug-related offenses.

The inception of MHCs was considered a favorable opportunity to deal with this specific population. As the Council of State Governments Justice Center (CSGJC, 2008) pointed out, "mental health courts serve a significant role within the collection of responses to the disproportionate number of people with mental illnesses in the justice system" (p. 3). Further, Steadman, Davidson, and Brown (2001) promoted a working definition of MHCs based on four criteria:

1. Initial booking and handling of individuals with mental illness identified from a single court docket for referral to community-based services

2. Use of a courtroom team, including a professional whose role is to create service linkages within the team, to make treatment recommendations and supervision plans

3. Availability of treatment slots to provide services to these offenders

4. Court monitoring of offenders to guarantee compliance and when necessary initiate sanctions for noncompliance

Subsequently, Steadman and colleagues stated that an MHC may be a diversion program with all staff and services circulating around a single judge or a court of jurisdiction within a broader jail diversion program. They acknowledged that today's MHCs "are led by innovative judges looking for creative alternatives for the defendants and the community" (p. 458).

This article will focus on a unique MHC that deals with adult offenders eligible for services from a forensic unit of a county developmental disability agency in a large urban Midwestern metropolitan community. Previous studies (Tsagaris, Seck, Keeler, & Rowe, 2015, 2016) have documented characteristics of these offenders and a geographic information system analysis of service provided to this population. Further, a number of researchers have published articles providing more information on MHCs and offenders diagnosed with mental illness and other co-occurring disorders.

Literature Review

The development of MHCs was the result of the increasing number of serious mentally ill offenders in jails and prison. A 2006 study (James & Glaze, 2006) reported that, at mid-year 2005, more than half of all prison and jail inmates had a mental health problem, including 705,600 inmates in state prisons, 78,800 in federal prisons, and 479,900 in local jails. In addition, James and Glaze reported high recidivism rates among these inmates, showing that nearly 25 percent had prior incarcerations. When compared to non-mentally-ill inmates, these inmates were at least three times more likely to have spent time in prison. Analyzing the gender variable, James and Glaze noted that female inmates were incarcerated at a higher rate than males in prisons (73% vs. 55%) as well as in jails (75% vs. 63%). Almost three-fourths of mentally ill state prisoners and jail inmates, including a substantial number of adult offenders with developmental disabilities, met substance abuse or dependence criteria, and nearly two-thirds used drugs before their arrest as compared to only one-half of inmates without a mental health problem.

Individuals with developmental disabilities represent as much as 4 to 10 percent of the prison population (Petersilia, 2000), and 4.2 percent have an intellectual disability diagnosis (Veneziano & Veneziano, 1996). Offenders with developmental disabilities are often victimized in prisons (Luckasson, 1992; Sobsey, 1994) and by law enforcement (Perske, 2000, 2003) and arrested because of false confessions (Perske, 2008, 2011). Because of these conditions, court personnel including judges, prosecutors, and lawyers, as well as social agency workers and forensic unit liaisons, have recognized that individuals with developmental disabilities need specific treatment due to their conditions, which in many cases have undoubtedly contributed to their offending behavior. The Individuals with Disabilities Education Act and the Americans with Disabilities Act are two major laws passed to acknowledge and improve the specific condition of this population and to prohibit discrimination against these individuals in employment, transportation, public accommodation, communication, and government activities.

The development of MHCs reinforced this trend toward specific treatment for individuals with disabilities, as illustrated by Redlich, Steadman, Monahan, Robbins, and Petrila (2006). These researchers identified several universal characteristics of MHCs: these courts were criminal courts, had separate dockets for the mentally ill, and aimed to divert offenders with mental illness from jails or prisons. Such offenders were compelled to engage in community treatment, take medication, and comply with mandated court conditions. Further, they had to engage in court supervision and judicial reviews; subsequently, they could be praised for compliance. Participation in MHCs was assumed to be voluntary, but Redlich, Hoover, Summers, and Steadman (2010) reported that, although most of the two hundred offenders participating in their study claimed to have chosen to enroll, many also claimed that they were not told that the court was voluntary or been informed of the requirements prior to entry. Although these researchers recognized that these claims were a limitation of their study, they still predicted the development of MHCs.

In fact, the reported number of MHCs in the United States varies because of differences in the definitions of MHCs from one jurisdiction to another. According to the National Center for State Courts (B. Kavanagh, personal communication, April 21, 2016), there were 357 mental health courts in the United States. The states with the largest number of MHCs were California (34), New York (28), Ohio (27), Florida (25), and Illinois (21). Some of the MHCs located in these states were identified as first generation MHCs and others as second generation MHCs (Ennis et al., 2016; Goldkamp & Irons-Guynn, 2000). Second generation MHCs showed increasing acceptance of felony defendants, acceptance of post-adjudication models as opposed to pre-adjudication models, propensity to impose jail sentences, and various uses of supervision. Three supervision intervention strategies were implemented using community treatment providers and/or court personnel.

Only a few studies evaluated whether MHCs have reduced criminal recidivism. In order to fill this gap, Hiday and Ray (2010) studied recidivism rates of ninety-nine defendants for two years after their release from an established MHC. They found that defendants had significantly reduced recidivism from pre-court entry to post-court exit. Comparing offenders who participated in an MHC program to a control group, Frailing (2010) found that MHC participants had significantly fewer jail days, a drop in hospitalization days, and a decrease in positive drug and alcohol tests over the course of enrollment and after the MHC program. In addition, Frailing found that MHC sessions occurred in a non-adversarial atmosphere in which participants interacted directly with the judge, and praise and encouragement were issued far more often than sanctions.

Although modeled on drug courts, MHCs usually accept a wider range of charges rather than focusing on drug-related charges. Accepted charges include monitoring, treatment plans, advocacy, service delivery, and having higher expectations of defendants (CSGJC, 2008). Their treatments plans are more flexible and individualized than those in drug courts. Their advocates often operate specific programs and raise mental health concerns, whereas drug courts support minimal community involvement. Service delivery in mental health courts is usually contracted with agencies in the community and requires coordination, whereas service delivery in drug courts is usually independently established with the jurisdiction. Drug courts require sobriety, employment, and self-sufficiency. Conversely, mental health courts understand that, even in recovery, defendants may not be able to work or take classes and may require multiple supports (CSGJC, 2008).

A Mental Health Court with a Specialized Docket on Disabilities

The MHC studied in this article was established in 2002. It stemmed from an initiative developed by suburban court partners and community stakeholders who focused on identifying programs and services for adult offenders with mental illness and developmental disabilities. This initiative identified service delivery gaps and expanded resources including training and communication to provide consistent, efficient, and effective service delivery responses by applying the MHC docket model. Eight years later, this MHC was renamed as the Mental Health and Developmental Disabilities Court, with five judges overseeing its operations. In addition, there was a team of highly trained probation, pre-trial, and post-conviction officers (Cuyahoga County Common Pleas Court, 2016).

The current study will not only examine the mental health diagnoses of adult offenders with developmental disabilities involved with the criminal justice system, but will also evaluate the outcomes of the Mental Health and Developmental Disabilities Court, which specializes in sentencing individuals with developmental disabilities. Judges in this court have developed their knowledge in developmental disabilities and mental health through training and experience; consequently, they are prepared not only to oversee the treatment and supervision of sentenced offenders but also to facilitate the collaboration between developmental disabilities, mental health, and court professionals. Judges that are not affiliated with mental health court have a limited background in the field of developmental disabilities and mental health.


The institutional review board of a large urban university granted the researchers the authorization to complete this study.

Sampling, Data Collection, and Analysis

One northeast Ohio agency provided a database including 850 individuals diagnosed with developmental disabilities or intellectual disability. These individuals had received services delivered by social workers, psychologists, and forensic liaisons assigned to the agency's forensic unit. From the sampling frame of 850 clients, a random sample of 160 cases was drawn, including 155 (96.9%) males, a majority of African Americans (112; 70%), and a predominantly young population of eighteen- to twenty-two-year-old offenders (68; 42.5%). The researchers analyzed data from the court psychiatric clinical evaluation of the participants and the categories of the offenses with which they were charged. In addition, they analyzed court outcomes as well as recidivism rates based on the types of violations committed by the offenders and the decisions of MHC or non-MHC judges.


Descriptive data analysis tests revealed that, of the 160 participants, 40 (25%) had not been evaluated by the court psychiatric clinic. Of the 120 (75%) offenders evaluated, 23 (19%) were diagnosed with developmental disability only, 45 (37.5%) with developmental disability and mental health/mental illness, 32 (27%) with development disability and substance abuse, and 20 (16.7%) with a combination of developmental disability, mental health/mental illness, and substance abuse.

Using the Ohio Revised Code, the researchers found that the most commonly committed offenses were burglary/robbery/trespassing/safecracking (31; 19.4%), homicide and assault (27; 16.9%), and drugs/narcotics (27; 16.9%) (see Table 1).

Of the 160 offenders, 104 appeared before either MHC judges (64; 61.5%) or non-MHC judges (40; 38.5%). They were sentenced to prison (36; 34.6%) or to community control (68; 65.4%) (see Table 2). For various reasons, 56 cases (35%) were dismissed. In those cases, 51 defendants (91%) were either found incompetent to stand trial and unrestorable and continued under court jurisdiction or released on the prosecutor's request due to credit for time served. Of the remaining defendants, 3 (5.4%) had their charges dismissed at the request of the probation department and 2 (3.6%) had ongoing cases at the time of this research.

Court outcomes varied based on the offenses but also on the training and experience of the MHC or non-MHC judges as they arrived at a decision with regard to community control or prison (see Table 3).

Following their sentencing, 68 offenders committed violations that led them back to court. The violation factors were classified as technical, nontechnical, both, or none (see Table 4).


In the current study, the largest groups of adult offenders with developmental disabilities were diagnosed with co-occurring mental health disorders including mental health, substance abuse, and developmental disability diagnoses. In fact, a large percentage of the offenders (37.5%) was diagnosed with mental health and developmental disability disorders, followed by 27 percent with developmental disability and substance abuse disorders, 19 percent with developmental disabilities only, and 16.7 percent with all three disorders (developmental disability, mental health, and substance abuse disorders). These results reflect the findings of Steadman, Osher, Robbins, Case, and Samuels (2009) on the prevalence rates of serious mental illness, determined as major depressive disorder; depressive disorder not otherwise specified; bipolar disorder I, II, and not otherwise specified; and schizophrenia spectrum disorder. These diagnoses combined with the nature of the offenses that were identified according to the ORC categorization further exemplify the need for a multidisciplinary team addressing the specific needs of this population.

Regarding the various offenses committed, the current study results revealed that burglary, robbery, trespassing, and safecracking (31; 19.4%) were the leading offenses. The second most prevalent offenses were homicide and assault (16.9%) and drugs and narcotics-related offenses (16.9%). These results align with previous study findings reporting that the majority of offenders with developmental disabilities were charged with stolen property, felonious assault, aggravated assault, and resisting arrest (Tsagaris et al., 2015) and with crimes categorized by the FBI as crimes against persons, crimes against property, and crimes against society (Tsagaris et al., 2016).

This current study provides information on sanctions that courts use when dealing with offenders with developmental disabilities. Griffin, Steadman, and Petrila (2002) acknowledged that sanctions have apparently been used sparingly to date in MHCs, but could be expanded as these courts consider expanding their jurisdiction over some types of felonies. The current study findings suggest that both MHC and non-MHC judges have reached different levels of understanding of the special needs of offenders with developmental disabilities. The slightly higher frequency of nontechnical violations in non-MHC courts suggests that non-MHC judges are taking more corrective actions with these offenders. In fact, non-MHC judges were more likely to pronounce prison terms than MHC judges, who were more likely to choose community control sentences. In effect, MHC judges usually gave longer community control sentences, placing offenders within their own communities and under court supervision on probation. This provides the offenders with the opportunity to resume their daily activities away from prisons and to receive appropriate services. There were differences between MHC and non-MHC judges in that MHC judges would sentence offenders to longer periods of community supervision to avoid recidivism. In effect, these differences demonstrate that MHC and non-MHC judges have a different understanding of the offenders' needs and the specific mental health diagnoses. These unique differences were reflected in the court dispositions and the special needs of individuals with developmental disabilities as illustrated by the propensity of MHC judges to impose community control sentences. A contributing factor may be that MHC judges have biweekly staffing sessions with MHC team members to determine therapeutic approaches and use boundary spanners (Steadman et al., 2001) such as forensic liaisons or probation officers to create service linkages for effective community supervision. Therefore, comparatively lower percentages of prison terms were imposed by MHC judges. Of the 38 cases dismissed by judges, 66 percent were dismissed by MHC judges and 34 percent by non-MHC judges.

In the MHC that was studied, the biweekly staffing sessions scheduled by judges illustrate the judges' role in designing a well-established MHC procedural justice system. Wales, Hiday, and Ray (2010) evaluated a similar model and found that MHC offenders held strong positive beliefs not only about the procedural justice they experienced in MHC, but also about the role of the judges in establishing procedural justice. Wales and colleagues reported that the role of the MHC judges in conveying elements of procedural justice may contribute to the reduction of recidivism among offenders because it provides a heightened level of interpersonal treatment of offenders. This practice affords dignity, respect, voice, and accountability to defendants as well as service providers. In addition, it promotes transparency for decisions reached through an open negotiation process. Further, in comparing MHC and non-MHC judges, Boothroyd, Mercado, Poythress, Christy, and Petrila (2005) reported that MHC judges had more successfully diverted defendants into treatment, giving them greater access to mental health services. In contrast to these previous studies, the current research does not compare MHC and non-MHC judges to determine whose decisions were more successful. However, in the study the researchers reported that non-MHC judges sent a higher percentage of defendants to prison (37.5% vs. 32.8%) whereas MHC judges committed a higher percentage of their defendants to community control (67.25% vs. 62.5%).

This study analyzes the reasons for recidivism after a first conviction (Table 4). Reasons are labeled technical, nontechnical, both, or none. Technical violations are violations of probation or court orders, for example, failure to participate in treatment or failure to keep probation appointments while on probation or court supervision. Nontechnical violations involve new criminal activities after a prior conviction, for example, committing a new burglary, theft, or drug offense after having been convicted for a previous crime or while completing a sentence. An offender may commit both types of violations. The fourth reason is labeled none, indicating that the offender committed new offenses after getting off probation or any type of court supervision. This type of recidivism, as described in this study, reflects a new phenomenon introduced in the literature, the idea that a large number of offenders with developmental disabilities have a limited understanding of the terms of their release or probation. Often these offenders with developmental disabilities do not understand the consequences of their actions and most of the time cannot control their behavior; consequently, they end up back to court.

In sum, this study's findings seem to support the need for MHC dockets specialized in handling offenders diagnosed with developmental disabilities and co-occurring disorders such as mental health and substance abuse disorders. In order to enhance the effectiveness of these courts, a number of measures should be considered toward best practice in mental health.

Recommendations for Best Practices

This study's findings revealed that early identification and adequate evaluation of offenders with developmental disabilities would result in better dispositions and access to targeted service delivery models. The establishment of MHC dockets specialized in handling offenders with developmental disabilities contributes to the improvement of the conditions of offenders with co-occurring diagnoses moving through the criminal justice system. Further, this study emphasizes the effects of post-disposition support initiated through community control by judges who understand the nature of developmental disabilities and the consequences of their decisions. As noted, the MHC judges in the specific court studied in this article promote biweekly meetings with mental health/developmental disabilities staff to ensure team commitment and provide effective therapeutic approaches for defendants. This may promote best practices with this population.

Criminal justice professionals exposed to disability-specific training will be more likely to reach better court outcomes as they are more inclined to adhere to human rights principles in dealing with offenders with developmental disabilities as well as those with co-occurring disorders. Additional improvements would require cultural diversity training that embraces the context of race and ethnic relations and the institution of a therapeutic environment in which service would be provided to adult offenders with developmental disabilities who face a multitude of challenges due to their diagnoses.

Limitations of the Study

The court psychiatric clinic did not assess a large number of participants (40; 25% of the sample) for co-occurring disorders. Consequently, the sample of offenders with developmental disabilities having a co-occurring clinical diagnosis is smaller than expected. Another limitation relates to the lack of in-depth DSM classification within the categories of the co-occurring diagnoses.


The inception of MHCs has contributed to the promotion of respect for human rights in prisons as offenders with developmental disabilities and co-occurring disorders are provided with more effective forensic liaison services. As judges along with court personnel become more conscious of their need for additional training in developmental disabilities and mental health, MHCs will better assess offenders in order to improve court outcomes. A more in-depth assessment of the diagnostic profile and mitigating circumstances would prove beneficial to offenders. Forensic units working within MHCs should consider investing more agency and community supports to evaluate and develop additional programmatic preventative services. Factors affecting offenders with developmental difficulties such as residency, types of offenses, and court outcomes can profoundly influence the suitability of services that require collaboration between law enforcement, court and mental health professionals, and social workers as well as forensic liaisons.


Boothroyd, R. A., Mercado, C. C., Poythress, N. G., Christy, A., & Petrila, J. (2005). Clinical outcomes of defendants in mental health court. Psychiatric Services, 56, 829-834.

Council of State Governments Justice Center. (2008). Mental health courts: A primer for policymakers and practitioners. New York, NY: Criminal Justice/Mental Health Consensus Project.

Cuyahoga County Common Pleas Court. (2016). Mental health and developmental disabilities court (MHDD). Retrieved from

Ditton, P. M. (1999). Special report: Mental health and treatment of inmates and probationers. Washington, DC: US Department of Justice, Bureau of Justice Statistics.

Ennis, A. R., McLeod, P., Watt, M. C., Campbell, M. A., & Adams-Quackenbush, N. (2016). The role of gender in mental health court admission and completion. Canadian Journal of Criminology and Criminal Justice, 58, 1-30.

Frailing, K. (2010). How mental health courts function: Outcomes and observations. International Journal of Law and Psychiatry, 33, 207-213.

Goldkamp, J. S., & Irons-Guynn, C. (2000). Emerging judicial strategies for the mentally ill in the criminal caseload: Mental health courts in Fort Lauderdale, Seattle, San Bernardino, and Anchorage (NCJ 182504). Washington, DC: U.S. Department of Justice. Retrieved from

Griffin, P. A., Steadman, H. J., & Petrila, J. (2002). The use of criminal charges and sanctions in mental health courts. Psychiatric Services, 53, 1285-1289.

Hiday, V. A., & Ray, B. (2010). Arrests two years after exiting a well-established mental health court. Psychiatric Services, 61, 463-468.

James, D. J., & Glaze, L. E. (2006). Mental health problems of prison and jail inmates. Washington, DC: U.S. Department of Justice, Bureau of Justice Statistics. Retrieved from

Luckasson, R. (1992). People with mental retardation as victims of crime. In R. W. Conley, R. Luckasson, & G. N. Bouthliet (Eds.), The criminal justice system and mental retardation (pp. 209-220). Baltimore, MD: Brookes Publishing.

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Perske, R. (2003). Parents who moved against the tide. Mental Retardation, 41, 133-134.

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Perske, R. (2011). Perske's list: False confessions from 75 persons with intellectual disability. Intellectual and Developmental Disabilities, 49, 468-479.

Petersilia, J. (2000). Doing justice? Criminal offenders with developmental disabilities. Berkeley, CA: California Policy Research Center, University of California. Retrieved from

Redlich, A. D., Hoover, S., Summers, A., & Steadman, H. J. (2010). Enrollment in mental health courts: Voluntariness, knowingness, and adjudicative competence. Law and Human Behavior, 34, 91-104.

Redlich, A. D., Steadman, H. J., Monahan, J., Robbins, P. C., & Petrila, J. (2006). Patterns of practice in mental health courts: A national survey. Law and Human Behavior, 30, 347-362.

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Steadman, H. J., Osher, F. C., Robbins, P. C., Case, B., & Samuels, S. (2009). Prevalence of serious mental illness among jail inmates. Psychiatric Services, 60, 761-765.

Tsagaris, G. S., Seck, M. M., Keeler, J., & Rowe, R. (2015). Characteristics of adult offenders with developmental disabilities in large urban environments. Best Practices in Mental Health, 11(2), 60-72.

Tsagaris, G. S., Seck, M. M., Keeler, J., & Rowe, R. (2016). Geographic information system analysis of developmentally disabled adult offenders. Journal of Intellectual Disabilities and Offending Behaviour, 7, 1-10.

Veneziano, L., & Veneziano, C. (1996). Disabled inmates. In M. McShane & F. Williams (Eds.), Encyclopedia of American prisons. New York, NY: Garland Publishing.

Wales, H. W., Hiday, V A., & Ray, B. (2010). Procedural justice and the mental health judge's role in reducing recidivism. International Journal of Law and Psychiatry, 33, 265-271.

Mamadou M. Seck, PhD, MSSA, LSW, is associate professor, Cleveland State University, Cleveland, OH. George S. Tsagaris, PhD, LISW-S, is assistant professor, Cleveland State University, Cleveland, OH. Robert Rowe, ACSW, LISW-S, CCFC, CSOTS, is a private practitioner in Parma, OH.
Table 1 Offenses categorized according to the Ohio Revised Code (ORC)

Offense                                    ORC   Frequency  Percent

Burglary/robbery/trespassing/safecracking  2911      31       19.4
Homicide and assault                       2903      27       16.9
Drugs/narcotics                            2925      27       16.9
Theft/fraud                                2913      19       11.9
Sex offenses                               2907      18       11.3
Kidnapping                                 2905      10        6.3
Arson and related offenses                 2909       6        3.7
Offenses against public peace              2917       6        3.7
Offenses against family members            2919       6        3.7
Conspiracy/weapon/attempt                  2913       3        1.8
All other offenses                         2950       7        4.4
  Total                                             160      100.0

Table 2 Court outcomes by MHC and non-MHC judges

Type of judge   Prison   Community Control    Total

MHC            21 (33%)      43 (67%)        64 (100%)
Non-MHC        15 (38%)      25 (62%)        40 (100%)
Total          36            68             104

Table 3 Community control and prison sentences by MHC and non-MHC judges

           MHC                        Non-MHC  MHC     Non-MHC   MHC
Sentence   judge                      judge    judge   judge     judge

  control  [less than or equal to]12  months    13-24  months    25-36
            11                          13      17        9       9
           (46%)                       (54%)   (65%)    (35%)   (82%)
Prison     [less than or equal to]6   months     7-18  months    19-36
             4                           2       6        5      10
           (67%)                       (33%)   (55%)    (45%)   (71%)

           Non-MHC   MHC     Non-MHC  MHC    Non-MHC
Sentence   judge     judge   judge    judge   judge

  control  months     37-60  months
             2         6        1
           (18%)     (86%)    (14%)
Prison     months     37-60  months   >60     months
             4         2                1        2
           (29%)    (100%)            (33%)    (67%)

Table 4 Recidivism rates by leading factors after sentencing by MHC and
Non-MHC judges

Leading factor in recidivism     MHC      Non-MHC     Total

Technical                     10 (24%)    7 (27%)   17 (25.0%)
Nontechnical                   5 (12%)    6 (23%)   11 (16.2%)
Both                           1 (2%)     1 (2%)     2 (3.0%)
None                          26 (62%)   12 (46%)   38 (55.8%)
Total                         42 (100%)  26 (100%)  68 (100%)
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Author:Seck, Mamadou M.; Tsagaris, George S.; Rowe, Robert
Publication:Best Practices in Mental Health
Geographic Code:1USA
Date:Sep 22, 2017
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