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To compare the prevalence of psychiatric disorders in youths processed in adult criminal court with youths processed in the juvenile court.
Participants were a stratified random sample of 1829 youths (10–18 years of age) arrested and detained in Chicago, IL. Data on 1715 youths (13–18 years of age) from version 2.3 of the Diagnostic Interview Schedule for Children are presented, including 1440 youths processed in juvenile court and 275 youths processed in adult criminal court.
Among youths processed in the adult criminal court, 66% had at least one psychiatric disorder and 43% had two or more types of disorders. Prevalence rates and the number of comorbid types of disorders were not significantly different between youths processed in adult criminal court and those processed in the juvenile court. Among youths processed in adult criminal court, those sentenced to prison had significantly greater odds of having disruptive behavior, substance use, or comorbid affective and anxiety disorders than those receiving a less severe sentence. Males, African Americans, Hispanics, and older youths had greater odds of being processed in adult criminal court than females, non-Hispanic whites, and younger youths, even after controlling for felony-level violent crime.
Community and correctional systems must be prepared to provide psychiatric services to youths transferred to adult criminal court, and especially to youths sentenced to prison. Psychiatric service providers must also consider the disproportionate representation of racial/ethnic minorities in the transfer process when developing and implementing services.
More youths are processed in adult criminal court than ever before. All 50 states and the District of Columbia have legal mechanisms to try juveniles as adults in criminal court (1–3). Historically, most states transferred juveniles to adult criminal court primarily through judicial waiver. That is, juvenile court judges made decisions on a case-by-case basis, considering the characteristics of the charge and of the youths (1,4,5). An increasing number of juveniles are now transferred to adult criminal court using automatic transfers (29 states) and prosecutorial direct file (15 states) (1). Automatic transfers exclude juveniles from the jurisdiction of the juvenile court based solely on the type of offense, criminal history, and age of the youths; judges are not involved in this form of transfer. Prosecutorial direct file mechanisms allow prosecutors to determine when to file certain juvenile cases directly in criminal court.
The increased availability of legal mechanisms to process juveniles in adult criminal court is largely responsible for the 366% increase between 1983 and 1998 in juveniles held in adult jails (6). As of 2004, approximately 7% of the approximately 2 million arrests of youths eligible for processing in the juvenile justice system were transferred directly to adult criminal court (7). Given the substantial numbers of youths transferred to adult criminal court on an annual basis, accurate epidemiologic data on the prevalence of psychiatric disorders in this population are important. Youths with serious psychiatric disorders who are processed in adult criminal court have the right to receive needed treatment for seve1re mental disorders (6).
Recent studies indicate that a substantial proportion of juvenile detainees need mental health services (8); between one-half to two-thirds of juvenile detainees have one or more psychiatric disorders (9,10). Yet, to our knowledge, no study has examined the prevalence of psychiatric disorders specifically among youths transferred to adult criminal court. Data on the prevalence of psychiatric disorders among youths processed in adult criminal court (“transferred youths”) are needed for three reasons.
First, transferred youths are composed disproportionately of underserved sociodemographic groups. Numerous studies indicate that transferred youths are disproportionately male and racial/ethnic minorities (4,6,11–16). Although disproportionate confinement of racial/ethnic minorities is found at all levels of the juvenile justice system, it is even greater for youths transferred to adult criminal court. One study of youths in California found that racial/ethnic minorities arrested for a violent crime were 3.1 times more likely to be transferred and convicted than non-Hispanic white youths arrested for a violent crime (17). Males and racial/ethnic minorities have significantly lower odds than females and non-Hispanic whites of receiving needed mental health treatment after youths are detained (18). Thus, the concern over disproportionate minority confinement of males and racial/ethnic minorities is also a health disparities concern.
Second, youths transferred to adult criminal court typically wait substantially longer for their case to be adjudicated (i.e., a finding of guilt or innocence) than their peers in the juvenile system (19–21). They are also less likely than adults to be released prior to adjudication (22). Because transferred youths are incarcerated for longer periods of time than youths processed in juvenile court, their mental health needs are even more important than those held in detention for shorter periods of time. The conditions associated with extended detention (e.g., separation from loved ones, crowding, solitary confinement) may increase risk for suicidal behavior (23–26).
Finally, findings from an experimental study suggest jurors may be biased against a youth being tried in an adult court, leading to a greater likelihood of a finding of guilt, higher confidence in the defendant’s guilt, and a lower standard of proof for guilt (27). Indeed, youths processed in adult criminal court are more likely to be convicted and to receive more stringent sentences than those processed in juvenile court (20,22,28,29). Transferred youths are also more likely to receive more severe punishments than young adults charged with similar crimes in adult criminal court (30). Nearly 60% of all transferred youths charged with violent offenses are adjudicated to prison compared with 26% of similarly charged adults (22). Approximately 5400 convicted youths are housed in adult prison facilities (6), where they may not receive age-appropriate interventions (31). Before we can develop age-appropriate interventions and plan for their implementation in the adult correctional system, we need to know which psychiatric disorders are most prevalent.
Despite its importance, we could find only one study that examined mental health problems among youths processed in adult court (32). This study, based on one clinician’s coding of 50 of his case records, investigated only posttraumatic stress disorder (PTSD) and learning disorders.
To our knowledge, our investigation is the first large-scale study of psychiatric disorders among youths transferred to adult criminal court. Using data from the Northwestern Juvenile Project (9), we compare youths processed in adult criminal court with youths processed in the juvenile court. Specifically, we examine the following questions:
Participants include 1829 youths (aged 10–18 years of age) randomly sampled from intake into the Cook County Juvenile Temporary Detention Center (CCJTDC) (Chicago, IL) from November 1995 through June 1998. The CCJTDC receives approximately 8500 annual admissions (33) and is used solely for pretrial detention and for offenders sentenced for less than 30 days. All detainees younger than 17 years are held at the CCJTDC, including youths processed in adult criminal court. Youths up to age 21 years may be detained in the CCJTDC if they are still being prosecuted for an arrest that occurred when they were younger than 17 years. Like juvenile detainees nationwide, approximately 90% of the CCJTDC detainees are male, and most are racial/ethnic minorities (77.9% African American, 5.6% non-Hispanic white, 16.0% Hispanic, and 0.5% other racial or ethnic groups). The age and offense distributions of the CCJTDC detainees are also similar to detained juveniles nationwide (34).
In Illinois, the minimum age at which a juvenile can be transferred to adult criminal court is 13 years (705 ILCS 405/5-4). The juvenile court has jurisdiction over all youths 16 years or younger, unless they have been transferred to adult criminal court. At the time the data were collected, Illinois statute 705 ILCS 405/5-4 specified six felony offenses for which youths were automatically transferred to adult criminal court for processing. Four of these offenses (first-degree murder, aggravated criminal sexual assault, armed robbery committed with a firearm, or aggravated vehicular hijacking committed with a firearm) are violent offenses; the other two offenses (unlawful use of weapon on or within 1000 feet of school property and delivery of a controlled substance on or within 1000 feet of school property or public housing property) are not.
Youths were eligible to participate, regardless of psychiatric morbidity, drug or alcohol intoxication, or fitness to stand trial. Project staff explained the project to participants in their units and assured them that anything they told us (except acute suicidal or homicidal risk) would be confidential. Data are protected by a Federal Certificate of Confidentiality and Title 28 Code of Federal Regulations, Part 22. Participants signed an assent form or consent form, depending on their age. The Northwestern Institutional Review Board, the Centers for Disease Control and Prevention Institutional Review Board, and the US Office of Protection from Research Risks waived parental consent, consistent with Federal Regulations. We nevertheless tried to contact parents; however, despite repeated attempts, none could be found for 43.8% of the participants. In lieu of parental consent, youths’ assent was overseen by a participant advocate who represented the interests of the participants.
Participants were interviewed for 2 to 3 hours in a private area, almost always within 2 days of intake. Female participants were always interviewed by female interviewers. Interviewers were trained for at least one month; most had a master’s degree in psychology or an associated field and had experience interviewing high-risk youths. One-third of the interviewers were fluent in Spanish. We maintained consistency throughout the study by monitoring scripted interviews with mock participants. Additional information on our methods can be found in a prior publication from this study (9).
To determine the diagnoses, we used version 2.3 of the Diagnostic Interview Schedule for Children (DISC 2.3) (35), the most recent English and Spanish versions then available. The DISC 2.3 assesses DSM-III-R disorders in the past 6 months. We include the following disorders: affective (major depression, dysthymia, mania, and hypomania), anxiety (generalized anxiety, separation anxiety, obsessive-compulsive, and over-anxious disorders), psychosis, disruptive behavior (conduct, attention-deficit/hyperactivity [ADHD], and oppositional defiant disorders), and substance use (alcohol, marijuana, and drug other than marijuana). A prior publication details the special procedures associated with the determination of psychosis and ADHD (9).
Data collection for PTSD began 13 months after the larger study began because PTSD was not included in the DISC 2.3. PTSD was measured with the DISC 4.0, which provided 12-month rates using DSM-IV criteria for PTSD. Data on PTSD diagnoses were examined using a subsample of 898 participants. The subsample was composed of 532 males (59.2%) and 366 females (40.8%); 490 African Americans (54.6%), 154 non-Hispanic whites (17.1%), 252 Hispanic (28.1%), and 2 of other race/ethnicity (0.2%).
Data on arrest charges were obtained from intake records at the CCJTDC.
The sample was stratified by gender, race/ethnicity (African American, non-Hispanic white, Hispanic), age (10–13 years old or 14 years and older), and legal status (processed in juvenile or adult criminal court). Stratification by legal status was conducted only for males; not enough females were transferred to adult criminal court to make stratification feasible. Within each stratum, we used a random numbers table to select names from the CCJTDC intake log. Selected demographic strata (females, non-Hispanic whites, 10–13 year olds) were oversampled to obtain adequate numbers of participants in key subgroups. The final sampling fractions ranged from 0.018 to 0.689 (additional information on the sample is available from the authors). Because certain strata were oversampled, all statistics were weighted to reflect CCJTDC's demographic characteristics. The overall rate of refusal to participate was 4.2%; within the stratum of youths transferred to the adult criminal court, the refusal rate was 7.1%, largely because their lawyers advised they not participate.
We restricted the final sample to participants 13 years and older (n=1715) because juveniles younger than 13 years are not eligible for processing in adult criminal court in Illinois. The PTSD subsample consisted of 840 participants 13 years and older. The final sample of youths processed in the adult criminal court (n=275) includes 21 females and 254 males, 199 African Americans, 69 Hispanics, and 7 non-Hispanic whites. The sample of youths processed in the juvenile court (n=1440) includes 616 females and 824 males, 727 African Americans, 429 Hispanics, 280 non-Hispanic whites, and 4 participants who self-identified as an “other” race or ethnicity. The mean age was 15.7±0.5 for youths processed in adult criminal court and 15.0±1.2 for youths processed in juvenile court.
Among youths processed in the adult criminal court, 39% were charged with a felony-level violent crime, 78% were found guilty, and 51% were sentenced to prison. Among youths processed in the juvenile court, 15% were charged with a felony-level violent crime, 65% were “adjudicated delinquent” (the juvenile justice equivalent to being found guilty), and 1% were sentenced to prison. Significantly more youths processed in the adult criminal court were charged with a felony-level violent crime (odds ratio [OR]=3.6, 95% confidence interval [CI] = 2.5–5.1, p<.001), found guilty (OR=2.0, 95% CI = 1.3–2.9, p<.001), and sentenced to prison (OR=160.1, 95% CI = 44.0–583.0, p<.001) than those in juvenile court.
Table 1 presents the demographic characteristics of the sample and the weighted proportions of juveniles processed in adult criminal court vs. juvenile court by gender, racial/ethnic subgroup, and specific age groups. As shown in Table 1, males, racial/ethnic minorities, and older youths had greater odds of being transferred to the adult court than females, non-Hispanic whites, and younger youths. Furthermore, African Americans had greater odds of being transferred than Hispanic youths. We examined if the results changed when we controlled for who received a charge for a felony-level violent crime. The results did not change; males, racial/ethnic minorities, and older youths still had significantly greater odds of transfer to adult court than females, non-Hispanic whites, and younger youths.
All descriptive statistics and model parameters were weighted using sample weights derived from CCJTDC's demographic characteristics and the sampling fractions for each stratum. Taylor series linearization was used to estimate standard errors (36,37). Logistic regression, which estimates odds ratios, was used to assess differences in prevalence rates. Poisson regression, which estimates rate ratios, was used to assess differences for count data. Because we observe significant differences in transfer status by gender, race/ethnicity, and age, and these demographic factors have been shown to be associated with psychiatric disorder (9), we adjust all analyses by gender, race/ethnicity, and age.
We first compared the prevalence of specific psychiatric disorders (Table 2) and comorbid psychiatric disorders (Table 3) among youths processed in adult criminal court and those processed in juvenile court. No significant differences in the prevalence of specific psychiatric disorders were found between youths processed in juvenile court and those processed in adult criminal court; both groups had high rates of disorders. As shown in Table 3, no differences were found for any combination of comorbid psychiatric disorders. Furthermore, no differences were found in the number of specific disorders or the number of types of psychiatric disorders (affective, anxiety, disruptive behavior, and substance use) across the two groups.
We next examined only youths processed in adult criminal court (n=275) to compare prevalence rates of psychiatric disorders among those who did and did not receive a prison sentence. Table 4 shows the prevalence rates of specific psychiatric disorders. Transferred youths who received a prison sentence had significantly greater odds of any disorder, any disorder except conduct disorder, any disruptive behavior disorder, oppositional defiant disorder, conduct disorder, any substance use disorder, alcohol use disorder, marijuana use disorder, and comorbid alcohol and drug use disorders.
Table 5 shows the prevalence rates of comorbid disorders among transferred youths by prison status (sentenced to prison, yes/no). Transferred youths who received a prison sentence had significantly greater odds of nearly all combinations of comorbid disorders. In comparison to transferred youths who did not receive a prison sentence, those youths who received a prison sentence had significantly greater odds of having 2 or more, 3 or more, and all 4 types of disorders. Finally, transferred youths who received a prison sentence had significantly greater numbers of specific disorders and types of disorder than those who did not receive a prison sentence.
Our findings indicate that the prevalence rates of specific and comorbid psychiatric disorders are as high or higher for youths processed in adult criminal court as for youths processed in juvenile court. These findings are consistent with the clinical data reported by Beyer (2006), who found no differences between youths processed in adult criminal court and juvenile court on a clinical assessment (32). To our knowledge, the current study provides the first evidence that many transferred youths, like their peers processed in the juvenile court, have substantial need for psychiatric and substance abuse services.
These findings also suggest transferred youths may have greater need for psychiatric services than detained adults. Prior research indicates that less than 35% of detained adult males have a psychiatric disorder (excluding antisocial personality disorder) (38); in contrast, 64% of transferred youths have a psychiatric disorder, even when excluding conduct disorder. The 6-month prevalence rate of major depression is three times greater for transferred youths than the lifetime rate among adult male detainees (15.9% for transferred youths vs. 5.1% for adult male detainees (38)).
Our study replicated prior findings that youths processed in adult criminal court are disproportionately male, African American, Hispanic, and older. Although these findings underscore the importance of addressing disproportionate minority confinement (39), the findings also have implications for psychiatric services. The sociodemographic factors associated with greater odds of youths being processed in adult criminal court are the same sociodemographic factors associated with lower odds of receiving psychiatric services, regardless of need (18). This finding suggests an urgent situation in which the largest numbers of transferred youths in need of psychiatric services are also the least likely to receive them.
We also found that the odds of having a psychiatric disorder were greater among transferred youths sentenced to prison than those receiving less severe sentences. The specific disorders associated with increased odds for a prison sentence were, not surprisingly, disruptive behavior and substance use disorders. Higher rates of disruptive behavior and substance use disorders may reasonably be expected among youths with greater antisocial traits, assuming that a sentence to prison is a proxy for greater antisociality. In other words, disruptive behavior and substance use disorders may reflect an underlying antisocial trait. A parallel result has been found among adult male prisoners, of whom approximately half meet criteria for antisocial personality disorder (40).
The higher prevalence of comorbid disorders found among prison-bound youths, however, is not as easily explained by underlying antisociality. On average, youths transferred to adult criminal court and sentenced to prison have more than one psychiatric disorder, and 15% have all four major types of psychiatric disorders. Furthermore, the types of comorbid disorders are not limited to behavioral or substance use disorders; receiving a prison sentence is associated with greater odds of having comorbid affective and anxiety disorders. These findings suggest that transferred youths sentenced to prison not only have greater needs for behavioral rehabilitation to address disruptive behavior and substance use disorders than transferred youths receiving less severe sentences but they also have greater need for psychiatric treatment of major affective and anxiety disorders.
This study has several limitations. Because our findings are drawn from a single site, they may pertain only to detention centers with a similar demographic composition and legal mechanisms for transfer to adult criminal court. For example, the generalizability of these findings may be limited to states that limit juvenile jurisdiction up to age 17 years; most states extend jurisdiction of the juvenile court up to age 18 years. Differences in prevalence of disorder by transfer status may vary if diagnoses were based on DSM-IV instead of DSM-III-R. Because it was not feasible to interview caretakers (few would have been available), our diagnostic data are also limited by the reliability and validity of youths’ self-report. This may result in an under-reporting of some disorders (e.g., disruptive behavior disorders). Despite oversampling within specific strata, the sample size for specific sociodemographic groups, such as non-Hispanic white females, may be too small to conduct reliable comparisons. Finally, transfer processes may have changed since these data were collected; the findings may have less applicability to areas with different mechanisms for transfer.
Based on the findings from this study, we suggest the following directions for future research:
The findings of this study have several implications for public policy:
The transfer process should be reserved for the most serious, chronic, and violent offenders (44). Clinicians can assist in this process by determining when and how mitigating psychiatric factors should be considered in transfer to adult criminal court, and which transferred youths may respond best to alternative sentencing. Correctional systems must be prepared to provide psychiatric services to youths transferred to adult criminal court, and especially to youths sentenced to prison. Community health systems must also be prepared to provide services for these youths when they are released into the community. Psychiatric service providers need to consider the disproportionate representation of racial/ethnic minorities in the transfer process when developing and implementing services.
This work was supported by National Institute of Mental Health grants R01MH54197 and R01MH59463 (Division of Services & Intervention Research and Center for Mental Health Research on AIDS), and grants 1999-JE-FX-1001 and 2005-JL-FX-0288 from the Office of Juvenile Justice and Delinquency Prevention. Major funding was also provided by the National Institute on Drug Abuse, the National Institute on Alcohol Abuse and Alcoholism, the Substance Abuse and Mental Health Services Administration (Center for Mental Health Services, Center for Substance Abuse Prevention, Center for Substance Abuse Treatment), the Centers for Disease Control and Prevention (National Center on Injury Prevention & Control and National Center for HIV, STD & TB Prevention), the NIH Office of Research on Women's Health, the NIH Center on Minority Health and Health Disparities, the NIH Office on Rare Diseases, the Department of Labor, The William T. Grant Foundation, and The Robert Wood Johnson Foundation. Additional funds were provided by The John D. and Catherine T. MacArthur Foundation, The Open Society Institute, and The Chicago Community Trust. We thank these agencies for their collaborative spirit and steadfast support.
Many more people than the authors contributed to this project. This study could not have been accomplished without the advice of Ann Hohmann, Ph.D., Kimberly Hoagwood, Ph.D., Heather Ringeisen, Ph.D., Grayson Norquist, M.D., and Delores Parron, Ph.D. Celia Fisher, Ph.D., guided our human participant procedures. Leah Welty, Ph.D., provided assistance on analytic issues. We also thank Eugene Griffin, Ph.D., for his review of an earlier version of this article.
Disclosures: None for any author