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Young people within the criminal justice system are estimated to be at least three times more likely to have mental health problems than those in the general population, says a report from the Mental Health Foundation published this week.¹

There are several factors at play. First, the origins of their offending, such as erratic parenting, harsh discipline or childhood hyperactivity, contribute to mental health problems. Second, various aspects of offending itself may cause mental health problems and, third, interactions with the criminal justice system are stressful and may lead to anxiety and depression.

Conduct and emotional disorders and hyperactivity are the most common childhood mental health problems. For young people in the criminal justice system, add depression, anxiety and post-traumatic stress disorder.

Many professionals believe that early detection of mental health problems may reduce the chances of youth offending continuing into adulthood. Despite this, young people in the criminal justice system are not subject to routine screening for mental health problems. When a young offender is first referred to the youth offending team, they are assessed to ascertain the reasons for their behaviour. Youth workers can then put together a programme to tackle the circumstances causing them to offend. Known as Asset, this assessment has no explicit mental health focus.

However, the Youth Justice Board has commissioned the University of Manchester and the Forensic Adolescent Service of Salford NHS Trust to design a tool specifically to identify the mental health needs of young offenders. Specific questions will help youth justice staff detect mental health problems and will be compatible with the screening used by children and adolescent mental health teams. This tool will be incorporated into the Asset form and is expected to be rolled out nationally in September.

The team developing the tool will train YOT workers and staff working in secure units and young offender institutions. And, as the MHF report argues, there are substantial training needs among non-psychiatric staff who work in environments where at least a third of their clients are likely to have mental health problems.

There is little research on the prevalence of mental health problems in the youth justice system. But what there is supports the adage that prevention is better than cure. A recent study compared the cumulative costs of public services used through to adulthood by individuals with three levels of antisocial behaviour in childhood.² It revealed that, by the time they were 28, costs for individuals with conduct disorder were 10 times higher than for those with "no problems". The authors conclude that antisocial behaviour in childhood is a major predictor of how much an individual will cost society and, though this cost is large and falls on many agencies, relatively few agencies contribute to the prevention services that could save money later.

Susan Bailey, chairperson of the child and adolescent faculty at the Royal College of Psychiatrists, is an acknowledged expert in this field and is a member of the University of Manchester team developing the Asset screening tool. She believes there are two ways to reduce the number of young people with mental health problems in the criminal justice system. First, professionals need to recognise that all the initiatives which promote mental health and prevent mental illness early on, such as Sure Start, have benefits for this group too.

Second, the causal link between mental health and offending needs to be understood. Children in the criminal justice system are likely to have conduct disorder, so it is not helpful to identify just this, she says. What needs to be more carefully examined is whether there is a co-morbidity diagnosis, for example conduct disorder and depression. With a full diagnosis, professionals can address their health problems which may in turn reduce their offending.

Deryck Browne, policy development officer at rehabilitation agency Nacro, says: "There is clearly some overlap between the factors associated with getting into trouble and those associated with the onset of mental health problems."

Although early identification is an issue, it is not that simple. Browne says: "There are issues around not wanting to label or stigmatise youngsters so problems are not addressed until later when they are obviously worse."

In 1997, a study by the Office for National Statistics revealed that more than a quarter of young men and 41 per cent of young women under 21 in prison had received treatment for mental health problems in the year before they were jailed. They are the ones who have been assessed, says Charlotte Day, policy officer at the Howard League for Penal Reform.

"The problem is the lack of community resources for young people with mental health problems. As a result, many end up in the prison system and, once there, there isn't the appropriate care for them or the resources to get them out into a bed in the community," Day says.

In many cases, imprisonment is likely to exacerbate the mental disorder. The current system is not good enough, says Sharon Moore, youth justice programme manager at the Children's Society. "We can't get young offenders assessed at court prior to a decision about remand. Even if the conclusion is that this child is mentally ill, the court might feel that the child is better off locked up than out on bail. There can be a view that if they are locked up they will be able to get the assistance they need."

Moore says it needs to be recognised that these young people are not primarily criminals: "They are young people with mental health problems, but because they go down the criminal route they often end up with a conviction and criminal record, where really what they need is help and treatment."

¹ A Hagell, The Mental Health Needs of Young Offenders, MHF, 2002

² S Scott et al, Financial Cost of Social Exclusion, BMJ, 2001

³ D Lader, N Singleton, H Meltzer, Psychiatric Morbidity among Young Offenders in England and Wales, The Stationery Office, 1997

Key findings

An estimated 13 per cent of girls and 10 per cent of boys have a mental health problem. For young people in custody, estimates rise dramatically, ranging from 46 per cent to 81 per cent. For those in the criminal justice system but outside custody, calculations vary from 25 per cent to 77 per cent.

Overall, the mental health needs of young offenders are not being met. There are problems in providing specialist services within the youth justice system and with referring young people out to existing child and adolescent mental health services.

Problems arise with inadequate screening and assessment, lack of staff training, insufficient funding, limited treatment options and a lack of research. This needs to be addressed on a multi-agency basis.

There is a demand for services in substance abuse counselling, structured residential behavioural programmes for delinquency, educational programmes, anger management programmes and diagnosis and treatment of medical problems. Specific services need to be developed, given the crisis in adolescent psychiatric services within the NHS as a whole.

Meanwhile, having unmet mental health problems in custody is likely to increase chances of being bullied and also make young people more likely to injure themselves or commit suicide.

Solutions include:

• Prevention and early intervention in the community and in the youth offending system.
• Improved assessment and treatment of young offenders with mental health problems.
• Changes in culture in youth offending institutions and improved alternatives to custody.
• Effective rehabilitation and support for discharged young offenders.
• All youth offending teams should have a specialist mental health worker.

Source: The Mental Health Needs of Young Offenders, MHF, 2002

"I ache inside"

Carol is a quiet, meek young woman - at times, writes Rachel Downey. Alcohol forms a big part of her life and, when she drinks, her behaviour changes. Her mother is a barmaid, her father an alcoholic, and she started drinking heavily at 15 after being excluded from school at 13. Her father used to self-harm.

Carol’s depression began more than a year ago after she visited her brother, who is serving life in prison for murder. She was 16. Soon she felt “really low all the time”.

Heavy drinking led to offending. She received a supervision order for “having a go at a copper”. Then, while drunk, she pushed a glass in a woman’s face. She received a detention and training order, half of which was to be spent in custody, the other half in the community. She was placed in a local authority secure unit but felt too old to be among children and asked to be moved to an adult prison. There she began cutting her arms because she was “pissed off”. Eventually she saw a psychiatrist. “They were not really interested,” she says. She was placed on suicide watch and her room checked every five minutes for two weeks. “I was depressed but not suicidal,” she says.

She was moved to a women’s prison where she became rebellious and was locked up for 23 hours a day when her privileges were taken away. She had no association with other inmates and  began to cut herself. “I felt I couldn’t cope any longer.” She was placed on suicide watch and given anti-depressants. She waited for weeks before she saw a counsellor. She knows when she starts spiralling downward she will offend.

The youth offending team could not place Carol with specialist child and adolescent mental health services because there were no places. Although she is only 17, the youth offending team referred her to the community mental health team to ensure that someone is looking out for her when her sentence and contact with the YOT end.

"People were following me"

David cannot sit still. He fidgets constantly and jumps up and down. He is worried because there is a chance he will go to prison. He is on his sixth supervision order and beat up a man while drunk, writes Rachel Downey.

His lifestyle is chaotic. He was diagnosed with attention deficit hyperactivity disorder when he was five and put on Ritalin. He has a strained relationship with his mother, no relationship with his stepfather and his father is a heroin addict. David takes drugs, mainly ecstasy. When he was 16 his mother stopped giving him Ritalin because she thought he would sell it.

He left home and took a job on a building site. Just before Christmas his condition deteriorated. He started hearing voices. He felt the radio was taping his words. “A lot of people were following me and told me they were going to kill me,” he says. Some of his fear stems from the fact that he is in debt to drug dealers.

The youth offending team got him an emergency appointment with a psychiatrist, who prescribed anti-psychotic drugs to still the voices. David, now 17, says: “I don’t take them because they don’t work.” But when he doesn’t take the drugs, he becomes paranoid. “Every time I get drunk or E-ed up, I get into trouble,” he says. “I take Es because they give me confidence.” David was laid off. The child and adolescent mental health service team would not take him because he was on a supervision order. The youth justice workers believe David’s mental health problems will worsen, especially if he is jailed.