Catch them young

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.