Nature and Extent of Mental Health Disorders in the Tri-State Area Forensic Sciences: Methods and Techniques

It is estimated that 70% of all youths that come into contact with the juvenile justice system meet the criteria for at least one mental health diagnosis. Twenty-five percent have serious emotional issues. These mental health issues are significantly complicated by the presence of a co-occurring substance use disorder. For many of these youths, contact with the juvenile justice system results directly from untreated mental health issues that manifest in delinquent behavior. For this reason, it is crucial to understand the nature, extent, and possible alternatives to the mental health pandemic faced by the juvenile justice system in this county. This study examines the nature and extent of mental health disorders moving through the juvenile justice system, and whether juvenile probation officers consider the juvenile’s mental health status when making sentencing recommendations. This qualitative study surveys all juvenile probation officers in the Tri-State area: Kentucky, Illinois, and Indiana. The results show 90% of all youths moving through the juvenile justice system have mental health issues (extent), and the two types (nature) of mental illness that were recorded the most were Attention Deficit Disorder (ADD), and Attention Deficit Hyperactive Disorder (ADHD). Juvenile probation officers were painfully aware of the mental health issues facing juveniles that they were in contact with. Suggestions for policy, practice, and future research are offered.


Introduction
Over the last decade, concern has escalated over the number of youth with significant mental health needs involved with the juvenile justice system. Recent studies have found that 50% to 70% of all juveniles who come into contact with the juvenile justice system meet the criteria for at least one mental health disorder [1][2][3]; 50% among youth at probations intake [4] and 65% to 70% among youth in residential juvenile justice facilities [5]. For many of these juveniles, contact with the juvenile justice system results directly from untreated mental health issues that manifest in delinquent behavior. Contact with the juvenile justice system is often seen by parents, teachers, and the police as the only means for accessing services and treatment not readily available in the community [6]. The juvenile justice system, unlike other child-serving systems, cannot refuse to accept a juvenile and is seen as the only option for accessing these needed services [2].

Purpose of the study
The purpose of this study was threefold. First, to establish the nature and extent of mental health disorders moving through the juvenile justice system; specifically, in the Tri-State area; Kentucky, Illinois, and Indiana. Second, to ascertain if juvenile probation officers consider the juvenile's mental health status when making sentencing recommendations. Finally, to advocate for collaboration in dealing with juveniles with mental health disorders that are so severe that their ability to function is significantly impaired.

Literature Review
There is a growing body of research that suggests that a large number of youth that come into contact with the juvenile justice system have mental health disorders. Until the last two decades, however, there was a scarcity of research available documenting the degree to which youth in contact with the juvenile justice system were experiencing mental illness [7][8][9]. New research has significantly expanded our knowledge and understanding of the nature and extent of mental health disorders among the juvenile justice population with calls for increased collaboration, coordination, better data on the prevalence and manifestation of disorders, and greater availability of screening, assessment, and treatment.
In the 1990s researchers [6,9,[10][11][12] began to find that a significant proportion of youths in the juvenile justice system were classified under the general heading of Disruptive Behavior Disorders; estimated that within the general population, 1.5% to 8.7% of youth have a conduct disorder, whereas 50% to 90% of youths in the juvenile justice system have been diagnosed with a conduct disorder. In addition, these studies found that 25% to 67% of youths in juvenile justice have a history of substance abuse. Disruptive Behavior Disorders are characterized by actions that disturb or harm others and that cause distress or disability [13]. Conduct disorder is the most common of the disruptive behavior disorders and is defined as a repetitive and persistent pattern of behavior in which the basic rights of others or rules of society are violated [14]. Conduct disorder behavior can include aggression toward people and animals, theft and destruction of property, and serious violations of rules and laws [15].
In 2001, the Office of Juvenile Justice and Delinquency Prevention (OJJDP) launched their largest investment in mental health research aimed at providing the field with guidance to help address the problem and to improve the lives of juveniles and their families with mental health needs who end up involved with the juvenile justice system. The work created from this effort was titled Blueprint for Change: A Comprehensive Model for the Identification and Treatment of Youth with Mental Health Needs in Contact with the Juvenile Justice System [16]. This document offers a conceptual and practical framework for juvenile justice and mental health systems to use when developing programs aimed at improving mental health services for youth involved with the juvenile justice system and advocates collaboration between systems.
The United States Department of Justice also emphasized the importance of collaboration. The Juvenile Accountability Block Grant (JABG) now encourages the establishment of information sharing systems designed to facilitate more informed decision-making on the part of the juvenile justice system around the identification, supervision, and treatment of youth. In addition, the Bureau of Justice Assistance (BJA) within the United States Department of Justice has recently funded state and county based collaborative efforts to jointly respond to the mental health needs of juveniles in contact with the juvenile justice system. Similarly, major reports from Presidents Clinton and Bush recommended that juvenile justice agencies partner with other child serving agencies to transform mental health care for youths, particularly focusing on early identification and referral to home and community-connected services [17,18]. Finally, the Obama administration focused on the problem of youth exposed to trauma and made efforts to reduce youth violence and childhood trauma [19].
More recent studies [1][2][3][4]16,20] have consistently found that that about 70% of all juveniles who are exposed to the juvenile justice system meet the criteria for at least one mental health disorder, one in five youth (20%) have a serious mental health disorder, and the majority who meet criteria for a DSM-IV diagnosis actually meet criteria for multiple disorders; 79% met criteria for two or more diagnoses and over 60% were diagnosed with three or more mental health disorders. Disorders are said to be co-morbid, or co-occurring when a youth simultaneously meets criteria for two or more different disorders [21]. Youths with co-occurring disorders often have more complex needs than those with a single disability and . 03 . identification and assessment of youths with co-occurring disorders can be more difficult [12]. It is not uncommon for a youth to have more than one disorder. In addition, learning disorders and substance use disorders are common in all of these conditions. For many of these juveniles, contact with the juvenile justice system results directly from untreated mental health issue(s) that manifest in delinquent behavior. Contact with the juvenile justice system is often seen by parents, teachers, and the police as the only means for accessing services and treatment not available in the community [2]. The juvenile justice system, unlike other child-serving systems, cannot refuse to accept a juvenile, and therefore, is seen as the only option for accessing these needed services [15].

Gender and mental health disorders
Over the past decade there has been a marked increase in the number of girls arrested in the United States. While little research on the mental health needs of delinquent juveniles exists in general, even fewer studies focus on the mental health needs of females in the juvenile justice system. The mental health needs of females in the juvenile justice system have been ignored in large part because of the small number of female delinquents; however, females are now the fastest growing population [22]. Understanding the difference in mental health needs between genders is important. Females record higher rates of internalizing disorders such as depression and anxiety that can lead to suicide ideation and typically arise from more abusive and traumatizing experiences. Without appropriate gender and trauma specific treatment, these girls are likely to experience a high rate of criminality, substance abuse, early pregnancy, and continued interpersonal violence [15].
Research [6,[23][24][25][26][27][28][29] suggests that a majority of girls in the juvenile justice system meet the criteria for at least one mental disorder, and in some studies, girls show higher prevalence rates than boys. There are complex issues facing girls with mental health issues being processed through the juvenile justice system; girls in contact with the juvenile justice system who have mental health needs do not fare well in the system designed for boys and many of these girls present complicated clinical profiles as a result of the pervasive violence in their lives.
History of physical and sexual abuse is virtually universal among girls in contact with the juvenile justice system. Abuse often results in significant and long-lasting mental health problems and self-harming behaviors regardless of involvement in status offenses or delinquency. Specific anti-social behaviors include suicide attempts [30][31][32], depression and anxiety disorders [23,24,33], running away [34][35][36][37], and increased likelihood of future sexual assault, rape [38,39], prostitution [34], property offenses, drug sales [40], substance abuse, dependency, and arrest for violent crime [41].
While the body of research on youth moving through the juvenile justice system with mental health issues is growing, little research has been conducted on the juvenile probation officers' perception on this issue. This is troublesome as juvenile probation is the "cornerstone" [42] of the juvenile justice system. Juvenile probation departments play a central role in the administration of juvenile justice in the United States because they are responsible for screening cases, determine how cases should be processed, make detention decisions, prepare investigation reports, provide supervision, and deliver aftercare services. The policies and programs advanced by probation departments greatly define the Nation's response to juvenile crime and the growing number of youth that are now moving through the juvenile justice system with mental health issue(s).

Methods
This study sought to examine the relationship between individual characteristics of juvenile probation officers and their perceptions regarding the nature and extent of mental health moving through the juvenile justice system. In addition, it sought to ascertain if they considered the juvenile's mental health issues when making sentencing recommendations. Finally, to advocate for collaboration in dealing with juveniles with mental health disorders that are so severe that their ability to function is significantly impaired. This study was exploratory in nature. ATLAS.ti software was employed for data analysis. The qualitative analysis, presented in a survey that was part of a larger study, sought to answer the following questions.

Research Questions
Ocimum Scientific Publishers survey instrument for this study was constructed by the primary investigator, and disseminated using Survey Monkey. This study was qualitative in nature. The total population for this study was 758. The expected rate of return for this study was set at 30 percent (n=227).

Instrumentation
The primary researcher developed the survey instrument based upon previous literature [1]. The instrument consisted of four sections: court information; sanctioning and disposition issues; demographic information; and qualitative strategy questions. This article presents the findings from the qualitative strategy questions only.

Procedures
The survey instrument for this study was constructed by the primary investigator and disseminated using Survey Monkey. All survey responses were considered confidential and no individual identifiers were used. All surveys were destroyed once the analysis was completed. The survey instrument and research protocols were reviewed and approved by The University of Southern Indiana Institutional Review Board.
The survey was accompanied by an email of explanation and an information sheet for consent to participate in the study. Participants were given the opportunity to receive, via email, a copy of the executive summary by responding to the email provided in the email of explanation. There were three disseminations of the survey through Survey Monkey; the initial and two follow up.

Data analysis
The researchers entered the data derived from the survey instruments into two software packages; SPSS and ATLAS. ti. Descriptive statistics were used to calculate the means, frequencies and standard deviations for the demographic information collected from the participants in this study. The descriptive statistics were analyzed using version 24 of SPSS. The data was then analyzed using ATLAS.ti. ATLAS. ti allows a researcher to upload and import from various data sources into the program for analysis. In this study, the survey responses were downloaded from Survey Monkey to SPSS. The qualitative data was pulled from SPSS into MS Word files then uploaded and analyzed in ATLAS.ti. This software was useful in organizing the data by allowing the researchers to create a coding structure or network of broad terms that then could be broken down into more specific ones. We then proceeded to look for themes in the justifications our respondents gave during subsequent rounds of coding. This process allowed the researchers to pull rich data upon which to base the findings.

Limitations
There were several limitations that the researchers placed on the study. First, all of the participants in this study were current juvenile probation officers in the Tri-State area; Kentucky, Illinois, and Indiana. Second, a survey was used to gather the qualitative data allowing respondents, if they wished, to skip certain questions and or answer with one-word responses which lacks depth. Finally, the researchers disseminated the survey via Survey Monkey which might have caused technological challenges for one or more of the respondents.

Assumptions
The researchers relied on several assumptions when conducting this study. First, the juvenile probation officers who participated in this study took the survey seriously and completed the survey instrument as truthfully and completely as possible because participation in this study was voluntary and confidentiality assured. Second, the juvenile probation officers are representative of all juvenile probation officers in the survey states; Kentucky, Illinois, and Indiana, at the time the study was conducted. Third, that not all juvenile probation officers would return the survey. The entire population was given the option to participate. It was assumed that a representative sample of officers, to include a representation of demographics, was the basis of the findings as the actual demographic factors for the population was not publically available. Similarly, when conducting survey research return rates can be of concern. However, there is no "national average response rate" as a host of factors drives response rates: administration mode, survey length, invitation quality, relationship the researcher has with the audience, etc.

Qualitative results
Two hundred and seventeen, (217), juvenile probation officers (80%) answered the question, in your opinion, what is the degree to which youth involved with the juvenile justice system experience mental illness? The researchers were able to place the responses into three board categories; nature (type), extent (amount), and responses to mental health issues.
First, the respondents overwhelmingly (88%) agreed that juveniles involved with the juvenile justice system who experience mental illness has become an increasing and frequent problem. In addition, they asserted that there were a large number of dual diagnoses, and that the cases seem to be getting worse. For example, one of the respondents stated, "Most of my case load is made up of youth with mental issues or addiction issues. Rarely do I see a youth who made a bad decision and committed a crime." This sentiment was repeated over and over. The estimated amount of youth involved with the juvenile justice system that experience mental illness ranked from unknown to 90%. The two types of mental illness that were recorded the most were Attention Deficit Disorder (ADD), Attention Deficit Hyperactive Disorder (ADHD). In addition, juvenile probation officers noted these two types of mental illness were being over diagnosed and used as a crutch for the youth's poor behavior. Other recorded types of mental illness were as follows by extent: Reactive Attachment Disorder (RAD), Bipolar Disorder, Oppositional Defiant Disorder (ODD), Conduct Disorder, Post-Traumatic Stress Disorder (PTSD), and depression. Finally, the juvenile probation officers noted that mental health issues in their jurisdiction were being dealt with through counseling, medication, and hospitalization. They noted that the most notable hindrance to dealing with juveniles with mental health issues, next to lack of community services, was the family's refusal to participate in treatment.
Two hundred and thirty-two, (232) juvenile probation officers (85%) answered the question, in your opinion, is mental illness in the juvenile justice system an issue? Ninety-four percent (n=218) of the respondents stated that mental illness in the Ocimum Scientific Publishers juvenile justice system is an issue. Further, they asserted that it becomes an issue when the youth has more mental health issues rather than criminal type behaviors. In other words, some youth with mental health issues, who did not knowingly or intentionally commit crime, ended up in the juvenile justice system, and some juveniles who were considered guilty had significant mental health needs. Juvenile probation officers resoundingly agreed that the lack of community mental health services was the reason that many youths with mental health issues were being processed through juvenile justice system. For example, one of the respondents stated, "…there are not enough resources available within the community, therefore, the juvenile is labeled a delinquent." Many juvenile probation officers felt that those clients who were guilty, but also had mental health issues, needed proper mental health care if they were to reenter society effectively.
Mental health issues "are very prevalent and yes, if these youths are not getting their mental health needs met or refuse to comply with treatment, then they have a greater risk of reoffending" [juvenile probation officer].
The 14 respondents (6%) who did not believe that mental health in the juvenile justice system was an issue stated the following reasons why. First, that mental illness in the juvenile justice system was not an issue because services were adequate. Second, that many times youth were misdiagnosed or over diagnosed with mental illness where none actually existed. Finally, that the juvenile justice system felt the need to label youth mentally ill in order to get them services.
"It is in that many times youth are misdiagnosed with mental illness when none actually exist. This is done in order to get counseling services. We have to label youth to get them help. So, they end up with somewhat permanent diagnosis for what may have been a temporary phase of normal development that parents/schools didn't want to have to deal with" [juvenile probation officer].
Two hundred and twenty-eight, (228), juvenile probation officers (84%) answered the question, in your opinion, do juveniles with mental illnesses end up moving through the juvenile justice system because of the lack of community-based mental health treatment? Seventy-three percent (n=166) of the juvenile probation officers agreed that juveniles with mental illness end up moving through the juvenile justice system because of the lack of community-based mental health services while 58 disagreed, and 4 officers were uncertain.
The juvenile probation officers who agreed did so not because of the lack of services, but the inability of the family to access services without the juvenile probation department's influence.
Juvenile probation officers stated that they have been told by family members that they had been advised by mental health, school professional, and other community service organizations to have their child arrested in order to either receive services or as a way to expedite services. Juvenile probation officers cited long, out of control wait lists and times, lack of communitybased mental health providers, and financial issues as barriers to receiving community-based mental health treatment. For example, one respondent stated, "Absolutely; we regularly meet with families who say they've been advised by mental health and school professions that having their child arrested is the most expedient way to get their child services." It was the opinion of the juvenile probation officers that a court order or referral from juvenile probation assures mental health providers of payment and thus expedites mental health services.
…often times juvenile probation is forced to pursue formal charges in an effort to provide services to a juvenile that could have otherwise been diverted from the legal system [juvenile probation officer].
Further, it was the opinion of juvenile probation officers that using the judiciary to obtain services had become a common process that many organizations came to rely on. The officers explained that this process had become so ingrained in the course of catering to juveniles with mental health needs that sending them through the juvenile justice system had become the most efficient way for families to find the appropriate treatment options.
One juvenile probation officer provided an alternative explanation for the pronounced presence of clients with mental health problems beyond the lack of community-based treatment; private industry.
Yes, not only because there is a lack of community-based services but because it is nearly impossible for parents to access services outside of the community, especially emergency care and placement. It is amazing how many parents call and say 'if you give me a court order I can get my child the help they need.' This is what parents are told by the facilities and the insurance companies. Mental health services for children should be accessible to parents without a court order. Residential facilities that allow parents to access services have become increasing scarce. But this problem is not so much a justice system problem as it is a provider/insurance problem. Putting the stigma of delinquency (denoting criminality) on a child is detrimental to that child in the future. Providers and insurance companies do not delay medical services for physical health emergencies; they shouldn't delay mental health services either [juvenile probation officer].
. 07 . Fifty-eight (25%) of the juvenile probation officers did not agree that juveniles with mental illnesses end up moving through the juvenile justice system because of the lack of community-based mental health treatment. They asserted there were adequate community-based mental health services, but families were not willing to make the effort to seek out, participate, or follow through with said services.

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The earlier you can treat a problem in any circumstance the better. I think it's a systematic failure of the family support system that leads to more issues. If there was a responsible, healthy guardian in many of these kids' lives they can get the treatment they need and never be involved in the system [juvenile probation officer].
Another juvenile probation officer explained: I don't think the issue is so much that services aren't available as families aren't willing to make an effort to seek out or participate in services. We have a lot of families that just want us to waive a magic wand and 'fix' their kids rather than acknowledge any issues and work on improving them. We have services, and the schools are good at directing families to those services, they just frequently don't follow through.
And another juvenile probation officer asserts: Often it is the parents' inability or neglect in getting the youth into treatment. Often parents do not avail themselves of treatment for the youth even though they know where to go and have Medicaid to cover it! It was uncertain why parents did not seek out mental health treatment for their youth; however, juvenile probation officers did allude to several factors; the lack of financial means and knowledge of community-based mental health services. It may be possible that a parent's denial; not my child syndrome, being unaware, and/or negligent were possible causes as well.
Finally, two hundred and fifty-five (255) juvenile probation officers (94%) answered the question; do you consider the juvenile's personality problems as identified by MMPI when making sentencing recommendation(s)? One hundred and fiftysix (156) indicated that they did (61%). Sixty-two respondents (24%) had no opinion. Thirty-seven respondents (15%) did not consider the juvenile's personality problems as identified by MMPI when making sentencing recommendation(s). In order to understand the data further, the researchers looked at gender, race, level of education, and jurisdiction of the juvenile probation officers.
The majority of the respondents were female (61%). When asked if they considered the juvenile's personality problems as identified by the MMPI when making sentencing recommendation(s), 65% of females compared to 35% of males stated that they did. Of the 223 respondents that identified with white, not of Hispanic origins, 132 (59%) reported that they did consider the juvenile's personality problems as identified by the MMPI when making sentencing recommendation(s); 54 (24%) had no opinion and 35 (16%) reported that they did not consider the juvenile's personality problems when making sentencing recommendation(s). Of the 25 respondents that identified with a minority population, 21 (84%) reported that they did consider the juvenile's personality problems as identified by the MMPI when making sentencing recommendation(s). At least for this study, this suggests that minority juvenile probation officers are more likely than Whites to consider the juvenile's personality problems when making sentencing recommendation(s). It is important to note that 82% of the respondents identified with White, not of Hispanic origins.
The majority of the respondents reported their level of education as undergraduate degree (63%). When asked if they considered the juvenile's personality problems as identified by the MMPI when making sentencing recommendation(s), 39% of undergraduate degrees compared to 20% of graduate degrees stated that they did. Finally, with regard to jurisdiction, the majority of the respondents reported being located in a rural jurisdiction (52%). Of the 141 respondents located in a rural jurisdiction 86 (61%) considered the juvenile's personality problems as identified by the MMIP when making sentencing recommendation as compared to 52% in urban and 55% in suburban jurisdictions. All of these findings might be different with a more diverse population.

Conclusion
In this study, the two types (nature) of mental health issues reported the most by juvenile probation officers in the Ocimum Scientific Publishers at least one mental health diagnosis and 25% have serious emotional issues. This study has substantiated the extent of mental health disorders moving through the juvenile justice system in the Tri-State area mirrors that of the national averages. Furthermore, at least in the Tri-State area, juvenile probation officers are painfully aware of the mental health issues facing juveniles that they are in contact with. It is their perceptions that not only is this a substantial issue for the youth, but for the system, and it appears to be getting worse.
Data on treatment for mental health and substance use disorders are more limited for youth than for adults. Parents or guardians may have difficulty identifying mental health disorders or helping youth access the right types of treatment. On average, as reported in the NCS-R, the time from the onset of a mental health disorder, which is often first experienced in childhood or adolescence, to initial treatment is nearly 10 years [43]. This study found that the majority (84%) of juvenile probation officers in the Tri-State area agreed that juveniles with mental health disorders ended up moving through the juvenile justice system because of the lack of community-based mental health services and the inability of the family to access services without the juvenile probation department's pull.
According to the Substance Abuse and Mental Health Services Administration's (SAMHSA) 2012 behavioral health report [44], mental health and substance use disorders are among the leading causes of disability in the United States. The symptoms of mental health and substance use disorders may affect a youth's ability to function from day-to-day. Youth with these disorders may find it difficult to maintain interpersonal relationships, find and sustain employment, complete school assignments, and care for themselves. Similarly, youth who experience serious emotional disturbances are more likely than their peers to drop out of school, fail a grade, and spend time in a juvenile correctional facility. Impairment experienced at any time during the life span may be debilitating. This is especially true if the impairment is experienced during a critical developmental period such as adolescence. In this study, the majority (61%) of juvenile probation officers in the Tri-State area indicated that they considered the youth's personality problems as identified by the MMPI when making sentencing recommendations.
Finally, accessing mental health services can be an overwhelming task for youth and their parents or guardians. Each agency providing services to youth have their own procedures, rules, and terminology. Navigating through two or more of these systems, which is usually the case, increases the likelihood of fragmented treatment or disruption in services via changes in medications, changes in providers, lag time in receiving information about their medical and or mental health history, and conflicting requirements. Active partnerships with the mental health community and other child-serving organizations can improve the care and treatment of these youth and prompt healthier results for individuals, families, agencies, and communities.

Recommendations for policy or practice
The researchers make several policy and practice recommendations. First, there is a continued need to examine the validity and reliability of screening instruments that identify youth who may have mental health needs upon entry into the juvenile justice system. Similarly, because mental health records of youth are rarely available upon intake, appropriate mental health screening and assessment becomes paramount to providing appropriate treatment for juvenile offenders. In addition, there needs to be greater advocacy for comprehensive mental health screening within the juvenile justice system. Next, there is the need for standardized mental health screening tools across child serving agencies. Furthermore, persons who are administering such standardized mental health screening tools need to receive sufficient training. Finally, better solutions for youth moving through the juvenile justice system with mental health needs need to be created in the community.

Recommendations for future research
The researchers make several recommendations for future research. First, there appears to be a need for more research on the impact of race and gender on mental health at multiple key points of contact in the juvenile justice system. In addition, there appears to be a need for more research to examine the differences between mental health needs of females, males, and Diverse Sexualities and Genders (DSG) so that gender specific treatments can be implemented. Furthermore, given the substantial number of youths experiencing co-morbid disorders, research needs to continue to examine the prevalence of comorbid mental health disorders among incarcerated youths and examine effective treatment methods for these youths. Finally, research needs to examine the relationship between mental health status, offense, and recidivism among juveniles.