Slide 1 - The University of Texas School of Public Health by panniuniu

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									Juvenile Justice & Mental
Health: Paths to Care
J. Scott Hickey, Ph.D.
MHMRA of Harris County, Texas

Pam Boveland, Ph.D., Diana Quintana, Ph.D., & Matthew Shelton, Ph.D.,
Harris County Juvenile Probation Department,

William Schnapp, Ph.D.
University of Texas Mental Sciences Institute,.

Keith Burau, Ph.D., & Charles Begley, Ph.D.,
University of Texas School of Public Health

Rebecca DaCamera, J.D.
Mental Health Association of Greater Houston

Philip Emmite, Ph.D.
Houston Independent School District
  Paper first presented to the Joint
National Conference on Mental Health
               Statistics


  Center for Mental Health Services


   Washington, D.C., June 1, 2006
Greater Houston Health Services
Research Collaborative

   Initiative of the Houston Endowment
   Funded through UT School of Public
    Health
   Goal: Increase collaboration between
    academic and public sector researchers
   Purpose: Improve the quality of research
    relating to public health care
   We are pleased to show the first product
    of the collaborative
Why Does It Matter?
   That our jails have become the primary
    institutions for the care of the mentally ill is a sad
    but well-described phenomenon. “Fewer than
    55,000 Americans currently receive treatment in
    psychiatric hospitals. Meanwhile, almost 10 times
    that number -- nearly 500,000 -- mentally ill men
    and women are serving time in U.S. jails and
    prisons. As sheriffs and prison wardens become
    the unexpected and often ill-equipped caretakers
    of this burgeoning population, they raise a
    troubling new concern: Have America's jails
    and prisons become its new asylums?”[1]

    [1] Public Broadcasting System, 2005, Frontline: The New Asylums,
    http://www.pbs.org/wgbh/pages/frontline/shows/asylums/view/
Headline: U.S. leads in mental illness,
lags in treatment
              Washington Post June 6, 2005
         National Comorbidity Replication
          Study
         ¼ of all Americans met criteria for
          having a mental illness some time last
          year
         ¼ of those had symptoms severe
          enough to disrupt their day-today
          functioning
National Comorbidity Replication Study, p. 2

Prevalence

   Half of all Americans will have a mental
    disorder at some time in their lives
        Against: “Pretty soon we’ll have a syndrome
         for short fat Irish guys with a Boston accent,
         and I’ll be mentally ill”
                   Dr. Paul McHugh, Professor of Psychiatry, Johns Hopkins
                    University

        For: “If I told you that 99% of Americans had
         a physical illness, you wouldn’t blink an eye.”
                   Dr. Ronald Kessler, Professor of Health Care Policy,
                    Harvard Medical School
National Comorbidity Replication Study, p. 3

   Good news:
       Rates are flat over the past ten years
       Previous decades showed rising rates
   Bad news:
         Less than half get treatment
         They have often suffered and delayed treatment for
           ten years
         During those ten years they develop additional
           problems
         When they get treatment, it’s inadequate
         Young are overlooked
           50% of those diagnosed showed signs by age 14
           75% by age 24
           “Mental disorders are the chronic illnesses of
           youth.”
                 -Dr. Thomas Insel, Director, NIMH
Statistics in Context


   “Baseball fans use statistics like a
    drunk uses a lamppost, more for
    support than for illumination.”
       Vin Scully
Mental Disorders in the Juvenile
Justice System

   From 70 to 100%, have a diagnosable mental
    disorder. (2-3 times higher than other youth)

   Approximately one out of five (20%) has a
    serious mental disorder.

   These rates remain high even when you eliminate
    conduct disorder from the identified disorders-
       60% of boys and 70% of girls still meet criteria for some
        other psychiatric disorder.

   Rates of mental disorder are consistently higher
    for girls than for boys,
       especially for affective and anxiety disorders.
National Center for Mental Health &
Juvenile Justice
   Increasing sense of awareness and crisis surrounding
    the care and treatment of youth with mental disorders
    in the juvenile justice system.
       population of youth whose mental health needs have been
        neglected for a long time.
       Growing concern over the criminalization of mental illness.
       Increasing attention by the media, advocacy organizations (NAMI,
        NMHA, Federation of Families), and funding organizations (private
        foundations like MacArthur and Casey, as well as federal agencies
        such as SAMHSA and OJJDP).

   DOJ investigations into the conditions of confinement
    of youth in juvenile detention and correctional facilities
    across the country.
       These investigations have consistently highlighted the lack of
        appropriate screening, assessment and treatment available to
        youth…..(DOJ, 2003)
Research Question: To what degree do
the public mental health and juvenile
justice systems serve the same
children and adolescents?

   Method: Probabilistic data matching
   See CMHS IDBSE website for a report on
    the method and for SAS routines to
    perform the match
    The Two Databases to be Matched



   99,371 Harris County Juvenile
    Probation Department Records
    gathered from 1990 forward
        Records of all children and adolescents
         referred to Juvenile Probation
   294,020 Mental Health records
    obtained between 1992 and 2006
        Records of all persons receiving public
         mental health or retardation services
   Entire contents of both databases
Probabilistic Method

   Matched on:
       Soundex phonetic name translations
       SS#
       DOB
       Gender
       Race
       Zip Code
Results: About one in four overlap
   24,668 matches
   24.8 % of individuals present in the
    juvenile justice database were also
    present in the mental health database
   When one considers research indicating
    50-75% incidence of mental disorder
    among juvenile offenders, the match rate
    is disappointingly low
Conclusions

   Very significant overlap, but
   Low rate compared to rates of
    mental disorder in published
    probation samples
   Raises question: Why do children
    with mental disorders fail to receive
    services?
Question 2: Do matched cases
differ from the usual child mental
health caseload?


Method: Comparison of
characteristics of the matched sample
to those of a “mental health service
only” sample
Matched vs. Mental Health Samples

   Comparison sample: all cases
    served in the mental health system
    in 2005
   ~= 4500 cases
   Some overlap in this sample
   2133 cases remain if matched cases
    are removed from the MH Only
    sample
Gender & Baseball: 1866 Vassar Women’s Team
The mental health only sample
is…..predominantly (2/3) male
                         SEX
                         Female
                         Male




                  33




           67
……African-American & Hispanic
           1,000




            800




            600
   Count




                            41.58%
            400                        37.46%




            200                                                      18.75%




                   1.17%                                     0.98%
              0                                    0.05%
                   Asian    African-   Hispanic    Native    Other   White
                           American"              American
                                           Ethnicity
…..English-speaking
            2,000




            1,500
    Count




            1,000
                            84.62%




             500




                                                         14.49%


               0    0.47%               0.05%    0.23%               0.14%
                            English     Sign     Other   Spanish   Vietnamese
                                      Language
                                      Primary Language
….age at onset (system entry)
            250




            200




            150
    Count




            100




             50




              0


                  0   1   2   3   4   5   6   7   8   9   10   11   12   13   14   15   16   17   18
                                              Age at Onset
In contrast, the “matched sample”…
                              Gender x Sample


             0.8




             0.7




             0.6




             0.5
Percentage




                                                    HCJPD/MHMRA Match
             0.4
                                                    MHMRA 2005 Sample



             0.3




             0.2




             0.1




              0
                   Unknow n    F                M
….whiter
                                                    Ethnicity x Sample


              0.45



               0.4



              0.35



               0.3



              0.25
 Proportion




                                                                                          HCJPD/MHMRA Match
                                                                                          MHMRA 2005 Sample
               0.2



              0.15



               0.1



              0.05



                0
                     Asian    African-   Hispanic       Native American   Other   White
                             American"
….more English-speaking
                1
                                       Primary Language x Sample

               0.9



               0.8



               0.7



               0.6
  Proportion




               0.5



               0.4                                                                HCJPD/MHMRA Match
                                                                                  MHMRA 2005 Sample

               0.3



               0.2



               0.1



                0
                     English   Other        Spanish       Vietnamese   Unknow n
….. Young (17 year-old rookie)
…older
                                                                                      sample
           5,000
                                                                                      HCJPD/MHMRA
                                                                                      Match
                                                                                      MHMRA 2005
                                                                                      Sample

           4,000




           3,000
   Count




           2,000




           1,000




               0


                   0   1   2   3   4   5   6   7   8   9 10 11 12 13 14 15 16 17 18
                                                   age2
“How Old Would You Be If…..”
                                                                             Proportion
                                   U




                                                     0
                                                         0.05
                                                                0.1
                                                                      0.15
                                                                             0.2
                                                                                                                       0.25
                                                                                                                              0.3
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                                                                                                                                           0.4
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                                       nk
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                                                                                                                                                                                    Less Distractible




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       iv                             ab
         e
                                                                                                                                                        Diagnostic Group x Sample




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                                                                                                                                                                                    Diagnostic Group: Less Affective &




                                                                               MHMRA 2005 Sample
                                                                                                   HCJPD/MHMRA Match
Two Groups within Matched Sample

PATH


                           Frequency           Percent


Missing Episode Data                   2542       8.735695


MHMRA Portal                           6472       22.24131


HCJPD Portal                           15604      53.62384


MH Only Comparison Group               4481       15.39915


Total                                  29099             100
Conclusions
   Younger children enter the “system” through the
    mental health portal
   Mental health case openings peak at age eight,
    and gradually decline
   Children with Affective Disorders (Depression &
    Bipolar Disorders) make up a larger proportion of
    the mental health sample
   Children with ADHD also form a larger part of the
    mental health group
   “Biologically-based” disorders are apparently
    more frequently steered to mental health services
   Behavioral Disorders are more frequent among
    the matched group
More Conclusions

   The system is male-oriented
   The public mental health system
    has a relative under-representation
    of White child consumers while the
    probation system does not
Ray Chapman: The only major league
baseball player killed while playing the game
Question: Do Adolescents differ
according to portal of entry?

   Are there detectable differences
    among members of the matched
    sample depending on the door
    (mental health or probation)
    through which they entered the
    system?
The two paths: 70/30 {10% (~=2,500)
cases had no information regarding
program of first mental health episode}
                               PATH
                              MHMRA Portal
                              HCJPD Portal




                      6,292




             15,041
Gender x Portal
                                    Gender x Portal


               0.9



               0.8



               0.7



               0.6



               0.5
  Proportion




                                                                     F
                                                                     M
               0.4



               0.3



               0.2



               0.1



                0
                     MHMRA Portal                     HCJPD Portal
Ethnicity x Portal
                                                        Ethnicity x Portal


               0.45



                0.4



               0.35



                0.3



               0.25
  Proportion




                                                                                                 MHMRA Portal
                                                                                                 HCJPD Portal

                0.2



               0.15



                0.1



               0.05



                 0
                      Asian   African-American"   Hispanic     Native American   Other   White
                                                                               Proportion
                                     U




                                                       0
                                                           0.05
                                                                  0.1
                                                                        0.15
                                                                                    0.2
                                                                                                                0.25
                                                                                                                       0.3
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                                                                                                                                          Diagnostic Group x Portal




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                                                                                                                                                                      Diagnostic Group x Portal




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                                                 er
                                                                                  HCJPD Portal
                                                                                                 MHMRA Portal
                                                                       MHMRA Portal Only
                                    U




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                                                                 0.1
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                                                                                         0.2
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                                                                                                            Gender x Diagnostic Group




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                                                                                                                                        Mental Health Portal: DX x Gender
                                                                         Probation Portal Only

                                    U




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                                                                 0.1
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                                                                              0.2
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                                                                                                                                                    Probation Portal: DX Group x Gender




                                                                                    F
                                                                                M
Age at Onset by Portal
                                                                                    PATH
         4,000
                                                                                    MHMRA Portal
                                                                                    HCJPD Portal




         3,000
 Count




         2,000




         1,000




             0


                 0   1   2   3   4   5   6   7   8   9 10 11 12 13 14 15 16 17 18
                                                 age2
                                                                                                                         r
                                                                                                                       de
                                                                                                                     or
                                                                                                                  is
Age at Onset x Diagnostic Group




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                                                                                                                             Diagnostic Group
                                                                                 D
                                                                             ty               or
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                                  14




                                       12




                                                 10




                                                            8




                                                                6
                                        Mean Age at Onset
Behavior Disorders: Secondary Axis I
Diagnoses

                                                             Frequency    Percent
No Secondary Axis I Dx                                             5554        81.94158
Cannabis Abuse                                                      458        6.757156
Cannabis Dependence                                                 114        1.681912
Alcohol Abuse                                                        57        0.840956
Disruptive Behavior Disorder NOS                                     57        0.840956
Adjustment Disorder With Depressed Mood                              52        0.767188
Adjustment Disorder With Mixed Disturbance of Emotions and           51        0.752434
Polysubstance Dependence                                             45        0.663913
Attention-Deficit/Hyperactivity Disorder NOS                         43        0.634405
Learning Disorder NOS                                                36         0.53113
Adjustment Disorder With Mixed Anxiety and Depressed Mood            31        0.457362
Reading Disorder                                                     31        0.457362
Mood Disorder NOS                                                    25         0.36884
Depressive Disorder NOS                                              24        0.354087
Attention-Deficit/Hyperactivity Disorder                             23        0.339333
Oppositional Defiant Disorder                                        23        0.339333
Conclusions
   Entry through the Probation Portal is
    twice as likely
   Entry through the mental health vs.
    probation portal is associated with:
       Proportionately more Females
       Proportionately fewer Whites, more Hispanics
       Younger Age at Onset
       Greater likelihood of Affective Disorder and
        ADHD lower likelihood of Behavioral Disorder
More Conclusions

   Females using either portal are
    more frequently suffering from
    affective disorders
   Males entering through either portal
    are more likely diagnosed as
    behavior disorders
Steroids & Baseball
What to do….?
Question: Is portal of entry associated
with differences in juvenile justice
outcome?

   Is offense severity related to portal?
   Is probation history associated with
    portals?
Frequency of Probation Activity

   Does portal of entry relate to
    probation “file thickness?”
       One-way analysis of variance
       Dependent variables
          # of Referrals to Probation Dept.
          # of Referrals Rsulting in Court
           Disposition
          # of Dispositions to Probation
Probation Activity x Diagnostic Group
            Analyses of Variance: Groups Differ
            Significantly (Portal of Entry Matters)
                              Frequency of JJ Activity x Portal


        6




        5




        4
Count




                                                                                 MHMRA Portal
        3
                                                                                 HCJPD Portal




        2




        1




        0
                # Referrals     # Court Dispositions              # Probations
Portal of Entry and “File Thickness”

   Although individuals enter the
    mental health portal at younger
    ages than those entering through
    the probation portal, their
    subsequent juvenile justice activity
    is “thinner”
Portal of Entry and Severity

   Entering through the mental health
    portal is associated with fewer
    charges whether less severe
    (misdemeanors) or more serious
    felonies.
Number of Felonies, Misdemeanors
                            Number of Charges x Type x Portal


  3.5




   3




  2.5




   2
                                                                        MHMRA Portal
                                                                        HCJPD Portal

  1.5




   1




  0.5




   0
        Misdemeanor Count                                Felony Count
Cumulative Ratings as Severity
Indicators

   Each offense can be rated on a locally
    developed nine-point severity scale
    ranging from level one, Class C (mild)
    Misdemeanor to level nine, Capital Murder
   For cumulative index, sum across
    individual history to get total lifetime
    severity
   Play a little loose and treat ordinal data as
    if it were continuous
       Lifetime Severity x Portal
                                        Cumulative Rated Severity x Portal




Cumuilative Referral Severity




                                                                                            HCJPD Portal
                                                                                            MHMRA Portal




 Cumulative Petition Severity




                                0   2     4        6        8       10       12   14   16
Conclusions

   Entering through the mental health
    portal is associated with lower
    cumulative, “lifetime” severity of
    offenses
Looming Questions

   Is mental health treatment
    responsible for improved outcomes?
   Or
   Are different types of individuals
    entering through these two portals?
Next Steps
   Follow a sample of individuals
    following an index offense
   Examine the impact of mental
    health service type, quantity and
    duration on juvenile justice re-
    referrals
   With adults we have demonstrated
    enduring effects for specific
    treatment types
Propensity Groups

   Collaborating with public health
    types
   Lacking true control groups, plan to
    construct a matched sample…
   …matched on “propensity scores,”
    single indices quantifying multiple
    predictors
Grand conclusion
   Results of recently released National Comorbidity
    Study indicate that a majority of persons who
    develop mental disorders as adults have shown
    signs of distress at age fourteen or earlier
   Current results tend to support conclusion that
    there are benefits to entering the system through
    the mental health rather than juvenile justice
    system
   Provide additonal support for policies aimed at
    early detection of mental disorder, and for mental
    health diversion from criminal justice
“Where the rubber meets the road”
   Added impetus to our Juvenile Justice system’s efforts
    to allocate more resources to screening and
    assessment
   Added emphasis to MHMRA Board’s legislative agenda
    – addressing criminalization of mental illness
   Contributed to current legislative lobbying efforts to
    accurately assess the prevalence of mental retardation
    in the criminal justice systems
   Provided a model of the value of needs assessment
    provided by this data matching – other major providers
    to juveniles are interested in supporting similar
    research describing the mental health needs of the
    children they serve.
   Served as the basis for discussions among service
    providers to create specialty mental health clinics for
    these children.
A solution to the “unsanitary pitch”
   Grandfathered Spitballers
   The 17 spitball pitchers designated after the 1920 season were:
   National League:
   Bill Doak
   Phil Douglas
   Dana Fillingim
   Ray Fisher
   Marv Goodwin
   Burleigh Grimes
   Clarence Mitchell
   Dick Rudolph
   American League:
   Doc Ayers
   Ray Caldwell
   Stan Coveleski
   Red Faber
   Dutch Leonard
   Jack Quinn
   Allan Russell
   Urban Shocker
   Allen Sothoron
Grandfathered steroid users?

								
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