INTERNATIONAL PERSPECTIVES

							INTERNATIONAL PERSPECTIVES
Norwegian perspective on the care and treatment of offenders with a learning
disability.

Erik Søndenaa
National unit for mandatory care, Norway

Our organisation

The national unit of mandatory care is the only unit in Norway focusing upon these
issues. We work under the forensic department at Brøset that has a regional secure
unit and a forensic research unit. Brøset is a part of St.Olavs hospital that offers
specialist health services in the central part of Norway. There are five health regions
in Norway (East, south, west, central and north) with a population of about one
million in each region.

Since 1990 all people with learning disabilities are integrated in the local communities
in Norway. All institutions were closed and the service-responsibility was moved
from county-governed health institutions to the social services of local communities.


Organisation of care for people with learning disabilities

The normalisation movement has been widely introduced in Norway and since there
are no institutions left, people with learning disabilities are seldom recognized as a
group, but more as inhabitants who are in need of more or less social and medical
services. The services are organized within general services in the community that
also include geriatric and psychiatric home-based services. The idea of normalization
also include public schools, leisure facilities and workplaces. Some appropriate
centres for daily activity offers meaningful activity to those who have special needs,
but most people are helped through supported employment programs.

In the old system people were categorized as with or without learning disability or
developmental delayed as we say in Norway. You were either institutionalised or not.
Today this is more difficult for several reasons. One is that there are several terms to
describe the same phenomena. Services for children use general and specific learning
disabilities, and their placements are based on school performances. Adult services
use developmental delay as a general term for people who are in need for services
because of cognitive, and social or psychiatric problems.

The Norwegian model is partly following the mainstream tendency that people with
learning disabilities should live in their home community, receive ordinary services
and have the same human rights as other citizens. There are also strong parent
advocacy groups that influence political decisions in a direction of more inclusion and
participation for people with learning disabilities.

In comparison to neighbour countries Sweden and Denmark, I think Norway have
made more progress in establishing non-institutional services. The specialist services
for people with learning disabilities are maintained in Sweden and Denmark, and
Norwegian studies by Nøttestad and Linaker confirm a decrease in available specialist
services after 1990. There are lots of cooperation between the Nordic countries, and I
think that services will develop with references to neighbouring counties.

Laws

The law that regulate social services in Norway are based on human rights which
include people with learning disability. Regulation of use of coercion in care for
people with learning disabilities was decided in 1999. Within the formulations of this
law, there will be opportunities to prevent most offences from people with learning
disability. This is also the case for most disabled people who receive social services.
On the other hand there are many disabled persons who are unknown to the social
services including people with learning disabilities. Among these are drug abusers,
alcoholics and asylum seekers whose offences are not prevented by use of care-
coercion although the learning disability is obvious.

The Norwegian penal legislation was revised in 2002. Until 2002 there was unclear
distinction between offenders with learning disability who were imprisoned and those
who were put on secure residencies in local communities. After 2002 there seems that
most offences committed by learning disabled persons are not prosecuted by the
court. It seems to be a public opinion that learning disabled persons don’t have a
necessary penalty responsibility. The penal legislation that is used is designed for
offenders with a significant low functioning. The criteria for mandatory care will
include serious criminal offences such as arson, sexual offences, and murder or
attempted murder. The learning disability has to be in a degree of IQ below 55 and a
ICD-10 category moderate intellectual disability. Compared to international literature
(Barron et.al, 2002 and Lyall et.al 1995) this seems to be a very narrow perspective of
offenders with learning disabilities. There seems to be a very small group of offenders
that fulfil these criteria (so far 10 persons in Norway). The Danish and Swedish penal
legislation differs a lot from this. Denmark have had a long tradition of treating
offenders with learning disability within medium and high secure units, while Sweden
have no defined system that organises social protection.

The Norwegian penal legislation doesn’t separate offenders with mild or borderline
intellectual disability. They are imprisoned, and there are no data on prevalence in
Norwegian prisons. We have discussed this with criminal justice authorities, and the
question will probably be studied in the near future. Learning disabled offenders with
IQ above 55 are mentioned as “reduced responsible” and evaluated in front of
alternative imprisonment settings and less sentences.

A resume of two recent studies on offenders with learning disability in Norway found:

   1. Noreik and Grünfeld studied forensic reports of all offenders with learning
      disability between 1980-1996. 294 offenders were fond (ICD-10: F70 (251)
      and F71 (43)). the offenders distributed between Sexual offences n=129,
      Arson (n=71), other (assaults, burglary etc.) (n=94). Commorbidity with
      psychiatric diagnosis were fond in 25 % of the total sample. Few had problems
      with alcohol or other intoxicants. Noreik and Grunfeld notice that the number
      of offenders with learning disability who are assessed in forensic reports are
      significantly increasing through the period 1980-1996.
   2. Nøttestad studied 27 offenders with a learning disability that had secure
      community residences before 2002. 80 % were men. 50 % had IQ below 55
      and 50 % had IQ between 55 and 70. Some regions of Norway were
      significantly dominating with 80 % of the offenders coming from 30 % of the
      regions. Sexual offences dominated with more than 40 % of the cases. Other
      offences were assaults, arson and property crimes.

Knowledge on the prison population and prevalence of learning disability is very
limited, but Rasmussen, Almvik and Levander have found that among a
representative sample of Norwegian prison inmates, about 50% filled criteria for
ADHD. One in three performed very poor reading skills. As many as 86% filled
criteria for one or more personality disorder.

How the work at the National unit of mandatory care is organised

The secure unit at Brøset has five beds for offenders with learning disability (IQ<55).
The unit is meant to have an acute function for people immediately following contact
with the criminal justice system or after their sentencing. We start as soon as possible
to establish contact with the offender’s home-community to establish a local based
secure residence. The time spent in the hospital unit will be a period of assessment
and evaluating preparing the local placement. After moving out of the secure unit, the
national unit still keep responsibility for security and treatment. We therefore depend
on having good and lasting relations with the local services. The duration of each case
is at a minimum three years. The case will then be evaluated and the offender will
either be set free, or sentenced for three new years. Advisors from the national unit
visit the local cases frequently. Since 2002 ten offenders have been sentenced to
“mandatory care”.

Staff

The staff of the unit are multi-professional, qualified and selected on the basis of their
high level of competency. The staff are put together from two different backgrounds.
Those who have practiced as health and care services in local communities and those
with competency from specialist psychiatric services. The consulting team that
operate in the local communities consist of professionals (social educators,
psychologists and medical doctors) who have a long experience from similar
consultant services.

Economics

The unit is a national, as opposed to local, service. Its budget planning therefore is
more challenging than usual and requires it to undertake continuous monitoring of
developments in criminal justice practice. The possibility that national economic
support will increase the amount of cases under prosecution is worrying, but still not
confirmed in any cases.

Focus

The unit has focused a lot on being a part of the criminal justice system. These
strivings include contact with and knowledge on criminal proceedings, prison services
and a differentiated prison regime. We have established a formal cooperation with
prison authorities in an attempt to build and exchange competence on offenders with
learning disability. We take part in the treatment of groups for prisoners with
sentences for sexual offences. We are also in preparation for establishing a treatment
programme for arsonists. The study on prevalence of learning disabled offenders in
prison also came through this cooperation.

Offenders with learning disability who lives in their local community receive local
health services. And also have consultant services from a regional specialist
habilitation service. Target competence on offences or criminal justice is offered from
the national unit of mandatory care, and in some cases we arrange conferences in the
local communities. Once a year we also arrange a national conference as a miniature
of this international conference.
       The German Forensic System and the Contribution of the Nursing Staff

Dieter Böcherer, Ward 24, Forensic Department ZPE Emmendingen, South-West
Germany (Black Forest)

The possible causes that lead a person to commit an offence and thus become a
forensic patient in Germany include:

        in connection with a spiritual disturbance(psychical disease): the unlimited
         duration of the accommodation is related to the corresponding relapse danger .
        connected to the problem of drug addiction: the accommodation is restricted to
         a period up to two years.

A unified German jurisdiction regulates the accommodation prerequisites:

       From the German Criminal Code (section 20 ):

         incapacity because of spiritual disturbance
        Not guilty is the one whose deed relates to a disease/ spiritual disturbance (like
         psychosis), to a consciousness disturbance in an exceptionally emotional
         situation or to a state of mental retardation or finally to a personality
         disturbance, as well as sexual deviation.

Section 21 deals with the problem of restricted capacity:

            If the ability of the client to admit the wrong of his deed or to handle
             accordingly is considerably reduced because of some reasons as described
             above (§20), then the punishment can be moderated according to section
             49, article. 1.

The Court must decide whether the client corresponds to the 63§ of the Criminal
Code, i.e.:

    Somebody who has done an illegal deed in the state of total incapacity (§ 20) or
      restricted incapacity (§ 21), will be accommodated in a psychiatric hospital ,
      in order to avoid future deeds that might endanger the public community.

The section 64 deals with the accommodation of a client in an institution that treats
     addicts (also within the forensic hospitals):

       “ Somebody who drinks alcohol or takes other toxic substances/drugs to himself
       and has become an addict is going to be sentenced by the Court because of a
       criminal /illegal deed done in a state of intoxication or caused by his addiction.
       It is also possible that this person will not be sentenced to prison, because his
       incapacity has been proved or is to be considered; therefore he will be ordered to
       accommodation in a treating institution of drug addiction if they consider that
       future criminal deeds of the client may be feared to happen because of his
       addiction.
This order is legally prescribed all over Germany. The way it is being practiced differ
from region to region and is a matter of regional politics and financing.

The number of ordered accommodations differ from region to region sometimes in a
one hundred percentage; statistics show the increasing number of accommodations
between 2002-2004 (20%) and the large number of accommodations in Thüringen as
compared to other regions (it has been reported that patients had to sleep in bathtubs,
as their number was greater than the number of beds).

The therapy orientation has much to do with the clinic and also with the tradition of
every single federal land in Germany!

The intensified public discussions about safety and security have led to the use of
modern therapy forms like psychoanalysis, behavioural or social therapy.

Features of the forensic treatment in Germany

    Forensic departments are often linked to hospitals of general psychiatry
    Treatment course consists roughly of two systems: chronological sequence of
      treatment modules on different wards; specific disturbances are treated on
      special wards.
    Modified forms of the psychoanalysis, behaviour therapy, social therapy and the
      like are being used according to the groups of patients or to tradition.

There is a more liberal handling of the sanction and safety stipulations as in Great
Britain and rather little cooperation with not forensic institutions; regional features
influence the type of the therapy.

The therapeutic orientation, spatial, personnel and financial equipment are very
different. Intensified discussions on the matter of public safety, as well as the
increasing lack of public financing give birth to a special kind of dynamics, whose
results are often doubtful.

An example is the forensic treatment ward in Emmendingen the department contains
nine wards for about 140 people:
    a ward for reception and diagnostic (28)
    a ward for the crisis management(29)
    a ward for the psychosis treatment (25)
    a ward for the treatment of personality disturbances (24)
    a ward for long-term treatments (also for patients with learning
       disabilities)(23)
    two wards for the treatment of addictive clients
    two groups of people sharing the rooms of two houses and living
       independently.

Ward 24 is for 16 patients and is led by 2 psychologists and 11 nurses. Most of the
clients are sexual offenders.
The ward is conceived as a therapeutic community. Within the multi-professional
team, there are nurses (male and female) responsible for 4-5 patients, representing the
so-called “personal related nursing care” (these persons get into relation with their
patients and accompany them throughout their daily life and treatment).

This kind of personal nursing is active in the organization and the networking of all
activities connected to the patient, necessary to his treatment and development. We
guide ourselves upon the nursing model of Hildegard Peplau.

Communication and cooperation within the nursing process takes place on two levels:
   A. in the relation with the patient, the relationship process, as well as
   B. with the others involved in the treatment process

The main features of the nursing attitude to work are:
     understanding
     continuity
     clearness and
     transparency

Understanding is an essential factor to our everyday work with the patients; we see
the whole person in front of us and do not reduce the patient only to his deed(s).
Every person has good and bad sides and it is very important to us to find out what
the good healthy sides in our clients are.

Furthermore understanding means knowledge about the illness and disturbance
symptoms (be it psychosis or personality disturbance, addiction or mental
retardation). The knowledge about the legal grounds of the accommodation (§ § 20,
21, 63, 64, 81, 126 a, StGB/ZPO etc.) is also required.

We also want to understand our work and the work of our colleagues better. This is
why we want to know what we do and why we act this way or another and what
influence does our work have upon the patients:

      How do we feel about it
      What process is taking place
      What is the patient doing
      Why
      How
      What does that have to do with us
      How does the patient feel about it
      What is just taking place

Aim: developing an attitude towards the patient, that does not try to excuse his deeds,
     but tries to understand him and how it came to his deeds.

Understanding finally means a permanent explaining of our work:
   What are we doing?
   Why
   How
      How does this work on the patient?
      How does it work on us?
      Why
      How is the patient doing with that?
      Which dynamics does it give birth to?

The actual contents and meaning of our nursing work is to be found in the prognostic
work/report that we do together with the therapist.

The Prognostic Process

The individual 'PC Nurse Report' forms the basis for extensive discussions. This
report is circulated within the team (especially the psychotherapist and the head
physician) for approval (normally one week before the 'Prognostic Meeting'). During
a 'prognostic meeting' (planned with the patient) there are the reports of the therapist
and the PC nurse discussed with the other members of the team and the head of the
department - here is the time to question the results and to discuss discrepancies.
From this a summary and focus are formed and the patient gets a chance to present
his point of view.

The therapist creates from this collection of opinions the 'Advisory Opinion' that will
be send to the competent court after having been approved and signed by the head
physician – the PC nurse will get it for inspection.

The nursing prognostic construction consists of a framework made up of the cause
and duration of the accommodation as well as a short report on the personality
development of the patient and their social behaviour and participation in therapy.

a.) The Personality Development

That can be divided in

      the patient's 'Understanding Of His Personal Range Of Problems' – as the PC
       nurses see it
      The Reality Perception – are there differences and agreements examined from
       the team/s point of view - why?
      The Self-Criticism – how far can the patient question himself self-critically?
      The Therapy Motivation – its aim, purpose, duration
      the Therapy Expectations – gives us information about the ideas and concepts
       the patient has about his 'disease', it also allows us to judge how these ideas
       cope with development or limits that are set by his personal development
       potential and institutional possibilities.
      the Resistance To Stress – should point out, where the strengths and the
       weaknesses of the patient are, and how this effects the (aggressive) Impulse
       Control, The Self-control – how much self-control has the patient in everyday
       life that is available in a critical situation
      The question about the patients Ability To Manage Relations – focuses on
       how far can the patient get involved with opposite persons?
      The assessment of Empathy and Sympathy towards other people should not be
       mixed up with self-pity as it happens sometimes to some patients.
       The patient's Self-Esteem, also its continuity and the 'Sources' that feed it
       must be considered.
      An exact examination of the Non Delinquent Value System can give us
       information about the existence and consistence of a 'Conscience'

b.) The Social Behaviour and Participation to Therapy.

      Very close attention should be turned to the behaviour in critical situations, as
       this will very often uncover conformist behaviour.
      The type of contacts with patients and staff allows us to assess therapeutic
       improvements or stagnation concerning the patient's 'relation management
       system' (e.g. does he see the people around him only as objects for his
       personal desires, doe he try to split the people surrounding him, or does he
       respect the personality and the will of his neighbour).
      The type of participation in therapy often gives information about the
       seriousness, the efforts or the authenticity of the involvement.
      The work behaviour from the view of the therapist (from the WT-meeting)
       builds an important cornerstone, especially concerning the future outlooks and
       planning.
      The assessment of reliability in keeping agreements can draw a picture of
       existing or only partially available personal inner structures
      The importance that the patient gives to hygiene and personal hygiene can
       among other things also form an important hurdle concerning the placement of
       the patient in post-treatment institutions.
      The independence in structuring daily routines shows us to which extent the
       patient still needs a 'Holding Environment'.
      How the patient is dealing with his money can show us, if the patient favours a
       short term, medium term or longer term approach.
      The special areas of interest and leisure time, their intensity and their selection
       can give insight to which extent the patient has alternatives in his behavioural
       repertoire (or not).
      How did various easing restrictions and measures go with the patient? The
       question can give us an assessment of the patient's longer term abilities to keep
       agreements.
      The Special Incidents can point us to special problems that should be
       examined more closely
      The conclusions should include an overall evaluation and an outlook into a
       possible future.


How does the patient experience the professional work of the nursing care?

The results of a survey made by patients for patients of the ward 24 in the Centre for
Psychiatry in Emmendingen.

To the question “ Does the therapist/nursing staff/ occupational therapist do his job
with me well”, there are answers of the patients that show they are pleased with their
therapists, more pleased with their personal nurse and rather pleased with the work
of their occupational therapist with whom they share an intensive contact during their
working hours.

Only the occupational therapist is keeping to his promises ( ! ) Note: the occupational
therapist is not part of the decisional team.

 A similar result to the topic “therapist/nurse/occupational therapist imposing his/her
will on me, telling me what I should do”. The occupational therapist gets the best
evaluation.

To the theme “I feel well with therapist/nurse/occupational therapist “the opinions are
different, rather neutral to therapist/nurse and favourable to the occupational therapist.

The feeling that somebody has time enough for someone also favours the
occupational therapist.

To the question “who knows me better, is there someone who understands my way or
am I rather misunderstood”: the answers show that nursing staff cannot really give
the patients the feeling that they are well understood, this problem is a cause of
constant pain that can only be eased but not healed by the nursing staff. And who does
it better? The occupational therapist, of course!

Who knows better of the problems and needs of the Patients? You have guessed.

The lack of confidence is not surprising in the case of patients with personality
disorders. Intensive efforts of the nursing care with regard to continuity, transparency
and clarity in the everyday work with these people seems relevant to only a small
number of patients. Most of them tend to trust their occupational therapists more.

Are my needs treated well? It could be better in the case of my therapist/nurse; the
occupational therapist is the best again.

It is difficult for patients with personality disorders to get into relations and keep to it,
when the related person (therapist/personal nurse) also has to take decisions that are
not necessarily loved by the patients.

In summary
     Our system should allow us to understand the patients better and thus carry on
      with our work better and better.
     We (the nursing staff) are the group to spend most of the time with our
      patients; therefore we consider that the question of relapse cannot be answered
      without us.
     International and national information exchange helps to improve the
      efficiency and quality of our work.

Human and personal insufficiencies are there everywhere. My work is an attempt to
an ideal working model for the nursing staff to create a better atmosphere for us and
our patients.
Learning          Disabled          Juvenile         Offenders:           A     USA
Perspective
Deborah Shelton, PhD, RN, CNA
Program Director, Child & Adolescent Behavioral Health
Associate Professor –School of Nursing
The Catholic University of America Washington, DC
Email: dssquared@earthlink.net


Background:


Youth with disabling conditions are over represented in juvenile correctional facilities
(Burrell & Warboys, 2000). An estimate of the prevalence of youth with disabling
conditions in juvenile corrections is 32%, notably higher than the estimated 9%
prevalence of disabilities among school-age children in the United States (U.S.
Department of Education, 2000). In the US, disabling conditions are broadly defined
and include emotional disturbance, physical disabilities, developmental delays and
learning disabilities. In a meta-analysis of studies of the prevalence of youth with
disabilities in juvenile corrections, however, Casey and Keilitz (1990) found that
youth with learning disabilities and mental retardation were over represented
(estimates were 35.6 % and 12.6%, respectively).


While the exact mechanisms associated with over representation are not well
understood, evidence suggests that youth may be more vulnerable to involvement in
the juvenile or criminal justice system when poorly developed reasoning ability,
inappropriate affect, and inattention are misinterpreted by professionals (particularly
school teachers) as hostility, lack of cooperation, and other inappropriate responses.
These factors, in combination with issues related to limited financing, access and
availability of targeted services are felt to contribute to the over representation of
youth with disabilities and minority race youth. What is known indicates some
relationship between special education and juvenile justice system involvement. Of
the 9% of public school students who qualify for special education services, 40% will
have some interface with the juvenile justice system, and 20% of students with
emotional disabilities are arrested at least once before they leave school (Huizinga,
Loeber, & Thornberry, 2000). Further, nearly 70% of incarcerated youth suffer from
disabling conditions (Leone, Zaremba, Chapin, Iseli, 1995) and youth with learning
disorders or who have a mental illness are arrested at higher rates than non-disabled
peers.   This evidence and common sense suggest that early identification and
intervention of youth experiencing school difficulties can lower the odds of
involvement with the juvenile justice system (American Academy of Pediatrics,
2003).


Numerous laws have been passed in the US mandating the “entitlement” of every
child between the ages of 3 years to 21 years to a free public education, including
children with disabilities, who have been suspended or expelled from school, or who
are involved in the juvenile justice system (US Department of Education, 2000).
These policies have been a failure for those children who move in and out of the
juvenile system. The primary problem lies in the conflicting policies for punishment
and rehabilitation.     Recent legislative efforts to "get tough" with juveniles who
commit, or are accused of committing a crime reflect a growing public perception that
locking away troubled children and youth will insulate society from future harm. The
politically popular "zero tolerance" policies in our schools often contribute to
overcrowded juvenile facilities and to the increased use of public funds for additional
detention facilities.


A System in Crisis: Clearly, the US system for handling these youth is in crisis. In a
2003 report by the National Council on Disabilities, more than one-fourth of youth are
in correctional facilities which do not routinely assess academic, vocational, and
personal needs; and 40% do not meet minimum standards of mental health care
established by the American Correctional Association (1991). Overcrowding and
understaffing in juvenile facilities are impediments to education and treatment
programs. While rehabilitation is a component of the mission of juvenile justice
systems, incapacitation and punishment frequently are considered higher priorities.
These conditions pressure juvenile facilities to restrict education and treatment
services when the differences in age, gender, ethnicity, academic performance, and
offense history among youth indicate a need for differentiated programming (Leone,
Quinn, & Osher, 2002).
In a survey, Rutherford, Nelson, and Wolford (1985) found that although services
offered in most states varied widely, not all youth with disabilities in juvenile
corrections were receiving the special education services to which they were entitled.
Their findings indicate that most juveniles who are detained or incarcerated are
enrolled in an educational program, with the type of facility affecting the availability
of education.    Respondents reported that 84% of youth in short-term detention
facilities, 48% of youth in long-term correctional facilities, and 29% of youth in adult
corrections facilities were enrolled in education programs. However, only 29% of
juveniles in adult corrections facilities were enrolled in education programs. This is a
cause for concern as states have increased the number and percentage of youth
transferred from juvenile to criminal courts and from juvenile to adult correctional
facilities (Juszkiewicz, 2000). This finding may also confirm the difficulty that adult
correctional facilities have had in providing educational services, especially to youth
with disabilities.


Causal Chain Theories: Explanations of how children with LD become involved with
juvenile systems are attributed to two theories.         The first, a “school failure
hypothesis” suggests that learning disabilities themselves produce academic failure,
which increases the occurrence of a negative self-image and which in turn, increases
the likelihood of school drop-out and delinquent behavior (Malmgren, Abbot, &
Hawkins, 1999).      While poor academic achievement alone cannot be held fully
responsible for contributing to delinquency, a process of marginalization does occur
when children are not in school. The second, a “susceptibility theory” suggests that
children with LD possess certain personality characteristics that make them more
susceptible to opportunities for engaging in delinquent activities. Such characteristics
may or may not be related to LD, but include impulse control, inability to anticipate
consequences to actions, irritability, suggestibility, and a tendency to act-out (Murray,
1976). These characteristics may indeed be challenging but, alone do not predict
delinquent behavior. One must consider the balancing effects of individual protective
factors and supports –such as an involved adult upon the outcomes.


Diagnostic Classification of Learning Disorders: Difficulty in diagnosing is in part
due to the reliance on standardized tests.       Performance on these tests may be
compromised by an associated disorder in cognitive processing (e.g. dyslexia), a co-
morbid mental disorder (e.g. anxiety disorder) or general medical condition (e.g.
vision difficulties), academic opportunity or attributed to ethnic or cultural
background (importance of education). Differential diagnosis, according to the DSM-
IV (APA, 1994), requires an accounting for the presence of academic opportunity,
impaired vision or hearing and the presence of mental retardation. This is particularly
important, as you will see by the data to follow; all hold significance for the young
offenders in this study who report high rates of vision, speech and hearing problems.
The diagnostic features of associated with LD (estimated 10-20% co-morbidity rate)
include    Conduct      Disorder,    Oppositional     Defiant     Disorder,     Attention-
Deficit/Hyperactivity Disorder, Major Depressive Disorder, and Dysthymic Disorder
(APA, 1994).


Risk Factors for Delinquency Among Youth with LD: A review of the literature
supports the presence of early language deficits, pre-school developmental
limitations, impulsivity, irritability, borderline intelligence (IQ 71-84) and brain injury
as risk factors (Raver, 2003; McClelland, Morrison, & Holmes, 2000; Crawford,
1996).    Common criteria for LD include: (1) achievement (as measured on
standardized tests) below what would be expected for age, IQ and education; (2) a
disturbance that interferes with academic achievement/daily living; and (3) if sensory
deficit is present, the difficulties are in excess of those associated with the sensory
deficit (Katz, L, 1991). Genetic predisposition, perinatal injury, various neurological
or other general medical conditions (such as lead poisoning, fetal alcohol syndrome,
or fragile X syndrome) may be associated with LD but do not invariably predict a LD
(Blair, 2003).


Methods:


A secondary data analysis of a random sample equaling 25% of the total juvenile
justice population (N=376) in Maryland in 1998 was examined for youth who met
diagnostic criteria (as determined through a formal assessment) for a learning
disability as defined by DSM-IV (APA, 1994). In adherence to the DSM criteria,
specific learning disorders as defined as a reading disorder (315.00), mathematics
disorder (315.1), Disorder of written expression (315.2), or Learning Disorder not
other wise specified (315.9). Those youth selected were diagnosed with a learning
disorder, noted on Axis 2 of the classification system, and had educational difficulties
identified on Axis IV as a psychosocial or environmental problem.


Data was collected from multiple sources, including an extensive diagnostic interview
using the Diagnostic Interview Schedule for Children (NIMH, 1992), a health self-
report instrument (Starfield, Ensminger, Green, Riley, Ryan, Kim-Harris, et al.,
1995), a state computerized records system, and the paper field records.            For
additional information regarding data collection methods, you are referred to Shelton,
1998.    Descriptive and Chi-square analyses were conducted utilizing SPSS
programming.


Findings:


The household data indicated that these youth were from families below the poverty
line (defined as <$35,000 annually for a family of 4 persons). Some households
consisted of large extended families living together.           The “typical” family
constellation was composed of a grandmother with a disabled daughter and multiple
children, another adult female family member with multiple children and the
inconsistent presence of a related or non-related male. The mothers of these youth
were more likely to be employed (50%) and maintaining their involvement (72%)
with their child while in the care of the juvenile justice system. Fathers were less
involved in the lives of these youth, 47% incarcerated and 24% were dead. Forty-
three percent of families earned less than 30,000 annually; 53% were insured through
Medicaid, 24% had no insurance.


The health status of family members presented patterns of ill health. Twenty-two
percent of mothers and 17% of fathers were reported a physical illness. Additional
health problems included substance abuse (mom=48%; dad=45%) and mental illness
(mom=15%; dad=17%).          Siblings of the incarcerated child also experienced
difficulties, 10% were substance abusing and 17% had a criminal history.


Youth Data:    Thirty-eight percent (N=143) of the sample we diagnosed with a
learning disability (LD) as noted on Axis 2 of the DSM classification schema. Of
these, all were male (100%), 93% were urban residents, 79% were African American,
79% were between the ages of 15 and 17 years of age, and 96% were assessed as low
average intelligence (IQ 70-82). Only a small number (20%) were in the borderline IQ
range (71-84). Sixty-six percent of these youth were in high school, 4% not in school
and the remaining 30% were suspended or expelled. Only 16 youth were diagnosed
with a LD prior to their involvement with this juvenile justice system.


Comparison of those youth with a LD and those without, both groups were similar in
the frequency of more serious crimes (60%) vs less serious crimes and in the number
of out-of-home placements through the juvenile justice system (range = 1- 22, x =6-
10 episodes). However, youth with a LD were more frequently found “in need of
services” by the courts (43%) than youth without a LD who were more frequently
adjudicated (37%). The groups did differ in that youth with LD were more likely to
run away (38%, ns). Further, 71% of youth with a LD had been physically/sexually
abused (2=13.41,df=2, p=.001) and 43% were suspended or expelled from school
(2= 19.85, df=5, p=.001).

Health status of youth with a LD: Young offenders with a LD were frequently
found to have both health and mental health problems. Seventy percent of
youth had one or more health problems, most frequently vision (N=84), speech
(N= 88) and hearing difficulties (N=100). Seventy-three percent (N=104) also
had a history of head injury. These physical conditions may contribute further
to the difficulties these youth experience in the academic setting.

Thirty-one youth with a LD (22%) also were diagnosed with a psychiatric
disorder and nearly half of these (n=11) were diagnosed with more than one
psychiatric diagnosis (see table # 1).

Table 1

Psychiatric Diagnoses among Young Offenders with a Learning Disorder

Diagnosis                                 N=31                    Percent
Anxiety                                   6                       19.4%
Disruptive behavior                       6                       19.4%
Schizophrenia/psychotic                   5                       16.2%
Miscellaneous disorder                    1                       3.2%
Affective                                 3                       9.7%
Substance abuse                           6                       19.4%
Personality Disorder                      4                       12.9%
Co-occurring         psychiatric          11                      35.5%
disorders




Treatment and services: Only 20% (n=29) of young offenders with a LD
received any treatment, with the availability of services dropping dramatically
over juvenile justice (JJ) episodes (graph 1).          An over-reliance upon
institutional and residential care was evidenced across juvenile justice episodes,
with prevention and diversion services utilized only during the first two JJ
episodes, and community-based services utilized through the fifth JJ episode.
Treatment services that were provided focused upon the family and rarely
included medications, individual or group therapy.

Graph 1

Young Offenders with a Learning Disorder Who Received Treatment
Services
     percent
       25

       20

       15

       10

         5

         0
               1   2   3   4   5   6   7   8   9 10 11 12 13 14 15 16 17 18 19 20 21 22
                                                  JJ episode




Discussion:

Using a highly structured definition of learning disorder as defined by the
DSM-IV (APA, 1994), the data indicate that 38% of youth in this sample of
young offenders have a learning disability. This rate is slightly higher than the
32% estimate of the prevalence of youth with disabling conditions (Burrell &
Warboys, 2000) in juvenile corrections and notably higher than the estimated
9% prevalence of disabilities among school-age children in the United States
(U.S. Department of Education, 2000). These high rates of LD co-exist with
high rates of physical health problems (70%) and mental health disorders (38%)
for the youth sampled.




This sample differed somewhat from the diagnostic features published in the
DSM-IV (APA, 1994) that identify diagnostic features most commonly
associated with LD to include Conduct Disorder, Oppositional Defiant
Disorder, Attention-deficit/Hyperactivity Disorder, Major Depressive Disorder
and Dysthymic Disorder. This sample was statistically different than other
youth sampled for major depression, dysthymia, phobias and substance abuse.
This may be related to the fact that over half of the original 1998 sample was
African American and male. Rates of anxiety among the population are higher
than for other races (USDHHS, 2001). This group differed in that they were
not significantly different than the rest of the population for behavior disorders.
Other associated features, such as demoralization, low self-esteem, social skill
deficits and cognitive processing difficulties contribute to poor academic
success. With these combined challenges, it is easy to see why these youth are
more likely to come to the attention of school personnel or be suspended or
expelled from the school environment. The school dropout rate is 1.5% higher
for youth with a LD than non-diagnosed children (National Council on
Disability, 2003).

The literature suggests an overlap between achievement difficulties, particularly
reading disorders and “acting out” or externalizing behaviors. This trajectory
shifts to depression by adolescence (Lock & Strauss, 1994). Combining these
findings with other studies (Shelton, 2004a, 2004b, 2001; Preski & Shelton,
2001) and drawing upon the literature (Vitaro, Brendgen, & Tremblay, 1999;
Crawford, 1996; Waldie & Spreen, 1993; Tremblay, Masse, Perron, Leblanc,
Schwartzman, Ledingham, 1992), a pathway to delinquency for youth with
learning disorders is proposed in graph 2.        Developmentally oriented, the
effects of early risk factors that influence language development and impact
school readiness are exacerbated by disruptive behavior, peer rejection and
school suspension/expulsion.      Evidence of very aggressive and difficult
behaviors at a younger age is now being associated with later violent criminal
behavior (Snyder, Espiritu, Huizinga, Loeber and Petechuk, 2003; McGarrell,
2001; McEvoy, & Welker, 2000).




Graph 2
Pathways to Delinquency for Youth with Learning Disorders


Community




                                                                Disruptive behaviour/
                                                                suspension & expulsion

                          Learning
 Family                   difficulties/
                          poor school
                          readiness

                                                    Rejection in
                                                    classroom

 Child



                                                    High dropout rates/             Depression/
                                                    association with                delinquent
                                                    deviant peers/ risky            activity
                                                    behaviors




early risk factors    school entry              early        school        years
preadolescence




The lack of services made available to young offenders with LD and other
difficulties in this study was not surprising. The National Council on Disability
(2003) noted that 25% of juvenile facilities do not routinely assess for LD, and
40% did not meet standards for mental healthcare as established by the
American Correctional Association (Parent, Leiter, Livens, Wentworth &
Stephen, 1994) or special education services as defined by the law (Redding,
2000).      For youth with learning difficulties, targeted interventions are
recommended. Key components of effective special education programs in
correctional facilities have been documented (Leone, Quinn & Osher 2002;
Forbes, 1991). These include a multidisciplinary service delivery approach, a
competency-based curriculum, pro-social skills, and direct and peer-mediated
instructional strategies in an organizational climate that commits resources and
professional training for this type of programming. Recommendations by the
American Academy of Pediatrics (2003) to implement a full assessment and
develop a preventive treatment strategy at the point of “risk” for suspension or
expulsion from the school setting as required by the Individuals with
Disabilities Education Act (IDEA, 34 C.F.R. § 300.7 (c) are well founded and
should be implemented.

Conclusions:

The question becomes one of whether we, as a society, will treat or incarcerate
children in the US. The behavioral outcome of high use of incarceration as a
method of control indicates a “disconnect” between our society and our youth.
Missed opportunities for prevention, barriers to early childhood services and a
lack of recognition by school personnel of the meaning of disruptive behavior
have contributed to the dumping of primarily minority youth with “troubled and
troublesome” behaviors into the juvenile justice system.           This was aptly
captured in a report of the US Surgeon General on Mental health, Culture, Race
and Ethnicity (2001) which stated that youth most likely to encounter service
gaps were those with substance abuse and mental health problems, who were
adjudicated as delinquent with multiple health problems, including those with
learning disabilities and who were likely to drop out of school.

Clearly, more research is needed to understand the impact of disability on delinquent
behavior.    Currently, a number of hypothesized relationships exist but empirical
evidence is scarce. Information about the adequacy of education services for youth
with disabilities in correctional settings is limited to a description of compliance with
statutory requirements and not a review of the implementation of empirically based
instructional practices and outcomes for youth. Juvenile correctional systems in the
US need to envision themselves as a component of the “children’s system of care”
(Shelton, 2002) and strengthen their demonstrated actions that address the component
of their mission to rehabilitate.

References

American Academy of Pediatrics (2003). Out-of-School Suspension and Expulsion.
Committee on School Health. Pediatrics, Vol. 112 No. 5, November, pp. 1206-1209.


American Correctional Association. (1991). Standards for juvenile training schools.
(3rd ed.). Washington, DC: St. Mary’s Press.


American Psychological Association (1994). Diagnostic and Statistical Manual
of Mental Disorders (4th ed.). Washington, DC: Author.


Blair, C. (2003). Self-regulation and school readiness. (ED477640).
Champaign, IL: ERIC Clearinghouse on Elementary and Early Childhood
Education.          Retreived       March          10,        2004         from
http://www.ericfacility.net/ericdigests/ed477640.html.


Burell, S., & Warboys, L. M. (2000). Special education and the juvenile justice
system. Washington, DC: US Department of Justice, Office of Juvenile Justice
and Delinquency Prevention. (ED450515)


Casey, P., & Keilitz, I. (1990). Estimating the prevalence of learning disabled
and mentally retarded juvenile offenders: A meta-analysis. In P. E. Leone (Ed.),
Understanding troubled and troubling youth (pp. 82-101). Newbury Park, CA:
Sage.


Crawford, D. (1996). Review of research on learning disabilities and juvenile
delinquency. Pp203-209. In S. Cramer & W. Ellis (Eds.), Learning disabilities:
Lifelong issues. Baltimore, MD: Paul H. Brookes Publishing Co.


Forbes, M. (1991). Special education in juvenile correctional facilities: A literature
review. Journal of Correctional Education, 42, (1): 31-34.
Huizinga,D., Loeber, R. & Thornberry, T. (2000). The co-occurrence of persistent
problem behavior: A report of the program of research on the causes and correlates of
delinquency.    Juvenile Justice Bulletin, (NCJ 182211). Washington, DC: US
Department of Justice, Office of Justice Programs, Office of Juvenile Justice and
Delinquency Prevention..


Juszkiewicz, J. (2000). Youth crime-adult time: Is justice served? Washington, DC:
Building    Blocks     for    Youth.        Retrieved      March   20,   2004     from
http://www.buildingblocksforyouth.org/.


Katz, L. (1991). Readiness: Children and schools. (ED330495). ERIC Clearinghouse
on Elementary and Early Childhood Education. Retrieved March 10, 2004 from
http://www.ericfacility.net/ericdigests/ed330495.html.


Leone, P., Quinn, M., Osher, D. (2002). Collaboration in the Juvenile Justice System
and Youth Serving Agencies: Improving prevention, providing more efficient
services, and reducing recidivism for youth with disabilities. College Park, MD:
Center for Effective Collaboration and Practice, American Institutes for Research.


Leone, P., Zaremba, B., Chapin, M., Iseli, C. (1995). Understanding the
overrepresentation of youths with disabilities in juvenile detention. District of
Columbia Law Review, 3: 389-401.


Lock, J. & Strauss, G.D. (1994). Psychiatric hospitalization of adolescents for conduct
disorder. Hospital and Community Psychiatry, 45: 925-928.


Malmgren, K., Abbot, R., Hawkins, J. (1999). LD and delinquency: rethinking the
link. Journal of Learning Disabilities, 32 (3): 194-197.


McClelland, M., Morrison, F., & Holmes, D. (2000). Children at risk for early
academic problems: The role of learning-related social skills. Early Childhood
Research Quarterly, 15(3), 307-329.
McEvoy, A., & Welker, R. (2000). Antisocial behavior, academic failure, and school
climate: A critical review. Journal Of Emotional And Behavioral Disorders, 8(3), 130-
140.


McGarrell, E. (2001). Restorative Justice Conferences as an early response to young
offenders. Juvenile Justice Bulletin, (NCJ 187769). Washington, DC: US Department
of Justice, Office of Justice Programs, Office of Juvenile Justice and Delinquency
Prevention.


Murray, C. (1976). The link between learning disabilities and juvenile delinquency:
Current theory and knowledge. Washington, DC; US Government Printing Office.


National Council on Disability. (2003). Addressing the needs of youth with
disabilities in the juvenile justice system: the current status of evidence-based
research. Washington, DC: author.


National Institutes of Mental Health (1992).       DISC-C: The Diagnostic Interview
Schedule for Children. Rockville, MD.


Parent, D., Leiter, V., Livens, L., Wentworth D., Stephen, K. (1994). Criminal
victimization in the United States, 1992: A national crime victimization survey report.
Washington, DC: U.S. Department of Justice, Office of Juvenile Justice and
Delinquency Prevention.


Preski, S. & Shelton, D. (2001).     Modeling the Role of Contextual, Child, and
Parental Factors in Predicting Criminal Outcomes in Adolescence". Issues in Mental
Health Nursing, (22) 2, 197-206.


Raver, C. (2003). Young children's emotional development and school readiness.
(ED477641). ERIC Clearinghouse on Elementary and Early Childhood Education.
Retrieved               March                10,              2004                from
http://www.ericfacility.net/ericdigests/ed477641.html.
Redding, R. (2000). Conditions and programming for juveniles in correctional
facilities. Juvenile Justice Fact Sheet. Charlottesville, VA: Institute of Law,
Psychiatry, & Public Policy, University of Virginia.


Rutherford, R, Nelson, C, & Wolford, B. (1985). Special education in the most
restrictive environment: Correctional/special education. Journal of Special
Education, 19, 59-71.


Shelton, D. (2004a). Experiences of detained young offenders in need of mental health
care. Journal of Nursing Scholarship. 36:2, 129-133.


Shelton, D. (2004b). Pathways to mental health care for minority young offenders.
Manuscript submitted for publication.


Shelton, D. (2002) Failure of mental health policy-Incarcerated children and
adolescents. Pediatric Nursing, 22 (3), 278-281.


Shelton, D. (2001). Youthful offenders with emotional disorders. Journal of Nursing
Scholarship, 33, (3): 259-263.


Shelton, D. (1998) Estimates of emotional disorder in youth placed in the Maryland
Juvenile Justice System (Final Report). Baltimore, MD: Maryland Department of
Juvenile Justice.


Snyder, H., Espiritu, R., Huizinga, D., Loeber, R. & Petechuk, P. (2003). Prevalence
and development of child delinquency. Juvenile Justice Bulletin, (NCJ 193411).
Washington, DC: US Department of Justice, Office of Justice Programs, Office of
Juvenile Justice and Delinquency Prevention.


Starfield, B., Ensminger, M., Green, B., Riley, A., Ryan, S., Kim-Harris, S., et al.
(1995). The Child Health and Illness Profile: CHIP-AE. Baltimore, MD: The Johns
Hopkins University.
Tremblay,R., Masse, B., Perron, D., Leblanc, M., Schwartzman, A., Ledingham, J.
(1992). Early disruptive behavior, poor school achievement, delinquent behavior, and
delinquent personality: Longitudinal Analyses. Journal of Consulting and Clinical
Psychology, 60 (1), 64-72.


US Department of Education (2000). Twenty-second annual report to Congress on the
implementation of the Individuals with Disabilities Education Act. Washington, DC:
Author. (ED444333).


US Department of Health and Human Services (2001). Mental Health: Culture, Race,
and Ethnicity- A Supplement to Mental Health: A Report to the Surgeon General.
Rockville, MD: U.S. Department of Health and Human Services, Substance Abuse
and Mental Health Services Administration, Center for Mental Health Services.


Vitaro, F., Brendgen, M., & Tremblay, R. E. (1999). Prevention of school dropout
through the reduction of disruptive behaviors and school failure in elementary school.
Journal Of School Psychology, 37(2), 205-226.


Waldie, K., & Spreen, O. (1993). The relationship between learning disabilities and
persisting delinquency. Journal of Learning Disabilities, 26 (6), 417-423.