Comorbid Psychiatric Disorders
Comorbid Psychiatric Disorders
Comorbid Psychiatric Disorders in Youth in Juvenile Detention Karen M. Abram, PhD; Linda A. Teplin, PhD; Gary M. McClelland, PhD; Mina K. Dulcan, MD
Objective: To estimate 6-month prevalence of comor- bid psychiatric disorders among juvenile detainees by demographic subgroups (sex, race/ethnicity, and age). Comorbid Psychiatric Disorders
Design: Epidemiologic study of juvenile detainees. Mas- ter’s level clinical research interviewers administered the Diagnostic Interview Schedule for Children Version 2.3 to randomly selected detainees.
Setting: A large temporary detention center for juve- niles in Cook County, Illinois (which includes Chicago and surrounding suburbs).
Participants: Randomly selected, stratified sample of 1829 African American, non-Hispanic white, and His- panic youth (1172 males, 657 females, aged 10-18 years) arrested and newly detained.
Main Outcome Measure: Diagnostic Interview Sched- ule for Children.
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Results: Significantly more females (56.5%) than males (45.9%) met criteria for 2 or more of the following disor- ders: major depressive, dysthymic, manic, psychotic, panic, separation anxiety, overanxious, generalized anxiety, ob- sessive-compulsive, attention-deficit/hyperactivity, con-
duct, oppositional defiant, alcohol, marijuana, and other substance; 17.3% of females and 20.4% of males had only one disorder. We also examined types of disorder: affec- tive, anxiety, substance use, and attention-deficit/ hyperactivity or behavioral. The odds of having comor- bid disorders were higher than expected by chance for most demographic subgroups, except when base rates of dis- orders were already high or when cell sizes were small. Nearly 14% of females and 11% of males had both a ma- jor mental disorder (psychosis, manic episode, or major depressive episode) and a substance use disorder. Com- pared with participants with no major mental disorder (the residual category), those with a major mental disorder had significantly greater odds (1.8-4.1) of having substance use disorders. Nearly 30% of females and more than 20% of males with substance use disorders had major mental dis- orders. Rates of some types of comorbidity were higher among non-Hispanic whites and older adolescents.
Conclusions: Comorbid psychiatric disorders are a ma- jor health problem among detained youth. We recom- mend directions for research and discuss how to im- prove treatment and reduce health disparities in the juvenile justice and mental health systems.
Arch Gen Psychiatry. 2003;60:1097-1108
M ANY OF our nation’syouth are involved inthe juvenile justicesystem. The US De-partment of Justice es- timates that each year there are 2.5 mil- lion juvenile arrests.1 Moreover, nearly 1.8 million cases are referred to juvenile courts.2 On an average day in the United States, approximately 109 000 youth younger than 18 years are incarcerated3; nearly 15% of these are youth housed in adult facilities that may lack mental health services for youth.4 African American and Hispanic youth are overrepresented in the juvenile justice system, accounting for more than 60% of young offenders in ju- venile justice facilities.5 The number of fe- males in the juvenile justice system is in-
creasing at an even faster rate than the number of males.5
Many detained youth have psychiat- ric disorders.6-9 Teplin et al8 found that even after excluding conduct disorder (symptoms of which include delinquent behaviors), approximately 60% of males and 70% of females had a psychiatric dis- order. These rates of disorder far exceed those of youth in the community.8,10
Advocacy groups and public policy experts believe that many youth in the ju- venile justice system have comorbidity: more than 1 alcohol, other drug, or men- tal (ADM) disorder.11 The Surgeon Gen- eral’s report12 on children’s mental health notes that youth with comorbidity may be arrested because our fragmented mental health system has little to offer them. Re-
From the Department of Psychiatry and Behavioral Sciences, Feinberg School of Medicine, Northwestern University (Drs Abram, Teplin, and McClelland), and Children’s Memorial Hospital (Dr Dulcan), Chicago, Ill.
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lated research suggests that ADM comorbidity among ju- venile detainees is common. Comorbidity is prevalent among youth in the community,13-16 adolescent treat- ment samples,17,18 and adult jail detainees.19,20 Rates of comorbidity among detained adolescents may be even higher than rates among detained adults.15,21,22
Despite its importance, there have been few empiri- cal studies of ADM comorbidity among juvenile detain- ees and no large-scale investigations, to our knowledge.23
Three studies found high rates of comorbidity24-26; how- ever, their samples were too small to estimate its true preva- lence or how patterns of comorbidity vary by sex, race/ ethnicity and age.
Data on ADM comorbidity among juvenile detain- ees are needed for 2 reasons:
1. To improve treatment of detained youth. De- tention centers are legally mandated to treat detainees with major mental disorders.27 However, treating detain- ees who have ADM comorbidity is far more complex than treating youth who have only one disorder.28,29 Sound epi- demiologic data on comorbidity will help us target youth with the most common diagnostic profiles.
2. To improve treatment for high-risk youth in the community. Although committed (sentenced) juve- niles stay an average of 5 months,5 juveniles in deten- tion have an average stay of 2 weeks.5 Moreover, many high-risk youth (eg, substance abusers, abused and ne- glected youth) eventually cycle through the juvenile jus- tice system. Without treatment, disorders are likely to persist and worsen, contributing to negative social out- comes and recidivism.30 Data on ADM comorbidity among detainees are needed to develop more effective interven- tions for high-risk youth in the community and to tailor services for special populations, such as females and mi- norities.
We present findings on the prevalence and pat- terns of ADM comorbidity from the Northwestern Juve- nile Project, a large-scale study of psychiatric disorders in detained youth.
PARTICIPANTS AND SAMPLING PROCEDURES
Participants were 1829 male and female youth, 10 to 18 years old, randomly sampled at intake into the Cook County Juve- nile Temporary Detention Center (CCJTDC) from November 20, 1995, through June 14, 1998. The sample was stratified by sex, race/ethnicity (African American, non-Hispanic white, His- panic), age (10-13 years or �14 years), and legal status (pro- cessed as a juvenile or as an adult) to obtain enough partici- pants to compare key subgroups (eg, females, Hispanics, and younger children).