Prevalence, Comorbidity, and Continuity of Psychiatric Disorders in a 15-Year Longitudinal Study of Youths Involved in the Juvenile Justice System.

Importance: Previous studies have found that one-half to three-quarters of youths detained in juvenile justice facilities have 1 or more psychiatric disorders. Little is known about the course of their disorders as they age. Objective: To examine the prevalence, comorbidity, and continuity of 13 psychiatric disorders among youths detained in a juvenile justice facility during the 15 years after detention up to a median age of 31 years, with a focus on sex and racial/ethnic differences. Design, Setting, and Participants: The Northwestern Juvenile Project is a longitudinal cohort study of health needs and outcomes of 1829 randomly selected youths in a temporary juvenile detention center in Cook County, Illinois. Youths aged 10 to 18 years were interviewed in detention from November 20, 1995, through June 14, 1998. Participants were reinterviewed up to 12 times during the 15-year study period through February 2015, for a total of 16 372 interviews. The sample was stratified by sex, race/ethnicity (Black, Hispanic, and non-Hispanic White), age (10-13 years or 14-18 years), and legal status (processed in juvenile or adult court). Data analysis was conducted from February 2014, when data preparation began, to March 2020. Exposures: Detention in a juvenile justice facility. Main Outcomes and Measures: Psychiatric disorders, assessed by the Diagnostic Interview Schedule for Children, version 2.3 at the baseline interviews. Follow-up interviews were conducted using the Diagnostic Interview Schedule for Children, version IV; the Diagnostic Interview Schedule, version IV; and the World Mental Health Composite International Diagnostic Interview (beginning at the 6-year follow-up interview). Results: The study included 1829 youths sampled at baseline (1172 males and 657 females; mean [SD] age, 14.9 [1.4] years). Although prevalence and comorbidity of psychiatric disorders decreased as the 1829 participants aged, 52.3% of males and 30.9% of females had at least 1 or more psychiatric disorders 15 years postdetention. Among participants with a disorder at baseline, 64.3% of males and 34.8% of females had a disorder 15 years later. Compared with females, males had 3.37 times the odds of persisting with a psychiatric disorder 15 years after baseline (95% CI, 1.79-6.35). Compared with Black participants and Hispanic participants, non-Hispanic White participants had 1.6 times the odds of behavioral disorders (odds ratio, 1.56; 95% CI, 1.27-1.91 and odds ratio, 1.59; 95% CI, 1.23-2.05, respectively) and greater than 1.3 times the odds of substance use disorders (odds ratio, 1.90; 95% CI, 1.55-2.33 and odds ratio, 1.39; 95% CI, 1.11-1.73, respectively) throughout the follow-up period. Behavioral disorders and substance use disorders were the most prevalent 15 years after detention. Conclusions and Relevance: This study's findings suggest that persistent psychiatric disorders may complicate the transition from adolescence to adulthood, which is already challenging for youths involved in the juvenile justice system, many of whom are from racial/ethnic minority groups and low-income backgrounds. The pediatric health community should advocate for early identification and treatment of disorders among youths in the justice system.

Psychiatric disorders and violence: a study of delinquent youth after detention.

OBJECTIVE: To examine the relationship between psychiatric disorders and violence in delinquent youth after detention. METHOD: The Northwestern Juvenile Project is a longitudinal study of youth from the Cook County Juvenile Temporary Detention Center (Chicago, Illinois). Violence and psychiatric disorders were assessed via self-report in 1,659 youth (56% African American, 28% Hispanic, 36% female, aged 13-25 years) interviewed up to 4 times between 3 and 5 years after detention. Using generalized estimating equations and logistic regression, we examined the following: the prevalence of violence 3 and 5 years after detention; the contemporaneous relationships between psychiatric disorders and violence as youth age; and whether the presence of a psychiatric disorder predicts subsequent violence. RESULTS: Rates of any violence decreased between 3 and 5 years after detention, from 35% to 21% (males), and from 20% to 17% (females). There was a contemporaneous relationship between disorder and violence. Compared to the group with no disorder, males and females with any disorder had greater odds of any violence (adjusted odds ratio [AOR] = 3.0, 95% CI = 1.9-4.7, and AOR = 4.4, 95% CI = 3.0-6.3, respectively). All specific disorders were associated contemporaneously with violence, except for major depressive disorder/dysthymia among males. Substance use disorders predicted subsequent violence. Males with other drug use disorder and females with marijuana use disorder 3 years after detention had greater odds of any violence 2 years later (AOR = 3.4, 95% CI = 1.4-8.2, and AOR = 2.0, 95% CI = 1.1-3.8, respectively). CONCLUSION: Aside from substance use disorders, the psychiatric disorders studied may not be useful markers of subsequent violence. Violence assessment and reduction must be key components of ongoing psychiatric services for high-risk youth.

Comorbidity and continuity of psychiatric disorders in youth after detention: a prospective longitudinal study.

IMPORTANCE: Psychiatric disorders and comorbidity are prevalent among incarcerated juveniles. To date, no large-scale study has examined the comorbidity and continuity of psychiatric disorders after youth leave detention. OBJECTIVE: To determine the comorbidity and continuity of psychiatric disorders among youth 5 years after detention. DESIGN, SETTING, AND PARTICIPANTS: Prospective longitudinal study of a stratified random sample of 1829 youth (1172 male and 657 female; 1005 African American, 296 non-Hispanic white, 524 Hispanic, and 4 other race/ethnicity) recruited from the Cook County Juvenile Temporary Detention Center, Chicago, Illinois, between November 20, 1995, and June 14, 1998, and who received their time 2 follow-up interview between May 22, 2000, and April 3, 2004. MAIN OUTCOMES AND MEASURES: At baseline, the Diagnostic Interview Schedule for Children Version 2.3. At follow-ups, the Diagnostic Interview Schedule for Children Version IV (child and young adult versions) and the Diagnostic Interview Schedule Version IV (substance use disorders and antisocial personality disorder). RESULTS: Five years after detention, when participants were 14 to 24 years old, almost 27% of males and 14% of females had comorbid psychiatric disorders. Although females had significantly higher rates of comorbidity when in detention (odds ratio, 1.3; 95% CI, 1.0-1.7), males had significantly higher rates than females at follow-up (odds ratio, 2.3; 95% CI, 1.6-3.3). Substance use plus behavioral disorders was the most common comorbid profile among males, affecting 1 in 6. Participants with more disorders at baseline were more likely to have a disorder approximately 5 years after detention, even after adjusting for demographic characteristics. We found substantial continuity of disorder. However, some baseline disorders predicted alcohol and drug use disorders at follow-up. CONCLUSIONS AND RELEVANCE: Although prevalence rates of comorbidity decreased in youth after detention, rates remained substantial and were higher than rates in the most comparable studies of the general population. Youth with multiple disorders at baseline are at highest risk for disorder 5 years later. Because many psychiatric disorders first appear in childhood and adolescence, primary and secondary prevention of psychiatric disorders offers the greatest opportunity to reduce costs to individuals, families, and society. Only a concerted effort to address the many needs of delinquent youth will help them thrive in adulthood.

Prevalence and persistence of psychiatric disorders in youth after detention: a prospective longitudinal study.

CONTEXT: Psychiatric disorders are prevalent among incarcerated juveniles. Most juveniles eventually return to their communities, where they become the responsibility of the community mental health system. However, no large-scale study has examined psychiatric disorders after youth leave detention. OBJECTIVE: To examine changes in the prevalence and persistence of psychiatric disorders during the 5 years after detention, focusing on sex and racial/ethnic differences. DESIGN: Prospective longitudinal study with up to 5 interviews (1829 youth: 1172 males and 657 females). To ensure representation of key demographic subgroups, the randomly selected sample was stratified by sex, race/ethnicity (African American, non-Hispanic white, and Hispanic), age, and legal status (juvenile or adult court). SETTING: The Northwestern Juvenile Project, sampling youth from the Cook County Juvenile Temporary Detention Center, Chicago, Illinois. PARTICIPANTS: Detained youth, aged 10 to 18 years at baseline interview. MAIN OUTCOME MEASURES: At baseline, the Diagnostic Interview Schedule for Children Version 2.3. At follow-up interviews, the Diagnostic Interview Schedule for Children Version IV (Child and Young Adult versions) and the Diagnostic Interview Schedule Version IV (substance use disorders and antisocial personality disorder). RESULTS: Five years after baseline, more than 45% of males and nearly 30% of females had 1 or more psychiatric disorders with associated impairment. More than 50% of males and more than 40% of females had 1 or more psychiatric disorders without impairment. Substance use disorders were the most common; males, however, had higher rates over time (5 years after baseline, adjusted odds ratio [AOR], 2.61; 95% CI, 1.96-3.47). Non-Hispanic whites and Hispanics also had higher rates of substance use disorders vs African Americans (AOR, 1.96; 95% CI, 1.54-2.49 and AOR, 1.59; 95% CI, 1.24-2.03). Females had higher rates of major depression over time (AOR, 1.59; 95% CI, 1.22-2.08). CONCLUSIONS: Although prevalence rates of most psychiatric disorders declined as youth aged, a substantial proportion of delinquent youth continue to have disorders. There are notable sex and racial/ethnic differences in the prevalence and persistence of psychiatric disorders in this population.

Can parent reports serve as a proxy for teacher ratings in medication management of attention-deficit hyperactivity disorder?

OBJECTIVE: While American Academy of Pediatrics guidelines recommend obtaining symptom reports from both parents and teachers when treating children with attention-deficit hyperactivity disorder (ADHD), information from parents is easier to obtain and practitioners may prefer to rely solely on parent report when managing medications. There are, however, few empirical data on the relationship between parent and teacher reports during medication management of ADHD. This study examined the relationship between parent and teacher reports of symptoms of ADHD during a clinical trial. METHODS: A study to improve medication management of ADHD was conducted in 24 pediatric practices with 270 children. Children meeting criteria for ADHD were randomized by practice to treatment-as-usual or specialized care groups, with data combined from the groups to examine parent-teacher agreement. Parent and teacher reports on the ADHD Rating Scale-IV were obtained at pretreatment, 4 months, and 12 months follow-up. RESULTS: At each assessment, correlations between parent and teacher ratings were statistically significant, but the magnitudes of the correlations were low, accounting for no more than approximately 17% of the variance between measures. Correlations between change scores on parent and teacher ratings were statistically significant but low for Total and Inattentive scales and not significant for the Hyperactive-Impulsive scale. For agreement on extreme scores, 6 of 9 kappas were statistically significant but all were unacceptably low. CONCLUSIONS: Agreement between parent and teacher ratings of symptoms of ADHD is too low for clinicians to rely on parent reports while managing medications. Teacher reports are still needed to ensure optimal management.

Computer-assisted management of attention-deficit/hyperactivity disorder.

OBJECTIVES: Medication management of attention-deficit/hyperactivity disorder (ADHD) is often suboptimal. We examined whether (1) brief physician training plus computer-assisted medication management led to greater reduction in ADHD symptoms and (2) adherence to the recommended titration protocol produced greater symptomatic improvement. METHODS: A randomized medication trial was conducted that included 24 pediatric practices. Children who met criteria for ADHD were randomly assigned by practice to treatment-as-usual or a specialized care group in which physicians received 2 hours of didactic training on medication management of ADHD plus training on a software program to assist in monitoring improvement. Parent and teacher reports were obtained before treatment and 4, 9, and 12 months after starting medication. RESULTS: Children in both specialized care and treatment-as-usual groups improved on the ADHD Rating Scales and SNAP-IV, but there were no group differences in improvement rates. Brief physician training alone did not produce improvements. When recommended titration procedures were followed, however, outcomes were better for total and inattentive ADHD symptoms on both the ADHD Rating Scales and SNAP-IV parent and teacher scales. Results were not attributable to discontinuation because of adverse effects or failure to find an effective medication dose. CONCLUSIONS: Brief physician training alone did not lead to reductions in ADHD symptoms, but adherence to a protocol that involved titration until the child's symptoms were in the average range and had shown a reliable change led to better symptom reduction. Computer-assisted medication management can contribute to better treatment outcomes in primary care medication treatment of ADHD.

Suicidal ideation and behaviors among youths in juvenile detention.

OBJECTIVE: To examine suicidal ideation, suicide attempts, lethality of suicide attempts, and the relationship between psychiatric disorder and recent attempts in newly detained juveniles. METHOD: The sample included 1,829 juveniles, ages 10 to 18 years, sampled after intake to a detention center in Chicago. Interviewers administered the Diagnostic Interview Schedule for Children to assess for thoughts of death, suicidal ideation, suicide plans, lifetime suicide attempts, number of attempts, age at first attempt, attempts within the past 6 months, method of suicide attempts, and psychiatric disorder. RESULTS: More than one third of juvenile detainees and nearly half of females had felt hopeless or thought about death in the 6 months before detention. Approximately 1 in 10 (10.3%, 95% confidence interval: 7.7%-12.8%) juvenile detainees had thought about committing suicide in the past 6 months, and 1 in 10 (11.0%, 95% confidence interval: 8.3%-13.7%) had ever attempted suicide. Recent suicide attempts were most prevalent in females and youths with major depression and generalized anxiety disorder. CONCLUSIONS: Fewer than half of detainees with recent thoughts of suicide had told anyone about their ideation. Identifying youths at risk for suicide, especially those suffering from depressive and anxiety disorders, is a crucial step in preventing suicide.

Practitioner perspectives on evidence-based practice.

Most aspiring child mental health professionals would support the premise that clinical practice should have a scientific foundation. Why, then, is the implementation of evidence-based practice in child and adolescent psychiatry so difficult? Considering the multiple stakeholders in clinical work, impediments are not surprising. Practitioner delays in implementation of research findings are common to all specialties of medicine. This article outlines the barriers to implementation of evidence-based practice and suggests changes to motivate and enable clinicians to use evidence-based practices.

Posttraumatic stress disorder and trauma in youth in juvenile detention.

OBJECTIVE: To determine prevalence estimates of exposure to trauma and 12-month rates of posttraumatic stress disorder (PTSD) among juvenile detainees by demographic subgroups (sex, race/ethnicity, and age). DESIGN: Epidemiologic study of juvenile detainees. Master's level clinical research interviewers administered the PTSD module of the Diagnostic Interview Schedule for Children, version IV (DISC-IV), to randomly selected detainees. SETTING: A large, temporary detention center for juveniles in Cook County, Illinois (which includes Chicago and surrounding suburbs). PARTICIPANTS: Randomly selected, stratified sample of 898 African American, non-Hispanic white, and Hispanic youth (532 males, 366 females, aged 10-18 years) arrested and newly detained. MAIN OUTCOME MEASURES: Diagnostic Interview Schedule for Children, version IV. RESULTS: Most participants (92.5%) had experienced 1 or more traumas (mean, 14.6 incidents; median, 6 incidents). Significantly more males (93.2%) than females (84.0%) reported at least 1 traumatic experience; 11.2% of the sample met criteria for PTSD in the past year. More than half of the participants with PTSD reported witnessing violence as the precipitating trauma. CONCLUSION: Trauma and PTSD seem to be more prevalent among juvenile detainees than in community samples. We recommend directions for research and discuss implications for mental health policy.

Comorbid psychiatric disorders in youth in juvenile detention.

OBJECTIVE: To estimate 6-month prevalence of comorbid psychiatric disorders among juvenile detainees by demographic subgroups (sex, race/ethnicity, and age). DESIGN: Epidemiologic study of juvenile detainees. Master'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 juveniles in Cook County, Illinois (which includes Chicago and surrounding suburbs). PARTICIPANTS: Randomly selected, stratified sample of 1829 African American, non-Hispanic white, and Hispanic youth (1172 males, 657 females, aged 10-18 years) arrested and newly detained. MAIN OUTCOME MEASURE: Diagnostic Interview Schedule for Children. RESULTS: Significantly more females (56.5%) than males (45.9%) met criteria for 2 or more of the following disorders: major depressive, dysthymic, manic, psychotic, panic, separation anxiety, overanxious, generalized anxiety, obsessive-compulsive, attention-deficit/hyperactivity, conduct, 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: affective, anxiety, substance use, and attention-deficit/hyperactivity or behavioral. The odds of having comorbid disorders were higher than expected by chance for most demographic subgroups, except when base rates of disorders were already high or when cell sizes were small. Nearly 14% of females and 11% of males had both a major mental disorder (psychosis, manic episode, or major depressive episode) and a substance use disorder. Compared 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 disorders. Rates of some types of comorbidity were higher among non-Hispanic whites and older adolescents. CONCLUSIONS: Comorbid psychiatric disorders are a major health problem among detained youth. We recommend directions for research and discuss how to improve treatment and reduce health disparities in the juvenile justice and mental health systems.

Psychiatric disorders in youth in juvenile detention.

BACKGROUND: Given the growth of juvenile detainee populations, epidemiologic data on their psychiatric disorders are increasingly important. Yet, there are few empirical studies. Until we have better epidemiologic data, we cannot know how best to use the system's scarce mental health resources. METHODS: Using the Diagnostic Interview Schedule for Children version 2.3, interviewers assessed a randomly selected, stratified sample of 1829 African American, non-Hispanic white, and Hispanic youth (1172 males, 657 females, ages 10-18 years) who were arrested and detained in Cook County, Illinois (which includes Chicago and surrounding suburbs). We present 6-month prevalence estimates by demographic subgroups (sex, race/ethnicity, and age) for the following disorders: affective disorders (major depressive episode, dysthymia, manic episode), anxiety (panic, separation anxiety, overanxious, generalized anxiety, and obsessive-compulsive disorders), psychosis, attention-deficit/hyperactivity disorder, disruptive behavior disorders (oppositional defiant disorder, conduct disorder), and substance use disorders (alcohol and other drugs). RESULTS: Nearly two thirds of males and nearly three quarters of females met diagnostic criteria for one or more psychiatric disorders. Excluding conduct disorder (common among detained youth), nearly 60% of males and more than two thirds of females met diagnostic criteria and had diagnosis-specific impairment for one or more psychiatric disorders. Half of males and almost half of females had a substance use disorder, and more than 40% of males and females met criteria for disruptive behavior disorders. Affective disorders were also prevalent, especially among females; more than 20% of females met criteria for a major depressive episode. Rates of many disorders were higher among females, non-Hispanic whites, and older adolescents. CONCLUSIONS: These results suggest substantial psychiatric morbidity among juvenile detainees. Youth with psychiatric disorders pose a challenge for the juvenile justice system and, after their release, for the larger mental health system.

Practice parameter for the use of stimulant medications in the treatment of children, adolescents, and adults.

This practice parameter describes treatment with stimulant medication. It uses an evidence-based medicine approach derived from a detailed literature review and expert consultation. Stimulant medications in clinical use include methylphenidate, dextroamphetamine, mixed-salts amphetamine, and pemoline. It carries FDA indications for treatment of attention-deficit/hyperactivity disorder and narcolepsy.