Mental Health and Substance Use Associated with Criminal Activity in Adolescent Inpatients

Shannon L. Stewart, Western University
Philip Baiden, University of Toronto
Wendy den Dunnen, University of Ottawa
John P. Hirdes, University of Waterloo
Christopher Perlman, University of Waterloo

Using logistic regression, this study seeks to examine the prevalence and correlates of criminal involvement in the previous year among adolescents in inpatient psychiatric facilities across Ontario, Canada. A sample of 2,613 adolescents aged 12 to 18 years who were admitted to adult inpatient mental health beds were examined. Just over one quarter of adolescents engaged in criminal activity within the past year. Older age, male gender, previous psychiatric admissions, a history of child abuse, poor insight into mental illness, substance use, specific types of mental health disorders, and aggressive behavior were all significantly associated with the presence of prior criminal activity. The well-founded association between mental health problems, substance use, and criminal behavior highlights the need for effective screening in settings providing services in the areas of juvenile justice, mental health, and addictions. Clinician awareness in all three settings is recommended so that these factors associated with at-risk behavior can be identified and appropriate treatment and referrals can be provided at the earliest point of involvement with any of these service systems.

criminal activity, adolescents, mental health, insight, substance use

In adolescence research, many studies have shown that criminal activity rises in early adolescence, peaks in adolescence, and begins to decline in adulthood. This pattern can also be seen in a data analysis from the Canadian Uniform Crime Reporting (UCR) survey, which indicated that in 2010 crime rates were the highest among individuals between the ages of 15 to 20 years.

Various factors have been associated with adolescent criminal activity, such as being a male, having mental health problems, and a history of maltreatment. For female adolescents, experiencing sexual abuse and family problems increases the likelihood of participating in delinquent and criminal activity. “While the majority of patients with mental illness do not engage in illegal activity, the risk of engaging in criminal activity increases for some patients with mental illness. In one of the first Canadian studies documenting the rates of mental health problems in incarcerated adolescents, Ulzen and Hamilton in 1998 found that psychiatric disorders and related comorbidities were 7 to 8 times higher than that exhibited in a matched community sample. This finding clearly outlines the fact that many adolescents in conflict with the law are struggling with underlying mental health issues.” (p. 34) Additionally, maladaptive behaviors, such as lying, cheating, stealing, teasing, and bullying, are associated with adolescents who experience maltreatment and trauma-related events.

Although many predictors have been identified for criminal activity, “systematic reviews produced by both Collins et al. (2010) and Fazel and Danesh (2002) indicated that research, particularly on the relationship between mental illness and criminal activity among adolescents, is still underdeveloped relative to what is known among adults. Most of the existing studies on insight into mental illness with adults have found that individuals with poor insight into their mental illness have an increased risk of engaging in violent behavior. Buckley et al. (2004) also found that individuals with poor insight into their mental illness were not only more likely to engage in violent crime, but they were also less likely to accept responsibility for their crime. However, it is unknown whether these associations found in adult populations are consistent for adolescents.” (p. 34)

The current study examined “the prevalence and correlates of criminal involvement among adolescents in inpatient psychiatric facilities across Ontario, Canada.” (p. 33) It was undertaken to add to the existing, limited knowledge on the prevalence and correlates of criminal activity for adolescents with mental health problems. The objective was to further examine factors associated with criminal involvement in a large sample of Canadian, adolescent inpatients. In particular, it aimed to examine previously identified correlates of criminal activity in adolescence, such as age, gender, previous maltreatment, and various mental health problems, to provide increased empirical evidence and understanding related to these factors. In addition, this study examined the role of insight into mental illness on criminal activity in this inpatient sample… Given that many adolescents with mental health problems do not engage in criminal activity, it is possible that insight into one’s mental illness may differentiate those who engage in such activities from those who do not.” (p. 35)

This study used retrospective data from the Ontario Mental Health Reporting System, collected by the Canadian Institute for Health Information (CIHI) using the Resident Assessment Instrument-Mental Health (RAI-MH) from October 2005 through March 2011. The adolescent inpatients in the study were between the ages of 12 and 18 and were admitted into adult inpatient mental health beds in Ontario, Canada for more than 72 hours. The final analysis included 2, 613 adolescents with a mean age of 17.15 (SD=1.13).

Variables on the RAI-MH include demographic and background factors, history of involvement with the criminal justice system, mental health service use history, reasons for referrals, mental state indicators, physical and behavioral factors, substance use and excessive behaviors, self-harm and harm to others, history of abuse and other traumatic events, medications, and provisional DSM-IV diagnostic categories.

This study found that age, gender, previous psychiatric admissions, aggressions, history of child abuse, level of insight into mental illness, substance use, and certain mental health diagnoses were associated with criminal activity. “In particular, impulse control disorders, disorders of childhood/ adolescence, and schizophrenia and other psychotic illnesses were associated with a history of involvement in illegal activity. A significant proportion of youth (one in four) admitted for mental health issues had a history of criminal activity within the past 12 months. However, this is lower than what has been previously reported for criminal involvement of adolescents in inpatient, psychiatric treatment.” (p. 39)

“The association between childhood abuse and engaging in criminal activity supports the long-standing findings related to the cycle of aggression and violent behavior. Specifically, child abuse is a risk factor for aggressive behavior among children and youth and it increases the likelihood of future antisocial behaviors by more than five times. Such trauma in childhood has been specifically linked to an increase in a variety of lifelong criminal behaviors.” (p. 39)

“One important contribution of this study to the existing literature was the association found between level of insight into mental illness and adolescent criminal activity. Most of the existing studies on insight into mental illness examined adult samples. The current findings suggest that the relationship between poor insight into mental illness and increased risk of engaging in violent behavior is consistent throughout adolescence and adulthood.” (p. 40)

“This study found that about 80% of adolescent patients had limited or no insight into their mental illness. Poor insight is a common phenomenon among patients with mental illness, particularly those suffering from psychosis. Adolescents who lack insight into their mental illness may require more extensive work establishing a realistic understanding of their mental illness and identifying problematic symptoms before treatment is commenced. The degree of awareness or insight may be a protective factor that influences the risk of criminal involvement in mentally ill adolescents. Evaluating insight and incorporating interventions that address self-awareness deficits is an important primary goal for treatment. This approach to treatment could also allow for the identification and application of more adaptive behavioral responses in stressful situations and potentially prevent future engagement in criminal actions.” (p. 40)

“Mental health interventions for adolescent patients who exhibit violent and aggressive behavior should focus on enhancing prosocial skills in order to moderate their violent and aggressive behaviors. Approaches to enhance adaptive emotion-regulation strategies, such as teaching these adolescents about the need to reflect on their actions before responding to events, have been found to be effective. Mindfulness training has also been found to improve aggressive and disruptive behaviors in adolescents with conduct disorders as it teaches adolescents to attend to conditions that trigger maladaptive behaviors. The well-founded association between mental health problems, substance use, and criminal behavior also highlights the need for effective screening in the juvenile justice, mental health, and substance use settings. Clinicians in all three service settings should be aware of and screen for the factors associated with at-risk behavior so that appropriate treatment and referrals can be provided at the earliest point of involvement with any of these systems, preferably before all three of these high-risk factors become areas of concern. This is particularly important given that previous admission to a psychiatric facility was associated with criminal activity, indicating that earlier targeted treatment for criminal behavior and mental health problems may have been possible.” (p. 40)

“Children and adolescents receiving services in mental health, juvenile justice, or substance use settings should be screened for these risk factors and provided targeted treatment to increase insight into their mental illness and reduce aggressive behavior, mental health problems, and involvement in criminal activity as early as possible to prevent further problems with the justice system in adulthood.” (p.41)

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