ORIGINAL RESEARCH

The Nature and Characteristics of Psychiatric Comorbidity in Incarcerated Adolescents

Thaddeus PM Ulzen, MD, FRCPC, Dip Child Psych¹, Hayley Hamilton, MA²

Objectives: To determine the prevalence of psychiatric disorders, the degree of psychiatric comorbidity, and the relationship between these and sociodemographic variables in a sample of incarcerated adolescents. A comparison with an age- and sex-matched community sample was conducted.

Method: Age- and sex-matched samples of 49 incarcerated adolescents and 49 nondelinquents were compared for psychiatric morbidity and psychosocial characteristics. Psychiatric diagnoses were determined using the Diagnostic Interview for Children and Adolescents-Revised (DICA-R). Additional information on psychosocial, family, and offence characteristics was obtained using a semistructured interview designed specifically for this study. The prevalence of single and comorbid psychiatric disorders was determined.

Results: Approximately 63.3% of incarcerated adolescents had 2 or more psychiatric disorders. The degree of psychiatric morbidity was directly related to indicators of family adversity, physical abuse, other psychosocial variables, or polysubstance abuse. Psychiatric comorbidity was more frequent in females. Incarcerated adolescents were more likely to endorse symptoms of thought disorder.

Conclusions: Findings identify preventive intervention foci for policy makers and planners in the area of adolescent corrections. Implications for education and training of nonclinical custodial staff are discussed as is the need for a more therapeutic orientation in correctional facilities.

(Can J Psychiatry 1998;43:57–63)

Key Words: incarceration, adolescents, psychiatric comorbidity, family adversity

In Canada, it is estimated that there are 2100 incarcerated youths per million (1). In the United States, despite a reported overall decrease in the juvenile crime rate in recent years, the number of incarcerated youths has remained at over half a million for over a decade; a rate of approximately 2500 incarcerated youths per million (2). These youths reside in institutions with varying standards of care. Treatment and correctional philosophies are as diverse as the quality of staff training and experience. Additionally, sentencing practices generally bear no relationship to the mental health needs of this population.

In Canada, the annual cost of incarceration per adolescent is $95 000, more than twice the $40 000 per year required to keep an adult in jail (3). In Canada, 56% of all custodial dispositions result in incarceration (1). There has been an overall increase in custodial dispositions of 41% from 1987 to 1993 (1). The annual cost of incarceration does not include the human, social, and property costs of offenses. An evaluation of the needs of incarcerated adolescents is important because this expensive and intrusive intervention has yet to produce the desired result of reduced recidivism. Disruptive behaviour disorders, which are common in this population, are increasing in prevalence and have the potential to become a leading public health concern in youths.

Mental disorder has been linked with increased recidivism, and numerous studies have consistently pointed to the high prevalence rate of psychiatric disorders in incarcerated adults (4–8). Given the high rate of juvenile delinquency and the rapidly rising economic and social costs of incarcerating these youths, the paucity of studies on the mental health problems of incarcerated juvenile offenders (including nondelinquent control or comparison groups) is striking.

The comorbidity of other psychiatric disorders with conduct disorder, the most common diagnosis in incarcerated adolescents, has long been reported (9,10). Lewis and colleagues highlighted the limited utility and validity of the diagnosis of conduct disorder in this population without due consideration to coexisting psychiatric disorders (11). Lewis and others and Lewis and Shanok reported on the tendency of custodial institutions to focus on punishment at the expense of careful diagnosis and treatment of coexisting psychiatric disorders in incarcerated youths (11–13). Thorough neuropsychiatric and psychoeducational assessments are necessary because aggressive behaviour may divert attention from significant yet treatable psychiatric, neurological, and psychoeducational problems. It has also been reported that incarcerated youths and those in psychiatric hospitals or treatment centres have similar clinical characteristics (14).

The relationship between delinquency and psychiatric disorder, although a complex one, reveals some consistent patterns. First, former delinquents have a high risk for psychiatric disorders as adults (11,15). Second, the greater the number of offences and the earlier the occurrence of the first offence in adolescence, the greater the risk of psychiatric disturbance in adulthood (5). This suggests that secondary preventive efforts and active treatment of psychiatric disturbances in incarcerated youths may reduce the risk of later psychiatric disturbances and hospitalizations. The lack of psychiatric treatment contributes to increased rates of criminality and further psychiatric disturbances in adulthood (16,17).

To our knowledge, no study of psychiatric disorder in incarcerated youths exists in which a structured, broad-based instrument designed specifically for assessing adolescent psychopathology has been used. In addition, with the exception of Lewis’s 1987 study, reports on psychiatric comorbidity of incarcerated adolescents, both cross-sectional and longitudinal, have usually not included nonclinical comparison groups.

Most previous studies of psychiatric morbidity in incarcerated adolescents have focused on the prevalence of single disorders, not on the coexistence of psychiatric disorders and the resulting implications for treatment planning and prognosis. The single disorders reported on include depression, conduct disorder, and personality disorders (4,9,18–21). Even fewer studies report on the prevalence of psychotic disorders and mental retardation in incarcerated adolescents (9,12,22). The prevalence of substance abuse has also been studied in incarcerated juvenile delinquents (23–25).

This study’s objectives are to determine the prevalence of psychiatric disorders in a sample of incarcerated adolescents, to compare the prevalence of psychiatric disorders among incarcerated adolescents with that among a community sample of adolescents, and to determine the degree of psychiatric comorbidity in incarcerated adolescents and its relationship to sociodemographic and family variables.

Method

Participants

A total of 98 adolescents participated in this study. The incarcerated group consisted of 49 adolescent offenders from 2 secure custody facilities in the Toronto area. Participants were first informed of the study by designated staff at each facility or by the study’s investigators. Informed consent was obtained for those who were interested in participating in the study. Both parental and adolescent consent was obtained for those under the age of 16; only adolescent consent was obtained for those 16 years of age and over. The incarcerated group consisted of 38 males and 11 females between the ages of 13 and 17 years (M = 15.39, SD = 0.95).

The age of first offence for this sample of adolescent offenders ranged from 5 to 17 years inclusive (M = 12.61, SD = 2.35). Their offence histories included property offence (60%), physical assault (45%), sexual assault (13%), escape from custody (33%), and failure to comply (51%).

The community group consisted of 49 adolescents who had never been convicted of an offence and had not received mental health treatment within the past year. The community group was matched to the incarcerated group on age and sex. Participants in the community group were recruited through advertisements in a community newspaper, a notice on a school bulletin board, and advertisements at youth employment offices. Community group participants were paid $15 for their participation. Only 4 (8%) adolescents from the community group reported ever committing an offence (age of first offence: M = 14.25, SD = 1.71, age range = 12 to 16 years).

Measures

The Diagnostic Interview for Children and Adolescents - Revised (DICA-R) is a highly structured interview that assesses the presence or absence of symptoms of disorders represented in DSM-III-R (26,27). Good agreement has been reported (k = 0.75) between diagnoses that were DICA-R-generated and those that were clinically derived (26). Parent–child agreement on the presence or absence of diagnoses has also been reported as good (k = 0.62) (26).

The adolescent version of the DICA-R was administered by a research assistant. The examined disorders were externalizing disorders (attention deficit hyperactivity disorder [ADHD], oppositional defiant disorder [ODD], conduct disorder, and mania) and nonexternalizing disorders (alcohol dependence, depression, overanxious disorder, separation anxiety disorder, posttraumatic stress disorder, and dysthymia).

A semistructured interview questionnaire was developed specifically for this study. It addressed various aspects of adolescent functioning, including peer relations, academic performance, family life, intimacy, parental characteristics, and patterns of delinquency. Chi-square analyses and t-tests were used to compare the demographic and diagnostic characteristics of the 2 groups.

Results

Sociodemographic Characteristics

Sociodemographic characteristics of families and individuals are provided in Table 1 for comparison purposes. In addition to lower paternal education and occupation levels among incarcerated adolescents, these adolescents also experienced family stressors that have frequently been found among children and adolescents who exhibit antisocial behaviour. For example, high rates of parental divorce or separation, physical abuse, and parental alcohol and drug use were common among these youths.

Psychiatric Disorders

Incarcerated adolescents had significantly more psychiatric disorders than adolescents in the community group (t = 6.65, P < 0.0001). The examined disorders were found to be absent in only 14.3% of the incarcerated adolescents; 22.4% had one disorder, and 63.3% had 2 or more disorders (Figure 1). In comparison, the disorders were absent in 69.4% of the youths in the community group; 18.4% had one disorder, and 12.2% had 2 or more disorders. Each examined disorder was found to be present in more incarcerated adolescents than in those in the community group. The rate of disorders can be found in Table 2. The disorder with the highest rate among incarcerated adolescents was ODD. Twenty-two (44.9%) incarcerated adolescents had ODD. The proportion of incarcerated adolescents who met the criteria for at least one of the externalizing disorders was 59.2%. Sixty-nine percent met the criteria for at least one internalizing disorder. Other disorders with high prevalence rates were alcohol dependence (38.8%), conduct disorder (30.6%), and depression (30.6%).

Figure 1. Presence of psychiatric disorder.

Although the number of females in this study was very small (n = 11) compared with the number of males (n = 38), some general comparisons can be made. The rate of present depression among incarcerated females was very high, with 8 out of 11 (72.7%) meeting the DSM-III-R criteria (Table 3). ADHD and conduct disorder had very low rates among females compared with moderate rates among males. ODD had the highest rate among incarcerated males.

Incarcerated adolescents who were physically abused had a greater number of disorders than those who were not abused (F = 6.07, P < 0.05). Although ODD and alcohol dependence were the disorders for which the criteria were most frequently met, the presence of ODD or alcohol dependence did not discriminate between incarcerated adolescents who were physically abused and those who were not abused.

Substance Use

Alcohol dependence and substance use were particularly prevalent among incarcerated adolescents. Thirty-nine percent of the incarcerated adolescents met the criteria for alcohol dependence compared with none of the adolescents in the community group. Alcohol dependence also appeared to be more prevalent among incarcerated females, with 63.6% meeting the criteria for dependency compared with 31.6% of males.

Marijuana was the substance used by the highest proportion of incarcerated adolescents (69.4%), followed by street drugs (cocaine, crack, speed, LSD or PCP, downers) (57.1%), and glue or fumes (14.3%). Ten percent or less of the community group had used these substances.

Comorbidity

The rate of comorbidity in this sample was very high. Multiple disorders were found among 63.3% (n = 31) of incarcerated adolescents compared with 12.2% (n = 6) of adolescents in the community group. Given the similar rates of ODD, depression, and alcohol dependence, high rates of comorbidity were expected.

Of the incarcerated adolescents who met the criteria for ODD (n = 22), 63.6% also met the criteria for alcohol dependence, 59.1% met the criteria for present depression, 54.5% met the criteria for ADHD, and 36.4% met the criteria for conduct disorder. Of those with ODD, only one adolescent did not meet the criteria for at least one other disorder.

Most of the incarcerated adolescents with multiple disorders had both externalizing and internalizing disorders. Only 4 (18.2%) adolescents had externalizing disorders exclusively. The remaining 18 (81.8%) adolescents had both externalizing and internalizing disorders. Conversely, comorbidity among adolescents in the community group involved mostly internalizing disorders.

A greater proportion of incarcerated females than males appeared to have multiple disorders. Nine of the 11 incarcerated females in the sample met the criteria for 2 or more disorders (81.8%). In comparison, only 57.9% of the males (n = 22) met the criteria for multiple disorders. The highest level of comorbidity among females involved present depression. Of the 8 incarcerated females with present depression, 7 (87.5%) met the criteria for ODD, 7 (87.5%) met the criteria for alcohol dependence, and 6 (75%) met the criteria for both ODD and alcohol dependence. In contrast, the highest level of comorbidity among males involved ODD. Of the 15 males with ODD, 10 (66.7%) met the criteria for ADHD, 8 (53.3%) met the criteria for alcohol dependence, and 7 (46.7%) met the criteria for conduct disorder.

Psychotic Symptoms

Incarcerated youth reported a greater number of psychotic symptoms than youth in the community group (t = 3.94, P < 0.001). The average number of psychotic symptoms reported was 2.8 for the incarcerated group compared with 1.1 for the community group. Seventy-five percent of the youths in the incarcerated group reported one or more psychotic symptoms compared with 49% of the community group.

The most frequently reported symptoms (Table 4) were suspiciousness (incarcerated = 49%, community = 20.4%), hearing thoughts spoken out loud (incarcerated = 38.8%, community = 10.2%), the feeling that people could read their minds (incarcerated = 32.7%, community = 20.4%), and being able to read someone else’s mind (incarcerated = 28.6%, community = 18.4%).

Discussion

The results of this study confirm and add to the findings of earlier studies on the presence of significant psychiatric morbidity in incarcerated adolescents (9,28–30). These earlier studies described adolescents who appeared considerably more violent than those reported in this study.

The use of the DICA-R, a structured clinical interview for children and adolescents, provides the advantage of reliability and reproducibility that is not present in the assessment modules of the earlier studies. The added presence of a nonclinical, nondelinquent community comparison group is an additional improvement on previous methodology. Prevalence rates were determined for disorders that were largely undetected in previous studies on psychiatric morbidity in incarcerated adolescents. These include internalizing disorders, such as dysthymia (26.5%), separation anxiety (30.6%), overanxious disorder (26.5%), and posttraumatic stress disorder (PTSD) (24.5%), all of which require specific interventions. The surprisingly strong presence of anxiety disorders may be a function of the state of incarceration itself or a result of the numerous out-of-home placements that typically precede a youth’s incarceration.

Other disorders identified include ADHD (26.5%) and mania (26.5%), for which previous prevalence data in this population are nonexistent (21). Polysubstance abuse was highly prevalent, with 75.5% of incarcerated youths abusing 2 or more substances other than alcohol. The prevalence rate for alcohol dependence was 38.8%, which confirmed earlier findings (23–25).

Our findings suggest that a broader range of psychiatric problems than has generally been acknowledged exists in these youths, including both internalizing and externalizing disorders. Armistead and others reported on a controlled study that applied the general personality and social–psychological approach (31). A psychometric instrument, the Revised Behavior Problem Checklist (RBPC), was used to determine the prevalence and coexistence of externalizing and internalizing disorders in incarcerated adolescents (32). The RBPC does not provide specific psychiatric diagnoses per se.

Our findings confirm that psychiatric comorbidity is not only common but that the presence of treatable multiple psychiatric disorders is more the rule than the exception. Far from being an incidental concern, identification and treatment of psychiatric disorders in incarcerated youths should be a priority in the consideration of rehabilitative interventions because mental disorders have long been implicated in recidivism among delinquent youths (4). Lack of treatment results in higher rates of multiple psychiatric problems being seen in arrested adults (8). The successful treatment of even one comorbid disorder may lower the symptom levels of associated disorders (33).

Family adversity and psychosocial stressors are common in conduct-disordered adolescents, and such difficulties are more often present in incarcerated adolescents (30,34–38). In this study, the most significant sociodemographic differences between the incarcerated group and the comparison group were those of physical abuse, parental divorce and separation, and violence between parents. Other significant differentiating factors were excessive drinking by parents, psychiatric treatment of parents, and the experience of remedial education by adolescents. Additional significant family stressors included the presence of excessive yelling and screaming, serious parental medical illness, and sexual abuse. Substance abuse, excluding alcohol, and a family history of criminality were highly prevalent in the incarcerated group. These findings identify possible target areas for primary and secondary preventive interventions in families of younger children at risk for conduct disorder and future incarceration. The focus of prevention and early intervention should be on identifying and reducing causal risk factors and increasing causal protective factors as much as possible.

Our investigation demonstrates the nature of psychiatric morbidity on the basis of DICA-R generated DSM-III-R diagnoses. This is of direct relevance to psychiatrists and other clinicians involved in the evaluation and treatment of incarcerated adolescents. In this study, 71.4% of incarcerated adolescents met DSM-III-R criteria for at least one internalizing disorder as opposed to 59.2% who met criteria for at least one externalizing disorder. This is contrary to the general expectation that externalizing disorders would be more common in this population.

Although females comprised only 22.4% of the total sample, they presented with a higher level of prevalence for several psychiatric disorders and a distinct pattern of comorbidity. For example, the rate of present depression among females was as high as 72.7% compared with 18.4% in males. Among the externalizing disorders, ODD had a prevalence of 63.6% in females compared with 39.5% in males. ADHD and conduct disorder had a lower prevalence in females as expected.

The rate of psychiatric comorbidity in incarcerated adolescents was high, with multiple disorders being found among 63.3% of this population. This trend was stronger among females, who had a multiple disorder rate of 81.8% compared with 57.9% in males. These results underscore the need for an emphasis on the accurate diagnosis of coexisting psychiatric illness in rehabilitative planning for incarcerated adolescents. They are likely to be far more psychiatrically disturbed, with multiple disorders, requiring multi-modal interventions. Given that the cost of incarceration of adolescents is extremely high, the allocation of resources between the competing needs for correction of behaviour and psychiatric treatment should be guided by empirical findings. These results indicate that the current policy of incarcerated adolescents receiving psychiatric treatment incidentally is ill-advised. The overwhelming prevalence of multiple psychiatric disorders should guide policy toward optimal allocation of resources to psychiatric treatment, despite the fact that these adolescents are ostensibly held for correction of behaviours.

Young offender facilities are generally underresourced in terms of the clinical expertise needed to provide for all the mental health needs of the incarcerated youths in residence. Active training in mental health aspects of correctional work is strongly desirable because the psychiatric needs of these adolescents are largely underestimated, unmet, and underserved (16,17). Although the relationship between delinquency and psychiatric illness is a complex one, the literature suggests that an early history of delinquency is positively correlated with psychiatric illness in adulthood and its attendant demands on expensive and diminishing mental health resources (5,8,9).

Early identification and treatment of psychiatric disorders in this population will aid in supporting well-formulated follow-up treatment on their release from correctional facilities. Currently, adequate follow-up treatment for psychiatric disorders in incarcerated adolescents is a rarity in most jurisdictions (39). Accurate psychiatric diagnoses and appropriate interventions for incarcerated adolescents can only improve fiscal and service efficiency in this population. Using the Child Behavior Checklist (CBCL), Cohen demonstrated that incarcerated adolescents did not differ significantly from those in treatment settings (14). No psychiatric diagnoses were available, however.

Planning for the mental health needs of incarcerated youths on the basis of accurately gathered clinical information will have additional implications in determining the level of clinical sophistication, training, and educational requirements of front-line staff in custodial facilities. The general level of clinical resourcing for these programs could be improved with the knowledge that a high level of clinical sophistication is required for treatment and the reduction of recidivism and long-term costs.

Our results suggest that future research in this population should include controlled prospective evaluations of incarcerated adolescents, who receive adequate psychiatric assessments and multidisciplinary treatment during incarceration, and who are beneficiaries of adequate psychiatric follow-up in the community. This would help clarify the relationship between psychiatric illness and recidivism. Incarceration should be viewed not only as a correctional opportunity but as an opportunity to engage familial and clinical resources for the full benefit of these adolescents. Further study is required on the specific needs of incarcerated female adolescents because few studies of incarcerated adolescents include females or report on gender differences with respect to the prevalence and comorbidity of psychiatric disorders. Our findings suggest that different vulnerabilities exist between incarcerated male and female adolescents, which may require appropriate gender-specific interventions.

Our results are limited by the fact that family information was obtained by uncorroborated youth self-reports. Previous reports attest to the reliability of youth self-reports, however, especially when the youths respond to questions from a computer and record their own answers (40). We did not systematically confirm the presence of specific learning disorders by psychometric testing. We inferred from a history of grade retention or enrollment in special education classes that a learning disorder may be present. As expected, both phenomena were more common in the incarcerated group. All reported DICA-R diagnoses were based on adolescents meeting full criteria for the disorders, and, as such, our prevalence rates may underrepresent the scope of psychiatric problems in this population.

The comparison group was matched only for age and gender but not for socioeconomic status (SES). In this study on SES, the groups differed on paternal occupation and education but were similar for maternal factors. Neither the index nor comparison group was randomly selected because consent was necessary. The design’s strength lies in the use of a structured assessment instrument normed for adolescents.

Further research is required to understand the emergence of psychiatric comorbidity, its role in the development of delinquent behaviour, and its relationship to family adversity and other psychosocial stressors.

Acknowledgements

This work was made possible by support from The George Hull Centre Research Fund, the staff of Rotherglen Centre in Ajax, Ontario, and the staff of the Secure Custody Program at Sylapps Youth Centre in Oakville, Ontario.

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Résumé

Objectifs : Déterminer la prévalence des troubles psychiatriques, le degré de comorbidité psychiatrique et la relation entre ces éléments et les variables sociodémographiques d’un échantillon d’adolescents incarcérés. On a effectué une comparaison avec un échantillon communautaire apparié suivant l’âge et le sexe.

Méthode : Des échantillons appariés suivant l’âge et le sexe de 49 adolescents incarcérés et de 49 non-délinquants ont été comparés quant à la morbidité psychiatrique et aux caractéristiques psychosociales. Les diagnostics psychiatriques ont été déterminés au moyen de l’entrevue diagnostique pour enfants et adolescents remaniée (Diagnostic Interview for Children and Adolescents-Revised [DICA-R]). D’autres renseignements sur les caractéristiques psychosociales, familiales et infractionnelles ont été obtenus au moyen d’une entrevue semistructurée, conçue spécifiquement pour cette étude. On a déterminé la prévalence des troubles psychiatriques uniques et comorbides.

Résultats : Environ 63,3 % des adolescents incarcérés souffraient de deux troubles psychiatriques ou plus. Le degré de morbidité psychiatrique était directement lié aux indicateurs de l’adversité familiale, de la violence physique, d’autres variables psychosociales ou de l’abus de plusieurs substances toxiques. La comorbidité psychiatrique était plus fréquente chez les femmes. Les adolescents incarcérés couraient un plus grand risque de manifester des symptômes du trouble de la pensée.

Conclusions : Les constatations permettent d’identifier les éléments sur lesquels les décideurs et les planificateurs doivent insister dans le domaine du système correctionnel pour adolescents. Les répercussions sur l’éducation et la formation du personnel de garde non clinique font l’objet d’une discussion, ainsi que la nécessité d’une orientation davantage axée sur le traitement dans les établissements correctionnels.

Manuscript received January 1997 and accepted May 1997.

This paper was presented at the Third European Conference on Psychology and Law at the University of Siena in Italy on August 29, 1996.

¹Psychiatrist-in-Chief, George Hull Centre for Children and Families, Etobicoke, Ontario; Assistant Professor, Department of Psychiatry, University of Toronto, Toronto, Ontario.

²Research Assistant, Thistletown Regional Centre, Rexdale, Ontario.

Address for correspondence: Dr TPM Ulzen, George Hull Centre for Children and Families, 600 The East Mall, 3rd Floor, Toronto, ON M9B 4B1

Can J Psychiatry, Vol 43, February 1998