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Compared with youths from the community, a disproportionate number of juvenile delinquent individuals from urban environments suffer from behavioural and substance use problems (1). Studies have found elevated rates of DSM Axis I and II disorders among juvenile delinquent youths (2)—especially conduct disorder (CD) and attention-deficit hyperactivity disorder (ADHD) (3–5). One study that included 108 Dutch juvenile delinquent individuals found elevated rates of ADHD (28%) and CD (76%) (6). In another study that involved 1956 American delinquent youths, 55% were diagnosed with ADHD (7). Substance use disorder (SUD) is also common among these youths (8). A study involving 118 Australian delinquent youths found that over 90% had used either pain relievers, other medicines, cannabis, alcohol, or tobacco (9). This study also found a high use of “hard drugs,” such as amphetamines (47%), heroin (35%), and hallucinogens (64%). Although it is well known that delinquent youths generally show high rates of behavioural problems, identifying priority areas for treatments in correctional settings requires accurate information about population needs. For the most part, previous studies on the health of incarcerated juvenile delinquent individuals are urban-based and, consequently, may have limited generalizability to those individuals from rural communities. Studies of community adolescents have shown that urban environments, compared with rural settings, provide greater opportunity to socialize with deviant peer groups, leading to higher rates of conduct problems among male youth (10,11). We are unaware of any published studies that compared prevalence rates of behavioural and substance use problems in delinquent youths in rural settings with those in urban settings. Thus, the objective of the present study was to examine rural and urban differences in rates of behavioural and substance use problems in an incarcerated sample of delinquent youths. MethodParticipants Measures The Drug Use Screening Inventory (DUSI) is a 149-item self-report questionnaire that measures involvement with drugs and alcohol, social competence, family functioning, academic performance, and peer relations (12). The DUSI measures disturbance in 10 domains: substance use, behaviour patterns, health, psychiatric disturbance, psychiatric disorder, family adjustment, school adjustment, peer relations, social competence, and leisure and recreation. The DUSI provides a problem density score, ranging from 0% to 100%, reflecting the percentage of problems endorsed across all 10 domains. The response format is “true” or “false.” In a sample of individuals aged 16 years, a problem density severity score of 24% predicted SUD diagnoses with 84% accuracy (13). The DUSI has shown validity in psychiatric populations, reliability over time (1-week test reliability coefficients that range from 0.95 to 0.88), and internal consistency (14). The Youth Self-Report (YSR) is a 112-item self-report assessment of social competencies and behavioural problems in adolescents (15). The YSR measures internalizing and externalizing problems in 8 scales: withdrawn, somatic complaints, anxiety and (or) depression, social problems, thought problems, attention problems, aggressive behaviour, and delinquent behaviour. In addition, male scores are calculated on a scale that measures self-destructive and (or) identity problems. The YSR has shown good stability over time (1-week test–retest reliability coefficients that range from 0.65 to 0.83), internal consistency, and predictive validity with DSM criteria in both community and psychiatric settings (15). Achenbach reported probabilities of 0.67 to 0.93 for YSR total-problem scores from a clinic-referred population, depending on the range of scores (15). YSR scores observed in the present study correspond to an accuracy of 0.78. Procedure ResultsOf the 76 delinquent youth approached, 70 (92.1%) agreed to participate. Two participants (2.9%) were female and were excluded from the analysis. Of the 68 males, 41 (60.3%) had lived in rural communities, 24 (35.3%) in urban centres, and 3 (4.4%) in both rural and urban settings. Proportions of rural and urban participants were equivalent to the population served in Newfoundland and Labrador. No rural and urban differences were found in characteristics of the sample (Table 1).
Table 2 shows the prevalence estimates of problems that were based on the DUSI and the YSR cut-off scores. In all, 95.7% of the sample scored over the DUSI cut-off of 24% problem density severity. Elevated rates were also found in all problem areas assessed by the YSR but were highest for delinquent behaviour (85.5%), externalizing behaviour (75.4%), internalizing behaviour (43.5%), attention problems (27.5%), and self-destructive and (or) identity problems (24.6%).
Table 2 shows rural and urban differences in rates of behavioural and substance use problems. Greater proportions of urban delinquent youths than those from rural communities scored within the clinical range for attention problems (c2 = 4.7, df 1, P = 0.029) and externalizing problems (c2 = 7.7, df 1, P = 0.006). Similarly, more urban than rural juvenile delinquent individuals scored within the clinical range for delinquent (antisocial) behaviour, but this difference only approached statistical significance (c2 = 3.0, df 1, P = 0.084). DiscussionBased on the accuracy of the YSR and the DUSI, it may be inferred that at least 52% of the sample may be diagnosed with a behavioural problem, and 80% may be diagnosed with a SUD. A caveat in interpreting this finding is that, with a small sample size and the absence of a matched comparison group of community youths, these are crude indicators of the prevalence of disorders. It is perilous to base prevalence estimates on a single self-report screen. Still, these data from validated assessments reveal considerably elevated rates of psychological disturbances in delinquent youths. Urban participants reported more substance use and behavioural problems than did rural participants, corresponding to community studies that found urban male adolescents, compared with their rural counterparts, report more behavioural problems (10,11). Such differences may also be attributed to greater opportunity in urban environments to join deviant peer groups or to a lack of services for troubled youths in rural settings, which ultimately results in the use of detention as a first-line service for less disturbed rural youths and a last-line service for more disturbed urban youths (16). Thus, it is worth investigating in future studies whether incarceration rates of juvenile delinquent individuals in Canada are influenced by the proximity to psychiatric services in rural and urban settings. These results emphasize the importance of psychological treatments for behavioural disorders and SUD in rehabilitation programs for delinquent youths. They also suggest that criminality in urban youths may more likely coincide with externalizing or “acting out” behaviour than in rural youths. Such rural and urban differences in behavioural and substance use problems have implications for the organization and delivery of rehabilitation programs in correctional facilities and community-based programs for disturbed youths who leave incarceration. Funding and SupportThis study was supported by a research grant from the Janeway Research Advisory Committee, St John’s Health Care Corporation, St John’s, Newfoundland. The writing of this article was supported in part by doctoral fellowships awarded to Frank J Elgar. These fellowships were from the Hospital for Sick Children Foundation and the Nova Scotia Health Research Foundation. References1. Hollander HE, Turner FD. Characteristics of incarcerated delinquents: relationship between development disorders, environmental and family factors, and patters of offence and recidivism. J Am Acad Child Psychiatry 1985;24:221–6. 2. McManus M, Alessi NE, Grapentine WL, Brickman A. Psychiatric disturbance in serious delinquents. J Am Acad Child Psychiatry 1984;23:602–15. 3. Forehand R, Wierson M, Frame C, Kempton T, Armistead L. Juvenile delinquency entry and persistence: do attention problems contribute to conduct problems? J Behav Ther Exp Psychiatry 1991;22:261–4. 4. Milin R, Halikas JA, Meller JE, Morse C. Psychopathology among substance abusing juvenile offenders. J Am Acad Child Adolesc Psychiatry 1991;30:569–74. 5. Wierson M, Forehand RL, Frame CL. Epidemiology and treatment of mental health problems in juvenile delinquents. Advances in Behaviour Research and Therapy 1992;14:93–120. 6. Doreleijers TA, Moser F, Thijs P, van Engeland H, Beyaert FH. Forensic assessment of juvenile delinquents: prevalence of psychopathology and decision- making at court in the Netherlands. J Adolesc 2000;23:263–75. 7. Zagar, RA, Arbit J, Hughes JR, Busell, RE, Busch K. Developmental and disruptive behavior disorders among delinquents. J Am Acad Child Adolesc Psychiatry 1989;28:437–40. 8. Milin R, Halikas JA, Meller JE, Morse C. Psychopathology among substance abusing juvenile offenders. J Am Acad Child Adolesc Psychiatry 1991;30:569–74. 9. Lennings C, Pritchard M. Prevalence of drug use prior to detention among residents of youth detention centres in Queensland. Drug Alcohol Rev 1991;18:145–52. 10. Atkins FD, Krantz S. Stress and coping among Missouri rural and urban children. J Rural Health 1993;9:149–56. 11. Elgar FJ, Arlett C, Groves RM. Stress, coping styles and behaviour problems in rural and urban adolescents. J Adolesc 2003;26:505–13. 12. Tarter RE. Evaluation and treatment of adolescent substance abuse: a decision tree method. Am J Drug Alcohol Abuse 1990;16:1–46. 13. Tarter RE, Kirisci L. Validity of the Drug Use Screening Inventory for predicting DSM-III-R substance use disorder. Journal of Child and Adolescent Substance Abuse 2001;10:45–53. 14. Kirisci L, Tarter RE, Hsu TC. Fitting a two-parameter logistic item response model to clarify the psychometric properties of the Drug Use Screening Inventory for adolescent alcohol and drug abusers. Alcohol Clin Exp Res 1994;18:135–41. 15. Achenbach TM. Manual for the Youth Self-Report and 1991 Profile. Burlington (VT): University of Vermont Department of Psychiatry; 1991. 16. Patterson GR, Reid JB, Dishion TJ. Antisocial boys. Eugene (OR): Castalia; 1992. Author(s)Manuscript received October 2002, revised, and accepted May 2003. 1Research Fellow, School of Social Sciences, Cardiff University, Cardiff, Wales. 2Research Statistician, Centre for Rural Health Studies, Memorial University of Newfoundland, St John’s, Newfoundland. 3Director, Centre for Rural Health Studies and Professor of Family Medicine, Memorial University of Newfoundland, St John’s, Newfoundland. 4Assistant Professor of Family Medicine, Memorial University of Newfoundland, St John’s, Newfoundland. Address for correspondence: Dr F Elgar, School of Social Sciences, Glamorgan Building, King Edward VII Avenue, Cardiff, Wales CF10 3WT e-mail: elgarf@cardiff.ac.uk
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