MHYO Volume I - STATE OF ART, CHALLENGES AND GOOD PRACTICES

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INTERNATIONAL JUVENILE JUSTICE OBSERVATORY (IJJO) Rue Mercelis, 50. 1050. Brussels. Belgium Phone: 00 32 262 988 90 oijj@oijj.org www.ijjo.org

PARTNERS

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ASSOCIATE PARTNERS ASSOCIATE ASSOCIATE ASSOCIATE PARTNERS PARTNERS PARTNERS ASSOCIATE PARTNERS

With the support of the Prevention of and Fight against Crime Programme European With With theCommision-Directorate-General With support the support the of support the of Prevention theofPrevention the Prevention of and of and Fight of Fight and against Fight against Crime against Crime Programme Crime Programme Programme European European European Justice, Freedom and Security With the support of the Prevention of and Fight against Crime Programme European Commision-Directorate-General Commision-Directorate-General Commision-Directorate-General Justice, Justice, Freedom Justice, Freedom Freedom andand Security Security and Security Commision-Directorate-General Justice, Freedom and Security

ASSOCIATE PARTNERS

With the support of the Prevention of and Fight against Crime Programme European Commision-Directorate-General Justice, Freedom and Security

Author International Juvenile Justice Observatory (IJJO) Director of publication Dr. Francisco Legaz Cervantes Project Coordinators Cédric Foussard Agustina Ramos Scientific review Prof. Gary O’Reilly

© IJJO November 2011 Published by the International Juvenile Justice Observatory (IJJO) 50, Rue Mercelis, Brussels, 1050 Belgium. oijj@oijj.org

This publication has been produced with the financial support of the Daphne III programme of the European Commission. The contents of this publicationare the sole responsibility of the International Juvenile Justice Observatory and can in no way be taken to reflect the views of the European Commission.

MENTAL HEALTH RESOURCES FOR YOUNG OFFENDERS EUROPEAN COMPARATIVE ANALYSIS AND TRANSFER OF KNOWLEDGE MHYO

JLS/2008/CFP/DAP/2008-1

MHYO VOLUME I

MENTAL HEALTH RESOURCES AND YOUNG OFFENDERS: STATE OF ART, CHALLENGES AND GOOD PRACTICES

Index

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Foreword

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Acknowledgements

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Project Overview: Objective and methods

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Preface

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Introduction

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Chapter I: How will international standards at UN and EU level protect children and young people in conflict with the law suffering from mental illness?

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Mental Health and Young Offenders in the EU Member States

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Chapter II: Psychiatric problems and juvenile delinquency: scientific links support calls for innovative management, Belgium

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Chapter III: Mental health Intervention for young offenders in France: between the child psychiatry issue and the reform of juvenile justice

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Chapter IV: Mental health of young offenders in the Italian context: analysis of the phenomenon, interventions and recommendations

112

Chapter V: Young offenders and mental health in the Netherlands: profile, legal framework and interventions

181

Chapter VI: Analysis of the current situation of young offenders with mental problems in Poland

253

Chapter VII: Young offenders and mental health: the Portuguese experience

299

Chapter VIII: Legal and Care resources for young offenders with mental health issues: The Spanish intervention approach and regulation

332

Chapter IX: Promoting emotional and social well-being – the mental health needs of young offenders in the United Kingdom

378

Youth justice and Mental Health: Intercontinental Challenges and best practices

455

Chapter X: Mental Health and Child Justice in Africa: A brief appraisal of the law and practice

456

Chapter XI: Juvenile Justice and Mental Health in Brazil: context, perspectives and challenges

471

Conclusions

505

Annexes

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MHYO VOLUME I

Foreword

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by Dr. Francisco Legaz Cervantes Chairman of the International Juvenile Justice Observatory

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Recently more attention has been given to the trend of minors and young people who carry out illegal behaviour and who also suffer from mental health disturbance or illness, associated in large part with the consumption and abuse of drugs. These are minors and young people in whom mental illness, either alone or in combination with addiction to toxic substances, has been the cause or a contributing factor to the occurrence of antisocial behaviour.

When in 2006 a European Union strategy on mental health1 was mentioned, the European Parliament pointed out that with regards to adult delinquents “approximately 40% of prisoners suffer from some form of mental illness, and the probability of them committing suicide is seven times greater compared to people who are integrated into society. Inadequate prison conditions can aggravate illness and impede rehabilitation”. In the case of young detainees, they have a greater tendency to develop mental illness than adults, given that 95% of them suffer from at least one mental health issue and 80% suffer from more than one illness2 (Lader et al., 2000).

According to Prison Reform Trust3, the probability of minors of detention age committing suicide is eighteen times higher than for people who live in the community.

Evidence must be provided to support the objective and quantitative data (which experts deem to be irrefutable). Scientific discoveries in recent years, in the fields of genetics and neuroscience, are leading to profound transformation in the areas of knowledge and intervention relating to mental illness. Furthermore, if we bear in mind that the first onset of mental disorders usually occurs in childhood or adolescence4, the search for a new focus in the understanding of mental disturbances is a truly fascinating one, which will without doubt have consequences for the prevention, diagnosis and treatment of mental health disturbances.

1 European Parliament (2006). European Parliament resolution on improving the mental health of the population. Towards a strategy on mental health for the European Union (2006/2058(INI)).

2 Lader, D., Singleton, N. & Meltzer, H. (2000). Psychiatric morbidity amongst young offenders in England and Wales. London: Office for National Statistics.

3 Prison Reform Trust (2007). Prison Factfile Bromley Briefing May 2007. London: Prison Reform Trust.

4 Kessler RC, Amminger GP, Aguilar-Gaxiola S, Alonso J, Lee S, Ustün TB. Age of onset of mental disorders: a review of recent literature. Curr Opin Psychiatry. 2007. Jul;20(4):359-64.

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FOREWORD

Young offenders with a mental health illness find themselves in a paradoxical situation, facing two different systems which categorise them in a contradictory manner: the judicial system considers them to be a delinquent, and the health system considers them to be a victim of mental illness. This is the reality which should lead us to the following consideration: minors with mental health disturbances should not be criminalised, whilst at the same time neither should young offenders be pathologised.

The use of specialised methods and tools for the diagnosis, detection and evaluation of mental health problems should be considered highly relevant in the process of intervention with these minors. It is very important that these minors and young people whose deviant behaviour (which we maintain is caused or facilitated by the mental disturbances from which they suffer) places them in the middle of a criminal process, perceive the various professionals who work with them not as separate entities but as teams which are completely involved and integrated, and that collaborate closely from a multidisciplinary perspective.

This outlook of the problem and model of action is one which is supported by expert organisations and institutions in this area, including the International Juvenile Justice Observatory, who are committed to finding solutions.

The International Juvenile Justice Observatory began its journey in 2003 as a consequence to increased awareness of the connection between minors and young people in conflict with the law, regardless of their location, and the variety and insufficiency in many cases of response from various organisations and judicial and political systems.

With the topic of Juvenile Justice without Borders, the IJJO has become a space for finding and collaborating with professionals, experts, institutions, etc., to improve international development of policies, programmes, research and resources aimed at preventative and sanctioned educational action that permits effective integration of minors and young people in conflict with the law. All of this is within the framework of international norms and standards adopted by the United Nations, with the United Nations Convention on the Rights of the Child as a reference point.

The commitment of the IJJO should be strengthened in times such as this. Facing the global economic crisis we must continue working to ensure that socio-economic circumstances do not negatively affect collective needs for better protection for minors and young people in conflict with the law and for those who suffer from mental health disturbances. The IJJO recognises the growing interest in and concern for this area in the research, journals and meetings we have organised or participated in.

In this context, and within the DAPHNE III Program, the European Commission supported the IJJO in the development and coordination of a research, analysis and comparative project into the current situation in Europe of young offenders with mental health problems. This was carried out in collaboration with other European

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organisations and institutions that share an interest in this area. The “European Comparative Analysis and Knowledge Transfer of Mental Health Resources for Young Offenders” (MHYO) is an innovative project with the objective of sharing knowledge and experience regarding minors that, as victims of mental health disturbances, have infringed criminal law, leading them into a vicious circle of delinquency and recidivism.

This project has created a training and good practice framework adapted to the needs of professionals working in the areas of development and psychological processes in young people, within an integrated and multidisciplinary perspective of the justice and health systems.

Within the framework of this research project, the IJJO decided to make this topic a key issue in its international conference in Rome in November 2010. The title was “Development of Integrated Juvenile Justice Systems: Focus on and Methodologies for Mental Health Disturbances and Drug Abuse” and within the IJJO training and research framework, this fourth meeting of experts and professionals from various continents aimed to examine, debate and evaluate, from a multidisciplinary perspective, the problems and challenges of these pathologies and additions to the field of juvenile justice.

The result of the conference made evident the need to articulate programs and resources that permit effective intervention with minors and young people with mental health issues and/or the consumption of toxic substances which in turn leads them to conflict with the law. The development and promotion of integrated juvenile justice systems with close coordination and collaboration in judicial, health and socio-educational matters is considered essential.

The publication of these two volumes is a consequence of the work, debates and experience developed over the course of the current MHYO project. The publications recognise the results of developed interdisciplinary work in which the perspectives of the various participating organisations and institutions come together: nongovernmental organisations, administrative bodies and universities. The authors state the pressing need for innovative mechanisms capable of generating change and a convergence of organisations and agents who have a responsibility in intervention with young offenders with mental health issues, including judicial, health and welfare. The creation and specialisation of resources within the juvenile justice system regarding mental health issues for young offenders is also equally important, on local, regional and national levels.

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FOREWORD

Acknowledgements

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Cristina Goñi Secretary General. International Juvenile Justice Observatory

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The many European partners who have supported the DAPHNE III Program ‘European comparative analysis and knowledge transfer on mental-health resources for young offenders’, in various ways, include The European Commission, the external expert reviewers - Ms. Marianne Moore and Mr. Gary O’reilly-, stakeholders in the field, researchers, and the IJJO team.

Moreover, we have received great contributions from representatives of United Nations, EU institutions, national and regional local authorities, university experts and NGOs, which participated in the 9th and 10th November 2010 at the Fourth IJJO International Conference, in Rome (Italy) under the title ‘Building Integrated Juvenile Justice systems: Approaches and methodologies regarding mental disorders and drug misuse’ achieving a comprehensive understanding of the situation of young offenders with mental disorders.

We do appreciate and thank the special collaboration and contribution of the international experts with all their knowledge, expertise and vocation to improve the situation and treatment of young offenders with mental health issues.

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Project overview: Objective and methods

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by CĂŠdric Foussard. Director Agustina Ramos. MHYO Project Coordinator International Juvenile Justice Observatory

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The European Comparative Analysis and Transfer of Knowledge on Mental Health Resources for Young Offenders, hereafter referred to as MHYO project, is an innovative project which has been developed in cooperation with eight different European countries throughout the last 2 years. The Project aimed to share knowledge and expertise concerning young offenders with mental health (MH) issues, meaning children and youngsters, who are at the same time offenders and victims of their own mental health.

The MHYO project paid special attention to young offenders with mental health issues who are in contact, on the one hand, with the judicial system which considers them only as an offender, and on the other hand, the health system which recognises the same child as a victim of a mental disorder.

European Union Member States have to face similar problems in terms of developing an effective way to enhance the collaboration of health, social, and justice institutions dealing with children in conflict with the law. In this context, the MHYO Project’s aim was to study the different national mechanisms to promote the necessary changes both in policy and practice, as well as to agree on minimum standards concerning the functioning of institutions dealing with young offenders, including judicial services, across the EU. As a result of this research, the lack of specific mental health programmes within juvenile justice systems in the different countries has become evident. In this context, it has been a priority of the MHYO Project to focus on the identification of practices which have improved the MH services for young offenders, as well as, fostering the cooperation between different entities in charge.

Young offenders with mental health issues: a common European problem to be addressed.

Throughout the last decade, a lack of adequate treatment as well as accurate strategies and policies to deal with young offenders with mental health issues has been identified across Europe. According to several national studies (see bibliography), children and young people in detention are struggling with a high risk of mental pathologies or

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PROJECT OVERVIEW: OBJECTIVE AND METHODS

disorders, a situation that has not been sufficiently taken into account. These young people are at risk of even a greater prevalence of poor mental health than adults, facing at least one mental health problem. Moreover, they often lack proper assistance which leads them to mental breakdown or finding suicide the best solution for their current situation.

In conclusion, the most crucial task for the EU as well as national entities is the recognition of the needs of young offenders with mental health problems, illnesses or disorders, when designing the policies and strategies in the fields of justice, health or children’s rights.

European as well as national entities dealing with young offenders with mental health issues need to address the set of identified issues including: the essential need for early screening and assessing of mental health problems, illnesses or disorders among children and young people which might prevent them from entering the justice system; appropriate placement within facilities suitable for the effective treatment of their mental health issues; improvement of training standards of personnel who work with young offenders with mental health issues; application of multi-disciplinary and multi-agency approaches enhancing the communication and collaboration, aimed at safeguarding the wellbeing of children and young people with mental health issues, illnesses and disorders.

As a result, a prevailing objective for European countries, instead of institutionalising mental health illnesses through prisons, juvenile justice or health, should be facilitating the provision of individual, adapted to particular needs of children and young offenders with mental health issues - resources, through for example creation of specific units or community therapy.

An effective liaison between judicial and mental health professionals would develop a multidisciplinary common framework of intervention to prevent recidivism.

The Project´s global strategy focused on the analysis of the national health and judicial systems for young offenders with mental health disorders aged between 10 and 21 years old. The basis of the present study is the research findings on the comparative analysis of the national legal frameworks, as well as European good practices. The research has identified the current treatment strategies for young offenders with mental health issues in order to promote practical tools and adequate policies that involve children’s mental health and the juvenile justice systems.

Within the Framework of the MHYO European research project representatives of UN, EU institutions, national and regional authorities, university experts and NGOs,

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gathered on the 9th and 10th November 2010 in Rome (Italy) to participate in the Fourth IJJO International Conference, entitled: ´Building Integrated Juvenile Justice systems: Approaches and methodologies regarding mental disorders and drug misuse’.

The main objective of the above mentioned conference was to investigate how the needs of young people with mental health problems can be managed in the juvenile justice system through a coordinated, integrated multi-agency response, identifying the support required for such an approach and for achieving successful cooperation.

To achieve this goal the Conference programme was divided into two main themes.

First, it concentrated on mental health disorders and drug misuse amongst minors in conflict with the law. It included conducting the study on the situation of young offenders with mental disorders or disorders related to drug misuse, in order to identify appropriate interventions on the basis of the young offender’s profile in the psychosocial context. The analysis also highlighted that the establishment of accurate definitions on integrative interventions for young offenders with mental disorders and with addictive behaviour were of great importance.

The second theme concentrated on the juvenile justice and health systems necessary to enhance their multidisciplinary and integrative collaboration. In this field the conference called for: more effective and coordinated communication between sectors, development of common intervention tools, and promotion and establishment of common links between the different systems.

Altogether, more than 350 representatives from 50 countries coming from Europe, America, Africa, Asia Pacific also debated juvenile justice issues more broadly, including: the study of the situation of minor offenders suffering from mental health disorders or drug misuse; the juvenile justice systems´ responses to the offences committed by minors or young people that suffer from mental disorders; the profile of the minor offender and the analysis of resources employed towards his/her social integration and the ethical aspects of the treatment of Mental health disorders.

The conference emphasised the need to achieve a comprehensive understanding of the situation of young offenders with mental disorders referring to their individual social, familiar and personal circumstances, improving an integrative and multidisciplinary coordination and collaboration between all the stakeholders and agencies involved in the field. The IJJO’s main focus for 2010-2012 is to take forward the concrete recommendations of the Scientific Committee of the Fourth International Conference, on the promotion in the international and European agenda of an improvement of health resources for young offenders in prevention and intervention policies, to provide an effective response for minors.

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PROJECT OVERVIEW: OBJECTIVE AND METHODS

To conclude, the current project delivered strongly against its expected results. The Observatory is pleased to present two volumes of MHYO Publications which document these results - firstly Volume I ‘Mental Health Resources and Young Offenders: State of art, challenges and good practices’, and secondly Volume II ‘MHYO Manual for improving professional knowledge and skills, and developing advocacy programme. The first section of this Manual sets out MHYO training tools for improving professionals’ knowledge and skills, and the second section includes recommendations and an advocacy programme.

Volume I (‘Mental Health Resources and Young Offenders’) contains an analysis of the current status of mental health of young people in conflict with the law, conducted in different European countries such as: Belgium, France, Italy, the Netherlands, Poland, Portugal, Spain and the UK. Each national report gave an insight into the problems of serious mental health issues that young people, involved in criminal behaviour, struggle with. Each country described its legal framework for juvenile offenders and principles of the access to appropriate services. Therefore, the main emphasis in Volume I, has been put on the mentally ill juvenile offender’s profile, the specific legal framework concerning penal and child care and the role of professionals and development of their skills. In addition, Volume I also explores the effectiveness of applied intervention approaches in European countries as well as recommendations and concrete proposals for good practices. It also includes the contributions of Brazil and the continent of Africa which allow us to gain an understanding and comparative insight into the situation of children in conflict in the law with mental health issues.

The International Juvenile Justice Observatory‘s Mental Health and Young offenders Manual Volume II is aimed at improving professional knowledge and skills. This is a global manual for all of the stakeholders in contact with young offenders with mental health problems. Thus, the international partners of the MHYO project have contributed their knowledge and expertise in the preparation of this second Volume.

The first section, the MHYO Training Tools for improving professional knowledge and skills has been designed to guide the reader through the pathway of young offenders with mental issues through the criminal justice system. Each point of contact of the young people with health and justice agencies or professionals is described to allow the reader to consider the different difficulties and problems a young person can face.

Each chapter can be read in chronological order or separately. The second section is a toolkit for advocacy, MHYO Advocacy Tools. It aims to help national stakeholders and experts to develop an advocacy and evaluation program to improve the provision for young offenders with mental health problems, illness and disorders.Therefore, three tools have been developed to allow the development of national advocacy programmes thanks to, firstly the MHYO Recommendations (as a result of the 4th IJJO International Conference together with its Scientific Committee and the MHYO project partners)

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in order to bring this problem to the national agenda, then, secondly, an evaluation toolkit to evaluate national specific programs and resources for MHYO target group, and finally a ‘Charter for the rights of children deprived of liberty with mental health issues’ in order to foster the cooperation between professionals and to set up standards at national level.

The IJJO would like to thank the MHYO partners, external experts’ reviewers, the Fourth IJJO Scientific Committee, the European Commission and the intercontinental contributors, without all of whom the development of this ambitious, challenging and important project, would not have been possible.

Special gratitude is extended to all those who have been surveyed or who have responded to the questionnaire. These responses were the basis for drafting each national report and outline of good practices.

Finally, the IJJO would like to express its gratitude for the support and contribution of the African and Brazilian perspective that broadened our knowledge, enhanced our understanding, and allowed us to place relevant results of European study on children and young offenders with mental health issues, in the global context.

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Preface

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by Ms Frances Fitzgerald T.D. Minister for Children and Youth Affairs. Ireland

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It gives me great pleasure to be associated with the European Comparative Analysis and Transfer of Knowledge on Mental Health Resources for Young Offenders (MHYO) and particularly this publication which has great relevance to the Irish context.

The MHYO is an important project which aims to share knowledge and expertise on young people in conflict with the law who have mental health needs. Such information is essential in enabling us to identify the most effective interventions and make positive changes for these young people.

The project also provides youth justice workers with practical guidance on identifying and responding to young people’s mental health needs. This might mean planning an intervention that promotes positive mental health or identifying if more specialist assessment and intervention is required.

The Department of Children and Youth Affairs is committed to leading the effort to improve outcomes for children and young people in Ireland. Youth justice is now under the remit of my Department specifically the section managing the children detention schools. The section responsible for community programmes remains under the Department of Justice and Equality but their co-location in my Department facilitates close working relationships on key issues of mutual concern. Together we will work with external stakeholders including the Department of Health and the HSE to ensure that young people in conflict with the law who have mental health needs achieve the best possible outcomes.

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Introduction .......................................................................................................................................

by Prof. Gary O’Reilly Dept. of psychology, University College Dublin

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The extent and nature of mental health difficulty among young people involved in the juvenile justice system in various nations has become apparent through recent advances in research in this area over the last decade (Desi, Goulet, Robbins, Chapman, Migdole, & Hoge, 2006). A number of US studies established baseline data through detailed assessments that comprehensively apply the internationally accepted DSM-IV criteria (Diagnostic and Statistical Manual 4th Edition; American Psychiatric Association, 2000) to large samples through the administration of different editions of the Diagnostic Interview Schedule for Children (DISC; National Institute of Mental Health, 2000). The advantage of this system is that mental health status is established through detailed assessment of symptoms experienced by a young person compared with the established criteria for various mental health disorders. This approach ensures a very high reliability of diagnoses. In a pioneering study Wasserman, McReynolds, Lucas, Fisher, and Santos (2002) report that among 292 males (average age = 17 years) recently admitted to post adjudication secure juvenile justice settings in New Jersey and Illinois 68.5% met DSM-IV criteria for at least one disorder. 50.3% met the criteria for a substance use disorder; 32.5% for a disruptive disorder; 19.5% for an anxiety disorder; and 9.6% for a mood disorder. Similar studies indicate rates of psychiatric disorder among detained youth as ranging from 52.1% to 76% (Garland, Hough, McCabe, Yeh, Wood, & Aarons, 2001; Pliszka, Sherman, Barrow, & Irick, 2000).

Vreugdenhil, Doreleijers, Vermeiren, Wouters, and Van Den Brink (2004) extended this approach to mental health assessment to 204 young people resident in six of the nine youth detention centres in the Netherlands. 90% of sentenced detainees met criteria for at least one disorder. High levels of conduct disorder (73%) and substance abuse (55%) were identified among Dutch detainees. Anxiety (9%) and affective disorders (6%) were present among the sample but reported at a relatively lower level. Similarly, Hayes and O’ Reilly (2007) administered the DISC to 30 young people whose average age was 14.9 years who were detained for their criminal behaviour in the Republic of Ireland. They found 83% met DSM-IV criteria for at least one mental health disorder.

Again high rates of conduct disorder (68%) and substance abuse disorders (67%) were evident along with generalised anxiety disorder (10%) and major depression (7%).

Abram, Teplin, McClelland and Dulcan (2003) also administered the DISC system to 1829 male and female youths aged 10-18 years who were randomly selected from Cook

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INTRODUCTION

County Juvenile Temporary Detention Centre in Chicago which detains young people pre-trial or sentenced for a period of less than 30 days. This study again highlights high levels of mental health difficulty, but adds the substantial presence of psychiatric comorbidity among juvenile justice populations, and the influence of gender. Abram et al. report that 27.2% of females and 34.8% of males did not meet the criteria for any DSM disorder. 16.3% of females and 19.3% of males met the criteria for a single disorder.

56.5% of females and 45.9% of males were co-morbid for two or more disorders. The greater co-morbidity among females was statistically significant.

In addition feelings of hopelessness, thoughts of suicide, and actual attempt are identified to a high degree among youth in juvenile detention. Wasserman et al. report 12.3% of their sample had attempted suicide, with 3.1% having done so in the previous month. In a further analysis of the Cook county data, Abram, Choe, Washburn, Teplin, King and Dulcan (2008) report 36.2% of their sample felt life was hopeless. 10.3% reported thoughts about committing suicide in the previous six months. 11% had a history of prior suicide attempt, which was specifically associated with experiencing major depression or generalised anxiety disorder.

The evidence is very clear and consistent. Young people involved in juvenile crime have very substantial mental health difficulties. However, these are very often not documented, recognised, understood, or responded to appropriately within juvenile justice systems the world over. The purpose of the present volume is to document the current status of research in this area in eight different countries and to describe the juvenile legal system in each nation. In doing so it provides clear insight into how well each nation currently balances the administration of juvenile justice with its equal responsibility to guarantee the human rights of its young people ensuring their development, well-being and mental health.

This volume brings together contributions from nine nations on the current status of young people who engage in serious criminal behaviour who also experience mental health problems. The countries included are Belgium, Brazil, France, Italy, the Netherlands, Poland, Portugal, Spain, and the United Kingdom. The present publication provides also a broaden scope through the contribution of Africa. Each national report gives an insight into the wide-scale problem of serious mental health issues among young people who become involved in criminal behaviour. Each nation describes its legal framework for juvenile offenders and to varying degrees how principles of equality of access to appropriate juvenile mental health services are recognised within each nation. It is evident in most nations the provision of appropriate assessment and intervention often lags behind the recognition of what constitutes good practice regarding the mental health care of young people involved in the juvenile justice system. Each national report concludes with a set of pragmatic recommendations

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that would improve the treatment of young people involved in juvenile crime who experience mental health problems.

Africa The authors of the article from Africa begins by analysing the prevalence of mental illness or mental disability in this continent. Therefore, children with mental illness or intellectual disabilities often come into conflict with the law for reasons either directly related to the disability or not. Consequently in their analysis, it is described the contextual reality and the legal framework on justice for young offenders with mental illness in Africa. In addition to this, the author of the African article states that this region is large and wide in range, and it is hard in a short paper to develop in detail the various national circumstances and legislation in African countries. However, the authors gives a broad perspective on this issue and a general overview of the legal framework on the rights of children with mental health problems or disabilities in the African context.

Belgium The authors of the Belgian article highlight and review the literature concerning Juvenile delinquency and psychiatric disturbances in Belgium and provide an analysis of the justice and therapeutic systems for young offenders. In this way, they have developed an innovative model since 2003 which, creates forensic psychiatric units for adolescent delinquents, and more recently at institutional level they have been creating a network of cross sector care (health, education, and disability) based on a strong will of fostering coordination. The authors report that Belgium is at the forefront of research into psychiatric problems in this section of the population, thanks to their programmes providing specific care and education, being developed at the crossroads of judicial, health and youth authorities.

Brazil The author of the Brazilian report indicates that the relatively recent democratization of his nation has resulted in a recognition that children and adolescents are citizens with full and equal rights. This has led to an important shift from an orientation that promoted the exclusion and punishment of young people in conflict with the law to one which also recognises their rights as citizens. As such the Brazilian Statute of Children and Adolescents makes special provision for young people who engage in criminal behaviour who have mental health problems stipulating they require mental health services in an appropriate setting. The provision of these services is the responsibility of the regular state health service. Brazil simultaneously underwent a revision of its mental health system moving away from an institutionally based approach to one of care in the community. The overlap between juvenile justice and juvenile mental health has been the subject of a number of National Mental Health Conferences and a

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INTRODUCTION

national agency established (SINASE) to oversee standards of care for the mental health needs of young people detained for criminal behaviour. However, the author of the Brazilian report describes the experience of youth in the juvenile justice system as one where such a young person is still likely to experience a system where mistreatment and torture are still present. He further argues that the rights as citizens of young people with mental health difficulties who offend is still frequently compromised by the actions of state institutions focused solely on the punishment, detention and segregation of juvenile offenders. The author reports the profile of mental health needs of young people in conflict with the law in Brazil is still unknown. However, a 2008 survey of the practices of 272 detention centres regarding mental health provision to juvenile offenders indicated a high percentage of onward referral to similar types of institution offering mental health services or psychiatric hospitals rather than accessing the regular local health care system. The same survey also found high levels of psychiatric medication use, high levels of use of restraint and isolation, and a lack of cooperation between detention centres and the public health service. The author continues with a clear consideration of how the concept of dangerousness linked to psychopathology can be misused to undermine the development of adolescents and how consequently the quality of the environment in which a young person labelled as “anti-social� is detained can also negatively impact on his development. The author concludes by describing two pilot schemes which represent a positive way forward for managing the needs of young people with mental health difficulties who engage in criminal behaviour while respecting their rights as individual citizens.

France The authors of the French report start their study by putting into perspective the current European relevant studies and researches, with the French practices in order to develop a comparative analysis. In this way, the French report defines the different states of mental development of adolescents in conflcit with the law, the impact of the transition from childhood to adluthood and the process of development of their psychological progress thanks to specific programs for young offenders with mental health issues. Furthermore on a more political perspective, they provide a clear analysis of the ideological influences of the different institutional approaches, mainly divided betwee health and justice systems. The report also describes different programmes and procedures to identify possible models and trends concerning youth justice for young people suffering from mental health issues.

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Italy The authors of the Italian report begin by providing some context on youth mental health from the general international literature. The authors report there are no empirical studies of the rates of mental health difficulties in young people who engage in crime in Italy. Based on joint work from the General Directorate for the implementation of judicial provisions (Italian Juvenile Justice Department, Ministry of Justice) and the Don Calabria Institute they report that mood disorders, anxiety disorders, disruptive disorders, substance abuse and thought disorders are frequently found in young offender populations. Evidence is presented of increasing drug use among young people in contact with the Italian justice system. They highlight that 50% of young people coming into contact with the juvenile justice system are non-Italian nationals. The legal framework of youth justice in Italy is under-pinned by principles of simplicity of process to ensure a minimum disruption the young person’s educational development.

Young people in detention in Italy are described as potentially being subject to a Tailored Educational Programme by a judge that may attempt to assist the young person in a number of dimensions of their life including psychological intervention.

While all juvenile offenders are assessed by a general medical practitioner who may seek further assessment from other specialists if he deems this appropriate, there is no standardised screening system or screening tool to establish mental health status currently in use in the Italian system. Mental health services for young offenders are accessed through the same public and private services used by the general population.

The provision of mental health services to juveniles in the criminal justice system is the responsibility of the National Health Service since 2008. There is no specialist training within the juvenile justice system or mental health system regarding young people who criminally offend who also have mental health difficulties.

The report concludes with recommendations for good practice. It does so through a series of interviews with key stakeholders in the Italian juvenile justice and mental health system. They make a number of key recommendations including the need for national planning to provide adequate services for young people involved in crime who have mental health difficulties, the need for structured approaches to the assessment of mental health difficulties in young people involved in crime, and the need for greater provision of services to meet the mental health and drug addiction problems of young people who become involved in crime.

Netherlands The report form the Netherlands clearly describes the current state of a national approach to juvenile offending from a society which has made considerable attempts to move away from a purely punitive approach to a system oriented towards assisting young people towards rehabilitation and a cessation of their criminal behaviour.

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The author begins by establishing the research evidence to show the rates of mental health difficulty in young people engaged in criminal behaviour in the Netherlands.

From this data some interesting findings are clearly established: The rates of mental health difficulty among young people who engage in crime are 6-7 times higher than those among young people who do not. There is a correlation of increasing mental health difficulty with increasing rates of criminality as evidenced by those who receive a custodial sentence. Some types of mental health difficulty are particularly prevalent: externalising disorders; affective disorders; substance abuse disorders; and personality disorders. The presence of intellectual disability is also identified as a factor found at significantly higher rates among all juvenile delinquents (9%) and those who are incarcerated (60%) compared to population rates of roughly 2%. Further problematic behaviours and experiences associated with mental health difficulty are also found in young people in detention including trauma, suicidal behaviour, self-harm, and risky sexual behaviour. The author goes on to indicate that a national database on the background characteristics of young people who offend will be established in 2012 but already there is clear evidence that they are often identifiable through disrupted behaviour in school where they also experience significant learning problems, have a range of social and psychological vulnerabilities, experience poorer health and diet, are over represented in lower socio-economic groups and migrant groups. The evidence from the Netherlands further indicates that the family life of young people who engage in criminal behaviour is characterised by adversity and disadvantage. The problems faced by their families include poverty, substance abuse, violence, separation and divorce, insecure attachment to parents, being taken into care and inconsistent placements. The author concludes this section by establishing that many young people simultaneously experience more than one mental health difficulty. From this extensive review of relevant research the author concludes that the evidence from the Netherlands indicates that there are five areas of special need in the life of young people who engage in criminal behaviour: 1. their mental health; 2. education/work; 3. social relationships; 4. risky behaviour; and 5. violent behaviour.

The youth care system in the Netherlands is described as child and family centred in its orientation. The author describes a system characterised by easy access, integration of services and designed to meet the needs of clients rather than fitting clients into services. A philosophy informs this system which is oriented towards helping a young person change their criminal behaviour so as not to re-offend rather than to punish the young person. It is described as a system that offers a continuum of response to juvenile crime from referral to appropriate youth support services, to diversion from the youth justice system to organised restorative activities, to alternative sanctions such as community service, to detention. When detention is the outcome of legal proceedings an effort is made to avoid punishment for punishment´s sake and forensic mental health professionals assist the court in their determinations.

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The report from the Netherlands very clearly and helpfully delineates the training and experience of the various professionals who come into contact with young people who engage in criminal behaviour and outlines suggestions for training that would further enhance their practice. For the legal profession training in how to better use a system that promotes behavioural change in young people convicted of criminal behaviour is suggested along with support for an initiative that encourages skilled, experienced lawyers to take on juvenile cases. A need for an increased number of mental health professionals is identified. For existing mental health professionals training in cultural issues for immigrants is recommended, along with training in knowledge of the legal system, and specific assessment and intervention techniques, particularly family therapy. For care staff it is acknowledged that the Dutch system has moved towards a philosophy of intervention rather than control. As such training to support the development of providing young people with pro-social skills is recognised. The authors also outline practical obstacles to inter-professional co-operation and some examples of best practice.

The report outlines impressive wide-scale programmes designed to assess and tackle problematic behaviour in young children that may leave them vulnerable to the development of criminal behaviour. A widely used Dutch screening tool developed by the Child Protection Board (the BARO) is described. With regard to intervention an emphasis is placed on evidence based programmes and some very effective evidence based examples developed in the Netherlands are described in the areas of parent training, the promotion of positive behaviour in children, and functional family therapy.

The report from the Netherlands concludes with the following recommendations.

There is a need to support the training of lawyers with special expertise in working with young people who offend. There is a need for the provision of an increased number of mental health professionals with specific training in youth mental health in a forensic context. There is a need to motivate staff to work in this area and to ensure they do not experience burn-out. There is a need for a continuum of services from detention centres to the community. There is a need for the further integration of services in the judicial system, the mental health system, and the child protection system to better understand and intervene with young people with criminal behaviour and mental health difficulties.

Poland The author of the report from Poland begins by indicating that there are no official research studies on the rates of mental health difficulty in young people involved in the juvenile justice system. Consequently their description of the mental health status of young people involved in juvenile crime is based on interviews with professionals

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working in this area and reports from centres of detention. The latter indicate that 93% of young people in detention in Poland experience some form of mental health difficulty. Intellectual functioning in the Intellectually Disabled range is also reported to be about four-five times higher than that expected in the general population. A report from the Polish Ministry of Justice indicates that interviews with professionals working with young people in custody indicate that all experience significant family dysfunction. The author of the Polish report particularly identifies the developmental vulnerability towards violence and criminality among those children who were among the thousands of former residents of over-crowded and poorly staffed orphanages.

This is an important developmental vulnerability towards mental health difficulty and criminality uniquely identified in the Polish report. The legal framework for youth justice in Poland is described as stemming from the 1982 Juvenile Act which defines juveniles as aged between 13 and 18 years for the purpose of criminal proceedings and up to the age of 21 for educational and reformatory measures. Family courts may order a range of measures which include required participation in restorative or educational classes, or the appointment of a supervising professional, or placement with a foster family.

The most severe judicial response is placement in a centre of detention. The author describes very clearly different options available for management of young people in detention. The child care system is also clearly described as comprised of elements of various governmental ministries in Poland including Education, Justice, Health, Labour and Policy, and the Interior. The author also outlines detailed legislation regarding children’s rights and the practice of various professionals regarding confidentiality and its limits. A clear need is identified for specific training in working with young people in a juvenile justice context who experience mental health difficulties for professionals with either a legal or mental health background. The author describes a centralised service with some regional organisation available to assist young people in the court system in Poland who have mental health assessment and intervention needs. The operation of this service and the assessment and intervention approaches it follows are well described. The report concludes with a number of recommendations including the need for greater provision of regular juvenile mental health care across many currently un-serviced regions of Poland, the need for more professionals qualified to work in the area of juvenile mental health, the greater inclusion of family in interventions for young people with mental health difficulties who are involved in juvenile crime, and the development and rolling out of preventative programmes.

Portugal The author of the report from Portugal indicates there are no research data on the extent of mental health problems in children and adolescents in the general population. There are also no research data on the rates of mental health difficulties in young people who engage in criminal behaviour. However the author indicates that a Portuguese Directorate General of Social Reintegration survey in 2008 reports that

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54% of young people in detention centres met the diagnostic criteria for one or more psychiatric disorders under the DSM or ICD classification system of mental disorder.

The author also reports that in Portugal although planned, there are at present no specific residential centres designed to meet the mental health needs of the juvenile offender population with personality disorders or serious addictions. The juvenile detention system in Portugal is described as providing for the mental health needs of young people through accessing private care or accessing the local public health system.

The author also describes the juvenile justice law in Portugal. The age of criminal responsibility is 16 and those aged between 12 and 16 years who commit a crime are subject to educational intervention which can range from receiving a verbal warning, to community work, to supervision, to detention in an educational centre. Within community based sanctions a judge may seek a mental health assessment of a young person but their entry into treatment requires the young person’s consent when they are 14 years of age or older. The author describes the Government policy in relation to general youth mental health as having three levels, primary care for cases requiring low levels of intervention provided locally, specialist local services, and specialist regional services. However, actual service provision at each level meeting this plan is described as still very limited. Portugal is also described as having a separate child protection law. In February 2011 the Portuguese government proposed an amendment to the juvenile justice law to ensure that young people in custody receive therapeutic input for any mental health difficulties with which they present. As of yet this proposal has not been enacted.

The author identifies a need for the co-ordination of staff and agencies in Portugal who come into contact with young people who engage in criminal behaviour who also have mental health problems. Available protocols for the confidential handling of data on young people who engage in criminal acts is described. There is no specialist training for professionals working with young offenders who have mental health difficulties.

However, brief training events are sometimes organised by various state and private institutions.

A presentencing assessment of all young people for whom detention at an educational centre is being considered is mandatory in Portugal. Formal assessment by mental health professionals involves the gathering of information from parents and the young person through interview and standardised measures. For those young people in the custodial rather than the educational system Portuguese law enacted 9 years ago makes provision for specialist therapeutic centres. However, as of yet these have not been established. There are no nationwide programmes aimed at targeting youth at risk of mental health difficulty and criminal behaviour. Some personal development

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programmes are, however, available within the school system.

The author of the Portuguese report makes a number of recommendations. These include the need for special training to be incorporated into the current training of professionals who will come into contact with young people who engage in criminal behaviour who also have mental health problems. National research to establish the extent of the mental health difficulties of young people who engage in criminal behaviour in order to appropriately plan services. The need for preventative programmes which are community based which can identify and intervene at an earlier stage with youth at risk of behavioural problems and associated mental health difficulties.

The need for further awareness of youth mental health among professionals in the juvenile justice system. And the need for greater inter-agency and inter-professional co-operation.

Spain The authors of the Spanish report begin by establishing that national studies of the rate of childhood mental health difficulties for the general population are not available. Instead, studies of specific communities provide relevant information on the mental health status of young people in Spain. From the limited information available it is reported that 21.7% of regular young people experience some form of mental health difficulty. In relation to the mental health of young people who engage in criminal behaviour there are no formal research studies to draw from. Consequently the Spanish report provides evidence from a Youth Rehabilitation Therapeutic Centre (Pi Margall) founded in 2002 to accommodate 14 young people and subsequently expanded to cater for 20 young people aged between 14 and 18 years. The evidence from this centre from the year 2009 indicates that young people in Spain detained for their criminal behaviour experience mental health difficulties most frequently in the areas of conduct disorder and other disruptive disorders, substance abuse, difficulties associated with experiences of family violence and neglect, difficulties associated with sexual abuse, and sexually abusive behaviour. At the Pi Margall centre, of the total number of young people who experienced a mental health difficulty 78% also had more than one disorder.

In section 3 the Spanish report begins by describing special legislation to deal with the criminal behaviour of minors. The mental health needs of young people who engage in criminal behaviour is the responsibility of the universal free national Public Health System. However the authors report the Spanish health system does not have a speciality for child and adolescent psychiatry but does have special units providing mental health services solely to children and their families. They also indicate that the provision of special residential settings for young people in need of placement outside the home for mental health or child protection are very limited as are community based services. Spanish law allows the mitigating effects of mental health difficulties

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on the part of the young person to be taken into account and juvenile courts have discretion to direct that the young person receives appropriate assistance. The mental health needs of the young person takes priority over the punitive aspects of the judicial system.

The authors report that a key principle of the Spanish Framework Law on the criminal liability of minors is the integration of judicial procedure with appropriate assistance from psychologists, social workers and social educators. There are reported to be no specialist training for mental health professionals in dealing with the specific needs of young people who engage in criminal behaviour. Instead, the generic skills of mental health professionals are utilised. The Spanish report indicates that often mental health professionals dealing with the needs of young offenders do so with very limited training or understanding of the relevant Spanish framework law regarding the criminal responsibility of minors.

The authors of the Spanish report indicate that there is no standardised system or protocol used for routinely assessing the mental health needs of young people detained for criminal behaviour. In many instances young people have had frequent previous contact with the public mental health systems and accumulated between 3 and 5 different psychiatric diagnoses in the process. It is usual practice for this information on previous diagnoses within mental health services to be available to medical staff attached to juvenile centres of detention. With regard to suitable intervention for the mental health needs of young people who engage in criminal behaviour, the Spanish authors indicate that the principles applied to their needs are to understand them from a bio-psycho-social perspective. Intervention programmes are informed by the international “what works� literature, emphasising cognitive-behavioural models and avoiding punitive approaches or psychoanalytically informed models. The Pi Margall centre’s approach is described as an example of good practice in Spain as it blends individual therapy with family therapy and group work.

The Spanish team makes a number of recommendations. They suggest that young people at risk of criminal behaviour who have mental health difficulties should be targeted for early diagnosis in childhood and a suitable preventative intervention programme offered to them. This is best achieved according to the authors through the regular health-care and education system. They also recommend the need for the development of the speciality of child and adolescent psychiatry in Spain along with specialist training for staff working with juvenile offenders with mental health needs. They recommend research to better understand the mental health needs of the general youth population in Spain encompassing the special sub-group of young people who also engage in criminal behaviour. Finally, they recommend the need for co-ordinated plans and action to meet the needs of young people who offend who

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also have mental health needs between Government Ministries of Social Welfare, Education, Health and Justice along with the different public and private institutions involved.

United Kingdom The authors of the UK report begin by drawing on a number of national studies which clearly illustrate that young people who engage in serious criminal behaviour have significant mental health problems. They report 1 in 10 children aged between 5-16 years in the general population have a diagnosable mental health disorder. This compares with 43% of young offenders on community sanctions. Learning difficulties, and experiences of abuse and neglect are also more common. Their criminal behaviour is contextualised by the various adverse developmental experiences described by the authors and the significance of family dysfunction and substance abuse are highlighted.

The authors describe a context where the criminal behaviour of these young people requires not simply a judicial response but also an appropriate and evidence based response to their mental health needs. This combined approach has the potential to reduce their personal suffering and reduce their risk of re-engaging in criminal behaviour in their community.

The authors of the UK report clearly describe complex legal frameworks covering youth justice legislation, child welfare legislation and mental health legislation. They provide a clear account of how these three aspects of government in the UK have an overlap in the lives of young people who engage in criminal behaviour and convey a sense that in the construction of each system the points at which they overlap were not formally integrated. As such successfully dealing with the criminal justice needs of society and the mental health needs of young offenders while respecting their rights as children depends on an ad hoc co-ordinated approach of relevant services and on the quality of the staff and resources available.

The UK describes examples of good practice in meeting the mental health needs of young people within the youth justice system in the UK. In particular the potential benefit of a “reach-in� system by local Child and Adolescent Mental Health Services (CAMHS) is described. Within this system young people in offender institutions receive the assessment and intervention needs offered by their local CAMHS team as a normal part of their custody. The benefits for the young people concerned and the staff in the units in which they reside are described. However, the provision of this system depends on the resources available for youth mental health in different locations. In this way a promising system that needs support in its further development is described. A further issue is highlighted regarding the need for continuity of care for the mental health of young people as they transition back into their communities after a period of detention.

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Commonly used standardised instruments for assessing the mental health needs and personal strengths of young people in the criminal justice system are described.

They also describe some of the effective intervention strategies for young people who engage in criminal behaviour with mental health needs including multi-systemic therapy, cognitive behavioural therapy and parenting programmes. The authors give an emphasis to interventions informed by the principles of attachment theory.

The authors of the UK report identify the need for staff charged with responsibility for young people in detention to have suitable training and qualification in mental health in order to appropriately assess and intervene to meet the needs of young detainees.

They identify a particular need to address the national shortfall in the UK of suitably trained psychiatrists and psychologists. Within existing staff training they feel that those with responsibility for residential aspects of care would be assisted by training informed by attachment theory. They recommend a need for continuity of care from residential settings to a young person’s community. Finally the authors conclude that examples of good practice integrating criminal justice and mental health services do exist in the UK but these are to the credit of local agencies and local personnel. They require structured global support to ensure all young people who need to benefit from them do so.

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References Abram, K. M., Choe, J. Y., Washburn, J. J., Teplin, L. A., King, D. C., & Dulcan, M. K., (2008).

Suicidal ideation and behaviours amoung youths in juvenile detention. Journal of the American Academy of Child and Adolescent Psychiatry, 47 (3), 291-300.

Abram, K. M., Teplin, L. A., McClelland, G. M., & Dulcan, M. K., (2003). Comorbid psychiatric disorders in youth in juvenile detention. Archives of General Psychiatry, 60, 1097-1108.

American Psychiatric Association (APA; 2000). Diagnostic and Statistical Manual of Mental Disorders (4th ed., Text-Revision.). Washington, DC: American Psychiatric Association.

Desi, R. A., Goulet, J. L., Robbins, J., Chapman, J. F., Migdole, S. J., & Hoge, M. A., (2006).

Metal health care in juvenile detention facilities: A review. Journal of the American Academy of Psychiatry and the Law, 34, 302-14.

Garland, A. F., Hough, R. L., McCabe, K. M., Yeh, M., Wood, P. A., & Aarons, G. A., (2001).

Prevalence of psychiatric disorders in youths across five sectors of care. Journal of the American Academy of Child and Adolescent Psychiatry, 40 (4), 409-418.

Hayes, J., & O’ Reilly, G., (2007). Emotional Intelligence, Mental Health & Juvenile Delinquency.

Dublin, Juvenile Mental Health Matters. www.juvenilementalhealthmatters.com National Institute of Mental Health. (2000). Diagnostic Interview Schedule for Children IV (NIMH DISC-IV). New York: State Psychiatric Division of Child and Adolescent Psychiatry.

Pliszka, S. R., Sherman, J. O., Barrow, M. V., & Irick, S., (2000). Affective disorder in juvenile offenders: A preliminary study. American Journal of Psychiatry, 157 (1), 130-132.

Vreugdenhil, C., Doreleijers, T. A. H., Vermeiren, R., Wouters, L. F. J. M., & Van Den Brink, W., (2004). Psychiatric disorders in a representative sample of incarcerated boys in the Netherlands. Journal of the American Academy of Child and Adolescent Psychiatry, 43 (1), 97-104.

Wasserman, G. A., McReynolds, L., Lucas, C., Fisher, P., & Santos, L. (2002) The Voice DISC-IV with incarcerated male youths: Prevalence of disorder. The Journal of the American Academy of Child and Adolescent Psychiatry, 41 (3), 314-321.

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Chapter I How will international standards at UN and EU level protect children and young people in conflict with the law suffering from mental illness? .......................................................................................................................................

by Dr. Francisco Legaz Cervantes. Chairman CĂŠdric Foussard. Director International Juvenile Justice Observatory

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CHAPTER I: HOW WILL INTERNATIONAL STANDARDS AT UN AND EU LEVEL PROTECT CHILDREN AND YOUNG PEOPLE IN CONFLICT WITH THE LAW SUFFERING FROM MENTAL ILLNESS?

Introduction Measuring compliance with international standards According to the World Health Organization (WHO) mental health is defined as ‘a state of well-being in which the individual realises his or her own abilities, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to his or her community’. Unfortunately, not everyone can enjoy this state of well-being; for instance, at the moment, around 450 million people worldwide suffer from mental or behavioural disorders. As a matter of fact, in Europe, one in four people are or will be affected by mental health problems at some point in their life5.

Prisoners are not spared by this scourge. Thus, according once again to the World Health Organization, “mental health disorders are especially prevalent in prison populations.

The disproportionately high rate of mental disorders in prisons is related to several factors: the widespread misconception that all people with mental disorders are a danger to the public; the general intolerance of many societies to difficult or disturbing behavior; the failure to promote treatment, care and rehabilitation, and, above all, the lack of, or poor access to, mental health services in many countries. Many of these disorders may be present before admission to prison, and may be further exacerbated by the stress of imprisonment. However, mental disorders may also develop during imprisonment itself as a consequence of prevailing conditions and also possibly due to torture or other human rights violations6”.

Thus, in Europe, of the two million persons held in custody, at least 400 000 suffer from a significant mental disorder7, and even more suffer from common mental health problems such as depression or anxiety.

Among these prisoners affected by mental health disorders (MHD), there are a significant number of children. As a matter of fact, children in detention are more likely than adults to suffer from MHD. According to a British study, 95% of children held in detention have indeed at least one mental health problem and 80% have more than one (Lader et al., 2000). By the same token, the Mental Health Foundation suggests that “the prevalence of mental health problems for young people in contact with the criminal justice system range from 25 to 81%, being highest for those in custody8”.

Nevertheless, “the detection of mental health problems in young offender populations

5 http://www.euro.who.int/en/what-we-do/health-topics/noncommunicable-diseases/mental-health 6 http://www.who.int/mental_health/policy/mh_in_prison.pdf 7 Ibidem 8 http://www.mentalhealth.org.uk/content/assets/PDF/publications/mental_health_needs_young_ offenders.pdf

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is imprecise, and tends towards underestimation, particularly when it comes to internalizing disorders9”. Thus, among the nearly 50,000 children and young adults held in custody in Europe10, it is hard to say how many of them suffer from mental health disorder. Yet, they have to be defended and represented by someone at a national, continental and international level.

As an inter-disciplinary system of information, communication, debates, analysis and proposals, the International Juvenile Justice Observatory (IJJO) seeks to address problematic matters affecting the proper development of juvenile justice in the world.

To this extent, the IJJO aspires to tackle a wide variety of problems among which the non-respect of the rights of detained children with MHD. Rigorous in its work, reflections and proposals, the IJJO leans on the relevant international and European standards available, such as the ones set up and implemented by the United Nations, the Council of Europe or the European Union.

When it comes to young offenders’ mental health issues, these standards could be divided into two categories: standards dealing with mental health issues and referring to children the one hand, and child-friendly justice standards mentioning young offenders with MHD on the other hand.

1. MHD International and European standards – the specific case of young offenders MHD International and European standards were set up and implemented by a wide variety of institutional organizations. Yet, one could focus on only three of these institutions that is to say the United Nations, the Council of Europe and the European Union in so far as these are the most important ones.

Thus, as early as 1966, the United Nations recognised “the right of everyone to the enjoyment of the highest attainable standard of physical and mental health11” in the International Covenant on Economic, Social and Cultural Rights. This very concept was later taken up and emphasised by two other United Nations standards, the Convention

9 Ibidem 10 Council of Europe Annual Penal Statistics – SPACE 1 – Survey 2008 – an analysis by Marcelo F. Aebi and Natalia Delgrande, University of Lausanne, Switzerland – Diagram on the age structure of prison population on September 1st 2008 – p.54 – Available at: http://www.coe.int/t/dghl/standardsetting/ prisons/SPACEI/PC-CP%282010%2907_E%20SPACE%20Report%20I.pdfn 11 Article 12 of the 1966 UN International Covenant on Economic, Social and Cultural Rights

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on the Rights of the Child (CRC) of 198912 and the Principles for the protection of persons with mental illness and improvement of mental health care of 199113.

In the 1989 Convention on the Rights of the Child, the United Nations also recognizes “the right of a child who has been placed by the competent authorities for the purposes of care, protection or treatment of his or her physical or mental health, to a periodic review of the treatment provided to the child and all other circumstances relevant to his or her placement14”. Moreover, this text states “the right of every child to a standard of living adequate for the child’s physical, mental, spiritual, moral and social development15”.

Later on, that is to say in 1991, the United Nations agreed on the Principles for the protection of persons with mental illness and improvement of mental health care.

Those principles argue that “all persons have the right to the best available mental health care16” and that “all persons with a mental illness, or who are being treated as such persons, shall be treated with humanity and respect for the inherent dignity of the human person17”. Furthermore, according to these principles, “special care should be given [...] to the protection of minors18”. Eventually, the 20th Principle for the protection of persons with mental illness and improvement of mental health care, which especially deals with criminal offenders, stipulates that “such persons should receive the best available mental health care as provided in Principle 119”.

In 2004, the Council of Europe issued a Recommendation concerning the protection of the Human Rights and dignity of persons with mental disorders in which it stated that “member states should [...] ensure sufficient provision of hospital facilities with appropriate levels of security and of community-based services to meet the health

12 “the right of the child to the enjoyment of the highest attainable standard of health and to facilities for the treatment of illness and rehabilitation of health” : Article 24.1 of the Convention on the Rights of the Child 13 “all persons have the right to the best available mental health care” : Principle 1 - Article 1 of the United Nations Principles for the protection of persons with mental illness and the improvement of mental health care – 17 December 1991 14 Article 25 of the Convention on the Rights of the Child 15 Article 27 of the Convention on the Rights of the Child 16 Principle 1 - Article 1 of the United Nations Principles for the protection of persons with mental illness and the improvement of mental health care – 17 December 1991 17 Principle 1 - Article 2 of the United Nations Principles for the protection of persons with mental illness and the improvement of mental health care – 17 December 1991 18 Principle 2 of the United Nations Principles for the protection of persons with mental illness and the improvement of mental health care – 17 December 1991 19 Principle 20 of the United Nations Principles for the protection of persons with mental illness and the improvement of mental health care – 17 December 1991

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needs of persons with mental disorders involved with the criminal justice systems20”.

In this Recommendation, one article in particular deals with young offenders suffering from mental health disorders; it affirms that “a minor should not be placed in a facility in which adults are also placed, unless such placement would benefit the minor21” Moreover, this article stipulates that “minors subject to placement should have the right to a free education and to be reintegrated into the general school system as soon as possible22”.

Concerning the European Parliament, it issued two major resolutions dealing with mental health: the Resolution on improving the mental health of the population of 2006 and the Resolution on mental health of 2009.

In the Resolution on improving the mental health of the population of 2006, the European Parliament “believes that good mental health of mothers and parents helps children to develop without hindrance and grow into healthy adults23” Moreover, it “calls for a multi-disciplinary and multi-agency response to tackling complex mental ill health situations, such as how best to support children or adolescents with developmental and behavioral problems24”. It also “points out that mental ill health and mental disorders commonly have their roots in early childhood and stresses the importance of research into a healthy early childhood25”. Eventually, in this Resolution, the European Parliament “believes that emphasis should be placed on the link between the consumption of alcohol and illegal drugs and mental disorders <as well as> considers that alcohol and drug addiction cause serious mental and physical health problems and problems for society as a whole26”.

In the Resolution on Mental Health of 2009, the European Parliament reaffirms these principles and addresses new matters. For instance, in article 27, it “stresses the need for health system planning which meets the need for specialist mental health services for children and adolescents, taking into account the move from long-term institutionalized care towards supported living in the community27”. By the same token, it “stresses the need for the early detection and treatment of mental health problems

20 Article 10 of the Recommendation N.Rec(2004)10 concerning the protection of the Human Rights and dignity of persons with mental disorders – 22 September 2004 21 Article 29-4 of the Recommendation N.Rec(2004)10 concerning the protection of the Human Rights and dignity of persons with mental disorders – 22 September 2004 22 Article 29-5 of the Recommendation N.Rec(2004)10 concerning the protection of the Human Rights and dignity of persons with mental disorders – 22 September 2004 23 EP Resolution on improving the mental health of the population – 6 September 2006 24 Ibidem 25 Ibidem 26 Ibidem 27 Article 27 of the EP Resolution on Mental Health of February the 19th 2009

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in vulnerable groups, with particular reference to minors28”.

Thanks to this sample of international and European standards, it appears that the complex situation of children, and especially the ones with MHD, is being taken into account when it comes to dealing with mental health issues. By the same token, juvenile justice standards, just like mental health standards, also refer to minors suffering from mental ill health.

2. Child-Friendly Juvenile Justice Standards – young offenders with MHD In the Standard Minimum Rules for the Administration of Juvenile Justice, also known as the Beijing Rules, and published in 1985, the United Nations recalls that “the objective of training and treatment of juveniles placed in institutions is to provide care, protection, education and vocational skills, with a view to assisting them to assume socially constructive and productive roles in society29”. Moreover, according to the Beijing Rules, “juveniles in institutions shall receive care, protection and all necessary assistance - social, educational, vocational, psychological, medical and physical - that they may require because of their age, sex and personality and in the interest of their wholesome development30”.

Whereas the Beijing Rules deal with the general well-being and care of young offenders, the United Nations Rules for the Protection of Juveniles Deprived of their Liberty, also known as the Havana Rules, go even further in protecting the rights of young offenders affected by MHD by stipulating that a “juvenile justice system should uphold the rights and safety and promote the physical and mental well-being of juveniles31”.

These rules also specify that “as soon as possible after the moment of admission, each juvenile should be interviewed, and a psychological and social report identifying any factors relevant to the specific type and level of care and programme required by the juvenile should be prepared32” to make sure that each individual receives the appropriate care upon arrival. “When special rehabilitative treatment is required, and the length of

28 Article 28 of the EP Resolution on Mental Health of February the 19th 2009 29 Part Five – Institutional treatment – 26 – Objectives of institutional treatments 30 Ibidem 31 Article 1 of the 1990 UN Rules for the Protection of Juveniles Deprived of their Liberty 32 Article 27 of the 1990 UN Rules for the Protection of Juveniles Deprived of their Liberty

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stay in the facility permits, trained personnel of the facility should prepare a written, individualised treatment plan specifying treatment objectives and time-frame and the means, stages and delays with which the objectives should be approached33”.

Furthermore, knowing that detention should always remain a measure of last resort “detention of juveniles should only take place under conditions that take full account of their particular needs, status and special requirements according to their age, personality, sex and type of offence, as well as mental and physical health, and which ensure their protection from harmful influences and risk situations34”.

Eventually, articles 49 to 55 of the Havana Rules deal especially with the medical care of young offenders deprived of their liberty. In these articles, it is stipulated that “every juvenile shall receive adequate medical care, both preventive and remedial, including dental, ophthalmological and mental health care35”. Moreover, according to article 51 of the Havana Rules, “the medical services provided to juveniles should seek to detect and should treat any physical or mental illness36”. Eventually, the entire article 53 is dedicated to young offenders affected by mental health disorders and recalls that “a juvenile who is suffering from mental illness should be treated in a specialised institution under independent medical management37”.

More recently, that is to say in 2007 and 2011, the United Nations issued a series of general comments specifying the content of the 1989 Convention on the Rights of the Child. Two of these general comments deal specifically with juvenile justice matters.

For instance, the UN General Comment N.10 of 2007 deals with children’s rights in juvenile justice and guarantees that a “child sentenced to this imprisonment should receive education, treatment and care aiming at his/her release, reintegration and ability to assume a constructive role in society38”.

Concerning the UN General Comment N.13 of 2011, it deals with the right of the child to freedom from all forms of violence. According to this general comment, all forms of violence against children, however light, are indeed unacceptable – that includes physical as well as mental violence, scourges that could both lead to mental health disorders39.

33 Ibidem 34 Article 28 of the 1990 UN Rules for the Protection of Juveniles Deprived of their Liberty 35 Article 49 of the 1990 UN Rules for the Protection of Juveniles Deprived of their Liberty 36 Article 51 of the 1990 UN Rules for the Protection of Juveniles Deprived of their Liberty 37 Article 53 of the 1990 UN Rules for the Protection of Juveniles Deprived of their Liberty 38 Article 77 of the UN General Comment N.10 of 2007 39 IV Legal analysis of Article 19 of the Convention on the Rights of the Child – A – Article 19, paragraph 1 – 1 “all forms of” – paragraph 21 on mental violence

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As for the Council of Europe, in its 2006 Recommendation to member states on the European Prison Rules, it recalls that “prison staffs carry out an important public service <thus> their recruitment, training and conditions of work shall enable them to maintain high standards in their care of prisoners40”. Moreover, it stresses different important facts such as the necessity for “children under the age of 18 years <to> not be detained in a prison for adults, but in an establishment specially designed for the purpose41”. Furthermore, “if children are nevertheless exceptionally held in such a prison there shall be special regulations that take account of their status and needs42”.

Eventually, “persons who are suffering from mental illness and whose state of mental health is incompatible with detention in a prison should be detained in an establishment specially designed for the purpose43” and like children “if [...] nevertheless exceptionally held in such a prison there shall be special regulations that take account of their status and needs44”. Thus, the rights of children as well as individuals suffering from mental health problems are being taken into account by the Council of Europe, thus ensuring the rights of children suffering from MHD. The European Prison Rules Recommendation also stipulates that “prison authorities shall safeguard the health of all prisoners in their care45” and that “medical services in prison shall seek to detect and treat physical or mental illnesses or defects from which prisoners may suffer46”. To this extent, “all necessary medical, surgical and psychiatric services including those available in the community shall be provided to the prisoner for that purpose47”.

As for the articles 47.1 and 47.2 of this Recommendation, they especially deal with mental health issues specifying that “specialized prisons or sections under medical control shall be available for the observation and treatment of prisoners suffering from mental disorder or abnormality48” and that “the prison medical service shall provide for the psychiatric treatment of all prisoners who are in need of such treatment and pay special attention to suicide prevention49”.

40 Article 8 of the Recommendation CM/Rec(2006)2 of the Council of Europe’s Committee of Ministers to member states on the European Prison Rules 41 Article 11.1 of the latter 42 Article 11.2 of the latter 43 Article 12.1 of the latter 44 Article 12.2 of the latter 45 Article 39 of the latter 46 Article 40.4 of the latter 47 Ibidem - Article 40.5 48 Ibidem - 47.1 49 Ibidem - 47.2

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Eventually, this recommendation suggests that “staffs who work with specific groups of prisoners, such as foreign nationals, women, juveniles or mentally ill prisoners, etc., shall be given specific training for their specialized work50”. By the same token, the European Prison Rules recommends that “as far as possible, the staff shall include a sufficient number of specialists such as psychiatrists, psychologists, social and welfare workers, teachers and vocational, physical education and sports instructors51”.

In 2008, the Council of Europe also issued the Recommendation to member states on the European rules for juvenile offenders subject to sanctions or measures.

The latter aspires “to uphold the rights and safety of juvenile offenders subject to sanctions or measures and to promote their physical, mental and social well-being when subjected to community sanctions or measures, or any form of deprivation of liberty52”.

Thus, according to these rules, when it comes to young offenders with mental health issues, “the imposition and implementation of sanctions or measures shall be based on the best interests of the juvenile offenders, limited by the gravity of the offences committed (principle of proportionality) and take account of their age, physical and mental well-being, development, capacities and personal circumstances (principle of individualization) as ascertained when necessary by psychological, psychiatric or social inquiry reports53”.

Moreover, “the rights of juveniles to benefits in respect of education, vocational training, physical and mental health care, safety and social security shall not be limited by the imposition or implementation of community sanctions or measures54”.

This Recommendation also ensures that “juveniles deprived of their liberty shall be guaranteed a variety of meaningful activities and interventions according to an individual overall plan that aims at progression through less restrictive regimes and preparation for release and reintegration into society. These activities and interventions shall foster their physical and mental health, self-respect and sense of responsibility and develop attitudes and skills that will prevent them from re-offending55”.

On top of that, “as juveniles deprived of their liberty are highly vulnerable, the

50 Ibidem - Article 81.3 51 Ibidem - 89.1 52 Recommendation CM/Rec(2008)11 of the Committee of Ministers to member states on the European rules for juvenile offenders subject to sanctions or measures 53 Ibidem - Article 5 54 Ibidem - Article 28 55 Ibidem – Article 50.1

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authorities shall protect their physical and mental integrity and foster their well-being56”.

Moreover, “juveniles who are suffering from mental illness and who are to be deprived of their liberty shall be held in mental health institutions57” not in prisons. Besides, “the provisions contained in international instruments on medical care for the physical and mental health of adult detainees are applicable also to juveniles deprived of their liberty58“.

Overall, thanks to this Recommendation, the Council of Europe wants to make sure that particular attention is paid to “the needs of vulnerable prisoners, among which young offenders, drug addicts and alcoholics and juveniles with physical and mental health problems59”.

Eventually, the Council of Europe issued another text in 2003, the Recommendation to member states concerning new ways of dealing with juvenile delinquency and the role of juvenile justice, in which it especially underlines the usefulness of “a broader spectrum of innovative and more effective (but still proportional) community sanctions and measures60”. Nevertheless, it does not mention the advantages such measures could bring if some of them were designed to address the specific situations faced by young offenders suffering from mental health disorders. As a matter of fact, mental health issues should also be taken into account when setting up new answers and measures aiming at rehabilitating youngsters in conflict with the law knowing that MHD may concern a great number of them.

56 Ibidem – Article 52.1 57 Ibidem – Article 57 58 Ibidem – Article 69.1 59 Ibidem – Article 73 60 Article 8 of the Recommendation Rec(2003)20 of the Council of Europe’s Committee of Ministers concerning new ways of dealing with juvenile delinquency and the role of juvenile justice

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Mental Health and Young Offenders in the EU Member States

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Chapter II Psychiatric problems and juvenile delinquency: scientific links support calls for innovative management, Belgium ....................................................................................................................................... by Hoffmann, E, Jadot, D. Hoffman, D. Van Audenaege, J. Grajek, G. Joiret, E. Servais, L. Centre Hospitalier Jean Titeca

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Table of Contents

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1. History 2. Juvenile Delinquency And Psychiatric Disturbances: Review Of The Literature 3. The Fundamental Principles Which Govern The System 4. Descriptive Data Concerning Young People Welcomed Into Our System 5. Therapeutic Systems 6. Conclusion References

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In creating forensic psychiatric units for adolescent delinquents in 2003, then the network of cross sector care (health, education, and disability) based on coordination, Belgium is at the forefront of research into psychiatric problems in this section of the population from the perspective of providing care and education.

This article provides a brief overview of its development, a review of the literature supporting the issue regarding the coexistence of psychiatric problems and behaviour that conflicts with the law/transgressive delinquents, followed by a description of new therapies in place since 2003 at the Centre Hospitalier Jean Titeca (Brussels), as well as some information regarding its reception by the population after its opening.

Keywords: delinquency in adolescents – psychopathology – adolescent detainees – specific psychiatric care unit – educational therapy

1. HISTORY Since 1996, noting in their clinical practice the frequency of psychiatric disturbances in juvenile delinquents placed in public community institutions of the youth protection authorities (ICPPJ is the French acronym), which has recently been corroborated by international scientific literature, the authors of the current article have questioned the Belgian political authorities with the intention of creating a specific management unit.

Indeed in Belgium at the time, there were no residential psychiatric centres tailored to adolescents presenting both psychiatric and behavioural problems requiring protective educational and social measures. Within the youth protection services, educational management was not well adapted to both new and established psychiatric problems.

However young people cannot be placed in an environment of therapy owing to multiple transgressive behavioural issues (attacking members of staff) from which they are suffering. In brief, there was no structure of care at the interface of community networks in youth aid, in the disability sector and in the mental health sector, aimed at the consideration of psychiatric issues as being linked to difficult behaviour and the development of a therapeutic framework which prioritised “non-readmission”, with the ambition of integrating behavioural issues under this management, in a way that avoided the justification of a breakup in therapeutic relations.

In 2001 the European Committee for the Prevention of Torture and Inhuman or Degrading Treatment or Punishment recommended the creation of specific units for this section of the public.

In 2002, the Belgian minister for Health and Social Affairs obtained the necessary

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means to create 5 pilot units of eight beds each designed for this section of the public.

In October 2003 the first of these pilot units, named Karibu, opened its doors to adolescents who met previously defined inclusion criteria. This unit was welcomed by the Jean Titeca Hospital, a psychiatric hospital situated in Brussels. This hospital deals with around 250 adult patients daily, admitted almost exclusively under restrictive legal measures owing to psychiatric problems associated with major behavioural difficulties. These adult patients are placed within nine care units.

In 2007, after an evaluation of this operation, the minister for Health and Social Affairs decided to enlarge the project, allowing for the opening of a twelfth unit (named Kalima), situated close to Karibu which accommodates up to 11 stable young people or on the road to becoming stable, with the aim of working on their ability to be independent and their integration back into society.

Furthermore, additional resources have facilitated the creation of eight places in closed rooms (supervised independence), as well as the creation of a mobile outreach team, which manages, through an outpatient centre, adolescents presenting difficulties comparable to those presented by the patients of Karibu, but which do not require a period of hospitalisation. This service has the particular goal of avoiding hospitalisation; either through reducing the duration of hospitalisation or of limiting the chances of rehospitalisation.

The coexistence of intrinsic vulnerabilities and environments constitutes the greatest factor in predicting violent criminal behaviour at an adult age.

2. JUVENILE DELINQUENCY AND PSYCHIATRIC DISTURBANCES: REVIEW OF THE LITERATURE International scientific literature has shown, since the beginning of the last decade, there is a growing interest concerning the existence of psychopathological manifestations, psychiatric disturbances in adolescent delinquents and, it has been argued over the course of the last decade, the need to offer specialised management of this specific section of the population (either through outpatients departments or residential centres).

Previously, at least to our knowledge, only a very few publications related to this problem area existed. This assessment is shared by Vermeiren (1).

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Amongst others, in 1989, Lewis (2), was interested in identification factors regarding the risk of re-offence among adolescent delinquents, and carried out a prospective study on the population who had been placed in centres for young offenders. He demonstrated that the coexistence of intrinsic vulnerabilities (on a cognitive, psychiatric and neurological level) and environmental factors (a previous history of violence and/ or familial abuse) constitute the greatest factor in predicting violent crime in adulthood.

Psychotic manifestations (experiencing paranoia, audio or visual hallucinations, troubled thoughts marked by deregulation of association, incoherent speech or illogical thinking) constitute a significant predictive factor.

In 1995, H채fner (3) demonstrated through a retrospective study into schizophrenia in its initial stages (before the age of 20) that it is characterised by, during the pre-diagnosis period which can develop over many years, either the emergence of straight forward symptoms of psychosis, a mixture of non-specific and undifferentiated symptoms, or dominant behavioural disturbances/transgressions, in boys, criminal or not.

In 1996, Hodgins published the first prospective study conducted on more than 300,000 adult subjects which demonstrated a link, although tenuous, between major mental disorders (MMD), and criminal behaviour. Compared with adolescent delinquency, this study indicates that more than half of MMD cases diagnosed in adulthood, committed acts of delinquency before the age of 18, or when they were minors and their psychiatric disturbance was not yet identified.

Since the last decade we have noticed, as have Vermeiren (5) or Davies (6), that the number of publications related to these issues has increased. Therefore, there are numerous authors [Vermeiren (1.5)] highlighting the significant prevalence of psychiatric disturbances in adolescent delinquents. Teplin (7) for example, has shown how six of seven adolescent delinquents present severe mental disturbances associated with a number of functional deficit disorders.

We note that most authors who have studied these issues have used diagnostic category tools (DSM - DISC).

For example, Abram (8) studied the prevalence of psychiatric disturbances in a sample of 1,829 adolescent males and females between the ages of 10 and 18 (average age 14.9) who had been placed in institutions for adolescent delinquents in the USA. Over all, the authors identified sever psychiatric disturbances in 7.7% of adolescent males sampled, psychiatric trouble or a manic episode in 1.9% of adolescents sampled, and a major depressive disorder in 7.4% of the adolescents sampled. This prevalence increases significantly in adolescents who consume psychoactive substances (the prevalence here is 21.4%, 4.6%, and 18.5%; respectively).

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Fazel (9) through meta-analysis (including 25 studies into 16,750 adolescent delinquents) demonstrated that 3% of adolescent delinquents placed in institutions have psychotic disturbances and that 11% of adolescent male delinquents placed in institutions have major depressive disorders (compared to 29% of adolescent delinquents).

Certain authors have taken care to exclude the diagnosis of problematic behaviour in order to study the prevalence of psychiatric problems in adolescent delinquents.

Therefore, Teplin (10) demonstrated that 60.9% of adolescents suffer from psychiatric trouble on top of behavioural problems. Among these psychiatric problems, the author found that 18.7% of adolescent males present various emotional problems (major depression, dysthymia, maniac episodes), 1% present psychotic trouble and 21.3% suffer from anxiety related problems.

Among adolescent delinquents who have been placed in institutions in Belgium, 78% reported at least one psychotic experience.

Other authors have based their research upon the presence of symptoms rather than syndromes corresponding to categorical diagnostics of DSM-IV, notably following the example of Sourander (11), bearing in mind the limits of these categorical systems in adolescents.

Vreugdenhill (12) has also studied the prevalence of psychotic symptoms in a group of 204 male adolescent delinquents aged between 12 and 18 years who have been placed in institutions in Holland. Among these, 34% meet the diagnostic criteria of someone suffering from psychotic trouble: 25% report at least one pathognomonic symptom of schizophrenia and 9% report at least three non-pathognomonic symptoms. Furthermore, 33% of adolescents evaluated reported one or two isolated or atypical psychotic symptoms.

Recently, Collins (13) carried out a study into the prevalence of psychotic manifestations in institutionalised adolescent delinquents in Belgium. The author demonstrated that 78% of these adolescents reported at least one psychotic experience, 72% referred to delirious thoughts and 43% reported at least one hallucinogenic episode. Manifestations of paranoia were particularly frequent (67%), the author excluded them and highlighted that the prevalence of psychotic manifestations remained high even in this case, since the figures reached 51% in relation to psychotic manifestations and 25% in relation to delirious thoughts.

In light of this information, the authors highlight the need to put in place a diagnostic evaluation system, formed and tested by clinicians, for adolescents who come into contact with the judicial system in sight of early management of psychiatric problems (6, 9, 11, 12, 14, 15, 17,).

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The authors estimate that, furthermore, it is indispensible to develop intervention strategies for adolescents presenting behavioural problems associated with psychopathological factors (7, 11, 12, 14, 17).

Certain authors equally advocate the creation of a type of evaluation of structured designed for the management of this section of the population. Therefore, Teplin (10) deplores the lack of resources related to the efficiency of management programs for adolescent delinquents presenting psychiatric trouble, underlining the need to set up research which guides policies on health care and better understand the complex interactions between management subsystems of these young people (notable mental health, education and justice).

In conclusion, numerous scientific publications today support the clinical findings which have presided over the creation of our care system.

3. THE FUNDAMENTAL PRINCIPLES WHICH GOVERN THE SYSTEM Since the opening of the Karibu unit, very precise inclusion criteria have been defined: -

-

- -

By sex and age: adolescent males between 12 and 18 years of age (or even until the age of 20 in the case of an extension of measures imposed by the juvenile court). Young people under the age of 15 are only admitted under exceptional circumstances; Present severe psychological disturbance (both new and existing psychotic manifestations, and both sever thymic and persistent manifestations) which require medical-psychiatric residential management; Present sever behavioural problems characterised by: recurrent self harm or aggression towards others which is or is not dangerous; Fulfil legal proceedings due to a crime.

In regards to exclusion criteria, average mental slowness, which is serious and profound (IQ <70) and problems interfering with development (such as autism issues) are admitted because they require specific treatment.

To take on responsibility of this group defined by the criteria of inclusion, people involved in the project had no knowledge of any reference model from which they could reproduce.

Henceforth, they set about constructing an original intervention model, leaning on an

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ensemble of ethical and humanitarian principles, drawing inspiration from current theories on the management of residential therapies. Fundamentally, a single dogma was admitted: which was to have none. An ensemble of principles and regulations were accepted each permitting that every rule of functioning would not be valuable if not democratically and collectively modified.

Even though current theories inspired this model, systematic intervention ideas and models occupy a central role in management philosophy. The situation of the young person (1), which is in constant development (diachronic perspective), has a major influence on the adolescent both vertically, (empowerment and individuation through relationships with parents) and horizontally (groups of peers).

Therefore, in concrete terms, every person who is a part of the adolescent’s universe either significant emotional figures (2), including others who have intervened to which the adolescent is attached, and the judicial tiers (the judge, lawyer, court councillor) – are considered as resources in the therapeutic processes and are therefore implicated within it.

These young delinquents are above all beings in profound suffering, even if their mode of expression is predominantly characterised by hostility and aggression.

It is in this spirit, knowing that the young people admitted are beings in profound suffering, even if their mode of expression is predominantly characterised by hostility and aggression, that the notion of welfare was withheld as a founding ethical stance of the project. Developed from a systemic perspective by J. Barudy, this has been defined as “the result of the mobilisation of community resources and of parental capabilities aimed at responding to the needs of the child, by considering also the resilient resources of all people involved in the process” (Barudy et al., in Mauroy, 2001). He adds that “the human capacity for resilience is mostly linked to reassuring experiences of attachment, to the possibility of becoming conscious of one’s reality and above all the affiliation to healthy and stable familial and community relationships” (Barudy et al., in Mauroy, 2000).

Therefore, the chosen name for the unit, “Karibu” (3), recalls the “founding principles” indicating: “whoever you are, whatever you have done, you are welcome!”

In short, in continuation of this principle, attacks upon members of staff, including those aimed at care givers, cannot alone denounce management of them, and so halt the process. This principle holds a double significance. Primarily, difficult behaviour in adolescents is imagined to be their preferred mode of functioning, their “signature manner”. In summary, these adolescents “cultivate” or “allow themselves to be seen”

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right away as having a negative identity, a result of traumatic past and continual marginalisation. Early behavioural or developmental problems are inherited from a history in which insecurity and violence were the norm. Over the years, these young people no longer find any value, or even sense in existing, and through trangressive behaviour they obtain an emotional and instinctual unburdening, and which leads them correlatively to identify with other peers suffering from similar difficulties.

Therefore, their behavioural disturbances should not be approached as being associated or competing with their difficulties, but as being at the heart of their problems, directly linked to a profoundly altered estimation of themselves.

Secondly, applying the principle of â&#x20AC;&#x153;not being sent backâ&#x20AC;? allows for a break with their previous experiences. In fact, the large majority of these young people have experienced significant rejection and exclusion (familial, schools then institutions, notably within the framework of care) even because of their behavioural difficulties.

Whoever you are, whatever you have done, you are welcome!

4. DESCRIPTIVE DATA CONCERNING YOUNG PEOPLE WELCOMED INTO OUR SYSTEM The data presented below illustrates certain dimensions.

In order to highlight the characteristics of our population, we have collected anamestic retrospective data (through hospitalisation within our unit) of 40 patients (average age = 16.2 years; standard deviation = 1.1 years).

Certain essential characteristics appear before us through analysis of this data. A first observation regarding our population concerns previous victimisation. In fact, almost the entirety of patients were victims before becoming perpetrators of violence themselves. Table 1 shows the proportion of patients who were victims of negligence, of psychological, physical and sexual mistreatment. It is noted that for these three categories, in around 90% of cases, the abuse was linked to the familial network, while sexual mistreatment occurred in both familial and non-familial environments.

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Table 1: the proportion of patients who have suffered from negligence, psychological, physical and sexual mistreatment Type Negligence Psychological mistreatment Physical mistreatment Sexual mistreatment

Proportion of patients

65.7% 82.9% 80.0% 37.2%

The victimâ&#x20AC;&#x2122;s history (principally on a familial level) is reflected, from a young age, in difficulties which appear during their school career.

The victimâ&#x20AC;&#x2122;s history (principally on a familial level) is reflected, from a young age, in difficulties which appear during their school career. In fact, all patients recounted behavioural, interpersonal or learning difficulties, and this being very early in their schooling. Table 2 sums up the age of the appearance of these behavioural, interpersonal and learning difficulties observed in these young people.

Table 2: average age (and standard deviation) at the emergence of behavioural, interpersonal and learning difficulties within education.

Type of difficulties

Average age in years of their emergence (standard deviation) Behavioural difficulties

7.36 (3.99) Interpersonal difficulties

6.27 (3.49) Learning difficulties

8.35 (3.89)

Owing to these difficulties, almost half of these patients (48.6%) have been, at some point during their school career, transferred to special education: 47.0% were directed towards special education type 3 (behavioural issues), 35.3% to special education type 8 (learning difficulties) and 5.9% towards special education type 2 (mild mental retardation). For 11.8% of patients, we were aware of transfer to special education, but not the specific type of special education. The average age at which they were transferred to special education is 7.7 years (standard deviation 3.3 years), which reflects early deterioration in their school career.

Furthermore, 85% of young people disassociate from their schooling and this occurs, on

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average, from the age of 11.5 years (standard deviation 3.4 years). Subsequently, from the age of 12.7 years on average (standard deviation 2.4 years), a real disengagement with schooling is noted through absenteeism in 68.5% of cases.

This trend of victimisation, according to us, contributes significantly to the emergence of behavioural and criminal problems and of psychopathological problems in the experiences of the young people in our population.

Our patients are characterised by behavioural difficulties which have emerged at an early age: on average, around the age of 6.9 years (standard deviation 4.2 years).

On average, these young people committed their first offense (criminal or not) at 13.7 years of age (standard deviation 2.4 years). Table 3 presents the types of offenses committed prior to hospitalisation (and their prevalence) and illustrates the complexity of criminal experience of the patients. This data demonstrates that the group of adolescents present a â&#x20AC;&#x153;multi-criminalâ&#x20AC;? profile: no single patient committed only one single type of offense.

On average, these young people commit their first offense (criminal or not) at 13.7 years of age.

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Table 3: Types of first offenses committed by patients of the system prior to hospitalisation and the proportion of patients who committed these offenses The type of first offense

Proportion of patients who committed this type of offense Non-sexual first offenses Extortion

Verbal aggression Unarmed physical aggression Armed physical aggression Theft Unarmed aggressive theft Armed aggressive theft Drug trafficking

Pyromania

Handling stolen goods Murder or attempted murder

45.7% 97.1% 94.3% 49.6% 80.0% 42.9% 25.7% 20.0% 31.4% 11.4% 17.1%

Sexual first offenses Indecent assault

Molestation

Rape

Gang rape

40.0% 40.0% 37.2% 2.9%

In addition to their behavioural and criminal problems, these patients also suffer from a range of sever psychiatric symptoms. The first psychopathological signs are first identified early in their development, on average at the age of 8.3 years (standard deviation 5.3 years). Table 4 shows the ensemble of symptoms observed within our population and the proportion of patients presenting these symptoms.

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Table 4: Psychiatric symptoms and the proportion of young people who present these symptoms Symptoms

Proportion of young people presenting symptoms Positive symptoms Hallucinations

Delirious thoughts

Bizarre behaviour

Non-deficit formal thought disorders Negative symptoms Withdrawal or affective poverty Alogia

Avolition/apathy

Anhedonia/social withdrawal

Depressive symptoms Suicide attempts

77.2% 88.6% 88.5% 60.0%

88.6% 65.7% 80.0% 80.0%

80.0%

28.6%

This history of criminal and psychopathological problems permits a better understanding of their lengthy institutional past. In fact, the data shows that the large majority of these young people have been placed within residential institutions at least once by juvenile authorities (comprised of the ICPPJ and closed federal centres for minors).

The average number of placements in institutions is 4.8. if we take into account the number of placements in the ICPPJ and in closed federal centres, the average number of placements is 2.1, and they refer to 80.0% of young people admitted (average total length of stay: 5.5 months).

In terms of previous hospitalisation, almost 80% of young people have already stayed in a psychiatric centre and, the majority of them, more than once. This observation, along with others, regarding the severity of psychopathological inclusion, should silence for good the criticism of certain inventions which note through the creation of systems such as our own an attempt at â&#x20AC;&#x153;psychiatrisationâ&#x20AC;? of minors.

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5. THERAPEUTIC SYSTEMS Analysis continues into the demand for care by protagonists (the judge, young person, family networks....) permitting the creation of individual therapeutic projects. Official reports and basic notes illustrate senior guidance, on a daily basis, of multidisciplinary intervention teams. This, combined with the patient and their family, directs daily action towards a process of sustained clinical consultation (1 meeting/2 to 3 seminars) based on the references of medical staff, psychologists, social workers, psychiatric doctors and teachers.

The individual therapeutic framework (psychiatric, psychological, sexual therapy support and educational and school support) is based upon, on the level of clinical meetings, a network of management (familial, social, judicial) and groups (group therapy).

Adolescents are accompanied through all stages of the judicial process (legal, public and assessment meetings....) by their social workers.

The process of clinical evaluation leads to the development of relationships with the young person, their family and the judicial authorities.

Adolescents are accompanied through all stages of the judicial process by their social workers.

6. CONCLUSION The existence of psychiatric problems requiring institutional management of adolescent delinquents is supported by international scientific literature. The system of care presented briefly in this article is an innovative project aimed at the specific population situated at the crossroads of judicial, health and youth authorities. The development of this network offers a real perspective of specialised management for a section of the public which, by default, ends up within the framework of prison or social services. The social aim of these operations rests in: offering accessible care to adolescents who, due to their behavioural and psychiatric issues, were dealt with at the limits of general networks in therapeutic centres.

The putting in place of these “interface” services requires broad and continual multisector consultation. Our system has supported this project since 2004 through cooperation with “Mental Health Justice for Minors” and “Mental Health Education”.

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The congress held on the 19th and 20th of May in Brussels with the title of “Adolescence, Violence, Psychiatric Disorders and mandated care – If you please, draw me your Hell” was an opportunity, not only for professionals in the judicial, social care and health systems to exchange perspectives on this complex issue, but also to support a more precise definition of the scientific and legal basis which must preside over the creation of our forensic care systems. This congress also helped to create a foundation of necessary scientific collaboration between the various sectors in order to support a methodology aimed at prevention.

Notes 1. Context: from the Latin «contexere» – to weave: both interactions with their family circle (horizontal and vertical) and others in the stage of adolescence.

2. By “significant emotional figures” we refer to all those people with who the young person is attached emotionally. Significant “family” members does not cover this, as adolescents admitted into our system, have generally experienced, with some rare exceptions, particularly chaotic, unstructured and multi-component familial systems. Related to the concept of trans-parenting (Fossion, Rejas et Hirsch, 2007), as opposed to “non-parenting” and “anti-parenting” for example.

3. “Karibu” was proposed by an educator, it means “welcome” in Swahili.

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References 1. Vermeiren R. Psychopathology and delinquency in adolescents: a descriptive and developmental perspective. Clinical Psychology Review 2003;23:277-318.

2. Lewis DO, Lovely R, Yeager C, Femina DD. Toward a theory of the genesis of violence: a follow-up study of delinquents. J Am Acad Child Adolesc Psychiatry 1989;28(3):4316.

3. Häfner, Nowotny B. Epidemiology of early-onset schizophrenia. Eur Arch Psychiatry Clin Neurosci 1995;245(2):80-92.

4. Hodgins S, Mednick SA, Brennan PA, Schulsinger F, Engberg M. Mental Disorder and Crime – Evidence From a Danish Birth Cohort. Arch Gen Psychiatry 1996;53(6):48996.

5. Vermeiren R, Jespers I, Moffitt T. Mental health problems in juvenile justice populations. Child Adolesc Psychiatr Clin N Am 2006;15:333-51.

6. Davies M, Banks SM, Fisher WH, Gershenson B, Grudzinskas AJ. Arrests of adolescent clients of a public mental health system during adolescence and young adulthood.

Psychiatric Services 2007;58:1454-60.

7. Teplin L, Abram K, McClelland G, Washburn J, Pikus A. Detecting mental disorder in juvenile detainees: who receives services. American Journal of Public Health 2005;95:1773-80.

8. Abram K, Teplin L, McClelland G, Dulcan M. Comorbid psychiatric disorders in youth in juvenile detention. Arch Gen Psychiatry 2003;60:1097-1107.

9. Fazel S, Doll H, Längström N. Mental disorders among adolescents in juvenile detention and correctional facilities: a systematic review and metaregression analysis of 25 surveys. J Am Acad Child Adolesc Psychiatry 2008;47(9):1010-5.

10. Teplin L, Abram K, McClelland G, Dulcan M, Mericle A. Psychiatric disorders in youth in juvenile detention. Arch Gen Psychiatry 2002;59:1133-43.

11. Sourander A, Jensen P, Davies M, et al. Who is at greatest tisk of adverse longterm outcomes? The Finnish from a boy to a man study. J Am Acad Child Adolesc Psychiatry 2007;46(9):1148-61.

12. Vreugdenhill C, Vermeiren R, Wouters LF, Doreleijers TA, van den Brink W. Psychotic symptoms among male adolescent detainees in the Netherlands. Schizophr Bull 2004;30:73-86.

13. Colins O, Vermeiren R, Vreugdenhil C, et al. Are psychotic experiences among detained juvenile offenders explained by trauma and substance use? Drug and Alcohol Dependence 2009;100:39-46.

14. Ryan EP, Redding RE. A review of mood disorders among juvenile offenders.

Psychiatric services 2004;55:1397-1407.

15. Gosden NP, Kramp P, Gabrielsen G, Andersen TF, Sestoft D. Violence of youth criminals predicts schizophrenia: a 9-year register-based followup of 15- to 19-yearold criminals. Schizophrenia Bulletin 2005;31(3):759-68.

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Chapter III Mental health Intervention for young offenders in France: between the child psychiatry issue and the reform of juvenile justice .......................................................................................................................................

by Erwann Besnard Psychologist SĂŠbastien Marchand Project executive Association Diagrama. France

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Table of Contents ..........................................................................................................................

Introduction 1. PROFILE OF THE MENTALLY ILL JUVENILE OFFENDER 1.1. General background of young offenders with mental health problems 1.2. Family situations of young offenders with mental health problems 1.3. Misuse of substances and behavioural disorders among young offenders 2. LEGAL FRAMEWORK : PENAL AND CHILD CARE REGULATION 2.1. The child care system in France 2.2. The child protection system in France 2.3. The juvenile justice system in France 2.4. Penal responsibility of young offenders with mental health problems 3. INTERVENTION APPROACHES AND SPECIFIC UNITS 3.1. Early prevention program for young people with behavior problems Projet Sensations Fortes à Gévezé : diagrama France 3.2. Specific mental health units for young offenders with mental health problem 3.2.1. The « Closed therapeutic educational centres » 3.2.2. Therapeutic Unit For Children and Adolescent, Unit« Earth and Sea » (TUFCA) - (Saint-Brieuc) 3.2.3. Reception and Orientation Psychiatric Centre (ROPC) – (Paris) 3.2.4. Institution of Educational Placement and Crisis Treatment ( IEPTC) – (Suresnes) 3.3. Development or worsening of mental health problems during deprivation of liberty

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4. OTHER CARE ESTABLISHMENT EXCLUSIVELY OFFERING INTERESTING APPROACHES 4.1. Care Centre for children and adolescent - (Bohars) 4.2. Antares Unit – Wood Perrin Centre – (Rennes) 4.3. House of Solenn – House of Teenagers - (Paris) 4.4. Intersectoral Structure of Treatment of Difficult Adolescent (ISTDA) – (Nice) 4.5. Educational and Pedagogical Therapeutic Institute (EPTI)– (Brest) 5. SYNTHETIC DESCRIPTION OF CHARACTERISTICS OF TREATMENT INVESTIGATED

6. CONCLUSION

Glossary

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Introduction This study, concerning the treatment in mental health area, refers to the organisation of care for the population under 18 in conflict with the law, in Europe nowadays throughout this research we will try to compare French practices.

The objective of this research is to put the current European practices into perspectives to propose an overview. We will question the caretaking capability of each country and the institutional pathways developed, with this specific population that includes the young offenders suffering from mentally illness.

At our level, we will focus on the situation in France. We will focus on the situation of adolescents in suffering and in conflict with the law, under specialised care that can treat psychiatric disorders presented by the young person as well as the general critical condition of the adolescent, taking into account that adolescence is a transition time of construction and psychic development.

First of all, it was first necessary to become familiar with the French political logic as well as ideological and institutional one, which concerns the health and legal organisation, especially vis-à-vis the adolescents. The first awareness period was devoted to the collection of various data. Secondly, we have been led to reach out to different institutions and professionals working in order to distinguish these “pathways of care.”

Based on this observation, we focused on the particular devices that exist in France.

Given that the problem is about global and continuous care, we were interested in residential structures welcoming our population target: adolescents with significant behavioral disorders. To have a good understanding of the possible treatments existing, we also turned our attention to other modes of intervention such as ambulatory care or crisis management. Additionally, we decided not to restrict our research to the health area but to also show our interest in educational and judicial institutions, also involved in working with these adolescents.

This study is not aimed to make an exhaustive presentation of the different institutions but to try to identify characteristics of care modalities as well as original initiatives.

We chose to propose a presentation of the study in four axes. It outlines initially the profile and characteristics of the population studied including mental health, juvenile justice and intervention modalities.

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In the second step, we describe the institutional framework treatment of our target population by different actors. A diagram showing this development is offered at the end of this part.

After we gradually present the structures that interested us in the approaches offered, by giving the details of the different characteristics of each of them.

These concerned the status and the funding of the institution, care modalities, the population and disturbances involved admission criteria, number of places available and the average length of stay, the staff constituting the team, the main objectives of the structure, various elements related to the functioning, information on equipment, and, finally, the limitations that we have identified. We conclude this presentation with a summary of the main advantages and limitations identified.

By following this synthesis, we suggest what we identify as good institutional approaches and relevant elements.

All of these elements enable us to raise in a conclusion recommendations to implement a treatment that will establish an appropriate care of these adolescents often considered as “unlabelled”.

1. PROFILE OF THE MENTALLY ILL JUVENILE OFFENDER 1.1. General background of young offenders with mental health problems Anxiety: this is widely spread among adolescents and especially among those who show offending behaviour. The young people who suffer from it are able to get into especially dangerous situations because of high risk behaviour (violence, drug use, scarification, suicide attempts…). The main objective of this behaviour is to reduce the intensity of their anxiety. The prevalence of anxiety among the general adolescent population is estimated at 8%. Among the target group that concerns us, anxiety is shown under different forms by almost all the individuals. It is most often associated with other symptoms and together they determine a pathological classification.

Depressive disorders : we discover that a lot of adolescent offenders show characteristics of a depressive disorder (its intensity varies according to the individual) : a problem of separation, break-up and/or grief, a general feeling of low self-esteem, aggressiveness towards others or themselves, problems, gloominess…

Psychotic disorders: This is less spread but the prevalence is higher than that of the general population. The offences of adolescents with psychotic disorders are very often determined by their deliriums (paranoia, all-mightiness…)

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Borderline disorders: These subjects show a strong anxiety disorder and the problems can be expressed under different forms, according to the circumstances. These adolescents have a strong tendency to consume drugs and alcohol, high-risk behaviour and sometimes they can suffer from delirious episodes…

Psychopathy: it is typical for these adolescents to have problems with socialisation and they have great mental troubles. As far as socialisation goes, these young people show impulsive and aggressive behaviour. If they get the least bit frustrated, they can suddenly become aggressive and they do so repeatedly. They do not think any longer and these adolescents express themselves via their behaviour. They often express their needs which have to be immediately satisfied, and this in turn can make their already frustrating situation very difficult. The families of these young people are generally quite typical families, an absent or strongly belittled father who cannot symbolically represent the law, a mother who is usually characterised by a certain incoherent behaviour towards her child (sometimes warm, sometimes cold, sometimes passive, sometimes aggressive…). The cognitive functioning of these young people is particularly disharmonic (impossibility to anticipate the consequences of their acts, impossibility to plan ahead…).

These different disorders are at the same time the causes and the consequences of their difficulties with justice, of their fostering and sometimes even of their imprisonment.

They are all determinants of their acting out and they are all important restraints on their social education and integration. So the educational or therapeutic care of minor offenders cannot overlook the specific consideration and accompaniment of these problems, regardless of the chosen place and form of care concerning the different behavioral problems.

They are generally adolescents with a very important identity problem. This identity problem is expressed by the young person’s incapacity to recognise himself in a group, no matter what the family and/or social scale is. On a family level, there may be family matters we have already referred to (abandonment, mistreatment, and the position of the father…). On a social level, there may be important identity difficulties regarding the culture of origin and the current culture. Young people will change from one system to another without being able to build up stable criteria. These two problems are often related.

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1.2. Family situations of young offenders with mental health problems Parents with their parental authority are the first people to be responsible for their children’s deviant behaviour, a behaviour which they apparently cannot prevent nor suppress. However their responsibility is not equal. In certain families, the parents themselves sometimes have such difficulties.

Family specialists agree on recognising the close family as a determining influence on the child’s behaviour. Nevertheless, here is not a more precise consensus on the nature of the family difficulties that most likely favour aggressiveness and delinquency.

Undoubtedly, the structural family mutations and parental discords potentially explain these disorders. The number of single-parent families has increased regularly for the last twenty years. Reconstituted families, as a result from remarriage, are very normal today. However, contrary to a widespread intuition, the most detailed studies conclude that juvenile behaviour disorders are less likely to appear in a stable single-parent family than in a family which has become a place of conflict. If it is violent, the divorce period favours the appearance of depression in the child which is expressed in deviant behaviour: running away, lapse of concentration or absenteeism at school, violence, drug addiction. The structure of the family itself does not really explain child or youth delinquency, but combined with other difficulties, it becomes a potential risk factor.

Financial and social precariousness also has a strong position among the obstacles to the families’ development.

No difficulty can be explained only by the family’s educational failures.

Nevertheless, a set of indications allows identifying the parents that are least fit to fulfill their role. This research work is difficult and calls for a coordination between social agents (PMI, school…) which for the moment only exist in situations that are too rare.

Several studies done by child specialists underline that the appearance of violent behaviour is not restricted to adolescence, but dates back to early childhood. One of them, “Families and delinquency” – CESDIP – under the direction of Laurent Mucchieli (2000 , No. 86) specifies even that the first “peak” of violent behaviour would be situated between the ages of 6 and 8. At that age, 4% of the children are chronically violent people and will still be at the age of 15; 28% were violent in their early childhood, but these disorders did not continue in time. The other children from the sample were not considered to be having serious behaviour difficulties.

The central instruction of this statistic work is to place the source of violent delinquent behaviour in childhood and to explain it through the mistreatment these young children are a victim of.

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A variety of situations like parental negligence, conflicts within the families, perverted behaviour, social, financial or cultural difficulties, or sometimes a combination of them, contribute to the fact that parents are not able to guarantee their children an environment that favours their education, and explain that the children consider delinquency as an outlet for their family life. Nevertheless, regardless of whether parents are prevented from or reluctant to play their role, they are not the only cause: within the close or extended family environment there are other actors ready to help them or to compete with them depending on the case and whose influence grows as the child is growing up.

All parents have a triple mission towards the child: guarantee their care, security and education. These dispositions are the counterpart of the parental authority parents have over their children, according to the terms in article 371-1 of the Civil Code, “to protect his security, his health and his morality, to guarantee his education and allow his development in due respect to his person”.

Regarding the minors in the justice system and suffering from psychiatric pathologies, there are currently no epidemiological data available. The purpose of the first set of data is to estimate the prevalence of psychopathological disorders among the population of minors in the justice system. (Judicial Youth Protection General Directorate for Health (GDH) and General Directorate for Social Action (GDSA).

The second one will reveal the links between delinquency and risk behaviour, addictions, sustained and acted out violence (Federal Research Institute on Industrial economies and Societies (FRIIES), the CNRD, Sociological and Economic Study and Research Centre of Lille (SESRCL)).

However, new data that are the result of French research tend to put the link between delinquent behaviour and family structure into perspective in a sociological sense, without necessarily undoing the correlations between the appearance of psychopathological disorders and family functioning.

A possible relativisation coming from sociology Indeed, the results of Publisher in Delinquency and family socialisation: a limited explanation, researches and previsions, CNAF, 2008, no. 93, September 2008, say that.

In 2006, 57,000 minors were sentenced and, according to the statistics, more than half of them will appear before the judge again in less than five years. In 2007, 32 children under 13 have been tried for crimes. And regularly, a good number of cases put the delinquent behaviour of young people in the headlines of the news. To try and understand the parents’ implication in these phenomena better, the sociologist

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Sebastian Roché from the laboratory “Public policies, political action, territories” (Pacte) together with his research team based themselves on the surveys done in 1999, 2002 and 2005 among representative samples of young people between 13 and 19 years old, school goers or placed in specialised establishments in two big French urban areas, Grenoble and Saint-Etienne. The conclusions he reached are sometimes surprising. Seeing his analysis is about relations between families and delinquency, it clearly takes the idea of the dysfunction of the “classical” family cell (divorce, singleparenthood, reconstituted family) being the main responsible factor for the criminal behaviour of certain young people the opposite way. “There is of course a cause-andeffect relation between the disruption of the family unit and delinquency, but it is a “small” responsible effect, according to our results, between 1 and 3% of the delinquent phenomenon regarding minors. In the same way, when we look for a link between the family structure and the socio-economic level of the home, and the delinquent behaviour of the young people, we barely obtain any conclusive results. The fact of having working parents increases delinquency a bit for single-parent families, but only a bit (although definitely a bit more for more serious crimes), explains Sebastian Roché.

On the other hand, the area where they live has a clearer effect on delinquency than the parents’ socio-professional category.”

Moreover a lot of other variables are revealed to be more important: the quality of the relationships with other family members, the number of close delinquent friends, the presence of chaos in the neighbourhood, school integration and, especially, the parents’ supervision over the minors (the fact that they control their “little ones’” school activity, how they spend their time, who they hang out with…). All these factors, that cannot be reduced to the family alone and which are valid both for girls and boys, are obviously combined over and over again. “Just like taking medicine all together can aggravate the undesirable effects of each molecule, poor supervision by the parents will increase delinquency among children who are badly integrated at school”, says Sebastian Roché.

What about the impact of family structure on the criminal process itself? To have a database which is as big as possible, the researchers have computerised all the legal files on minors (about 1,600) tried in Isère for serious acts (armed robbery, homicides, voluntary bodily injuries, sexual crimes…) between 1985 and 2007. It shows that in terms of serious crimes, young people who live with both their parents are generally less severely punished than those who live alone and that, if the family structure plays a protective role, it decreases in proportion to the minor’s previous convictions.

If the young person does not have any known criminal record, and he is growing up in a “classic” parenting environment, this moderating effect is very strong. On the contrary, justice is clearly far less lenient to delinquents who have a criminal record and are

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deprived of a classic family structure. “The judge is likely to think that a classic family environment is suitable to supervise the adolescent’s erratic behaviour and so he pronounces a light sanction”, states Sebastian Roché, “but facing the accumulation of crimes, the judge considers that there are not any other resources left but to reinforce the sanction.”

For youth delinquency that turned out to be multi-factorial, “it is advisable to integrate this reflection in order to act efficiently”, concludes the same expert. “The prevention of this phenomenon starts first with a successful integration at school. In addition, it seems paradoxical that the absence of a classic family plays “against” the minors when they come before justice, because they are not responsible for it.”

1.3. Misuse of substances and behavioural disorders among young offenders Although studies among children are still rare, they show that, in opposition to what people have thought for a long time, the use of psychoactive substances is not exceptional at this age. 15 to 20% (sometimes more) of children between 9 and 10 already had an experience, at least once, with tobacco, 2 to 8% consume it more or less on a regular basis.

Multiple surveys show that drug users, in the widest meaning of the word, are more frequently perpetrators of criminal acts.

The epidemiological survey mentioned before, carried out by Mrs. Marie Choquet and Mrs. Sylvie Ledoux, underlines that violent behaviour goes together with: -Alcohol consumption: among violent young people, 21% regularly consume alcohol (against 7% of the “non-violent” ones). 36% of the extortionists have such a level of consumption.

-Tobacco consumption: among the violent ones, 22% smoke on a daily basis (against 11% of the “non-violent” ones). Tobacco addiction concerns 32% of the extortionists.

-Drug use: among the violent ones, 16% have used an illegal drug at least ten times (against 5% of the “non-violent” ones). 23% of the extortionists are regular drug users.

In the same way, there is a survey ordered by the Ministry of Justice among young people between 14 and 21 years old under judicial youth protection: “Marie Choquet: A survey on young people under the JPY services, 1998”. It reveals that there is a link between delinquent behaviour and the consumption of psychotropic products. 70% of these young people consumed alcohol. At the age of 18, 49% can be considered as regular consumers. When we talk about cannabis, 60% of the young people have taken it in their life. So, when they consume cannabis, the children of intermediate settings

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or professions are more often fraudulent than users (87.5% against 64% of the nonconsumers) and more often involved in dealing (25% against 5%). It also very often leads to fights (29% against 11%) and to carrying a weapon (20% against 5%) or even to cause serious damages like torching a car or a building (13.5% against 4.5%).

A study of NIHMR (National Institute of Health and Medical Research) on the effects of cannabis showed that the risk of psychosis when this drug was used was multiplied by 4.

Certain pharmacologists insist on the danger of cannabis which is a lot more concentrated than in the â&#x20AC;&#x2DC;60s and which disturbs memory, causes spatial and temporal disorders and increases the risks of a heart attack, without even speaking about its carcinogenic effect.

Although a lot of adolescents experiment with psychoactive substances, in comparison, few of them will develop an addiction. This means that the factors that influence the beginning and the experimenting with drugs are undoubtedly different than the ones leading to abuse or addiction. To that respect, studies have shown that the first experiments with tobacco were generally experienced in a negative way by adolescents, underlining the intervention of other factors in the consumption becoming permanent.

Globally, the beginning and experimentation with psychoactive substances among adolescents seem to be fundamentally determined by the socio-cultural, situational and environmental factors, whereas the psychological, psychiatric and biological factors seem to have a predominant role in the development of abuse and addiction.

Adolescence is a period of transition marked by important changes that affect the body, the mind, social life and self-representation. The developmental process in this period includes the need for the adolescent to test and modify his attitudes and behaviour throughout his evolution and the interactions with the environment. This trial and error learning allows the adolescent to discover and then elaborate his own social values system through self-consciousness and the affirmation of his identity. It allows him to achieve the feeling of individualism and social integration at the same time.

The experimentation of psychoactive substances is part of this process as an organising experience of mental life, the practice of the body and the reactions of the social group. Adolescentsâ&#x20AC;&#x2122; attitudes and behaviour are largely dominated by the subjective notion of compliance with the presumed normality. The social pressure regarding the compliance with the ideal models, promoted by culture and the media, and, in an even more restricted way, by the group of peers, can explain the importance today of the consumption behaviour of these adolescents which are conviviality factors through which social and cultural values of a period are marked.

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Therefore, curiosity, peer group pressure, boredom, stress, getting into a relaxed state and for pleasure, self image and self-affirmation, rebellious spirit are often quoted as initiation and experimentation factors.

Numerous studies highlight the role of temperamental and personality variables in the consumption of psychoactive substance by adolescents. A high level of researching novelties and a low level of avoiding danger would be significantly predictive of early initiation, between the age of 10 and 15. In the same way, low self-esteem seems to be predictive among girls of early experimentation which can lead to subsequent consumption.

All the studies underline the frequency of the mental disorders found among adolescents who show an abuse or an addiction to psychoactive substances. Anxiety disorders and, to a lesser extent, depressive disorders seem to have an influence on the initiation and the regular consumption and accelerate the process leading to addiction.

Also, the attention deficit hyperactivity disorder, especially when it is associated with other disorders (behavioural disorders, depression and anxiety) would be predictive of an early initiation and the seriousness of the addiction. Although the links between consumption and mental disorders are still under discussion, these data plead in favour of the self-medication hypothesis.

The authors who have simultaneously studied the role of psychopathological factors (personality features, mental disorders) and the psychosocial factors (influence of the peer group and/or family) show that the psychopathological factors are more predictive of the adolescentsâ&#x20AC;&#x2122; consumption behaviour than the psychosocial ones.

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2. LEGAL FRAMEWORK: PENAL AND CHILD CARE REGULATION 2.1. The child care system in France

The French psychiatric system is ruled by a logic of division. Sectors are established in the health area and in function of the density of populations (approximately 70 000 inhabitants for an adult sector). An infant-juvenile sector covers three adults sectors.

The health and endowment policy in institutions terms are contained in Regional Schemes of Sanitary Organization (RSSO). This latter is established with three years of actions to implement, as well as goals to reach. The last RSSO (2001-2004) has underlined the need of developing residential units aimed at treating children´s disturbances and more specifically those of teenagers. The RSSO III (2005-2008) set out this action.

Since the year 1960, a movement of deinstitutionalisation of psychiatry has emerged.

The number of beds decreased since then, at the advantage of ambulatory treatment.

Medical-psychological centers (MPC) imposed themselves as a turning point of care in mental health matters. Nonetheless, they are overcharged: the waiting time for a meeting can take up to at least a month.

It matters to also point out that the deficit of psychiatrics is getting larger in France.

Numerous institutions are looking for psychiatrist. Establishments welcoming teenagers who are hard to handle are, however, not the most appreciated by doctors.

In order to expose, in a systematic way, different routes that the teenager presenting

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psychiatric disturbances can take, we have indentified different levels of intervention.

We have found three actors that can be solicited following a crisis emergence, the time of expression of psychiatric and psychologist disturbances. Those institutions differ by the moment of their intervention, even if some can be introduced at several levels. We will briefly describe actors of this group of “First stakeholder”, and those from “emergency management“and those implied in the “orientation and treatment”.

First stakeholder • Liberal doctors: Generalist still being privileged interlocutors when health problems appear, whether they are physical or psychic. Child psychiatrist treats these emergency situation trough their consultations.

• Medical staff of the national education system are privileged observants of the appearance and expression of disturbances • The Medical-Psychological Center (MPC) as an essential actor of mental health services can be subjected to request. However, as we mentioned, the waiting lists are very long.

• “15” the phone number of the SAMU (French emergency service of medical help), leads to an intervention in brief waiting time.

• Teenager´s houses that the RSSO plans to install in each department (French territorial division) by 2020, have the role of offering an educational, social, medical and paramedical support to teenagers. They have to encourage exchanges between different institutions treating the latter. The Young Listening Point (YLP) has noticeably the same role but in a less important frame.

Emergency management Professionals as parents can be directly solicited by emergency services in a crisis period.

Reception services and emergency treatments (Emergency Receptions Services), the Proximity Unit of Reception, Treatment, and Orientation of Emergencies (PURTOE) or emergency services of general hospitals allow admitting for a short-term the teenager and stabilising his condition.

Services have been developed these last years with the purpose of offering an alternative to hospitalisation.

Crisis centers have been introduced by child psychiatric sectors in order to offer a space-time of stabilisation of the condition of the children and an adapted orientation.

• Mobile teams have as goals to offer a speaking time besides the place of residence of the teenager and hospital buildings. They can intervene in order to defuse emergency situations and to offer, sometimes, a short-term follow up.

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â&#x20AC;˘ Consultation centers extended have been designed to not react at the crisis moment in emergencies, but to consider the waiting time as a therapeutic time. They concede more time to the analysis of the situation in order to recommend the most adapted care.

Orientation and treatments After these two steps, the teenager can be offered different treatments.

1. The ones coming under the psychiatric area: teenager could be on the one hand orientated to hospitalisation structures on a full time basis. These units are limited in number and comprise few rooms. On the other hand, the extra-hospital time could be recommended. Different services, dependent on the ambulatory or partial time, maintain all a tight link with the PMC. Teenagers are then followed in consultation, in therapeutic workshops or discontinue hospitalisations.

2. The one entering medico-social-educational institutions: these private institutions generally offer a large diversity of treatment, with characteristics and objectives sometimes widely different. Therapeutic, Educational and Pedagogical Institute (TEPI) address children with behavioural disturbances with a therapeutic, pedagogic and educative aim; while Medico-Psycho-Pedagogical Centers (MPPC) rather address teenagers with psychiatric disturbances with mainly a therapeutic goal.

The ones attended by liberal doctors that are child psychiatrists or generalists once the condition of the teenager is stabilised, it is frequent that they are then referred to those liberal generalists. The generalist is strongly recommended and asked at this time.

There is one scenario that appears us particularly important to report which we found again and again at each step of our schema: the lack of answers. Indeed, it is frequent that following a crisis period or a stay in emergency management the teenager goes back to his home environment without putting in place an intervention. It can lead to a new crisis and thus to the establishment of a vicious circle.

2.2. The child protection system in France The child in the core of the system - In an article where a general principle is explained (art L 112-4 du CASF), the law defines three axis to guide decisions concerning the child protected during his childhood, namely: Child`s interest - The taking into account of his fundamental needs, defined as physical, intellectual, social and affective needs - The respect of his rights (Reference to the International Convention on the Rights of

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the Child) - Several rules dedicate/give consideration to the child and his right to be informed about his situation and his right to be heard in certain circumstances The text takes into account certain concepts borrowed to the notion of interest as it is defined in other legislations (e.g. Quebec and Italy: the interest of the child is defined as the protection of his security and his intellectual and affective development).

- The law of March 5th introduced the physical, affective, intellectual and social development of the child as having to be protected when it is in jeopardy, at the same capacity that his education condition.

- On the other hand, the law brings some particular consideration to the continuity of links established for a child and to the importance of this continuity for his development; it is aimed to ensure a relational stability of the child in very specific situation.

A treatment adapted and diversified In the concern of adapting feedback given to children and families, the protection system of childhood has seen its development since a few years from new hosting habits and interventions bringing diversified and flexible solutions. The interest of diversifying answers has been underlined by all the observants before the reform. The reform introduced new possibilities of action by creating new performances: - Accompanying measure in home and social economics - Able to help managing the family budget - Possibility of emergency reception of children for three days without parental consent but subject to informing or notifying the public prosecutor, - Day care - Periodic or modular home, as part of an administrative temporary reception -the AEMO with accommodation, under a strict frame of legal condition.

The article L223-1 of the social and family action code mentions that the allocation of one or several services has to be preceded by an evaluation of the situation taking into account three elements: the condition of the minor, the family situation and help that can be mobilised in his environment.

This evaluation has to allow the establishment of a document named â&#x20AC;&#x153;project of the childâ&#x20AC;?, a new tool that constitutes a support to state and the parents regarding the general evaluation of their situation and to define actions that will be lead by the service and their contribution to each action. In this document, the person in charge of ensuring the outline has to be identified as well, that is to say the continuity of actions undertaken besides by the family. It could also serve, notably, if the decision of the judge requires, to define between the parents and the service concrete modalities of organisation of visit and accommodation rights of the child in treatment.

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The text legalises media coverage in child protection cases but also in the case of a divorce and the separation (with the objective of promoting the continuity of the bond between the child and his two parents).

A new rule in article 375-7 of the Civil Code prescribes that “if the situation of the child allows it, the judge can set the nature and the frequency of visit and accommodation rights and can decide that their implementations are determined jointly by parental authorities, and the service or the establishment in whose charge the child is placed, in a document that will be transmitted. He is seized in the case of a disagreement.” This rule can enable the organisation of intervention to combine flexible modalities and/or sequential residential placement of the child and an important educational support from home.

2.3. The juvenile justice system in France “Few problems are as serious as the ones that concern child protection, and among them, those regarding the fate of children brought to justice. France does not have enough children in its territory to neglect all the measures making them healthy human beings. The war and the material and moral disruptions it has provoked have increased juvenile delinquency alarmingly. The matter of guilty childhood is one of the most urgent ones at the present.”

This is the introduction of the statement of the reasons for the ruling of February 2nd 1945 regarding offending children which sets a deep evolution of the responses given to juvenile delinquency.

The text is based on three essential principles which have never been doubted afterwards: the primacy of education over repression, the specialisation of jurisdictions, and the extenuating excuse of minority.

The 1945 ruling is the founding text of youth justice in France. This ruling recognises that the applicable justice for minors is not the same as the one for adults. Youth justice fulfils two missions: it protects minors in danger and it judges minor offenders.

As far as minor offenders go, criminal justice sets out several principles: The educational measure prevails over the criminal sanction.

No criminal sanction can be pronounced against a minor under 13.

Minors get a mitigated responsibility regime and a reduction of their punishment.

Minors get particular procedure rules adapted to their age (custody, remand…)

Outline of the criminal procedure for minors: When a minor commits an offence, a misdemeanour or a crime and he is taken in for

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questioning, the youth prosecutor has to be informed. He verifies the procedure of the remand according to the specific criteria and decides, based on the elements of the remand period, whether or not to refer the case to the youth judge (or examining judge in case of a crime). If the case is not referred, it will be filed together with alternative measures to the criminal ones (measure of repair, a warning…) in case the facts are proven but fall more under an offence. When the case is referred to a judge, he can either immediately remand the young person, or set a date for a later hearing. During this hearing, if the minor’s participation in the offence is established, an investigation will be ordered by the judge. The judge can then pronounce provisional measures (hand over to the parents, provisional placement, judicial control or sometimes even remand) while awaiting a ruling. Here we speak of pre-trial measures.

The trial takes place, according to the nature and the seriousness of the facts (appearance or not of joint tort-feasors, offence or crime…) in a private hearing, at the youth court or at the criminal court. The decisions (in addition to the acquittal) can be a conviction to one or more educational measures or a punishment. In a private hearing, the youth judge can only pronounce educational measures.

The educational measures are: The reprimand Hand them over to the parents, guardian Repair Probation Educational placement Judicial protection The main objective of the educational measure is to make the minor aware of the consequences of his acts.

The punishments can only be decided upon by a court. They can be: Community Service if the minor is older than 16.

An educational sanction (confiscation of the object related to the offence, banned from one or more places, forbidden to see one or more people, care obligation, the obligation to participate in civic training).

Closed imprisonment, a suspended prison sentence or probation.

Notice that the judicial control and the suspended prison sentence are related to different conditions which must be respected by the minor. If he did not respect them, the judge could revoke the judicial control or the suspended sentence and imprison the minor.

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These conditions can be: Execution of a repair measure Respecting a care obligation Execution of an educational sanction Respecting the conditions of an educational placement, particularly at a Reinforced Educational Establishment or a Closed Educational Centre

2.4. Penal responsibility of young offenders with mental health problems The principle of criminal responsibility in relation to mental disorders is not as systematic as the relation â&#x20AC;&#x153;presence of a pathology = criminal irresponsibilityâ&#x20AC;?. The question the expert has to answer is more: are there any psychiatric elements that could have altered or abolished the judgement of the person involved? Therefore this person is open to receive a criminal sanction. Does it imply a sanction that makes sense or do the psychiatric elements make the person inaccessible to the sanction?

If the psychiatric expert considers that the judgement was abolished at the time of the criminal acts, then the person may be considered as criminally irresponsible and cannot be tried.

If the psychiatrist considers that the judgement was not altered, then the person is criminally responsible and can be tried and sentenced. The problem is that this expertise is controversial because it is particularly subjective and it is very rare that the expertise considers that there was a total abolition of judgement.

In fact, an alteration of judgement is often recorded and this generates a socio-judicial follow-up for which a care injunction can be issued. The task of this injunction is very limited because of the lack of means and the fact that the people who receive it are most often in a bad position towards this injunction and few of them stick to it. It is a fundamental problem of psychiatric care under restraint. This partially explains the particularly high number of people suffering from a psychiatric pathology in detention (60% of the general population of prisoners).

There is no specific legislation but specific resources for minor offenders with mental disorders. Some Closed Educational Centres have the special project to receive minor offenders (within the framework of a criminal measure) with a psychiatric pathology.

These centres have specific human resources that allow responding to the needs of these minors (a psychiatrist and spsychiatric nurse).

Although there is no specific legislation, the specificity of the ruling from 1945 with the principle of education prevailing over repression, leaves the youth judge the possibility

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to favour medical solutions for young people who need it.

In addition, new detention modalities for minors have been developed over the last years. These are Penitentiary Establishments for Minors (PEM). These establishments receive up to 60 minors in detention but with an educational, a pedagogic and care team apart from the guards of the penitentiary administration. Imprisoning a minor in these establishments allows guaranteeing a particular educational and therapeutic follow-up.

3. INTERVENTION APPROACHES 3.1. Early prevention programmes for young people with behavior problems Nowadays in France, no specific intervention programs exist that focus on the disturbances that some minors present.

The community based its action on existing services such as the infantile maternal protection, the school and the centres of care established in the national territory.

However, there are experimental projects guided at a local scale managed by the community.

Strong Sensations Project at Gévezé: diagrama France - Description: Since January, a dozen of young people participate in a project of awareness and interchange of risk-taking. The project will last until October at the rate of one session per month.

- Objective: To raise awareness among young gévezéens of risks incurred in various situations of everyday life, where the danger is not necessarily meaningful. Exchanges with professionals and volunteers acting in the safety area (road safety, fire, MPC Beaulieu ...) enable to nourish the debate and especially to inform young people about the realities in the field.

- The sports tabloid: young people appreciate this kind of activity as they face a certain amount of risk in a secure environment. During the climbing practice in January, some concepts such as ensuring one´s mate, respecting the safety rules explained by the adult, beyond its limits, facing one´s fear, are highlighted.

- The formative and informative activities: alternating between sports practices and “theoretical” ones allow a look back on the sensations felt. The fact of sharing with professionals and volunteers, in a non-institutional frame, gives another dimension to the term discussed, namely, “alcohol among minors” JF Blouin of Road Safety was involved with 13 young gévezéens, and participated in a discussion with young people.

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3.2. Specific mental health units for young offenders with mental health problems 3.2.1. The “closed therapeutics educational centers”.

The Ministry of Justice, through the speech June 22, 2007 by the Minister of Justice, has developed the establishment of five Closed Educative Center ( CEC) for therapeutic purposes.

The move comes following a report of deteriorating mental health of minors housed in the structures of the Judicial Protection of the Youth (JPY). The device was designed to accommodate adolescents for whom a psychiatric care at the hospital is not justified (because of the lack of psychiatric pathology proven), but which, because of their behavior, undermine the educational structures as a whole.

This pilot project started in January 2008 and has allocated additional resources to the development of personalised treatment programs for five of the 37 Closed Educational Centres. The stated aim is to develop an educational care and treatment received by minors.

The CEC chosen have received a supplementary budget, which must in particular enable the recruitment of 5 full-time professionals: a psychiatrist, psychologist, and three nurses.

A process of ongoing evaluation of this device has been developed, both by the Judicial Protection of the Youth (JPY) and the Directorate of hospitalisation and care organisation of the Ministry of Health.

The example of the closed educational center of the Jubaudiaire Status: Private center authorised by JPY. It belongs to the Association of Catholic Cities (ACC). It is located on the site of the city “Gautrêche”.

This center is one of five participating in the pilot CEC therapy initiated by the Ministry of Justice. This experiment began in Jubaudière in June 2008.

Funding: JPY subsidises treatment realises within the Closed Educative Center (CEC), up to € 545 per day. The budget allocated for one year, in addition to operating costs of a conventional CEC, is 400 000 €. Child psychiatry sent the bills to the CEC that pays it.

Modalities of care: Placement under judicial warrant.

Population: Minors between 13 and 15 years.

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They are all under court order under a judicial review of a suspended sentence with probation, on parole or work release.

Disorders: The device was designed to accommodate adolescents for whom a psychiatric care hospital is not justified, but who have undermined number of educational facilities due to the expression of major behavioral disorders.

The CEC therapy, however, is not specialised in the care of children with psychological disorders. They therefore continue to take care of minors that are addressed by the courts nearby.

Jubaudière professionals have been able to update the similarity of family profiles of adolescents hosted: “Very close and incestuous mothers and absent fathers (resigned face to these possessive mothers, alcoholics, or have not recognised the child)”.

Exclusion criteria: Minors with perverse type of behaviour or psychopathic tendencies, are usually very quickly facing prison. The institution believes that it is not able to handle them, it is not a suitable structure for them.

Number of Treated: The center is authorised to receive 12 minors. It currently hosts 11.

Average duration of treatment: 6 months of investment, renewable once.

The CEC does not work with a waiting list. When there is a place, the Director notifies the various legal institutions.

Staff: A team of 27 persons is present within the facility: • a director.

• 2 heads of services • a psychologist.

• an art therapist at halftime.

• A person in charge of the insertion, which was also responsible for coordinating the daily interventions with the youth.

• 2 teachers, one of which is detached from the national education.

• a sports teacher.

• a person responsible for administering the activities of outdoor sport and to support young people in the various steps of finding an internship.

• a craftsman working part-time. He performs the various repairs with youth. This same person also works part-time as an educator within the CEC. • Educators. These posts are provided by individuals holding DEFA (state diploma in animation functions). These professionals know how to manage groups, but are less effective in the coaching. They are between 30 and 50.

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• a housewife.

• Secretaries. They work together with other services of the site.

The health centre’s staff reinforces the intervention of the CEC team. In theory, five fulltime professionals would be recruited, a psychiatrist, a psychologist, and three nurses.

In fact, the healthcare division of Jubaudière counts a psychiatrist at 0.28 of EFT (i.e presence of 10 hours per week), a full-time psychologist, one part-time art therapist and a registered nurse who should start soon.

A position of psychiatry team controller child psychiatric team should be established shortly. The recruitment of these persons is made by the child psychiatry.

The director told us that the healthcare division of the CEC was better equipped than the other four establishments participating in the experiment, especially because of the presence of a psychiatrist.

Main objectives: - As part of an alternative to incarceration, the goal is to develop an educational care coupled with intensive therapeutic intervention.

- Requirement that young people accept the placement.

- Will of the clinical and educational team to daily place the youth in debate, always within the law.

- CEC professionals have developed practices that aim to play the role of a third institution in the mother / child relationship. This approach is based on the finding of a link between crime and the failure to separate from the mother. The institutional mechanism should allow the adolescent to gradually separate from his/her mother, and within the contained framework. This necessarily implies a work of opening to the outside.

Mechanism: - A partnership agreement was signed between the CEC, the child psychiatry services in the region, the prefect, the general council, the mayor of Jubaudière, JPY and the Ministry of Education. It allowed for the confirmation of the link between the CEC and child psychiatry.

- Work is performed upon admission about the possibilities of orientation at the end of the investment. This allows the young to make plans for the future.

- The support takes the form of various workshops and institutional time and by the application of certain rules: • Riding sessions take place twice a week, and sailing trips once a month.

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• Every Friday, a group of control takes place with young people and the various professionals present. At first, the teens did not grasp much of what institutional time was, but they now have invested in it well.

• Always in the aim of accountability, young people choose their own punishment among the three possibilities offered by the director. They may possibly suggest an alternative. The lunches are prepared by a kitchen in the city. Evening meals are chosen and cooked by the young people accompanied by educators.

• Every 6 weeks a summary is made for each youth.

- The behavior of young people is assessed daily. Points earned enable them to access various levels which offer various benefits. The level of permitted point reflects the socialisation developed by the young person.

- The institutional logic of CEC assigns specific roles to the various professional speakers from the centre.

- Both managers have distinct functions.

• One of the two works on the course of the young. He makes a report every week.

• The other regulates the team, schedules, organises activities and is responsible for managing groups.

These are department heads (and especially the one who deals with teenager’s course) and the director who goes to hearings.

- The young person has two educator referents. However it is important to emphasise the role of the general referent department head in charge of his course. There are two educators in the morning, three in the afternoon and two in the evenings. The institution requires them above all to be relevant in the field. The role of reference, report writing or the construction of draft guidance, are secondary.

- For the director, it is important that professionals working directly with young people have had a special history with violence. For psychologists this is not necessarily needed.

Indeed, psychologists are not in the frustration, but in the empathy and confidentiality logic. Therefore they are not directly confronted with violence.

- At the end of the treatment, even though most of the young people want to return to their family, it is often impossible because of family problems. The team members are therefore working towards an orientation generally in a living or foster care.

- We have to notice the presence of two dogs, which are described by the director as “transitional objects”.

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The therapy CEC project takes place within this close environment of the service by the establishment of a health centre. This centre takes place through the following elements: - It allows the introduction of psychiatric follow-up with the child psychiatrist, and collective follow-up with the psychologist.

- Discussion groups with external professionals on the prevention of addictive behavior (drug, alcohol, tobacco), have been created. CEC professionals and the healthcare division currently thinks about the relevance of setting up outside of the CEC, a discussion group for juvenile sex offenders. A group which is not seen as stigmatising for the young people.

- The Psychologist from the healthcare division organises prevention groups, sets up discussion groups and tests. It can also provide support to team members in times of stress or anxiety.

- The youth participate in a particular discussion group referred to self-regulation.

They are then divided into two groups. Since the establishment of the exchange time, the director observes an appeasement of the tension between teenagers.

- Each week, the art therapist sets up a workshop in child psychiatry services. She goes there being usually accompanied by one or two minors. The latter has become familiar with the child psychiatric intervention.

- The presence of nurses is essential. In effect, they watch over the compliance with prescribed medical treatments.

- 3 of 11 young people have a Tercian prescription (neuroleptics and antidepressants).

This reduces the anxieties of young people, thereby making them more available to the education and reflection on their relationship with their parents.

- In a crisis situation, the emergency psychiatrist (who is the doctor who intervenes at the CEC), takes in priority the youth from the centre because he already knows their situation.

Schooling : Minors follow private lessons for a month so that they can improve.

Afterwards, they work in pairs with teachers.

Facilities: - The CEC is divided into four buildings of the nineteenth century entirely renovated with a central courtyard. They have respectively: - The offices of the director and administrative staff - Classrooms and meeting rooms, educators and department head offices

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- Chambers of minors and laundry.

- The dining room, gym, activity room and room for art therapy.

The director had mentioned to us the limited functionality of buildings. He would have been more relevant to use the building where the bedrooms are (often too large), to allocate the activities rooms and the dining area.

- Young people have access to a small television room in the rooms building.

- The CEC also has access to vegetable greenhouses in the city, as well as a basketball court.

- It should be noted that in case of damage (broken windows, damaged television), the institution has chosen not to repair directly.

3.2.2. Therapeutic Unit For Child and Adolescent, Unit “Earth and Sea” (TUFCA) (Saint-Brieuc) Status: Unit of the hospital Saint Jean de Dieu . Non profit private hospital Participating to the Public Hospital Service ( PPHS) specialised in the field of mental health. It offers various modalities of care ranging from outpatient to full-time hospitalisation.

The opening of a full time unit of hospitalisation for children and adolescents was one of the objectives of the Saint Jean de Dieu establishment of 2003-2007. It was realised in January 2005. The TUFCA is located inside the centre of the Saint Benedict Menni care, Saint Jean de Dieu Hospital structure.

Funding: Regional office of health insurance of Bretagne.

Modalities of care: Full-time hospitalisation. Hospitalisations are mostly free, but may be forced. The service closes for three weeks in August as applications are limited at this time of the year. It is also closed on Christmas Day, because it can be difficult for a teenager to spend that day in a child psychiatric unit.

Population: Children and adolescents aged 10 to 18 years. However, the service encourages applications for admission of 13/16 years old. Large age differences are indeed not always easy to manage. It is institutionally established that before 18 years of age, the patient is referred to infant-juvenile services, and to adult services after he reaches majority. Teens can come from the whole department of Cotes d’Armor.

The unit is mixed.

Disorders: Adolescents admitted generally have depressive symptoms, behavioral

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disorders with manifestations of aggression, school phobias , rush of deliriums, emerging psychosis or autistic disorders. Youth who attempt suicide are also supported. Patients with eating disorders are generally addressed in pediatrics and especially because of physical risks.

It should be noted that even if at the beginning the unit hosted mainly young people with significant behavioral disorders, the situation has since changed.

Indeed treatments have been very complicated to implement. The team members have decided to favor the reception of adolescents with heterogeneous disorders.

Admission criteria: The agreement of the child psychiatrist is required for admission.

Requests are always submitted to him through a doctor, he then examines the situation.

The file will not be revisited, if the orientation is recommended by the doctor working jointly in pediatrics and TUFCA, and who assesses daily similar situations in child psychiatry. The agreement of the family is required and the procedure is simplified if the young accedes. From the Provisory Order of Placement (POP) of the juvenile judge, the unit is obligated to accommodate the youth.

The unit avoids welcoming patients in crisis. They remain initially in the emergency services. Once the crisis passes, admission to TUFCA is made possible.

Number of Treated: Opening with 12 beds, but the unit now has 10. Both beds have been converted into a reception room and an appeasement room.

Average Duration of treatment: It is about 3 weeks. The treatment may vary from one week to four months.

The unit prefers to work after several short episodes of hospitalisations, rather than a long term stay. This allows, in particular, the prevention of a ‘routine’ treatment and to maintain the therapeutic setting.

Staff: • a part-time child psychiatrist, • a part-time psychologist, • 15 nurses (10 in the day unit and 5 in night unit), • an educator, • agents of hospital service.

At the opening of the service, two teachers were on duty. When one of them is gone, the institution has chosen to replace him by a nurse.

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Main objectives: Stabilise adolescent disorders.

Establish a therapeutic support.

Provide intermediary support for young people who disrupt the functioning the institutions that host them.

Provide a new modality of treatment in departmental devices for adolescents: full-time hospitalisation.

Functioning: - The early days of operation of the unit were not obvious. Many changes have occurred: The team members have quickly realised that as in services for adults, the presence of a calming down chamber was necessary. It has therefore been established.

Given the large number of runaways, the prosecutor and the head of the hospital requested that action be taken. Service doors are now locked.

The service was much damaged during the first year of operation. Many acts of violence, sometimes towards the professionals, happened. But now the team is more experienced and is able to manage difficult situations.

- TUFCA offers intermediary support in various structures. The Day Hospital regularly communicates with the unit with whom the hospital collaborates to stabilise the disorders of minors and enable the resumption of cares.Sometimes the service is requested by the medical and social structures in order to adjust the treatment of an adolescent. This latter is hospitalised during the time needed to make appropriate modifications.

The TUFCA works particularly in partnership with MEI (Medico-Educational Institute), the TEPI, ESA and also the YJP. - The reception room is used during the admission of the minors. They stay there for 24 hours before joining the group. This process allows professionals to create a bond with their patients, which will be much more complicated to implement once the teen has been integrated into the peer group.

- Contracts of care are developed with the youth upon admission. They can set up from Monday to Friday various therapeutic workshops which the young person agrees to attend. These activities may include swimming, horseback riding, relaxation therapy, manual expression (sculpting, painting, drawing ...), embroidery, cooking, board games (including the Eighth Dimension), or participation in the workshop â&#x20AC;&#x153;press reviewâ&#x20AC;?.

- After 10 days of hospitalisation a summary meeting is set up between the unit team and partners who work with the adolescents. This institutional time secures the hospitalisation time.

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Even if partners are notified of the date of the end of the stay, it frequently happens that hospitalisation prolonged because nobody comes to support the youth. With some institutions, the TUFCA directly establishes at the time of admission an exit contract.

Things are clearly established for the young person as well as for the requesting agency.

- The team works to minimise the impact of the â&#x20AC;&#x153;mass effectâ&#x20AC;? of the peer group. Professionals are thus very sensitive to the growth of scars that can be challenging among adolescents received.

- The hospitalisation of their child in psychiatry can be traumatic for parents, it is therefore important to support them and make the child available. Days of visit are offered. Teens can go home on weekends, except for the first weekend following hospitalisation. The patient is then hospitalised, allowing things to be set.

- The TUFCA has already solicited neighboring adult psychiatry services so that they support during a few days a young person who presents great difficulties for them to treat. These requests are generally poorly received, as the staff of the adult services are fewest for a higher number of patients.

- The psychologist receives the young people in interview and can set up balance sheets if necessary. The child psychiatrist works with adolescents and families.

- The unit increasingly participates in meetings within the Teenagers House of SaintBrieuc. These times of encounter between different professionals working on the same situation, are intended to articulate the various supports. A partnership between various institutions is in development.

- If the state of the young person has been stabilised, and he/she seems better and his/ her environment is ready, the possibility of release is proposed.

- In the presence of depression, the most common orientation is a psychological followup, that is achieved by PMCCA (Psycho-Medical Center for Children and Adolescents) or by professionals working in private practice.

If the youth was already under a follow-up before, the child psychiatrist re-establishes contact with his colleagues.

Schooling: Even if that were established in the initial project, no education is provided within the unit. Adolescents may continue to attend their school, but it is very difficult to implement in the long term. Particularly because the institutional framework of the service does not allow night hospitalisation only. Lack of education is a disadvantage, especially for adolescents whose length of stay is important.

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Additional information: - The unit was set up following the demands of professionals of the department and the findings of the need in this area. Indeed, before only existed day hospitalisation for children and adolescents under 14 years old.

- If during the admission to the emergency unit, teenagers are too agitated, they are transferred to adult emergency units.

- The house of teenagers of Saint-Brieuc has grown following a tripartite agreement between the Hospital of St-Jean de Dieu, the Social Help to the Childhood (SHC) and the JPY. Limits: - Originally the unit was established to meet needs in terms of supporting adolescents with significant behavioral problems, with aggressive acts and putting the various professionals in difficult situations After a few months of functioning, the team decided to host teens with various pathologies. They maintain that mix disorders tend to minimise the effects of the peer group. The service does not respond anymore to the demand.

- The team highlights the difficulties in working with a young person sent by the Provisory Prescription of Placement (POP).

3.2.3. Psychiatric Centre of Reception and Orientation ( PCOR) - (Paris) Status: The Reception and Orientation Psychiatric Center ( PCOR), opened in 1967 to answer to the need to support emergency psychiatry in Paris.This is a regional sanitary emergency service of Hospital Center of Saint Anne in Paris (HCSA) ; private hospital, association under the law 1901 “Families and Emergencies.”

Funding: Public fund from the Regional Agency of Hospitalization (RAH).

Modalities of care: - Reception of the emergency on a full-time basis.

- Home visits.

Population: The original structure was not designed to accommodate children and adolescents. The center has adapted the reception to the population coming and therefore takes care of any person over 15 years old. The choice of age is partly due to

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problems they had with girls with no sexual majority.

Disorders: There is no disorder ruled out of the support. In general, emergencies are characterised by the presence of a disorder, sometimes slight, as well as an act aggressive in itself or hetero-aggressive. This act usually leads people to seek the intervention of the PCOR. Disorders detected in adolescents who are admitted: o 25% of delirious disorders, o 25% of anxiety-depressive, o 5 to 10% of eating disorders (increasing), o The remaining 40% are acting out without immediate categorical diagnosis.

Criterion for admission: The admission is unconditional, it focuses on handling the crisis, responding to the urgency felt by anyone. It can be a request made by the adolescents themselves, parents, judges, somatic care services, schools, police (Brigade of minors), accommodation facilities, educators, etc.

Requests for forced hospitalisation are increasing.

In general, being an emergency service outlined objectives and relationships with professionals who may make an admission application to them.

Number of Supported: The PCOR has a capacity of 8 rooms including 4 emergency beds.

There are 10,000 young people supported a year, including 1,800 for under 25, and 600 adolescents between 15 and 18.

Average duration of the support: The matter of emergency in adolescence has been the object of the establishment since 15 years, of a systematic protocol of offering a support of a minimum of 24 hours. Some situations, such as suicidal crises, conflicts with parents or educational institutions, the waiting time for a place in a hospital service require a week of care to consider the context and to assess the situation.

Staff: • a Department head psychiatrist, full-time • 3 part-time hospital practitioners • an internal Pool Care • a Pool of Senior Care • a pool of hospital doctors on call • 3 Health executives • 2 Agents of Hospital Service • 33 Nurses • 3 Secretaries

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Main objectives: The reception of the medico-psychological, medico-social or medico-psychiatric emergency of the patient and the family. The treatment of the crisis in a second step, allowing the clinical evaluation of the patient. The orientation towards an ambulatory consultation (related to PMC) or hospitalisation.

Functioning: The Aim of the stay at the PCOR is to manage a crisis situation and to asses needs. During the stay, a few activities are available to adolescents (electronic games, magazines). Education is not assured, but the professionals are linked with schools.

Emphasis is placed on the intensity of monitoring, time of open discussion, interviews and daily conversations with doctors and nurses.

The frame of care is flexible, the emergency situation requires some flexibility in the functioning as allowing young people to arrive at midnight, parents can stay and sleep with their children, to stay until 3 am chatting, etc. Some rules are, however, given: do not to leave the service unless they are accompanied, do not hold cell phones etc.

For four years, the PCOR also arranged home visits, at the request of parents. These are usually made in fallback situations when the teenagers stay at home over a period of three months and create an “asylum at home”. The team of five professionals makes visit to their home in order to assess the situation and establish a support.

Following this period of evaluation, the team decides the orientation of the teenager.

For 60% of them, the orientation will be realised at an ambulatory level (CMP, CMPP...)

There is indication of hospitalisation when: • There is a categorical proved diagnosis (depression, delusional disorders, etc...).

• There are behavioral disorders overwhelming the relatives circle : High-risk behavior requiring hospitalisation in order to avoid the spiral of risk.

• There is a need to implement a separation from the parents: the return to the family may be pathogen.

• We are facing a case of school phobia in which the teen retreats at home and does nothing, it is necessary here to operate a separation process.

Demand for hospital stay will be done in a teen service if the pathology is adolescent; it appears during the period of adolescence and is associated with a diagnosis of borderline diagnostic. The orientation will also be made under “hospital-separation” indications.

The orientation of the hospital stay in adult services will be offered during the detection of a proven pathology: acute psychosis, schizophrenia, bipolar disorder, etc… And when it comes to older teenagers, close to majority.

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In addition to internal coordination at the Sainte Anne Hospital (inpatient services Sectors 13, 15 and 18), a broad partnership work is conducted with the structures of emergency reception and acute hospital stay for Paris and the Paris region, Such as: • Montsouris Institute, • The Hospital of Salpetriere, • The ICPRA (Interhospital Centre of Permanent Reception for Adolescent), when they are stabilised, • The CASA in Montreuil, • The adolescent unit in Bicetre, • Beds in medical and psychological pediatric in periphery, for situation that can have suicidal crises, • The adult services, such as Saint Anne’s Hospital, where two beds are reserved for teenagers, close to 18 years and whose pathology (schizophrenic type) lasts for 3 years.

Finally, for some adolescents, particularly those held for a week, a post orientation follow-up can be achieved. Psychotherapy can be started with teenagers, at their request, even several years after their stay at the PCOR. Professionals can also precisely trace the parents.

Facilities: The PCOR is a pavilion located within the hospital complex of Hospital Sainte Anne. The center is not closed, but gives direct access to the street.

Additional Information: The matter about the reception of the young people with adults have been discussed after the double observations of, first, a non-contagion of adults’ pathology towards adolescents, and secondly, the expression of a positive instinct from teenagers who demonstrate the need to care for others.

Limits: The limits found are relative to the lack of solutions at the time of release from hospitalisation structures. Institutions that are lacking are intermediate structures such as a day hospital offering an intermediate stay for teenagers no longer attending school or a nursing home offering a framework less strict than a hospital, more than a simple special school, one that would support both educational and medical care.

A project for this type of structure was proposed in 2002 at the RAH. In the project presented, the objective of the “placement” was to improve the indication and the global care of adolescents by multidisciplinary professionals creating a link with the

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outside. This link takes the form of agreements with schools, school hospital, etc.

Indeed, the other issue is the risk of a frequent hospitalisation due to an iatrogenic hospitalism contracted by teenagers during long hospitalisations. The link to the outside, discontinuous, is no longer necessary because projects (schools, courts) are conducted at the hospital; the release is actually very complicated.

3.2.4. Institution of Educational Placement and Crisis Treatment (IEPCT) - (Suresnes) Status: Socio-educational institution, opened in September 2006. Administratively attached to the public sector of the JPY. Experimental structure in partnership with the directorate department of JPY (Les Hauts de Seine), the Interdepartmental Théophile Roussel Hospital Centre and the General Council of Hauts de Seine.

Funding: 70% by JPY, 20% by the General Council and 10% by Theophile Roussel Hospital Centre.

Modalities of care: full-time admission Population: Minors between 13 and 18 years old. Provisional Order Placement by the Juvenile Court or Magistrate, as a “juvenile delinquency” or “children in danger.”

Receptions of juveniles held in collective accommodation from the Hauts de Seine (92), Yvelines (78) and Paris (75).

Disorders: “Aggressive Behavior, acting out violently and repetitively“ Admission criteria: The team is solicited by phone. The team is committed to answer in the next 48 hours following the call.

- Either a meeting is proposed with the team requesting a prevention of a first-time acting out or recurring episodes.

- Either it offers intervention in crisis situations or offers an effective placement.

In every case, the proposals will be retained only with the commitments of the original structure: - Keep the bed of the young place followed and take him back at the end of the placement in IEPCT - Be available and mobilised in collaborative work Number of Treated: 6 places and monitoring of youth “at distance”.

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Average duration of treatment: 8 days to 1 month maximum. Possibility of “sequential placements” Staff:Multidisciplinary team: • a Director • 1 Head of Service • 6 FTE Educators • 3 Agents Technical Education • a Psychiatrist • 2 Nurses • a Psychologist • 2 Cooks • 1 Secretary

Main objectives: Psycho-social-educational intervention during a crisis time which is in line with the continuity of engaged educational action with young people by the teaching staff of origin (open environment). This procedure allows to keep distance from the situation that led to the crisis.

The action performed by the team IEPCT starts from a crisis defined as the result of interactions between the youth, professionals and family history. Understanding these interactions is then the best prevention of future crises.

Functioning: Intervention is based on three main principles: • Principle of brevity, by the short duration of stay, • Principle of subsidiary, do not substitute existing structures, • Principle of intervention as Third-position, provide the opportunity for applicants to re-examine their service modality of care and / or the Individual project of the young.

The frame project of IEPCT is performed around diagnostic assessment, cathartic or “function lock” , function of elaboration or mobilisation, capacity, and finally dealing with the crisis.

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The course of the treatment has a strict chronology. First, the admission decision is followed by a welcoming interview with an educator and the department head. Within three days, the young meets formally the director, he will sign a convention on this occasion. Every 10 days, the two teams meet to exchange information with a clinician and a member of the educational team.

At the departure of the minor, a formal exchange about a mini-review of the stay is made with a member of the original structure, the minor and a professional of IEPCT. Within 3 weeks after the release of the minor, a new and final synthesis is organised between the two teams. Support and educational teams persist in maintaining liaison work at least two months after the release of the young.

The partnership work is done on a large area and with many partners: JPY homes, SEAT, SHC, PPC, etc.

The IEPCT is an educational establishment wit medical reinforcement and not a care facility in the strict sense, even if a clinical activity is held rigorously. The management of the crisis is distinguished from the psychiatric emergency that is only for medical services.

Limits: Insufficient working relationship with the parent institution lead to lose the effects of this break time and to constitute only a breaking in the course of the young person. We wonder about the principle of brevity of this placement, precisely because these pathways cares are punctuate of a multiplicity of placement.

On the other hand, we had difficulties in collecting information on this structure.

3.3. Development or worsening of mental health problems during deprivation of liberty We cannot now assess the impact of incarceration on minor subjects with mental disorders because there is no relevant data outlining these situations.

However, it was found that half of the young in placements in France present behavior disorders that could be expressed prior to incarceration that can also be revealed while detained.

4. OTHER CARE ESTABLISHMENT INTERESTING APPROACHES

EXCLUSIVELY

OFFERING

4.1. Care centre for children and adolescents - (Bohars) This service has the advantage of allowing rapid and short term hospitalization

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of children and adolescents in crisis. The stabilization of their condition is the main objective. Management and evaluations are intended to advocate a proper orientation. All is well developed during the stay to mean that it is only a step.

It is not always easy to find devices and subsequent management in particular because of the stigmatization induced by the hospitalisation in child psychiatry. The supports are then extended, which on the one hand, lead the centre to lose its status as a crisis service, and on the other hand, undermines the functioning of a unit that was not designed for receptions at mid-term and particularly in relation to the issue of tuition.

4.2. Antares Unit Centre Wood Perrin - (Rennes) The visit of Antares has enabled us to understand the pathway care of one adolescent with psychiatric disorders, from the crisis moment to the ambulatory care of the patient in the community. The interview revealed the statement already made by a mutation of the population, which are the adolescents with increasing behavioral problems, â&#x20AC;&#x153;at the educational and mental limitsâ&#x20AC;?.

This situation requires an opening of psychiatric services providing an external help and therefore the establishment of a multidisciplinary and competent network. The partnership is in fact developed by the professionals of the unit.

Particular attention is paid to continuation of care and monitoring situations.

Institutional choice is to carry out a support in the exclusive registry for the care, psychiatric, however the institution is not intended to provide the educational one.

The further improvement of knowledge of practices of the unit functionality will be interesting.

4.3. House of Solenn - House of Teenagers - (Paris) The visit of the House of Solenn allowed us to perceive the functioning of this House of Teenagers and identify the limits in terms of mission and caretaking. This is an institution that has substantial resources in terms of infrastructure, staff and work opportunities.

It provides an interesting support for eating disorders, despite the existence of some other therapeutic options that can be (vestothèque, therapeutic kitchen). However, it does not cover all the needs of the population.

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4.4 Intersectoral Structure of Treatment of Difficult Adolescents (ISTDA) - (Nice) Due to a retirement of the Head of department and the disappointment of the service functionality run by the new management, ISTDA is closed for two months.

We were therefore unable to meet the professionals.

This structure seems interesting because it focuses on therapeutic and medical support, the adolescents with serious behavioral disorders, which they do not characterise as a proven pathology. Therefore, we are in a teenagersâ&#x20AC;&#x2122; logic who might find themselves outside of education, judicial and health systems.

ISTDA must be able to serve as a relay when many support services are already in saturation, but always in the dynamic of creating cooperation with the services that will take back the young in order to develop a unifying project for the young.

At present time we still do not know if the structure was reopened.

4.5 Educational and Pedagogical Therapeutic Institute Jean-Louis Etienne (EPTI) - (Brest) We contacted the Director of EPTI in Brest who did not wish to receive us, telling us that he did not share the positions of Diagrama association.

The EPTI seems particularly relevant regarding their intervention that combines therapy, education, and teaching as a part of care that can be residential. They offer a stable and suitable home for the long term.

The EPTI orientation is generally recommended for children and young adolescents with behavioral problems making it too difficult to be taken care of by the ambulatory care or in a classical environment (at school). These structures offer prevention from disorders which can get worse later on and appear as acts of violence or even criminal acts.

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5. SYNTHETIC DESCRIPTION TREATMENT INVESTIGATED

OF

CHARACTERISTICS

OF

We wanted to include in this part a comparative analysis of characteristics which we distinguished. The following reflections are supported by the data made for each institution.

Status: • We have been brought to pay attention to public and private establishments. In the context of private structures, a greater freedom in institutional choices should be noted, regarding, for example, staff recruitment, or caretaking modalities.

• The institutions depend on health, justice, and educational and social activities.

• Many of the visited facilities are located within hospitals. This location gives them the know-how acquired through experience, and particularly when the structures are secured and that the hospital has already developed such methods of caretaking.

The localization within a hospital usually enables to work with professionals who are used to intervene in mental health.

Moreover, generally it allows to benefit from different services found within the hospital, either for returning to service, for the guidance after a stay, for the access to other services (somatic or pediatric), or in order to dispose of equipment of the establishment.

As part of the structures are outside of the hospital environment, stigmatisation is generally less important.

When structures depend on associations working in the education sector they may well benefit from the know-how of these institutions in this field.

However, it should be noted that when structures are part of an association nonspecialised in the taking care of adolescents with disabilities, functional difficulties may appear during the implementation of the service.

Funding: The vast majority of establishments we have studied depend on public funds. Private organisations sometimes receive the fund from private financial sources.

A significant portion of funding results exclusively from funds related to the sanitary field. Endowments related to the matters of youth, justice or disability zone complete

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the list of funding bodies.

Only one experimental structure (the IEPCT) had funds from the justice as well as from the health and social sector.

Localization of the environment: When schools are located in rural areas, they are really off-centre and geographically isolated. These institutions are more likely to live in autarky. Networking and social integration are not really enhanced.

However, in most situations, these structures have many facilities such as sports fields or areas of outdoor activities. The implementation of activity promoting contacts with nature through gardening or the care of animals is also facilitated.

They represent a minor part in the institutions we were interested in.

In the case of an installation in urban areas, the development of network and partnership with the social and educational actors is easier to implement. Access to the network is facilitated. Contact with families is also more easily maintained, with more frequent visits of the latter.

The lack of space, regarding the interior of the structure or access to an outdoor area, can be explained by the interest of such localisation.

Design: A considerable part of the investigated structures was specially designed for the treatment of adolescents presenting disorders, particularly serious behavioral problems. They have been studied and realised according to the needs of the public hosted in terms of structural arrangements as well as the materials used. These recent years, the number of projects and structures for teenagers has significantly increased.

The construction of new establishments demonstrates the will to make projects more concrete and to take care of those teenagers in a more adequate way.

The creations and adaptations of services are often made in response to requests from professionals who have found gaps in the implementation of caretaking, or illustrate a political will in the area concerned.

Modalities of care: Because of our study framework , we focused more our research on the structures offering a full time support.

The fact is that in most of the cases, this caretaking takes form of hospitalization.

The ambulatory follow-ups are generally provided within centres and notably strategic centres. They can also take the form of VAH (Visit At Home). When this is implemented, this device shows a real institutional choice.

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Actors of the admission application: With regards to the demand of adolescentsâ&#x20AC;&#x2122; caretaking, the major role of justice actors should be noted as well as of those belonging to the health institutions.

The judges may sometimes place adolescent directly within establishments, what usually complicates the implementation of the intervention.

It is important to take into consideration the work of emergency services and those of first lines (social assistance, health professionals involved in school ...), groups intervening at the first application level. They represent an important link of the system and determine the course of care for adolescents.

In some situations, the approval of authorised institutions is necessary before any study of admission application can take place. Many protocols have been established in this way; they set out clearly the various study steps of the application and its assessment.

Requests from educational institutions, for example, are often relayed via a psychiatrist who evaluates at his scale the for intervention. Moreover, it may sometimes be easier that this professional describes the situation directly with one of his colleagues.

Direct requests of families represent only a small proportion of admissions made in the institutions studied.

Age of persons hosted: If the age range of children hosted within the structures we visited is between 0 to 25 years, it should be noted that the age group under caretaking care is generally a population of adolescents aged from 12 to 18 years.

The reception of younger adolescents generally poses problems because of the importance of the age difference compared with the rest of the population present in the institution to which the unit belongs. In hospitals, these patients are mainly supported by pediatric services (services welcoming teenagers but only those with Alimentary Behavioral Disorders (ABD) or depressive disorders).

Regarding the older ones, the lack of structures available, the proximity of the issues presented, or the continuation of a project undertaken, are the main reasons for their presence.

We found that the age of majority frequently lead to the end of the treatment, although in fact the reception continues frequently after the age limit. A transfer of the admission application to services reserved to adults can also take place, when the youth is sent shortly before the age limit and he presents significant disorders.

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Gender: The majority of establishments visited hosts simultaneously girls and boys.

In this situation, the area reserved for rooms are systematically distinct.

Attention is also paid to the reason of the admission, in the presence of sexual assaults case; professionals look after not to allow coexisting within the same unit adolescent perpetrators of sexual assault and victims of such acts. This principle is implemented in function of the situation of each adolescent and to the possible extent.

Within the framework of structures exclusively reserved for boys, it should be noted the link with a highest number of violent disturbances in the latter and the opinion of professionals considering that is more convenient to accommodate adolescents of the same sex.

Disorders presented: It should be noted that there is a wide range of disorders hosted by the institutions studied. Psychiatric diagnoses proven are rare, which is justified by many professionals because of the evolutionary nature of the structural organisation due to the age Therefore, it is difficult to globally represent the problems treated , especially because professionals sometimes use different terms for similar events. The description of certain disorders will be very precise while in other cases only the symptoms will be mentioned.

It should be noted that the naming of a disorder is often linked with institutional guidelines. So if in a systemic orientation structure, the term of attachment disorder will be easily used, other institutions will prefer the expression: affective disorders.

However, we observe a clear prevalence of behavioral disorders, then an importance of personality disorders, of psychotic disorder and finally the frequent presence of personality disorder and self-or hetero-aggressive behavior.

Moreover, in most cases, we noticed the presence of behavioral disorders plus mental disorders. They are disorders damaging various institutions and are difficult to treat within conventional structures.

We ask our-self about the relevant presence of a population with very heterogeneous disorders within the same institution.

It is also important to note the evolution in some institutions, of the admission criteria related to disorders. These changes are generally linked with the difficulty to treat behavior disorders.

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The number of people hosted: Reception capacities varies depending of the nature of the structure. We mostly observe the deployment of small units, allowing the stay of a dozen teenagers.

The average length of stay: A significant heterogeneity in the duration of care exists; it is linked with the main objectives of the institutions. There are three levels depending on the duration of the support.

On the one hand there are short stays, they range from several days to three weeks of treatment. The purpose of these institutions is the stabilisation of the general state during a crisis time, enabling to make an assessment of the situation and to orient the adolescent.

On the other hand, certain other structures offer a medium term stay, ranging from three weeks to five weeks of treatment. In addition to the stabilisation and the evaluation, the institution proposes a therapeutic project of intervention that will be recommended at the orientation level.

Finally, some structures provide support from medium term to long term, that is to say duration exceeding one month and a half and up to several years. This is a long support, made from the possibility of keeping the teenager several months or years.

The treatment plan is generally part of a long term prospect, but that is not defined in advance and sometimes that is not chosen.

Indeed, it should be noticed that the periods indicated are only averages, involving large disparities within institutions.

The composition of staff: Generally there are an important number of personnel within the structures, almost all teams are multidisciplinary. The presence of different professionals depends often on the therapeutic choices that the institution prefers, for example establishing in majority medical, paramedical, educational / social staff. However, we find in almost all the structures a hard core composed of psychiatrists, psychologists and nurses.

If one attempt is made to look more precisely at the distribution of professionals in relation to their function, we established several observations.

Almost all the institutions benefit from the presence of a psychiatrist, often responsible of the service. It is at the centres of different interventions and actions or choices of the treatment. Psychologists are often present; they typically provide therapeutic

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monitoring and evaluation of adolescents.

Nurses are present in predominant numbers. In parallel of medical tasks, strictly speaking, they ensure the implementation of activities and the care for teenagers. They are actors in the daily care, especially within the hospitals.

Educators are often mentioned in the staff composition. Except for educational facilities, however, they are in limited in number.

Staff providing education is not present in all institutions. Services who have it, displayed a willingness to respect the obligation of tuition or of a scholar tutoring delivered by specialised professionals.

The objectives of the institution: We identified six key objectives that are the therapeutic treatment, the stabilisation, the assessment the orientation, the educational work and the social care.

All structures have a therapeutic aim at one point of the support. Educational structures, based on a primarily educational support, offer a therapeutic reinforcement, as an intervention supported by the medical staff and the psychologist.

The manifestation of behavioral disturbances often requires a stabilisation of the teenagers state, almost all services go through this step to allow subsequent appropriate intervention, whether it is therapeutic, educational, pedagogical, etc.

All the structures begin cares by an evaluation phase, more or less developed, operated in a multidisciplinary logic, to proceed then to the establishment of a follow-up.

The social care concerns all the work realised around the family and social dimensions (difficulties, deficiencies, work with the family) and the dimension of social and professional integration.

Finally, we found particularly interesting the role of the person in charge of the missions, at the Closed Educational Center (CEC) of Jubaudière. Indeed, she is particularly concerned to develop interactions between young people and professionals from the world of work. Given the strong representations associated with this population, the coordination work and the mobilisation of partners seems quite relevant.

The Treatment: The indications for medical treatment among institutions that we have encountered are multiple. They may cover all the teenagers or only some of them; in some cases it is limited to a stabilisation of the general state. All professionals agree to stress the importance of an adapted treatment, in order to be seriously effective. In addition, this allows the care to be done in optimal conditions.

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The issue of prescriptions is a subject that has been often difficult to talk about with the different professionals. We do not really have accurate data on the subject.

Schooling: Regarding the short-term support, designed for the stabilisation of the state and the evaluation of the situation, there is generally no education offered. This is more problematic when the period of stay is extended.

There are two types of schooling. On the one hand, there are modules included in the device of the unit. They are composed of specialised professionals who provide extrahelp or upgrading. It may take place within specific devices such as the â&#x20AC;&#x153;school of the hospital.â&#x20AC;? On the other hand, education can take place outside of the institution, in schools, in classes adapted.

The use of the partners is crucial within the hospital and also for the residential care including a full-time mode.

Partnership working, establishing the network: Overall, the network is highly developed as it is deemed necessary by professionals, given the population hosted and the multiplicity of actors involved in the treatment.

However, some work in a very small proportion with external institutions, and when they request them is more in the prospect of an ulterior orientation.

The establishment of a multidisciplinary network is essential, particularly regarding behavioral problems that are not labeled as psychiatrically pathology proven. Applications and guidelines are diverse; coordination work must provide a follow-up of the treatment as well as appropriate and integral propositions.

Implementation of coordination is a work that implies to mobilise time and investment, and this, by all the professionals. Indeed, the multidisciplinary feature of teams should allow the creation of complementary networks in the fields of medicine, psychiatry, psychology, of the education, social work, education, justice, etc.

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We also underline the establishment, concerning certain structures, of agreements between institutions of care, justice and education, etc.

The orientation of the support: Orientation is often difficult to implement, especially depending on how it has been prepared.

The family guidance, ambulatory monitoring and then guidance in other institutions (health, education) remain privileged recourses. The return into the family remains important even when the family situation is very complex and do not promote this solution. It is often accompanied by an ambulatory monitoring, which may take time to implement because of the relatively large timeouts.

One may wonder if the first guidelines are really a choice of the institution or if the service does not have sufficient opportunities and appropriate guidance to ensure the relay as it had hoped.

The orientation in the different institutions is the second recourse proposed. It may be composed of hospitalisation in units, placement of long-term, places ensuring a transition to a return to the family or a situation of autonomy, etc.

In all the cases, the proposed direction often implies a monitoring through the presence of a professional psychiatrist. Therefore they look for the establishment of a monitoring, continuity, a bond with the therapist who has already followed the young.

Hospitalisations in adults’ service are sometimes recommended although it may be difficult to implement, especially because the profile of adolescents scares and they have a long-term institutional course.

6. CONCLUSION Questioning different European practices, regarding adolescents exhibiting behavior disturbances and in conflict with the law was aimed to bring, given the European situation, plural perspectives in the treatment of this population.

The development of this research has highlighted the multiplicity of practices illustrating the heterogeneity between countries as well as within the countries. On the other hand, the difficulty of integrating these teenagers into the“classical” care pathway, highlights the involvement of structures specially designed for the reception of these teenagers, and others that had to adapt their practice.

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If we have not been able to identify an institution particularly adapted to meet the needs of the population in an adequate way, we have developed principles and methods of operation that we would recommend to the establishment. The recommendations that follow are based on the most relevant elements that we identified.

• The modality of treatment that we have retained is one based on a full time care.

It will be important that it takes place in a defined framework, in order to protect minors from themselves and to offer an adequate response to the management of their disorders.

• We recommend the setting of an institution including units of small numbers (below 13). In addition, these small modules will enable to accommodate a mixed population that would be distributed in function of the nature of the disorder and the evolution of the youth (maturity and institutional course).

• It seems important to not accommodate adolescents with a significant age difference. The latter requires a separate support responding to specific needs.

Thinking about the age issue requires to ask ourselves about the populations affected by the age limit, such as young adults who do no longer meet the admission criteria supported for minors. This leads to an imagined flexibility at this level.

• We will opt for a design of a stay not too short or too long, lasting in average one year, and keeping the ability to review the length of the stay according to the needs and the situations of the patient.

• Our targets are populations generally not treated by conventional structures (pediatrics, psychiatry, or educational institutions). Indeed, it refers specifically to behavioral, personality, psychotic, mental, personality changes, and emotional disturbances.

In all the cases, adolescents are treated because the manifestation of the disorder causes a possible endangering of the teenager himself and / or to the others.

The eating disorders, depression, or autistic syndromes are not selected because they are generally well supported by specialised institutions or child psychiatry.

• Enrollment in a medium or/ and a long term support will allow to stabilise beyond the crisis, to find a balance, and to think and build an orientation project as well as psychological than professional, as a life project (autonomy).

The primary objective of such an institution belongs to the therapeutic field. Indeed, it is aimed to treat disorders (medication and / or follow-up) in order to stabilise a state, but also enable the youth to be mentally ready to evolve in the other dimensions of care (educational, academic, social, ...).

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• The importance of disorders to treat implies the presence of an adapted framework and that requires the presence of a significant number of staff.

In order to answer to the multiple and complex needs of the adolescents, the professional team should be multidisciplinary. Its composition must allow a medical, paramedical, educational and social approach. It would seem appropriate that the number of nurses is equivalent to the number of educators. These two professionals offer different methods of intervention and are complementary.

On the other hand, it will enable not to label a youth as deviant or sick.

The presence of a psychiatrist is necessary, at least at part time, and especially for the adaptation and rehabilitation part of the treatment.

The interventions of these professionals should be balanced and distributed with care along the support.

• Regarding the education, at first it is important to bring the youth to become again familiar with school activities. The latter would take place in small groups of teenagers supervised by specialised professionals, in short periods of time.

Secondly, depending on the evolution of the young, it would be interesting to focus the treatment on maintaining and developing the school link in order to consider a “reintegration” progressive among communitarian educational institutions.

It should be based on specific devices in each country.

• Finally, the various recommendations that we have just described are only meaningful in the context of an institution working in partnership and dedicated to develop a network. These multiple collaborations would involve the opening of the institution to the outside, either in terms of education, psychological monitoring, integration and or social bond.

The aim of the treatment being the reintegration of the young into society, we highlight the relevance of establishing a position who would be in charge of achieving coordination and collaboration with the various professionals of integration: training organisations, social services, employers, etc...

The implementation of this coordination work is generally facilitated by the establishment of multi-partner agreements or agreements between the different types of institutions.

We have been able to essentially extract all these principles and operating procedures from the observations we made. They are related to visits we have made and representations we have built.

In the perspective to deepen the knowledge of the various devices that allow collecting information about these courses, it seems essential being able to

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observe precisely the functioning of these institutions, and professionals’ missions.

It is only in this aim that we could offer to adolescents with disorders a real appropriate support, therefore we could avoid that these “unlabelling” young get lost or become lost in the maze of institutions, condemned to wander in spirals.

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Glossary ABD: Alimentary Behavioural disorder ACC: Association of Catholic Cities AHS: Agent of Hospital Service ALS: Average Length of a Stay CEC: Closed Educational Centre CLSI: Class of Scholar Integration CIM 10: International statistic classification of illness and health problems DHDP: Departmental House of Disability Person DCSA: Departmental Center of Social Action DCSE: Departmental Commission of Specialised Education DRSSE: Directorate of Research, Studies and Statistic Evaluation EFT: Equivalent to Full Time EPTI: Educational and Pedagogical Therapeutic Institute (Brest) ERS: Emergency Reception Service FRIIES: Federal Research Institute on Industrial economies and Societies FTH: Familial Therapeutic Hosting GDH: General Directorate for Health GDSA: General Directorate for Social Action GISA: General Inspector of Social Affairs HAH: High Authority of Health HCPH: High Committee of Public Health HFSF: Health Foundation of Student of France HH: Home Hospitalization HHOD: Hospital and Health Organisation Directorate HOT: House of Teenagers HRT: Hospitalisation Requested by a Third person HSD: Handbook of Statistic Diagnosis HSSM: Hospital Association of Sainte Marie ICPRA: Interhospital Center of Permanent Reception for Adolescents (Paris) IEPCT: Institution of Educational Placement and Crisis Treatment (Nice) IH: Immediate Hospitalisation ISTDA: Intersectoral Structure of Treatment of Difficult Adolescent JPY: Judiciary Protection of the Youth MEI: Medico-Educational Institute MPC: Medico-Psychological Centre NE: National Education NIHMR: National Institute of Health and Medical Research PA-PH: Public Assistant- Paris Hospital PEM: Penitentiary Establishment for Minor

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PCOR: Psychiatric Center of Orientation and Reception (Paris) PHP: Private Hospital functioning as a Public one PMCCA: Psycho-Medical Centre for Children and Adolescent POHI: Primary Office of Health Insurance POP: Provisory Order of Placement PPHS: Non-profit hospital “Participating to the Public Hospital Service” PURTOE: Proximity Unit of Reception, Treatment, and Orientation of Emergencies RAH: Regional Agency of Hospitalisation RCSCAYA: Reception Center of Specialised Care for Adolescent and Young Adult (Rennes) RCSMSO: Regional Committee of Social and Medico-Social Organisation RCSO: Regional Committee of Sanitary Organisation RDSSA: Regional Directorate of Sanitary and Social Affairs ROHI: Regional Office of Health Insurance RSSO: Regional Scheme of Sanitary Organisation RTE: Reception and Treatment of Emergency SAMU: French emergency service of medical help SESRCL: Sociological and Economic Study and Research Centre of Lille SCUAYA: Specialised Care Unit for Adolescent and Young Adult (Rennes) SHC: Social Help to the Childhood SHOC: Social House of Children SSECAH: Service of Specialised Education and Care At Home TEPI: Therapeutic, Educational and Pedagogical Institute (former name: Reeducation Center) TUFCA: Therapeutic Unit for Children and Adolescent (Saint Brieuc) TRCPT: Therapeutic Reception Centre at Part Time UDP: Unit for Difficult Patient VAH: Visit At Home WHO: World Health Organization YLP: Youth Listening Point

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Chapter IV Mental health of young offenders in the Italian context: analysis of the phenomenon, interventions and recommendations ....................................................................................................................................... by Alessandro Padovani Sabrina Brutto Silvio Ciappi Alessandra Minesso Elisa Felicini Aby Chacko Don Calabria Institute Verona, Italy in close cooperation with General Directorate for the implementation of judicial provisions (Italian Juvenile Justice Department, Ministry of Justice)

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Table of Contents ...........................................................................................................................

Introduction 1. MENTAL HEALTH AND YOUNG OFFENDERS: A GENERAL OVERVIEW 1.1. Analysis of the phenomenon 1.1.1. Mental health and juvenile offenders 1.2. The issue of mental disorder diagnosis 1.2.1. Symptoms 1.2.2. Principles of psychopatology in the developmental age 1.3. Preventive intervention 1.3.1. Classification of preventive intervention 1.4. Psychological treatment for juveniles in the criminal justice system and affected by mental disease 1.4.1. The different approaches 1.4.2. The actual legal framework 2. MULTIPROBLEMATIC YOUNG OFFENDERS 2.1. Background 2.1.1. Family and relational background 2.2. Risk and Protective Factors 2.3. Antecedents of behavioural and personality disorders in adolescents 2.3.1. Youth offenders and behavioural disorders 2.3.2. Youth offenders and personality disorders 3. MENTAL HEALTH OF YOUNG OFFENDERS IN THE ITALIAN CONTEXT 3.1. Profile of the mentally ill juvenile offender 3.1.1. General background 3.1.2. Family 3.1.3. Types of mental illness suffered by young offenders in Italy 3.1.4. Correlation between the misuse of drugs and behavioural disorders in young offenders 3.1.5. Special needs of minors confronted with mental issues who are facing a custodial sentence

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3.2. Interventions. What is working and what is not?

3.2.1. The problem of psychiatric diagnosis for juvenile detainees with mental disorders 3.2.2. The therapeutic intervention for youth offenders experiencing detention and community based sanctions 3.2.3. Prevention programmes for young people suffering from behavioural disorders 3.3. Legal framework and protection 3.3.1. Penal and Child Care Regulation 3.3.2. Professional roles and development of skills 4. RECOMMENDATIONS AND GOOD PRACTICES 4.1. Guidelines concerning mental disorders affecting minors within juvenile criminal justice, Serenella Pesarin, General Director - General Directorate for the implementation of judicial provisions - Juvenile Justice Department (Ministry of Justice) 4.2. Interview with Maurizio Dusi, M.D, Psychiatric Psychotherapist, Verona, Italy 4.3. Interview with Alfio Maggiolini, M.D., Psychotherapist and professor of psychology of adolescence, University of Milano, Italy 4.4. Consultation with Testone Nicolò, MD, Counsellor of Ministry of Justice for the social issues and deviance.

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Introduction This report, which aims at deepening the issue of the mental health of young offenders in the specific Italian context, is a result of the joint work of the Juvenile Justice Department â&#x20AC;&#x201C; General Directorate for the implementation of judicial provisions and the Don Calabria Institute (Projectsâ&#x20AC;&#x2122; office).

To begin with, itâ&#x20AC;&#x2122;s important to specify that the Juvenile Justice Department is a national public body that forms part of the Ministry of Justice and is responsible for all its services, activities and personnel dealing with young offenders. The Department operates through 12 regional or inter-regional Juvenile Justice Centres (CGM), to which the following Juvenile Services refer to: - n.29 Youth Welfare Offices (USSM) providing assistance to minors in conflict with the law at all stages of the penal procedure, and collecting related data; - n.26 Juvenile Classification Homes (CPA), accommodating minors under arrest, custody or in preparation for the validation hearing, for a maximum period of 96 hours, under the custody of the penitentiary police and in the presence of a multidisciplinary team acquiring useful information; - n.18 Juvenile Detention Centres (IPM), ensuring detention for remand or expiation of the punishment; - n.12 Residential facilities ensuring execution of the dispositions of the judicial authority, particularly accommodation in day care centres and the security measures for minors undergoing an individualized educational programme.

The specific Office involved manages all these regional/local structures and hence its contribution in the project has to be considered as a real added value.

This report gives a general overview of the problem and a comprehensive analysis regarding the best practices followed in Italy. In particular we analyzed the legal framework and the main prevention models used by national and regional stakeholders working in the field of young offenders with mental disorders. All in all, we take into serious consideration some critical intervention procedures and stress the need for a real and urgent intervention for young offenders with mental disorders. A particular analysis will deal with the problem of re-offending, the associated risk of recurrence that should be properly measured when the juvenile offender enters the criminal justice system. The likelihood of re-offending in juvenile offenders puts into question the effectiveness of the interventions carried out by the justice system. As we know from international practices, interventions where the socio-educational treatment is integrated with the psychological one are the most effective ones in reducing recidivism.

Furthermore, in this report, we outline the role and some ethical issues concerning

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professionals working with this type of criminal population. Such figures should be specifically trained on children’s rights and health protection including: developmental psychology, minor’s welfare and international standards. At the end of the report, there are some examples of good practices and interventions regarding juvenile offenders affected by mental disorder in Italy. Final recommendations and good practices will be discussed in the form of stakeholder interviews at the end of the dossier.

1. MENTAL HEALTH AND YOUNG OFFENDERS: A GENERAL OVERVIEW 1.1. Analysis of the phenomenon Before entering into the specifics, we would like to highlight that as we go along we speak also about general topics coming from the psychiatric literature and then more specifically analyze specific laws and issues related to the Italian context.

According to the World Health Organization “health is a state of complete physical, mental and social wellbeing, not merely the absence of disease or infirmity“ (WHO, 1948)61 and “health promotion“ is not only disease prevention and/or education on healthy lifestyles, but it is attention to basic requirements for the quality of life and the dignity of individuals, such as education, housing, employment, peace, social justice, etc. (Ottawa Charter, WHO, 1986). To talk about health, therefore, it is essential to pay attention to the life context of individuals, in any state and conditions, including disability, chronic illness, or other62.

Minors’ and adolescents’ mental health includes a sense of identity and self-esteem; the ability to experience positive family and peer relationships as well as the capacity to be productive, to learn and to use developmental challenges and cultural resources to maximize development (Dawes et al., 1997). Good mental health in childhood is a prerequisite for an optimum psychological development, productive social relationships, effective learning, self-care ability, good physical health and effective participation in community life as adults.

Unfortunately, nowadays, a sort of numbness toward everyday life’s rewards, the increasing gratification threshold, the low capacity for pleasure lead many young people into different types of pathology. Only ‘risky’, extraordinary and dangerous

61 American Psychiatric Association. DSM-IV-TR: Manuale diagnostico e statistico dei disturbi mentali, Text Revision. Editrice Masson, 2002.

62 Child and Adolescent Mental Health Policies and Plans, World Health Organization, 2005.

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activities are worthy of their attention. Among these young people, it is not uncommon to encounter individuals who exhibit high-risk behaviours, more or less serious disturbances in keeping in touch with the reality, isolation with antisocial attitudes and disorders of impulse control. Sometimes we can also recognize significant difficulties in communicating, establishing positive relationships, and in expressing or understanding emotional states. In some cases there is a substantial inability to assume any responsibility for the consequences of their actions.

This fleeting contact with reality can often lead to more serious psychopathological disorders. The relational and emotional context, often problematic, in which juveniles are growing, is likely to encourage the development of certain forms of psychopathology otherwise considered as sub-clinical. Hence, there is a need for strong preventive approaches and intervention towards individuals, but also for families and the micro and macro social contexts, in order to prevent the development of even more problematic and unmanageable forms of mental health problems creeping up.

1.1.1. Mental health and juvenile offenders Mental health disorders are quite common among juvenile offenders and can be associated with self-harm and suicidal behaviour; obviously their treatment involves all staff coming in contact with the minor inserted in the juvenile justice system. To address in detail all issues relating to the juveniles, it could be useful to identify and define the phenomenon as plainly as possible, given the increasing number of minors and adolescents affected by personality and behaviour disorders63 who, individually or in groups, because of their conduct, can be included in this issue64.

The relationship between mental health problems or disorders and offending behaviour is not so clear by now. In fact, it is possible that there may be no specific relationship between mental health problems and offending. It could be a mere coincidence that such mental health problems or disorders are more common in juvenile offenders than among juveniles in general. However, it is possible that juveniles entering in contact with the juvenile justice system may experience events causing anxiety or depression not related to the offence. This suggests that mental health problems and offending behaviours could have similar causes.

63â&#x20AC;&#x201A; See paragraphs 1.1.1 and 1.1.2.

64 G. Tamanza, Analisi e ricerca â&#x20AC;&#x201C; le questioni prioritarie, Ipotesi di Lavoro, Iniziativa Comunitaria Equal, fase II in adolescenti con disturbi di personalitĂ e comportamento. (Analysis and Research, priority issues, Community Initiative Equal phase II, in adolescents with behavioural and personality disorders).

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The common factors individuated are: • • • • •

physical, sexual and/or emotional abuse and neglect; poverty and deprivation; family inefficiency and discord; school exclusion, poor academic attainment and high levels of unemployment; individual characteristics such as learning difficulties and hyperactivity.

Considering the origin of mental disorders, therefore, we can say that they could be a manifestation of serious physical or sexual abuses, neglect or poverty and deprivation leading to drug use-abuse as self-medication.

In the more severe types of mental disorder (such as bipolar disorder and psychosis), offending behaviours may represent a symptom of the mental disorder. Mental disorders, in turn, could also be a factor contributing to substance use or abuse (alcohol and drugs) as self-medicine. Such a deviant behaviour (poly-consume or drug addiction) may lead to offend in order to obtain money to buy drugs. Furthermore, the use-abuse of substances may accelerate a predisposition to a mental health problem65.

Talking about juvenile offenders, offending behaviours are considered as factors causing mental health problems: it is difficult to assess if such problems were present before the contact with juvenile justice system, but it is likely that the affection takes place by their interaction with it, as detention has long been recognized as a source of stress (Hagell, 2002).

Given the multiplicity of specific difficulties and behaviours, we can’t forget that while all people with mental disorders suffer discrimination, children and adolescents are the least capable of advocating for themselves. Also, on a developmental level, children think more dichotomously than adults about categories as “good” and “bad,” or “healthy” and “sick”. They are thus less likely to temper a negative remark with other more positive feedbacks, and may therefore more easily accept negative, misapplied labels66.

Additionally, in contrast to physical illnesses where parents may receive community support, stigma often results in parents being blamed for the mental health problems of their children67.

65 Recent studies and researches show a clear link between alcohol abuse and aggressive behaviours, while that link is more equivocal regarding other drugs (Hoacken and Steward 2003).

66 Stigma and discrimination include: bias, stereotyping, fear, embarrassment, anger and rejection or avoidance; violations of basic human rights and freedoms; denial of opportunities for education and training; and denial of civil, political, economic, social and cultural rights.

67 Child and Adolescent Mental Health Policies and Plans, World Health Organization, 2005.

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1.2. The issue of mental disorder diagnosis Minors’ mental disorders are frequently accompanied by a heavy burden, often compounded by stigma and discrimination. In many cases, the knowledge of these problems is limited and those who are affected are erroneously considered as people “who do not do enough” or “creating problems”.

Children and adolescents present a degree of mental complexity that is only now being recognized. While it has long been accepted that physical health can be affected by traumas, genetic disturbances, toxins and illness, it has only recently been understood that these same stressors can affect mental health, and have long-lasting repercussions.

When risk factors and vulnerabilities overcome protective factors, mental disorder can result. Child and adolescent mental disorders manifest themselves in different ways and can lead to continuing impairment in adult life.

In this paragraph we will analyse which are the symptoms of mental illness in minors and how the diagnosis is carried out.

A mental illness or disorder is diagnosed when a pattern of signs and symptoms is identified, it is associated with impairment of psychological and social functioning, and it meets criteria for disorder under an accepted system of classification such as the International Classification of Disease, version 10 (ICD-10, WHO, 1992) or the Diagnostic and Statistical Manual IV (DSM-IV, American Psychiatric Association, 1994).

Examples include: mood disorders, stress-related and somatoform disorders, and mental and behavioural disorders due to psychoactive substance use (See Annex – DSM IV Assessment Criteria).

1.2.1. Symptoms Symptoms in children vary depending on the type of mental illness, but some of the general ones include: • abuse of drugs and/or alcohol; • inability to cope with daily problems and activities; • changes in sleeping and/or eating habits; • excessive complaints of physical ailments; • defying authority, skipping school, stealing, or damaging property; • intense fear of gaining weight; • long-lasting negative moods, often accompanied by poor appetite and thoughts of death;

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• • • • • • • • • •

frequent outbursts of anger; changes in school performance, such as poor grades despite good efforts; loss of interest in friends and activities they usually enjoy; significant increase in time spent alone; excessive worrying or anxiety; hyperactivity; persistent nightmares or night terrors; persistent disobedience or aggressive behaviour; frequent temper tantrums; hearing voices or seeing things that are not there (hallucinations).

As with adults, the diagnosis of mental disorders in children is based on signs and symptoms; however, as we already said in previous paragraphs, diagnosing mental illness in children can be especially difficult.

Many behaviours that are seen as symptoms of mental disorders, such as shyness, anxiety (nervousness), strange eating habits, and outbursts of temper, can occur as a normal part of a child’s development. These behaviours may become symptoms when they occur very often, last a long time, occur at an unusual age, or cause significant disruption to the child’s and/or family’s life.

If symptoms are present, an evaluation by performing a complete medical history and physical exam is necessary. Although there are no lab tests to specifically diagnose mental disorders, practitioners can make use of various diagnostic tests, such as X-rays and blood tests, to individuate physical illness as the cause of the symptoms.

If no physical illness is found, the child may be referred to a minors’ psychiatrist or psychologist, health care professionals who are specially trained to diagnose and treat mental illness in children and teens. Psychiatrists and psychologists use specially designed interview and assessment tools to evaluate the presence of a mental disorder in a child. The diagnosis bases on reports of the child’s symptoms and on the observation of the child’s attitude and behaviour. Also reports from minors’ parents, teachers, and other adults of reference can be useful to make diagnosis as children often have trouble explaining their problems or understanding their symptoms; family’s support can be therefore of great help in determining if the child’s symptoms point to a specific mental disorder.

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1.2.2. Principles of psychopatology in the developmental age Infancy, childhood and adolescence are stages of individual development, characterized by profound changes. Within these age groups, mental health status is established based on the achievement of the various stages of development (motor, language, cognitive, social, and emotional), and on the typology of affective ties (also known as attachment).

A child or adolescent with a good level of mental health has a good quality of life, i.e., has a satisfactory relationship with family and peers, a good academic performance, and does not present neither disability nor psychopathological symptoms or possible bias in the normal process of individual development causing mental disorders.

• To better explain how a child or adolescent may develop a mental disorder, it is appropriate to recall some basic principles of psychopathology in the developmental ages68: • mental illness is the result of the interaction of biological, psychological and social factors that come into play in personal development. To understand the reason of certain behaviours of children and adolescents, therefore, it is necessary to know the history and the background of each well; • in children, there is the innate tendency to adapt themselves to the different contexts, so if a minor lives in a disturbed or pathological environment, the resulting process of adaptation will also be easily disturbed or pathological. The trend of adaptation reflects a fundamental feature of brain, the plasticity, which is highest during adolescence and gradually decreases over the years; • each behaviour must always be included in the right temporal context, or age.

For example, an intense reaction of discomfort following the removal from parents is normal during the first years of life, but can be a symptom of a disorder, whether it manifests itself in adolescence or later. Furthermore, a stressful experience can produce deep or light effects, or none at all, according to the age of the subject; • The environmental conditions in which children grow up are important for mental health. Several studies have shown that if conditions are unfavourable, adverse effects are determined in both the short and long term, not only at physical, psychological-emotional level but also from the point of view of social relations; • A pathological process of development is different from a normal one due to differences that, sometimes, are not easy to grasp. In some cases, for example, the differences between normal and pathological behaviour are only in intensity or frequency.

68 American Psychiatric Association. DSM-IV-TR: Manuale diagnostico e statistico dei disturbi mentali, Text Revision. Editrice Masson, 2002.

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1.3. Preventive intervention Infancy and adolescence are critical ages to acquire and maintain an adequate mental health status. It should be stressed, however, that not all those who are exposed to stressful situations automatically develop a mental disorder, much depends on “vulnerability“ (or predisposition) in terms of biological, psychological and social development.

The situations of distress and problems related to mental health may be connected in various ways. Sometimes they may represent risk factors for psychological problems like post-traumatic stress disorder in a child who has suffered sexual abuse. At the same time, problems related to mental health can in turn be a risk factor in situations of disease, such as when the adolescents make use/abuse of alcohol or drugs to overcome the sense of depression. Regardless of the relationship between mental problems and situations of disease, specific intervention strategies meeting the needs of children and adolescents should be defined.

Unless children and adolescents with mental disorders receive appropriate treatment, their difficulties are likely to persist, and their social, educational and vocational prospects diminish. It is also now known that individuals with untreated mental disorders represent a disproportionately large segment of the population in the juvenile justice system.

Preventive intervention and health promotion among children and adolescents can have particularly far-reaching implications. Assuming that most adults’ mental disorders have their origin in childhood or adolescence, one can therefore reduce the extent of long-term functional impairment by early recognition and prompt intervention. Health promotion interventions can focus on factors that determine or maintain mental illness, such as poverty and stigma (WHO, 1993; 1998).

The objectives of prevention in the field of mental health are included in the following categories:69 • primary prevention, aiming to reduce the incidence i.e. the appearance of new cases; • secondary prevention, seeking to reduce the prevalence (intervenes early and effectively in cases already in place).

Sub-objectives:

69 L. Rowling, G. Martin, L. Walker, La promozione della salute mentale e i giovani. Teorie e pratiche, (Italian edition by Alessandro Grispini, Pompeo Martelli), McGraw-Hill, Milano 2004.

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o delay the onset of the disorder; o mitigate clinical manifestations; o identify the early onset of the disorder and treat it appropriately; o reduce the period of unrecognized and untreated illness.

• tertiary early prevention aiming at: o minimize the symptomatic phase of the disorder; o slow its progression; o fight disability; o prevent disadaptation of family context.

1.3.1. Classification of preventive interventions Preventive interventions can be classified as follows (Mrazek and Haggerty 1994): • universal interventions, i.e. mental health promotion strategies; • selective interventions, targeted at high-risk individuals, but without objective signs of disorders or disturbance; • specific interventions, targeted at high-risk individuals with subjective and objective signs and symptoms of disease.

“Universal” preventive intervention Universal interventions can be defined as strategies aiming to promote mental health and targeted to healthy population.

Interventions aiming at the promotion of mental health, just because they are focused on health and not on illness, should assume as central focus of their philosophy the identification of protective factors, which are the preconditions for health promotion.

In the developmental age, universal intervention has different applications: • to teach empathy; • to promote the ability to handle stress (coping strategies), conflicts, impulse control; • to promote creativity; • to promote social competence; • to contrast processes of discrimination and stigmatization; • to educate to emotions; • to promote empowerment (intentional and constant process including mutual respect, critical reflection, care and group participation). Through this process,

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individuals gain access to resources and to their control contrasting the condition of disempowerment characterizing many adolescents at risk (Cornell Empowerment Group, 1989).

With regards the promotion of mental health in adolescence, it is assumed that the natural environment par excellence is represented by schools. The school and the involvement of teachers are an invaluable resource in promoting mental health.

Teachers are key figures in the early detection of the first symptoms of a psychiatric disorder or emotional distress in students, but also (and especially) to promote better cognitive and emotional development in their boys and girls. Their main task, in terms of promoting health, is to foster students’ emotional growth (development of empathic capacity of individual talent, effective communication styles, awareness of rights and duties, etc.).

“Selective” preventive intervention Selective preventive interventions are targeted to individuals or groups presenting a risk of developing mental disorders to an extent significantly greater than the general population. In this population, in fact, even in the absence of objective signs of psychopathology, there may be (in probabilistic terms) the risk of transition to a manifest mental disorder.

Some examples of selective interventions include: • The strategy of domiciliary visits targeted to mother-child presenting specific risk factors (single mother, unemployment, substance abuse, mental and personality disorders) reinforcing the possibility that the child can structure pathological attachment patterns; • Pre-school programme for children living in poor neighbourhoods; • Interventions on school drop-out; • Interventions on adolescent daughters/sons of patients affected by psychiatric disorders (Beardsalee et al., 1992).

The major obstacle to the realization of such interventions is the fact that the target (high risk subjects) does not carry any request for intervention.

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“Specific” preventive interventions Specific preventive interventions are targeted at individuals presenting minimal but identifiable signs of disease or illness (i.e. at high risk for developing psychosis).

This class of interventions falls into: • • • •

the strategies for the identification and early treatment of psychotic disorders; the interventions on conduct disorder in childhood; the prevention of suicide in adolescence; the prevention of abuses against children (Montague, 1998).

In the field of prevention, studies have found a continuum of anti-social behaviours from childhood to adulthood: the clinic supports this statement by the observation and study of the history of subjects affected by antisocial disorders. During developmental age, different possible paths of behavioural disorder can be identified. These are determined and influenced by variables such as family or social background - within which social behaviour is expressed, the severity (quality and quantity) of the behaviour and environmental responses to behaviour.

Fundamental for the genesis of deviant behaviours are: the individual characteristics, the structure of personality in evolution, the figures of reference, clinical and social supports to children/adolescents’ psychological disease according to the preventive perspective, the presence of alternative figures.

This knowledge allows the identification of the essential features for the development of antisocial and, in general, mental disorder, identifying this way a large field of assistance for the reference figures in the clinical and social health areas (neuropsychiatry, psychologist, educator, family structures and tutelary bodies involved in the care and protection of the minor).

Some studies point out a possible change over time on the basis of individual and social characteristics (Osborn 1980, Rutter 1996), and according to the possibility that highrisk individuals encounter “positive“ environmental factors. The literature agrees that as regards the implementation of an effective preventive intervention, we should act on signals occurred within the first five years of life. However, the tools/instruments currently available, do not allow a reliable interpretation of which subjects with risky behaviours during adolescence may develop criminal behaviour, describing in any case a tendency with high probability of expression70.

70 Conference: Minori e Giustizia, Ordine A.S. Regione Veneto, Psicopatologia e reato nell’adolescente, Mereu Donatella.

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1.4. Psychological treatment for juveniles in the criminal justice system and affected by mental disease Risk and protective factors, as indicated above, are clear examples of how the propensity to commit violent acts depends on internal and external factors.

Nowadays, the percentage of minors affected by mental disorders under the charge of the juvenile justice system is rather high and this requests the use of specific tools and instruments personalized.

In addition to the use of specific tools or instruments, however, in the assessment of adolescents submitted to criminal proceedings it is particularly important to identify the subjective sense (symbolic and developmental) of the crime for the minor and his/her context of belonging, as part of a more comprehensive valuation of his/her personality, understood as a modality of building his/her own social identity and his/her ability to take responsibility for the behaviour in question. In this perspective, a theft, for example, which could appear as expressing a mere sense of ownership of a valuable object, can really be understood as a sign of the inability by the minor to recognize his/her social value within the relational context of development. Sexual violence is not only a sign of a difficulty in controlling impulses, but can also have the value of a group introduction to sexuality.

The characteristics that inhibit, reduce or stop the “criminal career” or the implementation of a “deviant behaviour” include the ability to engage in long-term goals, the possibility to experience external limits to their antisocial behaviour (in peer groups, through a greater attention by parents and teachers/educators) and personal characteristics such as effectiveness in problem solving, a good internal control response and the ability to relate and communicate with the other.

In the description of different categories of juvenile offenders, it has been proposed a fundamental distinction between offenders whose behaviour is limited to adolescence (diffused, not pathological, in which the social component is dominant and the behaviour is not so aggressive), and those whose behaviour extends itself lifelong (more rare, pathological, accompanied by aggressive behaviour. Here, the neuropsychological hereditary component is very important).

To such groups/categories we can add yet another group that is moderately chronic with intermittent antisocial behaviour characterizing juvenile offenders who are often socially isolated (Moffitt, 2003). This distinction is a fundamental one, as it recognizes the importance of developmental tensions in determining deviant or antisocial behaviour distinguishing between transgressive and antisocial adolescents. However, this is not sufficient yet to guide the evaluation of services within the Juvenile Justice System.

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1.4.1. The different approaches In operating with juvenile delinquency, and specifically with juvenile exhibiting anti social behaviours and/or mental disorder, the logics and approaches put in place are different but they compliment each other. Some of the important approaches are: • punitive making use of detention or custodial measures; • psycho-social often implemented through alternative measures and the psychological, educative and social supervision; • diversionary aiming at avoiding an early entrance into the juvenile criminal system; • restorative focusing on the victim besides the offender; • safeguard and protection of minors’ rights • therapeutic focusing on the mental disorder that could represent one of the factors giving origin to the deviant behaviour.

Analysing these approaches, we can assess that alternative measures are more often adopted in case of light crime or offences while in case of serious crimes or deviant behaviours more intensive intervention or custodial measures are applied. In this perspective, penal institution, therapeutic community or probation can be considered as different strategies or instruments aiming at the same general objective.

1.4.2. The actual legal framework Within the actual legal framework, the type of approach/intervention outlined by the Minors’ Criminal Procedure Code (D.P.R. 488/88) constitutes an interesting path of treatment of juvenile deviance. The psychological approach implemented by Juvenile Justice Services is a multi-disciplinary one (social, psychological and educational) and aims to prevent the removal of the minor from his/her environment by promoting the ability to take responsibility for his/her own behaviour supporting the developmental process of the minor, irrespective of the difficulties preventing a full social inclusion path i.e. adolescents’ developmental conflicts, personality disorder, anti social behaviours or, in more general terms; mental disorders.

Since adolescents implement antisocial behaviours as a way to build their own social identity, in the process of analysis and understanding of delinquent behaviour it is important to consider their wishes, values and modalities of interpreting the relationships. The actual implementation of behaviour depends therefore on motivations and individual value systems (i.e. the ideal level) in relation to the opportunities offered by the territorial context, in terms of goals (Wikström, Sampson 2003), which are connected with the adolescents’ developmental tasks.

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For the definition of specific treatment objectives targeted to juveniles submitted to criminal procedures, therefore, there is the need for a specific assessment of minors’ personality, behaviours, needs, and in that frame the possible psychopathologies or mental disorders can’t be ignored (as stated in Art. 9 D.P.R. 488/88).

In implementing intervention with juvenile offenders, it is not always possible to put a special emphasis on the increasing of their capacity for understanding and self-analysis, often difficult to activate, particularly taking into account the institutional timetable and time of intervention.

It should also be considered that if a developmental psychopathology may be determined by strong environmental inadequacies or by a real inability of the minor to develop part of himself/herself, only a real and concrete change of the same environment will allow the development of such part of himself/herself to carry on. This view implies that it is possible to intervene step by step, either in the adolescent as well as in development contexts, with a great flexibility in setting and a strong technical relativism (that does not mean eclecticism)71.

The more effective intervention programs directed to the target group are therefore multidimensional, integrated and multitasking, combining educational and psychological strategies and acting directly on the minor and his/her different contexts (holistic approach) 72 .

Concluding, we can say that there are several common characteristics that are fundamental for the treatment of juveniles offenders inserted in the criminal circuit who are affected by mental disorder: • • • • • •

the importance of early intervention; the importance of family’s involvement; the need of specific tools/instruments; the importance of multidisciplinary approach; the importance of individual treatment programs; the importance of a close cooperation between all involved institutions (juvenile justice services, social services, health services and so on).

Juvenile Justice Services constitute, in some ways, a specialized treatment centre for behavioural problems, often at a high level of seriousness. For this reason, they can be an important laboratory for innovative techniques of intervention, which can usefully be 71 Alfio Maggiolini, Adolescenti delinquenti. Il lavoro psicologico nei Servizi della giustizia minorile (2002).

72 Alfio Maggiolini, Un modello di intervento psicologico con gli adolescenti antisociali.

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extended to the treatment of minors affected by behavioural problems not necessarily taken in charge by the criminal justice system. This perspective does not necessarily imply a psychopathological view of delinquent behaviour, but is compatible with the perspective of developmental psychopathology and psychotherapy.

2. MULTIPROBLEMATIC YOUNG OFFENDERS 2.1. Background The juvenilesâ&#x20AC;&#x2122; mental health may be influenced by many factors such as risk factors, protective factors etc. The risk factors may increase the incidence of psychological problems and protective factors may moderate, the effects of risk exposure, hence policies, action plans and specific actions should aim at reducing risk factors and promoting protective ones.

If children and adolescents with mental disorders do not receive adequate treatment, it is most likely that their difficulties persist, adversely affecting prospects for social life, education and employment.

Given the above, it becomes necessary to consider two variables: a) temporal (longitudinal monitoring of different stages of evolution i.e. infancy, preschool and school age, preadolescence, adolescence) b) multifactorial (the beginning of deviant behaviour holds the correspondence of various concomitant factors such as social and environmental, individual-constitutional and resilience).

The individual risk characteristics can be identified as: impulsivity, aggression, responses to environmental stress, learned behaviour patterns, processing of stimulus, reaction to unexpected events, unresolved past trauma, emotional life and satisfaction, deprivation and frustration and tolerance to the social context with respect to the disturbing conduct.

Psychiatric disorders in children and adolescents are constantly increasing, and the characteristics of adolescent pathology are inevitably linked with the developmental pattern of such a critical stage, where the focus is a further separation and emancipation from the original figures of reference, the parental authority and the adult society. In this search for identity carried on by the minor, the same juvenile, in crisis of transition, implements and activates the resources of previous developmental stages, with his/her past conflicts, his/ her evolution (more or less successful), his/her internal objects and internalized emotional relationships.

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During adolescence, as in other critical phases, the subject is engaged in a transition process involving role, identity and identification, implementing and activating everything that is present in the mental world. It is an opportunity to reveal latent instinctual aggressive and sexual impulses strongly activated by this particular stage of development.

Thus adolescence becomes, an occasion of crisis and an inevitable opportunity of growth, which in its necessary and inevitable review and evocation of the minor’s resources, within a process aiming to complete and mature the personality structure, according to specific developmental patterns, shows and implements, in its manifestations, the degree of stability and maturity achieved during the previous phases, the presence of conflict revealing silent states of disease.

In this moment of transition from childhood to maturity, the juveniles often come to a standstill, defined and characterized by the onset of symptoms, sometimes confused with typical expressions of the need for emancipation and autonomy. Such symptoms, exuberant and exceptional, betray in time, in mode and extent, the presence of pathological personalities, and, sometimes, of a personality structure close to the borderline, to antisociality or, still worse, to psychosis.

The characteristics of affectivity, base themselves on the following factors: • • • •

structure and quality of object relations; ego stability and functions; psychodynamics among instances of personality; nature of defences.

Such factors concur to create different clinical frameworks for quality of symptoms and number of cases including antisocial behaviours, borderline disorders, and psychotic symptoms.

The principal mental disorder affecting adolescents and juveniles and involving experts and institutions responsible for care and protection, both at regional and national level, are, as already stated: • • • •

conduct disorder; Antisocial personality disorder; borderline personality disorder; psychosis.

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The first two have strong elements of connection with the normal events of adolescence, especially with regard to rebellion, the search for alternatives to adult lifestyle, challenges against authority, short ability to test reality, and feeling powerful and omnipotent.

This makes it difficult to arrive at an early diagnosis, considering, furthermore, that these personality characteristics show symptoms of possible mental disorder or disease in previous developmental stages, and that, often, they are not perceived and felt as such by those who take care of the minor.

The psychotic symptoms in adolescents are anticipated by specific signs during the developmental age, but the frameworks they give, especially if they do not cause public alarm or disturbance, may be considered as confused and/or as peculiarities of the juvenilesâ&#x20AC;&#x2122; character and conduct.

2.1.1. Family and relational background The adolescent suffering from psychopathology has been a suffering child, who used to show signs and symptoms sometimes unrecognized by those who took care of him/her. In some cases, the familiar and social context tend to deny consciously or unconsciously what was taking place in the mental life of the subject, implementing a process of denial which did not interfere with the course of the disease.

The constitutional and resilience factors, the relational experiences made (i.e. the affective ones) and the anamnestic objective events all contribute to the formation of a specific clinical framework. The etiogenesis is multifactorial: early diagnosis and prevention through different approaches targeted at subjects at risk are obviously the only instruments able to prevent the onset of the disease and the structuring of an openly pathogenic personality.

Today, due to a considerable increase in psychiatric pathologies, there is a failure of prevention and treatment actions, a failure that leads to the return of these minors into the juvenile justice circuits. In fact, the pathological adolescent, more than the adult one, tends to commit crimes and to be victimized. He/she is a victim of himself/herself and/or of the peer group, the â&#x20AC;&#x153;gangâ&#x20AC;?, that carries out deviant and antisocial conducts as its common daily lifestyle. The values assumed are those of group cohesion and recognition of negative qualities such as force and omnipotence, while denying any feeling of anxiety and vulnerability. The affectivity is frozen and it assumes characteristics of forced emancipation and autonomy in order to confirm an uncertain identity, as regards sexuality and identifications: sexuality itself is often

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linked to aggressiveness and they express themselves simultaneously.

2.2. Risk and Protective Factors There is a number of factors that can affect the mental health of a child or adolescent (Offord, 1998), and they can be divided into risk and protective factors. The former refers to factors that increase the probability of occurrence of mental health problems or disorders, while the latter refers to factors that moderate the effects of risk exposure (see previous paragraph 1.2). These risk and protective factors can exist in the biological, psychological and social sphere. Policies, plans and specific interventions should be designed in a way that reduces risk factors and enhances protective factors.

What is a risk factor?

A risk factor is defined as any biological factor for example, genetic predisposition or negative event (i.e., exposure to noxious substances during the fetal period, or to traumatic events in childhood) which is able to increase the probability of but not necessarily be the cause of developing a mental disorder in a child or adolescent.

Often, it is the presence of a particular “risk factor” that determines the development of a pathological behaviour. The principal risk and protective factors for minors’ mental health are indicated in Tab. 1-2.

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Tab. 1 - Risk factors Biological

Psychological

Social

Exposure to toxins (e.g. tobacco and alcohol) during pregnancy

Learning disorders

Family Inconsistent care-giving Family conflict Poor family discipline Poor family management Death of a family member

Genetic tendency to psychiatric disorder

Maladaptive personality traits

School Academic failure School’s failure in providing an appropriate environment to support attendance and learning Inadequate/inappropriate provision of education

Head trauma

Sexual, physical and emotional abuse and neglect

Hypoxia at birth and other birth complications

Difficult temperament

Community Lack of “community efficacy” (Sampson, Raudenbush & Earls, 1997) Community disorganization.

Discrimination and marginalization.

Exposure to violence.

Lack of a sense of “place” (Fullilove, 1996).

Transitions (e.g. urbanization)

HIV infection Malnutrition Other illnesses

Source: Child and Adolescent Mental Health Policies and Plans, World Health Organization, 2005

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Tab. 2 – Protective factors Biological

Psychological

Social

Age-appropriate physical development

Ability to learn from experiences

Family Family attachment Opportunities for positive involvement in family Rewards for involvement in family

Good physical health

Good self-esteem

School Opportunities for involvement in school life Positive reinforcement from academic achievement Identity with a school or need for educational attainment

Good intellectual functioning

High level of problem-solving ability

Community Connectedness to community Opportunities for constructive use of leisure Positive cultural experiences Positive role models Rewards for community involvement Connection with community organizations including religious organizations

Social skills

Source: Child and Adolescent Mental Health Policies and Plans, World Health Organization, 2005

Several studies assessed the evidence of early antecedents to adult mental disorders in childhood (Tsuang et al., 1995). This applies to mood disorders (such as depressive episodes and bipolar disorder) and psychotic disorders (such as schizophrenia). Some minors’ health disorders, that can be diagnosed also in youths inserted in juvenile justice system73, may only be recognized in adulthood by health professionals. A specific training targeted to adult health professionals in minors’ and adolescents’ mental health allows to make these diagnoses earlier and helps to understand their impact on the person’s functioning.

73 Such as pervasive developmental disorders and hyperkinetic disorder.

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Early intervention with children and adolescents as well as with their parents/ families, can reduce or eliminate the manifestations of some mental disorders and improve the integration into mainstream educational and health services of children and adolescents who would otherwise require specialized, intensive services.

The emergence of specific risk and protective factors varies according to the developmental stage of the child or adolescent. For example, the family is likely to be more influential during the earlier years of childhood, while in adolescence the impact of peers on his/her mental health is likely to be particularly important. Intervention strategies that fail to recognize the different influences of risk and protective factors according to the developmental phase of the child or adolescent will either have less of an impact or be ineffective74.

2.3. Antecedents of behavioural and personality disorders in adolescents In the following paragraphs we will analyze antecedents of specific disorders i.e. behavioural disorders and personality disorders.

2.3.1. Youth offenders and behavioural disorders75 The individual development, both at personal and social level, the adaptation to life, the attainment of the expected roles, the acceptance of personal and social reality and the process of integration that each adolescent lives, may produce stress that, sometimes, can be expressed in the form of aggressive behaviour, rejection of rules or other socially undesirable behaviours.

Any sign of altered behaviour analysed may have an adaptive justification. Only the habitual individual operating model at global and particular level, the analysis of the behaviours and motivations for them may lead to understand some deviant and illegal behaviours according to a psychiatric approach.

Given the difficulty in establishing the limits between “normality” and pathology in many type of pathologies, in case of behavioural disorders and other disorders of psychiatric origin these limits are even more difficult to assess. Often, in fact, deviant behaviours are the symptoms of a disease and/or disorder.

74 Child and Adolescent Mental Health Policies and Plans, World Health Organization, 2005.

75 Fundacion Mapfre Medicina, Trastornos del comportamientos in niños y adolescentes.

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Each individual results from a cluster of genes, biochemistry, education, values, experiences, social circumstances, etc. Behaviours and attitudes are therefore the result of the interaction between internal and external demands with which the person compares himself/herself, having at his/her disposal a range of answers acquired so far in his/her life story.

With this premise, from the psychiatric point of view it is considered that the behavioural problems are diagnosed as psychiatric disorders when there is a persistent and pervasive pattern of behaviours transgressing social norms and limiting his/her freedom in a maladaptive way that is not consistent with the age and the developmental path of the minor. In general, speaking about pathology it is assumed that there is a loss of the juvenileâ&#x20AC;&#x2122;s individual freedom: in fact the minor is unable to control himself/ herself, until stopping his/her everyday activities to carry on the observed symptoms.

Once focused on the context from which we can speak of psychiatric disorders, we need to categorize the issue in order to plan specific and effective therapeutic responses.

Categories can be defined when a number of behaviours are characterized by similar prognosis, similar treatment and, in general, by common origin. Behaviour disorders are usually diagnosed during childhood and can be divided, according to the latest psychiatric classifications, in three basic categories: conduct disorder, hyperactivity and attention deficit disorder (ADHD) and oppositional/defiant disorder (DSM IV classifications of American Psychiatric Association and classification of WHO [World Health Organization], ICD-10).

In conclusion, we can define behavioural disorders as continuous and persistent deviant and illegal behaviours that do not respond to other basic psychiatric diagnosis belonging to a higher hierarchy (i.e. aggressiveness displayed by a psychotic patient, in general, is considered to be a part of the psychosis and not an independent conduct disorder). Character, intellectual skills, learning disabilities and genetic predisposition are key factors for developing of a behavioural disorder thus an early diagnosis can allow preventive and appropriate intervention in minors at risk.

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2.3.2. Youth offenders and personality disorders76 The link between adolescence and personality disorders is quite controversial, both at a theoretical-conceptual level, as well as at the clinical and methodological one (Bleiberg, 1994; Masina, 2001).

In the first case, the possibility of a diagnosis of a personality disorder during adolescence is analyzed. In particular, starting from a definition of a personality disorder as “a habitual pattern of inner experience and behaviour markedly deviating from expectations of the culture of the individual [...] the model is stable and long-term [...]”, it has been discussed along the possibility of the presence of such pathologies in adolescents, structurally characterized by a functioning “stable instability” (Nicholas Corigliano, 2001).

In the second case, indeed, the issues related to the instruments adopted for the assessment of personality disorders within adolescents and the approaches implemented for the treatment of such disorders are faced. Despite the literature being almost unanimous in supporting the diagnosability of Personality Disorders in adolescence, two questions remain open. Firstly, the validity of the DSM criteria for identifying various forms of pathological personality and, secondly, the validity and reliability of assessment tools.

In specific, n. 4 potential risks in traditional classification of personality disorders in adolescents have been identified i.e.: • the coexistence of two or more personality disorders making difficult to formulate clear diagnosis; • diagnostic criteria proposed by DSM dichotomized symptoms in terms of presence/ absence, without taking into account the fact that many of the variables considered are continuous and do not show clear break points; • DSM refers only to serious personality disorders excluding this way other dysfunctional patterns; • the significant interference of measurement instruments and related problems, the different instruments employed (questionnaires, structured interviews, etc.) show a rather weak convergence of results, both among themselves and compared with an overall clinical evaluation.

76 G. Tamanza, Analisi e ricerca – le questioni prioritarie, Ipotesi di Lavoro, Iniziativa Comunitaria Equal, fase II in adolescenti con disturbi di personalità e comportamento. (Analysis and Research, priority issues, Community Initiative Equal, phase II, in adolescents with behavioural and personality disorders).

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It emerges, therefore, that a diagnosis of personality disorder in adolescence is possible, but it requires the introduction of specific tools and methodological differences compared with the diagnosis of the same pathologies in adulthood. These differences concern both the diagnostic criteria as well as the traditional classification of disorders and the assessment tools.

Among the possible causes of personality disorders we can identify specific factors according to the different theoretical approaches of reference and the considered disorder. Based on this, a series of etiologic hypothesis which can be attributed mainly to endogenous factors (psychological and biological-genetic), deficiency and traumatic experiences in relationships of primary care, have been developed. In considering the etiopathogenetic hypothesis to explain the emergence of a personality disorder, therefore, we can speak of individual factors (biological-genetic and/or psychological) in terms of vulnerability, environmental factors, traumatic experiences, familiar and social factors and so on.

All these assumptions, however, if considered in a rigid and exclusive way do not grasp the real nature of suffering, being based on the need to reduce the complexity of the phenomena in order to identify the cause of the disease and, therefore, to remove it.

In fact, intra-psychic and interpersonal variables, real relationships and represented relationships, present and past, are not opposed and on mutually exclusive levels, but they are complementary and deeply integrated.

3. MENTAL HEALTH OF YOUNG OFFENDERS IN THE ITALIAN CONTEXT This Chapter, whose aim is to deepen the issue of the mental health of young offenders in the specific Italian context, results from the joint work of the Juvenile Justice Department – General Directorate for the implementation of judicial provisions and the Don Calabria Institute (Projects office). Such cooperation has allowed the compilation of the “EUROPEAN COMPARATIVE ANALYSIS AND TRANSFER OF KNOWLEDGE ON MENTAL HEALTH RESOURCES FOR YOUNG OFFENDERS (MHYO)” questionnaire, which forms the main benchmark for this chapter.

The chapter is divided into three parts: part one describes the profile of the juvenile offenders affected by mental disorder in Italy, starting from their background and going on with the characteristics that they most generally share; part two is devoted to the typology of interventions more or less directly addressed to these subjects from the problematic diagnosis to the therapeutic interventions, without omitting the

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interventions directed to prevention, which is carried out on various levels; finally part three is dedicated to the Italian legal framework and to the professional competences that are necessary in interventions targeted to juvenile beneficiaries.

3.1. Profile of the mentally ill juvenile offender 3.1.1. General background As mentioned before, the main problems of juvenile offenders affected by mental disorder come from the family sphere. Often, these children belong to multi-problematic families with contexts of serious socio-economic and cultural exclusion. There are, however, also familiar contexts characterized by a sufficient socio-economic and cultural level, where the pathology of the minor, misunderstood and/or concealed, is brought to social attention just through the crime, assuming this way the form of a message and a call for help by the adolescent.

Other issues are those relating to immigration: ‘to emigrate’ means to abandon, leave places and feelings that are the first tracks on which the code of psychic functioning was established. The experience of immigration is a traumatic factor, assuming a process of mourning and reshaping of identity to a greater or lesser extent and which may, in some cases, lead to forms of psychic distress that, if not promptly treated, can lead to overt forms of psychopathology. Among the foreign children entering into the Italian juvenile justice system, psychological problems are not an uncommon experience; moreover they are often accompanied by abuse of psychotropic substances.

In general, among these children, we can find the presence of all the diseases and risk factors affecting the life of children: • Deprived minors: this is a term saturated with with multiple meanings including the social, economic, emotional and interactive one, even covering every undesirable aspect of the early mother-child relation from cruelty to overindlugence. This is a social and psychological problem of difficult resolution for the observed tendency of the phenomenon to reproduce itself through an intergenerational continuity, in a cycle of transmission that seems to have its focus on the reproduction of a predetermined type of family relationships; • Addicted juveniles; • Dual diagnosis; • Juveniles with psychopathological problems requiring specialized interventions in close connection with clinical expertise; • juvenile sex offenders who are often victims of abuses; • unaccompanied foreign minors;

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• foreign minors of 2nd generation; • minors recruited by organized crime; • minors who are members of anti social groups such as baby gangs and juvenile LatinAmerican gangs.

3.1.2. Family In Italy, with regards to the specific situation of young offenders suffering from mental illness, problematic families are a recurrent element of the young offender’s background.

As already stated, within the family context we often observe a parental inefficiency that supports the development of the mental disorders. Due to diverse variables, parents have no skills to follow the subject who is growing; often there is also a breakdown of the family system and not only of the “adolescent”. In the past, parents were able to play more or less their roles but today it is often not the case and hence it also becomes a socially relevant disorder (not so in a depressive situation where the child is isolated). An offence is an expression of the failure and hardship in the context of an adolescent’s life, this fact in itself is just the tip of the iceberg that leads us to many other issues.

In some situations parents are conniving and their complicity can occur in many forms, for example families that are apparently contrary but that actually defend and protect the child.

Many times it’s better to try to “substitute” the family context, replacing it with other figures.

The phenomenon of unaccompanied foreign minors, the presence of second generation foreign minors, the gradual increase of Italian children involved in crimes related to the use and dealing of drugs, and those recruited by criminal organizations, is only a part of a phenomenology of deviance that since long has begun to be characterized not only (as it was in the past) by problems related to social marginalization and economic conditions but also by expressions of psychological distress revealing on one hand the difficult and suffered process of social integration and on the other a phase of weakness of the principal “educational agency” i.e. the family.

The recent years have seen a progressive increase in the number of multi-problematic families in Italy. Operators (social workers, psychologists, educators, teachers and doctors) getting in touch with those families observe how the diseases experienced

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assume increasingly complex characteristics, they are no more affordable according to the usual logic of the past.

These new diseases should be interpreted bearing in mind the so called ‘new poverty’.

If we assume as indicator of social ease/disease the availability of relational (networks), cultural (understood as skills in reading their own situation and using the services provided by institutions) and financial sources, placing people in a continuum ranging from those who have been provided with all three types of resources to those who are illiterate, actually, the dominant element seems to be the one of a greater social vulnerability experienced by many families, that, for different reasons (single parent families, job loss, immigration, etc.) are even more close to poverty and marginalization threshold (G. Mazzoli and M. Colleoni, 2008).

The increase in the numbers, variations and changes in the types of cases requires continuous training and upgrading in order to acquire innovative tools fit to produce a concrete and comprehensive response to the identified needs. Each operator involved in social contexts (drug addiction, youngsters, penal institutions etc ...) cannot ignore the knowledge of the dynamics characterizing the multi-problematic family, for it represents the primary target of intervention.

It follows that the acquisition of skills in order to operate with multi-problematic family is necessary within the social context, as well as, transversal to different fields of intervention. The intervention with the family is part of the treatment within the juvenile justice system. Particular attention is given to family relations, i.e. the relationship between and among members of the family that juveniles, often, like to think about in an idealized way.

3.1.3. Types of mental illness suffered by young offenders in Italy First of all, we must say that the overriding personality disorder seems like an aggressive outburst of “emotions”. The nosographic diagnosis as well as the “classification” is difficult as developmental disorders keep changing and evolving as the child grows.

Minors confronted with mental health issues entering in the criminal circuit are a growing phenomenon in our country. Even though there is a lack of epidemiological studies at the national level, certain common topics have emerged out of the empirical assessment of users: • Mood disorders such as depression and bipolar disorder; • Anxiety disorders such as obsessive-compulsive disorder and post traumatic stress

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disorder; • Disorders related to substance use, alcohol, drugs; • Disruptive behaviour disorders, oppositional-defiant disorder, conduct disorder; • Thought disorders such as schizophrenia or precursors of psychotic conditions.

3.1.4. Correlation between the misuse of drugs and behavioural disorders in young offenders Even if it is difficult to establish what comes before, whether drugs or disorders, nevertheless there is a functional proximity/closeness between them. Many crimes need to be supported by drugs and, vice versa, many crimes claim dependencies in a vicious circle. Though there isn’t always a direct correlation between drug and crime (not all forms of dependence result in criminal behavior), there is indeed a significant link between them.

In any case, with regards to the Italian situation, the picture shows a trend that, from 2006, indicates a marked and steady increase in minor drug users and/or polyconsumers in entrance and/or under the charge of Juvenile Justice Services. The increase is determined exclusively from data relating to Italian juveniles that, from 2006 to 2008, showed an alarming increase of 41.3%, compared with a decrease in foreign minors during the same period, equal to 11.8%. In 2008, therefore, Italians constituted over 80% of the total minor drug users’ population taken into custody by Juvenile Justice Services.

Tab. 3 - Minors into the Juvenile Justice System for substance abuse according to their origin during 2004 - 2008

With regards to 2008, the number of minors who abuse substances entering and/or under the charge of Juvenile Justice Services has increased by 8%. As mentioned before the vast majority of them are Italians, followed, at a considerable distance, by juveniles

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from Morocco (9%) and Romania (1.6%). Regarding their characteristics, the majority is composed by males (95%) and 71% of them are aged between 16 and 17 years.

These young people are mainly charged of offenses related to possession and trafficking (58%) and against patrimony (36%).

It seems necessary to indicate that among the various drugs, cannabinoids seem to be the most consumed substances (78%); also worrying is the use of cocaine (10%) and opiates (7%). These latter two substances increase their statistical significance with the increase of age, while the reverse happens with cannabinoids, which are consumed in particular by younger people. Within this general framework, alarming are the data indicating the percentage of daily drug abusers (35%, increase with respect to the previous year) and the ones concern forms of addiction for over a year (38%). Moreover, within this general framework, the introduction of new substances in the market and the evolution in their consumption has diversified the traditional modalities of their use. Cannabinoids, for example, can also be inhaled while it is possible to consume opiates or cocaine smoking substances such as crack or kobret.

The data concerning the consumption of substances record an increase in the percentage of consumption within a group. According to ISTAT data (National Institute on Statistics – Istituto Nazionale di Statistica) on “use and abuse of alcohol in Italy”, there is a strong increase in alcohol consumption among juveniles, with risky modalities as the consumption takes place outside the familiar context and not during meals. The age of consumption among minors has come down giving rise to a new problem to be affronted; alcohol becomes a kind of self-medication against anxiety and stress.

The extent of the problem among youth suggests that this problem also exists among minors inserted into the criminal system, even if it’s not always detectable. Data collected by Juvenile Services suggest that substance abuse is characterized by polyconsumption of alcohol and drugs. Moreover, the use of substances by foreign minors seems to be connected to drug dealing or “usual” consumption and it is not perceived as a symptom of deviance, being culturally accepted in the Country they come from, as in the case of populations from North Africa.

The problematic nature of a minor under the charge of Juvenile Justice Services is quite complex and varied, and very rarely focused exclusively on drug addiction.

The profile of the addicted juvenile cannot be in any way comparable to that of the adult, as drug abuse rarely leads to a certification as addicted even if it requires specialized interventions by Local Health Agencies and Drug Addiction Services, preventing the chronicalization of such behaviours. The different approaches and the rehabilitation paths should promote a tailored and individualized approach through the implementation of educational support measures. The insertion into the criminal circuit is, paradoxically, an opportunity of growth and responsibility with regard to the

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deviant behaviours connected to substances abuse.

The presence of a correlation between use-abuse of substances (or alcohol) and personality or psychiatric disorders may be considered almost a constant feature and not only among juvenile offenders. A pre-existing psychopathological disorder may constitute itself as an agent facilitating the use of psychoactive substances, used as a sort of self-care, or still a psychiatric disorder may be associated to substance abuse, another hypothesis being that the use of psychoactive substances may facilitate the onset or relapse of a psychiatric disorder. Multidisciplinary teams for taking over the care and management of the young offender are constituted. In these teams, each operator provides skills to avoid fragmentation of intervention, ensuring continuity of actions even after the criminal procedure.

Difficulties of intervention have been registered in cases of dual diagnosis, which are particularly increasing in recent years. Many are the cases of drug addiction associated with psychopathology, for which there are no specialized structures equipped for specific treatments.

3.1.5. Special needs of minors confronted with mental issues who are facing a custodial sentence In cases of minors confronted with mental issues within the juvenile justice system, the starting assumption should be that the offence is, or might be, an expression of the mental disorder itself. Therefore the basic need of these children is the best treatment or intervention, where the issue of care is more important than the need of social control. Care is the reorganization of a condition of life that needs reception, listening, continuity of relationships and so on.

Needs could be summarized as follows: - the definition of a therapeutic project to be carried out by Health Structures (daily centers and therapeutic communities), or by socio-educative facilities provided with the necessary medical support; - places of care differently modulated according to the levels needed for the implementation of a network strategy that are able to consider both the spectrum of health issues as well as the needs for social inclusion expressed by adolescents; - specific staff training.

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What works Early prevention Family care Use of standardized instruments School prevention What does not Lack of local welfare resources Prison overcrowding

3.2. Interventions. What is working and what is not?

3.2.1. The problem of psychiatric diagnosis for juvenile detainees with mental disorders As with adults, a mental illness or disorder is diagnosed when a pattern of signs and symptoms is identified. Even though there are various systems of classification listing the most common and general symptoms of mental illness or disorders, the diagnosis of these kinds of problems still remains difficult, especially as far as children and adolescents are concerned.

Many behaviours that are sometimes considered as symptoms of mental disorders, such as shyness, anxiety (nervousness), strange eating habits, and outbursts of temper, can occur as a normal part of a childâ&#x20AC;&#x2122;s development. Behaviours become symptoms when they occur very often, last a long time, occur at an unusual age, or cause significant disruption to the childâ&#x20AC;&#x2122;s and/or the familyâ&#x20AC;&#x2122;s life. Despite these evaluations, the diagnosis of mental disorders or illnesses in young offenders remains a critical issue.

In the Italian juvenile justice system, all children admitted are seen by a medical doctor (general practitioner) who carry on an anamnesis and a general physical exam.

This doctor, if necessary, can request further closer examination. Furthermore, on the request of the educators and/or the penitentiary police, a therapeutic approach in charge can be taken through intra and extra treatment programs.

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Given this, the assessment tools, beyond the ones traditionally used in psychological work, such as projective tests (Rorschach and TAT) or personality questionnaires (such as the MMPI), are useful instruments to collect institutional value allowing the assessment of factors including: the risk of recidivism or relapse, familiar background, personality characteristics most commonly associated with delinquent behaviours (narcissism, impulsivity, passivity and isolation, persecutory), supporting the observation of adolescents’ behaviours within the institutional procedure (relationship with adults, with peers, attitude towards the offence, project and planning skills, responsibility, adaptability).

Thus, the need emerges to use standardized assessment tools, whit spread diffusion and fit to provide a shared basis between operators notwithstanding the difficulty of carrying out psychiatric diagnoses in subjects living in a developmental phase.

3.2.2. The therapeutic intervention for youth offenders experiencing detention and community based sanctions The juvenile justice system provides a wide range of measures, from the less afflictive ones to detention (a low level sanction). The judge, imposing such measures, may request that the minor participate in a therapeutic treatment that is part of the Tailored Educational Program (PEI). This is a specific program with differentiated points ranging from work to family to psycho-therapeutic intervention, planned for and with the juvenile offender.

The approach is not based on pure clinical aspects but it is multidimensional (holistic approach).

PEI is the concrete operative implementation of the Judicial provision i.e. of the criminal measure, meaning that the minor is obliged to follow the therapeutic treatment, otherwise the Court can change and modify the measure, which normally becomes heavier. Rare are the cases of TSO (Compulsory Health Treatment) imposed by the Judicial Authority for juvenile offenders. Psychiatric treatments are under the responsibility of the National Health System.

The therapeutic treatment can be given at an outpatient level but also through placement in a therapeutic community. Juvenile offenders for whom a diagnosis of psychiatric disorder has been established are placed in therapeutic communities and/or socioeducative rehabilitating structures; for all the other issues with psychological disorders, the therapeutic intervention – provided by the National Health Service – provides counseling, support, psychotherapy and family counseling.

Depending on the situation, the structure is chosen. Adolescents need external activities as the recovery is more likely to be successful.

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In Italy there are multipurpose structures with different responses and structures for the more problematic cases. There are in fact national and regional regulations allowing a mixed system between public and private. These rules define the structural and organizational requirements and the qualitative/quantitative standards.

Toward mentally ill juvenile offenders, the medical staff working in the local services can also guarantee the realization of family therapies, if they are necessary, consistently with what has been provided by the Penitentiary Health Service reform, having among its goals also to give continuity and complementarity to the therapeutic intervention.

In general, the results of family therapies in terms of structural change are quite few. The percentage of adhesion in programs for families of minors with mental disorders (not yet offenders) is low (around 30-40%). Under the criminal circumstances, familiesâ&#x20AC;&#x2122; adhesion increases because the family in some way feels responsible for the offence.

The focus of the therapeutic intervention in penal institutions is on the coercive nature of the juvenileâ&#x20AC;&#x2122;s supervision. The role of operators in this case is to transform this constrictive situation into an opportunity of exchange, where the juvenile can find answers to emotional needs, understand the meaning of offense and activate the emotional potential.

Within the current legal framework, the psychological intervention within the Juvenile Justice Services is primarily targeted to prevent the removal of adolescents from the original social contexts, promoting at the same time the sense of responsibility for their own behavior. In this perspective, within the intervention for adolescents submitted to criminal proceedings, it is fundamental to support developmental process, understood in particular as accompaniment and support to the development of responsibility.

Psychological intervention does not consist, therefore, of making a diagnosis aiming to discriminate between normality, to which penalties can be applied, and pathology to be addressed by the care system. The objective is to support the developmental process of the child, in any case, whatever is the level of difficulty hindering his/her path of social inclusion, both in case of developmental conflicts, as well as in the presence of personality disorders and antisocial behavior or psychopathologies involving the loss of contact with reality. From this point of view, penal institutions, therapeutic communities or probation can be understood as different strategies targeted at the same general purpose.

While until April 2008, there were no particular specific units for minors/juveniles with mental health problems and offenders, the recent legislation (DPCM of April 1, 2008) previews the establishment of a specific multidisciplinary service (social worker, psychologist, educator, doctor) within each Local Health Agency. Since this law is quite recent, in the occasion of the Joint State-Region Conference, an inter-institutional

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technical group on penitentiary medicine has been established. This is composed of representatives of the Ministries of Justice and of Health, representatives of regions and local authorities, providing a tool for the assessment and monitoring, related to the implementation of the transfer of skills and to organizational systems that each region has adopted. Until now, we are not yet in possession of such data.

3.2.3. Prevention programmes for young people suffering from mental disorders As it has been stressed in Chapter 1, situations of distress and mental illness may be connected in various ways. Regardless of the relationship between mental problems and illness, specific strategies of intervention meeting the needs of children and adolescents should be defined, as infancy and adolescence represent critical periods of life during which mental health problems may be more easily acquired or maintained.

Intervention programmes are particularly important because if children and adolescents with mental disorders donâ&#x20AC;&#x2122;t receive appropriate treatment, their difficulties are likely to persist, and their social, educational and vocational prospects will be reduced.

Moreover, it is also known that individuals with untreated mental disorders represent a disproportionately large part of the population in the juvenile justice system. Assuming that most mental disorders in adulthood have their origin in childhood or adolescence, it is therefore possible to reduce the extent of long-term functional impairment by early recognition and prompt intervention.

As already mentioned, prevention includes three different categories, each related to a different objective: primary, secondary and tertiary prevention. In Italy there are primary prevention programs, implemented at the local level, which fall under the responsibility of Local Authorities, the National Health Service and also of the Ministries of Health, Education and Family. The Department for Juvenile Justice has priority functions in secondary and tertiary prevention, while on primary prevention it intervenes only by offering cooperation to other institutions or agencies involved.

At the national level, the possibilities are: a) Welfare system with permanent programs operating in schools â&#x20AC;&#x201C; they are oriented toward working in early childhood on early symptoms of discomfort and on various forms of developmental disharmony; b) programs activated in primary and secondary schools; c) self-help programs for parents, related to the accompaniment of children having problems; d) programs for new parents to accompany the infant-weaning and first steps (programs of support);

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e) programs with a specific attention to bodily disorders (education to food).

3.3. Legal framework and protection 3.3.1. Penal and Child Care Regulations First of all, it is necessary to provide a synthetic description of the general juvenile justice framework in our country.

The Italian Juvenile Justice System is built around the concept of imputability. To criminally proceed against a minor, it is necessary that the action must be chargeable, a concept that implies understanding and intention as a condition of guilt.

Briefly, the principles underlying the juvenile criminal proceedings are: • the minimum offensiveness of the process by activating all the actions necessary to facilitate a quick exit from the criminal circuit without interrupting the educational process; • the adequacy of the process to match the educational goals; • the residuality of detention for precautionary measures and execution of sentence.

An analysis of the juvenile justice system cannot ignore the fact that the number of entries has not substantially changed in the last five years. The population is composed of up to 50% of foreigners: unaccompanied foreign minors (especially from North Africa) and new EU juvenile citizens (especially Romanians) and the remaining 50%, of Italians. It is to be noted, although limited, the presence of people coming from Latin America and the second generation foreign minors.

The number of persons confined in Minors’ Penal Institutions is very low (equivalent to an average of 500 units per day), while data related to juvenile offenders submitted to noncustodial measures are much greater.

The number of subjects for which Social Services’ intervention have been activated is around 18.000 units.

Another indicator related to juvenile deviance in Italy concerning crime is that their number has not increased, but, surely, their gravity has increased. In the qualitative assessment of users some macro-areas have been identified, presenting sometimes interrelated characteristics:

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• drug addiction and alcoholism, in particular polyconsume; • the phenomenon of the involvement of minors in organized crime; • foreign minors without familiar references often unaccompanied, for whom it is difficult to realize re-inclusion paths; • people with personality disorders devoted to polyconsume; • children with psychopathological disorders requiring specialized interventions in close cooperation with clinical experts; • juvenile sex offenders; • crimes committed in a group or within gangs; • bullying to the limits of criminal law; • juveniles over 18 years of age, composed for the major part by young people expiating the sentence (they are often connected to organized crime).

The approach implemented by the criminal justice system is therefore an integrated intervention, creating inter-institutional networks aiming to realize a tailored and individualized project involving all the educational agencies for a quick exit from criminal circuits, but also for the minor’s working and social inclusion.

With regards to the specific childcare system/civil law concerning children with mental health, the system is based on a multi-focal approach where many professionals put together their knowledge. Since it is really difficult to work with this type of target, we verified that the multi-focal approach is the only one that can give effective results.

We must first make a distinction between what is welfare and what is the criminal justice system, because if the minor suffers from a disorder of personality then the health system shall deal first with his/her illness. In Italy, we are in general trying to differentiate approaches that can be summarized into three categories, according to the degree of containment: a) shelter; b) day hospital; c) Communities with the possibility of highly specialized intervention or purely pedagogical approaches.

Since the Juvenile Criminal Procedure Code (DPR 448/88) was established, inside the Services of juvenile justice a practice of intervention for children entering the criminal circuit has been consolidated, which places the role of psychological work in the process of evaluation and treatment in a developmental perspective. Through the Presidential Decree of the Council of Ministers, issued on the 1st of April 2008, all the health functions carried out within the Juvenile Justice circuit and the Penitentiary Administration were transferred to the National Health Service.

This Decree marks the end of a long path that began with the Legislative Decree n. 230 of 1999, which makes fully applicable the principle that acknowledges detained or interned persons, on the same terms of free citizens, shall have the right to the supply of prevention,

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diagnosis, cure and rehabilitation services normally provided at the essential levels of assistance.

All the health functions carried out by the Department of the Penitentiary Administration and the Department of Juvenile Justice have therefore been transferred to the National Health Service. The Regions guarantee the fulfillment of the service through the Local Health Agencies in whose scopes of competence the institutions and penitentiary services and the juvenile services of reference are located.

According to the Decree, starting from the principle of full equality of treatment for free individuals and individuals detained and interned the minors subjected to criminal measures, the health care is to be provided for the subjects enduring measures of the Authority Juvenile Court, also in reference to: • actions of protection, information and education for the development of individual and collective responsibility for health; • complete information on their state of health at the moment of entering the criminal institute, during the period of execution of the sentence and at the release; • interventions of prevention, care and support of psycho-social discomfort; • health assistance of the pregnancy and maternity; • pediatric assistance and services and childcare to children of women prisoners or interned, living with their mothers in the institute during early childhood; • identification and payment of fees relating to therapeutic Communities for drug addicts minors and young adults suffering from mental disorders, according to art. 46 paragraphs 6 and 6bis of the DPR 309/90, as well as to the therapeutic Communities cited in art. 24 of Legislative Decree 28 July 1989, n. 272.

Particular attention is given to arranged interventions in the following areas: 1. general medicine and assessment of health status of new persons entering the institutes; 2. specialized services; 3. responses to emergencies; 4. infectious pathologies; 5. prevention, treatment and rehabilitation for pathological addiction; 6. prevention, treatment and rehabilitation in mental health; 7. guardianship of the health of women prisoners and minors subject to criminal measures and their offspring; 8. guardianship of the health of immigrants.

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The juvenile offenders suffering from mental health problems in Italy shall be prosecuted except for those who are recognized as incapable of understanding and willing, according to the Italian Code of Criminal Procedure (see Articles 85, 97, 98).

The legislation in the field of juvenile criminal justice and the recent reform of penitentiary health include jointly taking over the charge of the child who suffers from mental health disorders. The several problems that the person may have (psychopathology, addiction, crime) require a multi-disciplinary and inter-institutional intervention, in order to define a coherent and shared individual project. Legal assistance is always guaranteed. If the person is not subject to criminal action, the treatment program is guaranteed under the National Health Service.

For young offenders affected by mental health problems, there are specific regulations within the health care system. The Juvenile Criminal Procedure Code provides for security measures that are implemented through legal measures of prescription or of placement in a residential facility (communities for the minors – socio-educational, for rehabilitation or treatment). Before the passage from the penitentiary medical perspective to the National Health Service, Juvenile Justice Services predisposed clinical therapeutic rehabilitation programs inside the individualized projects for each minor, with the help of local health services. Nowadays, under the new rules, local health services are responsible for the treatment in cooperation with the Juvenile Justice Services.

The Italian juvenile justice and health systems protect the best interest of the child by following important ethical principles that are prescribed in the current national legislation:  the recognition of full equality of treatment for minors subjected to criminal action;  the need for a full and fair inter-institutional cooperation among the National Health Service, Prison Administration and Juvenile Justice to ensure synergistically guardianship of the health and social rehabilitation of prisoners and minors subject to criminal action and also the security need inside the Penal Institutions for Minors, the reception Centres, the Community and Clinical Centres;  the measures to protect health consist of closely complementary interventions aimed at the social rehabilitation of the offender, through actions and programs with the participation of all relevant institutions, social cooperatives and voluntary associations; the effectiveness of such integrated interventions is favoured by the direct participation of prisoners in the activities of prevention, care and rehabilitation and also in paths to prepare themselves for the exit;

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 the prisons, the penal institutions for minors, the reception centres, the Community and Clinical Centres must ensure, compatibly with security measures, environmental and life conditions answering the criteria of respect for the dignity of the person, avoiding overcrowding, respecting the religious and cultural values, etc.;  the therapeutic continuity is a founding principle for the effectiveness of care interventions and must be provided on the entry into prison and/or in a juvenile facility, during any movement of prisoners from different prisons and juvenile facilities, and after the release and the return to freedom.

The above-mentioned principles are based on the idea, which is part of the established tradition of our country, that health is not just the absence of disease, but it is inextricably linked to the social and cultural aspects forming the main capital of each community. According to this perspective, prevention, treatment and rehabilitation are part of the same paradigm of health promotion, that aims at encouraging individual and collective empowerment. In the case of juvenile offenders, this idea of health leads to consider antisocial deviant behaviours as possible expressions of a psycho-social distress resulting from a “lack of health”, rather than as a derivative of a specific and exclusive individual-subjective attribute.

Ethical aspects regarding the following issues: 1. Bioethical issue on treatment without the consent of the parental/familiar authority; 2. Using medicines on children and specifically psycho-medicines, is it justifiable for minors?

3. Historical debate whether psychological therapies should be prescribed or if they should be proposed to the subject to freely and voluntarily follow them; 4. Relationship between care needs and social danger of the subject.

3.3.2. Professional roles and development of skills The professional cooperation between the various and different practitioners who are in contact with minors in conflict with the law (judges, psychologists, psychiatrists, social workers, teachers etc.) is very important.

In the Italian context, the Presidential Decree 448 of 1998 establishes by Article 6 that “at every stage and level of the proceedings the court uses the services of the Administration of juvenile justice. It also makes use of the services set up by Local Authorities”. The Legislative Decree of June 22nd 1999, n. 230 “reordering of penitentiary medicine”, in Article 1 stipulates that detainees and internees, like citizens in a state of freedom, are entitled to the supply of the benefits of prevention, diagnosis, treatment

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and rehabilitation provided in the basic level and uniform assistance. Article 2 defines the framework for actions to be put in place, providing that: 1. The State, Regions, Municipalities, local health units and institute conform their actions and contribute responsibly in the creation of conditions to protect the health of detainees and internees, through information systems and health education for the implementation of preventive measures and conduct of the performance of diagnosis, treatment and rehabilitation contained in the National Health Plan, both at the regional and local level; 2. The health assistance to prisoners is organized according to the principles of global intervention, unity and performance of services, integration of social and health care and ensuring continuity of care.

The collection of data and information on juvenile offenders is primarily made through court documents, interviews with offenders and their family members, relations with the local Social Services. This information is collected in personal and individual file and managed according to the rules concerning privacy and protection. All those who come into contact with such information, for reasons related to their profession, are prohibited from disclosing them and can deal with this kind of information only anonymously.

Concerning the reference figures mainly dedicated to the minor’s care/guardianship, we have to nominate the psychologist and the psychiatrist; these figures are absolutely bound by professional secrecy. Other professionals to be nominated are the experts commissioned by the court to perform a function of evaluation of the “minors”; they have a specific mandate that doesn’t consist of cure but in assessment; here we can’t speak about professional secrecy since they have to give their evaluation to the court.

Regarding the training, in our country there is not a specialized training within the juvenile justice system or the health system for professionals who are in contact with mentally ill young offenders.

Within the Italian system of Juvenile Justice, there are training schools for professionals and operators with programs on various subjects (training only for Juvenile Justice operators, not for external figures). The juvenile justice system acknowledges a fundamental role for vocational training. Operators who work in juvenile justice follow training courses organized by both the Justice department and other institutions. The scarcity of funds available does not, however, satisfy the training needs.

Training is centred on: the knowledge of the legislation; education and psychology; methodology; intervention activity and operative tools. According to the recent

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legislation on the transfer of health functions to the Regions, the Regions are expected to set up training courses for specific operators including joint actions with operators from the Justice department. Regarding the health system, continuous training is activated for example on the rules and operating procedures.

Sincerely speaking as of now there aren’t professionals who are prepared to work with this target group: the daily work allows a training thanks also in particular to the ongoing supervision groups foreseen in each structure. However, the creation of a common language inside the structures and the sharing among experts involved is a fundamental issue.

The “Guidelines for the National Health Service to protect the health of detainees and inmates in prisons and juvenile subject to criminal action” (Attachment A to the DPCM 1. 4. 2008) prescribes, within Local Health Agencies where there are IPMs, reception centres (CPA) or ministerial communities, to establish at Regional level a specific operative unit. This specific unit provides a multidisciplinary service for mentally ill young offenders, because it includes all the professionalisms that are necessary to the carrying out of the specific type of assistance, and it cooperates with the Social Service Offices of the Justice Department and of the territory with the main purpose of taking away the minor from the penal circuit.

This multidisciplinary team dealing with these minors works on the following fields/ aspects:  the field of education;  psychologist-psychotherapist aspects;  medical issues.

We can say that in Italy there exist certain good practices of intervention even if they are affected by strong territorial limitations of inappropriate distribution of social welfare structures. A key point is to distinguish all those practices which are based on the principle of reducing the risk (of relapse) rather than practices that leverage a psychological conception of the child based on their developmental needs. The good practices below provide an illuminating framework:

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4. RECOMMENDATIONS - GOOD PRACTICES 4.1. Guidelines concerning mental disorders affecting minors within juvenile criminal justice .......................................................................................................................................

Serenella Pesarin, General Director - General Directorate for the implementation of judicial provisions - Juvenile Justice Department (Ministry of Justice) In collaboration with: Simonetta Casciotti Official GEN. DIR. for the implementation of judicial provisions Alessandra Lagorio Official GEN. DIR. for the implementation of judicial provisions

........................................................................................................................................

As previously mentioned, on April 1, 2008 the President of the Council of Ministers (DPCM) issued a Decree by which all the health functions carried out within the Juvenile Justice and Prison Administration were transferred to the National Health Service. The Decree marks the end of a long path that began with the Legislative Decree No 230 of â&#x20AC;&#x2DC;99, which allowed the application of the principle that acknowledges the right of the detained or interned people (adults and minors) as for free citizens, to the services of prevention, diagnosis, treatment and rehabilitation provided at the essential levels of assistance. All health functions carried out by the Department of Prison Administration and by the Juvenile Justice Department were transferred to the National Health Service; now Regions guarantee the performance of this Service through the Local Health Authorities (ASL) in whose territory of jurisdiction there are penitentiary institutes and juvenile services. On October 1st 2008, the definitive transfer to individual Regions of labor relations, financial resources, equipments and capital goods took place.

In order to ensure uniformity of the interventions and health care and health treatments within the entire country, a Table of permanent consultation on prison health was established by the Joint Conference among the State, the Regions, the Autonomous Provinces and Local Governments. It consists of representatives of the ministries of Health and Justice of the Regions, Autonomous Provinces and Local Governments in which it participates as a representative of the Department of Juvenile Justice, the General Directorate for the implementation of judicial provisions.

Given the complexity of the matter and the diversification of regional health structures, the Table of permanent consultation monitors the application, verifies the results, highlights problems and proposes the necessary remedies to ensure an effective collaboration between the National Health Service, the Prison

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Administration and the Juvenile Justice Department throughout the country.

Until now, the following patterns of agreement, partnership agreements, guidelines and monitoring programs were approved in the Joint Conference State/Regions on the proposal of the Table: 1. “Agreement between the Government, the Regions, the Autonomous Provinces of Trento and Bolzano and Local Governments on the definition of forms of cooperation relating to the functions of security, the principles and criteria of collaboration between the health system, the penitentiary system and the juvenile justice in compliance with article 7 of Decree of President of the Council of Ministers on April 1, 2008”.

2. “Outline of standard agreement for the use by Local Health Authorities in whose territory penitentiary institutions and services of reference are located, of the premises allocated for the purpose of health functions” - Approval under Article 4, paragraph 2 , April 1, 2008 Prime Minister’s Decree, of April 29, 2009.

3. “Outline of standard agreement for the medical and legal services in favour of the staff of the Penitentiary Police Corps” - Agreement under art. 9 of Legislative Decree August 28, 1997, No 281 of October 29, 2009.

4. “Health care facilities in the Italian pentitentiary system”. Agreement under art.

9 of Legislative Decree August 28, 1997, No 281 of November 26, 2009.

5. “Guidelines for assistance to minors subject to provisions of the Judiciary Authority” - Agreement under art. 9 of Legislative Decree August 28, 1997, No 281 of November 26, 2009.

6. “Health data, information flows and medical record including also the computerized ones” - Agreement under art. 9 of Legislative Decree August 28, 1997, No 281 of November 26, 2009.

7. “Definition of specific areas of collaboration and priority directions on interventions in Judicial Psychiatric Hospitals (Ospedali Psichiatrici Giudiziari OPG) and in Care Homes and Detention Homes (Case di Cura e Custodia - CCC) in Annex C of the DPCM April 1, 2008 - Agreement under art. 9 of Legislative Decree August 28, 1997 No 28 of November 26, 2009.

8. “To monitor the implementation of D.P.C.M. April 1, 2008 concerning the modalities and the criteria for the transferral to the National Health Service of medical functions, labor relations, financial resources, equipment and capital goods in the field of penitentiary health”. Agreement under art. 9 of Legislative Decree August 28, 1997 No 28 of November 26 2009, n. 281.

As for the Organizational Model in specific, the Annex “A” of DPCM of April 1, 2008 already provided for, regarding Juvenile Justice, as follows: in the Health Authorities in whose territory there are Penal Institutes for Minors (IPM), Reception Centres (CPA) or

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Communities, the indication is to establish within the organizational structure instituted by the Region, a specific operational unit that intends to be a specific multi-disciplinary service. The operational unit includes all the necessary skills to supply the specific type of assistance and collaborates with the Social Service Offices of Justice (USSMs) and local Social Service Offices with the main task of removing the minor from the criminal circuit; it also has to ensure treatment programs granting timely interventions, continuity of care, appropriateness and quality of services, monitoring of results, also through appropriate guidelines. Interventions need to be integrated into the network of regional Health Services to ensure continuity of care in terms of equity and quality. The legislation provides for the creation of a specific multidisciplinary service (social worker, psychologist, educator, doctor) within each health organizational structure (Local Health Authority).

Among the reference principles of the document: • acknowledgement of the free treatment in matter of health care; • full and fair inter-institutional cooperation among the National Health Service, Prison Administration and Juvenile Justice to synergistically ensure the protection of health and the social rehabilitation of minors subject to criminal procedures, as well as the need for security within the IPMs, the CPAs, the Communities and Clinical Centers; • the actions to protect health are closely complementary to the interventions aimed at social rehabilitation of the offender, through actions and programs jointly carried out by all relevant Institutions, social cooperatives, voluntary associations; • the therapeutic continuity is the founding principle for the effectiveness of care interventions and must be ensured at the time of entry in a juvenile facility.

To encourage and implement cooperation between the area of health and that of treatment is a strategic key to combine the treatment objectives with those of protection and promotion of mental health through the most appropriate action both for the health protection of the person and for social security. This practice must be implemented since the first entry and pursued throughout the period of stay in the structures. Therefore health interventions, while maintaining their specificity, are part of the integrated social-health-educational intervention implemented within the criminal context, which further characterizes the quality of the action of the involved people.

On the basis of these organizational indications there arises the necessity to define “Specific guidelines for the assistance to minors subject to provisions of the Judiciary Authority”. This document highlights the importance of a multidisciplinary assessment implemented by a team of doctors, psychologists, educators, social workers - that can also be implemented at a later date - allowing to highlight the characteristics of the minor and his/her “care” needs (inlcuding health, educational, social needs) from which it will depend on the elaboration of a care program that will include all the necessary measures, identifying at the same

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time Authorities and operators responsible for their implementation. It follows that, in particular for those minors and young adults who present symptoms of psychopathological disorders, alcohol/drug addiction or for those characterized by dual diagnosis, it is needed not only a specialist assessment to be carried out in relatively short time, but possibly also the immediate placement in treatment facilities - for example in the case of subjects with acute syndromes - or the provision of therapeutic interventions.

The guidelines are based on the assumption that health is not just the absence of disease but rather it is inseparably linked to the social and cultural aspects which constitute the base of each community with an approach meant to promote the individual and collective empowerment. In this perspective, antisocial and deviant behaviours are considered as an expression of psycho-social discomfort resulting from a â&#x20AC;&#x153;lack of sanityâ&#x20AC;?. Therefore, in an organized system providing social services the actions of competence of Local Authorities must be integrated with those of the Juvenile Justice Services and the Specialized Health Services. In order to provide appropriate responses in any context, specific agreements at the regional level are required. These specific agreements must be very clear with respect to the following points: i. ii. iii.

when, from whom, how and where the assessment of the conditions of the subject must be realized also from the point of view of health; how the care, recovery and rehabilitation facilities must be set up; how to consolidate and/or activate strategic processes, planning and operational integration between Institutions and other subjects who are involved in the taking in charge of the problems related to the the juvenile criminal justice area.

An example of such collaboration is the Protocol of Intent signed by the following subjects: ASL (Local Health Authority) of Rome, Municipality of Rome, Santa Maria in Aquiro Institute, Center for Juvenile Justice of Lazio Region. The Protocol deals with the creation of semiresidential and residential therapeutic and rehabilitation facilities as part of a network of services for the psychiatric emergency in children and adolescents.

It is meaningful to underline the basic criteria of the document: 1) attention to integrate skills and resources of each Institution in order to pursue the objectives set out in the legislation; 2) synergistic and coordinated exercise of the institutional role of each one according to the principle of horizontal and vertical subsidiarity; 3) focus on the sustainability of the interventions over time by identifying and providing more favourable conditions for the continuity; 4) commitment to achieve an integrated planning at local and sector levels among subjects who are specialized in different aspects concerning

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psychiatric and psychosocial emergency during the developmental age, fostering the interaction of health, educational and social aspects; Under these principles the following facilities have been realized as a result of the concerted action of various Public Authorities: a Day Center and a protected temporary shelter for minors in the post-acute psychiatric disorders phase. A therapeutic Community is about to be created.

Final observations and proposals on the issue - also resulting from the exchange between different Countries during various events of exchange - can be summarized as follows: • to strenghten the strategies for common action at national and local levels, as effective method of intervention for the achievement of expected results; • to integrate the health care and juvenile justice staffs ensuring the presence of health personnel in all important phases of the criminal path of the minor; • to set up throughout the country uniform procedures for the implementation of health interventions and services, including the placement of minors subject to criminal proceedings with drug addiction and/or mental illness; • to build a network of community resources suitable for the reception of juvenile criminal justice users with respect to the specific health needs and in the perspective of designing an individual project enabling the participation of all the involved institutional stakeholders; • to increase the number of community facilities specifically meant for the treatment of drug addicted minors and make a list of the therapeutic and/or socio-rehabilitation communities that can receive drug addicted minors and those having mental suffering; • to focus on the individualized intervention respecting the centrality of the minor by ensuring all services and interventions regardless of the structure in which they are implemented; • to stipulate agreements at local level between Local Health Authorities (A.S.L.), Centers for Juvenile Justice and Juvenile Services to regulate the operational mode of collaboration; • to ensure, as provided by the law in force, the services of specialized medicine, pharmaceutical care and to do medical examinations of minors with problems of mental discomfort and/or drug addiction staying in the CPAs, in IPMs and in Communities; • to ensure, where there are specific therapeutic needs, in accordance with the principle of continuity of the taking in charge, the permanence of the minor in the same facility also at the end of the criminal measures; • to know the conditions and specific risk factors that cause or contribute to cause pathological symptoms, taking into account the condition of imprisonment and deprivation of liberty, in order to establish the appropriate procedures to reduce suicides and suicide attempts;

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• to provide support paths with a strong focus on education and mentoring of drug addicted minors, minors suffering from mental illness and subject to criminal proceedings through specific projects involving the family, the school, the peer group and the community; • to provide experimental projects combining school, leisure time, work, realized in integration with the relevant Institutions, alternating application phases and workshops with theoretical phases aimed to be an experience for the youth that encourages his/ her future social inclusion; • to activate integrated training courses between operators of Juvenile Justice System and the Health Service, Local Authorities, social private sector, volunteering and all educational agencies to harmonize the different skills and methods of intervention; • to provide for foreign juvenile offenders: a) a regulation of the administrative competences with regard to the last established residence as unitary and shared criterion, extended throughout the national territory, that allows thereby a certainty of operational and organizational referents; b) the activity of cultural mediation as an indispensable support in the definition and implementation of the treatment program.

We believe, in conclusion, that the model is that of an integrated intervention which builds interinstitutional networks having the youth as their focus with his/her specific health needs that are to be realized through a specialized and individualized project with the involvement of all educational agencies to allow him/her not only to get out of the criminal system, but also the possibility of social and work inclusion and the opportunity to be active citizens with both rights and duties centred on responsibility which in turn is very essential to obtain any successful rehabilitation.

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4.2. Interview with Maurizio Dusi, M.D Psychiatric Psychotherapist

1. What has changed about pathologies or antisocial behaviours of minors and young adults in recent years? What were the emergent phenomena?

It is necessary to do a premix.

First of all, the actual social context promises a lot to juveniles and young people and then fails to keep its promises. Therefore, to the availability of a wide offer - ranging from clothes to cars and even to a certain social status - do not match the real possibility that the juveniles achieve the proposed objectives. This leads to a sense of discomfort almost non-existent in previous generations and the promise of a “better life” then hardly finds any fulfilment.

Secondly, we also have to recognize that, actually, the policy proposes such ethical standards where smarter ones are rewarded, i.e., people choosing shortcuts to achieve the objectives are rewarded. Therefore, the lack of an adequate ethical support by policies and the society has to be highlighted.

Finally, also families are experiencing a crisis of values due to economic and social reasons; nowadays both parents are working and do not have enough time to spend with their children. Hence the family has failed in its traditional education, protection and monitoring role and functions.

These three aspects (not keeping promises, the lack of ethics in the political and social contexts and the crisis in the families) involves an increase of antisocial behaviours as indeed in the addressing and facing of the problems, there exists the tendency to look for shortcuts in order to overcome difficulties within a given context where family does not intervene, leaving the juveniles more free but unable to properly handle their freedom. Such freedom, which has increased with respect to the past, encourages antisocial and delinquent behaviours, especially in a context where proposed examples are certainly not edifying.

It is clear that this involves also psychological and psychodynamic implications with a consequent increase in behavioural disorders: the adolescent shows his/her conflict through his/her behaviour. Conflicts are of course typical of adolescence but it’s even more evident in the actual context and without doubt they have increased.

2. What are the intervention strategies and the implemented methodologies (counselling, psychological, network, with families and services or others)?

Adolescence, being a period of crisis and transition from childhood to adulthood involves a process of change and represents a “crossroad” among different instances:

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the adolescents themselves, their family, the school, the social context in which the juvenile lives (from Parish to sport). Adolescence requires, therefore, interventions integrating the responses from the various agencies and services operating within the juvenile field.

An offence committed by an adolescent represents of course a social problem but it also involves the family, school, juvenile services and police; a good methodology in an absolute sense, unfortunately, does not exist rather an integration of efforts that, in contemporary or slightly on a later date, are able to interact and cooperate within a context that is and must necessarily be common is required.

From my point of view, the required approach is a “multi-focal one” because the focus of the intervention, aiming to support the adolescent, has to “come” from different points of view.

Since the risk of a multi-focal approach is that of being unsystematic and that the process of integration among the different stakeholders does not always work, two aspects on the clinical level allowing to make the most effective approach are requested. The first is the presence of a referent person coordinating the educative project so a project manager who is not necessarily the psychiatrist but may be a psychologist or a social worker. The presence of a person making a synthesis among the work implemented by various institutions and agencies is fundamental. The presence of a project manager is crucial otherwise the different interventions on juveniles are likely to be unsystematic and inefficient. However it’s necessary that this role is officially recognized by the various stakeholders and social actors. Despite the importance of the project manager, this figure is still undervalued and non-existent so as not to be provided, for example, by recent Regional Plans of the Veneto Region.

The second aspect is the need, during the phase preceding the start up of a project, for the assessment of the subject. The assessment must foresee an institutional place i.e., a day centre. In our case it was implemented by the internal service of Villa Santa Giuliana Hospital77. The basic idea is that the assessment should not be based only on the clinical interview: just because the juvenile moves and manifests his/her difficulties through the behaviours. Hence, it must be carried out in a place where the juvenile interacts with peers, within a context that can be entertaining like sport or even of psychotherapeutic type (as psychodrama), i.e. situations in which the juvenile’s behaviour is seriously taken into consideration as means of manifestation

77 Villa Santa Giuliana Hospital, where Dr. Dusi has been in charge of Adolescent Service for years is a hospital for the care and psycho-social rehabilitation of persons with mental disorders sited in Verona.

It’s a religious institute and is classified as equivalent to a Sanitary Structure aiming at Public Assistance included in the Veneto Region Health Plan. The mainly treated disorders are: major depression and mood disorders; bipolar and psychotic disorder; personality disorders, relational and behavioural disorders; psychopathological issues of adolescence. The Hospital offers institutional treatment and rehabilitation according to the bio-psycho-social approach, integrating pharmacological interventions, psychotherapy, rehabilitation and welfare. The structure is one of the few in Italy that in addition to accommodate adult patients has a special area dedicated only to disorders of the adolescence.

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of the disease. Clinical interview may be an aspect of assessment, but it can’t be limited to this: a response taking into account counselling, psychology, the family, the network and all the involved services. Keywords thus become: - Multi-focal approach; - project manager; - assessment.

3. Staying in the psychological field or, if you prefer, in the medical-psychiatric one, what according to you is the diagnostic and treatment approach to be activated with juvenile offenders with mental disorders (cognitivebehavioural, pharmacological, social welfare, etc.). ?

As previously mentioned, the approach needs to be multi-focal. All contributions are welcome. It is clear that I speak about psychodynamic approach because that’s what I know and the one in which I am trained but I have no difficulty to think of a multiprofessional team composed by different professionalisms, the problem is if such skills are taken into consideration for having different points of view or rather are perceived as an obstacle. Potentially, they are resources and not obstacles.

No one nowadays thinks that the approach should be only psychological and not pharmacological: it is clear that the pharmacological approach is important too.

But it is equally wrong to think that the pharmacological approach should not be supported by something else, as medicine does not only have the value in the basis of chemical effect but also in the way it is given.

It is obvious that the various sectors should complement each other and, fortunately, this already happens, but not yet in a systematic way. It is necessary to move from integration - the one implemented nowadays – in charge often on the willingness of operators, to a type of an institutionally recognized integration and this depends on the institutions at the highest levels (Regions, ASL-Local Health Authority): these are the institutions that must propose an integrated approach.

Given the need for a basic training (in psychology, medicine, social work) and without going into detail, I think that the network within the structures and between different involved actors requests primarily the necessity to acquire a common language, a language in symbolic terms, therefore, to have a common language is necessary to have a common culture.

Within the work team there must be a dialectical situation allowing interaction as various stakeholders must learn to interact with respect to a problem that could be described as frightening as that of the juveniles’.

So if the base is that of an integrated approach, at the level of team work, there must be the acquisition of a common language and there must be someone encouraging

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and monitoring it. This role should be implemented by a coordinator and an external auditor as I believe that it’s important that someone who is not involved in the “daily activities” gives a helping hand in “finding thoughts”, as everyday life often makes us lose them as it often does, with regard to a common vision.

Besides the acquisition of a common language, it is necessary to create a common culture. From my point of view, supervision consists of a work of reflection on the clinical case, which must also be accompanied by some reading that can be an object of discussion. Literature can, in fact, provide some ideas on some issues allowing the members of the team to refine their modality of interaction. The reflections and discussions of experiences and/or cases handled mentioned in the literature can be useful for the team to acquire a common culture.

Taking into consideration the previously defined multi-focal approach, I argue that there may be integrations of therapies (art therapy, psychodrama, etc.), but their integration is effective only if it is conceived as an experience shared also by the operators. For example, it is very useful that even the operators participate as auxiliary to the psychodrama that is a clinical but also a training event (sharing of experiences and of everyday life).

Of course, what I am proposing involves quite high costs but, if the adolescent gets rehabilitated - and there’s a good chance that this happen – it helps us to avoid following up a chronic case for the whole life.

4. What are the principal problems with regards to assessment, treatment and subsequent taking in charge of such type of users?

The great difficulty with juvenile offenders affected by behavioural disorders lies in having to combine the therapeutic/curative aspect with the regulatory and containment aspects.

It is evident that closed structures preventing juveniles from committing further crimes are necessary. These structures must be severe or rather should have very precise rules. The issue of rules is fundamental for those dealing with adolescents: there must be rules and there must also be penalties for those who transgress them.

Such type of structures, with containing function, must in any case aim at social and psychological rehabilitation. On the other hand, a real psychological and social rehabilitation in the absence of specific structures is unrealistic. Both aspects are important and necessary: “the wall” on one side and rehabilitation on the other. If there is a delinquent behaviour, it must be contained and prevented by strict rules and penalties.

With regards to penalties, the punishment must not be definitive, there must exist a second - and even a third - chance, but we must ensure that prior to misconduct and banned behaviours necessary corrective steps are taken. At the same time, the

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structure cannot be merely punitive.

For example, within the service where I worked, we had foreseen the possibility of removing the juvenile for the breach of the rules but with the opportunity to be welcomed back with a new “contract/project”. Hence, we planned a system with a second and third step safeguarding the value of the rules.

The system of rules and sanctions must be formal and shared by both juveniles and operators. If the service is organized according to these modalities it has an effective psychodynamic function and at the same time a protective as well as a containment function, since what was missing in the family must be found within the institutions.

5. With regard to future perspectives, from your point of view, is there an awareness of these issues at national level? What are the answers that the system in general ought to give?

I can say that at the national level there is a lack of awareness about the issue and about the importance of the previously mentioned aspects i.e.: - multi-focal approach; - project manager’s role; - the need for an institutional place where assessment is to be done.

Currently, there are no clear criteria by which it is decided that a juvenile offender should be placed in a facility with a high protection level or in a low protection one.

Some youths must necessarily be hosted in facilities with high level of control otherwise the hosting structure with low protection is very likely to “break up” because at times there are juveniles affected by serious behavioural problems, hence they need to be controlled and contained.

In conclusion, I would repeat and emphasize that the most problematic juveniles whose numbers are not very large at present - need specific structures and operators that are able to contain them.

Only can there be place for psychology, otherwise there is only space for disaster.

In this optical assessment is a fundamental aspect and as such has to be seriously taken into consideration.

Surely, today we lack a complete awareness of the issues of juvenile offenders affected by behavioural disorders.

For example, the Regional Project of Veneto Region on Mental Health devotes only 8 pages of a total of 40 to children/adolescents and dedicates all the remaining 32 pages to adults: the situation, then, has not yet been taken into account. The problem of juvenile offenders with behavioural disorders, if treated in time, would allow us to save money at a later stage, as among others proved by the World Health

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Organization. Now weâ&#x20AC;&#x2122;re starting to think about it but this attention comes mostly from social services rather than the health sector where the issue of minors affected by mental disorders is not yet perceived as a problem: it is still considered as a social problem rather than a sanitary one. It should not be so.

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Maurizio Dusi, M.D Psychiatric Psychotherapist ....................................................................................................................................................

1973 Degree in Medicine and Surgery.

1978 Postgraduate in psychiatry and training in psychotherapy (personal analysis and supervision). He worked for thirty years at Villa Santa Giuliana Hospital, working initially with psychotic persons and subsequently within Adolescent Service in quality of coordinator of the service.

Collaboration with the CeRP (Center for Psychotherapy Research).

Among publications realized within Villa Santa Giuliana Hospital, the two most important related to the issue: - “L’urlo senza voce – I tentati suicidi e le condotte parasuicidiarie in adolescenza” (The voiceless scream – The attempted suicides and parasuicial conducts in adolescence).

Conference proceedings, Verone 2009; - “Lo psicodramma degli adolescenti” (Psychodrama in adolescents). Conference proceedings, Verone 2007.

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4.3. Interview with Alfio Maggiolini, M.D. Psychotherapist and professor of psychology of adolescence 1. What is the measure/rate of psychological or psychiatric disorders detected in juvenile offenders? What is the link between mental disorders and antisocial behaviours?

As regards the link, the mental disorder can undoubtedly represent a meaningful risk factor: longitudinal studies78 have shown that psychological factors, firstly the lack of feelings of guilt, can be risk factors for the development of antisocial behaviours. On the other hand, several studies confirmed that youth entering the criminal circuit, especially those subject to detention, have a probability which is three to five times higher than the general population to develop a mental disorder79. In general, while the presence of psychiatric disorders in the normal youth population is estimated to be around 15-20%, this figure may reach up to 80% in minors who are subject to criminal proceedings. A recent study realized at local level on a sample of 66 minors who entered the Juvenile Justice System in 2005 within the Juvenile Justice Services of Milan (detainees, minors residing in juvenile communities or in charge of the Office of Social Service for minors) confirmed this trend80. In fact, the assessment carried out by the operators of the Juvenile Justice Services during the research has detected internalizing problems (such as anxiety, depression, psychosomatic disorders) in 72% of adolescents and the same figure has been detected for externalizing problems (aggressive or oppositional behaviours)81. Moreover, this research - whose goal was to detect the extent of psychopathological problems among juvenile offenders and relating them with the risk of re-offending - shows that the analyzed disorders can be mainly found in juvenile offenders presenting a high risk of recidivism. In particular, the comparison of figures showed that as many as 91.2% of the adolescents with a high risk of recurrence presented significant psychopathological problems.

The results of this research, as well as of many others, show that this type of disorders are quite widespread among minors entering the criminal circuit. Furthermore, the fact that the psychopathological problems mainly in connection to minors who have a high

78 Loeber et al., 1998.

79 Boesky, 2002; Teplin, Abram, McClelland, Dulcan, Mericle, 2002; Wasserman et al., 2002; Vermerein, 2003; Retz et al., 2004; Steiner, Garcia, Matthews, 1997.

80 A. Maggiolini, A. Ciceri, C. Pisa, S. Belli, Disturbi psicopatologici negli adolescenti sottoposti a procedimenti penali. Mental Health problems in young offenders. Research carried out by Minotauro for the Juvenile Justice Centre of Region Lombardia, in collaboration with Juvenile Justice Services of Milan, with funds of Region Lombardia.

81 A recent review (Grisso, 2004) underlines that the most common problems are mood and anxiety disorders, disorders related to the use of psychoactive substances, behavioral disorders and thought disorders.

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index of risk of recidivism leads to the conclusion that the psychological intervention in addition to the socio-educational one can be useful in reducing recurrences and promotes the success of the overall intervention on the young offender.

The interventions in which the socio-educational treatment is integrated with the psychological one are the most effective in reducing recidivism82. In this regard, it is important to stress that the psychological intervention can not be addressed only to those minors with evident psychiatric problems, but it must also be addressed to a significant portion of minors, particularly those at high risk of recidivism83.

In the light of these considerations it is essential to implement effective procedures for the psychological assessment of the minor who is entering the Criminal Justice System in order to guide the Services towards more effective interventions.

2. What is, in your opinion and on the basis of your experience, the most effective approach for the psychological assessment of juvenile offenders?

As in the antisocial field, the psychological assessment is the basis for subsequent intervention on the juvenile offenders, there are different available models, focusing on different aspects, according to the objective to pursue through the following intervention.

I personally consider the developmental approach as the most effective and comprehensive one.

In the developmental approach, the assessment of the minor has as primary objective, rather than a specific diagnostic formulation, the understanding of the subjective meaning that the adolescent assigns to the deviant behaviour in relation to his/her personality characteristics and his/her developmental needs (Maggiolini, 2002). The psycho-diagnostic assessment should not be meant in nosographic and classification terms, but as an additional tool to collect information on the psychic functioning of the adolescent, in particular on those aspects that seem more related to the deviant behaviour (Riva, Saottini, Trionfi, Viganò, 2002).

Together with the identification of the subjective representations of the committed crime, an overall assessment of the minor’s development is carried out, in order to highlight the connections between the antisocial behaviour and the development of the minor. In other words, when the developmental approach is adopted, the psychological assessment of an antisocial adolescent mainly consists of the understanding of his/ her developmental needs. In order to do it, it is necessary to link the developmental

82 Associated Marine Institute, 1999; Fonagy, Target, Cottrell, Phillips, Kurtz, 2002), Gendreau, Andrews, 1990; Gendreau, Goggin, Cullen, 1999; Hollin, 1995; Hollin, 1999; Langan, Levin, 2002; Latessa, 1999; Latessa, Lowenkamp, 2006; Lipsey, 1995; McGuire, 1995; Rutter, Giller, Hagell, 1998; Schumaker, Kurz, 2000; Hengeller, et al. 1998; Lowenkamp, Latessa, 2006).

83 Novelletto, Biondo, Monniello, 2000; Maggiolini, 2002; Maggiolini, 2005.

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difficulties with the personality characteristics or with other possible deficiencies of his/her context of life. What in other theoretical models is considered as a symptom (for example the impulsiveness, the persecution complex, the delusions of grandeur), in this perspective it is to the contrary interpreted as a particular distorted declination of developmental difficulties or, better, as obstacles preventing the fulfilment of the real developmental need that the adolescent hides behind the antisocial behaviour.

What’s more! An assessment and a subsequent intervention based on the comprehension of the developmental needs in relation to the personality characteristics of the antisocial adolescent seems to overcome the controversy between the two main models of intervention in this field (Ward, Stewaer, 2003) – the actuarial model and the clinical model – which used to be considered opposite and irreconcilable while they can be integrated in an innovative approach perfectly balanced between the aspects of nomothetic type and those of idiographic type (Schwalbe, 2008; Shlonsky, Wagner, 2005).

The actuarial approach aims to an objective prediction of the recidivism risk through the observation of the subjects’ behaviour and adjusts the intervention on the antisocial adolescent on the basis of the purpose to avoid the commission of further crimes rather than on the basis of the developmental recovery of the minor. In this perspective, although the increase in the potential of the minor is desirable, this is not the primary objective of the intervention.

On the contrary, the clinical model at the first instance itself aims to increase the capacities of the minor with the goal of strengthening his/her resilience by reintroducing a dynamism in the developmental process that was interrupted by the commission of the offence and, in theory, preventing in this way the commission of new crimes (Ward, Stewart, 2003).

The supporters of actuarial models, whose main purpose is the detection of objective predictive criminogenic factors (“criminogenic needs”), believe that the actuarial assessment is far more accurate than the clinical one as it can detect the developmental dynamic. However, while it allows the detection of single criminogenic needs, the actuarial model fails to provide information on the clinical decisions that should be taken and does not allow to assess how to graft a change and a resumption of the developmental process which was interrupted by the commission of the offence: it merely informs the clinician of the likelihood of future recurrences (Shlonsky, Wagner, 2005).

The problem that arises from the separation of these two models is the lack of a link between the statistical significance and empirical prediction, on the one hand and on the other hand, the development of an individual treatment plan tailored to the specific developmental features of the minor. This means that, when the two models are not integrated, the developmental needs linked to apparently similar groups of criminogenic needs, cannot be detected.

The solution can be found within the developmental approach which considers the criminogenic needs as distortions of the normal manifestations of developmental needs

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(Ward; Stewart, 2003), so they are considered as internal obstacles (related to the personal features of the minor) or as external obstacles (related to the context and the environment of life) that prevent an optimal evolution process, rather causing a block.

Therefore, the psychological assessment should aim at the comprehension of the real developmental needs of the minor, both in relation to his/her personal features and his/her resources, and to the modalities through which the impediments to the realization of these needs depending on the features of the minor manifested through the so-called criminogenic needs.

The developmental approach allows realizing an integrated psycho-educational assessment which is necessary in order to implement interventions integrating educational objectives and psychological treatment, which result in the most effective in reduction of recidivism.

It is important to highlight the fact that the assessment does not have diagnosis as a result, but the formulation of an individual project shared both with the minors and operators.

3. What are the specific objectives of the assessment carried out on minors who enter the criminal circuit and what are the instruments through which the assessment is realized?

First of all, it is useful to make a distinction between the preliminary assessment (screening) and a more thorough evaluation (assessment).

In the first phase of reception a preliminary screening of the adolescent is made with respect to a possible suicidal risk, substance abuse and psychiatric problems, as well as to create the foundations for an alliance to work towards a shared goal and to avoid the risk of an immediate escape.

In the next step a more thorough evaluation (assessment) is carried out and it consists of an integrated psycho-educational observation of the minor, of his/her family and of the context. The psycho-educational assessment is mainly based on clinical interviews of psychological type but it also takes into consideration the informal conversations and the spontaneous daily behaviours of the minor. The personality characteristics (e.g. impulsiveness, coldness, aggressiveness etc.) and the possible psychopathological features (externalising and internalising problems, anxiety, depression etc.), usually detected through clinical interviews, are therefore integrated with observations of educative nature (e.g. ability to adhere to minimal rules of coexistence etc.).

Additional areas of assessment, more closely associated with the criminal field, regard the risk of recurrence and the social dangerousness of the minor, his/her life experiences compared to the offence, the subjective motivations and his/her possible awareness of the negative social value represented by the crime. Also the attitude towards rules, justice and the intervention of services can be assessed.

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During the evaluation (both screening and assessment) psychological tests are used84 as support material to respond to the following needs (Del Crono, Lang, 2008): 1) To understand some aspects of the normal and pathological human behavior beyond the individual awareness; 2) To use faster and cheaper tools compared to the clinical interview (that continues to be the main tool of the consultation and the psychological assessment); 3) To realize more objective assessments partly overcoming the bias of the clinical approach, the lack of homogeneity of models and methodologies of consultation.

Depending on the individual needs, certain tests are administered rather than certain others. Some of these tests are addressed to the operators working in the juvenile criminal system (Teacher Report Form - TRF), others to juvenile offenders’ parents (Children Behavior Check List – CBCL), some others to the adolescent himself/herself (such as the Youth Self Report - YSR85 and the Youth Psychopatic Inventory86). This allows a comparison between the perception of juvenile offenders and that of their parents or educators regarding the minor’s psychological situation. In some studies conducted, the comparison of data resulting from the administration of different type of tests shows that normally, juvenile offenders perceive and declare fewer psychological disorders than those detected by their parents or other adult people playing an educational role around them (teachers, operators of the juvenile justice system etc.). The analysis of this gap of information cannot ignore the influence played by the context which can cause an attitude of minimization of the problems by minors, as well as an attitude of amplification by the operators during the assessment. This gap might also depend on the poor capacity of the minor to understand the problems, due to both the low level of culture and the difficulties of language comprehension of foreigners who enter the juvenile justice services. In any case, this gap among data cannot be ignored or considered as the result of a falsification of someone’s answers (e.g. those given by minors), but must be seriously taken into consideration in order to better understand the problems through a double perspective.

Therefore, there is not a tool that can be considered as the best one or the benchmark, but it is useful to adopt various kinds of tools, depending on individual cases, in order to have multiple complementary viewpoints.

84 Youth Self Report; Teacher Report Form; Youth Psychopatic Inventory; Rorschach Inkblot Method; Raven’s Progressive Matrices etc.

85 Youth Self Report is a questionnaire aimed to assess various characteristics of people aged 11 to 18 years, on the side of the internalized and externalized problems.

86 Youth Psychopatic Inventory is a self-report questionnaire completed by the adolescent and created in order to assess psychopathic aspects, or predictive factors of violent behavior and recurrences of deviant acts.

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4. What are the problems that may arise during the assessment phase and what are your proposals to overcome them?

A problem might be the attitude of juvenile offenders undergoing psychological assessment. The information resulted from the interviews and tests are subsequently used in court and the adolescents are aware of this (Riva, 2002). This might result in anxiety and in a more or less conscious attempt to manipulate the tests. However, when the adolescent is informed in a direct and transparent way about the use of tests and of the role of the psychological assessment, he/she often ends up setting aside considerations of processual convenience.

The explanation of the objectives, procedures and the use of the materials gathered from the test is the first of a series of guidelines for the selection and the use of tests in the assessment of antisocial adolescents (Bonta, 2002).

Other recommendations to be included in the guidelines are: - - -

-

do not exclusively use actuarial tools or clinical tools; to use instruments that are able to detect criminogenic needs; to use tests based on significant and valid theories at empirical level, such as the Millon inventories, the PCL:YV based on the Hareâ&#x20AC;&#x2122;s theory of psychopathy or the YLS/CMI created within the theoretical framework provided by the social learning theory; to realize a multi-method assessment in which the weaknesses of one tool can be balanced by the strengths of another tool.

5. In addition to the detection of possible psychological and/or behavioral disorders, what other aspects should be considered and assessed at the entrance of adolescents in the criminal system to promote the implementation of more effective interventions?

Since the risk of re-offending in minors who enter the criminal circuit is generally high, the risk of recurrence should be properly measured when the juvenile offender enters the criminal justice system. The likelihood of re-offending in juvenile offenders puts into question the effectiveness of the justice system interventions and leads one to wonder whether the entry into the criminal circuit is a risk factor rather than a protection factor for adolescents87. Despite this, several studies have shown that while the criminal justice system interventions such as detention, or others characterized by a punitive approach, generally have a negative effect on recidivism, appropriate

87â&#x20AC;&#x201A; Gendreau, Andrews, 1990; Latessa, 1999.

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intervention programs can reduce the risk of recurrence of around 20% or more88. It is therefore necessary to invest in effective interventions that, according to several studies, are those that are based on an accurate assessment of the re-offending risk (risk principle), and those that are targeted to the needs on which the criminal behavior is based (criminogenic needs, such as psychological problems, family relationships, school and educational problems, drug consumption etc.)89. Among the various intervention models, the multisystem one (Ghengeller et al., 1998) shows particularly low rates of recidivism.

While in a punitive approach the assessment of the recurrence risk is a potentially aggravating element of the sentence, in a perspective of educational justice - like the one that inspired the Italian Code of Juvenile Criminal Procedure, the DPR 448/1988 – it can be at the basis of better targeted and more effective interventions.

Although the operator’s intuition and experience in the assessment of minors who enter the criminal justice system are crucial, support tools are useful and can be a guide for the operators. There are several tools, each one with specific objectives such as: the assessment of the risk of re-offending, which may contribute to the decision on the measures to be taken in the first phase of intervention; the assessment of the risk of violent behavior against themselves or others, in order to guide the supervision of the minor; the more comprehensive assessment of needs or psychopathology of the adolescent who enters the criminal circuit.

A particularly effective tool is the Assessment Form of the re-offending risk90 (Scheda di valutazione del rischio di recidiva), which can be a model to imitate also in other regional contexts: in fact, it has the advantage of being the result of a collaboration with the operators of various juvenile justice services - Reception Centres, Office of Social Services for minors and juvenile criminal detention centres (Maggiolini, Riva, 1998; Maggiolini, 2002). In fact, it is not always easy to obtain cooperation from various Services due to the burden of extra work that a systematic collection of data implies and due to the common belief that a structured assessment would threaten the working alliance with the minor who is in this type of Service, in which the meeting is not originated from a request for help but as a prescription of the penal system, is particularly precarious.

The Assessment Form of the re-offending risk (Scheda di valutazione del rischio di recidiva) includes indicators related to both the criminal path (age of the first report, number of previous reports, previous cautionary measures, response to previous interventions), the life context and development (past traumatic events, previous interventions of

88 Lipsey, 1995; McGuire, 1995; Ridondo Illescas, Sanchez-Meca, Genoves, 2001.

89 Dowden, Andrews, 1999; Dowden, Andrews, 2006.

90 This form has been used during a research funded by Region Lombardia within the Juvenile Justice Services of Milan, in the framework of the collaboration between Minotauro and juvenile justice Centre of Lombardia.

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the Services, cultural integration of the family, school and work engagement, type of friends, the relationship between the parents, family support, educational skills of parents).

Finally, I would like to underline the complexity of the interventions to be implemented on adolescents in the criminal circuit which inevitably implies a complex assessment.

A multidisciplinary team allows observing the adolescent in a comprehensive perspective that considers the assessment not primarily aimed to the diagnosis of a disorder but to understand the subjective meaning assigned by the minor to his/her choices and behaviors and their expressive and communicative value.

As regards the intervention programs, the multimodal ones have been found to be the most effective (projects acting on various contexts and by adopting different strategies) and mostly addressed to support the acquisition of cognitive and behavioral skills.

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Alfio Maggiolini, M.D. Psychotherapist and professor of psychology of adolescence ....................................................................................................................................................

Alfio Maggiolini is a psychotherapist and professor of psychology of adolescence at the Faculty of Psychology at the University of Milan, Italy. At Minotauro, he coordinates the Centre for research and treatment of antisocial behaviours in adolescence. Since many years, he works at the Juvenile Justice Centre of Milan, with young offenders. He wrote many books and articles on adolescence development and problems (Schoolhache, 1994; Counselling at school, 1997; Delinquent adolescents, 2002; Manual of adolescence psychology, with Pietropolli Charmet, 2005; Early adolescence and antisociality, 2005; Affective roles and psychotherapy, 2009).

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4.4. Consultation with Testone Nicolò, MD, Counsellor of Ministry of Justice for the social issues and deviance (Ministry of Justice) I believe that the building of integrated systems of juvenile justice is a crucial element for the work with this type of minors. The key issue is to pay attention on the meaning we give to the terms “integrated system”. In my opinion, such a system is a set of integrated national services among them that can be a point of reference for the taking in charge of children who are already in the criminal circuit in order to activate all the resources to start the rehabilitation process and to help not only them but also their family, where possible.

This involves a process of integration where we can distinguish two levels.

The first is the institutional organizational level in which the institutions have to integrate themselves connecting in a functional way. Therefore, Judicial Authorithy shall be integrated into a system that unites the social service of the Municipality and the Province, the National Health Service and the family counseling, the services of neuropsychiatry for children and of psychiatry for adults, services for addiction and all the private and social structures.

In this sense, the agreements signed at various levels can be an effective tool for defining roles, functions and modes of intervention.

The second is the “operational” one in which individual professions are integrated; here we can distinguish two stages: i. the first is the personal professional integration within a specific structure that regards the operators of a service, eg. psychologist and social worker; ii. the second, more complex, is the professional integration among different professionals belonging to various institutions and structures, eg. the doctor of the services of neuropsychiatry for children with the Judicial Authority.

All the operational levels are aimed at taking in charge of the children once identified and established the rehabilitation process.

It’s evident that it is a psycho-social and health care of a child with mental disorders or with drugs use. It is up to the Judicial Authority, on the basis of agreements, assumes a central role indicating roles, functions and responsibilities of each stakeholder involved in this complex integration process.

This integrated system has to perform on the one hand to take in charge the child but on the other side it has to avoid: I. the overlap of interventions; II. the multiplicity of figures of reference who could create confusion.

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....................................................................................................................................................

Testone Nicolò, MD, Counsellor of Ministry of Justice for the social issues and deviance (Ministry of Justice) ....................................................................................................................................................

Born in Sciacca, 13/03/1959, graduated in Medicine on 25/03/1986 at the University of Palermo. Since 1992 employed as Neuropsychiatry Medical Director, currently he heads the Unit “Operativa Semplice Materno-Infantile” and the Service of Child Neuropsychiatry of the Health District of Sciacca (Agrigento). Responsible for all activities, including relationship with the Juvenile Court of Palermo and the Multidisciplinary Coordination Unit concerning the education of students with disabilities. He reported and was a member of the organizing committees of several national conferences. Also he has a specialization in Sports Medicine. He has acquired the training certificate as Director of Management regards complex structures. He was a member of ASP at Trapani’s Scientific and Technical Committee for management of training courses. He has been identified by the “Union of Italian Provinces” as part of the National group of experts and social workers on drug addiction (Department of drug policy, Presidency of the Council of Ministers).

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Chapter V Young offenders and mental health in the Netherlands: profile, legal framework and interventions .......................................................................................................................................

by Anna Hulsebosch MSc Behavioral scientist Work-Wise. Netherlands

........................................................................................................................................

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Table of Contents

.........................................................................................................................

Acknowledgements Introduction 1. PROFILE OF THE MENTALLY ILL JUVENILE OFFENDER 1.1. Mental health problems among young offenders in the Netherlands 1.2. General background of young offenders with mental health problems 1.3. Family situation of young offenders with mental health problems 1.4. Misuse of substances and behavioral disorders among young offenders 1.5. Comorbidity of mental health disorders among young offenders 1.6. Special needs of young offenders with mental health problems

2. LEGAL FRAMEWORK: PENAL AND CHILD CARE REGULATION 2.1. The child care system in the Netherlands 2.2. The child protection system in the Netherlands 2.3. The juvenile justice system in the Netherlands 2.4. Penal responsibility of young offenders with mental health problems 2.5. Specific legislation concerning young offenders with mental health problems 2.6. Handling of information and professional confidentiality regarding young offenders 2.7. Laws and action protocols for mixed systems of closed and outpatient treatment 2.8. Legal and medical measures in case of non-completion of treatment

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3. PROFESSIONAL ROLE AND SKILLS DEVELOPMENT 3.1. Specialized training of juvenile justice professionals 3.2. Specialized training of health care professionals 3.3. Professional cooperation between juvenile justice and health care professionals 3.4. Ethical principles, practices and problems

4. INTERVENTION APPROACHES: WHAT IS WORKING AND WHAT IS NOT 4.1. Early prevention programs for young people with behavioral problems 4.2. Standardized resources for mental health screening and assessment 4.3. Therapeutic interventions for young offenders 4.4. Specific mental-health units for young offenders with mental health problems 4.5. Medical treatment of young offenders with mental health problems 4.6. Regulation and process of a psychiatric treatment 4.7. Development or aggravation of mental health problems during deprivation of liberty 4.8. Possibilities and outcomes of family therapy

5. RECOMMENDATIONS 5.1. Recommendations regarding the training of professionals 5.2. Recommendations regarding community-based intervention and prevention.

5.3. Recommendations regarding cooperation and interchange between juvenile justice and mental health systems.

References

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Acknowledgments This report is written by drs. Anna Hulsebosch MSc, behavioral scientist at Work-Wise â&#x20AC;&#x201C; a cooperation between Dutch juvenile custodial and closed youth care institutions, which aims to increase youngstersâ&#x20AC;&#x2122; chances of thriving in society. Work-Wise uses an integrated approach of individual attention and chain-oriented cooperation, to ensure that the youngster gets and holds on to a job, follows and completes a training course and finds a permanent and safe place to live . Attention is also paid to building up and maintaining a positive social network. The final aim is to prevent youngsters from reverting to the old, inappropriate behavior and to stop recidivism. Every youngster participating in Work-Wise receives his or her own Individual Routing Counselor who guides him or her through the routing.

The data for this report have been collected by means of a combination of literature research and the questioning of professionals in the field of juvenile justice and (judicial) youth mental health care. The author is grateful to those colleagues and professionals who contributed to this report. The author also wishes to express her gratitude to the collaborators who revised the earlier version of the report, Robert Vermeiren (professor of child and adolescent psychiatry, Leiden University medical centre; professor of forensic youth psychiatry, VU University medical centre Amsterdam) and Paul Vlaardingerbroek (professor of youth and family law, Tilburg University).

Introduction Over the last few decades, the mental health needs of children and young people have become more widely recognized, with moderate to severe problems affecting an estimated 10 to 20 per cent. Young people within the criminal justice system are far more likely to have mental health problems compared with their contemporaries in the general population. In the Netherlands, the increasing acknowledgement of the potential mental health vulnerability of young offenders has led to several changes in the juvenile justice system. Examples are the growing attention for the assessment of young offendersâ&#x20AC;&#x2122; health needs in several stages of the juvenile justice chain, grown access to health services and a moved emphasis in juvenile custodial institutions, from a system of punishment to one that encourages the education and treatment of young offenders. Integrated approaches involving judicial, law enforcement, educational, and mental health professionals are being called forth. All these measures are believed to contribute to a more effective reintegration and rehabilitation of juvenile offenders.

To exchange best practices regarding the mental health resources for young offenders, a

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European partnership has been established. This partnership will construct a ‘European good practice guide’, which will constitute the starting point to cross the social, health and law perspectives and to establish future European guidelines concerning the treatment of young offenders with mental health problems. To prepare for this, this national report has been written. The aim of the report is to give an overview on the topic ‘young offenders and mental health in the Netherlands’.

The report will start with an overview of the prevalence of mental health problems in this population and the specific characteristics of these juveniles. After this, the legal framework and educational background of professionals will be described. Furthermore, ethical dilemmas, and the need for preventive strategies will be discussed. Finally, the means of screening for, diagnosing, and treating these juveniles effectively will are described. The report will be of interest to both mental health and juvenile justice professionals.

1. PROFILE OF THE MENTALLY ILL JUVENILE OFFENDER 1.1. Mental health problems among young offenders in the Netherlands Mental health problems among young offenders Multidisciplinary diagnostic examinations based on the information provided by juvenile delinquents and their parents have lead to the conclusion that psychopathological disorders are six or seven times more common among delinquents who are brought before the Dutch Juvenile Court than among young people of the same age group in the general population. Especially disruptive behavior disorders are quite common among young offenders: 76% of juvenile offenders have an externalizing disorder. The following table gives an overview of the mental disorders and their prevalence among offenders aged 12 to 18 years.

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Table 1. Mental disorders among juvenile offenders in the Netherlands (source: Doreleijers, 1995).

Type of disorder

Mental disorder

DSM-IV Code

Prevalence (♂ + ♀)

Disruptive behavior disorders (externalizing psychopathology)

ADHD Oppositional defiant disorder Conduct disorder

314.01 313.81 312.8

14% 9% 4-33%

Affective disorders (internalizing psychopathology)

Major depressive disorder Anxiety disorder PTSD

296.xx 300.xx 309.81

11-15% 3-25% 14%

Substance-related disorders

Alcohol abuse Alcohol dependence Drug abuse Drug dependence

305.00 303.90 305.xx 304.xx

3% --9% 9%

Another problem that may be a focus of clinical attention among offenders is occasional antisocial behavior (DSM-IV code V71.02), which had a prevalence of 17% in the aforementioned study.

Mental health problems among young offenders in juvenile custodial institutions Young offenders that have received the penal measure ‘institutional placement order’ (Plaatsing in een Inrichting voor Jeugdigen; PIJ measure) reside in juvenile custodial institutions. Several relevant studies that have been carried out between 1997 and 2007 have found high rates of psychopathology among juveniles residing in juvenile custodial institutions (see: Boendermaker & Uit Beijerse, 2008). The data for these studies were collected by means of case record study, questionnaires and (diagnostic) interviews.

An important study (Vreugdenhil, 2003) concluded that 90% of the incarcerated boys were diagnosed with a DSM-IV disorder and 67% with several disorders. It appears that mental disorders are approximately ten times more common among incarcerated youngsters than among their peers in the general population. The following table gives an overview of the mental disorders and their prevalence among juvenile offenders in juvenile custodial institutions.

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Table 2. Mental disorders among offenders in juvenile custodial institutions in the Netherlands.

Type of disorder

Mental disorder

DSM-IV Code

Prevalence ♂ ♀

Disruptive behavior disorders (externalizing psychopathology)

ADHD Oppositional defiant disorder Conduct disorder

314.01 313.81 312.8

7-32% 14-42% 36-89%

21% 39% 56%

Affective disorders (internalizing psychopathology)

Major depressive disorder Anxiety disorder PTSD

296.xx 300.xx 309.81

11-36% 3-20% 15-33%

33% 2060% 2150%

Substance-related disorders

Alcohol abuse Alcohol dependence Drug abuse Drug dependence

305.00 303.90 305.xx 304.xx

35-50% 35-55% 35-50% 10-30%

19% 6% 52% 30%

Imminent personality disorders1

Antisocial personality disorder

301.7

27%

---

1

Before the age of 18, a personality disorder cannot be diagnosed, but in some cases, characteristics are present earlier.

Psychiatric examination thus reveals a high prevalence of both externalizing and internalizing psychopathology. Besides that, there are high levels of risk behavior, like the risky use of alcohol and soft- and hard drugs.

Pervasive developmental disorders / autism spectrum disorders are rarely found in the (general and especially) criminal forensic youth psychiatry. This is probably because these youngsters mostly miss the motor, cognitive and social skills to engage in delinquent behavior. Yet, among juvenile sex offenders (especially the ones that abuse young children), there has been a remarkable high proportion of boys with an autism spectrum disorder (‘t Hart-Kerkhoffs, 2010).

The proportion of mentally retarded and intellectually handicapped91 youngsters

91 A person is intellectually handicapped when two criteria are present: the level of intellectual functioning is clearly below the average (IQ≤70) and there are deficits in or restrictions of adaptational behavior.

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increases while continuing in the juvenile justice chain: from 9% among delinquents who are brought before the Juvenile Court (Doreleijers, 1995) to 60% among juvenile detainees (Vreugdenhil et al., 2004). Again, among juvenile sex offenders, a remarkably high proportion of boys with intellectual handicaps has been observed.

Other problems that may be a focus of clinical attention among offenders in juvenile custodial institutions are: - -

-

-

- -

-

-

Trauma. Almost all girls (95%) report one or several traumatic experiences in their past (Hamerlynck, 2008).

Sexual risk behavior among women. A relatively high percentage of detained girls reports no use of condoms and contraception at the last sexual contact, previous pregnancies and a high number of sexual partners.

Suicidality. Research shows that 47% of female juvenile detainees have experienced suicidal thoughts, intentions or attemps in the last year (Hamerlynck et al., 2006).

Self-mutilation. Research shows that 34% of female juvenile detainees have experienced moderate to severe self-mutilation in the last six months (Hamerlynck et al., 2006).

Dissociation. 6% of female juvenile detainees have experienced severe dissociative symptoms (Hamerlynck et al., 2006).

Psychoses. Some detained boys report the presence of at least one psychotic symptom (hallucinations, delusions) â&#x20AC;&#x201C; the exact proportion needs to be investigated.

Noncompliance with treatment. Youngsters with disruptive behavior often lack motivation for treatment and the tackling of their problems. But motivation for treatment can still be achieved by creating a sense of security in the contact with specialists and other juvenile detainees (Van Binsbergen, 2003; Otten, 2005).

Running away from the juvenile custodial institution or after parole (as a symptom of conduct disorder).

Even though there are some indications that actuarial approaches (diagnostic instruments like questionnaires) result in a higher prevalence of clinically relevant psychiatric disorders than clinical diagnostic strategies (interviews, observations), it can still be concluded that there is a high prevalence of mental illnesses among young offenders in juvenile custodial institutions. Only a small percentage of offenders in juvenile custodial institutions are not diagnosed with a DSM-IV disorder.

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1.2. General background of young offenders with mental health problems Even though it has been acknowledged that up-to-date information about background characteristics of the offender population in juvenile custodial institutions is crucial for research purposes, there is still no national database with this type of information.

This database is being expected by the end of 2012. Research that has so far been conducted in this area focuses on the background of young offenders in general. Young offenders often show the following characteristics:

Individual characteristics -

Approximately 75% shows serious problem behavior, which can start - especially among boys - at an early age (nursery / primary school). In those cases, the problem causes major restrictions in the social functioning.

-

Low educational level. The exhibited problem behavior is frequently associated with impaired school attendance (truancy, school expulsion, school changes and drop outs). A considerable part of the youth has also received special education but has ceased to attend/continue it or has been removed from it.

Low self esteem, especially among girls.

Low IQ (especially verbal IQ).

Lack of moral development.

External locus of control.

Low frustration tolerance.

- - - - -

Physical characteristics - -

Poor physical health related to risk behavior (smoking, use of alcohol and drugs), unhealthy food and lack of exercise.

In girls, self esteem is highly related to physical appearance.

Social characteristics - - -

Traumatic experiences in the past.

A big majority of youngsters has a history of health care (ambulatory, foster home, home).

Social problems at school (bad relationship with teacher and peers, bullying or being bullied).

Cultural characteristics -

Overrepresentation of youth from migrant groups (communities with a different ethnic-cultural background). But: there are indicators that show lower levels of mental health problems in minority groups.

-

Problems with integration / acculturation.

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Socio-economic characteristics - -

Overrepresentation of youth with a low socio-economic status.

Growing up in a relatively poor and unsafe residential area.

Although there are indications that similar factors are present among young offenders with mental health problems, this has not yet been determined (scientifically).

Therefore, more attention for the background characteristics of young offenders with mental health problems is recommended, especially because of the impact they can have on the behavior inside the juvenile custodial institution.

1.3. Family situation of young offenders with mental health problems Specific information on the family situation of young offenders with mental health problems is not available. But again, several studies provide us with information on the family situation in which the general population of delinquent boys and girls grow up: -

- -

Problems of the parents: serious financial problems, welfare dependency, risky substance use / addiction, illness or disability, criminality, mental health problems, lack of parental competencies (supervision and control, monitoring, random and harsh punishment).

Instable relations of (step) parents, domestic quarrels (25-51%), violence between parents, broken families.

Very difficult divorces accompanied by persistent family conflict and often violence.

-

Changes of caretakers: at a young age, children have had several places of residence (alone with mother, staying with family, in (foster) homes).

-

Families with a small social network, little social support.

-

Problems with integration / acculturation.

-

Child abuse (25-36%): physical and mental abuse, physical and mental neglect, sexual abuse (boys and girls).

-

Insecure attachment relationship. Only 7% of the boys and girls in juvenile custodial institutions appears to have a secure attachment with their main caretaker(s) (Zegers, 2007). The other 93% are insecurely attached, divided into three attachment patterns: avoidant (43%), disorganized (31%) and ambivalent (19%). The insecure attachment points to a lack of confidence in adults. This profoundly influences their social relations, including the relationship with mentors in the juvenile custodial institution: the more insecure the attachment, the less they will call on mentors for support and advice. And also: the less contact and the more hostile the behavior.

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-

Symbiotic relationship between parent and child.

-

The family lives in a neighborhood that is unsafe / dangerous and has low socioeconomic status.

In general, a picture arises of impotent parents, who experience several problems with the raising of their children. In many cases, this results in a disturbed parent-child relationship. At the same time, however, it must be emphasized that a small number of families experience no particular problems: several protective factors - such as the youngster has always lived in the same place / family, there is adequate social support in the living area, parents are involved / do their best - are present in those cases.

The prevalence of these family factors among young offenders with mental health problems needs to be examined.

1.4. Misuse of substances and behavioral disorders among young offenders Correlation between substance misuse and behavioural disorders Several studies identify a positive correlation between the level of aggression and externalizing psychopathology (ADHD, ODD and CD), internalizing psychopathology (depression, PTSS), the number of traumas and the prevalence of risk behaviour â&#x20AC;&#x201C; including substance abuse and dependence. Substance use is highest among juveniles with many behavioral problems. Despite the clear statistical link between various forms of abuse of and addiction to substances and externalizing and internalizing problems, the nature of the relationship is often unclear. It is known that alcohol and drugs can be used as â&#x20AC;&#x153;self medicationâ&#x20AC;? for ADHD, depression or psychosis or to gather courage to commit crimes.

Regarding ADHD, it is assumed that people with deficits in sustained attention insufficiently process information regarding the self-assessment of risk and the consequences of their behavior. As a result, they have an increased risk for substance abuse (Matthys et al., 2006). Furthermore, children with ADHD have a strong need for immediate reward. Children with behavioral problems might have an over sensitivity for reward as well as a reduced sensitivity for punishment (Matthys et al., 2006).

At over one third of the PIJ-youth, substance use at the time of the crime appeared to be the case (Van Rossum & Van der Steege, 2009).

A substantial proportion of young offenders in juvenile custodial institutions experience problems with the use of drugs, especially soft drugs (Vreugdenhil et al, 2004). Juvenile custodial institutions find it extremely difficult to prevent illegal drugs from entering the institution. Although the health risks of cannabis (the most widely used soft drugs) are limited, the use can result in a lack of interest and turning away from social

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activities in the juvenile custodial institution. Taking high doses may, in exceptional cases and especially in cases of oral intake, induce anxiety and panic reactions and hallucinations.

The abuse of alcohol is also prevalent in a population of juvenile detainees (Vreugdenhil et al, 2004). Even though the problems with alcohol attract less attention, this does not make them less serious. Alcohol too can be a dangerous substance and can conceal underlying problems. (Excessive) Alcohol use that appears innocent can result in (the aggravation of) depressions and anxiety disorders. Furthermore, these problems can be masked by the alcohol use, which makes them more difficult to recognize.

In general, there is a strong association between substance use disorders and externalizing disorders among incarcerated boys. Vreugdenhil et al. (2003) found that substance use disorders were not significantly associated with internalizing disorders.

However, cannabis abuse and alcohol, cannabis, other substance and poly-substance dependence were significantly positively associated with externalizing disorders.

Substance dependence, especially alcohol dependence, was also positively related to psychotic symptomatology.

The severity of substance use disorders (no SUD vs. abuse vs. dependence) was significantly positively associated with the number of comorbid internalizing (anxiety, affective disorders) and externalizing (disruptive behavior) disorders.

Moreover, externalizing disorders were much more common in participants with poly-substance dependence than in participants with single substance dependence.

Therefore, it seems that at least three levels of SUD severity can be discerned: abuse, single substance dependence, and poly substance dependence.

Age and prevalence patterns As far as is known, only one study has been conducted among juvenile offenders who are not (yet) deprived of their liberty. The results of this study show that 15% of the delinquents who are brought before the Juvenile Court report alcohol use (Doreleijers, 1995).

It has been shown repeatedly that substance use among incarcerated juveniles is much higher than among juveniles in the general population and/or normal education.

Research among 135 boys in juvenile custodial institutions revealed that among these boys, the use of alcohol and drugs previous to their stay in the institution is even higher than among boys in special education and truant care projects (Korf, Benschop & Rots, 2005). The differences in substance use between incarcerated boys and boys receiving regular and special education are especially large in the age category 13 to 14 years (Kepper et al., 2009). The following table gives an overview of the lifetime

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prevalence of substance use among incarcerated boys, compared to that of boys in general population92.

Table 3. Substance use among incarcerated boys in the Netherlands.

Substance

Lifetime prevalence among incarcerated boys1

Lifetime prevalence among school attending adolescents2

Alcohol

91.5%

79.0%

Cannabis

86.3%

17.0%

Other drugs, a.o.:

33.3% (total)

9.1% (total)

- ecstasy - amphetamine - cocaine - heroin - mushrooms

21% (total with amphetamine) 21% (total with ecstasy) 21% 5% ---

2.4% 1.9% 1.7% 0.8% 2.3%

Poly (two or more substances)

82.8%

---

1

Source: Vreugdenhil et al. (2003).

2

Source: Monshouwer et al. (2008).

These results show that especially the use of (soft and hard) drugs is relatively high among incarcerated boys.

Some specific results regarding the use of alcohol: - Kepper et al. (2009) researched substance use among 13 to 18 year old boys in juvenile custodial institutions. The results showed that boys in juvenile custodial institutions drank more alcohol in the month prior to their incarceration than boys in the regular and special education system. Fortunately, the results also showed a decrease in the use of alcohol since the incarceration. Approximately

92â&#x20AC;&#x201A; In European perspective, Dutch pupils score high on lifetime prevalence of alcohol use; also, the frequency and number of alcoholic consumptions is high. Dutch pupils score average on the use of nicotine, cannabis, amphetamine, LSD and ecstasy (Hibell et al., 2004).

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- -

one third of the boys reported alcohol use since detention; almost all of them drank alcohol within the juvenile custodial institution.

The prevalence of regular alcohol use among incarcerated boys is 33% (Brand & Van den Hurk, 2008).

Brand and Van den Hurk (2008) have mapped changes in the PIJ-population93 during the period 1995-2005. They conclude that alcohol problems show a small increase in scale and severity.

Some specific results regarding the use of drugs: - Several studies conclude that the use of cannabis among incarcerated boys is problematic. For example, compared to male adolescents in regular education, incarcerated boys were seven times more likely to have used cannabis prior to their placement in a juvenile custodial institution. Incarcerated boys who used cannabis, also smoked more joints per occasion (Kepper et al., 2009). The majority of boys (65%) reported the use of cannabis during the last month (53%; Konijn, 1999) / since incarceration (65%; Kepper et al., 2009) and almost all of them used cannabis within the juvenile custodial institution. So, even after the incarceration, the use of cannabis remains high.

- Also the use of hard drugs (XTC, cocaine, amphetamine, hallucinogens, GHB, LSD, crack or heroin) among incarcerated boys is problematic: more than 20% of the incarcerated boys used one or more hard drugs at least once prior to their incarceration, whereas this percentage was only 4% among boys that attended the regular education (Kepper et al., 2009). The use of hard-drugs seems to have decreased since the detention or pre-trial arrest: over 20% reported hard drug use before their stay in the juvenile custodial institution, compared to 6% hard drugs use since detention.

- In the study by Kepper et al. (2009), almost all of the interviewed boys (90%) reported that it is easy for them to obtain the cannabis in the juvenile custodial institution. According to 75% of the interviewed boys, even hard drugs are easy to get hold of. This shows that in the perception of the detained boys, the availability of drugs inside the institution is high.

- Incarcerated girls use much more drugs than school drop-out girls (Korf, Benschop & Rots, 2005).

- The prevalence of regular drug use in juvenile custodial institutions is high, namely 64% (Brand & Van den Hurk, 2008).

- Brand and Van den Hurk (2008) have mapped changes in the PIJ-population94

93 The penal measure ‘institutional placement order’ (Plaatsing in een Inrichting voor Jeugdigen; PIJmeasure).

94 The penal measure ‘institutional placement order’ (Plaatsing in een Inrichting voor Jeugdigen; PIJmeasure).

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-

during the period 1995-2005. They conclude that drug problems show a small decrease.

Recent drug use trends among juveniles in contact with the law are increased use of GHB and chemical drugs.

To conclude, there is also a group of incarcerated boys (6% in the study of Brand & Van den Hurk, 2008) that often uses both alcohol and drugs; a combination that is known as dangerous regarding the role it may play in the performance of unpredictable violent behavior.

The DSM-IV distinguishes two types of substance-related disorders: abuse and dependence. In case of abuse, there is a pattern of unadjusted use that causes significant restrictions and suffering. This is evident from failure to fulfill major role obligations at work, home or school, recurrent use in physically hazardous situations or use resulting in contact with the police. Characteristic for dependence of a substance is the continuous use thereof, without taking into account the physical, psychological and social damage.

Besides this, the craving for the substance is so strong that uptake can no longer be controlled. A more serious form of dependence is addiction.

In general, it can be said that among adolescents, abuse is more common than dependence, which occurs relatively often among young adults between 20 to 24 years (Bijl, Van Zessen & Ravelli, 1997). Only a few studies have investigated the prevalence of substance use disorders among arrested and incarcerated boys and girls in the Netherlands. The following table gives an overview of the prevalence of substance-related disorders among offenders aged 12 to 18 years. Poly abuse or dependence refers to the problematic use of at least two substances.

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Table 4. Substance-related disorders among juvenile offenders in the Netherlands.

Substance-related disorder

DSM-IV Code

Prevalence among juvenile offenders1 (♂ + ♀)

Prevalence among incarcerated juvenile offenders ♂ ♀2

Alcohol abuse Alcohol dependence Drug abuse Drug dependence Poly abuse3 Poly dependence4

305.00 303.90 305.xx 304.xx

3% --9% 9% -----

6-50% 22-55% 14-50% 10-30% 8% 14%

1

Source: Doreleijers (1995)

2

Source: Vreugdenhil (2003).

3

Source: Vreugdenhil et al. (2003)

4

Source: Vreugdenhil et al. (2003)

19% 6% 52% 30% -----

The results show that, of the 15% of the delinquents who are brought before the Juvenile Court that report alcohol use, only 3% of those young people were classified with ‘alcohol abuse’ (Doreleijers, 1995). Doreleijers concludes that young people of this age can apparently cope with large amounts of alcohol without it resulting in dysfunction. Levels of drug-related disorders are higher among juvenile offenders.

Prevalence rates of alcohol and drug related disorders among young offenders in juvenile custodial institutions are much higher than among the general population and juvenile offenders in general. Most prevalent among the incarcerated boys was cannabis use disorder (44%), followed by alcohol use disorder (28%) and other substance use disorder (10%) (Vreugdenhil et al., 2003).

Brand and Van den Hurk (2008) researched if among youth with the penal measure ‘institutional placement order’ (PIJ), problems had arisen because of their substance use. These could be: problems with work / school (concentration), with relationships and parents, with the police or justice system, physical problems or emotional / psychic problems. They define alcohol abuse as: more than five glasses of alcohol per day. Their results indicate that among almost two thirds of PIJ-youth (66%), alcohol has no problematic role in their lives. Among 26% of PIJ-youth, alcohol abuse occurs twice per week; 8% experiences abuse in a structurally higher frequency than twice per week. The results also indicate that problems with alcohol are often present before the age of 16. The figures also show that 34% of PIJ-youth experience drug abuse (the use of

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hard drugs or the use of soft drugs that results in concentration or sleeping problems).

Almost all of these youngsters are younger than 18 when being investigated.

1.5. Comorbidity of mental health disorders among young offenders Several researchers conclude that co-occurrence of mental health disorders in juvenile delinquents is the rule rather than the exception (a.o. Boendermaker & Uit Beijerse, 2008; Lodewijks, 2008).

Disruptive behavior problems and internalizing problems often occur together, which even increases the seriousness of the problems. Research among minor boys in juvenile custodial institutions has revealed that 67% of them suffered from several DSM-IV disorders (Vreugdenhil, 2003). Comorbidity appeared to be more common among youngsters with ADHD than among minors without ADHD (Moser & Doreleijers, 1996).

For that matter, emotional disorders, which are regularly seen among offenders, appear to constitute a protective factor against recidivism (Vermeiren e.a., 2002). To conclude, the presence of one substance use disorder significantly increases the probability of the presence of some other SUD (Vreugdenhil et al., 2003).

1.6. Special needs of young offenders with mental health problems A â&#x20AC;&#x2DC;needâ&#x20AC;&#x2122; is a significant problem that can benefit from an intervention. There are roughly five main domains of needs among young offenders: 1. Mental health (depression, deliberate self-harm, post-traumatic stress, anxiety, psychosis and hyperactivity); 2. Education / work (school attendance, education performance and weekday occupation for young people over 16 years of age); 3. Social relationships (relationships with peers and family members); 4. Risky behavior (substance use, inappropriate sexual behavior), and; 5. Violent behavior (violence to people and property).

Young offenders usually have high levels of need in several of these domains. The special needs of young offenders with mental issues are mainly related to the first domain: mental health. Their vulnerability on this domain can even be increased during placement in a closed environment. First of all, levels of depression may be higher because of judicial handling and the stressful process of the deprivation of liberty itself. The risk of selfmutilation and suicide attempts is increasing. Secondly, stress of all kinds â&#x20AC;&#x201C; including the stressful criminal procedure - can reinforce already present ADHD symptoms or yield similar images (attention deficit, impulsivity and hyperactivity).

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A clearly described schedule for the custody that is formulated right at the start is an option for helping juveniles with their (emotional) adaptation to the incarceration.

This may be achieved, for instance, by formulating a preliminary residential plan for all juveniles entering a custodial centre. A preliminary residential plan upon arrival can provide the juvenile with more certainty about his stay. It may be based on an initial screening of the juvenile, and may provide the basic definition for a training, education and leisure program. Such a screening should not be limited only to the (criminogenic) risk factors, but focus more broadly on the needs of a juvenile and the ways in which a juvenile offender copes with stressful situations (coping styles). Two instruments that are often used for this screening are the Massachusetts Youth Screening Instrument95 (MAYSI: a brief screening tool designed to identify youths who may have special mental health needs) and the Strengths and Difficulties Questionniare96 (SDQ: a brief behavioural screening questionnaire for 3-16 year olds). An early understanding of the coping styles of juveniles may provide staff in correctional institutions for juvenile offenders with starting points on how to deal with specific young individuals in order to reduce or prevent (imminent) emotional stress and related problem behavior.

95â&#x20AC;&#x201A; See: www.maysiware.com 96â&#x20AC;&#x201A; See: www.sdqinfo.com

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2. LEGAL FRAMEWORK: PENAL AND CHILD CARE REGULATION 2.1. The child care system in the Netherlands The Netherlands has an extensive system of child- and youth care. Figure 1 gives an overview of the main facilities and services.

Figure 1. Youth care in the Netherlands.

The Youth Care Act (Wet op de Jeugdzorg), introduced in 2005, is the legal framework of youth care services for youth at risk and their families. Its aim is twofold: to ensure that better care is made available to young people and their parents (the clients in the youth care process) and to strengthen their position. The client is at the centre of a more transparent, simpler youth care system. This principle is reflected in five policy objectives: - A single, recognizable access point to the youth care system (a Youth Care Agency in each province).

- Integration of other services such as child abuse and neglect reporting and consultancy, (family) guardianship and probation in the Youth Care Agency.

- The needs of the client come first. The assistance that is being offered must fit in with the questions and problems of youngster and parents. To put it concretely: clients must be consulted and have to be in agreement with the plans.

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Entitlement to youth care. Once the Youth Care Agency has set an indication for assistance, the client can claim this right. The indication decision comprises a claim on the following categories or a combination of them: youth care (ambulatory aid, therapeutic interventions – aimed at parents and/or youngsters), stay (in a foster home or residential institution) and observational diagnostic (aimed at gathering the necessary information to set an indication). With the indication decision, the client can approach a care provider. It is the responsibility of the care provider to offer well-balanced care, laid down in an assistance plan which has to be assessed by the Youth Care Agency.

Introduction of family coaching. The care provider is obliged to inform the parents and involve them in the care. It may also be necessary to offer parents more intensive counseling.

Since April 2011, the Dutch Children’s Ombudsperson (Marc Dullaert) has started his function. The Children’s Ombudsperson is a national functioning institute that independently monitors the compliance with the rights of children and juveniles. The Children’s Ombudsperson also handles complaints from children about youth care and education for example.

2.2. The child protection system in the Netherlands The Netherlands also have an extensive system of child protection, mainly laid down in the Civil Code. This system is carried out by the Child Protection Board (Raad voor de Kinderbescherming). The responsibility for the Board lies with the Ministry of Justice.

The Child Protection Board represents the rights of the child whose development and upbringing are under threat. The Board creates conditions to remove or prevent this threat. The Board makes inquiries, provides advice in legal proceedings and can suggest measures or sanctions. The Board works in close cooperation with other agencies. The scope of activities of the Child Protection Board is broad. The Board: • is involved with families where upbringing has become a problem; • is called in when divorcing parents are incapable of making arrangements concerning their children, such as arrangements regulating visitation rights or fixed abode; • is involved with cases concerning adoption and descent; • plays a role in criminal cases involving under-age children.

In protection cases, the Child Protection Board regularly gets into contact with parents or children with whom a psychiatric disorder is suspected. In such cases, the Board will aim for treatment in a voluntary framework. When this is not possible, the Board will try to admit the youngster in a children- and youth psychiatric hospital. In some of these cases, the parental authority will need to be restricted. Consequently, the Board

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will advise the juvenile courts, which can impose a supervision order on the parents97.

A supervision order restricts the parents’ authority, part of which is then assumed by an official family guardian (an employee of the Youth Care Agency). In this context, the family guardian can support the parents to send the young person to psychiatric care and ensure that this is continued (Zuur, 2004). The tasks and authorities of the Youth Care Agency regarding the execution of a child protection measure are mainly laid down in the Civil Code. The Youth Care Act does prescribe that even in the case of restricted or removed parental authority, assistance needs to center as much as possible around the questions and problems of the minor and his/her parents.

2.3. The juvenile justice system in the Netherlands The Netherlands is a small but densely populated Western European country. The total number of inhabitants is 16.6 million. Roughly 3.6 million of them are under the age of 18. Juvenile penal law applies to 12- to 17-year-olds98 (1.2 million) and is marked by its pedagogical character. The criminal act committed is important, but the following factors are decisive for the way the case is dealt with: the offender’s personal characteristics and background, the degree to which the youth can be considered guilty on the grounds of their physical and moral development and their age, and any psychosocial problems that may be signaled by the offence committed.

These factors could result in the underlying problems being tackled by means of a civil law intervention (child protection measure), rather than a criminal justice response.

If the criminal justice route is chosen, special prevention (avoid recurrence) is the guiding principle. The primary objective of any punishment is behavior modification: restoration, the award of damages and general prevention play less prominent roles.

This goes together with a measure of reserve and moderation: only respond and take action if that is really necessary, do not make the response more severe than needed with a view to behavioral change, and certainly don’t punish for punishment’s sake.

This approach is also known as a policy of minimal intervention: not every criminal act is prosecuted through the criminal justice system, not every case is brought before a judge, and a guilty person does not always receive the heaviest penalty possible99.

The police in the Netherlands can respond in roughly four ways:

97 Another possible child protection order is the total removal of parental authority, in which cases a guardian is appointed.

98 Children under the age of 12 cannot be held criminally responsible. In exceptional cases 16- and 17-year-olds can be tried according to adult law. Similarly juvenile law can be applied to young people aged 18–20 years who function mentally at a much younger age.

99 Even though the judicial climate in the Netherlands has become more punitive in the last 25 years (more juveniles have faced a formal sanction), restraint is still the order of the day in applying sanctions.

The principal response is in the area of alternative sanctions and supervision. If juveniles lose their freedom, this is (certainly form an international perspective) for a short time and there are clear indications that the duration is becoming shorter rather than longer (Van der Laan, 2006).

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Refrain from any further criminal justice action an instead refer a case to support services.

Issue a warning or reprimand, but take no further action. This only happens rarely.

Cases of vandalism or small property crimes, such as shoplifting, may be referred to the Dutch agency responsible for diversion projects, ‘Halt’. Halt is an institution where juveniles carry out up to 20 hours of restorative or other types of activities, or possibly damage compensation. Halt clients are very often first-time offenders.

Issue a summons and send this to the public prosecution service for further handling.

At the level of the public prosecution service, the policy of minimal intervention is expressed in a restraint from proceeding to a prosecution. Many cases handled by the public prosecution service are (conditionally) dismissed or, for example in the framework of an out-of court settlement, dealt with by imposing an alternative sanction. The prosecutor only issues an indictment in a minority of cases (35%).

In cases handled by the courts, the following punishments and measures can be imposed100: - Alternative sanction. This is the punishment most frequently applied to minors.

Around 70% requires some form of unpaid community service (up to 240 hours) and 30% involves an educational program101, sometimes in combination with community service. Alternative sanctions are generally imposed together with a conditional punishment.

- Fine. Only a very small percentage of all sanctions (5%) involve a fine - with a minimum of 3 euros and a maximum of 3.700 euros.

- Youth detention. Youth detention can only be imposed in case of a (serious) criminal offence (not in case of a – small - violation). The maximum length is 12 months (offenders 12-16 years) or 24 months (offenders 16-17 years while committing the crime).

- Behavior modification measure. Designed for youngsters with multiple background and behavioral problems; as a consequence, the expected results of a purely repressive response are small. The measure offers the possibility to

100 Additional punishments (confiscation and disqualification of the competence to drive motor vehicles) and other measures (withdrawal, take away illegally obtained advantage, compensation measure) are excluded from this overview.

101 The following educational programs are available: ‘Tools4U’ (cognitive social skills training), ‘WSART’ (aggression regulation training), ‘SIB(+)’ (victim empathy), ‘Sexuality’ and ‘Recidivism prevention project’ (sexual formation and education), ‘Substances and crime’ (education on risks of substance use) and ‘SOVA individual LVG’ (social skills for mentally retarded).

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intensively intervene in the lives of young offenders, even after a not very serious offence. The judge determines the content of the measure, which he can impose for a duration of 6 to 12 months. The youngster can participate in a program in some institution or follow an ambulatory program under supervision of an organization.

The custodial measure ‘institutional placement order’ (Plaatsing in een Inrichting voor Jeugdigen: PIJ measure) in order to re-educate the juveniles (for at most 4 years) or to treat them (for at most 6 years). The PIJ measure will be administered by the court if for a crime a precautionary detention is warranted, if the general safety of individuals or materials requires such a measure, and if the measure is in the best interest of the future development of the youth involved. Upon considering the administration of the PIJ measure, it is important to take into account whether or not the measure will be necessary for a proper treatment or beneficial to the upbringing of the youth, and whether there is a high risk of recidivism of criminal behaviour. The court is required to obtain advice from at least two forensic experts (psychiatrist and psychologist) who have made a pretrial forensic mental health evaluation (‘pro Justitia’ evaluation) of the youth.

The resulting report needs to lend support to the decision of the court and will be a starting or reference point for treatment. The measure will be imposed for the duration of 2 years, but prolongation is possible up to a maximum of 4 or 6 years.

The aforementioned punishments and measures can also be imposed conditionally.

In those cases, one of the general conditions is not getting in trouble with the law. A special condition can be the treatment by a social worker or psychiatrist.

The Netherlands makes extensive use of detention on remand, often in order to suspend it and speed up the start of focused treatment or support. An alternative to detention on remand is night detention, in which cases juveniles stay in the institution overnight and during the weekend but attend school or work during the day.

Young people are increasingly being supervised by the juvenile rehabilitation service.

This service supports and guides youths from when they are taken into custody up until their case is being heard, within the framework of a conditional sentence, while supervising an alternative sanction, and during and after detention.

If the criminal behavior of young people is largely related to family background, a civil measure can be imposed (civil supervision order). The juvenile court may do so at the request of a Youth Care Agency, the Child Protection Board or the Public Prosecutor.

Unfortunately, the latter is rare, perhaps due to insufficient awareness of awareness of the civil law by the prosecutor (Weijers, Hepping & Kampijon, 2010). Some professionals

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recommend to review the re-introduction of the criminal supervision order. According to them, this offers - in view of the family problems often present - the most viable framework for appropriate measures to be taken.

In the context of criminal cases, the earlier mentioned Child Protection Board performs the following tasks: 1 – Basic inquiry. a- Following a notification by the police or the attendance officer, the Board will start up a brief investigation, the so-called basic inquiry - sometimes through the screening instrument, the BARO (see part D of this report). The BARO should be applied to all first police notifications (first offenders), also in case of 10 to 12 year olds. But the use of the instrument takes a lot of time and it is not suitable for certain clients. For this reason, after every notification (based on certain criteria), consideration takes place on whether or not to use the BARO. b- Early help is a special form of the basic inquiry that is being carried out after a reported custody. The Board visits the minor in the police cell and acts as a source of information for all questions of the youngster, as well as responding to practical questions (informing parents / school / employer, organize clean clothes, etc). Finally, the counselor is the nominated person to assess whether further assistance to the juvenile in custody should be realized. If necessary, the counselor can refer to an aid authority.

2 – Follow-up inquiry.

The Board will start a more extensive investigation, following the basic inquiry, when concerns have arisen. The research is conducted with a view to advise the criminal prosecutor or judge. The investigating judge will ask the Forensic Psychiatric Service to mediate the behavioral experts, who will perform the inquiry. The report being drawn up, is called Pro Justitia report. The Board sometimes researches into the home environment of the accused minor (environmental inquiry).

3 – Protection inquiry.

In cases where there is concern (defined as: a (suspected) violation of the fundamental right of a minor to a healthy and balanced development and outgrowth to autonomy and a measure of child protection must be considered, the basic and follow-up inquiry may be followed by a protection inquiry.

4 – Coordination of community service.

The Board prepares and coordinates the enforcement of community service orders for minors.

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5 – Individual case control.

The Board monitors the procedure around the minor from the moment of notification by the police until – if applicable – the guidance after detention, in order to make sure that all activities by, for instance, the Board, the Police and the Prosecutor are properly coordinated.

June 2011, the Dutch Minister of State of the Ministry of Security and Justice has presented a proposal regarding the introduction of a special ‘adolescent criminal law’.

This criminal law offers, more than in a system of fixed age boundaries, the possibility to take into account the development of the juvenile, the seriousness of the offence and the circumstances under which it was committed. The adolescent criminal law will enable the conviction of juveniles between 15 and 23 years that have committed serious crimes, according to the adult penal law. The proposal also contains an accentuation of the current juvenile criminal law. For example, juveniles who do not comply with their alternative sanction will be dealt with more severely and it will be possible to convert a PIJ-measure into adult detention during Her Majesty’s pleasure. To conclude, the proposal also contains ways to further improve the guidance to youth care.

The adolescent criminal law will be further elaborated upon during the coming period.

After the summer, a concept law proposal will be presented.

2.4. Penal responsibility of young offenders with mental health problems The (juvenile) criminal law considers a suspect not punishable if he/she was not accountable while committing the offence. A person is not accountable if he/she was suffering from a psychiatric disorder or deficient development of mind at the time of committing the offence.

The determination of a psychiatric disorder or deficient development of mind will usually occur by means of a personality assessment in the context of a judicial preinvestigation (Doek & Vlaardingerbroek, 2009). The research is conducted by one or two behavioral experts (psychologists and psychiatrists), including in specified cases at least one psychiatrist.

If the accused is in pre-trial detention, two articles in the Code of Criminal Procedure make a study of the mental abilities of the suspect in an institution possible. In that case, the investigating judge shall order that the accused is transferred to a facility for clinical observation or to a psychiatric hospital. The personality assessment may also occur in the establishment where the accused resides because of the pre-trial

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detention. In addition, the (investigating) judge has the possibility to appoint an expert to issue a psychological or psychiatric report on the juvenile. This option is particularly suitable if the juvenile cannot or does not need to be taken in custody. It is a personality assessment in an ambulatory setting.

The determination of a deficient development or a pathological disorder of mental abilities - thus psychiatric reporting - is necessary to impose a PIJ measure with a maximum duration of six years. This also applies to the imposition of a forced placement in a psychiatric hospital or the imposition of a measure of placement in a forensic psychiatric clinic for adults (TBS-measure) through the adult criminal justice.

The educational goal also applies here because the court explicitly askes how the developmental perspective can be improved, possibly through assistance, to prevent recidivism.

In short, within the youth justice system, accountability is not directly relevant: accountable juveniles may also be imposed a PIJ measure. There is only an indirect importance: an assessment of whether the juvenile could have done otherwise than he did is of great pedagogical importance. For several reasons (development of the minor, complexity of the problem, lack of research resources on this aspect) it may be questioned whether the concept of accountability is suitable for minors. Because re-educating is the primary target for young people, it may be more useful to think from a ‘re-educate / treat, unless’-idea with young people up to 15 years; the ability to evaluate the accountability can be limited to specific circumstances, such as for youth from 16 years onwards that will be judged according to adult criminal law.

2.5. Specific legislation concerning young offenders with mental health problems In the first place, the penal rules apply to the juvenile delinquent with a psychiatric disorder: the special rules for juveniles in the criminal law and criminal proceedings law. The main section of the Penal Code is the article about the PIJ measure (art. 77s), in which i.e. the conditions for imposition (the need for re-education and in case of defective development or pathological disorder) and the option for placement elsewhere in a (youth) psychiatric hospital, boarding school for mentally retarded or a forensic psychiatric clinic for adults) are regulated.

The Youth Care Act and (to a lesser extent) the Law on the Medical Treatment Agreement (Wet op de Geneeskundige Behandelingsovereenkomst, WGBO) also play a role. The relevant parts of the Youth Care Act are related to the closed youth care in juvenile custodial institutions. The WGBO is primarily intended for all ‘voluntary’ admitted patients.

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Because of a legal provision in the civil code, medical examination and observation of juvenile delinquents also falls under the WGBO. This means that WGBO in principle also applies to young people with a PIJ measure in a juvenile custodial institution or a forensic psychiatric clinic.

Finally, some relevant provisions are included in the Principles Act Juvenile custodial institutions (Beginselenwet justitiĂŤle jeugdinrichtingen, BJJ). The main one, namely the provision about compulsory treatment (art. 37 BJJ), is discussed in detail in section D of this report.

For a very small group of youngsters with chronic psychiatric disorders, who are still a danger to themselves or others after six years of treatment in the context of a PIJ measure, the Act Special Admittance Psychiatric Hospitals (Wet Bijzondere Opnemingen Psychiatrische Ziekenhuizen, BOPZ) provides a solution. When using the BOPZ, the forced inclusion and treatment of this group can be continued in a regular psychiatric hospital.

2.6. Handling of information and professional confidentiality regarding young offenders Handling of information On several occasions in the judicial chain, information about young offenders is put down on paper or into a digital database: -

The National Transfer Form (LOF). Referral form, completed by police, containing the necessary data about the person and the offense to refer the offender to an alternative sanction. They are guiding factors that might, during the Judicial Case Consultation Youth (JCO), give rise to perform a further inquiry. In that respect, knowledge of risk factors contributes to making the most appropriate settlement decision.

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Client Tracking System Juvenile Delinquency (CliĂŤnt volgsysteem jeugdcriminaliteit, CVS-JC). Developed by the Ministry of Justice, in close cooperation with the police, the Public Prosecution and the Child Protection Board. The CVS-JC is a nationwide computerized system where all young people under 18 years with criminal contacts are recorded. It serves as a tool for a focused tackling of youth delinquency. The system is filled and accessed on site. Thus, it minimalizes the probability that a young person repeatedly receives a warning because of unawareness of crimes committed earlier. The clear and complete information makes informed decisions and early intervention possible. Although people under 12 years cannot be prosecuted, CVS-JC is also available for this group: those facts that would have resulted in an official police report if they had been

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older than 12 years, are registered.

The registration system of Halt Netherlands (AuraH). Besides details of the crimes committed and the settlements, AuraH contains individual characteristics of all Halt -youth. In a later phase of registration, the ethnic background (distinction between natives and foreigners first or second generation) is also determined.

In the future, the regsitration will be expanded with additional personal characteristics such as household type, having a job or benefits, information about the neighborhood, etc.

Implementation Program / Judicial Youth Institutions (TULP/JJI): information system to which all juvenile custodial institutions and a number of nonjudicial institutions are connected as well as in which the Ministry of Justice has purchased sites. The data in TULP/JJI include, among others, personal characteristics of the juveniles, data on current and possibly previous / next location(s) of residence, legal residency, imposing authority, acts committed and reason for deregistration.

Treatment file. The records of the juvenile as kept by the juvenile custodial institutions also include data about his health. The juvenile is entitled to inspect the data recorded in his file; without his permission, others can not see his data and receive information about it. Exceptions include the provision of access and information to involved social workers and those involved in the execution or preparation of the PIJ measure (staff of the facility, Minister of Justice, judges, lawyer). The legal representatives (parents or guardian) of the younger and stepor foster parents are entitled to access the file, at least until the young offender have not yet reached the age of 16 years. In the interest of the youth and to protect the privacy of third parties, inspection may be refused (Van der Linden, 2004).

Currently, the Project Screening and Diagnostics that runs in juvenile custodial institutions seeks to set up a procedure that allows the screening and diagnostics to be integrated into the regular operations of the juvenile custodial institutions. This way, the findings (can/may/should) directly affect the treatment process of youth offenders because all employees concerned have access to the relevant information. In this context, the creation of a suitable computer system is being prepared. The computer system should facilitate the procedure in juvenile custodial institutions, i.e. by allowing information from different informants to be combined and to make a graduated system of diagnosis possible (on the basis of preconceived decision points or manually entered commands). In addition, such a system should meet the requirements of confidentiality and security.

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Regulations on professional confidentiality Any professional who provides help, care, support or any other form of counseling to individual clients, has a duty of professional confidentiality. Such professional confidentiality obliges the professional not to disclose any information about the client to third parties unless the client has given him permission. Purpose of the professional confidentiality is to keep the threshold for access to care as low as possible and give the client the confidence that he can speak freely. The professional confidentiality also applies to professional counselors and social workers of the rehabilitation and judicial (youth) institutions, although the compulsory character of the criminal law in some cases makes a certain degree of violation of oath of secrecy, however this does not affect his responsibility to provide ‘proper care’. Information on the development of the younger and the course of the treatment will be provided to the management of the institution and the locating agency. Besides that, a copy of the record on the physical and mental state of young people must be provided to the public prosecutor when applying for an extension of the PIJ-measure. At that point, the judge at the hearing will also wants a verbal explanation from the practitioner (Van der Linden, 2004).

The above mentioned duty of confidentiality for social workers and supervisors is not specifically included in a particular law, but is derived from the privacy provisions of the European Convention on Human Rights and Fundamental Freedoms (article 8) and from the Dutch Constitution (article 10). These provisions are further supported by article 272 of the Dutch Penal Code, which contains a prohibition on breaking secrets entrusted to the professional.

Other relevant laws are: - Data Protection Act (Wet bescherming persoonsgegevens, WBP). The WBP provides general standards that focus on a careful handling of personal data. The main rule is that the processing of personal data and personal information about criminal or disturbing behavior – related to an imposed ban – is prohibited. Two articles mention some general and some specific exceptions to this prohibition.

- Criminal Justice Data Act (Wet justitiële en strafvorderlijke gegevens, WJSG). Central focus of the WJSG: regulation of the processing of juridical data in the juridical documentation that are needed for a good administration of justice. The law includes modalities on the delivery of juridical information to third parties.

2.7 Laws and action protocols foreseen for mixed systems of closed and outpatient treatment An important principle in the criminal justice system for youth is that criminal sanctions are - where possible - implemented extramurally. The aim to minimalize the number of youngsters in juvenile custodial institutions and let a larger number of

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youngsters qualify for another filling-in of sanctions has not been set out in specific legislation, but is explicitly formulated by the Council for Criminal Justice and Youth Protection (2009). It is reflected in the following ways: -

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The treatment facilities are limited (‘open’) or completely secure (‘closed’). This distinction is visible in the presence or absence of walls and fences. Furthermore, the young people in ‘open’ facilities have more freedoms and may have some consecutive days outside the juvenile custodial institution. Where possible, young people are placed in an open juvenile custodial institution. In addition, in 60% of the cases the open design is a continuation of the stay in a closed institution.

Participation in an educational and training program (STP) outside the juvenile custodial institution. This is a mix of activities as a further implementation of the imposed custodial measure on juveniles, following their stay in a juvenile custodial institution. The activities of a STP are focused around teaching specific social skills, providing education, increasing the likelihood of employment, providing special care (such as addiction care, mental health care or mentally handicapped care) and filling up the leisure time.

Despite the expectations at this point, it appears that the Behavior Modification Measure introduced in 2008 does not allow a flexible combination of outpatient and closed interventions (Weijers, Hepping & Kampijon, 2010). For example, night detention is formally still only applicable in the context of custody, while it could be an ideal part of an integrated approach.

2.8 Legal and medical measures in case of non-completion of treatment Legal and medical measures in case of non-completion of treatment In cases of outpatient treatment, the court is informed that the juvenile does not comply with the treatment. Usually efforts are made by the Child Protection Board to persuade the family and the young person to pursue the treatment. If necessary, forced admission and treatment can take place (see previous question).

In semi-open systems, motivation for treatment regularly appears a spoilsport for the completion of treatment: about one third of young people leave the juvenile custodial institution in an irregular way (running away, not returning from leave or transfer to another facility due to a serious incident). An important feature of these ‘non-regular leavers’ / ‘dropouts’ is the fact that they had run away frequently before their admission and have committed more crimes than those who complete their stay (Boendermaker,

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1998). In the subgroup of young people that have not stopped committing serious crimes around the age of 30, a relatively big proportion has not completed their stay in the juvenile custodial institution (Van der Geest et al., 2007). This implies that around two thirds of the juveniles complete the treatment program in ‘their’ juvenile custodial institution, sometimes by means of forced treatment.

Involuntary-admission measures Ex PIJ’ers can be admitted involuntarily to a psychiatric hospital following the Special Admissions to Psychiatric Hospitals Act (Wet bijzondere opnemingen in psychiatrische ziekenhuizen, Wet BOPZ102). In these cases, a crime has usually not been committed, but there is a risk of danger to themselves or others. At such times, there may be a serious risk that this person will commit an offense. When the danger cannot be averted with humans or institutions outside a psychiatric hospital, compulsory hospitalization and treatment has become necessary.

Research shows that within ten years after leaving, 6.1% of the ex-PIJ’ers was admitted to a psychiatric hospital following the Special Admissions to Psychiatric Hospitals Act (Hempel, Buck & Van Marle, 2009).

102 This law regulates the recording procedure and the status of those who have been taken into a psychiatric hospital involuntarily. The law is meant for people with a psychiatric disorder or mental disability and for older people who are demented.

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3. PROFESSIONAL ROLE AND SKILLS DEVELOPMENT 3.1. Specialized training of juvenile justice professionals Educational background of juvenile justice professionals The educational background of a juvenile judge or juvenile public prosecutor roughly is:

Dutch criminal law (university, 4 years) + minimum of 3 to 6 years judicial experience ↓ Judicial civil servant training (6 years of work and training; last 2 years specialization in judge / public prosecutor) ↓ Minimum 1 year of experience as a judge advocate / substituteprosecutor ↓ Juvenile judge / juvenile public prosecutor

Additional trainings can be followed at the Training and Study Centre for the Judiciary (Stichting Studiecentrum Rechtspleging, SSR), that also organizes professional meetings and theme days (for example ‘Theme Day Youth’) where it is possible to meet with other professionals. License vignettes for juvenile public prosecutors can also be obtained via SSR. But, more often than is desirable, juvenile judges and juvenile public prosecutors learn by means of practical experience.

The educational background of a lawyer representing minors in criminal cases roughly is:

Dutch criminal law (university, 4 years) ↓ Vocational training lawyer-trainee (general) ↓ Courses in juvenile justice cases ↓ Lawyer representing minors

Law courts often assign juvenile justice cases to lawyers that have done a certain number of juvenile cases in the previous year and have followed specialized trainings

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in juvenile criminal law103. For example, lawyers can take a postgraduate course â&#x20AC;&#x2DC;The practical juvenile lawyerâ&#x20AC;&#x2122; (organized by the University of Amsterdam). They can also follow additional trainings and attend professional meetings and theme days at the abovementioned SSR. But again, lawyers representing children are also expected to learn by means of practical experience. There are no law firms that exclusively focus on juvenile justice cases; in most firms, one or several lawyers are specialized in juvenile cases while colleagues have other specializations.

Wishes regarding the training of juvenile justice professionals - Training of legal professionals in the possibilities of the behavior modification measure.

Since 1 February 2008, juvenile judges can impose a behavior modification measure.

This measure is intended for youth for whom a PIJ-measure is considered too heavy but special conditions of a conditional sentence too light. The behavior modification measure is located between the two. The exact content of the measure (one or several behavioral interventions and treatments) is determined by the judge. It is up to the juvenile judge to impose the measure; a well motivated advice of the Child Protection Board can contribute to the demand and imposition of the measure.

In practice, the number of imposed behavior modification measures has strongly fallen short of expectations. This is partly related to factors like a shortage in treatment supply in some regions and a smaller than expected size of the target group (youngsters with multiple background and behavioral problems). But another important reason for the small number of imposed measures is a lack of knowledge and/or incorrect imaging among experts of the chain partners (public prosecution, judges, Child Protection Board and Youth Care Agency) (Buysse, Maarschalkerweerd, Loef & Hilhorst, 2010).

Examples are: unfamiliarity with the possibilities of filling in the behavior modification measure; lack of clarity about the consequences of (partial) failure, and; the idea that substituted youth detention with the same duration will be imposed if the youngster does not comply.

These unjust ideas hinder the use of the measure. To make sure that images of professionals coincide with actual possibilities and practices of the behavior modification measure, more education and training is necessary.

- (Further) Training of juvenile lawyers.

103â&#x20AC;&#x201A; In these cases, membership of the Association of Dutch Juvenile Law Lawyers (VNJA) is possible. In order to hold the membership, it is necessary to acquire a certain number of points in juvenile law.

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For some lawyers, juvenile cases are not very appealing. Examples of prevailing views among these lawyers are that those cases are badly paid and it is not possible to gain publicity with them because they are handled behind closed doors. Founded in 2006, the Association of Dutch Juvenile Law Lawyers (VNJA) aims to change this attitude.They explicitly propagate juvenile law cases as specialist cases, which require specific knowledge and skills. Therefore, they organize trainings and courses and have developed a system of membership that requires demonstrable knowledge and skills in this field. Slowly onward, juvenile cases are less dealt with by novice lawyers or lawyers that work out of ‘idealism’, but by motivated juvenile lawyers with knowledge of criminal and civil juvenile law, pedagogical understanding and empathy with the way of thinking of minors. This development needs to be continued in the future.

3.2. Specialized training of health care professionals Educational background of health care professionals The educational trajectory to become a child and youth psychiatrist nowadays roughly is:

Medicine1 (university, 6 years) ↓ Training program adult psychiatry (work and training, 2,5 years) ↓ Training program child and youth psychiatry (work and training, 2 years) ↓ Child and adolescent psychiatrist 1

Within the six years at the university, only little attention is devoted to the topic ‘psychiatry’ (one or two courses in the six year curriculum). The last few (two to three) months can be devoted to a traineeship in the field of (child and youth) psychiatry.

After this, additional training in the field of forensic child and adolescent psychiatry is available.

First of all, the Dutch Institute for Forensic Psychiatry and Psychology (NIFP) offers a range of trainings (for example, in pro Justitia reporting), modules, conferences and symposia for forensic psychiatrists. Invitations are actively sent to potential participants; participation is often compensated by the employer. The Dutch Association for Psychiatry (NVvP) likewise organizes further training and refresher courses in the field of forensic psychiatry. An extra motivation to follow additional courses is formed by the 5-year mandatory re-registration at the SRC (Medical Specialists Registration

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Commission). The psychiatrist needs to fulfill the SRC-requirements, namely (1) further training and refresher courses, (2) a minimum number of contacts with patients, and (3) positive evaluation by a visitation committee.

The educational trajectory to become a forensic child and youth psychologist nowadays roughly is:

Psychology (university, 4 years) ↓ Health-psychology (work and training, 2,5 years) ↓ Forensic evaluation1 (“Pro Justitia”) (work and training, 1 year) / Forensic psychology2 (work and training, 1 year) ↓ Forensic child and adolescent psychologist 1

Offered by NIFP and consisting of a preliminary and final ‘general module’ and three specific modules (‘adults’, ‘youth criminal’ and ‘youth civil’).

2 Offered by RINO Groep, Van der Hoeven Stichting and NIFP and consisting of three modules: ‘Context, inquiry and Pro Justitia reporting’, ‘Special diagnostics’ and ‘Treatment’.

After this, psychologists can take extra courses to skill themselves in the necessary supply of treatment. Again, the Dutch Institute for Forensic Psychiatry and Psychology (NIFP) offers a range of relevant trainings, modules, conferences and symposia.

Psychologists that are already working inside juvenile custodial institutions, but lack the abovementioned educational background, are offered the opportunity to follow relevant courses and trainings.

The educational trajectory to become a pedagogical employee nowadays roughly is:

Higher vocational education diploma in the socio-pedagogical area ↓ Pedagogical employee

An example of a higher vocational education is Social Pedagogical Aid (SPH, 4 years). A pedagogical employee coaches youngsters with their social, emotional and cognitive development. Besides that, (s)he attends to group conversations and pedagogical and behavioral therapeutic programs. The pedagogical employee also functions as a mentor by keeping in touch with probation, youth and addiction care and the social

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network of the youngster.

Senior pedagogical employees have extensive working experience as pedagogical employees or group coach and have finished additional coaching and training. In addition to the earlier mentioned tasks of a pedagogical employee, they contribute to the formulation of a ‘plan of perspectives’ and monitor and promote the quality of execution by the team.

The educational trajectory to become a group coach nowadays roughly is:

Intermediate (or higher) vocational education diploma in the pedagogical area ↓ Group coach Group coaches that are already working inside juvenile custodial institutions, but lack the abovementioned educational background, are offered the opportunity to follow a relevant intermediate or higher vocational education that is tuned to working with the target group. The vocational training to forensic supervisor is intended for people already working in prisons, juvenile custodial institutions, youth care, addiction care or psychiatry and aimed at assisting adults and juveniles who have collided with the law and have psychiatric disorders. The joint inspections (Inspectie Jeugdzorg et al., 2010) conclude that – due to a lower occupancy in juvenile custodial institutions – staff indeed follows more (vocational) trainings.

Besides these educations and trainings, there are also some internal trainings and initial programs. Examples are training in dealing with aggression and violence and mental and physical defensibility. Many group coaches are also trained by WorkWise, for example to become Individual Routing Counsellors (see 3.3), or improve their motivational interviewing techniques. Secondly, dual guidance of group coaches by behavioral experts and managers (‘dual management’) takes place. By means of ‘coaching on the job’, supervision and the promotion of expertise, group coaches are supported with the execution of their work. The joint inspections (Inspectie Jeugdzorg et al., 2010) conclude that – especially in juvenile custodial institutions that were not functioning optimally in 2007 – this has improved the degree in which employers tune their actions to the needs of the target group and working according to the YOUTURN methodology.

The educational trajectory to become a penitentiairy or judicial nurse nowadays roughly is:

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Nursing (higher vocational education, 4 years + 2 years working experience in psychiatry)/ Nursing (intermediate vocational education) + additional diplomas / certificates â&#x2020;&#x201C; Social Psychiatric Nurse (work and training, 1,5 years) Periodic training is available for all social-psychiatric nurses.

Wishes regarding the training of mental health professionals - Investing in early detection of mental disorders, especially among immigrant children.

Research by Boon, De Haan en De Boer (2010) shows that the probability that a nonwestern child is treated for a disorder is half of the probability for a Dutch child. But in a later stage, when they have committed a crime, they are twice as often charged with psychiatric care by the judge; Moroccans and Antilleans even trice as often. It looks like a part of the juvenile custodial institution-population ends up there because they are not treated early or adequately. Possibly, regular mental health care does not sufficiently reach immigrant families. Early detection of mental disorders therefore requires more attention.

- Training of forensic child and youth psychiatrists.

Improvement is possible in both the number of child and youth psychiatrists and the content of their training. First of all, some experts claim that the lack of forensic childand youth psychiatrists is worrisome104. At this moment, one psychiatrist is available for more than 400 juveniles, while they claim it is required to have one psychiatrist for 58 juveniles. Only then will it be possible to carry out careful psychiatric diagnostics and treatment for all youngsters in juvenile custodial institutions. Therefore, their conclusion is a serious need for the expansion of the number of psychiatrists in juvenile custodial institutions. Even though not all professionals claim that this is necessary, the 1:58 ratio has nevertheless come within closer reach because of recent decreases in the number of youngsters in juvenile custodial institutions.

Regarding the expertise of child and youth psychiatrists, the joint inspections (Inspectie Jeugdzorg et al., 2010) conclude that the recognition and treatment of mental disorders has significantly improved during the last years. The following knowledge and skills need to be trained more among (future) child and adolescent forensic

104â&#x20AC;&#x201A; Apart from that, there is a national lack of child and youth psychiatrists (Inspectie Jeugdzorg et al., 2010).

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psychiatrists (Duits, 2004; interview with psychiatrist): - Specialization in forensic psychiatry should be made possible, i.e. by means of mandatory internships in juvenile custodial institutions; - Knowledge of legislation for children and adolescents and the interdependence between the legal frameworks; - Knowledge on the changing regular and judicial care field for youth and adults; - Specific diagnostic knowledge combined with a certain attitude and skills for children / adolescents and their family systems, and; - Knowledge of positioning and responsibilities of various actors and stakeholders.

This includes the reconsideration of his/her own position. For example, in a juvenile custodial institution, the psychiatrist does not run the show –his/ her position is characterized by modesty. Another example: the relationship between the psychiatrist and client is fundamentally different because of the forced character of the setting. For instance, youngsters cannot choose their caregiver.

Thus, providing clarity about the fundamentals of judicial care is essential.

- Training of pedagogical staff in juvenile custodial institutions in the field of family therapy.

In the Dutch national MHYO-report, family therapy was identified as an effective intervention for juveniles in juvenile custodial institutions. But, despite the availability of accredited programs for family treatment, these interventions are rarely used. One of the reasons for this is the lack of trained staff in juvenile custodial institutions: the available pedagogical employees and behavioral experts often lack competence in the field of family therapy. Therefore, the recruiting of extra staff and/or training of current treatment staff in this field is highly desirable.

- Training of group coaches.

The main challenge lies with the training of group coaches: staff members who are responsible for creating an optimal living environment and the daily supervision, guidance and observation of youth in a juvenile custodial institution. Recently, a huge cultural change has taken place in Dutch juvenile custodial institutions.

Where ‘control’ used to play a big role in the past, the focus nowadays explicitly is on ‘treatment’. Especially for group coaches, this requires a new way of thinking and acting: a pedagogical approach is required.

The group coaches should be able to act consciously and directed, instead of intuitively. Skills like giving positive feedback, being a role model, giving positive attention, expressing appreciation, give compliments, addressing thinking errors, giving behavioral instructions, practicing social skills or moral reasoning are not present in the same degree among the staff. Therefore, training and constant peer supervision (colleagues that give each other feedback) are indispensable (Van der Laan et al., 2007). This might help group coaches in finding a balance between confronting youth

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with their behavior, without that being interpreted as rejection or offending; showing interest and listen carefully, without coming too close and expecting too much (Van Binsbergen, 2003).

However, there are limits to what can be trained. For example, attachment relationships of both the youth and educational workers play a role in the interaction between them. Understanding and responding well to the behavior of these young people requires a sensitive attitude from group coaches. The own attachment relationship partly determines how well they are capable to bring about this sensitivity.

Thus, not only knowledge and skills but also the own personality plays an important role in the way of dealing with minors (Boendermaker & Uit Beijerse, 2008).

In conclusion, several trainings are needed that specifically focus on dealing with this group of youngsters. This holds for trainings in prevention and control of aggression and violence, treatment climate, education and treatment and expertise among staff.

An additional reason why the national training programs should be intensified is because of ongoing ageing in Dutch society. The formation of a special academy that gives further training and â&#x20AC;&#x153;training on the jobâ&#x20AC;? on higher vocational educational level is recommended.

3.3. Professional cooperation between juvenile justice and health care professionals Cooperation between different professionals Interdisciplinary and inter-institutional cooperation are key principles in any intervention concerning young offenders, and takes place on both organizational / policy and executive levels.

On an organizational level, more and more multidisciplinary collaborations are brought to life, for the advancement of expertise within the field of forensic youth care.

To an increasing extent, they are using results of scientific research. Supplement I gives some examples.

At case level, interdisciplinary cooperation and coordination takes places at different moments in the judicial chain. The general goal is to come from monodisciplinary information to a shared (diagnostic / treatment) vision and form there to a disciplinary treatment- and guidance planning. Some examples: - Judicial Case Consultation Youth (JCO): a consultation between different chain partners (representatives of police, prosecution, Child Protection Board and (sometimes) Youth Care Agency / Juvenile Rehabilitation / addiction care) who examine which approach is the most suitable with regard to young people who have committed an offense. The targets of the JCO are to shorten turnaround times by a joint rapid response through

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coordination of work of the partners and also to enhance the quality of decision making and thus the quality of criminal prosecution and aid. The JCO is often integrated into a Chain Unit or Safety House. Both are consortia of organizations concerned with delinquency and worrisome behavior of adults and minors. Their objective is to achieve a problem-oriented and personal approach for at-risk youth and adults, offenders and victims. The partners work together at the same location, so all information about (young) people and their circumstances comes together. In this way, quick intervention can take place in a developing criminal career.

- Indication consultation Pro Justitia reporting. In this consultation should preferably take part: the behavioral expert from the Child Protection Board, a child and adolescent psychiatrist form the Forensic Psychiatric Service and â&#x20AC;&#x201C; when indicated - a behavioral expert from the juvenile institution. The tasks of the indication consultation are: (a) in the court proceedings, make an indication for investigation concerning the offender, (b) determine the desirable form of diagnostics (from simple reporting by an ambulatory rapporteur to multidisciplinary residential research in a juvenile custodial institution) and (c) give solicited and unsolicited advice to the (child) magistrate and the prosecutor.

- Psycho Medical Consultation (PMO) in juvenile custodial institutions: a secondary line care consultation that coordinates the individual indicated care, comes to multidisciplinary needs assessment and diagnosis, coordinates care and aftercare and gives individual advice to the director. It is conducted by the facility physician, nurse, a child and adolescent psychiatrist and a psychologist. The psychologist functions as chairman. She/he focuses on young people who require special care, to support the treatment team.

- The Work-Wise routing: an integrated approach of individual attention and chainoriented cooperation to ensure that youngsters in juvenile custodial institutions are prepared to get and keep a job, follow and complete a training course and have a safe place to live when leaving the institution. Attention is also paid to building up and maintaining a positive social network offering constructive support and leisure activities. An important role is played by the Individual Routing Counsellors in the juvenile custodial institutions. Together with the behavioral experts, they use all sorts of tools and interventions. Examples of products developed by Work-Wise are a tool for risk assessment and risk handling, the motivation monitor, an employment and care programme for girls and a repeat offender programme. For a better return into society and thereby to prevent recidivism, there is also increasing cooperation with (juvenile) rehabilitation, youth care and other organizations. There is more emphasis on aftercare and more is done to guide youngsters with regards to labour.

Even though these examples sound convincing, a critical report by several youth

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inspections (Inspecties Jeugdzorg, Onderwijs, Gezondheidszorg & Sanctietoepassing, 2007) concluded that there is still not enough coordination among the different services and staff who are in contact with the young person who is in conflict with the law.

Since then, there has been some improvement but more needs to be done.

Principle on professional cooperation To ensure that all activities of the parties are aligned, a permanent person (an employee of the Child Protection Board) accompanies the minor during or has direction over the entire criminal process, from arrest to aftercare. The acting of this case manager with a firm position is a prerequisite for the success of the project approach, in which continuity is a key concept. If the young person has a family guardian, (s)he should be involved intensively.

Main problems In the Netherlands, the following problems in the cooperation between juvenile justice and youth care disciplines can be identified: - Problems in the cooperation between partners in a Safety House.

In the Dutch national MHYO-report, Safety Houses were identified as a best practice in the cooperation between juvenile justice and youth care disciplines. Indeed, these consortia of judicial and care organizations concerned with delinquency and worrisome behavior among youth and adults are quite succesful in achieving a problem-oriented and personal approach for offenders, at-risk youth and adults and (for example in case of domestic violence) victims. The partners work together on the same location, so all information about young people and their circumstances comes together. In this way, a quick intervention can take place. Nevertheless, there are still problems in the cooperation: - The exact goals of the cooperation are somewhat unclear: exactly when are all the partners satisfied with the booked results? Organizations use different performance standards.

- The expectations regarding the partners are unclear or unrealistic: what exactly can the other partners bring in?

- Insufficient mandate: to what extent can the representatives make binding agreements for their organization? Instructions from direct managers can hinder the operation.

- The shirking of responsibilities to other partners.

- Different prioritization among partners (related to financial considerations).

- Restricting guidelines or protocols, while ideally there should be room for creativity in the form of new and/or unusual solutions.

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- The case manager of the Child Protection Board is excluded from important information.

In the Dutch national MHYO-report, case managers were identified as a best practice in the cooperation between juvenile justice and youth care disciplines. To ensure that all activities of the parties are aligned, a permanent person (an employee of the Child Protection Board) accompanies the minor during or has supervision over the entire criminal process, from arrest to aftercare. The acting of this case manager with a firm position is seen as a prerequisite for the success of the project approach, in which continuity is a key concept. But in reality, partners are not always convinced of the additional value of the case manager and (s)he is often left out of developments regarding the youth.

- Miscomprehensions between the child and youth psychiatrist / psychologist and jurists.

Jurists and psychiatrists / psychologists often have insufficient awareness about the different ways of thinking in youth health care and juvenile justice and the consequences thereof for their roles and positions. This regularly results in misunderstandings when the child and youth psychiatrist / psychologist appears in court (as an expert witness) or has to write a pro Justitia report. For example, jurists sometimes interpret the probability advice of the expert as an absolute judgment or an expert who presents his/ her findings in judicial categories. The roles in the multidisciplinary report process are not always transparent. But, several improvements have taken place. First of all, several trainings and courses are nowadays available (training Rapporteur pro Justitia, training Forensic psychology, courses offered by the Dutch Institute for Forensic Psychiatry and Psychology (NIFP)). Besides, initiatives have been undertaken to formulate guidelines for pro Justitia reports by forensic psychiatrists / psychologists. For example, they now work with standard questions that are clear and call on the expertise of the forensic psychiatrist / psychologist.

Best practices Interdisciplinary and inter-institutional cooperation part are key principles in any intervention concerning young offenders, and takes place on both organizational / policy and executive levels.

On an organizational level, more and more multidisciplinary collaborations are brought to life, for the advancement of expertise within the field of forensic youth care.

To an increasing extent, they are using results of scientific research. Supplement I in the Dutch national MHYO-report already gave some examples.

At case level, interdisciplinary cooperation and coordination takes places at different moments in the judicial chain. The general goal is to come from monodisciplinary information to a shared vision and from there to a disciplinary treatment-

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and guidance planning. Some of the best practices: - Preventive Case Consultation Youth (PCO): a consultation between different chain partners (representatives of police, municipality, Youth Care Agency, etc.) who examine which approach is the most suitable in order to prevent at-risk minors below 18 to get in touch with the judicial system.

- Judicial Case Consultation Youth (JCO): a consultation between different chain partners (representatives of police, prosecution, Child Protection Board and (sometimes) Youth Care Agency / Juvenile Rehabilitation / addiction care) who examine which approach is the most suitable with regard to young people who have committed an offense. The targets of the JCO are to shorten turnaround times by a joint rapid response through coordination of work of the partners and also to enhance the quality of decision making and thus the quality of criminal prosecution and aid.

- The PCO and JCO are often integrated into a Chain Unit or Safety House. Both are consortia of judicial and care organizations concerned with delinquency and worrisome problem behavior among youth and adults. Their objective is to achieve a problemoriented and personal approach. The partners work together on the same location, so all information about young people and their circumstances comes together. In this way, a quick intervention can take place in order to prevent the further development of the criminal career. Essential conditions for solid cooperation are the presence of necessary facilities and trust among the partners.

- Indication consultation pro Justitia reporting. In this consultation should preferably take part: the behavioral expert from the Child Protection Board, a child and adolescent psychiatrist form the Forensic Psychiatric Service and â&#x20AC;&#x201C; when indicated - a behavioral expert from the juvenile institution. The tasks of the indication consultation are: (a) in the court proceedings, make an indication for investigation concerning the offender, (b) determine the desirable form of diagnostics (from simple reporting by an ambulatory rapporteur to multidisciplinary residential research in a juvenile custodial institution) and (c) give solicited and unsolicited advice to the (child) magistrate and the prosecutor.

- Psycho Medical Consultation (PMO) in juvenile custodial institutions: a secondary line care consultation that coordinates the individual indicated care, comes to multidisciplinary needs assessment and diagnosis, coordinates care and aftercare and gives individual advice to the director. It is conducted by the facility physician, nurse, a child and youth psychiatrist and a psychologist (and sometimes pedagogue). The psychologist functions as chairman. It focuses on young people who require special care, to support the treatment team. The joint inspections (Inspectie Jeugdzorg et al., 2010) recently concluded that the multidisciplinary consultation takes place systematically

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in all juvenile custodial institutions, so that employees experience more coherence in the treatment of psychiatric disorders.

- The Work-Wise routing: an integrated approach of individual attention and chainoriented cooperation to ensure that minors in juvenile custodial institutions are prepared to get and keep a job, follow and complete a training course and have a safe place to live when leaving the juvenile custodial institution. Attention is also paid to building up and maintaining a positive social network offering constructive support and leisure activities. An important role is played by the Individual Routing Counsellors in the juvenile custodial institutions. Together with the behavioral experts they use all sorts of tools and interventions. Examples of products developed by Work-Wise are a tool for risk assessment and risk handling, the motivation monitor, an employment and care programme for girls and a repeat offender programme. For a better return into society and thereby to prevent recidivism, there is also increasing cooperation with (juvenile) rehabilitation, youth care and other organizations. There is more emphasis on aftercare and more is done to guide youngsters to labour.

- The activities of the National Framework Juvenile Justice Instrumentation, which are aimed at setting up a graduated system of screening and diagnosis all the partners involved (from police to juvenile custodial institution). The systematical study of the presence of psychopathology will result in optimal exploitation of the scarce diagnostical expertise.

3.4. Ethical principles, practices and problems Ethical principles and practices Both within the youth care and juvenile justice systems, the interests of the juvenile come first. Within the youth care system, the basic principle is that parents and children should have the opportunity to grow up healthy and safely, and receive assistance when necessary. Hereby, the Youth Care Agency works from the â&#x20AC;&#x2DC;as-as-as-as-policyâ&#x20AC;&#x2122;: aid should begin as soon as possible, as close to home as possible, be as short as possible and as light as justified. The Youth Care Act also stipulates that consultation of the client (the youngster and his / her parents) should always take place. Only if this is harmful to the child, this is not needed. In such a case, the reason for this decision must be put on paper. Even when the authority of parents is limited or completely transferred to the Youth Care Agency (guardianship), assistance needs to center as much as possible around the questions and problems of parents and youngsters.

Meanwhile, in such cases, the voice of the (family) guardian is of decisive importance when making decisions corcening the youngster.

Within the juvenile justice system, these are some of the guiding ethical principles:

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-

-

-

-

Independent position of the Pro Justitia draftsman. The behavior expert should adopt an independent attitude and not deal with truth finding, refutation or evidencial argumentation of complaints.

Closed hearings. In contrast to adult hearings, juvenile justice hearings take place behind closed doors. The idea for this is that the privacy of the child should be protected, and therefore, personal information is not discussed in public: that could be stigmatizing and hurtful for the developing juvenile.

Communicative approach childrenâ&#x20AC;&#x2122;s judge. In this approach, the communicative dimension of the juvenile justice system is made central. The hearing should have a pedagogical character: moral boundaries should be made clear, appeal to feelings of guilt should take place, the juvenile should get a chance to make up for the offense and sanctions should be motivated. The juvenile suspect is an active participant: for example, he could enter into conversation with the victim.

Standards of practice for lawyers representing children are being developed.

Main ethical aspects that have arisen in the Netherlands Some ethical matters that have recently gained attention in The Netherlands are: - Placement of youngsters with a supervision order in juvenile custodial institutions. Up till 2009, young people â&#x20AC;&#x201C; with a child protection order â&#x20AC;&#x201C; with severe behavioral problems who could not be treated in the home situation, were regularly placed in the same juvenile custodial institutions as young people that had committed a crime and had been sentenced. This was not a satisfactory solution. From 2010, young people with severe behavioral problems are placed in new forms of care (closed youth care institutions).

- Exchange of data between youth care institutions. Relevant data on a (non) safe child raising situation are not always properly exchanged by professionals, whereby they claim the protection of (medical) professional confidentiality.

Meanwhile, barriers for data exchange are somewhat reduced through legislation, codes for reporting child abuse and the Digital Record Youth Health Care (inaccessible to the police and judiciary).

This issue has recently become an actuality again. In March 2011, the Dutch College for Protection of Personal Particulars concluded that in two safety houses, the guarantees for carefully processing personal data regarding minors are insufficient, which implies a violation of the law. In these safety houses, clear criteria for the placement of minors on the agenda of the juvenile case consultation are lacking. This is conflicting with the Data Protection Act. The same applies to the registration of data regarding minors 6 to 12 years who have been in contact with the law.

- Assessing the effectiveness of treatments / behavioral interventions. Assigning

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-

juveniles to accredited programs/interventions or a control group is scientifically the best solution for effectiveness research. But, from an ethical point of view it is virtually impossible to assign juveniles to a control-group where nothing will be done with his behavior. Therefore, it is preferred to make a comparison with a group that receives treatment as usual. Unfortunately, this approach implies that it will be harder to prove a significant effect on behavior.

Ethical objections concerning early detection and preventive intervention. For example, the danger of social selection, which means that early prevention is limited to the lower classes. Preference is therefore given to a broad movement of approachable upbringing support, as part of an emancipatory policy to integrate large sections of the population and improve their life opportunities.

4. INTERVENTION APPROACHES: WHAT IS WORKING AND WHAT IS NOT 4.1. Early prevention programs for young people with behavioral problems In the Netherlands, there is a very wide range of prevention programs for children and teenagers. These prevention strategies often focus on all school going youth105or general groups of vulnerable children106 (children from disadvantaged neighborhoods, children of very young single mothers, etc.) and only in a few instances, children with antisocial behavior. The research area on the effectiveness of these programs is still under development. Effective Dutch preventive programs that tackle violence, delinquency and antisocial behavior at an early stage (up to twelve years) focus on three risk factors: tackling of early behavioral problems, learning delays and problems with familymanagement. Of these programs, only a few have been proven effective.

Interventions that have been proven effective by the Accreditation Board Judicial Behavioral Interventions are:

105 Quite some prevention takes place in an educational setting. Measures are taken to prevent truancy and school drop-out. Space is created in the curriculum to offer advice and to cover concrete activities, such as learning effective ways of resolving conflict. Parents are easier to reach through school, so they can be offered help and advice with difficulties in bringing up their children.

106 Broad prevention programs such as Communities That Care, which aims to make neighborhoods and residential areas safer, cleaner and more healthy, and to promote social cohesion.

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Table 5. Effective early prevention interventions.

1

Name

Target group

Description

Video-feedback Intervention to Promote Positive Parenting and Sensitive Discipline (VIPP-SD)

Parents of children from 1 to 3 with difficult behavior.

The program aims to prevent or reduce behavioral problems by strengthening parenting skills, with attention for positive interaction and sensitive discipline strategies. This is done in six home visits by means of feedback on video recordings of parent-child interactions.

Task Game (Taakspel, based on the Good Behavior Game)

Primary school pupils aged 7 -121.

A universal prevention program, consisting of a grouporiented approach for pupils in the 4th to 8th class of primary school, whereby pupils learn to better follow class rules and rules on the playground. The aim is to improve task behavior, reduce rule-breaking behavior and promote a positive educational climate. Ultimate goal is to reduce early starting problem behavior and redirect this into positive behavior.

Functional Family Therapy (FFT)

Juveniles aged 11 to 18 with behavioral problems (including criminality) and their families.

FFT has three phases: (1) connection and motivation phase, where the therapist puts up a relationship with the juvenile and his family and motivates them for the rest of the therapy; (2) behavioral phase in which the therapist works on behavioral change among the family members, and; (3) generalization phase, in which the family learns to apply the behavior outside the family and to cope with relapse. The therapy is of short duration. For families with moderate problems eight to twelve sessions are sufficient, families with serious problems may need more than thirty sessions.

Aggression Regulation Custom Made Ambulatory (Agressieregulatie op Maat Ambulant)

Juveniles 16 to 24 with severe aggression problems.

A long-term treatment of six months to two years.

The intervention uses a cognitive behavioral approach with drama therapy techniques and mindfulness, with continuous attention for the motivation of the juvenile and increase of belief in himself so as to increase learnability. Besides offering individual aid, there are 12 training sessions of group training.

Adjustments are available for: Special Education and (Special) Secondary Education.

The described interventions are proven effective when it comes to addressing the underlying causes of antisocial behavior of children. In addition, many interventions currently have received the predicate â&#x20AC;&#x2DC;theoretically well-foundedâ&#x20AC;&#x2122;. Examples are Parent Management Training (PMT) and Positive Parenting Programme (Triple P). Both are aimed at the training of parenting skills in parents of children under the age of twelve.

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Many children with behavioral disorders who do not voluntarily seek help for their problems, only come into contact with care provisions when a first police contact has occurred. Until 2010, all children younger than 12 years old with a first police contact were offered a so-called stop-response. It was a free offer to support parents with the correcting of their children’s behaviour when they have committed an offense. STOP consisted of “an activity of an educational purpose” for up to 10 hours. Evaluation showed, however, that the approach was insufficiently effective and did not have a clear theoretical substantiation. As of January 1, 2010, the response has been replaced by a “robust approach” of children below twelve. Building on the collaboration between the police and the Youth Care Agency a new, comprehensive approach for delinquent children below 12 and their parents is being prepared. In this approach, the police warn the children, talks with the parents and lead them to the Youth Care Agency. The Youth Care Agency screens for underlying problems, and - if necessary - directs parent and child to person-oriented, adequate aid. Where possible, light interventions will be advised and intensive interventions where necessary. The new approach has been fully implemented in late 2010.

4.2. Standardized assessment

resources

for

mental

health

screening

and

In order to determine disorders among juvenile offenders, both classificatory and descriptive diagnostics are used as much as possible. The first involves the determination of the presence of criteria associated with a disorder as described in a classification system (in the Netherlands: the DSM-IV). A crucial aspect hereby is the concept of dysfunction. In the forensic field, there is clear dysfunction in at least one area, but in individual cases it can be very difficult to determine to what extent the symptoms are actually associated with criminal behavior. In order to give a substantive explanation about behavior and performance, descriptive diagnostics are indispensable: attention must be paid to the origin, duration, severity and course of the criteria, previous interventions and conditions associated with the disorder.

The psychological and psychiatric assessment of juvenile offenders requires the collection of information in multiple areas which informs us about the functioning of the young person, as well as their family and social environment. Thus, it is an approach that uses multiple sources of information and multiple methods of data collection in different contexts. Since specific diagnostic instruments for juvenile offenders are deficient, general diagnostic instruments are often used. The most important standardized resources that are used in The Netherlands are: -

The BARO (Basis Raads Onderzoek), used by the Child Protection Board. The

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BARO is a screening tool for young people in case of juvenile criminal cases, used among approximately 60% of the youngsters. It is a semi-structured questionnaire which covers nine domains107. Information on these domains is obtained from the juveniles and their parents, and preferably in school or from family guardian / juvenile rehabilitation / police; on every domain, it is weighed how worrisome the situation is. These scores are entered into a scheme, that gives the opportunity to see at one glance how worrisome the situation is. The BARO enables a fast and efficient way to provide information to the juridical authorities on the person and living conditions of the juvenile suspect and to ascertain whether extensive research by the Board is necessary.

- Standardized resources that are used in the context of a ‘pro Justitia evaluation’.

The independent forensic psychiatrist or psychologist who is asked by the examining judge or prosecutor to make a pre-trial forensic mental health evaluation of a youngster, must clarify if and to what extent a mental disorder or deficient mental development has had an influence on the index offence, give an estimate of the risk of reoffending and give feasible advice about the most favorable development possible for the youngster. Pro Justitia reporting can be done ambulatory, residential or clinical. For approximately less than half of the juveniles who are brought before the court that have disorders, a forensic diagnostic examination is ordered.

In almost all the pro Justitia evaluations, psychological tests like the YSR (Youth Self-Report, a self-report questionnaire) and the DISC (Diagnostic Interview Schedule for Children, a structured psychiatric interview) are being used. Often, the CGAS (Children’s Global Assessment Scale) is also used because children have poor awareness about their own shortcomings. Two international risk assessment instruments for youngsters play an important role in the clinical assessment of violence risk: (1) SAVRY (Structured Assessment of Violence Risk in Youth). Factors of this violence risk assessment instrument in youth are used to judge the risk of violent recidivism. They include historical, contextual and individual risk factors as well as protective factors.

(2) PCL:YV (Psychopathy Check List: Youth Version). This diagnostic instrument is often used as risk assessment instrument, because of the strong link between psychopathological traits and violent as well as general recidivism.

Finally, the J-SOAP (Juvenile Sex Offender Assessment Protocol) is used for juvenile sex offenders. However, the choice for certain psychological tests has

107 The nine domains are: the offense, the (psychosocial) development, physical fitness, behavioral problems, internalizing problems, substance use, functioning at home / at school / in leisure time, circumstances (family, neighborhood). Luisteren Fonetisch lezen Woordenboek.

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shown to be insufficiently substantiated (Buysse, Komen & Nauta, 2009).

- Forensic diagnostic examinations in juvenile custodial institutions. When entering a juvenile custodial institution, most youngsters already have a file. In some cases, a diagnosis is already present. Virtually always, screening by means of the Massachusetts Youth Screening Instrument (MAYSI: a brief screening tool designed to identify youths who may have special mental health needs) and the Strengths and Difficulties Questionniare (SDQ: a brief behavioural screening questionnaire for 3-16 year olds) takes place. If there are suspicions that the young person suffers from a certain behavioral or psychiatric disorder, further diagnostics will take place. This will generally be done during the first weeks of the stay inside the juvenile custodial institution. In some cases, extensive examination in a special forensic observation department (see 4.4) will take place. Diagnostic tests, interviews with and observations of the minor and other stakeholders will be used. The results of the inquiry (usually a DSM classification) will be used for the formulation of a treatment plan.

The past few years, some important developments have taken place in the field of juvenile forensic diagnostics. The period 2003-2005 saw the phased implementation of the National Framework Forensic Diagnostics for Juveniles. The National Framework was set up following complaints in the field about the quality of forensic diagnostics for juveniles. The implementation aimed to improve the effectiveness of forensic diagnostics, to speed up forensic diagnostics and to improve quality of the diagnostic reports.

Another significant development is the National Framework Juvenile Justice Instrumentation by the Ministry of Justice. The aim is to achieve a coherent set of tools for the juvenile justice chain. The National Framework determines which precise information is needed for what purpose and how and by which chain partner that information should be collected and transmitted.

4.3. Therapeutic interventions for young offenders In 2007, the report of the joint inspections showed that treatment of adolescents with a mental disorder and behavior problems in juvenile custodial institutions has shortcomings. For example, the care was not carried out according to a standard protocol and therapeutic talks were found to take place only on a small scale and often without systematic diagnostic procedure, and (because of distance between behavioral experts and living units and limited availability of psychiatrists). The interventions used were not standardized or accredited by the Dutch Accreditation Panel. The accessibility of psychiatric care was often not adequately warranted. The sharp criticism of the four inspections on the treatment of youngsters led to various proposals for improvement,

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such as developing a screening tool, more differentiation of groups and reducing group size, the status of treatment institution for all juvenile custodial institutions and the introduction of a nationwide basic methodology (YOUTURN). Juvenile custodial institutions started to use only accredited behavioral interventions like discussed below. In 2010, it appeared that the juvenile custodial institutions have managed to renew and improve themselves.

Therapeutic intervention in juvenile custodial institutions Treatment of juveniles takes place within the framework of the custodial measure ‘institutional placement order’ (Plaatsing in een Inrichting voor Jeugdigen; PIJ measure). The young offender can be imposed with a two-year PIJ in case of a serious offense, a fouryear PIJ in case of violent crime and a six-year PIJ when a developmental disorder has led to commit a violent crime. The following table shows the number of PIJ-youngsters during the period 2005 to 2009.

Table 6. Number of young offenders under therapeutical custodial measures (PIJ) (source: Dienst Justitiële Inrichtingen).

Year

Number of young offenders with PIJ-measure in juvenile custodial institutions

Boys

Girls

Total

% of number criminally placed young offenders in juvenile custodial institution

% of total number placed young offenders in juvenile custodial institution

2005

377

161

538

49%

24%

2006

401

189

590

61%

26%

2007

389

175

564

58%

24%

2008

354

94

448

56%

28%

2009

322

44

366

54%

36%

In juvenile custodial institutions, a combined intervention that addresses both mental health problems and deviant behavior is required, whereby ‘intervention’ is an umbrella term for programs, projects, training methods, treatments and forms of coaching.

Therefore, youngsters stay in communal units and participate in a structured day program that includes education, vocational training, sports and recreation. Until 2010, different methods were used in the treatment institutions: most institutions used an individual approach, some a group-based approach. From 2010, all juvenile custodial institutions work with the basic methodology YOUTURN, which is designed to prevent recidivism and to reduce criminogenic factors. The methodology is an integration and expansion of two established methods that correctional institutions have good

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experiences with: the Social Competence Model108 and EQUIP109.

YOUTURN is all about learning responsibility. Group employees and teachers of the school (the coaches) teach young people to deal with anger, difficult moral choices and how they can behave in a socially skilled way. Then the young people help each other to resolve difficult situations. Meanwhile, they continuously get feedback on their behavior in the communal unit and in school. For young offenders, YOUTURN brings clarity and continuity. They know what their day program looks like and what they are required to do. Even in case of a possible transfer, because all the juvenile custodial institutions are working with the same methodology: the treatment is continued and the way of approaching the youngster is the same.

Besides the basic methodology YOUTURN, attention will have be paid to the complex underlying problems that are different for each individual. For every young person, an individual treatment plan is established consisting of (a combination of) individual or group therapy, psychoeducation, family counseling and pharmacotherapy.

Emphasis is usually on addressing serious behavioral or conduct disorder (Lodewijks, 2008). As much as possible, evidence-based interventions that are accredited by the Accreditation Commission Behavioral Interventions Justice are used. Supplement II provides an overview of (provisionally) accredited interventions focused on individual youngsters which can be used within a juvenile custodial institution. In short, it usually concerns the application of cognitive behavioral therapeutical methods, also in case of internalizing problems such as mild depression, anxiety problems and self-harm and suicide. With behavioral problems, the focus is on reduction of fallacies, mastering anger and provide an individual training component alongside a group component. In addition, a multi-modal approach is used as much as possible, meaning the dealing of multiple fields at the same time. Therapeutic interventions are mostly carried out by psychologists that work in the institution.

108 The social competence model focuses on learning the social skills that the juvenile offender and the family have not learned and whose absence also led to delinquency. The lack of social skills is compared to the ‘life tasks’ for which the young person and the family are placed, thus creating a competence- and shortage profile. The model is based on the paradigms of social learning and cognitive behavioral therapy.

LuisterenFonetisch lezen Woordenboek 109 A cognitive behavioral therapeutical programme in which juveniles are equipped to help and learn from each other. The negative subculture form which the juveniles are often derived, must be reversed into a positive. The program starts with a number of sessions on errors of reasoning and problems, followed by ten sessions on dealing with agression, ten sessions on social skills and finally ten sessions in which socially pure decisions must be made.

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Therapeutic intervention in community based sanctions The specific needs of the target group and the deficits to respond to them in the regular mental health care have stimulated the rise of several forensic adolescent psychiatric outpatient facilities. In addition, ambulatory assistance is given in the form of training on which a predetermined number of hours should be spent. These courses make use of educational information, which almost always includes videos with sample interactions. Most of these courses are for people who do not suffer from (severe) psychological or psychiatric problems. But it is possible that following such a course is a part of the treatment of a young person with (serious) mental illness.

Besides cursory sanctions (learning), there are youth work projects in which youngsters perform work in companies and institutions (that have made themselves available). The reception there, the participation, the daily meeting and dealing with colleagues, the reception of recognition for good work often form an important motivating (learning) experience.

Finally, there are also day programs or day care centers where a combination of skills trainings, employment, education and sport is offered. These programs are mostly intended for young people who have committed a serious crime and are an alternative for young people that would otherwise get an unconditional imprisonment of at least three months.

Guidelines for treatment ‘Treatment’ is defined as a set of actions aimed at the prevention, reduction or elimination of problems or physical, mental, social or pedagogical disorders that could adversely affect their development into adulthood. The starting point for a good treatment is that it meets the diagnosis and the needs of individuals and that the treatment has a realistic perspective. The treatment should be discussed with parents and the youngster, so that they will commit themselves to it.

Within juvenile custodial institutions, the living setting must be appropriate for the treatment (ranging from group to individual): get a group environment which is based on treatment principles, use the interaction within living units as a therapeutic agent, make sure the staff are professional and well trained, stimulate responsible group behavior, set clear and secure borders, make policies regarding the use of substances a structural component of a safe living and treatment environment, use control measures and urine tests as a last resort, and replace youth – when necessary – to youth mental health care. Besides that, it is important to use proven effective strategies and ensure a good position of the psychiatrist and behavioural expert (they have the last word regarding treatment - the legal final responsibility rests with the director).

The so-called equivalence principle of the European Prison Rules is explicitly endorsed in The Netherlands: youth inside the juvenile custodial institution should

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receive the same quality of care as they would get in the free society. It is even suggested that there may be even more demanding standards of care than in the free society.

Specific guidelines for outpatient treatment are: the assistance has to be nonbureaucratic (direct contact with the therapist, home visits, informal atmosphere), present the assistance as ‘supply’ (the therapist has to examine how the young can reorganize his life so that he can get a grip on it: focus on the training of skills instead of problems) and work with the legal framework (if the younger evades appointments, a penalty should follow).

Results of interventions As known, the measurement of outcomes of interventions is difficult. First, the question is how the effect or outcome is defined; secondly, the research design is important. Since 2005, the Accreditation Commission Youth Interventions functions in the Netherlands, which attempts to systematically map the effectiveness of interventions. As mentioned earlier, some interventions (mostly cognitive behavioral therapeutical) that have been found theoretically effective are described in supplement II. The actual effect of those interventions on the juvenile offenders still has to be proven. At this moment, there are no effect studies available that show the effects of accredited interventions.

In general, it can be said that young people on average move forward during their stay in the juvenile custodial institutions. But the problems are not over after leaving the institution. With regard to recidivism measurements from the past: after four years 70% of the criminally placed youngsters have been back in contact with the justice system. Predictors for recidivism are gender (more boys than girls re-offend) and having earlier judicial contacts (more judicial contacts before placement in the juvenile custodial institution, the faster and more recidivism after departure). In the longer term, it appears that the majority of the group stops with the commission of serious crimes; however, 12% persists in longer-term delinquency. Detailed and up-todate information about the prevalence of psychiatric disorders after departure from the juvenile custodial institution is not (yet) available.

4.4. Specific mental-health units for young offenders with mental health problems Until 2010, the juvenile custodial institutions were divided into facilities that only offer daily care and structure and facilities that actually treat the behavioral problems. The treatment facilities were for youths with a measure of placement in an institution for juveniles (PIJ measure) and for young people with a supervision order with authorization for closed placement. The “just care” facilities were for pre-trial juvenile offenders and convicted juvenile delinquents (punished by juvenile detention) and for

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youths awaiting placement in a treatment facility.

From 2010, all institutions have received the destination treatment facility. Within the treatment facility, all young offenders receive intense help and treatment (see previous section). Divided over the juvenile custodial institutions, there are specialist units for young offenders who need treatment which require specialized knowledge (Vlaardingerbroek, 2009): The FOBA (forensic observation and guidance department): for young offenders in a psychological crisis that must be stabilized. For example, people with serious drug dependence and dissociative disorders are often referred to FOBA. They then stay there for several weeks, are set on the right medication and then return back to ‘their’ juvenile custodial institution.

The mild mental disabilities (LVG-section): for young offenders with a low IQ (between 55 and 80).

The Very Intensive Care (VIC-section) for youngsters who need extra assistance because of a psychiatric disorder or personality disorder.

The ESP-division: for youth who have serious sexual problems.

The Individual Route Department (ITA): for young offenders who seriously disrupt the group process, so that they have a negative impact on their peers. At the ITA they receive individual treatment.

4.5. Medical treatment of young offenders with mental health problems

Soon after entrance in the juvenile custodial institution, the medical service (nurse and mostly the psychiatric nurse as well) perform a medical intake with the youth.

The psychologists and pedagogues study the (care) records of the youth, subject him/ her to screening instruments (MAYSI110 and SDQ111) and perform observations in the living unit (or receive information about the youth via group coaches). Only when the medical service and/or behavioral experts decide that this is indicated, referral to the child and youth psychiatrist takes place.

The main task of the psychiatrist is to perform a psychiatric diagnostic inquiry and write a report about it. For this purpose, both clinical diagnostic strategies (interviews, observation, ad hoc inquiries with colleagues, studying of (care) records of the youth) and actuarial approaches (diagnostic instruments) are used. When clinically relevant psychiatric disorders are diagnosed (this means: disorders that result in significant

110 Massachusetts Youth Screening Instrument: a brief screening tool designed to identify youths who may have special mental health needs.

111 Strengths and Difficulties Questionnaire: a brief behavioral screening questionnaire for 3-16 year olds.

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obstacles in daily functioning), additional treatment112 is deemed necessary. The starting point for the additional treatment is that it meets the diagnosis and the needs of the younger and that the treatment has a realistic perspective. Treatment is based on a concrete treatment plan; achieving the goals in this plan receives explicit attention.

The additional treatment can consist of three parts: psycho hygiene, medication and/ or treatment methods.

1- Psycho hygiene / educational interventions The child and youth psychiatrist educates the youth on the characteristics of the disorder, the effects on his/her functioning and possible treatment.

2- Medication / pharmacotherapeutical interventions Youngsters with a serious psychiatric disorder need medication in order to be able to function in the daily program inside the juvenile custodial institution. This medication is provided by the child and youth psychiatrist. There are four categories of medicines, which contain agents with similar action. It is recognized that certain medications are effective treatments for particular symptoms across a range of different disorders.

The required dosage and arising side effects determine which pharmacotherapy is chosen. The first group is the tranquilizers. With the exception of one drug, they are not prescribed because of their addictive effects. The second group of medicines, the antipsychotics, are prescribed in case of lacking aggression control, posttraumatic stress disorder (PTSD) and borderline symptoms. In some cases, they are used as a substitute for tranquilizers. The effectiveness of the third group, antidepressants, has not been demonstrated for youth; therefore, they are not prescribed. In case of mood swings, antipsychotics are prescribed because of their stabilizing effect. Among the last group of medicines, the psychostimulants, methylfenidate is the most effective agent. Of the youth with attention deficit hyperactivity disorder (ADHD), approximately fifty percent uses medication of this type. In many cases, the structured environment in the juvenile custodial institution suffices to reduce the ADHD-symptoms. The following table gives an overview of medicines that are frequently being prescribed in the juvenile custodial institutions.

112 ‘Treatment’ is defined as a set of actions aimed at the prevention, reduction or elimination of problems or physical, mental, social or pedagogical disorders that could adversely affect the development into adulthood. ‘Additional’ refers to the fact that this treatment is being added to the basic methodology YOUTURN, which is applied to all youth in a juvenile custodial institution.

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Table 7. Prescribed medication among offenders in juvenile custodial institutions in the Netherlands.

Category of medicines

Pharmacotherapy

Description of effects

Tranquilizers

Melatonine

Good night’s rest.

Antipsychotics

Risperdal / Risperidon

Reduction of symptoms of PTSS, PDD-NOS, conduct disorders, borderline symptoms and aggression-regulation problems.

Orap

Reduction of symptoms of PTSS, PDD-NOS, conduct disorders, borderline symptoms and aggression-regulation problems. Less side effects than Risperdal.

Dipiperon

Increased control of aggression.

Seroquel

Reduction of symptoms of PTSS, PDD-NOS, conduct disorders, borderline symptoms and aggression-regulation problems. Currently used as ‘a last resort’, but upcoming.

Antidepressants

-

-

Psychostimulants

Ritalin

Increasing / maintaining alertness, improving attention, reducing impulsivity and motoric hyperactivity (short-acting preparation: 4 hours).

Concerta

Increasing / maintaining alertness, improving attention, reducing impulsivity and motoric hyperactivity (long-acting preparation: 12 hours).

Equasym / Medikinet

Increasing / maintaining alertness, improving attention, reducing impulsivity and motoric hyperactivity (medium-acting preparation: 8 hours).

In principle, medicines are prescribed on a voluntary basis: the pupil gives consent and is motivated to take the medicines (Melchior, 2005). If youth and/or parents refuse the use of medicines, this will be discussed during the Psycho Medical Consultation113. Only if the symptoms (as determined by means of (a) questionnaire(s)) are very serious, the

113 A consultation in which the psychiatrist, psychologist, (pedagogue,) GP and nurse participate.

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psychiatrist will insist on the use of medication; but forced medication is rare.

Medication prescribed by the psychiatrist is delivered to the living unit by the nurse; group coaches are responsible for the administration. The effect(s) and possible sideeffects of the medication are registered by the group coaches, behavioral experts and nurse. Besides that, the youngster visits the psychiatrist on so called â&#x20AC;&#x2DC;check-up consultationsâ&#x20AC;&#x2122;. The frequency of these consultations depends on the phase of the medication use (more often in the starting phase, less often when the medication is well picked up).

3- Treatment methods / psychological and social interventions In various cases, pharmacological treatment in itself is not sufficient to effectively reduce mental illnesses: effective treatment will consist of a combination of psychopharmacological, behavior therapeutic, and multi-systemic intervention strategies (Van der Laan et al., 2007). Therefore, the psychiatrist and the treatment coordinator (psychologist) together formulate a treatment plan. The suggested treatment is discussed with parents and the youngster, so that they will commit themselves to it. In most of these cases, the focus of the treatment is on externalizing problem behavior with or without psychiatric comorbidity. The treatment is carried out according to the guidelines that apply within the mental health care and by using evidence based resources.

All juvenile custodial institutions have at their disposal an internal and/or external treatment supply for treatable psychiatric disorders (Inspectie Jeugdzorg, Inspectie van het Onderwijs, Inspectie voor de Gezondheidszorg & Inspectie voor de Sanctietoepassing, 2010). Behavioral experts have taken (or are taking) courses to skill themselves in the necessary treatments. For example, some psychologists in juvenile custodial institutions have recently been trained in EMDR (eye movement desensitization and reprocessing), a specialized form of psychotherapy that is used for treating PTSD and its associated conditions, including depression. Therefore, in most cases sufficient expertise is present inside the juvenile custodial institution.

In some cases, for example in case of addiction problems, external treatment is supplied by regional care institutions. Only rarely parent training is used, for example when dealing with the oppositional aspects of conduct disorder (CD).

The general impression of the earlier mentioned child and youth psychiatrist is that his juvenile custodial institution satisfies the so-called equivalence principle of the European Prison Rules: youth inside the juvenile custodial institution receive the same quality of care as they would get in the free society.

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4.6. Regulation and process of a psychiatric treatment Process regarding a psychiatric treatment Working with behaviourally disturbed adolescents and young people who might harm themselves or might have suicidal tendencies, requires close collaboration between employees in a juvenile custodial institution. In theory, every young offender with mental health problems in a juvenile custodial institution is therefore assisted by a multidisciplinary team composed of a (child and youth) psychiatrist, (child and youth) psychologist, (ortho)educationalist, group coach (or pedagogical employee / Individual Trajectory Coach), general practitioner and nurse (Lodewijks, 2008). The child and adolescent psychiatrist functions as the manager of this multidisciplinary team. Medication prescribed by the psychiatrist is administered by the group coaches.

Lodewijks (2008) indicates that psychiatrists are still often asked specifically for their neurobiological knowledge and their power to prescibe medications, while they stress that they have more to offer than their purely medical knowledge and skills.

Their intervention procedure first of all consists of the basic methodology YOUTURN, which is applied to all youth in a juvenile custodial institution. This methodology is explained earlier in this report. When clinically relevant psychiatric disorders are diagnosed (this means: disorders that result in significant obstacles in daily functioning), additional treatment is deemed necessary. The starting point for the additional treatment is that it meets the diagnosis and the needs of the younger and that the treatment has a realistic perspective. Treatment is based on a concrete treatment plan; achieving the goals in this plan receives explicit attention.

The additional treatment consists of three parts: psycho hygiene (education on the characteristics of the disorder, the effects on functioning and possible treatment), medication (if necessary) and treatment methods (in most cases behavioral therapy).

However, a report of the joint inspections (2007) showed that most institutions lack a professionally equipped multi-disciplinary working team responsible for the joint implementation of the proposed psychiatric, psychotherapeutic, system and group-based therapeutic approach. The main multidisciplinary link is the one between behavioral experts and the group coaches. Overall however, the group coaches are poorly trained in recognizing mental disorders and the guidance of the various target groups and psychopathology. After the publication of this report, improvement measures have been taken. But particularly the number of (child and adolescent) psychiatrists within juvenile custodial institutions is still very low and the skills of group coaches are susceptible to improvement.

Obligation to follow the treatment According to the civil code, a medical treatment in principle always requires consent by the juvenile and if he is not yet 16, his parents or guardian must give permission.

However, the director of a juvenile custodial institution may order a compulsory

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medical treatment, such as when immediate danger to the young person is imminent or when the younger seriously endangers others. Such a forced medical treatment will usually consist of the administration of forced medication, such as with young people with a serious mental disorder that perform uncontrollable and dangerous behavior.

This may be preferable to the fixing of mechanical devices such as a safety bed or a straitjacket. Before the director decides to proceed to a compulsory medical treatment, he should always consider whether the desired objective can be achieved with other, less far-reaching resources114. Consultation with a doctor is required. By or under the responsibility of the doctor, a plan of improvement has to be developed as soon as possible, aimed at a quick termination of the transaction. The forced medication used in this context is intended as a single event in a particular case. It would be better to transfer juveniles for whom compulsory treatment is deemed necessary to a mental health institution. For this reason, a judicial authorization for inclusion in a psychiatric hospital may be granted. Preferably, transfer takes place to a confined unit of a youth forensic psychiatric clinic: here, staff has experience with the criminal context.

Forced treatment is also possible in the context of secure youth care (Vlaardingerbroek, 2009). The Youth Care Act provides the framework for the treatment of those juveniles against their will, including the use of medical treatments like the administration of medicines. Treatment methods can be applied as long as this is necessary to fulfill the purpose of the stay or to the extent necessary for the safety of the juvenile or others.

The measures, methods of treatment and control, that can be included in the assistance plan, do not need the consent of the juvenile or the parent. However, the general rule is that the assistance plan shall be discussed with the juvenile. The so-called â&#x20AC;&#x2122;coercive elementsâ&#x20AC;&#x2122; of the assistance plan require the consent of a behavioral expert.

4.7. Development or aggravation of mental health problems during deprivation of liberty After studying Dutch (scientific) literature and talking to professionals in the field, the answer regarding this topic remains difficult to formulate.

In some Dutch publications, it is suggested that mental illnesses aggravate during the first period after placement in a closed (judicial) environment. According to these authors, the stressful criminal procedure and process of the deprivation of liberty may increase levels of depression (and therefore, the risk of self-mutilation and suicide

114â&#x20AC;&#x201A; An alternative could be isolation, sometimes combined with mechanical fastening means. However, according to the legislature, there is no general ranking in the radical nature of measures such as isolation, fastening of mechanical means or use of forced medication. This depends on the mental disorder of the juvenile.

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attempts) and the number of violent incidents (against both other youngsters and staff members). The stress could also reinforce already present ADHD symptoms or yield similar images (attention deficit, impulsivity and hyperactivity). For example, in the report on the care for youth with mental disorders in juvenile custodial institutions, the Council for Criminal Justice Administration and Youth Protection (Raad voor Strafrechtstoepassing en Jeugdbescherming, 2009) emphasizes that a prompt treatment of existing disorders is essential: the longer the absence of treatment, the higher the risk that the symptoms of disorders will aggravate.

However, substantiation of these rather general assertions with concrete Dutch data does not take place. Instead, some international publications are used to provide support for the claims made. For example, Van der Laan, Maaskant, Stams, Fukkink and Van der Voort (2007) use a publication of Harvey (2007) to point out that especially the first period of stay (the first months after entrance) are the most risky. According to Harvey, this is a very stressful period for the youth involved, during which most incidents occur (self-harm and suicide, violent incidents). Over time, the detainees have adapted to the new situation and the risk of incidents decreases.

Another international publication that is used to substantiate statements about the Netherlands is a study by Lee and Thompson (2009) about peer contagion in residential group care settings. Their results support the notions of (a trajectory class) of gradually increasing externalizing behavior problems, the strength of deviant peer density in predicting an individual youthâ&#x20AC;&#x2122;s externalizing behavior trajectories and significant associations between behavior patterns of youth and proximal peers.

However, while there is some evidence that suggests an increase in problem behavior during residential care, results from this study indicated that over 90% of the youth did not have an increase in problem behaviors and that positive peer influences may also be protective and inhibit problem behaviors.

Talking to an experienced child and youth psychiatrist in a Dutch juvenile custodial institution offers a somewhat different picture. In his experience, the opposite of aggravation of symptoms is what actually occurs: the strict regime, the fixed daily routine and the structured environment inside a juvenile custodial institution provides rest that causes a decrease in problem behavior. Although this does not happen instantly, after one of two weeks almost all youngsters are used to the rhythm in the juvenile custodial institution and this is reflected in their behavior. During this first period, having an eye for the stress that may be caused by the deprivation of liberty is sufficient. Youngsters can be helped to deal with this stress by using protective measures (more personal attention, moments of rest on their own room, a small group size, more contact with home, provision of information about the goal and perspective

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of their stay and formulation of a preliminary residential plan115). Still, there is one group that requires special attention, namely the mentally retarded and intellectually handicapped116 youth. They form a vulnerable group that experience a more than average amount of stress. This is translated into heavy worrying and unrest. The only form of ‘peer contagion’ that this child and youth psychiatrist has signaled in his extensive experience is the sporadic imitation of self-mutilation among girls.

In conclusion, the exploration of Dutch research literature and opinions of professionals does not allow for a conclusion about the relationship between the process of deprivation of liberty on the one hand, and emotional wellbeing and incidents in the area of selfmutilation, suicide attempts and externalizing problem behavior on the other hand.

As far as is known, the impact of a stay in secure, closed facilities on the emotional well-being of and mental disorders among young people has not been systematically studied in the Netherlands.

4.8. Possibilities and outcomes of family therapy Role of the family in the treatment Various laws stipulate that parents have some interference with procedures in the judicial youth institutions. For example, parents have some influence on the education and pedagogical activities as laid down in the treatment plan: the wishes of the youngster himself and his parents are as much as possible being taken into account. The director also involves the parents as much as possible when making a recommendation regarding an appropriate Schooling- and Training Program at the end of the stay in a juvenile custodial institution. Besides this, several accredited and provisionally accredited programmes for family treatment are available in the Netherlands (see table 8).

115 The joint inspections (Inspectie jeugdzorg, Inspectie van het Onderwijs, Inspectie voor de Gezondheidszorg & Inspectie voor de Sanctietoepassing, 2010) conclude that the provision of information to youth is a strong point of the Dutch juvenile custodial institutions. Juveniles are systematically being informed about the goal and perspective of their stay. On determined moments, the ‘Plan of Perspectives’ is discussed with every juvenile. This helps in offering the youth a predictable perspective which can reduce stress.

116 A person is intellectually handicapped when two criteria are present: the level of intellectual functioning is clearly below the average (IQ≤70) and there are deficits in or restrictions of adaptation behavior.

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Table 8. (Provisionally) Accredited family interventions that can be used within juvenile custodial institutions.

Name

Description

Functional Family Therapy (FFT)

A family-centered treatment system, designed for a wide range of clinical problems under the denominator ‘externalizing behavior problems of adolescents’ (12 -18 years), along with other family problems. FFT is aimed at changing the interactions between family members, improving the functioning of the individual members of the family and the family as a whole. FFT can vary from eight to twelve sessions with up to 30 hours of therapy to over 30 sessions with a duration from three to six months.

Multisystem Therapy (MST)

Treatment of behavioral disorders focusing on factors in the family, relatives, school, dealing with peers and the neighborhood. Can be imposed as a special condition. MST is designed for (delinquent) youth between 12 and 18 years who behave violently and antisocially.

The duration of MST can vary greatly, from two to four months to 47 months (up to 20 hours of therapy per month).

Multi Dimensional Family Therapy (MDFT)

Designed for youth between 12 and 18 years old who exhibit serious behavioural problems ranging from excessive alcohol or drug use, truancy, running away and all forms of antisocial and / or criminal behavior. A major underlying cause of such behavior is of psychopathological nature. MDFT focuses on the juvenile, his parents, problems at school, work and leisure. Each week, the therapist has two to three personal encounters with the juvenile, the parents or family members together – also third parties (like teachres) can be present.

Depending on the severity and complexity of the problem, MDFT takes three to nine months.

Luisteren Fonetisch lezen

Woordenboek -

New Perspectives upon Reentry (Nieuwe Perspectieven bij terugkeer)

An offer that is offered to the young ex-convict as part of aftercare. The intervention focuses on a wide range of problems, whereby the family is less central than in the previous interventions. The purpose of the guidance is to prevent recidivism and to enable the juvenile to function independently and to find a place in society. The youngster will be assigned a supervisor who is accessible 24 hours a day. If necessary, the supervisor can put in specific behavioral interventions. Family, friends, school and colleagues are involved in counseling. The target group is young people aged 16 to 23 years with an IQ over 75 who have committed at least three offenses, at least one of them being a serious crime. The guidance starts three months before the custody of the younger ends and takes about nine months.

Professionals in the Netherlands increasingly recognize the importance of involving the family in the treatment. Also young offenders appear to still find their parents and

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family important and expect support from them, in spite of the insecure attachment relationship. Despite this, it appears that possibilities for family therapy are not so often used. The reasons for this are: - Among the staff in juvenile custodial institutions, a lack of competence in this field is present. Expansion and/or training of treatment staff is highly desirable.

- Large travel distance between the parentsâ&#x20AC;&#x2122; home and the juvenile custodial institutions. Regional placement of youth is an important prerequisite for parents and guardians to be involved in the family treatment in juvenile custodial institutions. There should also be an adequate financial arrangement when parents have to live by an income at or below the social minimum.

- Parents do not meet the participation requirements (certain level of knowledge and skills, treatment motivation).

For the time being, parents often play a limited role in the treatment of youth in judicial youth institutions.

Outcomes and results The (expected) results of working with parents and families are promising: many studies show that the most effective programs are working with young people themselves and their parents and families (Baas, 2005; Boendermaker & Uit Beijerse, 2008; Van Rossum & Van der Steege, 2009). A treatment that only focuses on the individual youngster, hosts the danger that on release / return the juvenile will revert to the old behavior or the old situation. In the period after departure, factors in the home situation (crime or unemployment in the family, bad relationship with parents) appear to increase the risk of recidivism (Van der Geest e.a., 2005). Parent counseling therefore explicitly has a role in relapse prevention: the risk of recidivism in the period after departure can be influenced very focused.

5. RECOMMENDATIONS 5.1. Recommendations regarding the training of professionals Regarding the training of juvenile justice and health care professionals dealing with young offenders with mental health problems, the following actions should be undertaken: - Training of juvenile lawyers. Lawyers who handle juvenile cases should be (further) trained in knowledge of criminal and civil juvenile law, pedagogical understanding and empathy with the way of thinking of minors.

- Training of regular youth care in early detection and early treatment of mental

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disorders (especially among immigrant children) in order to prevent these youngsters from eventually ending up in a juvenile justice institution Training of forensic child and youth psychiatrists. First of all, there is serious need for the expansion of the number of psychiatrists that have received a forensic training during their university program. The future child and adolescent forensic psychiatrist needs to be trained on the following knowledge and skills: knowledge of legislation for children and adolescents and the interdependence between the legal frameworks; knowledge on the changing regular and judicial care field for youth and adults; specific diagnostic knowledge combined with a certain attitude and skills for children / adolescents and their family systems, and; knowledge of positioning and responsibilities of various actors and stakeholders (Duits, 2004).

In order to directly screen all juveniles for mental disorders at the entry of the juvenile custodial institutions, staff should be trained and expertise should be extended.

(Further) Training of pedagogical staff in juvenile custodial institutions in the field of family therapy is needed.

(Further) Training of group coaches in juvenile custodial institutions in adopting a pedagogical approach is needed.

During the first MHYO-meeting in London, it has been signaled that quite some professionals are not so motivated to work with young offenders (with mental disorders).

This especially applies to mental health professionals, but â&#x20AC;&#x201C; in a lesser extent â&#x20AC;&#x201C; also to judicial professionals.

Regarding the judicial professionals, it should be noted that there are no signs that the functions of juvenile judge and juvenile public prosecutor are unattractive to Dutch judicial professionals. But, as described earlier, juvenile cases have not always attracted lawyers. Juvenile cases were often viewed as not very appealing, for example because they were seen as badly paid and not resulting in any publicity. But in the last years, especially since the foundation of the Association of Dutch Juvenile Law Lawyers (VNJA), there has been a change in this attitude. More and more motivated juvenile lawyers with knowledge of criminal and civil juvenile law, pedagogical understanding and empathy with the way of thinking of minors have appeared.

Especially among mental health professionals, working with young offenders (with mental disorders) is not their first preference. Possible causes for this are: - Young offenders are seen as guilty perpetrators of sinful acts, not as victims. In the eyes of some mental health professionals, they should be punished instead of receiving help.

- Several mental health professionals, especially women, estimate the risk of being confronted with aggression and violence inside juvenile custodial institutions high. They fear physical and verbal violence against the staff.

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Mental health professionals are not always willing to work with clients that are not motivated for and/or disciplined in treatment; they prefer working with motivated clients in a voluntary context. These mental health professionals want to avoid spending time and energy in motivating the client to accept help and care.

Financial considerations: due to free market processes in health care, regular care institutions can offer better conditions of employment (salary). Especially executive staff members (group coaches) receive a relatively low financial reward when considering the seriousness of the problems among their target group.

The social status of a teacher in a juvenile custodial institution is experienced to be lower than that of regular teachers. Since becoming a teacher in a juvenile custodial institution could be considered a step down in someoneâ&#x20AC;&#x2122;s career, there is a risk that especially less talented teachers will work in juvenile custodial institutions.

A few years ago, there was indeed a high absence through illness, high staff turnover and low job satisfaction among group coaches (DJI, 2006). Possible causes were the low financial reward, lack of support and recognition and the stressful working environment. The situation is better now (Inspectie Jeugdzorg et al., 2010).

Suggestions to make working with young offenders in juvenile custodial institutions more attractive for mental health professionals are: - Reduce the level of experienced stress and give better salary to executive staff, so that they will stay longer. This will cause a shift in the focus from security to care / rehabilitation. Staff members who attach to care, experience more job satisfaction (Van der Laan et al., 2007). Better working conditions and more experience also result in elevated feelings of safety (Harvey, 2007). The level of experienced stress can be reduced by increasing support and recognition, giving training on the job, offering opportunities to follow relevant vocational education, formulating and executing policies regarding the prevention of control of violent incidents (etiquette, behavioral code) and offering aftercare after an incident.

- In recruitment campaigns or through general public relations, emphasize the attractive aspects of working in a juvenile custodial institution (like the variety in daily activities, for example crisis consultation, writing psychiatric / pro Justitia reports, inform judges when the case is being tried).

- Develop a strategy together with leading child psychiatrists how to engage more psychiatrists in the juvenile custodial institutions. Itâ&#x20AC;&#x2122;s very attractive to them if they can do research on psychiatric disorders besides the work as the psychiatrist. For example, in the Netherlands, the efforts of a passionate

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professor in forensic child and youth psychiatrist (prof. dr. Theo Doreleijers) have made this profession (and possibly even the whole field of forensic youth care) more popular among future health care professionals at his university.

5.2. Recommendations regarding community-based intervention and prevention The Netherlands are currently experiencing a reduced influx of juveniles in juvenile custodial institutions due to guidance to closed youth care and a shorter duration of placement. This development highlights the importance of the further expansion of community-based interventions. The following actions should be undertaken: - Make administrative agreements on stimulating an integral neighbourhood-

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oriented approach of the preventive youth policy, whereby the possibilities of welfare and social services are used and strengthened. Prevention and signaling should be designed locally: in short, powerful and practical direct lines between professionals, whereby medicalization and extra indication layers should be avoided. The own strength of citizens as well as stimulating the civil society should be central, whereby the own environment and volunteers offer a helping hand when necessary.

When necessary, make use of interventions that focus on factors in the home situation of the juvenile and those in his environment (“strengthening the pedagogical civil society”). This implies a further shift to a culture of community intervention. Training of pedagogical staff in the field of community-based intervention is needed.

The distinction between first line care (prevention: preventive, generalist, light ambulatory help in the environment of parents and children) and second line care (youth care: curative, specialist, with care plan) should be clear. Also, a smooth transition between the two is necessary.

Formulate administrative guidelines regarding ‘pressure’ and ‘compulsion’ with parental support. There is still a taboo among using pressure and compulsion in case of failure in parenting. Professionals need backing of the administration in order to intervene efficiently where necessary.

5.3. Recommendations regarding cooperation and between juvenile justice and mental health systems

interchange

Regarding cooperation and interchange between juvenile justice and mental health systems, the following actions should be undertaken: - To make the systematical study of the presence of psychopathology possible,

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it is important that - in collaboration between the judicial institutions and health care â&#x20AC;&#x201C; it is examined to what extent a graduated system of screening and diagnosis can be set up such that the scarce expertise is optimally exploited. The trajectory also has to be set up in such a manner that third party information can be utilized optimally and that the conclusions and recommendations are useful for all parties involved. In other words, the activities of the National Framework Juvenile Justice Instrumentation should be intensively continued.

Prevent miscomprehensions between the child and youth psychiatrist / psychologist and jurists by (further) investments in guidelines and trainings for mental health expert witnesses and pro Justitia reports.

Implement an even more coherent approach to youth problems. Before the Youth Care Act, voluntary and compulsory youth care were functioning as vertical columns, which caused severe problems. The unification of these systems has resulted in many improvements but there is still room for improvement. First of all, possibilities for exchange of data can be further expanded. Secondly, possibilities for non-judicial interventions (for example restorative efforts) should be further explored. Thirdly, more cooperation agreements / covenants between judicial and care partners should be made. This can reduce problems like parties who donâ&#x20AC;&#x2122;t know of each other, what they are doing, from which rules they are operating and in which way they can contribute to a positive development of youth and family.

Make the transition from residence in a juvenile justice institution to the free society more fluent by further improving data transfer and referral to youth care institutions. For example, regional coloring and embedding of the juvenile rehabilitation service could improve the chain cooperation.

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References Baas, N.J. (2005). Wegen naar het rechte pad. Den Haag: WODC. Bijl, R.V., Zessen, G. van, & Ravelli, A. (1997). Psychiatric morbidity among adults in the Netherlands: the NEMESIS-Study. Nederlands Tijdschrift van Geneeskunde, 141, 2453-2460.

Binsbergen, M.H. van (2003). Motivatie voor behandeling. Ontwikkeling van behandelmotivatie in een justitiele jeugdinrichting (proefschrift). Leuven-Apeldoorn: Garant.

Boendermaker, L., & Uit Beijerse, J. (2008). Opvoeding en bescherming achter tralies.

Amsterdam: SWP. Boon, A.E., Haan, A.M. de, & Boer, S.B.B. de (2010). Verschillen in etnische achtergrond van forensische en reguliere jeugd-ggz-cliënten. Kind en adolescent, 31(1), 16-28.

Brand, E.F.J.M., & Hurk, A.A. van den (2008). 10 jaargangen PIJ-ers. Kenmerken en veranderingen. Den Haag: Dienst Justitiële Inrichtingen.

Buysse, W., Komen, M., & Nauta, O. (2009). Evaluatie Landelijk Kader Forensische Diagnostiek Jeugd. Amsterdam: DSP-groep.

Buysse, W., Maarschalkerweerd, A., Loef, L., & Hilhorst, N. (2010). Overwegingen voor het adviseren van een gedragsbeïnvloedende maatregel. Amsterdam: DSP-groep.

Dienst Justitiele Inrichtingen (2006). Essentiele afbreukrisico’s & kwetsbaarheden. Justitiele Jeugdinrichtingen – een quick scan. Den Haag: Dienst Justitiele Inrichtingen.

Doek, J.E., & Vlaardingerbroek, P. (2009). Jeugdrecht en jeugdzorg. Amsterdam: Elsevier Juridisch.

Doreleijers, T.A.H. (1995). Diagnostiek tussen jeugdstrafrecht en hulpverlening (proefschrift).

Arnhem: Gouda Quint.

Duits, N. (2004). Jeugdstrafrecht en forensische jeugdpsychiatrie. In N. Duits, J.A.C. Bartels & W.B. Gunning (eds.), Jeugdpsychiatrie en recht (pp. 65-94). Assen: Koninklijke Van Gorcum.

Geest, V. van der, Bijleveld, C., & Wijkman, M. (2005). Delinquentie na behandeling. Een verkennend onderzoek naar geregistreerde politiecontacten, persoonlijke en omgevingskenmerken

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van jongeren uit een behandelinrichting. Leiden: NSCR. Geest, V. van der, Bijleveld, C., & Blokland, A. (2007). Ontwikkelingspaden van delinquent gedrag bij hoog-risicojongeren. Tijdschrift voor Criminologie, 49(4), 351-369.

Hamerlynck, S.M.J.J., Doreleijers, Th.A.H., Cohen-Kettenis, P.T., Vermeiren, R., & NautaJansen, L.M.C. (2006). Agressie en psychische stoornissen bij meisjes in justitiële jeugdinrichtingen.

Onderzoek naar de sociaaldemografische, psychiatrische en agressiegerelateerde kenmerken van meisjes van 12 tot 18 jaar die in gesloten justitiële jeugdinrichtingen zijn geplaatst. Amsterdam: VUmc / De Bascule.

Hamerlynck, S.M.J.J. (2008). Girls in Juvenile custodial institutions: psychopathology and Sexual Risk Behavior (dissertation). Amsterdam: Vrije Universiteit. ‘t Hart-Kerkhoffs, L.A. (2010). Juvenile sex offenders. Mental health and reoffending.

Amsterdam: Vrije Universiteit.

Harvey, J. (2007). Young men in prison: surviving and adapting to life inside. Cullompton: Willan.

Hempel, I.S., Buck, N.M.L., & Marle, H.J.C. van (2009). De PIJ Voorbij. Een onderzoek naar de justitiele en psychiatrische vervolgcontacten na een PIJ-maatregel. In: T.I. Oei & M.S. Groenhuijsen (red.), Forensische psychiatrie en haar grensgebieden. Actualiteit, geschiedenis en toekomst (pp. 607-621). Alphen aan den Rijn: Kluwer.

Inspecties Jeugdzorg, Inspectie van het Onderwijs, Inspectie voor de Gezondheidszorg & Inspectie voor de Sanctietoepassing (2007). Veiligheid in justitiele jeugdinrichtingen: opdracht met risico’s. Den Haag: gezamenlijke inspecties.

Inspectie Jeugdzorg, Inspectie van het Onderwijs, Inspectie voor de Gezondheidszorg & Inspectie voor de Sanctietoepassing (2010). Veiligheid in justitiele jeugdinrichtingen: risico’s aangepakt, maar kwetsbaar. Den Haag: gezamenlijke inspecties.

Kepper, A., Veen, V., Moshouwer, K., Stevens, G., Drost, W., Vroome, T. de, & Vollebergh, W. (2009). Middelengebruik bij jongens in Justitiële Jeugdinrichtingen. Het gebruik van tabak, alcohol, cannabis en harddrugs bij jongens met en zonder PIJ-maatregel. Utrecht: Universiteit Utrecht, departement Algemene Sociale Wetenschappen.

Konijn, C. (1999). Blowende jongeren: een toenemend probleem voor groepsopvoeders.

Tijdschrift voor Sociaal Pedagogische Hulpverlening, 28, 32-38.

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Korf, D., Benschop, A., & Rots, G. (2005). Geweld, alcohol en drugs bij jeugdige gedetineerden en school drop-outs. Tijdschrift voor Criminologie, 47(3), 239-254.

Laan, P. H. van der (2006). Just desert and welfare: juvenile justice in the Netherlands.

In J. Junger-Tas & S.H. Decker (eds.), International Handbook of Juvenile Justice (pp. 145-170).

Dordrecht: Springer.

Lee, B.R., & Thompson, R. (2009). Examining externalizing behavior trajectories of youth in group homes: Is there evidence for peer contagion? Journal of abnormal child psychology, 37(1), 31-44.

Laan, P. van der, Maaskant, G., Stams, G., Fukkink, R., & Voort, P. van der (2007). Veiligheid en continuiteit van zorg in justitiele jeugdinrichtingen.

Linden, A.P. van der (2004). Interactie gezondheidsrecht, civiel en strafrecht. In N. Duits, J.A.C. Bartels & W.B. Gunning (eds.), Jeugdpsychiatrie en recht (pp. 344-358). Assen: Koninklijke Van Gorcum.

Lodewijks, H. (2008). Een kinder – en jeugdpsychiater in een justitiële jeugdinrichting.

Tijdschrift voor orthopedagogiek, 47(2), 92-99.

Luijpers, E.T.H., Overbeek, G.J., & Meeus, W.H.J. (2001). Risicogedrag van adolescenten 2.

Prevalentie, persistentie en samenhang. Den Haag: Minsterie van VWS. Matthys, W., Vanderschuren, L.J.M.J., Nordquist, R.E., & Zonnevylle-Bender, M.J.S. (2006). Factoren die bij kinderen en adolescenten een risico vormen voor gebruik, misbruik en afhankelijkheid van middelen. Den Haag: ZonMw. Melchior, M. (2005). Verdriet komt wel als ik twintig ben. Een kinder- en jeugdpsychiater in een justitiele jeugdinrichting toont de praktijk. Medisch contact, 60(21), 884-886.

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Vermeiren, R., Schwab-Stone, M., Ruchkin, V., De Clippele, A., & Deboutte, D. (2002).

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Comprehensive psychiatry, 43, 142-149.

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Vreugdenhil, J. (2003). Psychiatric disorders among incarcerated male adolescents in The Netherlands (proefschrift). Amsterdam: VU Amsterdam.

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Vreugdenhil, C., Doreleijers, Th.A.H., Vermeiren, R., Wouters, C.F.J.M., & Brink, W. van den (2004). Psychiatric disorders in a representative sample of incarcerated boys in the Netherlands.

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Weijers, I., Hepping, K., & Kampijon, M. (2010). Jeugdige veelplegers. Amsterdam: Uitgeverij SWP. Zegers, M. (2007). Attachment among institutionalized adolescents. Mental representations, therapeutic relationships and problem behavior. Amsterdam: VU Amsterdam (proefschrift).

Zuur, G.M. (2004). De Raad voor de Kinderbescherming en civiel recht. In N. Duits, J.A.C. Bartels & W.B. Gunning (eds.), Jeugdpsychiatrie en recht (pp. 242-249). Assen: Koninklijke Van Gorcum.

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Chapter VI Analysis of the current situation of young offenders with mental problems in Poland ............................................................................................................. by Monika Barciszewska and Joanna Sadowska Fundacja Diagrama - Pomoc Psychospoleczna Experts Marek Ignaczak Director of the National Centre of Juvenile Forensic Psychiatry in Garwolin, maximum security unit (Krajowy Osrodek Psychiatrii Sadowej dla Nieletnich w Garwolinie) Piotr Szylko Head of the division for juveniles with mental disorders in Psychiatric Hospital in Lubiaz, reinforced security unit (Wojew贸dzki Szpital dla Nerwowo i Psychicznie Chorych w Lubiazu) Wanda Kosikowska Director of the Diagnostic - Consultative Family Centre at the Regional Court (Rodzinny Osrodek Diagnostyczno- Konsultacyjny)

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Table of Contents ......................................................................................................

Acknowledgements 1. PROFILE OF THE MENTALLY ILL JUVENILE OFFENDER

1.1. Mental health problems among young offenders in Poland 1.2. General background of young offenders with mental health problems 1.3. Family situation of young offenders with mental health problems 1.4. Misuse of substances and behavioural disorders of young offenders 1.5. Comorbidity of mental health disorders among young offenders 1.6. Special needs of young offenders with mental problems

2. LEGAL FRAMEWORK: PENAL AND CHILD CARE REGULATIONS

2.1. The juvenile justice system in Poland 2.2. The child care system in Poland 2.3. Penal responsibility of young offenders with mental health problems 2.4. Specific legislation concerning young offenders with mental health problems 2.5. Protection of the best interest of the child in juvenile justice and health systems 2.6. Entrusted entities involved in court proceedings in order to protect childâ&#x20AC;&#x2122;s rights 2.7. Handling of information and professional confidentiality regarding young offenders 2.8. Legal basis and possibilities for mixed systems of closed and outpatient treatment 2.9. Legal and medical measures in case of non-completion of treatment

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3. PROFESSIONAL ROLE AND SKILLS DEVELOPMENT

3.1. Co-operation between juvenile justice and health care professionals 3.2. Specialized trainings of juvenile justice and health professionals 3.3. Multidisciplinary cooperation between juvenile justice and health care professionals

4. INTERVENTION APPROACHES: WHAT IS WORKING AND WHAT IS NOT

4.1. Standardized resources for psychiatric diagnoses and assessments 4.2. Therapeutic intervention for young offenders 4.3. Specific mental- health units for young offenders with mental health problems 4.4. Family therapy- possibilities and results 4.5. Prevention programmes for young people with behavioural disorders 4.6. Legal regulations regarding a psychiatric treatment

5. RECOMMENDATIONS AND MAIN PROBLEMS

5.1. The main problems of the mental health intervention/ protection system in Poland 5.2. The training and role of professionals and actors.

5.3. Cooperation and interchange between mental-health and justice systems.

References Biographies of experts

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Acknowledgements The problems of mental health of children and adolescents do not belong to the questions that frequently arise in public discussion in Poland. Mental health of young offenders is an even more neglected subject. This publication was prepared with the help of professionals who deal with mentally ill children and adolescents in their daily work. We would like to express our gratitude for their contribution, in particular, thanks go to dr. Piotr Szylko, psychiatrist, head of the division of reinforced security for juveniles with mental disorders in Psychiatric Hospital in Lubiąż and to dr. Marek Ignaczak, psychiatrists, director of the National Centre of Juvenile Forensic Psychiatry of maximum security in Garwolin.

1. PROFILE OF THE MENTALLY ILL JUVENILE OFFENDER 1.1. Mental health problems among young offenders in Poland According to the Act on Mental Health Protection of 19th August 1994117, a person with a mental disorder is a person: mentally ill, mentally disturbed, showing other disturbances of mental activity which, in accordance with the state of medical knowledge are classified as mental disorders.

To present this issue properly, one should quote relevant statistics and surveys conducted recently in Poland on the mentally impaired young offenders. In fact, there are no resources that can provide us with actual and very precise data. To elaborate on this subject, we drew information from interviews conducted with professionals in contact with young offenders and from the report on reformative centres for juveniles118.

According to the data presented in the mentioned report, only 7% of young offenders in detention do not show any kind of mental disorder.

Organic damages are responsible for behavioural disorders in 10% of this population. Mostly young offenders in custody are extremely emotionally unstable ­ and have difficulty in the development of cognitive sphere and in their hierarchy of values. Such difficulties are normal effects of the process of adolescence, but residence in custody and former experiences of living in a dysfunctional family and/or of the adolescent social environment intensify those difficulties what may contribute to the

117 Ustawa o ochronie zdrowia psychicznego z dnia 19 sierpnia 1994 r.

(Dz.U.1994.111.535); Act on Mental Health Protection of 19th August 1994; 118 Raport o schroniskach dla nieletnich i zakładach poprawczych, Ministerstwo Sprawiedliwości, Warszawa 2005 (Report on juvenile shelters and reformative centres, Ministry of Justice, Warsaw 2005); www.ms.gov.pl/aktual/ raport.rtf

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development of serious Conduct Disorders (ICD 10 – F91).

Behaviour of young offenders is mostly characterised by: Anti-social behaviours - characterized as not taking into account the interest of other persons in the realization of one´s own purposes, manipulative attitude towards people, uncontrolled spontaneity in satisfying personal needs and aspirations; Emotional instability - uncontrolled emotions, sudden changes of emotional states, often very strong in intensity; Activity disorders - mainly hyperactivity, oversensitivity, irascibility, taking excessive risks, High level of aggression- (particularly destructive, often identified with hostility; this aggression is mainly directed outside; behavioural disorder of this type is characteristic of and increasing among girls); Auto-aggression- (leading to self-mutilation, injuries and suicide attempts), manipulation of surroundings (in custody this manipulation assumes the form of a seeming adaptation to the requirements and expectations of the centre); Sexual behaviour disorders- noticed particularly among girls in the form of intensive sexual drive (few cases).

According to the psychiatric and psychological surveys conducted on the population of juveniles in detention,119 behavioural disorders revealed by this group were diagnosed as: - Disorders of neurotic character, 40% of the population of detained juveniles - Personality development disorders which most often lead to the development of dissociative personality (ICD-10 F60.2) - 40% of the population of detained juveniles. Histrionic personality (ICD-10 F60.4) and avoidant personality disorder (ICD-10 F60.6) are also frequent.

The above mentioned source reports that juveniles in custody are characterized by a lower level of intellectual development.

- The average and above the average level of intellectual functioning is about 65 % of this population; - Mental retardation (IQ below 70) is about 10 % of this population.

Disorders most frequently diagnosed among young offenders: Conduct Disorders (ICD-10 F91), interviewed practitioners (see annex) state that

119 Raport o schroniskach dla nieletnich i zakładach poprawczych, Ministerstwo Sprawiedliwości, Warszawa 2005 (Report on juvenile shelters and reformative centres, Ministry of Justice, Warsaw 2005); www.ms.gov.pl/aktual/ raport.rtf

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disorders of this category are very often overdiagnosed.

Mixed Disorder of Conduct and Emotions (ICD-10 F92), disorders of this category are very often but, in contrary to conduct disorders, are underdiagnosed, in particular Depressive Conduct Disorder (F92.0). Depressive conduct disorders are very common among children and adolescents but the diagnosis is difficult as symptoms are different than in the case of adults. Development of a disorder of this kind is caused by the long chain of events since the birth day of the child. Every stage of upbringing has a meaning. Growing up in a dysfunctional environment – unfriendly, emotionally instable, characterised by antisocial and aggressive behaviour patterns causes strong feelings of anxiety.

“Depression in teens is confused with the personality changes, typical for adolescence. Teens experience the so-called Weltschmerz, world- pain. In this age group a significant proportion of suicides is noted. Depressive adolescents, particularly boys, display negativism, aggression and antisocial behaviour. There are also: anxiety, harshness, strong desire to leave home, impatience, dysphoria, hyperactivity, disobedience. Unfortunately, pouting, reluctance to help at home, school problems, alcohol and drug abuse, poor personal hygiene and messy room are assigned to the specifics of adolescence, ignoring the possibility of adolescent depression.”120 Disorders of psychological development (ICD-10 F80-F89), Asperger’s syndrome F84.5 is underdiagnosed.

Mental and Conduct Disorders due to the use of psychoactive substances (ICD-10 F10-F19) Personality development disorder, is considered to be a childhood risk factor or early stage of a later personality disorder in adulthood. This term is used to emphasize the changes in personality development which might still take place and the open outcome during development. According to this concept, in case of immature persons we cannot recognize personality disorders.

1.2. General background of young offenders with mental health problems Juvenile delinquency analysed in terms of mental disorders is a complex issue and it is impossible to point to a single factor responsible for this phenomenon. Mental disorders may contribute to the development of antisocial behaviour but if they are well diagnosed and properly rehabilitated and supported by loving parents, then the risk of young people offending will probably be reduced. On the other hand, mental conditions depend on previous childhood experiences (e.g. post traumatic stress, sexual abuse, indifferent attitude of parents, aggressive and violent behaviour patterns

120 http://portal.abczdrowie.pl/depresja-dzieci

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in the family, etc.), and on the abuse of psychoactive substances. The tendency towards substance misuse is also related to experiences in the family environment. Therefore, the background of young offenders displaying mental health issues should be described in the general context of social maladjustment which probably, in this case, is stronger than in a group of young offenders who do not display any mental health problems.

According to data provided by the Ministry of Justice (Report on juvenile shelters and reformative centres, 2005) and by interviews conducted with experienced practitioners, all young offenders in custody come from (strongly) dysfunctional family environments.

Only a small percentage of children come from the families which are apparently normal with hidden desocialization mechanisms.

The following factors contribute to the increasing tendency towards social maladjustment of minors: - Family history of alcoholism - Single-mothers families (lack of proper male influence) - Families with many children - Families with many children from different and absentee fathers - Violent and aggressive behaviour patterns in the family - Low educational competencies of parents - Attitude of rejection and lack of love and acceptance shown by parents - Physical, emotional or sexual abuse experienced by minors - Low economic status of the family - Increased unemployment - Neglecting children with initial symptoms of mental disorders in the first years of their life - Substance abuse among minors - Low effectiveness of preventive, educational and social rehabilitation measures used toward the minors It has to be mentioned that many young offenders are former foster-children of orphanages which in Poland are real â&#x20AC;&#x153;hotbedsâ&#x20AC;? of criminality. Almost all of them are overcrowded and run by inadequately small staff with low educational background and skills. In such an environment, the first manifestation of violence is just a matter of time. According to the data provided by the Ministry of Labour and Social Policy,121 in the first semester of 2010, there were about 22500 children in orphanages and over 62600 lived in foster-families. Almost every one of them experiences bullying and violence in various forms. Most of them (if not all), due to the pathological history of the family, display conduct disorders and mental health issues. Frustration of basic needs

121â&#x20AC;&#x201A; Statistics of the Department of Family Policy of the Ministry of Labour and Social Policy, MPiPS-03

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(safety, love and the need to belong) do not allow them to develop higher emotionality and is likely to turn into aggressive behaviour. Foster-children live in an unfriendly environment where it is essential to protect one´s own safety first. Therefore, violence is present in their lives from the start and is so prevalent that it becomes the only known way of solving daily problems and conflicts. Foster-children are more likely to break the law even if they were born in “normal” families.

1.3. Family situation of young offenders with mental health problems The family environment is a significant factor responsible for nearly every success and failure of a child. According to the data of the Ministry of Justice (Report on juvenile shelters and reformative centres, 2005) all juvenile delinquents in custody come from dysfunctional and strongly dysfunctional family environments with pathological substratum.

Family situation of the young offenders Types of dysfunctions

%

1.  Lack of educational skills combined with the presence of: • violence • alcoholism • broken family structure, informal relationships • delinquency  Broken family structure – single mother, single father, grandparents  Broken family – reconstructed, concubinage

2.

 Apparently fully-structured family with hidden desocialization mechanisms

75-92

8-25

In the first situation, we can point out families of low or non educational competences, where alcohol, violence and delinquency determine the quality of daily life. In such families almost every sphere of a child’s development is neglected. More often than not, a child may be sexually abused by the closest members of their family (brother, father, uncle, mom’s current partner). If a child suffers from any mental or physical dysfunction then parents are not able to provide for a suitable treatment and rehabilitation for them, especially in the first years of their life, which is essential for the improvement of their mental condition. The treatment should be started as early as possible, but

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very low parental awareness and consciousness of both the childâ&#x20AC;&#x2122;s mental defects as well as possibilities of rehabilitation, are the main reasons of negligence which as a consequence can result in the further maladjustment of the child. Even if children donâ&#x20AC;&#x2122;t display any initial mental disorders, the negligence of their emotional, social as well nutritional needs may contribute to the development of symptoms of mental retardation or behavioural disorders.

The second group is made up of single parent families, usually single mothers.

The general problem of these families is a lack of proper male influence which affects not only a childâ&#x20AC;&#x2122;s development but also the attitude of its mother. Single mothers may attempt to compensate for the lack of a father-figure. It may contribute to the development of a permissive attitude, which means providing children with a high level of freedom by demanding little in exchange. Such an attitude also means the lack of a daily structure and daily duties. Also, very often it is the case that single mothers try to keep the discipline, but if they are not consistent (some days they are too strict and punitive and others too permissive) the child is not able to learn the right behavioural patterns because they receive mixed signals: acceptance and rejection.

These factors may affect substance abuse or dependence.

1.4. Misuse of substances and behavioural disorders of young offenders Frequent use and abuse of alcohol and other psychoactive substances among young people is the most alarming problem nowadays contributing to increasing maladjustment and delinquency, and is a consequence of the social exclusion of young people in Poland. According to the data of the report of the Ministry of Justice (Report on juvenile shelters and reformative centres, 2005), almost 80% of juvenile males in custody and 60% of females use alcohol very often and a significant number of these minors abuse alcohol. About 3% of this population was recognized as alcohol dependents. With regard to drug use, about 75% of boys in custody and 60% of girls in custody regularly consume psychoactive substances of every kind. The most popular ones are highly addictive, synthetic drugs in their pure form.

The prevalent pattern of the use of substances is the combination of all kinds of substances with alcohol. Among 5% of the population, polytoxicomania was recognized - multiple drug use and/or simultaneous dependence on different drugs.

The data based on the interviews conducted with child psychiatrists of therapeutic centres for juvenile offenders with mental problems shows that abusing substances is very common among this group. The misuse of substances is most likely the outcome of other mental health difficulties. Although the predisposition or need for intoxication is caused or strengthened by the psychic problems, intense and longterm use of those substances may lead to the development of Mental and Conduct Disorders due to the use of psychoactive substances (ICD-10 F10-F19).

All psychoactive substances including alcohol may cause disorders of two types:

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substance use disorders and substance-induced disorders. Substance use disorders include abuse and dependence. Substance-induced disorders include intoxication, withdrawal, and various mental states such as: cognitive disorders, psychosis, anxiety disorders, depression, mood disorders, sleep and eating disorders that the substance induces when it is used.

Intoxication is the direct effect of the substance after an individual has used or has been exposed to the substance. Different substances affect individuals in various ways, but some of the effects seen in intoxication might include impaired judgment, emotional instability, increase or decrease in appetite, or changed sleep patterns.

Generally it is observed that long term intoxication may cause hyperactive behaviour, severely weakened auto-control and a tendency to risk behaviour such as prostitution.

Among addicted juveniles under custodial measures including therapeutic treatment, the most prevalent are Mental and Conduct Disorders due to use of psychoactive substances (ICD-10 F10-F19), Conduct Disorders (ICD-10 F91), Mixed Disorder of Conduct and Emotions (ICD-10 F92).

1.5. Comorbidity of mental health disorders among young offenders The precise number of young offenders under therapeutic measures is not easy as the problem of young people in conflict with the law is shared between two different ministries: the Ministry of Justice and the Ministry of Education. Depending on the type of offense committed, the family court can sentence a young person to placement in one of the centres under the control of the Ministry of Education such as: the Youth Centre of Sociotherapy, the Youth Educational Centre, or in one of the centres of Ministry of Justice such Reformative Juvenile Centre. Each of the mentioned centres has special wards or functions as an independent revalidation or therapeutic entity. Furthermore, there are psychiatric units of court psychiatry, subjected to the Ministry of Health, dedicated to profoundly mentally ill young offenders. One can estimate approximately the total number of young offenders displaying mental health issues according to the data coming directly from this particular entity.

1. In the custodial therapeutic system of court psychiatry (with security reinforcement) for juveniles, there are about 140 young offenders hospitalized with mental disorders.

2. Youth Centres of Sociotherapy for the mildly mentally impaired: about 85 juveniles; 3. Youth Educational Centres for the mildly mentally impaired: about 95 juveniles; 4. Detox treatment unit with reinforced security: 30 juveniles; 5. Reformative- Therapeutic Juvenile Centres (for young offending addicts): about 65 juveniles; 6. Reformative- Revalidation Juvenile Centres: about 215 juveniles.

Altogether there are currently about 630 juveniles suffering from mental disorders of

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different aetiology and intensity in custody. It should be mentioned that this number does not reflect the scale of the problem as the centres are usually full or overcrowded.

Many young offenders, including those with mental issues, sometimes have to wait months for a free place in a therapeutic centre or psychiatric hospital.

For example, according to the data provided by the Central System of Juvenile Direction122 (Centralny System Kierowania Nieletnich) at the Methodological Centre of Psychological and Pedagogical Assistance (Centrum Metodyczne Pomocy Psychologiczno- Pedagogicznej) the following are currently waiting for a free place (data from the 23rd of August 2010): - Over 60 mildly mentally impaired children (56 boys and 5 girls), and over 210 who have developed normally (155 boys and 56 girls), are waiting for a place in the Youth Centres of Sociotherapy; - Over 60 mildly mentally impaired children (49 boys and 13 girls), and nearly 480 who have developed normally (427 boys and 49 girls), are waiting for a place in the Youth Educational Centres;

1.6. Special needs of young offenders with mental problems For the full and harmonized development of every child, fundamental needs satisfaction is essential. The environment which best satisfies a child’s needs, is the family.

In psychology we may come across many theories of needs but all of them agree on this main point. In this study we use the theory of Abraham Maslow. According to him, there are two levels of needs – basic and higher. The higher needs cannot develop while the basic level is not satisfied. He specifies such fundamental needs as: physiological, safety, love and belonging and higher needs as: esteem, self-actualization, understanding and esthetical.

The physiological needs – food, water, and sleep - are fundamental. When these are relatively well met then new ones appear, among others the safety need. A child manifests the safety need by demanding undisturbed daily rhythm and order. Every child needs an organized environment, not chaos. Problems that frustrate the safety need are conflicts, parental separation, death of loved ones. Self-esteem, empathy and responsibility, depend on fulfilment of the need for love and the need to belong. When the cognitive and activity needs are met, intellectual and socialization abilities can be developed successfully.

Unsatisfied needs become a source of frustration, which, subsequently, can contribute to the social maladjustment of the person. It is widely believed that social maladjustment is an effect of a permanent frustration of needs. We distinguish such psychological symptoms of maladjustment as, among others, low self esteem, depression, feeling of injustice, oversensitivity, dependence in relationships, anxiety

122 https://www.systemkierowania.cmppp.edu.pl/

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of failure, unspecified anxiety of new situations, feeling of isolation, aggression, nonobservance of rules and other regulators of social coexistence.

Therefore, it depends on the family whether the child, in its adult life, will be a mature person who is able to fulfil various social roles, to face challenges, to build relations with others in a socially-accepted way, or rather will be a person displaying considerable anxiety and mental stress, which can contribute to the development of immature behaviour.

Juvenile offenders with mental disturbances are mainly children, whose basic needs have not been adequately met in the family environment, which usually is defined as educationally inefficient. Frustration of these needs led to the improper development of attitudes towards oneself and towards the environment, and subsequently to the emergence or deepening of deficits in the mental functioning sphere. The therapy of such persons first of all should focus on meeting the needs constantly neglected by the family. The correct and comprehensive psychological/psychiatric diagnosis is essential for the proper identification of patient needs and for planning an effective therapy. The approach to every minor, whether they display a mental disorder or not, must always have an individual character.

In all the institutions for minors, from Youth Centres of Sociotherapy to psychiatric units for juveniles, the treatment is based on individual diagnosis and therapy planning in accordance with techniques that are matched to the individual needs of each patient. These are assumptions, but in fact, staying in such institutions (in isolation) is not conducive to meeting most of the needs of the minor, and can frustrate even further, among others, the safety need.

Many minors staying in educational/rehabilitation centres display anxiety due to the new and unfriendly environment. Mainly, it is an anxiety caused by a new place, which is perceived by them as a severe punishment, and the fear of violence and of being sexually abused by other foster-children, which is usually justified.

The overcrowded environment of maladjusted minors and of underqualified and emotionally uncommitted educators, does not help in building deep and mature bonds, so that, for most minors, their stay in such a place turns into a struggle for survival.

In order to facilitate proper therapy and the rehabilitation process of mentally disturbed minors, it is fundamental to provide them with a safe environment â&#x20AC;&#x201C; that is free from any threats, predictable, friendly and, most importantly, full of acceptance.

The accepting attitude of educators towards minors allows them to build a mutual trust and closer ties. In most cases, this is arduous work, and the first effects are visible only after 6 months of consistent influence. The therapists underline, that the establishment of closer ties with minors, that is safety need satisfaction, is the first necessary step, and at the same time the first tremendous success of each therapeutic treatment. The majority of offending juveniles with mental problems comes from an environment where, among others, interpersonal relationships were based on aggressive, antisocial conducts, where an adult figure wasnâ&#x20AC;&#x2122;t able to provide secure life conditions established

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through love and trust. Therefore, the most urgent need of these children is the need for regular contact with one adult figure who is a behavioural scientist (psychologist, psychiatrist, pedagogue) who is able to build long-term, intense and stable contact with the minor consistently based on trust.

2. LEGAL FRAMEWORK: PENAL AND CHILD CARE REGULATIONS 2.1. The juvenile justice system in Poland The proceedings in juvenile cases are regulated in Poland by the Juvenile Act of the 26th October 1982. The most important aspects of these proceedings, based on the above mentioned act, are presented below: A minor is defined as a person: 1. under the age of 18, for the purpose of protection and preventing of demoralization123 2. between the age of 13 and 17, for the purpose of criminal proceedings 3. up to the age of 21, for the purpose of executing educational and reformatory measures Juvenile proceedings are conducted by family courts. The measures used are as follows: Educational measures: - reprimand; (etc.)

- obligation to behave in a certain way, redress wrongs, perform specific works, participate in educational classes - appointment of parental/guardian supervision - appointment of youth/social/work organization supervision - curator supervision - prohibition of driving - confiscation of goods obtained as a result of criminal offence - placement in a foster family, correction centre or socio-therapy centre.

123 Demoralization – according to the Dictionary of Polish Language, it is a slackness, especially moral, corruption and lack of discipline. According to the Juvenile Act, demoralization means an especially intensive and relatively lasting form of social maladjustment. It is a process of departing from socially binding moral norms displayed by carrying out prohibited acts, systematic evasion of school or occupational education obligation, use of alcohol or other intoxicating agents, prostitution, vagrancy, joining criminal groups.

The term “demoralization”, specific for Polish legislation on minors, is claimed to be imprecise and unclear. What is more, describing a juvenile as “demoralized” implicates a pejorative judgment and devalues the educational character of the law. It has been suggested to replace it by the term “if the child’s well-being is threatened…” Consequently, not only the negative connotation would be eliminated, such change would also give wider possibilities for its use i.e. a chance to take action in a situation when the child’s well-being is threatened.

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Before placing a minor in a youth correction centre, socio-therapy centre or educational centre, the court files for an opinion from a family diagnostic and consultation centre or another specialist institution. The court orders a mental assessment to be performed by 2 psychiatrists. The experts can observe the minor for no longer than 6 weeks.

The corrective and therapeutic measures are applied up to the age of 18.

Corrective measures: Placement in a correction centre (art. 5, art. 6, section 10 and art. 10 of the above mentioned Act) constitutes the most severe measure that can be taken against a minor. The decision is made when all previous educational measures have failed to reach the expected goals. Other reasons to place juveniles in a corrective centre are: high level of demoralization and the assumption that milder measures will not reach the anticipated objectives. The corrective measures are used until the age of 21. The order for corrective measures is assumed non-existent after the minor reaches the age of 23.

The order of the Minister of Justice of the 17th of October 2001 on young offender institutions and juvenile shelters124 describes the types and organization of juvenile correction centres and shelters. It sets out detailed rules for management, admittance, transfer, release and residence of the minors in these institutions as well as the manner of supervision, including pedagogical care. The execution of educational and corrective measures aims to raise an aware and honest citizen. This is why educational activity should aspire to the universal development of personality and abilities of juveniles as well as their preparation for socially useful work (art. 65, section 1 and 2). Young offender institutions and juvenile shelters offer: general and vocational education, cultural, educational and sports activities aimed at developing social activity of minors and training them for socially acceptable work, as well as improving their access to health benefits (art. 66 point 2).

The court can order placement in a specific type of correctional centre. The types of corrective measures are as follows: 1. Social rehabilitation - For mildly demoralized – educational work in an open community - For those in need of direct supervision - For severely demoralized – with intensive supervision 2. Rehabilitation and revalidation, for mentally impaired 3. Rehabilitation and therapy, for children with MH problems and/or addicted In the case that any substantial improvements are noted, the placement in the centre can be temporarily suspended for a period of 1 to 3 years, during which the court orders educational measures. If, during that time, juveniles do not follow the court orders (related to their responsibilities and supervision), or their behaviour points toward further

124 Rozporządzenie Ministra Sprawiedliwości z dnia 17 października 2001r. W sprawie zakładów poprawczych i schronisk dla nieletnich, (Dz. U. Nr 124, poz.1359)

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demoralization, or they commit a severe crime, the temporary suspension is annulled.

Any change or transfer to a centre of strict discipline requires the approval of a family court judge.

Minors can receive a conditional discharge after a stay of 6 months in a corrective centre and after a year long stay in a strict discipline centre.

Depending on their mental health condition, the court can rule for the minor to be placed in a: - Mental hospital or other health institution, if he/she is mentally impaired, mentally ill or addicted; - Nursing Home, if he/she is severely impaired; - Attendance centre or youth centre of therapy and social integration, if he/ she only needs educational care The court can review juvenile delinquency cases according to Criminal Law Code when: - the minor commits a severe crime (art. 10 of criminal law code), but the ruling was commenced before he/she came to age. In this case, preparatory proceedings are directed by the family judge; defence is obligatory.

- the minor commits a general or tax crime and the proceedings were commenced after he/she came to age.

Ruling on juvenile punishment According to legal regulations, rulings on juvenile punishment takes place as a last resort, when all other measures of resocialization have failed. Polish solutions in this matter do not differ from modern European regulations and do not pose a reason to believe that the entire model of dealing with juvenile delinquency is repressive in its character.

-

The first legal basis of the act of 1982 (art. 13), refers to a minor who committed a criminal act described in art. 1 section 2, section mark 2, but at the time of ruling is under the age of 18 and for whom there is a rationale to rule for placement in a correction centre. The ruling on punishment is possible only if, in the courtâ&#x20AC;&#x2122;s opinion, the correction measures would not be appropriate.

-

Another basis for ruling for juvenile punishment (art. 94) refers to a similar situation, except the minor reaches the age of 18 before the order for placement in a correction centre. The court rules such a placement inappropriate and is able to punish the criminal.

Ruling on juvenile punishment is unique in its character and, in the above instances, is related to a minor reaching the age of criminal responsibility, which means that they will be sentenced like an adult, even though they committed the crime while being a minor. At the time of ruling, the court commutes the sentence. Imprisonment or restriction of liberty

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cannot last longer than after the offender reaches the age of 21.

Apart from the above mentioned legal basis, there is also a regulation contained in art. 10, section 2 of the criminal law code, which states that a minor who committed a crime at the age of 15 bears criminal responsibility, provided that the circumstances and maturity of the offender, their abilities and personal assets weigh against the offender, especially if any previously used educational or corrective measures turned out to be futile. The lowering of the age (to 15 years) for the criminal responsibility, held for strictly described offences, poses certain modification on the educational and resocialization approach of dealing with the minors. Minors, according to article 10, section 2 of the criminal law code, are accountable for their actions in compliance with criminal law. Thus, all acts contained in the code are applicable. At the same time, minors under the age of 17 cannot be held accountable because they are not yet emotionally mature, which is a requirement for social assessment of a deed, and they are not able to differentiate deeds that are socially negative. However, art. 10, section 2 of criminal law code is an exception in this matter.

Minors are placed in a juvenile shelter (remand for minors) in the case of justified fear that they will go into hiding, cover up their tracks or the committed crime is severe.

The stay may not last longer than 3 months but it can be extended by the decision of 1 judge and 2 jurors. The overall time cannot extend over 1 year.

In the case that a juvenile takes up education or work, the court can waive the sentence.

The principal of the institution where minors stay is obliged to inform the court on their health condition and improvements every 6 months. The court, based on a doctor’s opinion, decides on the further stay of the minor in the institution or nursing home.

The use of means of direct force was regulated by art. 95a and 95b of Juvenile Law and by the regulation of 1st of February 2005 relating to the precise terms and manners of direct constraint used against the juveniles placed in juvenile detention centres, shelters, youth educational centre and youth centre of therapy and social integration.

Such measures can be used only when other means of psychological and pedagogic effect turned out to be ineffective. They are used in order to prevent: 1) juvenile’s attempt on his own or other’s life or health, 2) abetting to rebellion, 3) group escape, 4) damage of goods, which causes significant affray, 5) wilful leave by the juvenile of the institution or shelter, or in order to take the juvenile to such a facility (art. 95a of Juvenile Law). The used measures include: 1. physical 2. isolation ward – for 48 hours, for minors over 14 - for 12 hours, not used toward minors with visible impairment 3. security belt and straitjacket – in case of attempted suicide or homicide

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2.2 The child care system in Poland In accordance with the provisions of the Family and Guardianship Code of 25th February 1964 care is a legal institution and one of its forms is care of a minor.

Parents, exercising parental authority, have common responsibilities for upbringing and development of their child and for the best protection of his/her interests.

State authorities only support the family in its functions. The public institutions also provide a foster care, but only if the child is not, for various reasons, under the direct care of parents or when parental care is exercised in prejudicial manner. The paramount principle determining care actions undertaken by state entities towards children is the child’s best interests125.

The child care system in Poland is shared by the following Ministries: Ministry of National Education – education, care.

With responsibility for: kindergartens, schools, centres of psychological and pedagogical help, adoption and care centers, educational and care institutions (total and partial care, after-school care), foster family environment, therapeutic, rehabilitation and revalidation centers.

Ministry of Justice - legal aspects of child care, juvenile delinquency, offending towards children.

With responsibility for: family and juvenile courts, diagnostic centres, juvenile corrective centres, juvenile shelters, juvenile probation centres.

Ministry of Health – health care and prophylactic With responsibility for: different type of health institutions, also psychiatric wards for juvenile offenders with mental problems.

Ministry of Labour and Social Policy – matters of working minors, organization of welfare, care for disabled children.

With responsibility for: nursing homes, welfare centres and single mothers centres.

Ministry of Interior – matters of juvenile delinquency, offending towards minors, social negligence of children.

With responsibility for: police child chamber.

The child care system currently in effect in Poland functions in three fields: 1. Social care 2. Prophylactic and educational care 3. Rehabilitation and revalidation care The child care system is regulated by 4 main judicial acts:

125 http://biurose.sejm.gov.pl/teksty/i-625.htm

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Family and Guardianship Code of 25th February 1964126; Education System Act of 7th September 1991127; Juvenile Act of 26th October 1982128; Social Welfare Act of 29th November 1990129; With regards to children with mental health problems, a part from the above mentioned acts, Act on Mental Health Protection of 19th August 1994130 is also applicable.

Procedure of putting people in mental hospitals Issues connected with placing people suffering from psychic disturbances in mental institutions are subject to regulations of the Mental Health Act of 19th August 1994 (announced in the Polish journal of laws: “Dz. U.” No. 111 item 535 as amended) and the Ordinance of the Minister of Health and Social Welfare of 23rd November 1995 specifying a detailed plan for the functioning of a mental hospital in regard to admissions to and discharges from such a hospital (announced in the Polish journal of laws: “Dz. U.” No. 150 item 736).

Admission of a minor Admission of a minor or an incapacitated person to a mental hospital requires a permit in writing made by her/his statutory representative. However, in the case of an admission of a minor who is more than sixteen-years-old or an adult who is totally incapacitated, who is able to give her/his consent, the consent of such a person must be obtained in order to admit them to hospital.

When statements of such a person and her/his statutory representative with regard to admission to mental hospital are contrary, then consent to admission to hospital is given by the guardianship court.

An insane person may be admitted to a mental hospital with no consent only in a situation when her/his behaviour she/he has demonstrated till now indicates that she/ he endangers her/his own life or life and health of other people due to this sickness (art. 23 of the above mentioned Act).

A note sending a person to mental hospital is issued by a doctor upon examination of such an insane patient considering, in particular, her/his mental state and behaviour.

126 Ustawa - Kodeks rodzinny i opiekuńczy, z dnia 25 lutego 1964 r.; (Dz. U. z 1964 r. Nr 9, poz. 59 ze zmianami); 127 Ustawa z dnia 7 września 1991r. o systemie oświaty (Dz. U. z 2004 r. Nr 256, poz. 2572, ze zm) 128 Ustawa o postępowaniu w sprawach nieletnich, z dnia 26 października 1982 r.; (Dz.U. z 2010, Nr 33, poz. 178 t.j.)

129 Ustawa o pomocy społecznej, z dnia 29 listopada 1990 r.; (Dz. U. z 1993 r. Nr 13, poz. 60 ze zmianami); 130 Ustawa o ochronie zdrowia psychicznego z dnia 19 sierpnia 1994 r.; (Dz.U.1994.111.535)

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2.3. Penal responsibility of young offenders with mental health problems According to the current understanding of juvenile justice, a young offender is never treated as a guilty person but as an at risk person. Every child, whether they have mental problems or have developed normally, has to be protected by law and the country has to give them the best conditions and opportunities for treatment. The family court, when the child breaks the law, orders psychological assessment and analyses family and schooling history of a minor. If the results of the examination and interview indicate the presence of a mental illness or disorder, the family court rules on undertaking treatment and decides to place him or her in a special therapeutic or revalidation centre. It may happen sometimes that during psychological assessment the mental health problem is not diagnosed. In such, but not so rare, situations the family can take wrong decision.

Treatment is the most important of all. Depending on the type of mental deficiencies and of the level of demoralization of juvenile, the Family Court rules open, semi open or isolation treatment.

It can be in: a mental hospital or another health institution, if he/she is mentally impaired, mentally ill or addicted; a nursing home when he or she is severely impaired; or an attendance centre or youth centre of therapy and social integration, if a child only needs educational care.

Only after completion of the therapeutic process does the Family Court analyse progress and if there is no improvement then it may rule to apply a corrective measure. If the mental disorder shown by the juvenile is profound then the court will only apply a treatment measure, tailored to the individual situation of the juvenile. According to the main assumption of the probation treatment of juvenile justice, placement in isolation is a last resort and is applied only when the other measures are not effective.

2.4. Specific legislation concerning young offenders with mental health problems There is no specific judicial act which would regulate proceedings in cases of juveniles with mental problems. The Juvenile Act of 26th October 1982 is essential. Other questions are regulated by several complementary acts such as: Act on Mental Health Protection of 19th August 1994131; The Regulation of the Ministry of Health on detailed principals of directing, placing, moving, dismissal and placement of juveniles in public healthcare centres of 20th April 2005132;

131 Ustawa o ochronie zdrowia psychicznego z dnia 19 sierpnia 1994 r.; (announced in the Polish journal of laws „Dz.U.1994.111.535”) 132 Rozporządzenie Ministra zdrowia w sprawie szczegółowych zasad kierowania, przyjmowania, przenoszenia, zwalniania i pobytu nieletnich w publicznych zakładach opieki zdrowotnej z dnia 20 kwietnia 2005 r (announced in the Polish journal of laws „Dz.U. Nr 79, poz. 692”)

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The act mentioned above meticulously regulates the proceedings concerning juveniles with mental problems. According to the legal regulations, the treatment that should be applied toward the juvenile is decided by the Family Court taking into account the conditions listed below: § 5 While deciding about placing a minor in one of the mental health care units, the court shall particularly take into account: 1) The type of offenses committed by the minor in the past; 2) nature, incidence and consequences of aggressive behaviour or absconding in the past; 3) current health condition, including psychological and somatic functioning; 4) dependence on alcohol or psychoactive substances; 5) relationship between mental disorder and dangerous behaviour; 6) overall physical fitness; 7) specific indication for the treatment and rehabilitation; 8) course and outcome of treatment and rehabilitation applied so far.

The most important aspects taken up in the Regulation: - Types of health centres to which the juvenile should be directed to (psychiatric hospital with reinforced or maximum security, detox units, centre for mentally impaired juveniles, etc.). The decision is made in accordance with psychiatric assessment and diagnosis.

- Type and methods of rehabilitation and therapeutic treatment applied; - Security, safety and appropriate conditions of the stay in the mental health unit; - Rights and obligations of a juvenile during the stay in the mental health unit; - Implementation of compulsory education during the stay in the mental health unit.

2.5 Protection of the best interest of the child in juvenile justice and health systems The supreme ethical principal that must be followed by juvenile justice, welfare, education and guardianship systems, as well as the mental health system, is the best interests of the child.

The most important principals included in the Polish law that must be followed in judicial proceedings on juvenile cases are: 1. The right to be treated in a manner consistent with the promotion of the childâ&#x20AC;&#x2122;s sense of dignity and worth, 2. The right to be informed of the allegations.

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3. The principle of presumption of innocence, the right to remain silent.

4. The right to the presence of parents and guardian.

5. The right of appeal to a higher court.

6. The right to privacy protection.

Rights of ill children should be respected by all health service employees. The right of every child should be protected, irrespective of the age and of the progress of the illness, and according to the provisions in effect. In Poland, three juridical acts are fundamental for protection of the rights of the child: The Constitution of The Republic of Poland, The Convention on the Rights of the Child and The Act on the Children’s Ombudsperson of 6th January 2000.

Constitution of the Republic of Poland Art. 72 1. The Republic of Poland protects the rights of the child. Everyone has the right to demand from public authorities the protection of the child against violence, cruelty, exploitation and demoralization.

2. A child that is uncared for has the right to the care and assistance of the public authorities.

3. In the course of establishing children’s rights the public authorities and also the persons responsible for the child are obliged to listen to the child’s opinions and if possible to take these into account.

4. The act regulates the competences and the way of appointing the Children’s Ombudsperson.

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The Juvenile Law of 26th October 1982, Art. 3. § 1. in juvenile cases the court is obligated to act first of all with respect for the best interests of a child In proceedings in juvenile cases one should be guided first of all by the best interests of a child, aiming at achieving positive changes in personality and behaviour of the juvenile and if necessary aiming at correctly fulfilling child care duties of parents or of carers, taking the public interest into account. § 2. In the proceedings in juvenile cases, the juvenile’s personality and in particular: age, health condition, level of the psychological and physical development, character, as well as behaviour and causes and level of demoralization, character of the environment and conditions of childhood development, have to be taken into account.

Art. 19. During the hearing of the juvenile one should guarantee full freedom of the opinions of the child. The hearing of the juvenile should be held in conditions similar to their natural environment, if necessary in a place of residence of the juvenile. The rehearing of the juvenile in the circumstances already set out should be avoided.

The Act on the Children’s Ombudsperson of 6th January 20001 The Children’s Ombudsperson is guided by the principles enshrined in the Constitution of The Republic of Poland, in the Convention on the Rights of the Child and in the Act on Children’s Ombudsman, in particular: - The principle of welfare of the child; - The principle of the best interests of the child; - The principle of equality; - The principle of protection of the rights of every child; - The principle of respect for the responsibilities, rights and duties of both parents during the development and education of a child.

1

Ustawa o Rzeczniku Praw Dziecka z dnia 6 stycznia 2000r.; (announced in the Polish journal of laws

Dz.U.08.214.1345)

The Act on Protection of Mental Heath of 19thAugust 1994 Mental health is a fundamental right of every human being and the protection of the rights of persons with metal problems is one of the obligations of the public authorities.

Art. 4. 1. Preventive actions in the field of protection of mental heath are aimed at in particular towards children, youth, elderly people and towards people in a situation where their mental health is in danger.

Above was described the theory - legal fundaments of protection of child’s best interests. The reality, in fact, looks different. Firstly, the family court, for instance due to incomplete information on the minors, can make wrong decisions regarding his or her future and not to rule treatment, or place the minor in an environment which

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can aggravate the minor’s mental health. The child’s welfare can also be in danger even if the court’s decision was made carefully and wisely. The problem may lie in the organization of intervention in centres designed for providing care, treatment and rehabilitation. Usually the main factors responsible for state are: overcrowded facilities and not sufficient staff employment, inefficient therapy and rehabilitation methods, low staff competences (caused by: hard work conditions, low or lack of motivation, very low wages), conflicts and lack of agreement between medical staff and educational staff (inconsistent intervention approach, abusing pharmacological treatment, lack of one adult and friendly figure). One should also mention the living conditions of facilities for mentally disturbed children which definitely are not friendly. Typical hospital environment and atmosphere, white aprons and isolation, are not conditions beneficial to recovery. Psychiatrists report that many children are not able to open themselves during individual therapy sessions as they are afraid of the environment where the treatment is performed. Finally, the protection of the child’s best interests in Poland is in danger due to the complicated child care system which is shared by several ministries. Current legal solutions hinder respecting this paramount rule concerning children.

2.6. Entrusted entities involved in court proceedings in order to protect the rights of the child The establishment of the Children’s Ombudsman has meant the creation of an independent institution that will reinforce protection of children, with the powers of control, alarm and initiative.

The Children’s Ombudsman is a constitutional authority established in 2000 by Article 72 paragraph 4 of the Constitution of the Republic of Poland of 1997.133 According to the principles described in the Act of 6th January, he/she is independent of other state bodies and answers only before the Parliament, does not substitute the institutions and entities responsible for providing action in order to protect children’s rights such as the: Ministry of Health, Ministry of Justice, Ministry of Internal Affairs and Administration, Ministry of Education, Ministry of Labour and Social Policy and other entities like social welfare centres, orphanages and educational institutions. The listed institutions are obligated to provide a child with a complete and harmonized development, in the educational, social or medical sense with respect for his or her dignity and subjectivity, including during judicial proceedings.

The Children’s Ombudsman is a guardian of children’s rights, in particular the: 1) Right to live and to health protection, 2) Right to be brought up by the family,

133 Official web site of Children’s Ombudsperson; http://www.brpd.gov.pl/

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3) Right to dignified living conditions, 4) Right to an education.

The Children’s Ombudsperson undertakes actions in order to ensure complete and harmonious development of the child, with respect for his/her dignity and subjectivity (art.3 of the Act). The fulfilment of this mission requires the protection of the child against violence, cruelty, exploitation, negligence, demoralization and against other forms of harmful treatment.

The Ombudsman acts on his/her own initiative, taking into consideration information received about violation of the rights or welfare of the child. He/She deals with individual cases, if they have not been already resolved in an appropriate manner even though action was in accordance with the legal regulations in force.

The Children’s Ombudsperson takes care of all children, in particular of those with disabilities, who are at risk of social exclusion. He/She is guided by the principles enshrined in the Constitution of the Republic of Poland, in the Convention on the Rights of the Child and in the Act on Children’s Ombudsman, in particular: - The principle of welfare of the child; - The principle of the best interests of the child; - The principle of equality; - The principle of protection of the rights of every child; - The principle of respect for the responsibilities, rights and duties of both parents during the development and education of child.

One of the duties of the Children’s Ombudsman is the annual report presented to the Parliament about his/her activities and observations on the state of child’s rights in Poland. As this information is made public, it provides an excellent opportunity to kick start a nationwide discussion on the state of children’s rights in Poland.

The Bureau of the Children’s Ombudsperson created a special web service (http://www.strefamlodych.pl) dedicated to informing children about their rights and also facilitated the toll-free Child’s Hotline (Dziecięcy Telefon Zaufania 0800 12 12 12).

Children can call from Monday to Friday from 8.15 to 20.00 to talk with specialists about their problems, to notify them of any kinds of violation of their rights. At night time and during weekend children may leave a message which will always receive a response.

Another entrusted entity involved in protection of mentally disturbed child’s rights is Patients’ Ombudsman134. Such person is employed in every medical institution.

According to the Act of 19th August 1994 on the protection of mental health (No. 111,

134 http://www.bpp.gov.pl/ Patient’s Right Bureau

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item. 535), since January 2006, a person using healthcare services provided by any psychiatric hospital is entitled to receive help in protecting their rights. Protecting the rights of persons using healthcare services provided by the psychiatric hospital is the responsibility of the Patient’s Ombudsman of Psychiatric Hospital.

The tasks of Patient’s Ombudsman of Psychiatric Hospital: 1) help to pursue matters related to the reception, treatment, conditions of residence and living in a psychiatric hospital, 2) help in explaining patients’ complaints, 3) collaboration with the family or legal representative, 4) initiating and maintaining education and information on the rights of persons using healthcare services provided by the psychiatric hospital.

2.7. Handling of information and professional confidentiality regarding young offenders The legal regulations on protection of personal data established by Directive 95/46/EC were introduced into Polish law by the Act on Protection of Personal Data of 29th August 1997135.

The Act on Protection of Personal Data of 29th August 1997 Art. 1.

1. Everyone has the right to the protection of personal data concerning him or her.

2. The processing of personal data can take place on account of the public interest, the interest of the person who the data concerns, or the good of a third party.

Art. 27.

1. It is prohibited to process personal data revealing the racial or ethnic origin, political views, religious beliefs or philosophical, religious, party or trade union membership, as well as details about the state of health, genetic code, addictions or sex life and data on sentencing, statements about punishment and fines, as well as others issued in judicial or administrative proceedings.

This kind of information belongs to the sensitive category of data. The processing of sensitive data may only take place with the consent of the person who the data concerns.

Data concerning petty offences, punishable offences, behaviour of juvenile delinquents belong to sensitive categories of data. Such data constitutes confidential

135 Ustawa o ochronie danych osobowych (announced in the Polish journal of laws “Dz. U.” of 2002 No. 101 item. 926 as amended)

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information and is under particular protection. Records are not available for outsiders and are specially secured. Sensitive data on criminal records is an exception of this category. The processing of this kind of data is possible only among public entities involved in court proceedings or the execution of a court decision regarding a juvenile.

The data about the young offenders is handled mainly through an environmental interview.

The Minister of Justice in cooperation with the Minister of Internal Affairs described the detailed rules and procedures for conducting environmental interviews to gather information on minors (the Regulation of the Minister of Justice of the 16th August 2001 on detailed principles and procedures for conducting environmental interviews on juveniles136). This document regulates: the time, date and place of testing and the form of a final report taking into account the respect for the private sphere of the minor and his/her family.

All health professionals must practice professional confidentiality. For our studies the most important are: doctors of medicine (psychiatrists, paediatricians), psychologists/therapists, social workers. Each profession has its own juridical act describing the rules of professional confidentiality.

Medical confidentiality - the legal term introduced by the Law on Medical Professions of 5th December 19961.

Article 40: a doctor of medicine is obligated to maintain the confidentiality of the information relating to the patient, obtained due to the treatment process.

1 Ustawa o zawodach lekarza i lekarza dentysty z dnia 05 grudnia 1996 r. (announced in the Polish journal of laws „Dz. U”. z 2005 r. Nr 226, poz. 1943)

The confidentiality of the social worker - a legal term introduced by the Law on Social Welfare of 12th March 20041.

Article 119, paragraph. 2, point 5: “While carrying out tasks, the social worker is obligated to maintain the confidentiality of the information obtained in the course of professional activities, even after termination of employment, except if the withholding of information works against the good of the person or family.”

1

Ustawa o pomocy społecznej (announced in the Polish journal of laws “Dz. U”.04.64.593).

136 Rozporządzenie Ministra Sprawiedliwości z dnia 16 sierpnia 2001 r., w sprawie szczegółowych zasad i trybu przeprowadzania wywiadów środowiskowych o nieletnich, (announced in the Polish journal of laws „Dz.U”. 2001.90.1010.)

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The confidentiality of the psychologist The Law on the Profession of the Psychologist and the self-government of psychologists of 8th June 20011.

Article 14: The psychologist is obligated to maintain the confidentiality of client information obtained in course of professional activities.

The obligation of professional secrecy may not be limited in time.

The regulations do not apply if: 1) there is a serious health or life risk of the client or others 2) such are the statements in an act.

Ustawa o zawodzie psychologa i samorządzie zawodowym psychologów (announced in the Polish journal of laws “Dz. U.” No. 73, item 763) 1

The confidentiality of mental health - a legal term introduced by the Law of 19th August 1994 on Mental Health Protection1.

Articles 50-52: concern the protection of confidentiality of the mental health of a patient.

The obligation to protect confidentiality concerns both the information above as well as the confidentiality of persons performing under the Act. Chapter 6: Protecting confidentiality Article 50: 1st: Persons performing activities under this Act shall be obliged to observe confidentiality of all information obtained in connection with the performance of professional activities.

2nd Exemption from the obligation of confidentiality is allowed in relation to: 1) The doctor taking care of a person with a mental disorder, 2) The competent authorities of the government or local government when the disclosure of circumstances is necessary to perform tasks of social assistance; 3) The persons participating in performing social assistance.

Article 51: The documentation relating to medical examination or course of treatment of a patient must not include admission to committing offense under penalty. This rule also applies to the documentation concerning examination conducted at the request of authorised entities.

Article 52: 1st: It is prohibited to interrogate people obligated to professional confidentiality as witnesses in relation to the confession of a person, against whom action was undertaken in relation to committing an offence.

1 Ustawa o ochronie zdrowia psychicznego (announced in the Polish journal of laws “Dz.U.94.111.535”)

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The Law on Childrenâ&#x20AC;&#x2122;s Ombudsperson Article 10th, 2nd: The Ombudsman may refuse to disclose personal information of the person from whom information was received about violation of the rights or welfare of the child and of the person to whom the infringement relates, including those against public authorities, if it is necessary for the protection of freedom, rights and interests of the individual.

2.8. Legal basis and possibilities for mixed systems of closed and outpatient treatment In the juvenile justice system there are no regulations that allow for the application of a mixed system of closed and outpatient treatments.

The problem is that different issues are subject to different judicial acts and ministries which are not coherent in their proceedings and assumptions. There is a lack of a compact therapeutic, educational care system. Every time a minorâ&#x20AC;&#x2122;s case is subjected to judicial cognisance, other regulations are being applied, dependently on the case substance. We have to differentiate the systems which are responsible for children: Child Care System, Child Education System, Juvenile Justice System or Child Health and Treatment System.

Each of these systems is internally divided into smaller divisions and also, depending on the circumstances, is regulated by another judicial act. Consequently, we may observe the diffusion of responsibility which means that the intervention and therapeutic system is neither coherent nor effective. The mixed system is almost impossible to apply because no regulation or institution exists for the coordination of such practices. The Family Division orders adequate measures for the juvenile depending on factors such as mental condition or level of demoralization. If the juvenile only requires therapy, the judge may rule for an outpatient treatment. When it is also necessary to isolate him or her because of the high level of demoralization, then the court orders to put the minor in a specialized centre which is able to simultaneously provide a minor with both therapeutic and educational- correctional treatment.

2.9. Legal and medical measures in case of non-completion of treatment The Juvenile Law allows the Family Division to be flexible in its actions thanks to the wide range of educational, therapeutic and reformatory measures foreseen in the reformative system. Every case is considered individually, after examining the maximum amount of data about the personality and family situation of the juvenile. The judge, respecting the best interests of the child above all but taking the public interest into account, rules for the application of measures which are individually matched to each case and are substantial and not too strict. Prescription of the isolation measure (placement in youth centre of therapy and social integration, youth educational centre, juvenile detention centre or mental hospital) is stated as a last resort. Such a situation takes

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place only when the court states the high level of demoralization of the juvenile, when the juvenile is a threat to their own health or life or of other persons, and when the other means applied so far haven’t given the expected result. It is difficult to answer this question explicitly, since every time that circumstances change, the matter of the juvenile ends up being reconsidered by the Family Division. If there is a risk of the juvenile suffering from mental disorders or reoffending and he or she does not actively participate in formerly applied therapeutic measure in opened conditions or fails to complete it, then the court can rule for the placement of the juvenile in a mental hospital, but only when all the conditions and circumstances justify such a solution.

3. PROFESSIONAL ROLES AND SKILLS DEVELOPMENT 3.1. Co-operation between juvenile justice and health care professionals The proceedings in juvenile cases are far less formalized than in criminal cases for adults. The judge performing its duty should cooperate with representatives of other professions such as: psychologists, doctors, psychiatrists and also teachers, social workers, probation officers, and educators. The Juvenile Law allows the Family Court to act flexibly in order to apply the best measure, adapted to the individual needs of the minor with respect to the best interests of the child above all. The cooperation of the Court with other professionals in order to obtain expert opinions about the juvenile should be fundamental in order to make the best decision in juvenile cases.

In order to establish data on a minor and his/her environment, in particular concerning: behaviour, educational conditions of the minor, the family living conditions, course of study, ways of spending leisure time, environmental/peer contact, attitude of parents/guardians towards minor, effects of educational influence, health conditions and substance use or dependence, the judge orders that an environmental interview be conducted by a probation worker. The probation worker plays an important role in court proceedings – they are kind of a link between the Court and minor’s environment.

Their task is to gather comprehensive information on the juvenile through talks and contacts with people from his social group conducting so called environmental interviews.

In some cases the judge can order that an environmental interview be conducted by: representatives of social organizations, trustworthy persons, police officers (if psychological knowledge and competences are not necessary), psychologists and pedagogues – employees of family diagnostic-consultative centres, psychologists and pedagogues – employees of juvenile educational or reformative centres (Art.24 of Juvenile Law). If a complex psychological assessment is necessary, then the Family Court orders such an examination by at least two proficient psychiatrists. The entity entitled to conduct such an examination is a Family Diagnostic Consultative Centre

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which functions at every regional court in Poland. The characteristic of this institution is included in the section on standardised assessment methods.

The cooperation between health professionals and family court is continued after the sentencing of a minor. Medical staff employed in the facility where the minor is directed is obliged to provide the family division with the actual information on the juvenile: conduct, therapy results, and contacts with family, any other relevant information. During the period of treatment only the family court is entitled to take any decision regarding the minor, whether it is a visit in the family house, sooner completion of the treatment or an extension of stay in the facility.

3.2. Specialized trainings of juvenile justice and health professionals According to the knowledge of experts Marek Ignaczak and Wanda Kosikowska137, in Poland there are no specific forms of training for health professionals working with mentally ill juvenile offenders. Professional competence results from the academic education and the non-specific training courses and environmental conferences (court psychiatry, child psychiatry, previous judgements).

A similar situation takes place with regards to juvenile justice professionals. Almost all professional training provided for this sector is training on legal issues (analysis of new law regulations etc.). There is a huge lack in the field of specific training focused on mental (psychological) needs of young people and not only those offending or revealing mental problems. There is a certain amount of public money dedicated every year to specialised training of staff but the use of these resources depends on the decisions of directors of entities and on the available training offered.

Therefore, the need to train professionals is obvious. Most of the judges and prosecutors asked see this need. 48.5 % of them stated that they never had a chance to gain knowledge about child psychology and about the best way to interview a child.

Only 1.6% of them gained this knowledge during their studies, 10.6% - during training courses focused more on the legal aspects of juvenile justice. 34.8% had the chance to gain it during training specifically related to the theme of the report.

Specialists working with minors (offenders, victims or witnesses of crime) should have access to education, appropriate training and information in order to develop specialized methods, procedures and attitudes towards children in order to protect them.

137â&#x20AC;&#x201A; See annex

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3.3. Multidisciplinary cooperation between juvenile justice and health care professionals There are no interdisciplinary teams assigned for dealing specifically with young offenders. The Juvenile Law says that the Family Judge should consult with other specialists in order to make the most adequate decision about the future of a young offender. For this purpose, years ago, the Ministry of Justice appointed an entity specialized in psychological diagnosis and consultations called the Diagnostic-Consultative Family Centre at the Regional Court (Rodzinny Ośrodek Diagnostyczno-Konsultacyjny). When it is necessary to get a comprehensive diagnosis of the personality of a juvenile, which requires pedagogic, psychological or medical knowledge, the Family Division turns to the Diagnostic-Consultative Family Centre. The court can also apply to other specialized institutions for assessments, opinions and conclusions concerning the juvenile.

Regarding the need to provide a comprehensive and professional assistance to children and their families in Poland, the idea of the creation of multidisciplinary teams was adopted. According to the assumption of the best interests of the child, the multidisciplinary team is a group of cooperating professionals representing different disciplines and backgrounds, working in a coordinated manner. Its main objective is to respond effectively to allegations of injustice or negligence of children.

The activities of an interdisciplinary team shall be to: • provide assistance to the child in danger (intervention in an individual case) • improve ways of assisting children and their nearest environment through the creation of a local policy on the problem and working out procedures and standards of operation.

There are two types of interdisciplinary teams: one assigned to resolve child related issues at the local level (e.g. by creating an efficient policy and strategy) and another assigned to deal with the concrete case of an at risk child - composed of people who, in their professional work are in contact with the members of the family (e.g. teacher, social worker, probation officers).

The interdisciplinary team may include representatives of institutions that deal with the child and family and may have an impact on improving the situation. The team is not constant and depends on the specific situation of the child.

People who should be included in the multidisciplinary team are: - school teachers - paediatricians, school nurses, professionals - juvenile police officers - NGO’s representatives - social workers, employees of family assistance centres, shelters and hostels for victims of violence - probation officers Although the idea of creating multidisciplinary teams was adopted in Poland in the

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form described above, it is not specifically applied in the juvenile justice field, but more in the system of welfare and only in some districts of Poland. Appointing such teams is not regulated by the law and depends on the initiative of the local welfare centres.

4. INTERVENTION APPROACHES: WHAT IS WORKING AND WHAT IS NOT 4.1. Standardized resources for psychiatric diagnoses and assessments When, while performing functions in order to assess the situation of a juvenile, a family court encounters the necessity to obtain an opinion on mental conditions of that juvenile, it directs a motion to a Diagnostic – Consultative Family Centre [Rodzinny Ośrodek Diagnostyczno- Konsultacyjny (RODK)] being operated in every District Court in the country. 66 such centres are currently operating in Poland.

Family Diagnostic – Consulting Centres are specialized institutions of the Ministry of Justice that function by following the orders of family courts, public prosecutors, police and courts if they deal with cases involving juveniles. Their basic task is to give an opinion in line with needs of family courts in three basic kinds of cases: • criminal cases concerning juveniles. They determine the degree of their depravity and indicate an educational, corrective (or medical) measure aimed at the improvement of their social functioning; • divorce cases (including spouses’ separation and marriage mediation); • guardianship cases concerning scope of parental authority over children, cases concerning a child’s placement in an adoptive family or a foster family, in a guardianship – educational centre with regulated contacts between parents and their child.

Main tasks of the RODK are as follows: • carrying out psychological, educational, medical (psychiatric) and environmental examinations and giving opinions on juveniles, minors and their parents or guardians, • family counselling and special care for juveniles and young adults, • special aid designed for corrective and juvenile detention centres, • cooperation with institutions dealing with family issues and depravity prevention.

Diagnostic methods and techniques applied by earlier mentioned centres and a manner of preparation of a court-ordered examination are determined by experts that are individually appointed by a court with regard to each case based on their professional experience, knowledge, and, above all, the interest of the child. As such a situation could lead to some abuses; the Ministry of Justice prepared “Standards for giving opinions by family diagnostic – consulting centres” in 2005. This document includes, among others, a list of standardized testing tools which can be applied by experts preparing an opinion. All centres are obliged to comply with provisions included therein.

The most frequently used tools in preparing opinions in juvenile cases are:

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Intelligence tests: - Wechsler Adult Intelligence Scale – Revised (WAIS-R) and Wechsler Intelligence Scale for Children – Revised (WISC-R); - Raven’s Progressive Matrices.

Psychomotor tests: - Bender Visual Motor Gestalt Test (Bender- Gestalt Test); - Benton Visual Retention Test (BVRT); - DUM test (Diagnosis of Brain Injury); - Rey Auditory Verbal Learning Test (AVLT); - Rey- Osterrieth Complex Figure Test (ROCFT).

Scholar functioning: - Test Językowy – Leksykon (Vocabulary Test- Lexicon);138 - Test of scholastic achievements (different pedagogical tests); - Test Pomiaru Szybkości Czytania Głośnego, [Measurement Test of Aloud Reading Speed]139; Personality tests: - Eysenck Personality Questionnaire – Revised (EPQ-R), NOE-Five Factor Inventory (NEO-FFI), Formal Characteristics of Behaviour – Temperament Inventory (FCB-TI)140; - The Baum Test (or Tree Test) of Karl Koch; - The Rotter Incomplete Sentence Blank (RISB); - State-Trait Anxiety Inventory (STAI); - Beck Depression Inventory (BDI); - Thematic Apperception Test (TAT) and Children Apperception Test (CAT); - Kwestionariusz do Badania Kryzysu w Wartościowaniu (KKW), [Questionnaire for testing valuing crisis]141; - Kwestionariusz do Badania Poczucia Kontroli (KBPK), [Questionnaire for testing sense of control142;

138 Polish tool used for evaluation of vocabulary, developed by Andrzej Jurkowski http://www.practest. com.pl/leksykon-test-j%C4%99zykowy-leksykon 139 Polish tool developed by Władysław Plusiecki used to measure aloud reading speed.

140 FCB-TI is a tool developed by of Polish psychologists Jan Strelau, author of the Regulative Theory of Temperament (RTT), and Bogdan Zawadzki. The inventory allows for measuring formal aspects of behavior comprising energetic and temporal characteristics composed of such traits as: sensory sensitivity, emotional reactivity, endurance and activity (energetic aspect), briskness and perseveration (temporal aspect).[Polish name: Formalna Charakterystyka Zachowania – Kwestionariusz Temperamentu (FCZ-KT)] 141 KKW, created by Polish psychologist Piotr Oleś. The questionnaire is used for studying difficulties associated with functioning of the value system; http://www.practest.com.pl/kkw-kwestionariusz-dobadania-kryzysu-w-warto%C5%9Bciowaniu.

142 KBPK, Polish tool developed by Grażyna Krasowicz and Anna Kurzyp-Wojnarska. The questionnaire is used for measuring variable personality called sense of control of the consequences of behavior,

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Kwestionariusz Kompentencji Społecznych (KKS), [Questionnaire for testing social competences]143 Family relations: - Bene-Anthony Family- Relations- Test (FRT) - Kinetic Family Drawing (KFD) - Test Komunikacji Zadaniowej Rodzic- Dziecko (TKZ R-D); [Test of Task Communication Parent- Child]144 - Skala Postaw Rodzicielskich (SPR), [Questionnaire for testing parental attitudes]145 Through interviewing and testing of the juvenile, RODK collects an extensive amount of information. The collected data is transferred to a special form (see annex 1) and is presented in such shape to the family court.

4.2. Therapeutic intervention for young offenders Every juvenile centre is responsible for preventive, educational, reformative, therapeutic and re-adaptive actions. Art. 66 § 2 of Juvenile Law says that reformative centres and youth detention centres are obliged to provide children and teenagers with: comprehensive and professional education, cultural and educational activity, sport activity, actions which develop social activities among juveniles and lead them into socially useful work and to make health benefits available.

Young offenders with mental problems receive both psychiatric and psychological therapeutic support. Psychiatric methods are based on pharmacological treatment and are complemented by regular individual and group sessions with a psychologist.

They also receive a special individual work schedule, which is individually tailored and carried out in a few spheres i.e. educational-professional, psychosocial, health, family. In Poland, there are no obligatory systematic solutions that are applied in every juvenile centre, whether it is an educational or therapeutic centre. All the centres run their own programs. Methods of actions and their effectiveness depend on the competences and initiatives of employees (educators, therapists). Many directors of such centres are eager to cooperate with other centres and institutions which carry out educational, therapeutic and re-integrative actions. Cooperation with non-

as described in Social Learning Theory of Julian B. Rotter; http://www.practest.com.pl/kbpkkwestionariusz-do-badania-poczucia-kontroli.

143 KKS, Polish tool, developed by Anna Matczak, used for assessing social competences and skills in various social situations, http://www.practest.com.pl/kks-kwestionariusz-kompetencjispo%C5%82ecznych.

144 TKZ R-D, Polish tool developed by Anna Frydrychowicz used to diagnose the effectiveness of communication behaviors of child and parent in task situations; http://www.practest.com.pl/tkz-r-dtest-komunikacji-zadaniowej-rodzic-dziecko.

145 PR, Polish tool, author: Mieczyslaw Plopa. The tool is used for assessing parental attitudes. http:// www.practest.com.pl/spr-skala-postaw-rodzicielskich

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governmental organizations is also developed, but not to the required extent. The problem is caused due to: the scarcity of such organizations, the ways in which their actions are financed and the resistance of directors caused by unwillingness to take up new duties. If directors want to raise the effectiveness of actions, they do their best to adjust the educational and reformative offers of the centre to the needs of children.

Below are presented articles related to providing therapeutic intervention for juveniles with mental problems.

The Act on Protection of Mental Health of 19th August 1994, Art. 7. 1. Educational and revalidation classes are being provided for children and young people with mental retardation irrespective of the degree of impairment, in particular at nursery schools, schools, educational and nursery centres, rehabilitation-educational centres, in welfare institutions and healthcare centres, as well as in the family home.

The Regulation of the Ministry of Health on detailed principals of directing, placing, moving, dismissal and placement in of juveniles in public healthcare centres of 20th April 2005, § 18. A minor staying in the mental health unit is subjected to planned and therapeutic and rehabilitation treatment, aimed at improving health and behaviour to help him/her to reach a level enabling return to life in society and/or to continue treatment in open conditions § 19. 1. Rehabilitation is organised at the unit executing the treatment measure ruled by Family Court, in line with the regulations on organising rehabilitation at mental hospitals.

2. Individualized diagnostic treatment and rehabilitation proceedings in case of juveniles addicted to alcohol or psychoactive substances, incorporates in particular: 1) diagnostics of psychological disorders and behavioural disorder associated with abusing alcohol or psychoactive substances; 2) reducing health damages caused by abusing alcohol or psychoactive substances; 3) individual and group psychotherapy of addicted juveniles; 4) consultative-educational action for addicted juveniles and their families.

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4.3. Specific mental-health units for young offenders with mental health problems Juvenile Law of 26th October 1982 Art. 12. In the case when a minor is mentally disabled, ill, displays other psychological issues or does compulsively use alcohol or other psychoactive substances, the Family Court can rule to put the juvenile in the psychiatric hospital or other appropriate mental-health unit. If the juvenile only needs educational care, the court can rule to put him or her in the adequate care of an educational juvenile centre, and if the juvenile displays profound mental retardation and requires only full time care then the court may rule to put him or her in a welfare centre.

Below are listed all types of institutions dedicated for young offenders with mental health problems.

THE THERAPEUTIC-REHABILITATION JUVENILE DETENTION CENTRE in Świecie for boys with mild and moderate mental retardation, with personality disorders which are the effects of organic damage of the central nervous system.

Juveniles of this centre are characterized by poor discerning social rules and skills as a result of handicapped intellectual functions and of the lack of positive patterns in their family.

Places: 24; [address: Zakład Poprawczy, ul. Sądowa 12, 86-100 Świecie] The main objective of this juvenile centre is preparing boys to live in accordance with social norms and to practical self-reliance.

The aims are being carried out through: • integrated activity in the areas of rehabilitation, teaching, compensation and care • preparing the foster child for a future career • taking diverse action with a view to preparing the foster child for their return to society • cooperating with the minor and his/her family, social organizations, social welfare centres, relevant authorities of the government administration and the local authorities and other persons • treatment of the behavioural disorders arising as a result of damages of the central nervous system.

THE REHABILITATION AND REVALIDATION JUVENILE DETENTION CENTRE in Sadowice for boys with mild mental retardation, who are socially unadjusted or are at risk of social maladjustment, and who display behavioural disorders. The mental problems are mainly caused by lack of education and considerable educational negligence, as well as by the use and abuse of psychoactive substances.

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Places: 75; [address: Zakład Poprawczy, ul. Szkolna 10, 55-080 Sadowice] THE THERAPEUTIC- REHABILITATIVE JUVENILE CENTRE in Białystok for boys addicted to psychoactive substances. These boys display mild mental and behavioural disorders due to the use of psychoactive substances.

Currently the structure of the mental condition of its patients is: 20% displaying psychopathic symptoms 30% borderline disorders 40% narcissistic personality disorder 10% other Places: 40; (address: Zakład Poprawczy, ul. 27-go Lipca 89, 15-181 Białystok 25,) Below there is the list of the public mental health units which are listed in The Regulation of the Ministry of Health on detailed principals of directing, placing, moving, dismissal and residence of juveniles in public healthcare centres of 20th April 2005.

PUBLIC UNITS OF THE MENTAL HEALTH CARE WITH MAXIMUM SECURITY 1. National Centre of Juvenile Forensic Psychiatry Places: 40; (address: Krajowy Ośrodek Psychiatrii Sądowej dla Nieletnich, Al. Legionów 11, 08-400 Garwolin) Health services offered by this psychiatric unit include: 1. medical examinations and consultations; 2. treatment 3. psychological examinations and psychological therapy 4. diagnostic tests, including medical laboratory analysis 5. nursing of sick persons 6. nursing and care of disabled persons 7 stating and giving opinion about state of health 8. treatment and rehabilitation OTHER PUBLIC UNITS OF THE MENTAL HEALTH CARE WITH REINFORCED SECURITY 1. Regional Psychiatric Hospital; (Wojewódzki Szpital dla Nerwowo i Psychicznie Chorych, Places 30; ul. Mickiewicza 1, 56-600 Lubiąż).

2. Public Psychiatric Hospital; (Samodzielny Publiczny Szpital dla Nerwowo i Psychicznie Chorych, Places 30; ul. Poznańska 109, 66-300 Międzyrzecz).

3. Psychiatric Hospital; (Szpital dla Nerwowo i Psychicznie Chorych, Places 35; ul. Skarszewska 7, 83-299 Starogard Gdański).

PUBLIC UNITS OF THE DETOX TREATMENT WITH REINFORCED SECURITY 1. Wojewódzki Szpital dla Nerwowo i Psychicznie Chorych, (30 places) ul. Mickiewicza 1, 56-600 Lubiąż

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Juvenile centres for children and young people with mild mental retardation under the control of Ministry of Education.

YOUTH CENTRES OF THERAPY AND SOCIAL INTEGRATION This is the mildest type of all juvenile centres in Poland.

Youth centres of therapy and social integration are for minors with emotional disorders, who aren’t able to function at mass schools, they have family or environmental problems and they require socio-therapeutic treatment. Juveniles are placed there on the basis of the decision of the psychological and pedagogic assessment centre, upon a parent’s request (art. 71 b of the act on the care system) or upon the decision of the Family Division.

Altogether there were about 84 places for children with mild mental retardation in these centres YOUTH EDUCATIONAL CENTRES Youth Educational Centres are for juveniles with graver disorders in the sphere of social functioning. Juveniles are placed on the basis of the Family Court decision, according to the Juvenile Act. Altogether there are about 96 places for mentally ill children in these centres.

4.4. Family therapy- possibilities and results The only reference to the participation of the family in the therapeutic process we can find in the Regulations of the Ministry of Health on detailed principals of directing, placing, moving, dismissal and residence of juveniles in public healthcare centres of 20th April 2005,: § 19. 2. 4) The diagnostic, therapeutic and rehabilitation treatment of a juvenile addicted to alcohol and psychoactive substances should be individualized and the family should participate in the educational-consultative actions related to the therapeutic process.

Also, all operators (social workers, psychologists, psychiatrists, educators) getting in touch with young offenders, with and without mental health problems, underline the importance of the role of the whole family system in the treatment process of these children. In cases of apparently ‘normal families’, complex family therapy is easier to realize. The situation is not so simple in case of young offenders with MH disorders in custody or under the measures of treatment in psychiatric units. The above mentioned Regulations of the Ministry of Health states that the juvenile has to be placed in the closest health unit to his or her place of residence (article § 2. 3).

However, in Poland the system of directing to particular centres is currently central, so it means that sometimes young offenders with MH disorders are a huge

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distance from their families. Consequently, involving their parents in the treatment process is often not possible; moreover, usually they are single mothers, with very low economic status, who have many children and an alcohol problem. Even if some of these mothers would like to take part in the process, it would be very hard for them to leave the rest of the children without any assistance for the whole day once or twice a week and to afford the money for the journey. Sometimes the family environment is so deeply dysfunctional that parents don’t want to participate in the therapy and don’t want to be in touch with the child. In this case, educators and therapists very often do not believe in the involvement, in the therapeutic process, of figures probably contributed to child’s problems. In the opinion of some of the interviewed practitioners, such attempts may only worsen the mental condition of a child and annihilate any positive therapy results achieved so far. In consequence, they do not encourage any parents who do not show any willingness to improve the life of their child.

If mutual cooperation in the therapy is possible (short distance and involvement of parents) then the juvenile centres try to realize the rehabilitation and revalidation process with the participation of parents. Unfortunately, in most cases it doesn’t have the ability to use the proper form of the family therapy.

To sum up: family involvement in the treatment of minors is the best solution, but in fact this is not a common practice and this area should definitely be improved.

Although different juridical regulations state that every juvenile centre is obligated to inform parents regularly and cooperate with them due to the process of rehabilitation and treatment, there is a lack of clear provisions and system solutions for carrying out the family therapy of detained juveniles displaying mental disorders.

4.5. Prevention programmes for young people with behavioural disorders Preventive programs developed by the police, NGOs, public welfare institutions and health services, are mainly directed at young people in secondary schools, in postsecondary education, in youth educational centres, socio-therapeutic youth centres, in emergency intervention institutions – generally at young socially maladjusted people.

The main objective of these actions is raising awareness of the dangers connected with alcohol and drug abuse, which may cause behavioural disorders of different kinds.

Other programs which would directly touch on the problem of mental disorders do not exist.

4.6. Legal regulations regarding the psychiatric treatment The Family Court, in accordance with statutory regulations, may rule for the application of obligatory treatment and rehabilitation of addicted juveniles staying in reformative

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centres (Art. 37. item 1.of the Act of October 26th 1982 on Upbringing in Sobriety and Counteracting Alcoholism). Such a solution is the result of the psychological immaturity of minors, which means, that they do not always have an internal motivation to undertake the treatment. The period of the treatment cannot exceed two years. If an addict is over 18 years old before the termination of the treatment, the family court can extend his/her therapy until the purpose of the treatment and rehabilitation is achieved, but no longer than a period of 2 years. The only grounds for applying obligatory treatment and rehabilitation of a juvenile, is verification that a juvenile is an addict. One element of obligatory treatment in the case of drug or alcohol addicts primarily relates to children and adolescents and constitutes an exception to the rule of voluntary execution of treatment, rehabilitation and readaptation. A juvenile who shows symptoms of demoralization because of use or abuse of psychoactive substances is under the protection and assistance of such a treatment.

5. RECOMMENDATIONS AND MAIN PROBLEMS 5.1. The main problems of the mental health intervention/protection system in Poland The assessment of the condition and the level of government-guaranteed psychological and mental care over children in Poland were discussed at the meeting of 18 provincial and national consultants on paediatrics, paediatric psychiatry, neurology and surgery organized by the Commissioner for Rights of Children Ewa Sowińska on 17th September 2007146.

Conclusions: 1. The mental health protection system is organized improperly – medical care centres dealing with mental health are distributed unevenly in the country which results in a situation where mental care for children and teenagers is practically unavailable in some provinces. This has resulted in the fact that the availability of mental care in Poland is the worst in Europe (especially out-patient care).

2. The environmental therapy performed by the mental health system is poorly developed– there is a too small number of institutions dealing with ambulatory – environmental therapy. The system is based on hospital care mainly with poorly developed environmental services which are very effective in case of mental care for children and teenagers. Hospital treatment may lead to stigmatization in cases where environmental or ambulatory treatment would be enough. Such a situation results

146 http://www.brpd.gov.pl/detail.php?recid=564 (downloaded 07.07.2010)

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from the way of financing mental care services by the National Health Fund (Polish abbreviation: “NFZ”). The NFZ finances hospital care mainly. Psychotherapy which is of great importance in treatment is not being financed.

3. Insufficient number of paediatric psychiatrists. Data from the register kept by the Chief Board of Polish Physicians show that as of now 256 physicians are specialized in psychiatry of children and teenagers (as of 01.06.2010)147. It is estimated that about 15% of children and teen-agers in Poland (over one million) suffer from disturbances that need to be diagnosed, consulted, or treated by a paediatric psychologist or psychiatrist.

Such a small number of specialists means that there is one doctor for every 30,000 children and as a consequence this makes Poland the tail end of Europe (for example, in Sweden one psychiatrist provides care for every 6000 children). Consequently, needs in the scope of paediatric mental care are not satisfied sufficiently and paediatric mental wards employ physicians who are not specialized in paediatric psychiatry. It stems, among others things, from the low attractiveness of this medical specialization.

It is of great importance due to a growing demand for mental care which results from the need to increase the availability of mental care, to increase social awareness of the need to look for help from psychiatrists, and the documented total increase in distribution of psychic illnesses and disturbances among children and teen-agers.

4. A greater stress needs to be directed at the development of family aid institutions providing help in the scope of: crisis intervention, family violence prevention, counselling or special therapies for families (psychological-educational wards).

5. Employees of the above mentioned institutions / wards should be trained in a proper manner. Such training courses should be short and should concern issues of help for a family and a child (it is not necessary for employees of such institutions to become psychotherapists). Training courses should be repeated at proper intervals and supplemented by new achievements and therapeutic systems.

Though the above conclusions were made in 2007, they are still live issues as is demonstrated in the letter of the Commissioner for Rights of Children Marek Michalak to the Minister of Health of 21st June 2010. Additionally, the Commissioner stresses148: 1. Waiting a long time to be seen by a paediatric psychiatrist can result in diagnoses of mental health dysfunctions in children and teen-agers which are too late, as well as a late commencement of special treatment.

2. An uneven distribution of paediatric psychiatric wards means that reaching a hospital within an hour which is an European standard is impossible, that contact 147 http://www.nil.org.pl/xml/nil/rejlek/infstat 148 http://www.brpd.gov.pl/wystapienia/wyst_2010_06_21_mz_2.pdf (downloaded 19.07.2010)

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between a child and her/his parents is difficult, and in consequence parents incur high travel costs visiting a hospital and a child experiences huge stress due to separation from her/his parents.

3. A lack of special psychiatric institutions designed for minors who are alcohol and narcotic drug dependent, with sexual disorders or disorders of eating. A lack of specialization of paediatric psychiatric wards leads to a situation where, for example, victims of violence are treated in the same wards where violent offenders are treated.

A program titled National Program of Mental Health Protection was prepared considering a more effective mental health protection â&#x20AC;&#x201C; a reduction of the occurrence of mental health threats, an improvement of the quality of life of people with mental disturbances and their families, and making mental care services available.

The main goals of the Program are as follows: I. Promotion of mental health and prevention of mental disturbances; II. Provision of a multiple, integrated and available medical care for people with mental disturbances (..); III. Development of scientific research and information systems within the scope of health protection.

The program is not in effect yet.

5.2. The training and role of professionals and actors Professionals and actors in contact with juvenile offenders with MH issues should be trained in specialized institutions, so they can effectively protect and meet the needs of minors in contact with the justice system. The training should be designed according to the current issues and pedagogical/psychiatric achievements and approaches. The employees of the units for juveniles, of courts, probation workers, social workers, police officers as well as teachers, should have an opportunity and financial support to regularly improve their professional qualifications This training should include: - Relevant principles, rules, standards and rights of the child and mentally ill child; - The rules and ethical duties of their profession; - Signs and symptoms of mental disturbances; - Special measures and techniques for helping children, involved in criminal proceedings as offenders, victims or witnesses; - Issues of language, religion, social interaction and related to gender, taking into account age, cultural differences and mental issues; - Appropriate communication skills between adults and children; - Interrogation techniques and proper estimation of the situation, in order to minimize the trauma of the child and to maximize the quality of information obtained from him/her;

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5.3. Cooperation and interchange between mental-health and justice systems Mutual cooperation among the local juvenile justice and health care professionals can be strengthened by creating task groups, a coordinating committee and teams that are able to monitor the effects of the activity of the health care and the juvenile justice systems, to identify the problem and to exchange experiences. At this moment the cooperation is not mutual but more unilateral. It means that every entity is obligated to cooperate with the justice system and to provide it with any required information or data but it does not work both ways.

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References • ABC Health, Adolescent Depression: http://portal.abczdrowie.pl/depresja-dzieci.

• Konsumpcja substancji psychoaktywnych przez młodzież szkolną- młodzież 2008, Raport końcowy z badania CBOS na zlecenie Krajowego Biura ds. Przeciwdziałania Narkomanii, Warszawa: www.narkomania.gov.pl/portal?id=15&res_id=529514.

• Official web site of Children’s Ombudsperson: http://www.brpd.gov.pl/, http:// www.brpd.gov.pl/detail.php?recid=564 and http://www.brpd.gov.pl/wystapienia/ wyst_2010_06_21_mz_2.pdf.

• Patient’s Right Bureau: http://www.bpp.gov.pl/.

• Police statistics: www.statystyka.policja.pl.

• Pracownia Testów Psychologicznych: http://www.practest.com.pl.

• Raport o schroniskach dla nieletnich i zakładach poprawczych, Ministerstwo Sprawiedliwości, Warszawa 2005: www.ms.gov.pl/aktual/raport.rtf.

• Rozporządzenie Ministra Sprawiedliwości z dnia 16 sierpnia 2001 r., w sprawie szczegółowych zasad i trybu przeprowadzania wywiadów środowiskowych o nieletnich, (announced in the Polish journal of laws „Dz.U”. 2001.90.1010).

• Rozporządzenie Ministra Sprawiedliwości z dnia 17 października 2001r. w sprawie zakładów poprawczych i schronisk dla nieletnich, (announced in the Polish journal of laws „Dz. U”. Nr 124, poz.1359).

• Rozporządzenie Ministra zdrowia w sprawie szczegółowych zasad kierowania, przyjmowania, przenoszenia, zwalniania i pobytu nieletnich w publicznych zakładach opieki zdrowotnej z dnia 20 kwietnia 2005 r (announced in the Polish journal of laws „Dz.U. Nr 79, poz. 692”).

• Sierosławski, J. (2007), Używanie alkoholu i narkotyków przez młodzież szkolną - Raport z ogólnopolskich badań ankietowych zrealizowanych w 2007 roku. Europejski Program Badań Ankietowych w Szkołach ESPAD, Instytut Psychiatrii I Neurologii. Warszawa: www. narkomania.org.pl › czytelnia.

• Statistics of the Department of Family Policy of the Ministry of Labour and Social Policy, MPiPS-03.

• Supreme Medical Board: http://www.nil.org.pl/xml/nil/rejlek/infstat.

• System of directing to particular centres is currently central: www.cmppp.edu.pl &

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www.systemkierowania.cmppp.edu.pl.

• Ustawa o ochronie danych osobowych (announced in the Polish journal of laws “Dz. U.” of 2002 No. 101 item. 926 as amended).

• Ustawa o ochronie zdrowia psychicznego z dnia 19 sierpnia 1994 r. (announced in the Polish journal of laws “Dz.U.”1994.111.535).

• Ustawa o pomocy społecznej, z dnia 29 listopada 1990 r.; (announced in the Polish journal of laws “Dz. U.” z 1993 r. Nr 13, poz. 60 ze zmianami).

• Ustawa o Rzeczniku Praw Dziecka z dnia 6 stycznia 2000r.; (announced in the Polish journal of laws Dz.U.08.214.1345).

• Ustawa o zawodach lekarza i lekarza dentysty z dnia 05 grudnia 1996 r. (announced in the Polish journal of laws „Dz. U”. z 2005 r. Nr 226, poz. 1943).

• Ustawa o zawodzie psychologa i samorządzie zawodowym psychologów (announced in the Polish journal of laws “Dz. U.” No. 73, item 763).

• Ustawa z dnia 25 lutego 1964 r. - Kodeks rodzinny i opiekuńczy (Dz.U. z 1964, Nr 9, poz. 59 ze zm.).

• Ustawa z dnia 26 października 1982 r. o postępowaniu w sprawach nieletnich, (Dz.U. z 2010, Nr 33, poz. 178 t.j.).

• Ustawa z dnia 7 września 1991r. o systemie oświaty (Dz. U. z 2004 r. Nr 256, poz. 2572, ze zm).

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Biographies of experts COLLABORATOR’S NAME MAREK IGNACZAK BIOGRAPHY Director of the National Centre of Juvenile Forensic Psychiatry (maximum security unit) (Krajowy Ośrodek Psychiatrii Sądowej dla Nieletnich) Al. Legionów 11, 08-400 Garwolin Psychiatrist, specialist in therapy of young offenders with mental disorders, director of the only institution of this type in Poland.

COLLABORATOR’S NAME WANDA KOSIKOWSKA BIOGRAPHY Director of the Diagnostic- Consultative Family Centre at the Regional Court (Rodzinny Ośrodek Diagnostyczno- Konsultacyjny) ul. Kosciuszki 31, 50-046 Wroclaw Psychologist specialized in diagnosis and assessments of young offenders with many years of experience.

The centre is involved in diagnosis, counselling and specialized care in juvenile cases and also in the combating and prevention of demoralization.

COLLABORATOR’S NAME PIOTR SZYLKO BIOGRAPHY Doctor of medicine, specialization in psychiatry. Head of the division of reinforced security for juveniles with mental disorders in Psychiatric Hospital in Lubiaz.

(Wojewódzki Szpital dla Nerwowo i Psychicznie Chorych w Lubiążu)

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Chapter VII Young offenders and mental health: The Portuguese experience ........................................................................................................................................

by Helena Bolieiro Centro de Estudos Judiciรกrios (CEJ)

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Table of Contents ......................................................................................

Acknowledgements 1. PROFILE OF THE MENTALLY ILL JUVENILE OFFENDER 1.1. Mental health problems of young offenders in Portugal.

Specific mental health issues of young offenders in detention.

1.2. General background of young offenders with mental health problems.

1.3. The families of young offenders with mental health problems.

1.4. Correlation between the misuse of drugs and behavioural disorders in young offenders. Age, prevalence patterns and comorbidity of mental health disorders.

1.5. Special needs of young offenders with mental health problems serving custodial sentences.

1.6. Young offenders under therapeutical custodial measures.

2. LEGAL FRAMEWORK: PENAL AND CHILD CARE REGULATION 2.1. The juvenile justice system in Portugal.

2.2. Mental health services for children.

2.3. The child protection system in Portugal.

2.4. Young people with mental health problems and penal responsibility. Therapeutic measures and articulation between the Juvenile Justice System and the Mental Health System.

2.5. Specific legislation aimed at young offenders with mental health problems.

2.6. Ethical principles and practices to be followed by the justice and health systems to protect the best interests of the child.

2.7. Institutions entrusted with the protection of minors.

3. PROFESSIONAL ROLE AND SKILLS DEVELOPMENT 3.1. Level of cooperation between the different professionals who are in contact with the minor in conflict with the law. Specific principles regarding professional cooperation. Â 3.2. Handling of children and young offenders data and regulations on professional confidentiality.

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3.3. Specialized training of juvenile justice and health professionals who are in contact with young offenders with mental health problems.

3.4. Multidisciplinary teams assigned the duty of dealing with young offenders with mental health problems: composition and intervention procedure.

4. INTERVENTION APPROACHES: WHAT IS WORKING AND WHAT IS NOT 4.1. Psychiatric diagnoses and assessments for juvenile detainees with mental disorders: available resources.

4.2. Therapeutic intervention for young offenders in detention and serving community based sanctions.

4.3. Specific units for young offenders with mental health needs.

4.4. Family therapy.

4.5. Prevention and early intervention programmes for young people with behavioural disorders.

4.6. Rules and procedure regarding psychiatric treatment of minors.

4.7. Legal and medical measures foreseen for cases of noncompletion of treatment in outpatient or semi-open systems.

4.8. Juvenile justice system and closed and outpatient treatment.

5. PROPOSALS FOR GOOD PRACTICES 5.1. Young offenders with mental health problems: actions that should be implemented.

5.1.1. The training and role of professionals.

5.1.2. Community-based intervention and prevention.

5.1.3. Cooperation and interchange between mental-health and justice systems.

6. THE FOURTH IJJO INTERNATIONAL CONFERENCE References Biographies of experts

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Acknowledgments The author is grateful to those colleagues and professionals who contributed to this report. The preparation of the final draft benefited from the cooperation of all those who supplied the author with information and documentation. In particular, thanks go to the Directorate General of Social Reintegration and the staff of the NGO «Crescer Ser – Portuguese Association for the Rights of the Child and of Families».

The author also appreciates the assistance of the collaborators who revised the questionnaire. She similarly wants to express her gratitude to them.

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1. PROFILE OF THE MENTALLY ILL JUVENILE OFFENDER 1.1. Mental health problems of young offenders in Portugal. Specific mental health issues of young offenders in detention There is no statistical data that provides us with an exact number of young offenders in Portugal who suffer from mental illness. In fact, generally speaking, no national or regional psychiatric morbidity survey has ever been carried out in Portugal with respect to children, adolescents and adults.149 In the field of juvenile delinquency, experience shows us that issues of mental illness are very prevalent in young offenders who are involved with the juvenile justice system. In a general overview, the types of illnesses are not very different from those that were detected in juveniles in detention in 2008, as shown below. In addition to those illnesses, certain variations of personality disorders, such as antisocial personality disorder, are also relatively common in juvenile offenders.

In a brief screening carried out in 2008 by the Directorate General of Social Reintegration150, in the Portuguese Educational Centres for young offenders (custodial facilities for young offenders, envisaged in the juvenile justice law), it was found that 54% of the juveniles committed to those institutions had specific functional impairment of one or more psychiatric disorders.

With reference to DSM IV and ICD 10151, the mental illnesses that were detected are shown in the following chart.

149 World Health Organization, Alto Comissariado da Saúde, Coordenação Nacional para a Saúde Mental, Portugal - WHO country Summary, Effective and Mental Health, Treatment and Care for All, p.13, available online at <http://www.acs.min-saude.pt/cnsm/2010/03/17/countrysummary/> [Consult. 25 Mar. 2010].

150

2

Data provided by the Directorate General of Social Reintegration.

151 Diagnostic and Statistical Manual of Mental Disorders. The version IV of DSM was published in 1994.

A text revision of DSM-IV, called DSM-IV-TR, was published in 2000.

ICD stands for International Classification of Diseases. Information available online at <http://www.psych.org/ MainMenu/Research/DSMIV/DSMIVTR.aspx> [Consult. 20 Jan. 2011].

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Year 2008 - juveniles committed to the educational centres Mental Disorder

Code DSM IV

ICD 10

DEPRESSIVE EPISODE

296.30‐296.36

F33.

DYSTHYMIA

300.4

F34.

HYPOMANIC EPISODE

296.00‐296.06

F30.x‐F31.9

ALCOHOL ABUSE

305.00

F10.1

304.00‐.90 305.20‐.90

F11.1‐F19.1

SUBSTANCE ABUSE (Non‐ alcohol)

304.00‐.90 305.20‐.90

F11.1‐F19.1

TOURETTE’S DISORDER

307.23

F95.2

ADHD HYPERACTIVE/ IMPULSIVE

314.01

CONDUCT DISORDER

312.8

SUBSTANCE DEPENDENCE (Non‐alcohol)

PSYCHOTIC DISORDERS

297.3/293.81 293.82/ 293.89/298.8/298.9

F90.0 F91.x

F20.xx‐F29

GENERALIZED ANXIETY DISORDER

300.02

ADJUSTMENT DISORDERS

309.24/309.28 309.3/309.4

F43.xx

PERVASIVE DEVELOPMENTAL DISORDER

299.00/299.10/299.80

F84.0/.2/.3/.5/.9

Source: Directorate General of Social Reintegration

F41.1

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1.2. General background of young offenders with mental health problems According to the opinion of professionals who work directly with young offenders in Portugal152 as well as literature that has been developed on that subject 153, a significant number of such offenders presents a background with one or more of the following personal characteristics:  Negative cognitive and emotional states like rage, anger and defiance;  Impulsivity;  Restless/aggressive energy;  Egocentricism;  Below average verbal intelligence;  Low self-esteem;  High, if not inflated, self-concept;  External locus of control;  Low frustration tolerance;  A taste for risk;  Defiance (resistance to or disregard for authority);  Weak problem-solving skills;  Poor self-regulation skills;  Lack of personal and social skills;  Weak socialization;  Hostile interpersonal interactions;  Poor relations with peers and rejection by peers.

Also, according to the above mentioned sources, in the school environment, young offenders with mental health problems often show­:  School system that fails to meet the needs and expectation of youth;  Low cognitive skills;  Learning disabilities;  Below average verbal intelligence;  Attention deficit;  Lack of motivation for school;  Negative attitude towards school;  Low marks and high retention rates on student achievement;  High truancy rates;  High rates of school dropout;

152 Information provided by professionals from the Directorate General of Social Reintegration and from the NGO «Crescer Ser – Portuguese Association for the Rights of the Child and of Families», based on their experience and on internal data collected by the respective institutions.

153 See page 45.

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 Behavioural problems in school;  Disciplinary suspensions for classroom and/or school misbehaviour (e.g. violence, disrespect to teachers and peers).

At the neighbourhood level, these characteristics are common:  Unfavourable social environment (social exclusion, high unemployment rates, high welfare dependency – Portuguese social insertion subsidy);  High level of environmental stress, with tensions and high risk of neighbourhood conflicts;  Cultural identity - neighbourhood shares common values.

1.3. The families of young offenders with mental health problems According to the opinion of professionals who work directly with young offenders in Portugal154 as well as literature that has been developed on that subject155, generally speaking, families of young offenders with mental disorders have poor emotional relationships with their children, which lead to inadequate supervision and inconsistent discipline. In addition to the lack of supervision, general parental neglect is also common. Likewise, domestic violence is frequent in these family settings.

In some cases, there is a significant lack of balance in care giving and educational competencies between biological parents and step parents (often the latter does not ensure a consistent educational role towards their step children), which jeopardizes the quality of parental skills.

Moreover, it should be noted that families of young offenders with mental illness themselves often have mental health problems and a history of substance abuse.

When possible, the family is involved in the treatment of the youth, particularly in order to improve parental supervision skills and to enhance the positive outcome of the treatment. Parents are involved in psycho-educational activities and are given the opportunity to receive parent training.

Family involvement is thus crucial for the success of the treatment. Involvement being voluntary, however, not all parents are willing to participate in such an intervention.

For example, according to the November 2009 data 156, 20 families were asked to become involved in the educational supervision carried out by the juvenile justice probation services («acompanhamento educativo») in the Lisbon area – including offenders

154 Information provided by professionals from the Directorate General of Social Reintegration and from the NGO «Crescer Ser – Portuguese Association for the Rights of the Child and of Families», based on their experience and on internal data collected by the respective institutions.

155 See page 45.

156 Data directly provided to the author by the Directorate General of Social Reintegration.

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with and without mental health issues –, but only 5 of those families accepted the intervention and actually participated in the process.

1.4. Correlation between the misuse of drugs and behavioural disorders in young offenders. Age, prevalence patterns and comorbidity of mental health disorders According to the assessment carried out in 2008157, using the Mini International Neuropsychiatry Interview for Children and Adolescents, version 6.0, in the population confined to the Educational Centres for young offenders («centros educativos», which are the custodial facilities for young offenders), 14% of individuals diagnosed with a mental disease reported the use of drugs. The most common age of those individuals was 16 years old.

Moreover, 33% of people had co-morbidity with two diagnoses. The major prevalence of co-morbidity occurs with affective disorder and conduct disorder or a major mental disorder (psychosis, manic episode, or major depressive episode) and a substance use disorder.

In a general overview, substance abuse and dependence don’t have a relevant prevalence. Episodes of drug use are more common.

The above-mentioned 2008 assessment was the first one to be made in Portuguese juvenile facilities. In 2010 a similar study was planned to be carried out.

We stress the importance of scientific studies that allow a better understanding of these mental health issues and enable us to address the problem in a more adequate manner.

However, we must take into consideration, when using interview-based assessments, that circumstances like «social desirability bias» may affect the survey results in what pertains to the real number of cases. Therefore, reported cases of substance abuse may only represent the tip of the iceberg.

1.5. Special needs of young offenders with mental health problems serving custodial sentences The special needs of minors in conflict with the law require a combined intervention that addresses both mental health problems and deviant behaviour. The intervention must be adequate to deal with issues such as personal and social skills deficits,

157 9 Data collected by the Directorate General of Social Reintegration. See footnote 2.

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substance abuse problems, lack of emotion management skills, anti-social behaviour, sex offender treatment and anger management.

In addition to an adequate treatment of the particular mental health issue, the development of personal and social skills will enable the rehabilitation and social reintegration of the young offender.

Also, as far as possible (always bearing in mind that in custodial situations liberty is restricted), family should be involved in the process.

Moreover, any intervention programme must be tailored to the real needs of young offenders and must be subject to adequate scientific evaluation.

1.6. Young offenders under therapeutical custodial measures The current Law on Juvenile Justice does not envisage a specific therapeutical custodial measure.

According to the Law, young offenders who face custodial sentence and have mental health issues that have to be therapeutically addressed will receive psychiatric and/or psychological treatment during detention.

Although the current legal framework foresees the creation of special centres or residential units that would provide therapeutic programmes specifically designed for young offenders with personality disorder or serious addictive behaviours, such units and programmes do not yet exist.

There are several young offenders in custody who receive treatment, provided either by outside psychiatrists hired by the juvenile justice sector or by local or regional facilities integrated in the mental health system. They can also be followed by psychologists that belong to the Centre’s staff.

Whenever possible and adequate, juveniles (male and female) under a custodial measure who need therapeutical intervention are preferably placed in the «Centro Educativo Navarro de Paiva», located in Lisbon, which has many years of experience in the field of mental health and is seen as the best custodial option for these problems.

As of April 2010, there are 191 male young offenders committed to the 6 existing educational centres158 and 18 female young offenders. From those, 73 receive psychiatric treatment and/or psychological support, distributed as follows: • «Centro Educativo da Bela Vista» (Lisbon) – 6 boys; • «Centro Educativo Navarro de Paiva» (Lisbon) – 8 boys and 5 girls; • «Centro Educativo Padre António de Oliveira» (Lisbon) – 11 boys;

158 Data provided by the Directorate General of Social Reintegration. The number of educational centres has recently changed and there are currently 8 of those custodial facilities in Portugal: Bela Vista (Lisbon), Madeira (Madeira Island), Mondego (Guarda), Navarro de Paiva (Lisbon), Olivais (Coimbra), Padre António Oliveira (Lisbon), Santa Clara (Vila do Conde), and Santo António (Oporto).

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• «Centro Educativo Santo António» (Oporto) – 16 boys; • «Centro Educativo dos Olivais» (Coimbra) – 27 boys; • «Centro Educativo do Mondego» (Guarda) – none receiving treatment.

2. LEGAL FRAMEWORK: PENAL AND CHILD CARE REGULATION 2.1. The juvenile justice system in Portugal According to Portuguese Juvenile Justice Law – «Lei Tutelar Educativa» -, approved

by Law 166/99 of 14 September 1999, a person between 12 and 16 years of age who commits a criminal act is subject to educational measures (in the Portuguese penal system criminal responsibility begins at the age of 16).

These measures aim at the education of the young offender, so that he or she learns the basic values of society, protected by criminal law, thus promoting his or her integration into the community, in a responsible and respectable fashion.

The measures envisaged in the law are: oral admonishment; deprivation of the right to ride motorcycles or to obtain permission to ride motorcycles; reparation to the victim; payment of economic compensation to the community; community work; imposition of rules of conduct; imposition of obligations; participation in training programmes; educational supervision by the probation services; and detention in a educational centre.159 As part of the community based measure of imposition of obligations, the young offender may undergo medical, psychiatric or psychological treatment programs, in a public or private institution and on an inpatient or outpatient basis. The programs aim at the treatment of alcohol and drug habituation and/or psychiatric disorders.

Although this measure involves the judicial imposition of obligations, the judge must seek the young offender’s voluntary acceptance of the treatment and when he or she is over 14 years old, it is necessary to obtain his or her consent for the proposed treatment.

The measure of detention in an educational centre can be executed in accordance with one of three levels, based on the extent of the deprivation of freedom carried out by the specific measure:

159 In Portugal, custodial facilities for young offenders are called educational centres («centros educativos»).

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1) Open – the young person lives in the educational centre but can receive permission to spend some weekends and holidays with his or her family if he or she can achieve institutional goals and acquire social skills. Sometimes, he or she can also study or practice sports or other activities outside the centre, in the community.

2) Partially-Open - the young person lives and studies in the educational centre but can receive permission to spend holidays with his or her family if he or she can achieve institutional goals and acquire social skills. When the young person has progressed - and towards the end of the sentence - he or she may also have permission to spend some weekends with his or her family; and 3) Closed - the young person lives and studies in the educational centre but he or she does not have permission to leave the centre except for medical assistance or as required by the court.

The measures envisaged in the law are ordered by the judge and the procedural initiative rests with the public prosecution services. The imposition of custodial measures requires a trial before a panel of three judges, composed by one professional and two social judges (lay judges).

The Directorate General of Social Reintegration, a department of the Ministry of Justice, is responsible for probation services and for juvenile justice. This Directorate ensures the execution of educational measures in the community, with a very active role in what pertains to reparation to the victim, community work, imposition of rules of conduct, imposition of obligations, attendance of training programmes and educational supervision (in the latter, the intervention of the Directorate, as the service in charge of probation, is mandatory), and is also responsible for the execution of the custodial measure and the management and security of educational centres.

As stated by Portugal’s Justice Statistics160, the total number of juvenile justice cases handled by the courts in the 2000–2009 period was: 200012001 2002 2003 2004 -

2.255 1.138 1.041 1.011 1.138

2005 - 1.032 2006 - 1.135 2007 - 738 2008 - 859 2009 - 934

1 In year 2000, cases were handled under the former juvenile justice rules. Juvenile Justice Law, approved

by Law 166/99 of 14 September 1999, entered into force in January 2001.

160 Available on line at <http://www.dgpj.mj.pt/sections/estatisticas-da-justica> [Consult. 20 Jan. 2011].

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According to data provided by the Directorate General of Social Reintegration, in the period of 2003-2009 the average age of young offenders was 14 years old, at the time the offences were committed, and the most common community measures, applied by the courts, were educational supervision by the probation services, community work and imposition of obligations.

As far as custodial measures are concerned, the evolution of the total number young offenders committed to the educational centres in 2009 and 2010161 can be described as follows:

2009

2010

Jan. 182 Feb. 181 Mar. 191 Apr. 196 May 193 June 205 July 204 Aug. 202 Sept. 195 Oct. 197 Nov. 208 Dec. 204

Jan. 203 Feb. 201 Mar. 219 Apr. 220 May 217 June 219 July 218 Aug. 224 Sept. 217 Oct. 212 Nov. 225 Dec. 226

2.2. Mental health services for children The treatment and care of children with mental health issues is provided by mental health services that are integrated into the general health system, although those services are governed by specific legislation and action plans.

According to the 2005 data162, there were 56.984 child and adolescent outpatients attendances (about 15% were first attendances), 120 patients attended in day hospital (3.615 sessions), 271 inpatients admitted (a total of 24 inpatient beds available) and 1.423 patients attended in emergency services.163

161 Data available on line at <http://www.dgrs.mj.pt/web/rs/estat> [Consult. 20 Jan. 2011].

162 Report «Proposta de Plano de Acção para a Reestruturação e Desenvolvimento dos Serviços de Saúde Mental em Portugal 2007-2016», p.44, available online at <http://www.acs.min-saude.pt/wp-content/ blogs.dir/1/files/2008/01/relatorioplanoaccaoservicossaudemental.pdf> [Consult. 19 Jan. 2011].

163 Portugal’s population is around 10 million people and the proportion of population under the age of 15 is 15,9%.

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The Mental Health Law (1998)164 and Decree (1999)165 define the grounds and principles of both involuntary admissions (children and adults), and voluntary admissions, as well as the rights of people with mental disorders. They also define the principles of service organization (by the distinction between local mental health services and specialized regional services) and provide the basic rules for the articulation between social and health services.

The Mental Health Policy and Plan of 2007166 traces the current national context of mental health and sets up the goals and actions planned for 2007-2012. According to this Plan, the organization of mental health services for children and adolescents must be able to provide care at these three levels: primary health care (children’s mental health support teams, composed by professionals from the primary health care system and advised by a psychiatrist from the local level, with the role of detecting, assessing and assisting less serious cases, in articulation with other services of the community); specialized services at a local level (units or services specialised in child and adolescent mental health integrated in general hospitals); and specialized services at a regional level (regional departments of psychiatry and child and adolescent mental health, located in the cities of Lisbon, Oporto and Coimbra, which provide specialised inpatient units, as well as programmes and services for the more serious and complex disorders).

The Plan also envisages the implementation of prevention programmes, the improvement of already existing day hospitals and the creation of new facilities of such kind, the development of the existing inpatient units and the creation of community residential facilities for children and adolescents, as well as the establishment, in cooperation with the justice sector, social services and other government departments, of long term foster care facilities that are able to respond to the needs of children and adolescents who have serious behaviour disorders and who are without family support.

However, the goals foreseen in the Plan are far from being accomplished and the situation of mental health services for children and adolescents is still very limited, as far as facilities, human resources, local and community responses, prevention and intervention programmes.

164 Law 36/98 of 24 July 1998.

165 Decree Law 35/99 of 5 February 1999, amended by Decree Law 304/2009 of 22 October 2009.

166 Approved by Council of Ministers Resolution 49/2008 of 6 March 2008.

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2.3. The child protection system in Portugal In certain circumstances, the protection of children with mental health issues is provided by the system envisaged by the Law for the Protection of Children and Youth in Danger, approved by Law 147/99 of 1 September 1999.167 According to this law, an intervention to promote the rights and the protection of children and youth shall take place when parents, a legal guardian or a de facto guardian put the child/young person in danger (in terms of safety, health, education or development); or when such a danger results from an act or omission by a third person or the child/young person himself or herself, and the adult guardian does nothing or is unable to prevent or stop it.

For the purpose of this law, a child or youth is considered to be in danger when he or she is in one or more of the following situations: is abandoned or lives on his or her own; suffers physical or psychological harm or is a victim of sexual abuse; does not receive care or affection adequate to his or her age and personal situation; is forced into activities or work that are excessive or inappropriate for his or her age, dignity and personal situation or is harmful to his or her formation or development; is subject, directly or indirectly, to behaviours that adversely affect his or her safety or emotional balance; or adopts behaviours or participates in activities that severely affect his or her health, safety, formation, education or development, and the parents, legal representative or de facto guardian are unable to stop them.

The guiding principles of care and protection intervention are: a) Best interests of the child or young person – the intervention shall give primary consideration to the interests and rights of the child or young person, without prejudice to consideration of other legitimate interests that are present in the particular case; b) Privacy – the promotion of the rights and the protection of the child or young person shall take place in such a manner as to respect his or her privacy and right to his or her image; c) Early intervention – the intervention shall be initiated as soon as the situation presenting danger is known by the relevant authorities; d) Minimum intervention – the intervention shall be developed exclusively by the entities and institutions whose actions are essential to the effective promotion of the rights and protection of the child or young person in danger; e) Proportionality and up-to-date intervention – the intervention shall be proportional

167 Amended by Law 31/2003 of 22 August 2003.

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to the situation or danger confronting the child or young person and the intervention shall only interfere with the life of the subject and his or her family to the extent strictly necessary to achieve its protective purpose; f) Parental responsibility – the intervention should be effectuated so that the parents will be able to assume their duties toward the child or young person; g) Family prevalence – in the promotion of the rights and in the protection of the child or young person, priority should be given to measures that integrate them into their families or that promote their adoption; h) Obligation to inform – the child/young person, the parents, the legal representative or the de facto guardian shall be informed of their rights, of the grounds for the intervention and of the way the proceedings will take place; i) Obligatory hearing and participation – the child/young person, separated or in the company of the parents or the person chosen for the purpose (such as the legal representative or the de facto guardian), has the right to be heard and to participate at all stages of the proceedings, and to assist in defining the measures used to promote both their rights and their protection; and j) Subsidiarity – the intervention shall be made successively by the entities with competence in matters of childhood and youth, by the commissions for the protection of children and youth, and, in last instance, by the courts.

The Commissions for Protection of Children and Youth are non-judicial official institutions, with autonomy, that exist in every municipality and are composed by representatives of local entities: municipal services, social services, education and health services, police authorities, etc.

The intervention of such Commissions depends on the consent of the parents, legal guardian or de facto guardian and the non-opposition of the child or young person who is 12 years or more is also required. Moreover, such Commissions can apply protection measures for protection (except placement for future adoption), but only by agreement. If there is no agreement regarding the protective measures proposed by the Commission or if the necessary consents are withdrawn, the Commission reports the case to the Public Prosecutor.

The Public Prosecutor monitors and assesses the activity of the Commissions for Protection of Children and Youth and has the legal duty to represent children, by bringing to court the cases for the protection of their rights. In care and protection cases, the court can take protective measures by a care and protection agreement or by judicial order, after a trial (judicial debate, as it is called by the law).

The protection measures envisaged in this law are: support and guidance services for parents; support and guidance services for relatives; placement in the care of a

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suitable person; support for the transition to independent living; placement in foster family; placement in a foster institution; and placement for future adoption.

The measures are intended to remove children and youth away from the danger they are facing, to give them conditions that protect and promote their safety, health, education, well-being and full development, and to assure the physical and psychological recovery of those children and youth who were victims of any form of exploitation and abuse.

2.4. Young people with mental health problems and penal responsibility.

Therapeutic measures and articulation between the Juvenile Justice System and the Mental Health System According to the Portuguese penal system, criminal responsibility begins at the age of 16.168 A person between 12 and 16 years of age who commits a criminal act is subject to educational measures, as set forth in the Portuguese Juvenile Justice Law (ÂŤLei Tutelar EducativaÂť).

According to this law, in any phase of the proceedings, if the young offender is found to suffer mental disease that prevents him or her from understanding the meaning of the juvenile justice intervention, the case will be dismissed and the young person will be referred by the public prosecutor to mental health services. The public prosecutor will also provide for the assessment of the need of inpatient psychiatric treatment and, if necessary, of compulsory admission, in compliance with the Mental Health Law. As envisaged in this Act, a person may be committed as an involuntary inpatient in an adequate hospital if he or she has a serious psychiatric disorder and there is, as a consequence, a danger posed to protected values of relevant worth to the person or others, either of personal or of patrimonial nature, and refuses to submit to the necessary medical treatment.

Also, according to the Mental Health Law, a person with a serious psychiatric disorder who does not have the necessary discernment to evaluate the meaning and extent of consent can also be sent to inpatient confinement, when the absence of treatment causes a significant deterioration of his or her condition.

If, despite his or her mental disease, the young offender (from 12 to 16 years old) is capable of understanding the meaning of a juvenile justice intervention, the case will proceed and measures, including those of a custodial nature, can be applied.

168â&#x20AC;&#x201A; Article 19 of the Penal Code.

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2.5. Specific legislation concerning young offenders with mental health problems There is no specific legislation concerning young offenders with mental health problems, aside from the above-mentioned provision in the Juvenile Justice Law (case dismissal and referral to mental health services when the young offender lacks sufficient understanding of the meaning of intervention), the provision of the General and Disciplinary Regulation of the Educational Centres that foresees the creation of special centres or residential units that would provide therapeutic programmes, and the Mental Health Act (the latter applicable to offenders and non-offenders).

On 17 February 2011, the Government approved a proposal to amend the juvenile justice law, to be submitted to Parliament for discussion and approval. This proposal envisages a therapeutic custodial measure for young offenders with mental health problems. The Government describes it as a new juvenile justice measure that will provide a specific response for mental health problems related to deviant behaviour. In this particular aspect, the proposal points out the crucial importance of coordination between health and juvenile justice systems for the prevention of juvenile delinquency.

2.6. Ethical principles and practices to be followed by the justice and health systems to protect the best interests of the child The best interest of the child is the paramount concern in any matter concerning a juvenile, including both juvenile justice and mental health system.

One of the most important principles is the one of early intervention. The system should be put into action at an early stage, as soon as the child’s mental health issues are detected. In those circumstances, if a prompt action is carried out by the health system, in articulation with the education sector and social services, there is a much greater chance of preventing deviant behaviour.

A swift response, however, can be hampered by factors such as: the inadequacy of the existing information and referral systems; the lack of training of public health professionals in matters concerning child and adolescent mental health; a weak perception of the importance of these issues, in comparison with other health matters such as infant mortality; the reduced number of resources; and a failure of coordination among different levels and sectors of intervention, in order to boost the quality of the existing (and limited) responses.

The most productive response is one that occurs at the «front end» and that is

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proactive. Such an approach, coming early in the process, is much more likely to have a preventive effect. Unfortunately, a failure to undertake a mental health intervention at the initial stage is common, even though at that point less aggressive therapeutic approaches, or even a care and protection intervention, could achieve a positive result.

Instead, it is more common for such responses to occur only at a much later stage and, even then, usually in the juvenile justice system. In such circumstances, the effort is a much more difficult one as it amounts to an «end of the line» intervention.

There is another issue that our system should more adequately address, pertaining to the need for more active court intervention in cases involving the administration of psychiatric medication to young offenders committed to juvenile facilities («centros educativos»). In our opinion, a judicial determination for treatment with psychiatric medication should be required, even if the young person committed to the centre is over 14 years old (the age that, according to mental health law, a person is presumably competent to give an informed consent).

Although the educational centre informs the parents or guardians and the court about the treatment plan and the medication administered to the young person, that communication is in our opinion insufficient, as the power to authorize medication therapy rests almost exclusively with a non-judicial authority (the director of the facility), with little intervention by the court prior to the beginning of the treatment.

2.7. Institutions entrusted with the protection of minors As previously mentioned, the Public Prosecution Service plays a key role in the court proceedings of the care and protection system, the juvenile justice system and the mental health intervention related to involuntary admission of dangerous persons with mental disorders.

Also, as reported above, the Commissions for Protection of Children and Youth play an important role in any care and protection intervention concerning a child or young person who is at risk. Moreover, if such an intervention is carried out successfully prior to the occurrence of a judicial proceeding, such a proceeding may never be required.

Furthermore, the main function of the Portuguese Ombudsman («Provedor de Justiça»), established by article 23 of the Constitution, is to defend and promote the rights, freedoms, guarantees and legitimate interests of all citizens, ensuring, through informal means, that public powers act fairly and in compliance with the law. This broad mandate encompasses, inter alia, the rights of the child, and the Ombudsman has indeed dedicated specific attention to this field.

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In 1993, a toll-free telephone hotline («Linha Verde Recados da Criança») was created to receive complaints relating to children who might be at risk or in danger, and will take calls either made by the children themselves or by adults on their behalf.

The Line contacts the relevant entities (e.g. Commissions for Protection of Children and Youth, Social Security Regional Centres, Ministry of Education services, Courts), in order to collect information and to allow the appropriate agency to become involved in developing an adequate resolution of the case. In simpler situations, the Line may simply provide information or forward the caller to the competent entity. In more complex cases, formal proceedings are initiated.

The Department on Children, Elderly Persons and Persons with Disabilities, placed under the direct supervision of one of the two Deputy Ombudspersons, is in charge of coordinating the two existing hotlines, investigating complaints, providing information on the contents of rights and the role of the Ombudsman and developing cooperation initiatives at national and international level.

Concerning the work of the Ombudsman as it relates to the protection of children, special mention can be made to the inspections carried out at residential units and foster care institutions in Portugal, both on the mainland and in the autonomous regions. It should be noted, however, that the Ombudsman has no involvement in court proceedings, nor does his scope of activity include reviewing the work of the courts (with the exception of administrative matters, such as the excessive length of proceedings).

3. PROFESSIONAL ROLE AND SKILLS DEVELOPMENT 3.1. Level of cooperation between the different staff who are in contact with the minor who is in conflict with the law. Specific principles regarding professional cooperation

Interdisciplinary and inter-institutional cooperation are key principles in any intervention concerning children, including both care and protection intervention and juvenile justice matters. In this respect, the integration of services and joined-up approaches should be encouraged. However, there is still not enough coordination among the different services and staff who are in contact with the young person in conflict with the law. With respect to the execution of non-custodial measures, the level of cooperation is, to date, far from sufficient. The cooperation between services and professionals usually requires quite a significant system of formal requests of collaboration, instead of a more swift procedure based on pre-established protocols in which informal calls for assistance would be sufficient to trigger the joint involvement of all professionals.

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For instance, concerning the measure of educational supervision («acompanhamento educativo»), whose execution is ensured by the Directorate General of Social Reintegration, there should be a pro-active coordination among the probation services, the education sector, health and social services, following a team work format.

Nevertheless, in some areas of the country, especially in less populated regions, there are some initiatives that reflect a good level of cooperation between services and professionals, usually carried out within the framework of a protocol signed by the respective institutions.

3.2. Handling of children and young offenders data and regulations on professional confidentiality According to juvenile law, each file is confidential until the court order scheduling a trial. Even after this order, the publicity of the case must respect the young offender’s personality and privacy, preserving, as much as possible, his or her identity.

Although the trial is public, the law allows the judge to limit or even exclude the publicity concerning the trial, based on certain limited grounds, such as when the presence of the public might psychologically affect the young offender. Nonetheless, the Court’s final decision must be always read at public sittings.

The provisions of juvenile law also allow the judge to determine, on the basis of findings that he or she makes, that the media must refrain from narrating or reproducing certain acts or documents of the case file, or disclosing the young offender’s identity.

With respect to the execution of measures, the access to the young offender’s personal file is reserved and is only authorized to the staff who works directly with the young person.

In addition to that, during a custodial measure, the access to the young person’s clinical file is reserved to health professionals, the centre’s director and, through medical intermediation, to the parents or guardian. The juvenile detention officer who is in charge of the case can access the clinical information that is relevant for the educational plan.

If the young offender is transferred to another centre, the medical record shall be sent, separately from any other data, in a closed and confidential envelope to the director of the new centre. When the custodial measure ends, the young person and his or her parents or guardian can request that the record is sent to his or her medical assistant.

Finally, the law does not allow public officials to disclose personal data related to cases in which they are working and the use of information for statistical purposes shall fully respect the privacy of each young offender.

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3.3 Specialized training of juvenile justice and health professionals who are in contact with young offenders with mental health problems Currently there is no specialized training for those who are in contact with young offenders with mental health problems. However, even though there aren’t structured training programmes exclusively designed for issues related to mentally ill young offenders, there are training initiatives in the legal, health and educational fields that might be relevant for professionals who work with such young persons.

Some of those activities are provided by public institutions, such as the Centre for Judicial Studies («Centro de Estudos Judiciários»), the Portuguese institution in charge of training judges and public prosecutors (both initial and continuing training), others are offered by private institutions, such as private universities or qualified training facilitators that work on an independent basis. The Directorate General of Social Reintegration also provides some training initiatives for its professionals (e.g. crisis intervention, psychological assessment), either by internal training programmes with hired experts or by supporting the financial costs of the trainee’s attendance of university programmes.

3.4. Multidisciplinary teams assigned the duty of dealing with young offenders with mental health problems: composition and intervention procedure Despite the lack of therapeutic custodial measures in the Portuguese juvenile justice system, every young offender in custody (with or without mental health issues) is assisted by a multidisciplinary team composed by psychologists, educational officers and social workers.

Given the needs in this area, the Directorate General of Social Reintegration is planning to set up a team of qualified professionals in the field of mental health and in the field of criminology, composed by psychiatrists, psychologists, nurses, social workers and technical assistants.

In non-custodial measures, the probation officer who is in charge of the case performs his role primarily on an individual basis, although integrated in a team (usually composed of a psychologist, a social worker and a professional with a law degree) and in coordination with other services, such as education, health, social services, etc.

The court-ordered assessments are usually carried out by one probation officer who is integrated in a team, as described above. The probation officer does the assessment

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and, after completion, presents the report for final approval to his or her supervisor.

Usually the team does case discussion meetings, which are regarded as very useful for this type of activity.

4. INTERVENTION APPROACHES: WHAT IS WORKING AND WHAT IS NOT 4.1. Psychiatric diagnoses and assessments for juvenile detainees with mental disorders: available resources The diagnosis of mentally ill adolescents requires the collection of information in multiple areas which characterize the functioning of the young person, as well as their family and social environment. Thus, it is an approach that uses multiple sources of information and multiple methods of data collection in different contexts.

The diagnosis includes the assessment of adolescents, parents, caregivers and the young person’s behaviour and performance in school. The diagnosis is made through interviews, psychological tests and inventory risk assessment (this inventory is now in the final phase of validation for the Portuguese population).

If there are previous pre-sentencing reports or other assessment documents, the new diagnosis focuses on the areas of assessment that were not subject to prior evaluation or were less thoroughly evaluated.

Portuguese Juvenile Justice Law foresees a mandatory pre-sentencing assessment in all cases involving the application of the measure of detention in an educational centre at a closed level169. In the rest of the cases, such assessments shall take place whenever mental health issues are raised. If a mental health diagnosis is to be performed, a hired psychiatrist or a mental health institution in the community may become involved.

4.2. Therapeutic intervention for young offenders in detention and serving community based sanctions With regards to young offenders in custodial measures, Portuguese law (General and Disciplinary Regulation of the Educational Centres)170 foresees the creation of special centres or residential units for therapeutic purposes.

Those centres or special units would provide therapeutic programmes specially designed for young offenders with personality disorder or serious addictive behaviours

169 See page 14.

170 «Regulamento Geral e Disciplinar dos Centros Educativos», approved by Decree Law 323-D/2000 of 20 December 2000.

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for which the regular programmes offered in the other facilities are not adequate. Also, according to the law, the placement of young offenders in these special centres or units and their enrolment in such therapeutic programmes depend on the court’s approval.

Despite the law that has been in force for more than 10 years, in our country there are still no specialized therapeutic units within juvenile justice custodial facilities.

Therapeutic intervention is therefore carried out by hired psychiatrists. In some educational centres, there is the possibility of therapeutic intervention provided by a psychologist of the institution. Also, whenever possible, the young offenders are referred to mental health facilities in the community.

As previously noted, however, the response of the mental health system is not always adequate. One specific problem is the fact that responses within the mental health system are often neither timely nor sufficient, largely due to the lack of adequate resources. The tragedy is that delaying a response only makes the underlying situation worse by neglecting it. This, in turn, requires that even more resources be applied later on to the case of a young offender whose condition has worsened because of the failure to address his or her needs earlier.

With respect to community based measures, probation services try to coordinate their intervention with the mental health system and young offenders are referred to mental health services at a local level or even at a regional level.

Notwithstanding some local projects that have been producing good outcomes, it is in the main cities, such as Lisbon, that we find the (few) existing responses for outpatient treatment with more qualified programmes.

For example, the Day Hospital - Youth Clinic («Hospital de Dia da Clínica da Juventude»)171, located in Lisbon, is one of the few outpatient specialized units in the public sector that provides an integrated therapeutic response for adolescents from 13 to 17 years old, in coordination with community institutions such as schools, municipal services and employment and professional training departments. Adolescents with toxicophilic and alcoholic dependence or with severe behavioural disorders are not admitted to this programme.

171 The Day Hospital - Youth Clinic website is available at <http://hospitaldedia.no.sapo.pt/> [Consult. 2 Apr. 2010).

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4.3. Specific units for young offenders with mental health needs There are still no specialized mental-health units for young offenders within the juvenile justice system (custodial and non-custodial measures).

Nonetheless, the Directorate General of Social Reintegration is in the process of implementing a project («Projecto Clínica de Apoio Psicoterapêutico») that focuses on the needs of young offenders with mental health issues and aims to develop programmes with interventions in the individual, family and community systems, based on those experiences that have already demonstrated effectiveness at the international level in reducing both psychiatric symptoms and criminal behaviour.

The purpose of the project is to create a service delivery for youth and families with complex needs involving multiple service providers. These services might include assessment, clinical therapy, substance use treatment, and coordination with other sectors such as community services. This project thus seeks to create a response that will meet the specific needs of juveniles in the justice system who face mental health problems. It is expected to complement the educational and professional interventions already available, in order to promote social re-integration of young offenders in society and therefore prevent recidivism.

4.4. Family therapy Family intervention will be one of the components of therapeutic intervention in the future. Family intervention in the case of young offenders with mental illness aims to repair family relationships, to teach the skills needed to recognize the early signs of mental illness symptoms (and how to deal with them), to enhance parental supervision skills and to develop adequate disciplinary practices.

A crucial ingredient for a successful intervention – as viewed by professionals who work with young offenders and their families – is that it occurs on a voluntary basis.

There is, nonetheless, often a need for some court involvement. This can take the form of imposing therapy on families (e.g. subject to a fine), at least at a preliminary stage of the process.

Although there are some local family therapy projects that are able to provide family therapy services to the juvenile system and that have produced good outcomes (e.g. Centre for Family Therapy and Systemic Intervention, in Ponta Delgada, Azores), those initiatives are still scarce and far from a nationwide structured programme that runs on a regular basis and covers the global needs of the system.

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4.5. Prevention and early intervention programmes for young people with behavioural disorders We are not aware of a nationwide structured prevention programme that is specifically aimed at young people with behavioural disorders. There are, however, some programmes designed for general school populations whose goal is to prevent behavioural problems that may involve mental health issues. These programmes focus on the development of personal and social skills, in order to prevent violent behaviour among students. Moreover, there have been some initiatives at a community level, developed by local authorities (e.g. health, municipalities), in association with NGOâ&#x20AC;&#x2122;s and other private service providers. These initiatives are usually targeted at the young public in general, and therefore have a broader scope than prevention work with adolescents with a potential risk of behavioural disorders.

It should be noted that to develop any prevention programme, professionals must have an accurate knowledge of the mental health situation of children and adolescents in Portugal. Data collection with statistical purposes and epidemiological studies (which are lacking in our country) must play a key role when it comes to the adoption of prevention strategies.

This is a crucial point, because without quantifying the problem it is extremely difficult to develop adequate means of responses. Thus, it is necessary to know how many adolescents have mental health issues, what the pathologies they may suffer from are and what the nature and context of the risks associated with their various is.

4.6. Rules and procedure regarding psychiatric treatment of minors Young offenders committed to educational centres are treated by a psychiatrist / general practitioner, and medication prescribed by the doctors is administered by the educational officers. According to the law, only medication prescribed by a doctor can be administered to the young offender. The minors placed in these facilities are obliged to follow the treatment decided by the doctor.

In cases of outpatient treatment, often the young person doesnâ&#x20AC;&#x2122;t pursue the treatment. If he or she is subject to a community based measure, the treatment plan, including medication, relies mainly on the voluntary initiative of the young person and his or her parents or guardians.

In appropriate cases, the juvenile law foresees the possibility of submitting the young person to psychiatric treatment (inpatient or outpatient) in a private or public

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institution, for alcohol abuse, substance use or psychiatric disorder. In any case, the judge shall seek the young personâ&#x20AC;&#x2122;s compliance with the treatment programme and consent is even required, when he or she is over 14 years of age.

4.7. Legal and medical measures are foreseen for cases of non-completion of treatment in outpatient or semi-open systems In cases of outpatient treatment, the court is informed that the child does not comply with the treatment. Usually, efforts are made by the probation services (or even by the court) to persuade the family and the young person to pursue the treatment. However, the law does not allow the imposition of a custodial measure in the event of non-compliance, in order to conclude the treatment in a closed setting.

If the young offender is subject to a custodial measure in a partially-open educational centre, usually he or she completes the treatment programme, especially considering that in that custodial setting the administration of medication prescribed by a doctor is obligatory. In any event, the law does not allow the court to order the admission to a closed centre on grounds limited to non-compliance with psychiatric treatment.

It should be noted, however, that according to the provisions of mental health law, a young person may be committed as an involuntary inpatient in an adequate hospital. This may occur if he or she has a serious psychiatric disorder and there is, as a result, a danger posed to protected values of relevant worth to the person or others, either of personal or of patrimonial nature, and refuses to submit to the necessary medical treatment. Also, a young person with a serious psychiatric disorder that does not have the necessary discernment to evaluate the meaning and extent of consent can also be sent to inpatient confinement, when the absence of treatment may cause a significant deterioration in his or her condition.

4.8. Juvenile justice system and closed and outpatient treatment In the juvenile system there are no laws or action protocols that expressly envisage mixed systems of closed and outpatient treatment.

If the young offender is committed to an educational centre (closed or partially-open regime), the psychiatric treatment will be carried out either in the facility or by using community services. However, that young personâ&#x20AC;&#x2122;s daily routines, school attendance (usually in the centre) and other training activities that are provided by the centre will be executed in the same custodial way.

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If the young offender is subject to a community based measure, the therapeutic programme associated to the measure will follow the guidelines that are defined by the (public or private) health institution that provides for treatment, which may include a first stage of inpatient therapy and a further level of outpatient intervention (always bearing in mind that the latter is the desirable approach, closed treatment being a last resort).

5. PROPOSALS FOR GOOD PRACTICES 5.1. Young offenders with mental health problems: actions that should be implemented 5.1.1 The training and role of professionals The therapeutic work that must be accomplished involves, necessarily, qualified technicians, whether in the field of mental health or in the field of criminology and criminal psychology. That being the case, the training of technicians must be based on an understanding of those two fields.

Similarly, there is a need for more technical specialization in the field of child and adolescent mental health, including in the university curricula. It is, thus, crucial to ensure sufficient support to investigation initiatives in that area and to develop more consistent training programs for all professionals.

5.1.2 Community-based intervention and prevention The use of community-based intervention and prevention presents a number of needs, including a need for: • An early detection system and effective prevention programmes.

• More mental health responses at the level of care and protection intervention, which could achieve positive results and prevent deviant behaviour, thus avoiding the «end of the line» intervention of juvenile justice.

• More NGO’s to work in this sector (currently the number is almost nonexistent).

• More service providers, in general.

• A culture of community intervention, which is lacking, as a result of which we rely excessively on the formal mental health system, usually at the hospital level.

• A broad scientific study (here the collaboration of universities is crucial)

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to determine the scope of the need for services, including who such persons are (ages, gender, family, location, socio-cultural background), the nature of the disorders involved and the extent of their prevalence.

5.1.3 Cooperation and interchange between mental health and justice systems

More integrated training is definitely necessary. For example, justice professionals should know more about mental health issues, particularly the ones that are specifically related to children and adolescents, and mental health professionals should know more about the legal system, legal concepts and court intervention in matters involving children and adolescents, namely the protection system and juvenile justice. There is a significant need for a more integrated understanding and appreciation of the problems at hand along with the means for addressing them.

It is also necessary to have more team work and joined-up approaches, in an interdisciplinary and inter-institutional manner, always respecting each other’s field of work, but facilitating communication, coordination and integrated responses.

6. THE FOURTH IJJO INTERNATIONAL CONFERENCE Key facts from the Conference The Fourth IJJO International Conference was held in Rome, in 9-10 November 2010, under the title «Building Integrated Juvenile Justice systems: Approaches and methodologies regarding mental disorders and drug misuse».

The event took as central theme the need to develop programmes and resources that promote an efficient intervention with children and young people with mental disorders or some kind of addiction to toxic substances and who are in a situation of risk or in conflict with the law.

The two main issues focused in the Conference were: a) Mental disorders and drugs misuse: analysis of the situation of minors in conflict with the law; b) Juvenile justice and health systems: A necessary multidisciplinary and integrative collaboration.

Based on the experiences that were shared and on the information presented in this fruitful international initiative, we would like to point out the following aspects: • Presenters from various countries focused on the troubling fact that large numbers of young people are subject to the juvenile justice system and that mental health problems are often detected in these young offenders.

• Young offenders should be regularly assessed to determine their mental health needs. Moreover, professional approaches must be developed and implemented to achieve this end. Additionally, there is a need for enhanced training of staff,

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in order to develop professional skills for an adequate use of therapeutic tools, always bearing in mind that active family involvement is an essential element of the process.

• It is crucial that we recognize the need for early intervention with children and families at risk. That said, it is essential that children’s rights and their best interests are paramount considerations with respect to all issues relating to such interventions.

• It is important to adopt adequate guiding principles when developing intervention strategies and treatment programs for young offenders with mental health problems who are also in the juvenile justice system. A number of such principles were suggested by Thomas Grisso172, including: (1) the need for intake screening and assessment, recognizing the importance of accurately identifying young offenders with mental health and substance abuse disorders when they enter the juvenile justice system; (2) the need for emergency mental health services, considering the importance of always being ready to respond to a young person with mental health problems who is in crisis; (3) the need to integrate clinical treatment and general rehabilitation, focusing on the goal of reducing symptoms that have contributed to a young person’s delinquent behaviour; (4) the need to determine the value of various treatment methods, acknowledging the importance of using methods that are supported by evidence indicating both their value and their success; and (5) the need to place limits on what we try to do, in the sense that we should not widen the net of the juvenile justice system simply to supply mental health services to those entitled to receive assistance in a less intrusive way, including services through a community mental health system.

• The conference was instructive with respect to the various problems faced in different countries, while at the same time highlighting the similarities and shared experiences that exist. A focus was placed on how to identify and support a young person with mental health needs who is already in the juvenile justice system. Moreover, emphasis was placed on how best to access the right interventions for such young persons and their families. The prospect for doing so can best be accomplished only if there is an understanding that the challenges facing such individuals are problems of condition and not character, and that they are in fact ill rather than simply bad. Such a perspective is crucial in any effort to deal with this issue of serious concern. In order to provide young persons who have mental health needs with the assistance they require, we must support those professionals who work with this vulnerable population. Such

172 Grisso, Thomas, Guiding Principles when Developing Treatment Programs for Young Offenders with Mental Disorders, IJJO, IV International Conference on Juvenile Justice, Rome, 2010.

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support is central to the professional development of these service providers as well as to the effectiveness of their interventions. â&#x20AC;˘ The key ideas or take away points that we can glean from the various conference presentations and workshop discussions can be summed up as follows: (1) The treatment of young persons with mental health issues requires an appropriate understanding of their needs. We must appreciate that they are in fact individuals who suffer from an illness and not from a defect in their character.

(2) Understanding, in general the needs of such young persons, proper steps must be taken to identify those individuals who have mental health issues and to regularly assess them as to their own, particular mental health needs. (3) In identifying young persons with such needs, an emphasis must be placed on early intervention, to include the identification of families at risk, with full respect of the rights of those involved. (4) Having the mental health needs of a particular young person in mind, an appropriate strategy must be determined to ensure meaningful treatment and rehabilitation, utilizing evidence-based methodologies. (5) To the extent that a young person with mental health issues is also a young offender, any intervention should have as its focus the goal of reducing symptoms that have contributed to his or her delinquent behaviour.

(6) The universe of young persons with mental health issues includes young persons who are not, or need not, be involved in the juvenile justice system.

Consequently, we should not simply expand the juvenile justice system simply to supply mental health services to those for whom community mental health alternatives should be available. (7) To the extent possible, we should focus on the least intrusive form of intervention rather than rely on the most intrusive alternative, which is the juvenile justice system. Every effort should thus be made to increase the use of early intervention and community-based treatment, as well as family-oriented strategies. There is no doubt that the juvenile system performs an important service for those who are subject to it and who have mental health needs. But to the extent that the juvenile system is the primary source of assistance to young persons with mental health needs, it is an indication that as a society we have failed to address those needs adequately before they have taken their toll. (8) Clearly, the focus of any response to the mental health needs we have described should be the best interest of the young persons involved. It is equally clear, however, that the needs of such young persons can be successfully addressed only by staff and other personnel who are appropriately trained and supported and who are provided adequate resources to perform their important task, always bearing in mind that coordination among services and multidisciplinary based intervention strategies are crucial.

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References CARVALHO, Maria João Leote, «Jovens, espaços, trajectórias e delinquências», Sociologia, Problemas e Práticas, 49, 2005, 71-93.

Comissão Nacional para a Reestruturação dos Serviços de Saúde Mental, Proposta de Plano de Acção para a Reestruturação e Desenvolvimento dos Serviços de Saúde Mental em Portugal 2007-2016, available on line at <http://www.acs.min-saude.pt/wp-content/ blogs.dir/1/files/2008/01/relatorioplanoaccaoservicossaudemental.pdf> [Consult. 19 Jan. 2011].

FONSECA, A. C., Comportamento Anti-Social e Crime - Da Infância à Idade Adulta. Coimbra, Almedina, 2004.

GRISSO, Thomas, Guiding Principles when Developing Treatment Programs for Young Offenders with Mental Disorders, IJJO, IV International Conference on Juvenile Justice, Rome, 2010, available on line at <http://www.oijj.org/documental_ficha. php?rel=SI&cod=2959&idioma=en> [Consult. 22 Fev. 2010].

RODRIGUES, Anabela Miranda e DUARTE-FONSECA, António Carlos, Comentário da Lei Tutelar Educativa, Coimbra Editora, 2000.

World Health Organization, Child and Adolescent Mental Health Policies and Plans, 2005, available on line at <http://www.who.int/mental_health/policy/services/9_ child%20ado_WEB_07.pdf> [Consult. 10 Oct. 2010].

World Health Organization, Alto Comissariado da Saúde, Coordenação Nacional para a Saúde Mental, Portugal - WHO country Summary, Effective and Mental Health, Treatment and Care for All, available online at <http://www.acs.min-saude.pt/cnsm/2010/03/17/ countrysummary/>[Consult. 25 Mar. 2010].

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Biographies of experts COLLABORATOR’S NAME FLORBELA MOREIRA LANÇA BIOGRAPHY Academic Background Degree: Law Institution: Law School, University of Lisbon Dates: 1984-1989 Professional Background 1991-1993: Trainee at the Centre for Judicial Studies, Lisbon 1993-1996: Judge of Criminal, Civil, Commercial, Family, Minors and Juvenile Court (Continental Portugal) 1996-2005: Judge of Civil Court (including Family and Minors matters) (Seixal and Cascais) 2005-2009: Judge of Civil Court (Lisbon) 2009 - to date: Contact Point for Portugal of the European Judiciary Network in Civil and Commercial Matters, Contact Point of the Ibero-American Judicial Cooperation Network (IberRed), as representative of the Portuguese High Council of the Judiciary and Contact Point of the International Legal and Judiciary Cooperation Network for the Portuguese Speaking Countries, as representative of the Portuguese High Council of the Judiciary 2009 - to date: Trainer of European and International Law at the Centre for Judicial Studies, Lisbon

COLLABORATOR’S NAME HELENA GONÇALVES BIOGRAPHY Academic Background Degree: Law Institution: Law School, University of Lisbon Dates: 1980-1985 Professional Background 1986-1988: Trainee at the Centre for Judicial Studies, Lisbon 1988-2000: Deputy District Attorney of the Public Prosecution Service (Setúbal and Barreiro) 2000-2006: Legal Adviser at the Attorney General’s Office 2006-2009: District Attorney of the Public Prosecution Service at the Family and Minors Court (Barreiro) 2009 - to date: Trainer of Family and Children’s Law at the Centre for Judicial Studies, Lisbon

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Chapter VIII Legal and Care resources for young offenders with mental health issues: The Spanish intervention approach and regulation ........................................................................................................................... by Blanca López Marqués María Luisa Martínez Pastor Ignacio Valentín Mayoral Narros Amparo Pozo Martínez Antonio María Salinas Iñigo Juan José Periago Morant Fundación Diagrama. Spain Dr. Rafael Forcada Chapa Expert. Psychiatrist. Spain

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Table of Contents

........................................................................................................................

Introduction 1.

PROFILE OF THE MENTALLY ILL YOUNG OFFENDER

1.1. Introduction 1.2. Typology Of Mental Illness 1.3. Background Of The Mentally Ill Young Offenders 1.4. Family Situation 1.5. Drug Abuseâ&#x20AC;&#x201C;Behavioural Disorder Relationship

2. LEGAL FRAMEWORK: PENAL REGULATIONS AND PROTECTIVE LEGISLATION

2.1. The Spanish Juvenile Justice System 2.2. Special System For Mentally Ill Young Offenders 2.3. Criminal Liability Of Minors With Mental Health Problems 2.4. Ethical Principles Of The Justice And Health Systems 2.5. Public Institutions And The Protection Of Minors

3.

THE ROLE OF PROFESSIONALS

3.1. Cooperation Among Teams 3.2. Handling Of Data On Mentally Ill Young Offenders 3.3. Training Of Professionals 3.4. Work Teams Caring For Mentally Ill Young Offenders

4.

INTERVENTIONAL APPROACHES

4.1. Resources Available For Mentally Ill Young Offenders Treatments 4.2. Special Units For Mentally Ill Young Offenders 4.3. Prevention Programmes 4.4. Regulation Of Psychiatric Treatment 4.5. Protocols 5.

PROPOSALS FOR BEST PRACTICES

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Introduction Mentally ill patients173 comprise a particularly vulnerable population. As stated by the World Health Organisation (WHO henceforth): “Firstly, mental disorders can affect thinking and behaviour, as well as the ability of persons to protect their own interests and, in exceptional cases, their ability to make decisions. Secondly, persons with mental disorders are faced with stigmatisation, discrimination and marginalisation in most societies. Stigmatisation increases the likelihood that such persons will refuse the treatment they need or receive care of lesser quality which is inappropriate for their needs. Marginalisation and discrimination also increase the risk of infringement of their civil, political, economic, social and cultural rights by mental health service providers and others”.

While our reference is to under-age mentally ill people, it presupposes an even more vulnerable group since childhood and adolescence is a period of development which can be affected by the consequences of having a mental disorder. Consequently, it is especially relevant to promote mental health amongst young people, by minimising the primary risk factors, supporting protectors and providing effectual and effective solutions to the problem.

In this respect, the WHO in 2001 observed that one in every ten children suffers from mental illnesses serious enough to cause impairment, and that mental and behavioural disorders are common in childhood and adolescence.

With respect to minors in Spain with mental health problems, there is no objective data on the descriptive epidemiology of mental disorders in children and young people in the general population. There are only community surveys which, while they provide relevant information, are limited to a fixed geographic location since this data does not apply when making generalisations about this entire group. One of the surveys completed in Valencia (Goméz-Beneyto M, Bonet A, Catalá M., 1994) 174 indicates a 21.7% general prevalence of childhood and young people mental disorders.

173 Refers to both genders throughout the present Questionnaire for the purposes of linguistic economy and as a form of generalisation.

174 Goméz-Beneyto M, Bonet A, Catalá M. (1994). “The prevalence of child psychiatric disorders in the city of Valencia”. Acta Psichiatr Scand. 89:352-357.

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“Prevalence of psychiatric disorders in children and young people in some countries”, (WHO, 2005).

Country

Study

Age (years)

Prevalence (%)

Brazil

Fleitlich-Bilyk & Goodman, 2004

7-14

12.7

Canada (Ontario)

Offord at al., 1987

4-16

18.1

Ethiopia

Tadesse et al., 1999

1-15

17.7

Germany

Weyerer et al., 1988

12-15

20.7

India

Indian Council of Medical Research, 2001

1-16

12.8

Japan

Morita et al., 1993

12-15

15.0

SPAIN

Gómez-Beneyto et al., 1994

8, 11, 15

21.7

Switzerland

Steinhausen et al., 1998

1-15

22.5

US

United States Department of Health and Human Services, 1999

9-17

21.0

The preceding data shows that the global prevalence of mental disorders in Spain’s child/adolescent population is similar to that observed in other countries, and ranges between 10% and 20%, according to various studies: “Variations in the results are due to the characteristics of the sectors in which the study was based, the type of scale, and the diagnostic method used.” (Franco, C., 2004) 175.

It is a well known fact nowadays that more than half the number of illnesses in the general population appears in infancy and that there is a clear continuity between childhood mental illnesses and those of adulthood. There is also consensus on the negative consequences of failure to treat such illnesses.

According to Cauffman, E. (2004) 176: “Failure to diagnose and treat mental health problems in children and adolescents seriously affects their future, reduces their educational, vocational and professional opportunities, and entails a very high cost to families and a burden to society. The situation arises where a very high percentage of undiagnosed children and minors suffering from mental illness end up in Juvenile Correctional Centres and in an environment of delinquency; in 175 Franco, C., Arango C. (2004). “Prevalencia de trastornos mentales en niños y adolescentes”, Monografías de Psiquiatría, 3, pp. 19-27, 176 Cauffman E. (2004) “A statewide screening of mental health symptoms among juvenile offenders in detention”. Journal of the American Academy of Child and Adolescent Psychiatry. 43:430-439.

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other words, what the health system failed to do becomes a problem for the judicial system, by which time finding the solution is already very difficult.”

It is within this category that the group being dealt with in this report falls: young offenders with mental disorders. This group is placed between two different systems: on the one hand, the legal system considers them offenders and on the other hand, the health system considers them victims of mental illness.

With respect to the Health System pertaining to Childhood-Adolescent Mental Health, the “1985 Report of the Ministerial Commission on Psychiatric Reform” established in the foundations for change in the Mental Health welfare model in Spain. The new model incorporated Childhood-Adolescent Mental Health by acknowledging it in its basic outlines and by defining it as a special permanent Programme, thus following the trend in other countries of the European Union. In addition, this report urges the Autonomous Communities177 to develop the programme in accordance with their own characteristics and requirements, with consideration for comprehensive Community actions in keeping with the Community’s Mental Health Model which serves as its framework. In this same outline, the Mental Health Strategy of the National Health System (2007) points out that the principles of integrity, continuity, consistency and clarity must be adhered to.

Furthermore, there is a specific need within the Juvenile Justice system for mental health institutions at the local, regional and national levels as far as mental health resources for young offenders are concerned, as well as for mutual cooperation between organisations and agencies with shared responsibilities. This relates to children and young people requiring a biopsychosocial treatment, which takes account of their situation as adolescents, their mental pathology, the facts attributable to this, their familial and social situation, their personal characteristics, etc., and all from a comprehensive, multidisciplinary approach.

Turning our focus now to the scope of health care within the Spanish Juvenile Justice system, Framework Law 5/2000, of 12 January, on the criminal liability of minors (LORPM henceforth) stipulates that the public reform body must provide comprehensive and multidisciplinary health care to minors, aimed at prevention as well as recovery and rehabilitation. It must include among other things: diet supervision, hygiene supervision and preventive education with regard to the use of harmful substances and sexuality. It also refers to the Autonomous Communities, the execution of judicial

177 An autonomous community (Spanish: comunidad autónoma, is the first-level political division of the Kingdom of Spain, established in accordance with the current Spanish Constitution (1978). http:// en.wikipedia.org/wiki/Autonomous_communities_of_Spain

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measures, imposed upon minors of criminally responsible age, and includes therapeutic confinement (in a closed, semi-open or open system) as well as outpatient treatment among these measures.

If we also look at the Child Protection System, it is worth mentioning that procedural-legal changes are currently underway through the Draft Framework Law supplementing the Bill updating Child Protection Legislation (Anteproyecto de Ley Orgánica complementaria al Anteproyecto de Ley de actualización de la legislación sobre protección a la Infancia), which aims directly at regulating the treatment of minors with behavioural disorders in specialised centres, as well as the care and diet of those minors. Many other elements have been targeted to ensure actions undertaken in centres for minors with behavioural disorders are uniform throughout the country, whilst upholding childrens’ fundamental rights.

Finally, and in the absence of specific national legislation pertaining to ChildhoodAdolescent Mental Health, we are discovering that in dealing with the young offender group, it is necessary to take into consideration: - The LORPM (Framework Law on the criminal liability of minors).

- The International Norms pertaining to Mental Health.

- The National Health Norms.

- The National Health System Mental Health Strategy.

- The Autonomous Health Norms.

- The corresponding Autonomous Community Mental Health Strategy.

It is for these reasons that Fundación Diagrama has created this document, in order to carry out an analysis of the four cornerstones in this field: the profile of the mentally ill young offender, the legal framework, the professionals who intervene with these minors and the different intervention approaches used at present, in order to make a proposal for best practices when it comes to intervention with mentally ill young offenders.

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1. PROFILE OF THE MENTALLY ILL YOUNG OFFENDER 1.1. Introduction As illustrated beforehand, there is a distinct difficulty in painting a truthful and fair picture of the entire country of Spain with respect to children and young people’s mental health.

This is mainly due to the lack of studies pertaining to all minors with mental illness, whether or not they are offenders.

For this reason, a perspective based on practical experience and studies conducted by Diagrama Foundation for Psychosocial Intervention is made available, with more concrete reference to a specific resource used for the treatment of Mentally Ill Young offenders.

This resource is the “Pi Margall” Youth Rehabilitation Therapeutic Centre, in Burjassot, Valencia, Spain. This will serve as a reference, since its target population perfectly matches the purposes of the study, as it is an excellent and clearly representative example for analysing the profiles of mentally ill young offenders.

The “Pi Margall” Youth Rehabilitation Therapeutic Centre, owned by the Justice and Public Administration Consultancy (a Juvenile Justice Sector) and administered by Diagrama Foundation for Psychosocial Intervention, was officially inaugurated on 15 March 2002, to comply with the LORPM (Framework Law on the criminal liability of minors), where in Heading II reference is made to the measures, and specifies in Article 7.d Therapeutic Confinement in a closed, semi-open or open system: “In these types of Centres, specialised instructive care or specific treatment shall be provided for persons suffering from psychological anomalies or disorders, dependency on alcohol, harmful drugs or psychotropic substances, or perception disorders which may cause a serious reality awareness disorder”.

The Centre was initially created to accommodate 14 minors. This resource has currently been expanded to 20 places. The Centre is mixed, meaning that minors of both sexes inhabit the same space on a daily basis.

The age of minors admitted to the Centre is 14 to 18 years old inclusive, according to the Preliminary Heading, art., 1 and Heading I, on the scope of application of the law, art. 2, 3 and 4 of the LORPM (Framework Law on the criminal liability of minors).

In keeping with what has been outlined, and for the purposes of presenting a profile definition of the mentally ill young offender, the first problem identified is the lack of relevant information. On the one hand, there is a conspicuous absence of a focal point articulating the available information relating to mentally ill young offenders, and on the other hand, a lack of empirical studies on the profile of mentally ill young offenders.

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For the purposes of outlining this profile, various factors come into play such as the duration of the measures, the difficulty in making a diagnosis which takes adolescence into account, care provided by various professionals, etc., all issues which complicate the investigative effort.

1.2. Typology of mental illness in mentally ill young offenders With respect to the types of mental illnesses from which mentally ill young offenders in our country suffer and the frequency with which these illnesses are detected, it should be pointed out that a general increase in mental illnesses in minors has been observed, especially of the psychotic type. Furthermore, the State Attorney-General’s Office in its last memorandum on the year 2009 highlights the admission of children and young people for eating disorders.

Nonetheless, while taking this data into consideration, when it comes to combining the demographic information, as well as the question of the diagnosis and detection of mental illnesses, the difficulties again become apparent, primarily due to the legal guarantees of the confidentiality of diagnoses on minors. In the same way, this Memorandum emphasises this by recording the lack of adequate Outpatient Centres and Resources, and precise regulations for the treatment of minors with psychological illnesses and behavioural problems.

With regards to the population admitted to the “Pi Margall” Rehabilitation Centre during 2009, the high prevalence of Substance Abuse Disorders (SAD) and Behavioural Disorders (BD) stood out. Other disorders diagnosed were Psychosis, internalising disorders (anxiety, depression), Attention-Deficit Hyperactivity Disorder (ADHD), Personality Disorders (PD), Mental Retardation (MR), Eating Disorders, Factitious Disorders, among others. Furthermore, going by data on the “Pi Margall” Rehabilitation Centre, the mental problems of minors admitted to this Centre are listed as follows.

- Serious cognitive, behavioural and emotional problems, resulting from personality and behavioural disorders (33 minors treated during 2009).

This category comprises those problems manifested by young people which prevent them from functioning in society in an appropriate and suitable manner, and which are associated with elevated states of anxiety, lack of self-control, increased impulsiveness, failure to adapt to norms and lack of social and relational skills, delirium, etc. Concrete aspects of various disorders which require specific focus are discussed, such as psychotic disorders, borderline personality disorders, conduct disorders, ADHD, eating disorders, bipolar disorders, etc.

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With reference to psychotic disorders, the issues focus primarily on illness awareness as well as on adherence to medico-psychiatric treatment.

In the event that psychosis occurs during the psychiatric treatment which is given following the remission of delirium and hallucinations, the minor is handled in the manner most appropriately suited to his condition. Understanding the significant power which the minor can at times attribute to his hallucinations and to the delirium he is suffering, can lead to a change in power relationships, so that the humiliating and mortifying treatment the minor is receiving (continuous threats, insults, shouting, etc.) which is created and produced in his mind, gives way to a less tormenting relationship with his inner voices. In addition, efforts are made to dismantle the delirium, usually beginning with its most ordinary and fragile aspects, and subsequently dealing with the core of the delirium and encouraging comprehension and understanding of it, so that an awareness is gained of the illness being suffered.

Remission of the negative symptoms typical of psychotic disorders (affective flattening, apathy, lack of concentration, etc.) is also undertaken in this way, and encourage an autonomous and pro-social method of coping.

Special attention is paid to the secondary factors which can be triggered due to the illness (anxiety, stress, aggressiveness, etc.).

- Auto- and hetero-aggressive behaviours, highly problematic relationships due to domestic violence and familial abuse (13 minors treated during 2009).

It is used in treating minors with a tendency to use aggression as a habitual response method when faced with a perceived threat. Such minors generally manifest cognitive schemes that are rigid and inconsistent with reality, as well as a very rudimentary symbolisation system. They experience difficultly with abstractions (interpreting, reasoning, analysing...), tending to respond to their impulses in a very basic manner (verbal and physical aggression, auto-aggression, etc.) in the absence of other types of tools or more appropriate skills. They maintain and understand this aggressive behaviour, generally because they perceive it as an important mechanism for dealing with the frustration they experience when faced with a refusal to satisfy their desires.

Echeburúa, E., Corsi J., Del Pozo Delgado, M.P. Bandura, (cit. in Castells, P., 2007)178 define aggressiveness as an adaptive response by the subject in order to defend himself

178 Castells, P. (2007). Victimas y matones: claves para afrontar la violencia en niños y jóvenes. Barcelona: Ceac familia.

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from potential external danger, while violence is viewed through cultural parameters, where it is seen as learned behaviour and action which is the product of psychological processes.

Sempere et al. (2006)179 define those factors which are used to resolve violence, and which relate as much to personal risk factors (impulsiveness, substance abuse, prior violence, etc.), familial factors (authoritarian upbringing, childhood abuse, lack of parental support, etc.) and social factors (lack of a social support network, culture of violence, etc.), as to protective, trigger or maintenance factors, where the solution used depends on which one or more of these factors is manifested.

In the opinion of these authors, violent conduct occurs in a context of power imbalance, where the violent young person has asymmetrical relationships with the family, and where the minor has the control and power in the family in which he has grown up.

Normally, young people who are violent towards their parents manifest several rigid cognitive schemes which do not fit reality, adopting ideas and beliefs of being illtreated by everyone else. S/he sees the environment –either the general environment, or isolated situations or persons-, as a threat, and responds with defensive patterns of violence.

Taking into consideration the findings of the study conducted by Ibabe, I., Jaureguizar J. y Díaz O., (2007)180 on violence between children and their parents, these authors conclude that “the young people who exhibit violent behaviour towards their parents clearly do not fit the same profile as other young offenders”.

In their study, these authors summarise a set of characteristics that distinguish them from children and young people who commit other types of offences; these characteristics are cited verbatim as follows: - Minors with low levels of autonomy.

- Minors with low self-esteem and lack of empathy.

179 Sempere, M; Losa, B.; Pérez, M.; Esteve, G. y Cerdá, M. (2006). Estudio cualitativo de menores y jóvenes con medidas de internamiento por delitos de violencia intrafamiliar. Centro de estudios jurídicos y formación especializada. Departamento de Justicia. Generalitat de Catalunya.

180 Ibabe, I., Jaureguizar J. y Díaz O., (2007). Violencia Filio-parental. Conductas violentas de jóvenes hacia sus padres. Servicio Central de Publicaciones del Gobierno Vasco.

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- Minors with high levels of aggressiveness.

- Minors with harmful individual treatment and emotional disorders.

In cases of minors admitted for familial abuse, it should be pointed out that individual treatment is aimed at cognitive restructuring and changing acquired norms of behaviour. In these cases, working in parallel with the family is vitally important, since the family relationship model which has been established is generally inappropriate and dysfunctional. Aspects such as communication skills, problem resolution, coping strategies, the definition of familial roles, the establishment of limits and mutual respect, modification of dysfunctional dynamics, etc. are addressed. In these types of measures, the possibility of a regime which allows leave from the Centre is evaluated, so that the progress and changes the young person is experiencing can be materialised and put into practice.

In cases of abuse of partners and gender violence, we are referring to all the forms used to perpetuate the hierarchical system imposed by the patriarchal culture (Corsi, J., 2003).

As with the other cases addressed in this report, there is no single profile for young people committing domestic assault. Nevertheless, in practical terms a range of needs which have to be addressed from a therapeutic context, such as empathy, emotional callousness, power relationships, the phases of the relationship between the abuser and the abused, the consequences, the alternatives of various responses to violence, the analysis of the anger curve, the delegitimisation of violence, etc., have been identified.

In support of what has been mentioned, and in relation to auto and hetero-aggressive behaviours, special mention is made on confined minors belonging to violent youth gangs.

According to authors Walter, Schmidt and Lunghofer (1993)181, the main reasons a child or young person joins an organised gang are: the quest for affection, structure and discipline, the feeling of belonging and commitment; the need for recognition and power; companionship; a boost in self-esteem and status; the quest for a place where s/he can feel accepted and the need for physical security and protection, and family tradition. Therefore, the needs met by these types of groups are addressed in

181â&#x20AC;&#x201A; Walker, M. L., Schmidt, L. M.,&Lunghofer, L. (1993).Youth gangs. In M. I. Singer, L.T. Singer, & T. M. Anglin (Eds.), Handbook for screening adolescents at psychological risk (pp. 400- 422). New York: Lexington Books/Macmillan.

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the treatment (positive self-opinion and self-esteem based on membership of a violent gang, feeling of recognition, power and permanence, limits and norms...) and the type of characteristics and behaviours attributed to them (inflexibility, extreme behaviours, violence as an excuse, ...), and special emphasis is placed on developing a positive social identity detached from the group (and distinct from their personal identity), making it easier to acquire personal resources and social competence.

- Sexually-related problems (3 minors treated in 2009).

As quoted in the article “Model for the care of sex offenders under the age of 18” (Guzmán, G.; Jáuregui, M.C.; Isaza, M.C.; López, L.P. y Cuadros, I., 2007)182, “The primary goals in treating young people who have committed sexual offences have been comprehensively defined as safety of the community (NAPN, cooperative network of multidisciplinary professionals working with sexually abused youth in the United States and abroad; 1993), help young people control their abusive behaviour and increase their pro-social interaction (Cellini, 1995183), as well as prevent victimisation, arrest the development of further psycho-sexual problems, and help young people develop age-appropriate relationships (Becker y Hunter, 1997)184. In order to achieve these goals, highly structured treatments are recommended (Morenz y Becker, 1995185).

Therapeutic approaches include treatment of individuals, groups and families.”

We can similarly take into account the contributions of Arruabarrena (1996)186 who points out that minors who have been victims of abuse can become potential assailants; hypersexualised behaviours, such as compulsive masturbation, seductive behaviours or excessive curiosity about sexual subjects, are also habitually manifested. The sexual problems which are dealt with at the Centre are on the one hand associated with the typical problems of development which may affect the minor’s condition and progress, such as sexual maturity and related issues (lack of sexual definition, sexual risk behaviours, etc.); on the other hand, sexual abuse, both inflicted and suffered, are addressed, with the proposed treatment objectives being based on the minor’s sense of reality (awareness, empathy, self-esteem, sexual development, etc.).

Likewise, it is worth noting that in the Comunidad Valenciana (where the “Pi Margall”

182 Guzmán, G.; Jáuregui, M.C.; Isaza, M.C.; López, L.P. y Cuadros, I., (2007). Modelo para la atención de ofensores sexuales menores de 18 años. Asociación Afecto. Bogotá.

183 Barbara K. Schwartz, Henry R. Cellini (1995). The Sex Offender. Ed. Book.

184 Becker, J.V., and Hunter, J.A. (1997). Understanding and treating child and adolescent sexual offenders.

In Advances in Clinical Child Psychology, vol. 19, edited by T.H. Ollendick and R.J. Prinz. New York, NY: Plenum Press, pp. 177-197.

185 Morenz, B., and Becker, J.V. (1995). The treatment of youthful sexual offenders. Applied and Preventive Psychology 4(4):247-256.

186 Arruabarrena, Mª.I. “Evaluación y tratamiento familiar”. MASSON, (1996)

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Rehabilitation Centre is located), we have the support of the “Espill Institute”, a centre specialising in the treatment of psychological and sexual problems, featuring a service for the care of victims of childhood sexual abuse (also coordinated by the Valencian Parliament Consultancy on Social Welfare), and on occasion and in specific cases developing individualised outpatient programmes with some of the young people who have committed sexual abuses and are serving judicial measures as a result.

Simultaneously, the interdisciplinary work conducted by the Centre also deals with those areas which, depending on the problems, can become secondary issues, such as self-esteem, empathy, handling emotions and social skills. This is done with the aim of helping the child overcome his/her main problem.

- Drug dependency (15 minors treated in 2009).

A correct approach to problems resulting from drug use involves integrated coordination of numerous professionals and resources. The biopsychosocial nature of the abovementioned problems entails an entire range of special requirements, in view of the group for which they are intended.

With drug dependency, the needs of minors are focused on two clearly defined areas depending on the stage of their rehabilitation, i.e., the need to be aware of their illness or the development of strategies for preventing relapses.

As for those admitted to the “Pi Margall” Rehabilitation Centre, it should be pointed out that the treatment methodology may change depending on the young person’s condition and situation. In this respect, we propose treatment through the Centre’s psychoeducational programme and by means of medical and psychiatric monitoring. Similarly, individual therapy has been implemented with 15 minors as treatment for these problems.

It should be pointed out that the majority of the population admitted to Rehabilitation Centres exhibits problems related to substance abuse, and this treatment option has emerged out of those cases where consumption has resulted in serious problems (serious problems of aggressiveness, total conditioning of daily life, psychotic disorders from toxic abuse, etc.).

As part of the treatment plan in this area, psycho-educational workshops are used in an attempt to provide the minor with precise, current information on the different types of substances and the effects their use and abuse can trigger, cocaine and cannabis being the substances most consumed by these children prior to their admission to the Centre.

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Special mention must be made to the work being conducted in the area of relapse prevention. This is emphasised because of the possibility of the minor being granted leave from the Centre (weekend leave, visits to external resources, etc.). This area of therapeutic work, applied occasionally and on the basis of need, has been complemented by external consumption control, such as family-imposed controls to which the minor willingly agrees, since s/he is the person requesting these types of measures (agreeing to be accompanied at all times when going out, not going to certain areas or frequenting certain company, not consuming alcohol or if consuming, using lowalcoholic content, engaging in particular leisure activities, etc.). In addition, other types of external controls are habitually considered in all cases (agreement by behavioural contract, poison control analyses, etc.).

Generally speaking, drug dependency treatment is usually conducted by the Centre’s own professionals, who use external resources in those cases where it is considered relevant (minors who are already leading a positive lifestyle by participating in specific programmes, the requirement of continued attendance at the Addictive Behaviour Unit (UCA), either in order to promote awareness or to encourage the habit of participating in this programme in preparation for their departure from the Centre, etc.). There must always be coordination between the Centre’s professionals, as well as with those professionals in charge of external resources who may help with the minor’s treatment.

The result of this type of treatment depends on a wide variety of factors (personal characteristics, social environment, age, substance use history, etc.). Abstinence is usually maintained throughout the period of admission, since those young people returning to their homes may have engaged in occasional use of cannabis or cocaine.

In these cases emphasis is placed on therapy, and there is temporary suspension of leave to return to the family home or other types of leave such as attendance at training programmes, if this is considered appropriate. All of this is done with the minor’s rehabilitation and improvement in mind. During these periods, an analysis of the circumstances which have precipitated substance use is conducted, and the minor is provided with tools and skills to aid abstention, based on the actual situation in his/ her environment.

This graph illustrates a summary of the data used to support this typology based on the practical experience of the “Pi Margall” Rehabilitation Centre, as referred to in the introduction to this point, relating to the type of problems exhibited by minors, 2009.

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52%

20% 23%

5%

Drug Dependency

Behaviour-Personality Disorders

Auto/hetero - Aggression-Maltreatment

Sexual Problems

1.3. Background of the mentally ill young offender Socially and generally speaking, we would be referring to a minor who is coping in a cultural and socio-economic environment. However, we would follow this with trends in the profile of the young habitual offender, discarding for a start the archetype defined by a highly marginalised social context which includes extreme economic precariousness, a common factor of this being the immediate family’s flagrant involvement in criminal activity.

While this is significant, the fact remains that there is evidence of personal and familial psychiatric histories, as well as social maladjustment (“the neighbourhood lunatic”, children without a support network, friends or social relationships, etc...). For this reason, they have previously been seen by various specialists, and treated with various therapies, including medication.

Here again, the consequences of treating mental health problems in a sectorial manner, or within the scope of medicine and health care, or from a psychological or social perspective, are evident and consequently, so is the need to develop multidisciplinary treatments which help provide an understanding of the personal existence associated with each minor’s pathology. Similarly, this trajectory or journey through various therapies and professionals thus presupposes an additional risk factor, which conditions the rehabilitation or improvement of minors with mental health problems, so that when they commit an offence, and therefore violate a judicial measure, both the minors and their families feel overwhelmed and hopeless about the possibilities for change.

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These minors usually are not fully engaged in criminal activity and the pattern of their criminality is closely linked to their mental pathology, so that mentally ill young offenders situated on the psychotic extreme would tend to commit offences on their own, in response to internal factors, and would have limited awareness of and responsibility for the inappropriateness of their actions, while mentally ill young offenders situated at the neurotic extreme would have a tendency to commit offences as a group, in response to external factors and would exhibit greater awareness and degree of initial responsibility for the inappropriateness of their actions.

In relation to the general population of young offenders, there is a higher prevalence of added physical problems (visual, auditory, congenital defects, allergies, food allergies, cardiac complaints, etc.). Also with respect to the general population of young offenders, there is a higher prevalence of certified disabled or impaired persons or persons in circumstances which may cause them to be declared not responsible, etc.

The trajectory of the mentally ill young offender, and his/her early childhood, are distinguished by childhood ill health or psychological problems. No delinquent or social elements are attributed to or associated with this, with no initial attributions or connotations of a delinquent and/or asocial nature. On reaching adolescence, the antisocial aspect becomes more serious due to a failure to adapt to the environment and a worsening of the problem.

On the personal level, besides the characteristics which would be shared with other young offenders, it is important to highlight limited understanding with respect to the possibilities for change and improvement â&#x20AC;&#x201C; given that the previously taken course was a failure. Another distinctive feature would be instrumentalisation and/or assuming the role of patient vs. victim, in addition to an added level of anxiety, stress and angst, as a result of mental illness.

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1.4. Family situation The standard social/family profile of the mentally ill young offender matches that of a minor who lives in a district uncharacterised by confrontation, inhabits selfowned property, and enjoys adequate hygienic conditions. She/he is of a single-parent family, generally comprised of a mother – or a mother and a father - and one to three siblings, with a high incidence of confrontation in the household, little support from the extended family or social network, a history of abuse and substance use in the household, and no criminal history. Despite not being representative of the mentally ill young offender’s family system, it certainly highlights the high incidence of adopted children in relation to the general population of young offenders.

“Adopted children, especially those with a history of institutional experience before adoption, are more at risk of exhibiting developmental, behavioural and relationship disorders. Because of this, behaviour, development, affection, parental stress and child-parent relationships in these families should be monitored, especially during the pre-adoption period and the first few years of post-adoption”, (Ochando, G., Peris, S., Millán, MC., Loño, M., 2008) 187.

Generally, the family of the mentally ill young offender normally dedicates itself to him/her from early infancy, this being a symptomatic factor around which the family is defined. There is a notable tendency of all the members of the family unit to seek to attribute “culpability-responsibility-ownership” for the minor’s current trajectory and situation, while failing to clarify these responsibilities and making themselves incapable of dispensing with the established “status quo” when circumstances appear to indicate the need for change.

The lack of child-rearing abilities and skills is beneficial to a homeostatic perpetuation of the situation taking shape within the family nucleus, so that conflicts tend to be diffused or avoided, and so that this does not have a negative impact on the family environment; in this way stability is fostered in a dysfunctional situation.

Moreover, a form of dysfunctional extreme proximity is being observed in the family structure. This refers to strong affection and overprotection, generally displayed by the maternal figure towards the son. This gives rise to insufficient differentiation in the boundaries between the family members, as well a lack of appropriate distinction in the perceptions some of them have of others.

187 Ochando, G., Peris, S., Millán, MC., Loño, J. (2008). “Trastorno de conducta en niños adoptados”. Unidad Salud Mental Infanto-Juvenil. Hospital Universitario La Fe. Valencia.

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With regard to the role played by the family in the treatment of the minor, it should be noted that this is considered to be highly relevant. Minors in full-blown adolescence are in transition towards adulthood, and aspects linked to psychosocial changes are emphasised during this transition. It is therefore an enormously important stage for implementing interventions which fall in line with the promotion of healthy behaviour as well as pro-social values and beliefs. While in the general population the family framework is of great importance, this is even more emphasised in the case of the mentally ill young offender, and the direct influence of the family system on the minor is evident in his/her daily experience. This is why benefit of active family involvement in the treatment process is so highly valued.

1.5. Drug abuse-behavioural disorder relation From experience, a clear relationship is shown between drug use and behavioural disorders in young offenders. Similarly, a substantial increase is being noted in the occurrence of more serious pathologies, such as toxic psychosis.

Using the population admitted to the â&#x20AC;&#x153;Pi Margallâ&#x20AC;? Rehabilitation Centre as an example, and following the trend in recent years, there is a growing increase in the percentage of co-morbidity, followed by psychiatric disorders without toxic comorbidity at the expense of a reduction in the number of minors without pathologies or those suffering only from substance use disorders. The prevalence of co-morbidity is reflected in the following chart, from which we can draw conclusions on the enormous difficulty in administering psychiatric treatment to the sample of minors undergoing therapeutic measures in this centre.

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Pathologies of minors admitted to the â&#x20AC;&#x153;Pi Margallâ&#x20AC;? R.C. 2009.

2%

7%

13%

78%

Drug Dependency

Psychiatric Disorders

Dual Pathology

No Pathology

With respect to drug dependency, the majority of the sample exhibited addiction to one or more abuse drugs, highlighting Substance Use Disorder (SUD) as one of the main problems in these minors and the focus of direct, indirect or transversal therapeutic treatment.

The pattern of multiple uses with diagnostic abuse and/or dependency criteria continues to be more common. Cannabis and cocaine are by far the substances which have generated the most problems, and their ability to produce psychopathology and toxic psychoses such as serious dual pathology stands out in this respect. However, the frequency with which cases of abuse of other substances are observed is cause for concern.

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2. LEGAL FRAMEWORK: PENAL REGULATIONS AND PROTECTIVE LEGISLATION 2.1. The juvenile justice system in Spain This is incorporated into prevailing legislation in Spain, mainly the LORPM (Framework Law on the criminal liability of minors), which is responsible for its development under a Ruling approved by Royal Decree 1774/2004 of 30 July. Given that the Autonomous Communities have executive power to implement the measures, they also perform regulatory functions within the ambit of creating, organising and managing the specific resources required to carry them out.

The model created by this law is known as the judicial or liability model: the minor enjoys certain rights and guarantees similar to those of adults; a wide range of measures or sanctions for adapting to the personal, familial, training, and other needs and deficiencies of minors is provided, all of them having an educational and socialising objective rather than a retributive one; the competence of all persons involved in the proceedings is sought (police, lawyers, judges, prosecutors, government employees...); the investigation of offences is the responsibility of the Public Prosecutor’s Office which also files the indictment as required, since prosecution and the subsequent supervision of implementation devolves upon the Juvenile Court Judge; the procedure, though protective, is brief and not excessively formal; it is conducted on principles of flexibility both during the investigative phase (since it verifies in his/her file whether the censure received is adequate in educational or familial respects, or whether a degree of conciliation or reparation has been achieved) and during the phase when the measure is being executed (by means of substitution, reduction of its duration or cessation of effects).

Punishable conducts are not listed in the special law indicated but must be referred to in the common Penal Code of 1995.

2.2. Specific system for minors with mental illness From the perspective of health, young people with mental health problems are cared for by the Public Health System. In Spain, this care is universal and free and falls under the responsibility of the Autonomous Communities. There is no childhood-adolescence speciality, inasmuch as care of these children is provided by the same mental health specialists –psychiatrists– as for adults.

“The scarcity of care resources for children and young people in the Spanish territory this group

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indicates a deficiency in the advancement of childhood psychiatric care in Spain”.

“Spain and Romania are the only countries in the European Union which do not consider child and adolescent psychiatry a specialisation, and this has serious consequences in the delivery of care; there being no official recognition of the specialisation of child psychiatry, psychiatrists without specific knowledge and training are being employed to fill positions in care centres where experience and training in child psychiatry are required” (Mollejo Aparicio, E.) 188.

In any case, it should be pointed out that specialised psychiatric services do in fact exist for minors in the public health system via child mental health units and childhood-adolescent psychiatric hospitalisation units. We therefore need to stress that the existence of special resources despite the lack of regulated and specific training in this area emphasises even further the need being felt in the Spanish society, and more specifically by those persons concerned who are directly affected, by relatives and by professionals in specific childhood mental health intervention.

In cases where the seriousness of the pathology warrants it, these minors would be admitted to a mental health centre appropriate to their age, even if against their will, although in these cases the authorisation of a judge would be required, as well as a prior report from child care services (art. 763 of the Civil Prosecution law, 2000). The objective of these health services, however, is to stabilise the patients, diagnose them and prescribe the necessary medication and care when they return to their homes.

In Spain, public centres dedicated to residential care of children with serious chronic or incurable mental disorders are very scarce, except in the case of children who, because of their neglect, are safeguarded by the autonomous systems for child protection. These patients – the unprotected ones - are as a result compelled to remain in their homes under the care of their families, and be provided with outpatient healthcare or find private institutions (at very high economic cost to their relatives).

In this regard, we must also mention that in addition to the scarcity of residential resources, community and outpatient resources are insufficient or inadequate, so that the situation of mentally ill patients is affected, and thus the need for social welfare resources.

Since the 1980s, psychiatric reform has fallen under a legislative umbrella, so that community resources are beginning to be created; however, the spectrum of healthcare structures and the intervention programmes for psychiatric patients are not sufficient.

188 Mollejo Aparicio, E. (2007) “Editorial. Sobre la necesidad de crear la especialidad de Psiquiatría Infantil en España”. Revista de la Asociación española de Neuropsiquiatría. Revista nº99.

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2.3. Criminal liability of minors with mental health problems In the Spanish system, criminal liability of the offending minor varies â&#x20AC;&#x201C; at least in theory - depending on the gravity of the mental illness being suffered. Thus: -

If the mental illness being suffered impedes comprehension of the unlawfulness of the conduct or actions in accordance with such comprehension or produces a serious alteration of the awareness of reality, the Judge can declare absolute absence of criminal liability (full exemption).

-

If the mental illness being suffered, although significant, does not attain the level of seriousness of the effects previously indicated, the judge can declare attenuated juvenile-criminal liability (incomplete exemption, analogical mitigating circumstances or ordinary mitigating circumstances).

In any of these two cases, in practical terms, the Juvenile Court Judge exercises enormous flexibility so as to make the most satisfactory decision in the best interest of the child, and can consequently attribute: -

The measure of therapeutic confinement (in a closed, semi-open or open environment) in a specific centre for young offenders where specialised instructive care or specific treatment intended for the mental illness or anomaly being suffered will be given (art. 7.1.d) of the LORPM (Framework Law on the criminal liability of minors).

-

The measure of outpatient treatment, where the minor will continue residing at home and must go to the designated centre, as frequently as is indicated by the attending doctors and must follow the fixed guidelines for adequate treatment of the mental illness (art. 7.1.e) of the LORPM (Framework Law on the criminal liability of minors)).

-

Finally, the Judge can determine that the minor is to be admitted in an appropriate socio-sanitary centre for treatment of the illness being suffered. Strictly speaking, this latter measure is not a sanctioning-instructive measure from the range of measures listed by the LORPM (Framework Law on the criminal liability of minors), but an exceptional decision which the judge can take when the specific resources for juvenile justice are insufficient or inadequate to address the mental illness being suffered by the minor (art. 54.2 of the LORPM (Framework Law on the criminal liability of minors)).

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2.4. Ethical principles of the justice system and health services Consideration of the best interests of the child, in cases where the minor is suffering from a mental illness, determines that the main objective should be stabilisation and, if possible, recovery from the illness being suffered, and that secondary importance should be given to criminal judgement for the offending conduct committed. Proof of this is that the Law itself stipulates that in a case where several measures are imposed on a young person which s/he is unable to comply with simultaneously, s/he will satisfy as a first priority those concerning therapeutic confinement (art. 47.5.a) of the LORPM (Framework Law on the criminal liability of minors)).

In addition to this prioritisation of health concerns over penal concerns in the treatment of the mentally ill young offender, the young person will enjoy all the rights provided under the general legislation, which both regulate the processing of personal data (where the information on people’s health is subject to added protection), and specifically regarding minors (where once again reinforced protection is afforded to children and young people in order to prevent any harm that may occur as they develop and mature).

With respect to coordination between healthcare and judicial authorities, the principle of coordination between public services arises out of the Spanish Constitution (art. 103.1) and the regulatory legislation for administrative bodies and their operation. Specifically, coordination between the health service and the juvenile justice is mentioned in art.

6.j) of the LORPM (Framework Law on the criminal liability of minors) Regulations, as one of the principles on which implementation of the measures is based.

2.5. Public institutions and the protection of minors The main institution entrusted with the task of protecting the rights of minors is the Public Prosecutor’s Office. This institution counts among the duties listed in its Organic Statutes the protection of citizens’ rights, among these, the rights of minors in particular, both within the scope of civil procedures and of criminal liability. For this reason, it can initiate action by tribunals (bringing legal action or lodging complaints, or opposing applications for legal action on behalf of others) so that the prevailing legality can be applied and the designated rights fully respected.

Within the ambit of the Juvenile Justice System, it devolves upon the Public Prosecutor’s Office to investigate criminal acts of which minors are accused. At this phase of the investigation, it can use the principle of regulated opportunity, i.e., it can make

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decisions on the file of the proceedings in particular cases. If it is considered that there are sufficient indications of the commission of the acts or that the presumed author of these is the accused minor, it will present a complaint to the court in which it formalises these charges, specifying the acts of which the minor is accused and seeking the measures to be imposed as civil liability based on the acts.

Another institution which also sees after the interests of minors is the “Public Defender” or “Ombudsman”. In Spain, this figure exists at the level of the State (Spanish Ombudsman) as well as at an autonomous level.

Only the Autonomous Community of Madrid has a defender specifically devoted to the protection of children’s rights; this is the “Public Defender for Minors in the Community of Madrid”. In either case, the duty of these commissioners in the respective parliaments – state or autonomous - is to defend the basic rights of citizens as recognised by the Constitution and in the Statutes of Autonomy by overseeing the activity of public offices.

These representatives can act both as state-appointees and at the request of citizens, and where they discover that a minor has had any of his/her designated rights contravened, can give notice to the competent authorities to modify the rules or the form of the proceedings.

At present, with regards to Child Protection, a change in perspective relating to intervention with minors suffering from behavioural disorders is underway. Both legislation and legal tools are being developed and updated in order to guarantee that minors suffering from these problems are afforded uniform protection throughout Spain. Alongside these improvements and changes, a recent reform has been published through the Draft Framework Law supplementing the Bill updating Child Protection Legislation (Anteproyecto de Ley Orgánica complementaria al Anteproyecto de Ley de actualización de la legislación sobre protección a la Infancia).

This Bill will modify the Framework Law on the legal protection of minors, regulating the detention of minors with behavioural disorders in specialised Centres. These Centres are known as “Centres for minors with behavioural disorders” and their appearance and regulation is justified in the aforementioned Bill as follows: “(...) Cases of minors being admitted into protection centres are extremely complex. Many are admitted at the request of their own families, following highly conflictive situations deriving from aggressive behavioural problems, a failure to adapt to family life, and an impossibility of exercising parental responsibility.

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These minors, on occasions, when they need protection and are admitted to a centre, have specific needs which, in turn, require the necessary specialisation of the centres. Their psychological and social problems require different solutions to those offered in standard protection centres.

Centres specifically for minors who have difficulty adapting or who have behavioural disorders must offer specialised care. The very justification of the existence of these centres, from a Child Protection perspective, comes from the specific needs of the minors admitted to them.”

This clearly shows what steps regarding the specialisation of resources for minors with disorders are being proposed within the legal framework, in this case, within the Child Protection System which, in spite of continuing to exclude or shut out mentally ill young offenders in the reform or youth justice system, is making progress in care for minors with behavioural disorders. This is progress we feel could be extended to other areas of intervention with mentally-ill minors.

The Draft Framework Law supplementing the Bill updating Child Protection Legislation also modifies Article 9 of the Framework Law on Judicial Power (Ley Orgánica del Poder Judicial) in favour of the rights of disabled minors: “Minors have a right to be heard, without any exclusion based on disability, both in a family environment and during any administrative or judicial proceedings in which they are directly involved and which lead to a decision which affects their personal, social or family life.

In legal proceedings, the appearance of a minor shall be carried out according to their situation and level of development, taking care to protect their privacy.”

This modification ensures that a minor with a disability has a right to be heard during any administrative or judicial proceedings, which also involves, apart from minors as victims and/or witnesses, the inclusion of mentally ill young offenders.

As well as this guarantee, and especially in the field of Child Protection, the modification of the Framework Law on Judicial Power introduces a new chapter (chapter IV, in Title II) focusing on “Centres for minors with behavioural disorders” in which articles 25 to 33 are included, and through which the following things are regulated: the admission of minors to these centres, the duration of the measure, the use of detention measures, personal and material records, isolation measures, administering of medication to minors, disciplinary regimes and the control that authorities should have over these centres.

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3. THE ROLE OF THE PROFESSIONALS 3.1. Cooperation among teams The LORPM (Framework Law on the criminal liability of minors) has inter-disciplinarity in intervention with minors as one of its motivating principles. Consequently, the Juvenile Court Judge, in taking decisions which directly affect minors, has to be advised by a technical team comprised of specialists in non-legal sciences (psychologists, social workers and social educators), who will for said purposes be assessing the minor’s personal, familial and social circumstances rather than the proof or seriousness of these acts.

In cases where the minor is suffering from a mental illness for which the cause has to be assessed when choosing the measure to be imposed, the Juvenile Court Judge can also be advised by a specialist doctor (psychiatrist). The collaboration referred to takes place while the acts are being investigated, as well as while the public Prosecutor’s Office is requesting the measure in his written statement of allegations or when the Judge finally determines his sentence, and also while the measure is being executed.

During this execution phase, which – as previously mentioned - is carried out by the Autonomous Communities, there must be continuous coordination among all of the professionals involved: judges and public prosecutors, public employees of the competent services, staff of the juvenile justice resources or programmes (often belonging to NGOs and non-profit bodies to which the public service has been entrusted), regional community resource professionals (especially in non-custodial measures, as well as those where this right is divested), health resources, etc.

3.2. Handling of data on mentally ill young offenders The specific legislation on young offenders (the LORPM (Framework Law on the criminal liability of minors) as well as its Bylaw) is very strict with respect to the protection of data and information concerning these offenders. Consequently, apart from the Juvenile Court Judge, the Public Prosecutor’s Office and the Public Defender (stateappointed or autonomous), only the professionals directly connected to the execution of the measure can have access. The precepts specifically concerning this matter are art. 56.c) of the LORPM and articles 6.c) and 12.5 of its development Bylaw.

Furthermore, the general legislation specifically concerning the protection of personal data applies to young offenders (Organic Law 15/1999, of 13 December) and the

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provisions on this point are contained in Organic Law, of 15 January, on the Legal Protection of Minors (specifically article 4).

3.3. Training of professionals Professionals in the Juvenile Justice System, as well as those dealing directly with minors suffering from mental illness receive training from the competent autonomous services in the execution of measures. Similarly, in a case where the specific performance of the measures has been entrusted by these services to NGOs and other non-profit bodies, these organisations are the ones that also undertake the training of its workers.

In either case, our impression is that this training is still insufficient for the technical demands of work of this nature.

With regard to the training of health system professionals in the specialised care of young offenders suffering from this type of illness, according to our information, this is almost non-existent to date, meaning that such professionals are applying their general knowledge to these illnesses â&#x20AC;&#x201C; once again bearing in mind the non-existence in Spain of childhood-adolescent specialist psychiatry - without taking into consideration their circumstances as violators of the penal standards.

Similarly, and also in reference to this point, the need to connect the spheres of health and judicial action is evident, so that minors who commit offences, and who also suffer from mental health problems, can be dealt with in a comprehensive fashion; this is because childhood-adolescent mental health professionals generally have virtually no knowledge about the LORPM; conversely, expertise on the mental health problems affecting the minors they deal with continues to be scarce among juvenile justice professionals.

3.4. Work teams caring for mentally ill young offenders In the case of judicial measures involving outpatient treatment as well therapeutic confinement for mental health reasons, the multidisciplinary treatment teams are composed of: - Psychiatrists, (doctors specialised in the area of mental illnesses) - Psychologists - Occupational workers - Social workers

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- Educators - Nurses - Nurses’ aids The procedures for action are set out in the rules for the internal operation of each resource, and legislation approved by the respective authorities exists in some of the Autonomous Communities.

4. INTERVENTION APPROACHES 4.1. Available resources for mentally ill young offenders In terms of the diagnosis and psychiatric assessment of young offenders, several sources and channels exist. As there is no clearly established protocol, this largely depends on the particular case. Of the children and young people admitted to the “Pi Margall” Rehabilitation Centre, some of them come directly from a Psychiatric Hospitalisation Unit. Admission takes place following a crisis, and the mentally ill young offender is transferred to the Centre when s/he has stabilised – in such cases she/he is admitted with a diagnosis and pharmacological guidelines to be followed.

On other occasions the diagnoses are provided by community resources and outpatient centres, the reference Mental Health Unit which the child has been attending, a private psychologist or psychiatrist, the community’s Social Services, etc. In these cases, the transfer of information and the diagnostic evaluation usually take place after the minor has been admitted. In other cases, no diagnosis is made, but they are given treatment with resources, since the information from these resources is very valuable.

It is important to point out that there is no regulated protocol with respect to the transfer of information, since this depends on the willingness and involvement of professionals and family members.

It is worth mentioning that we generally encounter minors who have been given numerous diagnoses over the years (between 3 and 5 different psychiatric diagnoses).

Once a child is admitted to the Centre, all of the available clinical information is collected, and the diagnosis prior to admission is retained or modified according to the condition of the minor. This task is undertaken by the Centre’s own psychiatrist. In the case where Centres which do not have their own medical-psychiatric team and where it is considered advisable, normalised health services are used (district Mental Health Unit, hospital, etc.).

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Similarly, at the request of the Court, the Public Prosecutor or the minorâ&#x20AC;&#x2122;s attorney, the minor can attend a forensic pathologist for his evaluation. Furthermore, for the purposes of evaluating impairment and disabilities, reports can be requested from the Centre or the minor can alternately go to specialists if necessary.

With regards to the diagnosis made by the Centre, apart from the information previously collected, an assessment of the minorâ&#x20AC;&#x2122;s daily progress is taken into account, and semi-structured interviews, analyses, questionnaires or diagnostic tests considered appropriate (CAT, MRI, etc.) are conducted. In order to conduct these tests, the minors are incorporated into the community health system (Social Security), and attend Hospitals or Specialist Centres in order to have the relevant diagnostic tests conducted.

4.2. Treatments The intervention for mentally ill young offenders presupposes a biopsychosocial perspective, and employs a multidisciplinary treatment which can address and respond to the holistic and comprehensive approach on which it is based.

It aims to reduce and/or neutralise the risk factors which cause them to become involved in punishable activities, and to develop or foster protective factors, thus mitigating the anticipated pathological consequences of such factors in a risk situation.

Highlighted among the individual risk factors would be genetic-biological origin, temperament, ADHD (failure to follow norms and learning difficulties), intelligence, scholastic failure and frequent antisocial company. On this basis, an individualised programme in keeping with the characteristics and process of change in the child should be designed.

In terms of familial risk factors, poor parental supervision, punishment-based forms of discipline, regulatory inconsistencies, separated parents, a weak emotional link, criminality in parental figures, conjugal conflict and negligence stand out. Intervention from this standpoint would be aimed at modifying varieties and models of socialisation, from the micro to the macro-system, i.e. taking into consideration firstly family, school, peer groups, etc. in conjunction with the macrosystem (methods of communication, neighbourhoods, state, etc.).

Also in relation to risk factors, and in connection with cognitive factors in social development, various research studies point to the fact that the attributional style of children and young people directly influences their behaviour, so that aggressive children view and react to the world differently from non-aggressive ones. Along these

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lines, another approach is used which aims to modify the attributional style of mentally ill young offenders.

Social risk factors are also relevant for planning interventions, when one notes the influence which economic inequality, the attractiveness of violence, drug and alcohol consumption have on criminal behaviour. Depending on the young person and the relevance of these factors in his evolutionary process, this should be taken into account when setting objectives from this intervention standpoint.

Based on these risk factors present in mentally ill young offenders, practical intervention objectives would be designed giving attention to their criminogenic needs and based on dynamic – and therefore modifiable - risk factors. Although risk factors provide the basis for establishing intervention objectives, the “motivating force” of the programme to be pursued should be based on and supported by the development of protective factors which neutralise these risk factors.

There must be evidence of wide variability in the programmes used with young offenders, so that there would be no “magic wand” or standard programme for effectively addressing the needs of the entire population, as the efficacy of the programme is in fact based on designing, adapting and individualising the intervention in accordance with the needs of each minor.

Citing the contributions of Santiago Redondo (1994)189 in his meta-analysis of treatments applied to delinquents in Europe, the author points out that the most effective programmes are the ones built on behavioural and cognitive-behavioural theory models. Similar conclusions have been reached in Gendreau and Ross (1979)190, Ross and Fabiano (1985)191, Ross et al.

(1990)192, Andrews et al. (1990)193, Palmer (1992)194, Maguire (1992)195, Lösel (1995ª, 1996)196

189 Redondo, S. (1994): “El tratamiento de la delincuencia en Europa: Un estudio meta-analítico”. Tesis doctoral no publicada. Universidad de Barcelona.

190 Gendreau, P., and Ross, R. (1979). “Effective correctional treatment: bibliotherapy for cynics. Crime and delinquency”.

191 Ross, R. R., & Fabiano, E. A. (1985). Time to think: A cognitive model of delinquency prevention and offender rehabilitation. Johnson City, TN: Institute of Social Sciences and Arts.

192 Ross, R.R., Fabiano, E., and Garrido, V. (1990). El pensamiento prosocial. El modelo cognitivo para la prevención y tratamiento de la delincuencia. Delincuencia/Delinquency, Monographic n. 1, 116 pp.

193 Andrews, D., Zinger, I., Hoge, R., Bonta, J., Gendreau, P., and Cullen, F. (1990). Does correctional treatment work? A clinically relevant and psychologically informed meta-analysis. Criminology, 28, 369-404.

194 Palmer, T. (1992). The Re-emergence of Correctional Intervention. Newbury Park, CA: Sage.

195 McGuire, J. (1992). Enfocaments psicològics per a la reducció de la conducta delictuosa: Investigació recent i implicacions pràctiques. Papers d’Estudis i Formació, 10, 67-77.

196 Lösel, F. (1995). The efficacy of correctional treatment: A review and synthesis of meta-evaluations. In J. McGuire (Ed.), What Works: Reducing Reoffending (pp. 79-114). Chichester: Wiley.

Lösel, F. (1996). What recent meta-evaluations tell us about the effectiveness of correctional treatment.

In G. Davies, S. Lloyd-Bostock, M. McMurran, and C. Wilson (Eds.), Psychology, Law, and Criminal Justice (pp.

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and Redondo et al. (1997)197.

Among the studies referred to by the author, we consider it relevant to mention the contributions of Andrews et al. (1990)198, which point out that among ineffective treatments, those programmes based exclusively on dispensing iron discipline as the main strategy for change have no effect, according to research. Similarly, professionaltype programmes or programmes which use the area of learning as an exclusive medium for reintegration, also prove ineffective. Programmes built on introspection and analysing deep-seated problems, that is, exclusively pursuing psychoanalytical or constructed along psychodynamic lines, would also be ineffective. Consequently, the importance of individualising treatment and employing a comprehensive approach to children is once again highlighted.

Among the therapies assessed as effective on mentally ill young offenders, we would highlight the following; - Motivational interviewing: The motivational discussion is the quintessential tool for interventions in the area of drug dependency. It is a flexible and adaptable tool, although it is important to point out that it has substantial limitations when used with young people and when there is no spontaneity in the treatment.

- Systemic intervention, reality therapy and solution-focussed therapy: These provide intervention tools which have proved effective in the treatment of children and young people with antisocial behaviour and mental health pathologies. The importance of dependence on the family system and the circumstances of the minor are especially highlighted.

- Body work: this involves illustrating how the mind-body relationship is expressed particularly in mentally ill young offenders, and shows how bodily changes have a direct influence on other levels and vice-versa. This line of intervention takes the form of workshops in art therapy, relaxation, theatre and dramatisation, etc.

- Pharmacotherapy: Pharmacotherapy is necessary and essential depending on the case and the situation, for use in promoting the stability and/or progress of the

537-554). Berlin: De Gruyter.

197 Redondo, S. Garrido, V. y Sánchez-Meca, J. (1997). What works in correctional rehabilitation in Europe: a meta-analytic review. In S. Redondo, V. Garrido, J. Peréz, y R. Barberet (Eds.), Advances in Psychology and Law: International Contributions (pp. 499-523). Berlín: de Gruyter.

198 Andrews, D., Zinger, I., Hoge, R., Bonta, J., Gendreau, P., and Cullen, F. (1990). Does correctional treatment work? A clinically relevant and psychologically informed meta-analysis. Criminology, 28, 369-404.

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mentally ill young offender.

- Animal-assisted therapy: Specially indicated for promoting responsibility, and facilitating and channelling more effortless communication and expression in young offenders with mental illnesses, especially psychotic disorders, ADHD, etc.

- Neuropsychological intervention: Has proved to be an effective tool for evaluation, prevention and rehabilitation of damage affecting the neuroanatomical substrates of behaviour. It is especially effective on psychotic disorders, attention deficit, developmental disorders, etc. In recent years, neuroscientific research has also illustrated the relevance of neuropsychological alterations of executive functions in explaining different aspects of addiction, including the initial, progressive and chronic use of drugs, or the risk of relapse.

As mentioned, it is important to emphasise the importance of carrying out an exhaustive analysis to determine the needs of mentally ill young offenders as well as employing the most appropriate techniques and treatments for dealing with them, and designing an individualised programme. Likewise, special emphasis is placed on the biopsychosocial perspective and the comprehensive approach to treating minors.

At the “Pi Margall” Rehabilitation Centre, treatment is approached from the biopsychosocial perspective through programmes and workshops aimed at developing social and personal skills, medical and psychiatric supervision, and individual and family-based psychological intervention. This intervention starts with a multidisciplinary team that includes a medical and psychiatric team, a technical team, and an educational, management and services-maintenance team. Similarly, external bodies such as the Courts, the Minors’ Prosecuting Office and community-owned resources (Hospitals, recreational resources, businesses, etc.) are involved. A networkbased or root model of intervention is presented so that a team can directly tackle specific objectives and support the remaining ones in a direct or transversal manner.

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The intervention modalities at the â&#x20AC;&#x153;Pi Margallâ&#x20AC;? Rehabilitation Centre are as follows: - Individual therapy: The sessions are conducted in a parallel and complementary manner by both the psychiatrist and the psychologist, and the sessions are held weekly, fortnightly or monthly, depending on the needs of each minor, and last approximately 50 minutes per session. Generally speaking, the problems individually addressed relate to behavioural and emotional problems caused by personality and behavioural disorders, including familial abuse and auto-aggression, and sexual abuse, psychotic disorders are also dealt with.

- Family therapy: This is generally conducted with the families of minors admitted for child-parent violence, and is also proposed in other instances when assessing the need for intervention to bring about change in the minor (minors with psychotic

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disorders, drug dependency, dysfunctional relational systems, minors with bipolar disorders, etc.). Depending on the requirements and the circumstances (duration of the measure, proximity of the goal to this measure, characteristics of the family system, monitoring prior to admission to external resources, etc.) it would be proposed that familial intervention be carried out at the Centre or at an external resource. Initially, the general tendency is to conduct the intervention at the Centre, especially in the case of “handicaps” which would entail applying external intervention (need for a police escort, distance, etc.).

This kind of therapy is normally conducted simultaneously with the individual therapies provided for the child, and is administered by the same professional in the centre itself. This has the advantage of providing exhaustive knowledge about the problem and about the feelings of the child and his/her family, even though analysing and anticipating the relationships being established is of relevance; in this way, pursuing individual therapies with the minor, the family and with groups does not interfere with the therapy relationship. This type of intervention attempts to substitute the dysfunctional dynamic which has been established in the home with a more appropriate, positive one, and encourages the clarification and restoration of paternal roles, as well as respect among the members of family and the reestablishment of the nurturing and socialising functions of the system.

The frequency of the sessions is determined on the basis of need, as well as the family’s means. They are gradually increased when introducing liberties which the young person can enjoy at home, and are gradually spaced out according to improvements in relations and illustrated competence by the family to face crises, until therapy is discontinued once the objectives have been achieved. Various family members attend this type of therapy, depending on how the family system is structured. This work is carried out simultaneously and in combination with the familial intervention conducted by the Centre’s Social Worker, so that the messages and counselling that the family receives are consistent and identical.

Generally, in the case of families of children admitted to the Centre for familial abuse, the boundaries existing between its members are unclear, with roles being easily interchanged and with the minor usually displaying dominance towards his/her family. Similarly, there is evidence of normative inconsistency, along with an important hidden agenda in relation to past actions and unexpressed or inadequately expressed emotions. These lead to the creation of a vicious circle within the relationship.

Broadly speaking, the results are normally satisfactory, especially in those cases where the minor’s problems are restricted to a particular area of his/her life (family).

Most cases of familial abuse usually require continuing therapeutic treatment after

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discharge from the Centre, in light of the deeply ingrained nature of the anti-social behaviours to be treated.

Among the minors admitted to the Centre, approximately one-third are participating in family therapy sessions and individual therapy sessions simultaneously.

- A school for parents and family participation projects: Various resources are available, some of them psychoeducational in nature and others designed more along the lines of self-help groups intended to promote improved relations between the mentally ill young offender and family.

- Group workshops: Group sessions are held on topics of concern to all, such as anger management, the development of social skills, etc., and are addressed either from a group therapy perspective or from a psychoeducational perspective, or both, as required.

4.3. Special units for mentally ill young offenders The â&#x20AC;&#x153;Pi Margallâ&#x20AC;? Rehabilitation Centre is the only state-owned treatment Centre complying with detention measures, and has gained highly satisfactory results with respect to the improvement and progress shown by mentally ill young offenders. This does not necessarily correlate positively with the minorâ&#x20AC;&#x2122;s complete and sustainable re-entry into society once the detention measure has been concluded at the abovementioned resource. Notwithstanding, the improvement gained is evident, and thus there is a higher probability that a subsequent intervention with the minor could be more productive than if s/he had not passed through this resource.

4.4. Prevention programmes Prevention programmes are established out of zonal Social Services and through State campaigns. However, as indicated in the previous paragraphs, the importance of establishing an intervention plan constant with the needs of the minor so that it can be effective, must be stressed.

Generally speaking, there is an obvious lack of communication, coordination and effective management of the various agent actors and this could affect the prevention plan.

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4.5. Regulation of psychiatric treatment As in the case of therapeutic measures imposed for addiction to toxic substances, the possibility exists that the minor could reject the withdrawal treatment or abandon one that has already been started â&#x20AC;&#x201C; in which case the Judge will have to apply another measure appropriate to the circumstances. In the case of measures imposed for mental health reasons, the LORPM (Framework Law on the criminal liability of minors) does not allow for such a possibility since the minor is deemed to lack the necessary discernment required to take such a decision.

Consequently, the minor is obliged to follow this treatment and, where appropriate, it can be administered to him/her in a co-active manner if s/he is not considered fit to take decisions about his/her treatment.

When a minor with a therapeutic measure (either in a detention centre or as an outpatient) does not finish the treatment for the period set in the sentence, two things can happen: - If s/he does not complete it for reasons attributable to the minor him/herself (i.e., s/he escapes from the centre or refuses to continue as an outpatient) the Juvenile Court Judge is authorised to oblige him to complete it in the centre itself or to substitute the open-confinement measure with another one appropriate for his circumstances. Exceptionally, in this latter case, he could arrange to have the openconfinement measure (outpatient treatment) substituted by therapeutic detention in a semi-open environment during the period remaining for the originally imposed measure to be executed.

- If the period for the measure set in the sentence ends and the minor continues to suffer from the mental illness which s/he was suffering, the powers of the Juvenile Court Judge no longer apply; however, the mechanisms specified by procedure can be implemented in the case of persons with serious mental illness, who cannot be adequately cared for in the family environment, i.e., involuntary admission of the minor in a mental health hospital zone prior to authorisation by the competent judge.

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4.6. Protocols In the first instance, action protocols are defined and circumscribed according to the regime. In applying detention measures, considering that their goal is reintegration, the idea is to extend what is learned in the Centre to other contexts, so that solutions to open confinement and to a waypoint for mentally ill young offenders can be found, depending on their degree of responsibility and self-determination. Similarly, depending on the needs and situation of the minor, the possibility of receiving treatment outside of the Centre is being contemplated. For example, a minor who has followed treatment in his/her SEAFI (Family and Childhood Care Service) or in a UCA (addictive behaviour unit), or who has not followed treatment, but sees his/her participation in this resource as positive, could attend. However, minors who are serving measures in an open regime or in a case where they have served a confinement measure would not be able to participate in the activities being conducted in this detention centre.

5. PROPOSAL FOR BEST PRACTICES Having completed a general review of the current outlook for the ChildhoodAdolescent Mental Health System, at Fundaci贸n Diagrama we would propose a series of recommendations regarding specific intervention with mentally ill young offenders, which we believe are of vital importance: - Prioritising early childhood diagnosis As we indicated at the beginning of this document, it has been proven that a high percentage of current adult mental disorders begin in childhood and/or adolescence.

According to the guidelines in the Report on Mental Health in children and adolescents, compiled by the Spanish Association of Neuropsychiatry (AEN), more than half of the mental illnesses in the population emerge in childhood, and there is now no question within the scientific community about the continuity between childhood mental disorders and those suffered by adults. Neither is there any question about the fact that failure to diagnose and treat mental health problems in children and adolescents seriously affects their future (...) given that a very high percentage of children and young persons who suffer from mental disorders and who are not diagnosed end up in Juvenile Correctional Centres and in the world of delinquency.

In this respect, we recommend that the Spanish Mental Health System begin applying measures for diagnosis and effective early intervention, and for professionals involved in the care of children with mental disorders to agree on these criteria so that the variability which currently exists can be avoided.

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- Developing early action We feel it is essential to develop action aimed both at prevention as well as the promotion of mental health at an early age, with the ultimate goal of eliminating the stigma and the discrimination to which the group of persons referred to fall victim.

Likewise, we think policies should be developed to increase awareness among the general population.

Psychiatric or mental problems continue to be a cause of shame for families and even more so for children and young persons who have fewer intellectual and emotional resources for dealing with criticism and low regard (...) Persons with mental illness still remain a marginalised group.

There is limited knowledge in our social or even professional circles about mental disorders in the child and adolescent population. (...) Therefore attention to childhood and adolescent mental health, both in those who may develop disorders at any moment, and those in whom they are already clearly manifested temperamentally, is of great importance. (Quoted in the previously mentioned Report on Mental Health).

- Offering specialised care Following the same guidelines in the report compiled by AEN, age is a modulating variable of the clinical characteristics of mental disorders, so programmes and specific interventions based on the vital stages, targeting specific groups in the population, and devising tangible actions for each particular problem (child-parent violence, drug dependencies...) should be developed.

The lack of studies and research on childhood-adolescent mental health in Spain, as well as Europe, in addition to the scarcity of professionals and specific resources to meet the needs of this population, again suggests that we must channel this work towards the socio-healthcare and socio-educational sectors as a matter of priority, so that the minimum rights of mentally ill young offenders and their families can be guaranteed in the interest of prevention and social integration.

- Improvement and specialization of the training of professionals In Spain, unlike the majority of European Union countries, there is no specialisation in childhood-adolescent psychiatry. It is therefore essential to develop this specialisation in the near future with the ultimate goal of offering care suited to the particular characteristics of the childhood-adolescent population suffering from mental disorders.

Moreover, the majority of professionals who work with mentally ill young offenders (social workers, educatorsâ&#x20AC;Ś) have themselves not been specifically trained in the care

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of children with mental health problems, which is why we believe that NGOs and Public Services involved in the execution of therapeutic measures should make every effort to offer training in accordance with the needs of minors comprising the mentally ill young offenders group.

Training professionals should involve building on professional knowledge, as well as on skills and awareness attitudes towards the group being discussed in this report, since the treatment must be individualised, substantiated by the prospects for change, and have a constructive, creative method for problem-resolution. It must at the same time be suited to each of the diverse profiles mentioned when we refer to minors and young persons with mental health problems, and minors who, in addition to these problems, are serving a judicial measure.

Thus, once again, we would recommend developing research on the area of ChildhoodAdolescent Mental Health in general and on the population in conflict with the law, in particular.

- Fostering professional collaboration and making interdisciplinarity effective According to Jiménez, A. (2004)199, even nowadays it is difficult to take an integrated and comprehensive approach to the psychological, educational or social problems which may arise in childhood, as it is common for the various teams involved in such care to work separately.

In light of these facts, there is a specific need for the different agents involved in the field of childhood-adolescent mental health (professionals in health, education, the justice system, social services...).to intervene in an interdisciplinary and coordinated way.

This need is even more obvious, as many of the children and young people who are treated use several care systems simultaneously (educational, health, judicial and social services). Specifically, a study conducted in the Basque Country (Mendivil, Auzmendi, Aparicio, Bravo and Iruin, 1999)200 theorises that 13% of the patients attended to in the childhood-adolescent mental health system, simultaneously use the Social Services and even other services such as health, school, social or judicial.

199 Jiménez, A. (2004). “Intervenciones psicoterapéuticas en unidades de salud mental infantojuvenil y coordinación con otros dispositivos”. Revista de SEPYPNA. 200 Mendivil Eguiluz C, Auzmendi Yurrita M, Aparicio Tellería D, Bravo Albizu MV, Iruin Sanz A. (1999).

Experiencia en colaboración socio-sanitaria en Psiquiatría infantojuvenil. Volumen 11, Número 5-6, septiembre-diciembre 1999: 176-185.

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Following this same trend, studies conducted in the United Kingdom indicate the need for complex, multi-component programmes, where prevention or primary intervention in mental health would be the ultimate objective, and these studies specify the need for a systematic model of prevention, which is also lacking in our country (Durlak and Wells, 1997) 201.

To do so, sufficient coordination is needed between the various groups of professionals who care for children will promote comprehensive care, address the mental, judicial and social issues which arise, and will help to achieve fixed objectives in intervention, as well as promote change in the minor’s environment. Additionally, and once again quoting Jimenenez, A. (2004), a coordinated effort will contribute to the following aspects: - Unify, reconcile or at least respect the language and philosophy used from each field of work.

- Know the specific characteristics of each team, so as to avoid badly coordinated networks or parallel action.

- Improve the case referral system.

- Be familiar with the most relevant psychosocial and psychopedagogic problems for these ages and the involvement of the various teams.

- Create joint intervention protocols on the problems requiring these, and also deal with the preventive aspect.

-

Notify the competent authorities of needs detected with respect to prevention, joint action and resources needed.

In conclusion, it is important to consider that in order to achieve the interdisciplinary and intergroup coordination just discussed, it is necessary to have coordination and collaboration between the Ministries (Social Welfare, Education, Health, Justice...) along with accords and partnership agreements between the different public and private institutions involved in the process.

- Cooperating and exchanging information between the Mental Health and Juvenile Justice systems

201 Durlak, J.A., Wells, A.M. (1997). “Primary Prevention Mental Health Programs for Chil-dren and Adolescents: A Meta-Analytic Review”. American Journal of Community Psychology, 25, 115-152.

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It would be advisable to promote the flow of information, and have appropriate knowledge of the needs of mentally ill young offenders. Little is known about the current intervention programmes, which ones are most effective, why, etc. Likewise, it is necessary to join forces in reintegrating and rehabilitating mentally ill young offenders, and in defining common, similar objectives.

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References Andrews, D., Zinger, I., Hoge, R., Bonta, J., Gendreau, P., and Cullen, F. (1990). Does correctional treatment work? A clinically relevant and psychologically informed metaanalysis. Criminology, 28, 369-404.

Draft Framework Law supplementing the Bill updating Child Protection Legislation (Anteproyecto de Ley Orgánica complementaria al Anteproyecto de Ley de actualización de la legislación sobre protección a la Infancia).

Arruabarrena, Mª.I. “Evaluación y tratamiento familiar” (“Assessment and Family Treatment”).

MASSON, (1996).

Spanish Neuropsychiatric Association, (2006) “Guía de Recursos de la Salud Mental Infantojuvenil hospitalarios y ambulatorios de la Sección de Salud Mental Infanto-Juvenil” (“Guide to Hospital and Outpatient Mental Health Resources for Children and Young People in the Child and Young Persons’ Mental Health Section”). www.aen.es/aAW/web/cas/secciones/infan-juve/ GuiaRecursos.jsp.

Becker, J.V., and Hunter, J.A. (1997). Understanding and treating child and adolescent sexual offenders. In Advances in Clinical Child Psychology, vol. 19, edited by T.H. Ollendick and R.J. Prinz. New York, NY: Plenum Press, pp. 177-197.

Castells, P. (2007). “Victimas y matones: claves para afrontar la violencia en niños y jóvenes” (“Victims and bullies: keys to tackling violence among children and young people”). Barcelona: Ceac familia.

Cauffman E. (2004). “A statewide screening of mental health symptoms among juvenile offenders in detention”. Journal of the American Academy of Child and Adolescent Psychiatry.

43:430-439.

Penal Code approved by Framework Law 10/1995, of the 23rd November, of the Penal Code (Código Penal aprobado por Ley Orgánica 10/1995, de 23 de noviembre, del Código Penal).

Spanish Constitution.

Technical handbooks (2009). “Informe sobre la salud mental de niños y adolescentes” (“Report on child and youth mental health”).

Durlak, J.A., Wells, A.M. (1997). “Primary Prevention Mental Health Programs for

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Chil-dren and Adolescents: A Meta-Analytic Review”. American Journal of Community Psychology, 25, 115-152.

Franco, C., Arango C. (2004). “Prevalencia de trastornos mentales en niños y adolescentes”, Monografías de Psiquiatría ( “Prevalence of mental disorders in children and adolescents”, Psychiatric monographs), 3, pp. 19-27.

G. Ochando Perales, S. Peris Cancio, MC. Millán Olmo, J. Loño Capote. “Trastorno de conducta en niños adoptados” (“Behavioural disorders in adopted children”). Child and Youth Mental Health Unit. La Fe. University Hospital, Valencia.

Gendreau, P., and Ross, R. (1979). “Effective correctional treatment: bibliotherapy for cynics.

Crime and delinquency”.

Goméz-Beneyto M, Bonet A, Catalá M. (1994). “The prevalence of child psychiatric disorders in the city of Valencia”. Acta Psichiatr Scand. 89:352-357.

Guzmán, G.; Jáuregui, M.C.; Isaza, M.C.; López, L.P. y Cuadros, I., (2007). Modelo para la atención de ofensores sexuales menores de 18 años (“Model for the treatment of sex offenders aged under 18”). Afecto Association. Bogotá.

Ibabe, I., Jaureguizar J. y Díaz O., (2007). Violencia Filio-parental. Conductas violentas de jóvenes hacia sus padres (“Violent behaviour of young people towards their parents”). Basque Government Central Publications Service.

Jiménez, A. (2004). “Intervenciones psicoterapéuticas en unidades de salud mental infantojuvenil y coordinación con otros dispositivos” (“Psychotherapeutic interventions in child and youth mental health units and coordination with other measures”).

SEPYPNA Journal.

Civil Indictment Law of 2000 (Ley de Enjuiciamiento Civil del año 2000).

Framework Law 1/1996, of the 15th of January on the Legal Protection of Minors (Ley Orgánica 1/1996, de 15 de Enero, de protección Jurídica del Menor).

Framework Law 15/1999, of the 13th of December (Ley Orgánica 15/1999, de 13 de Diciembre).

Framework Law 5/2000, of the 12th of January on the Criminal Liability of minors (Ley Orgánica 5/2000, de 12 de Enero, de Responsabilidad Penal de los menores).

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Lösel, F. (1995). The efficacy of correctional treatment: A review and synthesis of meta-evaluations. In J. McGuire (Ed.), What Works: Reducing Reoffending (pp. 79-114).

Chichester: Wiley.

Lösel, F. (1996). What recent meta-evaluations tell us about the effectiveness of correctional treatment. In G. Davies, S. Lloyd-Bostock, M. McMurran, and C. Wilson (Eds.), Psychology, Law, and Criminal Justice (pp. 537-554). Berlin: De Gruyter.

McGuire, J. (1992). Enfocaments psicològics per a la reducció de la conducta delictuosa: Investigació recent i implicacions pràctiques (Psychological Approaches for the reduction of criminal behaviour. Recent research and practical implications). Papers d’Estudis i Formació, (Study and Training Papers) 10, 67-77.

Mendivil Eguiluz C, Auzmendi Yurrita M, Aparicio Tellería D, Bravo Albizu MV, Iruin Sanz A. (1999). Experiencia en colaboración socio-sanitaria en Psiquiatría infantojuvenil (Experience in socio-health collaboration in child and youth psychiatry). Volume 11, Numbers 5-6, September-December 1999: 176-185.

Morenz, B., and Becker, J.V. (1995). The treatment of youthful sexual offenders. Applied and Preventive Psychology 4(4):247-256.

MSC. (2007). “Estrategia en Salud Mental del Sistema Nacional de Salud” (“Mental Health Strategy in the National Health System”). Directorate General of the SNS Quality Assurance Agency. Health and Consumer Ministry.

Ochando, G., Peris, S., Millán, MC., Loño, J. (2008). “Trastorno de conducta en niños adoptados” (“Behavioural Disorders in adopted children”). Child and Youth Mental Health Unit. La Fe. University Hospital, Valencia.

World Health Organization. (2005). “Child and adolescent mental health policies and plans”.

WHO. World Health Organization. (2003). “Mental Health Legislation and Human rights”, WHO. Palmer, T. (1992). The Re-emergence of Correctional Intervention. Newbury Park, CA: Sage.

Redondo, S., Garrido, V., and Sánchez-Meca, J. (1997). What works in correctional rehabilitation in Europe: a meta-analytic review. In S. Redondo, V. Garrido, J. Pérez, and R. Barberet (Eds.), Advances in Psychology and Law: International Contributions (pp. 499523). Berlin: De Gruyter.

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Mollejo Aparicio, E. (2007) “Editorial. Sobre la necesidad de crear la especialidad de Psiquiatría Infantil en España” (“Editorial on the need for specialization in Child psychiatry in Spain”). Spanish Neuropsychiatry Association Journal. Journal nº99.

Electronic Journal (2009). “Iniciación a la Investigación” (“Initiation to Research”), Jaen University.

Ross, R. R., & Fabiano, E. A. (1985). Time to think: A cognitive model of delinquency prevention and offender rehabilitation. Johnson City, TN: Institute of Social Sciences and Arts.

Ross, R.R., Fabiano, E., and Garrido, V. (1990). El pensamiento prosocial. El modelo cognitivo para la prevención y tratamiento de la delincuencia (Prosocial thinking. The cognitive model for the prevention and treatment of criminal behaviour). Delincuencia/ Delinquency, Monographic n. 1, 116 pp.

Redondo, S. (1994): “El tratamiento de la delincuencia en Europa: Un estudio metaanalítico” (“Treating criminal behaviour in Europe: A meta-analytical study”).

Unpublished doctoral thesis. Universidad of Barcelona.

Redondo, S. Garrido, V. y Sánchez-Meca, J. (1997). What works in correctional rehabilitation in Europe: a meta-analytic review. In S. Redondo, V. Garrido, J. Peréz, y R. Barberet (Eds.), Advances in Psychology and Law: International Contributions (pp. 499-523).

Berlín: de Gruyter.

Sempere, M; Losa, B.; Pérez, M.; Esteve, G. y Cerdá, M. (2006). Estudio cualitativo de menores y jóvenes con medidas de internamiento por delitos de violencia intrafamiliar. (Qualitative study of children and young people detained for violence within families”) Centre of legal studies and specialized training centre. Department of Justice. Generalitat de Catalunya.

Barbara K. Schwartz, Henry R. Cellini (1995). The Sex Offender. Ed. Book.

Walker, M. L., Schmidt, L. M.,&Lunghofer, L. (1993).Youth gangs. In M. I. Singer, L.T. Singer, & T. M. Anglin (Eds.), Handbook for screening adolescents at psychological risk (pp.

400- 422). New York: Lexington Books/Macmillan.

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Chapter IX Promoting emotional and social well-being â&#x20AC;&#x201C; the mental health needs of young offenders in the United Kingdom ....................................................................................................................................... by Brian De Lord CEO Laida Quijano Secondary Research Coordinator Jim Rose Consultant Pupil Parent Partnership (PPP)

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Table of Contents

............................................................................................................................

Introduction

1. PROFILE OF A MENTALLY ILL YOUNG OFFENDER

1.1. Learning Disabilities and Learning Difficulties 1.2. Communication difficulties – speech and language 1.3. Looked after Children and Children in Care 1.4. Experiences of abuse 1.5. The relationship between mental health problems and offending 1.6. What kind of specific mental health needs does a young offender present in detention?

1.7. Types of mental illness – young people in custody 1.8. Self-Harm in Custody 1.9. The general background of young offenders with mental health needs 1.10. The family situation of the young offender suffering from a mental illness 1.11. Impact on the mental health of young offenders 1.12. The correlation between the misuse of drugs and behavioural disorders in young offenders 1.13. The special needs of minors in conflict with the law with mental health needs facing a custodial sentence.

1.14. The proportion of young offenders under therapeutical custodial measures

2. LEGAL FRAMEWORK – PENAL AND CHILDCARE REGULATION 2.1. The current Juvenile Justice System in England and Wales 2.2. The Youth Justice Board 2.3. Prevention 2.4. Community Sentencing 2.5. Custodial Sentencing 2.6. Section 90 2.7. Section 91 2.8. The specific childcare system/civil law concerning children with mental health needs 2.9. Mental Health Act 2007 2.10. Are young people with mental health problems penally

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responsible? If yes, are they in charge of the care or criminal system? If not, do they receive any legal and therapeutic assistance 2.11. Doli Incapax 2.12. Does a specific legislation exist concerning young offenders with mental health problems?

2.13. Wich ethical principles and practices must be followed by the justice and health systems to protect the best interest of the child? What are the main ethical aspects that have arisen in your country?

2.14. Are there any institutions, with involvement in court proceedings or otherwise, that are entrusted with the protection of minors (e.g. Children´s Ombudspersons, duties assigned to Public Prosecution Services in this respect?)

3. PROFESSIONAL ROLE AND SKILLS DEVELOPMENT

3.1. Levels of co-operation between the different staff that are in contact with the minor in conflict with the law (judge, psychologist, psychiatrist, social worker, teacher, etc)? Is there any specific principle on professional cooperation?

3.2. Example of joint working 3.3. About children and young offenders’ data / info, how is it handled? What about regulations on professional confidentiality?

3.4. What kind of specialized training is received by juvenile justice and health professionals who are in contact with mentally ill young offenders in your country?

3.5. What kind of multidisciplinary teams, if any, are assigned the duty of dealing with these minors? Can you please describe the professionals that form part of this team? What is their intervention procedure?

3.6 Assessment

4. INTERVENTION APPROACHES: WHAT IS WORKING AND WHAT IS NOT

4.1. What kind of standardized resources are available for developing psychiatric diagnoses and assessments for juvenile detainees with mental disorders?

4.2. What kind of therapeutic interventions do youth offenders receive in detention and community based sanctions? Are there any rules or particular treatment for them?

4.3. Community Based Interventions

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4.4. Pupil Parent Partnership 4.5. Are there any specific mental-health units for young offenders with MH needs in your country? What are the results of this intervention?

4.6. What are the possibilities for working in terms of family therapy? What would be the outcomes and results?

4.7. Evidence based programmes 4.8. Are there any prevention programmes (early intervention) concerning young people with behavioural disorders?

4.9.

What is the regulation or process regarding a psychiatric treatment? Who is in charge of it? Are minors obliged to follow the treatment decided by professionals?

4.10. What legal and medical measures are foreseen in cases of non-completion of treatment in outpatient or semi-open systems? When the minor fails to complete outpatient treatment, even when there is no situation to justify admission to a closed centre, if there is a risk of reoffending, do the Courts decide upon involuntary-admission measures?

4.11. Are laws and action protocols foreseen that would provide for mixed systems of closed and outpatient treatment? Please describe them if so

5. RECOMMENDATIONS AND PROPOSALS FOR GOOD PRACTICE Concerning young offenders with mental health needs and according to your knowledge and professional approach what actions should be implemented with respect to the following aspects?

5.1. The training and role of professionals and actors.

5.2. Community-based intervention and prevention.

5.3. Cooperation and interchange between mental-health and justice systems 5.4. Key facts from partnership conference in Rome

References

Abbreviations of Terms

Comments

Biographies of experts

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Introduction ‘When a child or young person experiences significant problems – often related to their feelings, thoughts or behaviours being ‘dysfunctional’ in some way – there are four main statutory systems across education, health, social care and youth justice that are designed both to help the child or young person, and to protect others. The different theoretical perspectives, training routes and legal frameworks that shape each of these systems lead to different ways of describing and framing these problems. In this report, we refer to them as mental health and psychological well-being problems. However, a point we are keen to stress is that they are the same children and young people with the same problems and needs, whatever the terminology used. ‘ (Children and Young People in Mind National CAMHS Review 2008:15) As the National Children and Adolescent Mental Health Service (CAHMS) Review confirms, one of the key issues in considering the mental health needs of young people whose behaviour has resulted in their involvement in the youth justice system is to remember that they are not a different ‘species’ but are likely to be the same young people who have previously been the subject of assessment and intervention by other statutory services, or whose family have been involved in receiving a service from one or more agencies, often over considerable periods of time. This understanding becomes even more relevant at the point of initial assessment of a young person’s presenting difficulty (wherever and by whoever this takes place) and in identifying appropriate intervention or treatment models. If a young person becomes involved in the youth justice system then it is essential that all this information is taken into consideration at the point of a court disposal, when the ability of the different agencies to work together and to share information is critical for effective intervention. However, it is important to bear in mind throughout this report that the priorities of the youth justice system as currently set out (see Part B) are to prevent and reduce offending underpinned by concerns about public protection and the need for proportionate punishment.

The World Health Organisation definition of mental health is used by the National CAHMS Review and is usefully stated here as a starting point for this report: ‘A state of well-being in which the individual realises his or her own abilities, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to his or her community.’

World Health Organisation (September 2010 Fact Sheet N.o220) Mental Health: Strengthening our response. Retrieved from http://www.who.int/mediacentre/factsheets/ fs220/en/

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The working definition of mental health, set out in the questionnaire used by Young Minds, the national voluntary sector organisation for children’s mental health states: “Mental health means much more than just the absence of mental illness. It is about physical and emotional well-being, about having the strength and capacity to live a full and creative life, and also about the flexibility to deal with its ups and downs.”

World Health Organisation (September 2010 Fact Sheet N.o220) Mental Health: Strengthening our response. Retrieved from http://www.who.int/mediacentre/factsheets/fs220/en/

If these are viable definitions of ‘good’ mental health then they become a template against which programmes and regimes for young offenders (including treatment programmes for mental illness) may be measured in terms of their outcomes and effectiveness. They also reinforce the point that the issue of the mental health needs of young offenders needs to be considered in a wider framework than solely ‘mental illnesses’. The term well-being is helpful in that it includes social and emotional dimensions that are critical in shaping services for young offenders that both confront antisocial behaviour but also support the development of the individual young person to achieve their potential and to make a positive contribution to the society in which they live.

Although the use of a strictly medical model to diagnose rates of mental illness in young offenders will, of course, be relevant for a small minority of these young people, a more helpful approach for understanding their wider mental health needs is a recognition of the importance of early attachment experiences to sustain healthy physical, cognitive and emotional development for all children and young people and the impact that poor early experiences can have on later behaviour. There are also a range of other social, cultural and socio-economic factors that have a bearing on youth offending.

Whatever specific intervention models may be advocated (and research shows that multi-modal treatment programmes are most effective for this diverse population) it is clear that those approaches that are based on an understanding of the principles of attachment and focus on helping young people to form and sustain positive relationships with their peers and key adult figures are most likely to achieve success.

Mental health may therefore perhaps be best thought of as a continuum with ‘wellbeing’ or ‘mental health’ at one end and ‘mental illness’ at the other. If young offenders are placed at different points of the continuum whilst relatively few may be seen as requiring specialist treatment for a mental illness, the vast majority does require

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specialist help and support to overcome the pervasive effects of social disadvantage, low educational attainments and delayed emotional development (the result of poor early attachment experiences). In addition, many young offenders will have experienced significant trauma during their early years, including emotional, physical, sexual abuse, family disruption and episodes of being in care.

All of the above contribute to the antisocial and delinquent behaviours that inhibit healthy development and ultimately bring young people to the attention of the youth justice system and their classification as young offenders.

This report addresses the questions posed in the questionnaire with reference to England and Wales and unless otherwise specified uses the term young offender to refer to young people under the age of 18 years.

1. PROFILE OF THE MENTALLY ILL JUVENILE OFFENDER Young Minds, the leading national charity for child and adolescent mental health issues, provides comprehensive data for mental health problems within the general population: • 1 in 10 children and young people aged 5 - 16 suffer from a diagnosable mental health disorder - that is around three children in every class1.

• Between 1 in every 12 and 1 in 15 children and young people deliberately self-harm2 and around 25,000 are admitted to hospital every year due to the severity of their injuries3.

• More than half of all adults with mental health problems were diagnosed in childhood.

Less than half were treated appropriately at the time4.

• Nearly 80,000 children and young people suffer from severe depression5.

• Over 8,000 children aged under 10-years-old suffer from severe depression6.

• 45% of children in care have a mental health disorder - these are some of the most vulnerable people in our society7.

Sources Green, H., McGinnity, A., Meltzer, H., et al. (2005). Mental health of children and young people in Great Britain 2004. London: Palgrave.

2 Mental Health Foundation (2006). Truth hurts: report of the National Inquiry into selfharm among young people. London: Mental Health Foundation 3 Fox, C. & Hawton, K. (2004). Deliberate self-harm in adolescence. London: Jessica 1

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Kingsley Publishers.

4 Kim-Cohen, J., Caspi, A., Moffitt, TE., et al (2003): Prior juvenile diagnoses in adults with mental disorder. Archives of general psychiatry, Vol 60, pp.709-717 5 Office for National Statistics (2004). Census 2001: national report for England and Wales. London: Office for National Statistics.

6 Office for National Statistics (2004). Census 2001: national report for England and Wales. London: Office for National Statistics 7 Meltzer, H., Gatward, R., Corbin, T., et al. (2003). The mental health of young people looked after by local authorities in England. London: Stationery Office.

• In terms of the group of young people in some form of secure, custodial setting the figures from Young Minds are: • 95% of imprisoned young offenders have a mental health disorder. Many of them are struggling with more than one disorder.8 Office for National Statistics (1997): Psychiatric morbidity among young offenders in England and Wales. London: Office for National Statistics.

8

A further confirmation of the prevalence of mental health problems amongst children and young people is provided by The Mental Health Foundation, who provides statistics on Mental Health Disorders among children and young people.

• One in ten children between the ages of 1 and 15 has a mental health disorder The Office for National Statistics Mental health in children and young people in Great Britain (2005) • Estimates vary, but research suggests that 20% of children have a mental health problem in any given year, and about 10% at any one time.

- Lifetime Impacts: Childhood and Adolescent Mental Health, Understanding the Lifetime Impacts, Mental Health Foundation (2005) • Rates of mental health problems among children increase as they reach adolescence.

Disorders affect 10.4% of boys aged 5-10, rising to 12.8% of boys aged 11-15, and 5.9% of girls aged 5-10, rising to 9.65% of girls aged 11-15.

Mental Disorder More Common In Boys, National Statistics Online (2004)

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The statistics related to mental health problems for young people in the youth justice system are, as would be expected, higher than for the general population. In the Healthcare Commission and HM Inspectorate of Probation report of their second joint review of healthcare in the community for young people who offend, Actions Speak Louder, (2009) it was found that 43% of young offenders on community orders had emotional and mental health needs.

In a research project funded by the Youth Justice Board (YJB) Dr. Susan Bailey and colleagues identified the following occurrences in a cohort of 300 young offenders within an age range of 13-18 years, 78% male, 22% female and 83% white, 9% AfricanCaribbean: • Depression - 18% • Anxiety - 10% • PTSD - 9% • Hyperactivity - 7% • Psychosis - 5% • Alcohol Abuse - 11% • Drug Abuse - 20% • Self-harm - 9% (Harrington and Bailey 2005)

Although the underlying thrust of this report is that poor early attachment is at the root of later problems of delinquency and associated mental health problems, there are many factors that impact on the mental health and wellbeing of young offenders.

Amongst the most critical of these are:

1.1. Learning disabilities and learning difficulties A review in 2002 by HM Inspectorate of Prisons and the Office for Standards in Education of almost 6,000 boys screened on admission to 11 custodial establishments found that: 4% had attainment at pre-entry level (i.e. lower than would be expected of a 7-year-old) in numeracy, and 4% had pre-entry level attainment in literacy, 38% had entry-level attainment (i.e. the level expected of a 7 year old) in numeracy, and 31% had entry-level attainment in literacy.

More recently, an assessment of children who offend in England and Wales by Harrington and Bailey (2005) found that 23% had an IQ of less than 70 (‘extremely low’) and 36% had an IQ of 70-79.

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In 2006 the YJB reported that: 25% of young offenders had special educational needs identified, 19% of whom had a Statement of Special Educational needs, and 46% were rated as under-achieving at school (Youth Justice Board 2006).

One of the critical issues for young offenders with learning disabilities (and mental health problems in general) is the failure for such problems to be identified at an early stage in a young person’s involvement with the youth justice system and a higher likelihood for such young people to receive a custodial sentence by way of their inability to present favourably in court, (see Talbot, Harrington and Bailey). The report from the Prison Reform Trust, Seen and Heard (2010) similarly concludes: ‘Children with learning disabilities, mental health problems and other impairments make up the majority of people in the youth justice system. Often they have passed through the education system with those needs unrecognised. We must ensure schools and other children’s services are properly equipped to identify and help these children - before they come into contact with the youth justice system.’

(Seen and Heard: 2010).

1.2. Communication difficulties – speech and language A number of research studies have demonstrated high numbers of children in the youth justice system with communication difficulties. One recent study showed that over 60% of children in the criminal justice system have a communication disability and, of this group, around half have poor or very poor communication skills. (Prison Reform Trust, Seen and Heard 2010).

In his review of services for children with speech, language and communication needs, John Bercow noted the high prevalence of these problems among children who offend and argued for better responses to such needs across the youth justice system (Bercow, 2008).

1.3. Looked after Children and Children in Care It has long been recognised that children who are or have been in care are overrepresented among the offender population. Research commissioned by the YJB found that 41% of children serving custodial sentences had been ‘held in care’, while 17% were on the child protection register (Hazel et al, 2002). A more recent review found

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that 22% of children aged under 14 years had been living in care at the time of their arrest and a further 6% were on the child protection register (Glover and Hibbert, 2009).

1.4. Experiences of abuse Many of the children and young people involved in the youth justice system have needs relating to experiences of abuse. Research shows that two in five girls in custody and a quarter of boys reported suffering violence at home; one in three girls and one in twenty boys in prison reported suffering sexual abuse and half the girls in prison have been paid for sex (Prison Reform Trust, June 2009).

1.5. The relationship between mental health needs and offending There is no simple causal link between mental illness and the propensity to behave in an antisocial or delinquent fashion. In consideration of the broader topics of antisocial behaviour and youth offending and the contributing factors to such behaviour, the presence of mental health problems in other family members as well as in individual children and young people, are noted to play a significant part and to require proper assessment and treatment.

The conclusions of the seminal book Antisocial Behaviour by Young People, (Hagell, Rutter & Giller, 1999) highlight the importance of identifying the kinds of intervention likely to be most effective in the management and treatment of the different manifestations of antisocial behaviour and the contributing factors, which are likely to be multiple. They summarise that antisocial behaviour is: • Very common amongst young people as British official statistics indicate that about a third of adult men will have a criminal record by the time they reach their mid-30s, which in the main has been acquired as juveniles. Most delinquency is relatively minor, short lived and theft related. Serious and persistent offending is exhibited only by a small minority of young people and only a small proportion of juvenile crime is violent.

• Very varied in its manifestations so that it is meaningless to talk of, try to explain, or treat antisocial behaviour as if it was of only one ‘type’. Consequently, interventions need to be multi-modal and consistent over long periods of time, focused and targeted on criminogenic factors, encourage pro-social behaviour,

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involve and encourage families, build on existing services, be applied consistently and combine different types of psycho-social treatments.

• Associated with a range of other problems including family characteristics, a history of disrupted or chaotic care, abuse and neglect, delinquent peer groups, school difficulties and health problems both physical and mental.

Whilst the varied nature of the behaviours makes it hard to identify significant groups of young people involved in antisocial behaviour for the purposes of intervention, the authors suggest that research indicates that the following factors are significant and have implications for planning intervention strategies: • Early onset of antisocial behaviour associated with Attention Deficit Hyperactivity Disorder • The age of onset i.e. early or adolescent specific • Association with violence • Psychopathy • Mental Disorder (linked to learning disability and substance abuse.) (see Hagell, Rutter and Giller 1999) The 2008 annual review by the Royal College of Psychiatrists explores the types of possible relationship between mental disorder and criminal behaviour in a young offender and makes the following distinctions in its analyses: • The antisocial behaviour is directly related to or driven by aspects of mental disorder.

In this case, effective treatment of the mental disorder would be likely to reduce the risk of further anti-social behaviour.

• The anti-social behaviour is indirectly related to mental disorder.

Treatment would be likely to make a contribution to a reduction in offending but would not be sufficient in itself to tackle offending behaviour.

• The anti-social behaviour and the mental disorder are related by some common antecedents, for example childhood abuse.

Treatment of the mental disorder in itself would not be sufficient to tackle re-offending.

• The anti-social behaviour and the mental disorder are coincidental.

The mental disorder is at least partly secondary to the anti-social behaviour.

(Extract from the submission to the review by the Forensic Faculty, Royal College of Psychiatrists 6 March 2008)

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The conclusions of the report confirm the findings of Rutter and colleagues that suggest that the proper assessment and treatment of mental health needs in young offenders, which differentiate between the aetiologies of the mental disorder and the antisocial behaviour, are essential in identifying the most appropriate intervention strategies for reducing the risk of young people offending.

1.6. What kind of specific mental health needs does a young offender show in detention?

According to the Office for National Statistics in 2000, mental health problems, drug and alcohol abuse are common amongst young people in prison. They are more likely than adults to suffer from mental health problems and are more likely to commit or attempt suicide than older prisoners.

(Singleton et al (2000) Psychiatric Morbidity among young offenders in England and Wales, London: Office for National Statistics) In 2010, the Institute for Criminal Policy Research together with the Prison Reform Trust mounted a study as a joint enterprise on children in custody in England and Wales. This study, Punishing Disadvantage â&#x20AC;&#x201C; a profile of children in custody, is the most recent and comprehensive survey of young people under the age of 18 years in custody.

At any given time, between 2,000 and 3,000 children aged 10 to 17 are likely to be in custody, either under sentence or on remand, in England and Wales. This study asked: who are these children, and why and how do they come to be in custody? The findings of the study were taken from a census of all children who received custodial sentences or custodial remands in the second half of 2008, who numbered approximately 6,000 in total. Secondly, the report also looked in more detail at the backgrounds and current circumstances of 300 of these children (200 sentenced and 100 remanded), who were randomly selected from the full population. They were thus able to produce a broad profile of all children who entered custody, and a detailed profile of 300 of them, from July to December 2008. No survey on this scale has been conducted in the last twenty five years, and as such, the study is a significant addition to a broader understanding of youth custody and its findings will be used to inform subsequent sections of this report regarding young offenders in custodial settings.

Young people sentenced or remanded to a custodial setting are most likely to have already been the subject of intervention by other agencies within the youth justice, education or welfare systems. In their study Secure Treatment Outcomes, Roger Bullock and colleagues from the Dartington Social Research Unit identify the career paths taken by the most difficult of adolescents whose behaviour results in placement in a

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secure setting. According to the Dartington study, the careers of these young people may be tracked along one of the following paths: experience of long term state care or special education; a very serious one of offence; serious and persistent offending or in the phenomenon of the â&#x20AC;&#x2DC;adolescent erupterâ&#x20AC;&#x2122;, i.e. those young people who only come to the attention of agencies in early or mid adolescence and then pass rapidly through the system into secure accommodation. They also identify that the characteristics of these groups of young people are not uniform which is important when it comes to planning services and interventions.

So whilst there is a small group of young offenders who come into custody as a result of a one off very serious offence and about whom relatively little may be known in terms of key background information, the vast majority of the young people in custody are well known to one or more statutory agencies. The potential availability of considerable amounts of information to help with the planning of programmes in the secure setting should therefore mean that programmes for individual young people can be immediately targeted and address identifiable factors contributing to the offending behaviour, including mental health issues. However, as will be examined in more detail later, this level of coordinated planning between community based and custodial settings rarely exists.

In consideration of the needs of young people in secure settings it is particularly important to draw the distinction between those problems which a young person experienced prior to custody and problems which are experienced as a result of being incarcerated. Of course there will also be an interaction between the two: a young person suffering from depression may well find their condition exacerbated by the experiences of being locked up, living in a small room or cell and spending large periods of the day in relative isolation or in large groups with other young people with little adult contact or supervision. Distance from home and contact with family and other key adult figures also contribute to a young personâ&#x20AC;&#x2122;s sense of wellbeing whilst in custody.

Other associated problems of daily life in a secure setting, e.g. bullying, fear of violence and a sense of isolation, may well affect a young person whose emotional health is fragile, increasing their sense of hopelessness and despair. In a similar way the absence of regular supplies of drugs and alcohol will provide difficulties for a young person accustomed to regular usage when at home or in the community.

These issues raise important questions for the design and management of regimes in secure settings in order to provide a safe environment in which each young person can feel secure within the constraints of daily group living and also feel that their individual needs are being addressed by adult staff who know them (not just know about them).

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1.7. Types of mental illness – young people in custody The comparative picture of young people serving the custodial element of a Detention and Training Orders (the short term custodial sentence (4-24 months, half the sentence in custody half in the community)) with those in the general population is quite stark: Type of mental health disorder

Young people in the general population

12 to 14 year olds on Detention and Training Orders

12 to 14 year olds on Detention and Training orders for breach

Self harm

7%

19%

21%

Formal mental health diagnosis

10%

13%

15%

SEN statement

3%

16%

20%

Attending a special school

1%

11%

18%

(Figures quoted in Glover, P., and Hibbert, P. (2009) Locking up or giving up? Why custody thresholds for teenagers aged 12, 13 and 14 need to be raised. An analysis of the cases of 214 children sentenced to custody in England 2007-8, London: Barnardo’s)

In her work with young people sentenced to long term custody for the most serious of offences (around 500 at any one time), Gwyneth Boswell (1995) highlighted the high levels of specific trauma that this group of young offenders had suffered. She found that in 200 cases studied, only eighteen young people had no reported experience of either some form of abuse or of significant loss in their lives and that 35 per cent of those interviewed had experienced both.

1.8. Self harm in custody Incidences of self harm in custody are amongst the most anxiety provoking of events for staff to manage. Regimes need to pay particular attention to the likelihood of selfharm from its most vulnerable young people.

In HM Chief Inspector of Prisons for England and Wales Annual Report 2006/7, (London: HM Inspectorate of Prisons) it was stated that young women under 18 are twice as likely to injure themselves as adult women. In 2007, 89% of girls under 18 in custody had selfharmed. According to Hansard, (House of Common written answers, 12 October 2009: Col 166W) in 2008 there were 686 recorded incidents of self-harm by girls in custody, and 743 by boys in custody. This compares with 430 and 434 incidents respectively in 2003.

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Once in custody, males aged between 14 to 20 are 18 times more prone to commit suicide than children of the same age in community. (FrĂźhwald, S., and Frottier, P., Suicide in prison, The Lancet, vol 366, issue 9493, 8 October 2005, as cited in Legal Action, February 2008). In fact, twenty-nine children under 18s have died in penal custody since 1990, most by self-inflicted death bar one following restraint (http:// www.inquest.org.uk/).

1.9. The general background of young offenders with mental health needs (individual, physical, social, cultural and socio-economic characteristics) There are various identifiable social factors that may be identified as contributing to the emergence of delinquent and antisocial behaviour in children and young people and which figure in almost all of the research undertaken with this age group (see Rose 2002: 28-34, Prison Reform Trust Report - Punishing Disadvantage). Although there is a wide range of factors that impinge on the healthy social, emotional and cognitive development of young offenders, those which might be deemed as having a particular impact on their mental health or indicate the possible emergence of mental illness include; early family trauma; mental illness in other family members; substance and alcohol abuse.

Whilst the following summary of research conclusions was written about young people in secure units, as has been shown previously the characteristics of young offenders in the community and in custody are similar: â&#x20AC;&#x2DC;These overviews and research summaries provide us with a picture of young people in secure units that makes for salutary reading. On the whole the units are dealing with young people who are likely to have had disrupted and disturbed experiences of family life from a very early age and many have been subject to various and often multiple forms of abuse by adults from whom they might have expected better. For a large number of these young people this has resulted in episodes of being in care, running away and fractured links with any form of stable home life. A significant number of the young people have had difficulties at school with both teachers and other children. This has resulted later on in either exclusion or truancy with the associated problems of having large amounts of unstructured time on their hands and contact with, or being influenced by antisocial peer groups. A high number have experimented with various forms of drugs or alcohol which in some cases means becoming dependent upon these substances. Many young people have long standing mental health problems and there are a significant number who have Attention Deficit Disorder. A high percentage have attempted self harm and / or had suicidal thoughts and many have attempted to act on these. Young people in secure units

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may present with one, some or all of these problems in any combination, with varying degrees of severity and differences in age of onset. There are also young people in secure units who have no such history and whose offence has been committed without any obvious antecedents or link to other known or associated factors. But what is clear is that by the time the overwhelming majority of young people come to secure units they have a personal history characterised by chaotic and disturbed developmental life experiences and relationships.’

(Rose 2002:33) Other socio-economic factors

‘It is widely recognised within the criminological research literature...that offending by children is strongly associated with various forms of disadvantage. These ‘risk factors’ for offending include disadvantages relating to: family life; the wider social environment in which children live; socio-economic status; experiences of and responses to education; and emotional and psychological needs and dispositions.’

(Prison Reform Trust - Punishing Disadvantage:47)

1.10. The family situation of the young offender suffering from a mental illness? What is the role of the family in the treatment to be carried out?

The lack of a stable family environment, poor early attachment experiences and other associated difficulties within family life, including adult family members with mental health problems or who are offenders, contribute greatly to the way in which children and young people in the process of growing up become enmeshed in the youth justice system.

In their work on identifying risk and protective factors related to young people’s involvement in offending behaviour, the Youth Justice Board highlight family conflict, low family income/poor housing and parental attitudes that condone antisocial behaviour, amongst the most common with regard to family life. (YJB 2005 Risk and Protective Factors) In their analysis of the rates of family disadvantage found in the sample of 200 sentenced young offenders and using the definitions taken from the core Asset form, the Prison Reform Trust found as a % factor of all the young people they studied: • Absent father (i.e. has lived apart from father for significant period of childhood; not solely through bereavement) - 76% • Living in deprived household (e.g. dependent on benefits) and/or unsuitable accommodation

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• • • • • • • • • • • • • • • • •

(e.g. overcrowded, lacks basic amenities) 51% Has ever run away or absconded 47% Ever on child protection register and/or has experienced abuse or neglect 39% Absent mother (i.e. has lived apart from mother for significant period of childhood; not solely through bereavement) 33% Has witnessed domestic violence 28% Ever accommodated in local authority care (through voluntary agreement by parents and/or care order) 27% Father/step-father involved in criminal activity 18% Sibling(s) involved in criminal activity 17% Chaotic or highly disorganised living arrangements 16% Large family size (at least five children in the family) 16% Parent with physical or mental health problems or learning disability 14% Mother/step-mother has misused drugs or alcohol 12% Is a parent him/herself or is pregnant 9% Father/step-father has misused drugs or alcohol 7% Bereavement – father 6% Bereavement – sibling(s) 4% Bereavement – mother 3% Mother/step-mother involved in criminal activity 3%

Overall it has been noted that 71% of children in custody have been involved with, or in the care of, social services before entering custody and that 75% of children in custody have lived with someone other than a parent at some time compared with only 1.5% of children in the general population. It has also been noted that there is a high occurrence of homelessness amongst young offenders with 40% of children in custody in England and Wales having previously had some experience of being homeless.

(Youth Justice Board, Accommodation needs and experiences, 2007, as cited in Legal Action, February 2008).

Experience of or witnessing domestic violence also features prominently in terms of the general background of young offenders in custody. Two out of five girls and one out of four boys in custody report suffering violence at home. One in three girls and one in 20 boys in prison report sexual abuse (Youth Justice Board, Accommodation needs and experiences, 2007, as cited in Legal Action, February 2008). One in 10 girls in custody self-reported that they had been paid for sex (Youth justice Board, Female health needs in young offender institutions, 2006, as cited in legal Action, February 2008).

According to the Youth justice Board “overall, female offenders had more mental health needs than males. Also, young offenders from ethnic minorities were found to have higher rates of post-traumatic stress.” (Youth justice Board for England and Wales 2005 – Mental

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Health Needs and Effectiveness of Provision for Young Offenders in Custody and in the Community, page 7)

1.11. Impact on the mental health of young offenders Throughout the research literature the lack of stability within the family unit recurs consistently as a key factor in the experience of young offenders. Viewed through the lens of risk, researchers have described the young offender as one who is ‘living in poverty while being deficient in confidence, social relationships, academic abilities, and parental support’ (Lerner & Galambos, 1998).

Whilst the “risk and protective factors work” makes clear links between family poverty, a history of mental illness in the family and having a parent or sibling in the criminal justice system and the mental health of a young person, whether this can then be linked to incidences of mental illness in an individual young person is another question and a much harder one to assess. The relationship between environmental factors and the specific onset of a mental illness is difficult to measure. It is evident that mental illness is not just experienced by people from poor or disadvantaged backgrounds. However, it is now clear that there is a strong relationship between early attachment experiences and healthy development, including the physical development of the infant brain.

Increasing knowledge about the neuro-science of brain development shows the vital contribution that quality parental nurturing of the infant makes to those processes essential for healthy growth. Whilst issues of poverty, housing, access to health services etc. have a bearing on a parent’s ability to care for their children, it is the relational aspects of their caring that is likely to have the longer term consequences in terms of the child’s development and growth.

1.12. The correlation between the misuse of drugs and behavioural disorders in young offenders. What are the age and prevalence patterns?

How prevalent is the co morbidity or co-occurrence of mental health disorders in juvenile delinquents?

According to a report by the Youth Justice Board in 2009, in a self questionnaire sample of 305 young people, 85% stated that they had used drugs at least one month before being arrested. 40% of this sample used heroin, crack or cocaine one month before being arrested. (YJB Substance Misuse and Juvenile Offenders).

‘The risk factors for youth offending and substance abuse overlap to a very large degree with those for educational underachievement, young parenthood, and adolescent mental health

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problems.’ (YJB 2005 Risk and Protective Factors).

However, in their report Substance use by young offenders: the impact of the normalisation of drug use in the early years of the 21st century (London: Home Office 2003) Richard Hammersley, Louise Marsland and Marie Reid from Department of Health and Human Sciences, University of Essex argue that ‘drug use has now become more common amongst young people, and is not necessarily coupled with the previously identified risk factors.’ Their study looked at drug use amongst 300 young people involved with the youth justice system with varying offending histories, (predominantly white males age 15 and 16, although females were represented proportionally to their appearance as YOT clients, and black and Asian ethnicities were deliberately over-represented.

Generally speaking, few characteristics of the cohort varied systematically with sex, age or ethnicity.).

The report states that the young people interviewed were amongst the most serious of young offenders and therefore their reported alcohol and drug use was likely to be higher than for the average young offender. Nevertheless the conclusions of the report are important in trying to ascertain the extent of drug and alcohol abuse within the population of young offenders.

Overall the research showed that the prevalence of drug use in the cohort was extremely high and included in the results were: • The self-reported prevalence of all drugs exceeded that reported in the Youth Lifestyles Survey and in the British Crime Survey 16 to 30 cohort (even without correcting for the fact that the present cohort are relatively young and would be expected to use drugs less than people in their 20s).

• However, the cohort contained relatively few heroin or crack cocaine users and use of these drugs was not generally that frequent. Instead, the cohort tended to use alcohol, cannabis and tobacco extensively, along with other drugs less often.

• There were signs of the ‘normalisation’ of drug use in that the cohort used a wider range of drugs, younger, than would have been the case 20 years ago.

Moreover, this diverse drug use did not indicate a progression or funnelling towards heroin or cocaine use. Instead, heavier users tended to use alcohol and cannabis frequently and other drugs occasionally.

• Drug use and offending in this cohort may represent a period of intense misbehaviour, which may or may not be temporary.

• There was no evidence in this cohort for two common media fallacies: that the age of first trying drugs has dropped (although progression to more serious substances has speeded up), and that heroin and cocaine dependence have become commonplace among people under 16.

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• There were only 13 drug injectors, who were disproportionately women, had experienced more life events and problems, less parental control and had lower self-esteem than the remainder of the cohort.

• Despite high prevalence of use, few of the cohort reported dependence and only 15 per cent were rated (by ASMA1) as at high risk of substance abuse problems.

However, 15 per cent is about 10 times the prevalence of high risk youth found in a large school survey.

In summary, current research would indicate that drug / alcohol use amongst young offenders is of a very high level and certainly greater than that in the normal adolescent population. Whilst as the University of Essex research shows it is important not to exaggerate the extent of drug / alcohol abuse (particularly the use of so-called ‘hard drugs’) the use of substances at such high levels clearly has an impact on the emotional and physical well being of these young people, often masking more serious mental health problems and contributing to the levels of antisocial behaviour and delinquency presented by them.

1.13. The special needs of minors in conflict with the law with mental health needs that are facing a custodial sentence According to the Centre for Mental Health, ‘Children who end up in custody are three times more likely to have mental health problems than those who do not. We also know they are very likely to have more than one mental health problem, to have a learning disability, to be dependent on drugs and alcohol and to have experienced a range of other challenges. Many of these needs go unrecognised and unmet.’ (http://www.centreformentalhealth.org.uk ) In a sample compiled by the Youth Justice Board the following conditions were identified:

Mental health need of offender

Percentage

Depression

20%

Self-harm (within last month)

10%

Anxiety and Post-Traumatic Stress 10% Disorder Hyperactivity

7%

Psychotic-like symptoms

5%

(YJB 2005 Mental Health Needs and Effectiveness of Provision for Young Offenders in Custody and in the Community) Staff working in secure settings have a particular responsibility for ensuring the safety and wellbeing of the young people in their care. As has already been demonstrated

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young offenders in custody are especially vulnerable whilst the impact of incarceration itself may add to the problems they are already experiencing.

‘Discussions about the mental health needs of young people in secure units usually focus on the issue of the insufficient numbers of forensic adolescent psychiatrists in post and the consequent difficulties in obtaining the necessary assessments, diagnoses and treatments that young people require. This is undoubtedly true and reflects a national problem which not only affects young people placed in secure accommodation but also young people in the community at large.’

‘There is an acknowledged national shortage of in-patient forensic beds for adolescents and consequently many of the young people who would more appropriately be looked after in hospital are having to be kept in secure units with staff who are not trained or equipped to provide the proper nursing care that they need. As with other aspects of service provision to secure units there are widespread differences in the level of services provided from area to area and in the arrangements for how these services are organised and managed.’

(Rose 2002:128) Although the issues about the recruitment and training of consultants in forensic work with adolescents are not going to be solved in the immediate future, there have been improvements made in recent years and which are discussed in the next section of this report.

‘In order for staff to be able to work positively and to develop an overall approach to a ‘healthy’ unit, definitions of mental health need to be more inclusive than just covering those young people who are seriously mentally ill, need to see a psychiatrist and may require transfer to hospital. The way mental health services are organised in secure units obviously requires oversight by a senior psychiatrist. Diagnosing mental illness in adolescents is notoriously difficult and often complicated by such factors as a young person’s drug and alcohol abuse. However, much of the day to day work can be undertaken by nursing staff working alongside prison officers or care staff whose training should include a basic introduction to the mental health needs of young people.

Although there is no question of residential staff undertaking assessments or making diagnoses we have already described how through their daily work with young people on a unit they can gather and collate important information about such things as mood swings, depression, general presentation and social behaviour. There is no doubt that the general atmosphere and climate on a unit contributes significantly to either promoting sound mental health and the general well-being of the young people who live there or it exacerbates the problems that they may already have and even creates new ones. For

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some young people the mental health problems they experience pre-date their admission to secure accommodation and may have been part of the reason for their offending and subsequent placement in a secure unit. Placement in a secure unit may serve to emphasise or highlight these problems and immediate treatment will be required. For others the experience of being locked up may make them feel depressed or anxious to the extent that they too will need specific help. The creation of a positive culture on a unit in which staff pay attention to the needs of the young people in their care, get to know them and in which everyone feels safe and secure goes a long way to alleviating lower levels of mental health problems and also provides a much better environment for the assessment and diagnosis of more serious problems.’‘ (Rose 2002:129)

1.14. The proportion of young offenders under therapeutical custodial measures The wording of the sub-heading belies the fact that there is no such order available in the youth justice system for England and Wales or indeed as part of any welfare provision for children and young people.

Young people involved in the youth justice system and brought before the courts are sentenced from the range of disposals available to the particular court and whilst there are responsibilities on the court to take into account the situation of the young person, the onus on the sentencer (magistrate or Judge) is to consider the criminal behaviour of the young person and to make a disposal proportionate to the offence.

In only a very few cases would a court consider a disposal to a hospital setting under mental health legislation for a young offender (under the age of 18 years) which reflects the reluctance of psychiatrists to make formal diagnoses of mental illness for this age group and also the scarcity of appropriate provision. Whilst the court may take into account any mitigating circumstances about the young person in passing a custodial sentence, it is not the court’s responsibility to identify the subsequent custodial placement. This is the responsibility of the Youth Justice Board Placements Section, who will take into account such factors as the home area of the young person, the length of sentence and availability of places.

The secure estate in England and Wales for young people aged 12- 18 years is made up of three different types of secure accommodation which offer varying levels of support and treatment across the sector. Although there are common regulatory and inspection regimes across the secure estate the size and nature of the institutions impact significantly on the quality of the regimes delivered.

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‘The creation by the prison service of a discrete juvenile estate carved out of the wider provision of Young Offender Institutions, (YOIs) along with the requirements for the delivery of a specific regime for 15-17 year olds is enshrined in Prison Service Order 4950. These establishments, of which there are currently 19 are generally large scale (300+) and housed in prison service accommodation. The majority of the establishments are for boys with separate and dedicated smaller facilities for older girls.

Whilst there has been a considerable spend on facilities designed for the younger population, notably in education and health care, much of the estate consists of older buildings not built with any explicit purpose other than to house a prison population.

The specific requirements that need to be considered, bearing in mind the needs of the young people pictured above, have not been generally addressed. With one or two exceptions these are Young Offender Institutions, often sharing a site and facilities with establishments for the older young offender population and remaining part of the prison service’s regional management structure. Despite attempts in recent years to develop alternative management for the juvenile estate they are now reincorporated into the general management arrangements that apply to all prisons.

Line management arrangements cannot therefore be specific to the circumstances relevant for the management of services for children and young people.’

(Rose 2009:25) The prison service has attempted to introduce specific units for the custody of more vulnerable and younger inmates. These units have higher staff ratios and have tried to develop regimes more reflective of good residential child care. Such units as the Carlford Unit, the Oswald Unit and more recently the Keppel Unit offer a more focused regime for vulnerable young people and are better resourced in terms of staffing, with higher ratios of prison officers and better access to education, psychology and health professionals.

‘The four Secure Training Centres, (STCs) are privately owned, built and run to specific contract specifications set out by the Youth Justice Board. They are smaller than the establishments within the prison service estate, ranging from 40 -80 places. The Centres provide places for both boys and girls and there is a dedicated unit for mothers and babies at one Centre.

The ownership of these Centres is highly complex and has changed over the years as a result of various mergers and takeovers amongst the larger companies of which the STCs are subsidiaries. The ‘parent’ companies have diverse service portfolios across a range of security, penal and related areas of work. The nature of the contract arrangements vary across the different STCs and the focus of external management is pretty much

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driven by the need to ensure compliance with the specific demands of the contract. As achieving compliance has financial implications in terms of possible penalties this plays a significant part in the prioritising of issues. ‘ (Rose 2009:26 ) Secure Training Centres are much better resourced than the YOIs for managing and treating the young offender population. They have access to good quality educational provisions and psychological services. They tend to look after the younger male offenders in custody (12-15 years) and girls up to the age of 17 years, although vulnerable older males may serve their sentence in an STC. ‘Local Authority Secure Children’s Homes (LASCHs) as these are now designated are in the main owned and managed by the individual local authority within which they are located. LASCHs are smaller in scale than the rest of the secure estate, usually between 16-32 places and are built to higher specifications. There are establishments for boys and girls and also single sex units. Line management arrangements for these units vary according to the particular structure of the managing authority. Although commonly located within the Children’s Services directorate the actual tier of management, at which both the line manager and the manager of the establishment sit, varies considerably. The external manager is likely to have broad responsibilities across the service and the very specific demands that arise in managing secure facilities are often difficult to balance with the more general demands of children’s service management. The situation is further complicated by the fact that secure children’s homes not only provide places for young people remanded or sentenced under criminal legislation but also accommodate those detained on welfare grounds under quite different conditions and for wholly different reasons.’

(Rose 2009:26) Placements in LASCHs are expensive and there have been several closures of these establishments in recent years thus reducing the availability of placements. The young offenders in these establishments are likely to be the youngest of the custodial population and the most vulnerable. These smaller units are able to offer more individualised care and provide a better environment for those suffering with mental health problems.

They are also likely to have better access to psychological and psychiatric services, but again this varies from location to location.

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2. LEGAL FRAMEWORK: PENAL AND CHILD CARE REGULATION 2.1. The current juvenile justice system in England and Wales The following extract is from the Youth Justice Board Brochure ‘the Youth Justice System Overview’ and despite recent changes with regard to the Youth Justice Board provides a comprehensive summary of the current arrangements for youth justice in England and Wales: ‘The youth justice system is ‘the laws, procedures and institutions which deal with those aged under 18 accused or convicted of crime in England and Wales’. It manages those who offend between the ages of 10 (the age of criminal responsibility) and 18 (the point at which they enter the adult criminal justice system). In 1996, the Audit Commission published the findings of an investigation into the way the youth justice system was operating. Misspent Youth: Young People and Crime described the system at the time as inefficient and ineffective. The report made a number of recommendations, and in 1998 the Crime and Disorder Act changed the face of the youth justice system in England and Wales, and stated its principal aim.

Aim of the youth justice system Section 37 of the 1998 Crime and Disorder Act states: ‘It shall be the principal aim of the youth justice system to prevent offending by children and young persons Objectives of the youth justice system In carrying out their roles and responsibilities, those working in the youth justice system have six key objectives: 1. The swift administration of justice, so that every young person accused of breaking the law has the matter resolved without delay.

2. Confronting young people with the consequences that their offending has for them, their family, their victims and the community, and helping them to develop a sense of responsibility.

3. Providing intervention that tackles the particular factors that put the young person at risk of offending, and that strengthens the aspects of their lives that protect them from offending.

4. Ensuring punishment is in proportion to the seriousness and persistence of the offending.

5. Encouraging young people to make reparation to their victims.

6. Reinforcing the responsibilities of parents The youth justice system in England and Wales is made up of the following

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organisations, which work together to administer justice and to help every young person involved with the system to live a life free from crime and anti-social behaviour: • The Youth Justice Board for England and Wales (YJB) • Youth Offending Teams (YOTs) • Police and the Crown Prosecution Service • Courts • Secure Estate for children and young people (Youth Justice Board Brochure, The System We Oversee)

2.2. The Youth Justice Board The Youth Justice Board (YJB) was established under the Crime and Disorder Act 1998, and its role has been to oversee the youth justice system for England and Wales.

Following a change of government in 2010, it has been announced that the YJB will be disbanded as an independent Non Government Organisation (NGO) and its functions assimilated into the Ministry of Justice.

The focus of the YJB’s work has been clearly targeted on the prevention of offending and reoffending by children and young people under the age of 18, and ensuring that custody for them was safe, secure and addressed the causes of their offending behaviour. Initially the Board reported to the Home Secretary, later the Minister for Justice, with responsibility for: • Advising on the operation of, and standards for, the youth justice system • Monitoring the performance of the youth justice system • purchasing places for, and placing children and young people remanded or sentenced to custody • Identifying and promoting effective practice • Making grants to local authorities or other bodies to support the development of effective practice • Commissioning research and publishing information.

Although its main line of responsibility and accountability was to the Home Office (later the Ministry of Justice) throughout its existence the YJB has sought to work collaboratively with other central government departments with responsibility for children and young people, primarily the Department for Children, Schools and Families, (DCSF), now rebadged as the Department of Education. To some extent, this collaborative approach has ensured consistency in central government policy and promoted cooperation at a local level between agencies within the youth justice system,

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primarily the Youth Offending Teams, and other childrenâ&#x20AC;&#x2122;s services with statutory responsibilities for education, health and social care.

However, having separate central government departments with responsibility for youth justice and what may broadly be described as the welfare needs of children and young people, reflects a profound disjunction in the way in which the needs of young people are viewed at the level of central policy making and how they are therefore able to be addressed in practice at a local level.

As part of the provision of the Crime and Disorder Act 1998 Youth Offending Teams (YOTs) were established as multi-agency teams in each local authority area. The statutory membership of these teams originally included education and health services along with social services, police and probation. However, these teams were made accountable to the Chief Executive of the local authority rather than being located within one of the major departments responsible for childrenâ&#x20AC;&#x2122;s services. So, whilst the main agencies are represented within YOTs there were, and still are, difficulties in achieving well coordinated services and responses to individual cases, with the quality of service often being determined by the experience and skills of individual personnel attached to the YOT and good working relationships established at a local level (see Harrington and Bailey). For example, the health workers in a YOT are not necessarily specialists in children and adolescents nor do they necessarily have any relevant forensic experience. As will be discussed later, this clearly has implications for services to young people with mental health needs.

Much of the research previously referred to in this report includes reference to the problems of achieving inter-agency collaboration and poor information sharing. The research also shows the failure of agencies to provide well coordinated services to children and young people in general and specifically to young people involved in the youth justice system who find it difficult to gain access to wider services, including health, housing, health and education.

2.3. Prevention A young personâ&#x20AC;&#x2122;s involvement in the youth justice system does not necessarily begin with a court appearance and a formal disposal. The YJB have been keen to introduce a number of schemes intended to divert young people away from further involvement in the criminal justice system. A Reprimand is a formal verbal warning given by a police officer to a young person who admits they are guilty of a minor first offence. In these cases, a young person can be referred to the local YOT to take part in a voluntary programme to help them address their offending behaviour. A Final Warning is a formal

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verbal warning given by a police officer to a young person who admits their guilt for a first or second offence. Unlike a Reprimand, however, the young person is also assessed to determine the causes of their offending behaviour and a programme of activities is identified to address them.

2.4. Community Sentencing The Youth Rehabilitation Order (YRO) is a relatively new generic community sentence for children and young people who offend. The YRO came into effect on 30 November 2009 as part of the Criminal Justice and Immigration Act 2008. Replacing nine existing sentences, it combines 18 requirements into one generic sentence. Having 18 requirements within one Order is intended to simplify sentencing, providing clarity and coherence while improving the flexibility of interventions.

The YRO also allows plenty of opportunity for reparation to be included, giving scope for victims’ needs to be addressed.

Additionally, the YRO puts Intensive Supervision and Surveillance and Intensive Fostering on a statutory footing. This is intended to help encourage sentencers to use what are described by the YJB as ‘robust alternatives to custody where they are available.’ To promote community sentencing, sentencers must now provide a reason if they do not use an alternative to custody for those young people who are on the custody threshold.

A number of requirements can be attached to an YRO, thus increasing the number and types of interventions available for the YOT to include in a programme for a young person.

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The following requirements can be attached to an YRO: •

Activity Requirement

•

Supervision Requirement

•

Curfew Requirement

•

•

Exclusion Requirement

Electronic Monitoring Requirement

•

Local Authority Residence Requirement

•

Prohibited Activity Requirement

•

Drug Treatment Requirement

•

Education Requirement

•

Residence Requirement

•

Mental Health Treatment Requirement

•

Programme Requirement

•

Attendance Centre Requirement

•

Intensive Supervision and Surveillance (based on the current ISSP)

•

Intensive Fostering

•

Unpaid Work Requirement (16/17 years)

•

Drug Testing Requirement

•

Intoxicating Substance Treatment Requirement

As may be seen from the above list there may be a requirement for mental health and drugs treatment to be undertaken with the possibility of a breach order if this is not complied with by the young person. The YRO may be offered at the level where custody is being considered as an option by the courts, so if breached the consequences for a young person may entail a custodial sentence.

2.5. Custodial Sentencing Young people may be sentenced to a period of custody under two orders: The Detention and Training Order (DTO) was introduced as part of the Crime and Disorder Act 1998 and is applicable to young people aged 12- to 17-years. The length of the sentence is between four months and two years. The first half of the sentence is spent in custody while the second half is spent in the community under the supervision of the local YOT. The court can require the young person to be on an Intensive Supervision and Surveillance Programme (ISSP) as a condition of the community period of the sentence.

A DTO is only given by the courts to young people who represent a high level of risk, have a significant offending history or are persistent offenders and where no other sentence will manage their risks effectively. The seriousness of the offence is always taken into account when a young person is sentenced to a DTO.

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Section 90/91 refers to sections of the Powers of the Criminal Courts (Sentencing) Act 2000 and is intended for young people (aged 10-17 years) convicted of an offence for which an adult could receive at least 14 years in custody. This sentence can only be given in the Crown Court.

2.6. Section 90 If the conviction is for murder, the sentence falls under Section 90 of the 2000 and is termed “Detention at Her Majesty’s Pleasure” and a mandatory life sentence will apply.

The sentencing court will set a minimum term (also known as the tariff) to be spent in custody, after which the young person can apply to the Parole Board for release.

The Secretary of State’s directions to the Parole Board (issued August 2004) set out the assessment criteria for the release of those serving a life sentence. Once released, the young person will be subject to a supervisory licence for an indefinite period.

2.7. Section 91 If a young person is convicted of an offence for which an adult could receive at least 14 years in custody, they may be sentenced under Section 91 of the 2000 Act. The length of the sentence can be anywhere up to the adult maximum for the same offence, which for certain offences may be life.

A young person given a Section 91 sentence is placed in custody. If the sentence is 4 years or less the young person, is released automatically at the halfway point and could be released up to a maximum of 135 days early on the Home Detention Curfew (HDC) scheme. Young people sentenced to over 4 years are eligible for a Parole Board Hearing at the half-way point of their sentence and may be released at this stage.

Once released, the young person is subject to: •

a supervisory licence until their sentence expires, if the sentence is 12 months or more • a Notice of Supervision for a minimum of three months, if their sentence is less than 12 months.

Custodial sentences may be spent in one of the three types of secure accommodation as described previously in this report.

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2.8. The specific childcare system / civil law concerning children with mental health problems Apart from the requirements detailed above as conditions of an YRO, there is no specific mental health legislation for children and young people. The main legislation for children and young people remains the Children Act 1989, although there have been several subsequent pieces of legislation that have strengthened various aspects of the original 1989 legislation. Through the process of case law (the so-called Munby judgement) it has been established that the Children Act 1989 applies to children (anyone under the age of 18) who are in custody. This means that the duties imposed on local authorities to safeguard and promote the welfare of children in need and to make enquiries in cases where it is suspected that a child is suffering or is likely to suffer significant harm, apply to these children. The Children Act 2004 specifically requires the Governor of a YOI or Secure Training Centre to ensure that they discharge their functions having regard to the need to safeguard and promote the welfare of children (section 11). Children and young people placed in a local authority secure children’s home also come under this legislation.

2.9. The Mental Health Act 2007 The Mental Health Act 2007 is currently the substantive legislation for mental health and introduces a number of significant amendments to the original 1983 Mental Health Act including the prevention of children from being admitted inappropriately to adult wards.

The 1983 Act includes provision for people suffering from a mental disorder (defined in the Act as ‘any disorder or disability of the mind’ and in court charged with a criminal offence liable for a custodial sentence to be remanded to a hospital setting for reports (Section 35) or for treatment (Section 36).

Section 37 provides Powers of courts to order hospital admission or guardianship in the following circumstances: ‘(1) Where a person is convicted before the Crown Court of an offence punishable with imprisonment other than an offence the sentence for which is fixed by law [. . .. . .], or is convicted by a magistrates’ court of an offence punishable on summary conviction with imprisonment, and the conditions mentioned in subsection (2) below are satisfied, the court may by order authorise his admission

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to and detention in such hospital as may be specified in the order or, as the case may be, place him under the guardianship of a local social services authority or of such other person approved by a local social services authority as may be so specified.’

Sections 47 and 48 of the Act make provision for transfer between prison establishments, including YOIs, in the circumstances that, ‘(a) that the said person is suffering from mental disorder; and (b) that the mental disorder from which that person is suffering is of a nature or degree which makes it appropriate for him to be detained in a hospital for medical treatment; and (c) that appropriate medical treatment is available for him. ‘ Although the YJB have developed a protocol for effecting the above placements and transfers in their Case Management Guidelines, they do not provide statistics on how often this legislation is used and their monthly reporting on the numbers of young people in custody does not include young people placed in secure hospital settings.

The extent to which these provisions are used for young offenders under the age of 18 years is clearly very low and it is significant that like those of the YJB the statistics, provided by the Department of Health regarding the use of the Sections of the Act identified above do not include the age of the people concerned. The reasons for this are likely to include problems of ensuring early assessment when a young person becomes involved in the youth justice system; difficulties in making diagnoses for this population; lack of suitable provision and the relatively short periods of time spent in custody by the majority of young offenders who are sentenced under the Detention and Training Order.

There is, however, still something of an anomaly in a situation where large numbers of young people in custody have formal diagnoses of mental illness but only a handful receives treatment in a hospital setting. It is a challenge to those working in the youth justice system to consider how or whether mental health legislation could be used more effectively to achieve more appropriate placements for young people with mental health problems. To achieve this shift in thinking would require a paradigm change in the way in which government and society as a whole regards young offenders and organises services to address their needs in collaboration with universal children’s services, such as health and education. It is still the case that young offenders are responded to primarily in terms of their offending behaviour rather than in the wider context as children in need.

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The promotion of children’s mental health and emotional wellbeing has been a strong element in government policy in recent years and there have been a number of initiatives to support this including the development of national Child and Adolescent Mental Health Services, (CAMHS). CAMHS are intended to provide high quality, multidisciplinary mental health services to all children and young people with mental health problems and disorders to ensure effective assessment, treatment and support for them and their families.

The remit for CAMHS includes children and young people involved in the youth justice system, however, the extent to which CAMHS are involved with local YOTs is highly variable as is the level of service provided by CAMHS to the secure estate.

Harrington and Bailey (2005) found in their research that within YOT teams the ‘Health workers with mental health training were valuable in the assessment and management of young offenders with mental health problems. However, they were at risk of being overwhelmed and unsupported, and few health workers had any clinical supervision from mental health services, although those who did found it valuable.’

(Harrington and Bailey 2005) And also that ‘From the geographically disparate sites included in the study, the perception of those interviewed was that provision of mental health services across the country was variable and often influenced by local factors – reasons included lack of resources and funding as the main obstacles to provision. There were few examples of regular opportunities for consultation liaison between YOTs and CAMHS. There was some evidence of joint working between YOT health workers and CAMHs, but this tended to be informal and based on individual cases. Many CAMHS professionals were concerned about the impact that the referral of young offenders with mental health problems would have on a service that is already overstretched and struggling to provide a service for those on their waiting list.

A CAMHS worker described the predicament faced by many within CAMHS concerning the impact that young offenders with mental health problems may have on their service.’

Across the secure estate Harrington and Bailey found ‘There were considerable differences in the models of mental health provision in secure establishments compared with YOTs. In many secure estate establishments, mental health provision was provided on a sessional basis by mental health professionals who had a personal interest in the area. Subsequently, continuing provision was vulnerable to changes in personnel and priorities. Unlike community CAMHS, multi-disciplinary input

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was rare. However, secure estate establishments with multi-disciplinary mental health teams reported comparatively high levels of well co-ordinated input to young people. One YOI had implemented a multi-disciplinary ‘in-reach’ mental health service, following extensive discussion between the YOI and local CAMHS. The service is based in the YOI, and has links with staff at operational and strategic levels.’

(Harrington and Bailey 2005) Subsequent to Harrington and Bailey’s work in 2005, the Department of Health commissioned a report from the Centre for Mental Health to review the provision of mental health services for young people in YOIs, particularly in the light of the additional funding that had been made available for this purpose. The report entitled Reaching out, reaching in: Promoting mental health and emotional well-being in secure settings (2010) concludes that whilst improvements have been made, many of the issues raised by Harrington and Bailey still apply, notably the variable levels of service available to the secure estate and the difficulty of embedding a culture that recognises the importance of promoting and supporting the wellbeing of children and young people in custody: ‘The introduction of specific funding to support CAMHS in-reach services in young offenders institutions has resulted in notable improvements in YOIs. We found evidence that young people with evident mental health difficulties are identified, assessed and supported much more quickly, whether directly within the secure settings or through liaison with multidisciplinary community-based services. Workers have made significant and energetic progress, despite a lack of guidance on appropriate services and systems for children and young people.

However, looking across the entire young people’s secure estate, we found that the additional funding for YOIs had served to highlight and exacerbate existing inequalities and inconsistencies in provision. We found a number of persistent challenges to the achievements of mental health teams and practitioners, including cultural barriers to developing an integrated, ‘whole unit approach’ in which the mental health and emotional well-being of young people who offend (and who have well documented vulnerabilities) are prioritised and considered ‘everybody’s business’.

We found evidence of practices in secure regimes that compromise rather than support the emotional well-being of young people in custody; a predominantly reactive approach to mental health problems rather than an early intervention and proactive approach to supporting mental health and well-being; variations in commissioning expertise and interest throughout the entire young people’s secure estate and across primary and secondary care; fragmentation in the provision of comprehensive CAMHS services; problems with access to sufficiently intensive support services at the point of resettlement;

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problems more generally with continuity of care, and underdeveloped work with particular groups of young people who offend. ‘ (Reaching out – reaching in 2010) However, the report is clear that the additional funding (£1.5 million) and the development of the CAMHS in-reach teams to YOIs has improved mental health services in terms of screening and assessment of needs, although there still remain problems in effecting transfer of young people to health service psychiatric facilities as noted above: ‘Many of those interviewed in YOIs felt that the introduction of the new in-reach teams had resulted in significant changes both in the awareness of mental health issues and in the delivery of treatment in these settings. One forensic child and adolescent consultant psychiatrist described witnessing “dramatic improvements” in the way mental health was managed in the unit.’

‘Staff felt that moderate to severe mental health difficulties were much more likely to be picked up and acted on following the introduction of the mental health in-reach teams.These teams said they were able to identify young people needing very specialist assessments within days of their arrival and were able to initiate assessments for transfer to medium secure psychiatric units much more quickly than previously. It should be noted, however, that this transfer was very rarely possible within the 14 days recommended for adults in the Bradley review (Department of Health 2009)’ (Reaching out – reaching in 2010)

2.10.

Are young people with mental health problems penally responsible? If yes, are they in charge of the care or criminal system? If not, do they receive any legal and therapeutic assistance?

In England and Wales the age of criminal responsibility is 10 years of age. Although youth justice services may be involved with children under the age of 10 years in one of a number of preventative schemes organised on a local basis, for these younger children the onus for identifying need and providing services lies with local authority Children Services Departments including education and social care and with the relevant Child and Adolescent Mental Health Service as part of the local health provision.

2.11. Doli Incapax Doli Incapax was the doctrine that there was a rebuttable presumption that a child aged

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between 10 and 14 years could not form the necessary criminal intent. This was abolished for offences committed on or after 30 September 1998 by Section 34 and paragraph 1 of schedule 9 of the Crime and Disorder Act 1998. This has subsequently been established in case law and means that young people over the age of 10 years can be assumed to have responsibility for their behaviour including acts of a criminal nature.

In England and Wales, fitness to plead is the capacity of a defendant in criminal proceedings to comprehend the course of those proceedings, although there is no particular provision made for children and young people appearing in court. If the issue of fitness to plead is raised, a judge is able to find a person unfit to plead. This is usually done based on information following a psychiatric evaluation. There is a dearth of research into fitness to plead in the UK, with no prospective studies and no studies involving the comparison of fit and unfit subjects. In particular, there have been no investigations into the meaning of ‘unfit to plead’ in terms of psychiatric symptomatology, or as to the relative importance of each legal fitness criterion in psychiatrists’ conclusions as to fitness. An appraisal of the use of the legal test for fitness to plead in England found that 40% of psychiatric court reports did not mention fitness to plead at all, and that only a third made a statement about fitness to plead that was supported by reference to the legal criteria.

As with the legislation concerning Hospital Orders and transfer from secure settings to more appropriate health care facilities, there is a challenge as to why the ‘unfit to plead’ option is not used more often, particularly bearing in mind the numbers of young offenders with identifiable learning disabilities. Again there are similar contributing factors of which, in this instance, the failure to complete a comprehensive early assessment by staff with sufficient knowledge and skill is at the forefront.

2.12. Does a specific legislation exist concerning young offenders with mental health needs?

As detailed above there is no specific legislation of the type suggested by the question.

See previous reference to the Mental Health Act 2007 and the Children Act 1989.

2.13. Which ethical principles and practices must be followed by the justice and health systems to protect the best interests of the child?

What are the main ethical aspects that have arisen in your country?

In Section 1 of the Children Act 1989, it is stated that when a court determines any question concerning a child’s upbringing the child’s welfare shall be paramount. This

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is the determining factor in all decisions taken by the court and should be the guiding principle of all assessment and intervention programmes drawn up by statutory agencies engaged with children, young people and their families.

However, the legislation under which a court sentences a young offender, whether considering either a community or custodial disposal does not reflect the same priority. Whilst reports presented to the court regarding a young person may well make reference to factors in their life that have influenced their offending, the decision of the court at the point of disposal is more weighted towards a proportionate sentence vis a vis the offence and the importance of public safety, than taking into account the personal circumstances of the young person.

2.14. Are there any institutions, with involvement in court proceedings or otherwise, that are entrusted with the protection of minors (e.g.

Children’s Ombudspersons, duties assigned to Public Prosecution Services in this respect?)

If a child or young person is appearing in court proceedings where the issues are to do with their welfare, e.g. care proceedings, there may be a number of agencies involved including the Children and Family Court Advisory and Support Service (CAFCASS).

This service was set up on 1st April 2001 under the provisions of the Criminal Justice and Court Services Act which brought together the family court services previously provided by the Family Court Welfare Service, the Guardian ad Litem Service and the Children’s Division of the Official Solicitor’s Office.

CAFCASS is independent of the courts, social services, education and health authorities and all similar agencies and its role is to: •

safeguard and promote the welfare of children

•

give advice to the family courts

•

make provision for children to be represented

•

provide information, advice and support to children and their families.

Other agencies will also of course be represented in court including the local authority social worker and any other relevant personnel from the statutory services.

There is no such similar service provided for young offenders in court where outside of their own legal representative the main agency likely to be involved on behalf of a young person is the YOT represented by their designated YOT worker.

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There will, of course, be the useful array of legal staff present in court and other expert professionals, including psychiatrists, may be involved if the case is particularly complex or serious.

3. PROFESSIONAL ROLE AND SKILLS DEVELOPMENT 3.1. Levels of co-operation between the different staff that are in contact with the minor in conflict with the law (judge, psychologist, psychiatrist, social worker, teacher, etc)? Is there any specific principle on professional cooperation?

Almost all of the independent research reports in this area identify lack of professional cooperation and inadequate information sharing as problematic for the development of coherent services for young offenders and recommend the need for better communication between the different professionals involved in their assessment and intervention programmes. This issue is relevant not only with regard to the situation of young offenders but extends all aspects of work with children, young people and families. This report has already indicated some of the reasons for the problem, i.e. in having different government departments with responsibility for children and young people and how this plays out at a local level. Although there are structural and organisational reasons why cooperation between professionals may be difficult to achieve, there are other factors to be considered as well.

One of the notable features of the youth justice system in England and Wales is a lack of a coherent theoretical model for understanding the needs of the children and young people involved in the system and this has implications for the way in which mental health is viewed in this context. As indicated in Part A and Part B of this report, the youth justice system is constructed with an emphasis on antisocial and offending behaviour by young people and the need to control and change this behaviour in the context of demonstrating that public protection is secured and proportionate punishment administered. In social care, education and health services (the ‘welfare’ systems) the priority as set out in the 1989 Children Act is that all decisions should be taken in the ‘best interests of the child’. There is an immediate and obvious disjunction between these systems that is exacerbated by a professional culture that is over-bureaucratic and within which control prevails over welfare, regulation prevails over professional judgment and protocol prevails over process. This has implications not only for individual workers in all agencies but also for the way in which whole organisations set out their priorities and values. In How Nurture Protects Children (2010), Jim Rose writes: ‘Professional activity in social care, education, youth justice and health services has been

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dominated for a number of years by policy directives that require copious forms to be completed, papers to be filed, boxes to be ticked, targets to be achieved and reports to be written. The latter usually in a formulaic style, with their conclusions already prescribed and sometimes even with helpful, prepared phrases ready for cutting and pasting.’

‘Even with the supposedly more sophisticated systems, where paper forms are replaced by electronic recording, the problems remain the same. For if – according to Adam Gopnik (2009), with reference to the eighteenth-century astronomer William Herschel – ‘science is a collection of stories about facts, not a mere collection of data dumps,’ then we have some way to go before our systems and evidence-based approaches help professional workers avoid simply dumping data into endless bundles of electronic forms, and instead help them connect the facts before them with the stories behind them. Along with the demands made on all professional groups to be overly exercised about procedure and protocols, increasing constraints are being placed on the use of previously accepted concepts, such as professional judgement and the use of discretion in making decisions.

Short-term outcomes are the order of the day, with a requirement for focused pieces of work that can be written off and added to the list of jobs ‘done’ and performance measures achieved. The rationale for much of this is shrouded in the perceived importance of evidence-based approaches and a reliance on quasi-scientific methodologies to justify short-term interventions that also, conveniently, meet the need for being cost effective. ‘ (Rose 2010:1) The consequences of this are considerable and contribute to the difficulties in establishing effective inter-agency cooperation, as workers’ priorities become focused on the administrative tasks required for demonstrating ‘performance’ and ‘output,’ rather than being encouraged and supported to think about the meaning of the data they are processing with opportunities to process and share this thinking with other professionals. The reports of the enquiries that have followed the tragic deaths of children expose serious weaknesses in the safeguarding systems designed to protect vulnerable children including the failure of workers from different agencies to share information and the way in which vital pieces of information are not brought together or woven into a continuing narrative account of evolving events, (Laming 2003).

The youth justice system in England Wales is awash with protocols, procedures and guidelines. However, the absence of a coherent model for an understanding of child development that recognises the importance of attachment and a professional culture that allows little space for thinking about the meaning of presenting behaviour rather than just making arbitrary responses to it, makes it hard for youth justice workers to sustain productive conversations with professionals from other agencies and disciplines.

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3.2. Examples of joint working There are examples of good collaborative work between professionals from different agencies and it is clear that where this is achieved there are considerable benefits for young people and especially for those with mental health needs. Improvements have been achieved across the secure estate with the establishment of the ‘in-reach services to YOIs (Lorraine Khan, Reaching out, reaching in: Promoting mental health and emotional well-being in secure settings Centre for Mental Health 2010).

‘The introduction of specific funding to support CAMHS in-reach services in young offenders institutions has resulted in notable improvements in YOIs. We found evidence that young people with evident mental health difficulties are identified, assessed and supported much more quickly, whether directly within the secure settings or through liaison with multidisciplinary community-based services. Workers have made significant and energetic progress, despite a lack of guidance on appropriate services and systems for children and young people.’

(Khan 2010:66)

Although there are clearly difficulties in developing services for young offenders with mental health problems in secure settings, the research indicates that given an appropriate level of resource and a management culture that supports the development of collaborative working across professional disciplines, it is possible within a secure establishment to implement strategies for screening and assessment and to support front-line staff in the day-to-day care and management of young people presenting with mental health needs.

Harrington and Bailey (2005), however, identified a series of problems in community settings with young offenders presenting with mental health needs: ‘Child and adolescent mental health services (CAMHS) were patchy and variable. The perceived reasons for this included lack of resources and funding being the primary obstacle to provision. There were few examples of formal and regular opportunities for consultation between YOTs and CAMHS.’ (Harrington and Bailey, 2005:5) They also found that: ‘Health workers were highly valued within YOTs when they were in post. However, their experience in mental health was variable and likely to have an impact on service delivery.’

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And also that ‘Few health workers had any clinical supervision from mental health services – although those that did found this valuable.’

(Harrington and Bailey 2005:5) These conclusions are supported by the Health Care Commission report Actions Speak Louder (2009): ‘We found that the nature and quality of initial health assessments, both in prevention work and in relation to those who have offended, were too frequently inadequate.

Health staff have not provided people who work in YOTs with sufficient training and updates to enable them to carry out timely, consistent and accurate initial assessments.

This can prevent children and young people from being referred to health specialists for further assessment, which means that their needs remain unmet. Even when the YOT made a referral, we found that specialist services did not always respond and provide the requested assessments. We did find examples of good assessments, referrals and appropriate interventions taking place, but they were not sufficiently widespread.’

(Actions Speak Louder 2009:3) One of the ongoing problems in this area remains the problems facing young people on their release from custody (see Harrington and Bailey). Achieving continuity of care is vital if young people with mental health needs are to receive appropriate care and treatment in the community on their release from custody. It has been a stated priority of the Youth Justice Board to ensure agencies address the issue of resettlement through a more coordinated and seamless approach to case planning and sentence management. In the National Children’s Bureau report, Managing Transitions from Secure Settings (2009), Di Hart summarised as follows the key messages of the study: ‘✦ It is difficult to engage services from the young person’s home local authority in transition planning from secure settings for young offenders. Even where they are engaged, there appears to be an inability to commit to firm plans until the last minute. ✦ Expectations about the purpose of the young person’s time in a secure setting are not usually made explicit. The secure settings develop a sound knowledge of the young people and the approaches that are helpful to them, but these are not fully utilised within the current planning arrangements. ✦ Young people have multiple assessments and plans that are not effectively joined up, such as an establishment care plan, LAC plan, remand or sentence plan, and they tend to be more service- than needs-led. ✦ The transition for young people serving sentences is obstructed by the difficulty of arranging external visits, whereas young people in welfare placements can have a

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mobility plan that helps to prepare them for release. ✦ There is a significant gap in mechanisms for preparing young people for transition to another secure setting, such as an STC or YOI. These moves may be sudden, unplanned and based on population pressures rather than the young person’s needs. ✦ There is a gap in the facilities that are there to help prepare young people – both practically and psychologically – for moving from a secure to an open setting, and an identified need for a phased approach. ✦ Considerable demands are placed on young people immediately after their release when they are likely to be struggling with the psychological effects of deinstitutionalisation. ✦ Although there are clear consequences for young people who do not comply with the plan made for them on their release (in that large numbers are ‘breached’), there are no parallel mechanisms for holding agencies to account when services are deficient. ✦ The importance of relationships with family and practitioners is insufficiently recognised in the plans that are made for young people in secure settings. Relationships are fractured at a time when young people are at their most vulnerable, and some of this could be avoided. ✦ The quality of the interactions between practitioners and young people is also important, including the ability to convey a sense that the young person is valued and can succeed.

(Managing Transitions 2009:24)

It is interesting to note that as well as identifying structural problems in the organisation of post-release support for young people Hart recognises the importance of maintaining continuity in the relationships these young people have with family members and other significant adults , prior to, during and after the period of custody.

The Health Care Commission report Actions Speak Louder (2009) also identified problems in transitions affecting young people with mental health problems although services for young people with substance abuse issues had improved. They found ‘problems relating to when young people transfer between the community and custodial settings. Staff in the two settings were not routinely exchanging information, and their lack of contact often meant that they were unable to engage appropriately with young people at points of transition. However, our inspections found that individuals who misused substances received better support than before, particularly from teams who provide resettlement and aftercare services.’

(Actions Speak Louder 2009:3) The current situation is that there is no legislative or policy requirement to provide anything for young people leaving custody other than what may be specified in their licence or in the community based section of their Detention and Training Order. The

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Final Sentence Review is intended to identify areas to be covered on release, but there is no mandatory requirement to ensure that the young person receives things such as a mental health referral or treatment continuity. The Centre for Mental Health says: ‘The care programme approach is a system of case management for those with mental health difficulties to promote continuity of care and resettlement. It is poorly understood and currently underused to promote care and speedy access to services on release’ (Reaching in, reaching out 2010] A final element to be considered with regard to issues of transitions for young offenders is the transfer between child and adolescent mental health services and adult services.

Young offenders at the age of 17 years are still the responsibility of youth justice agencies.

Affecting a smooth transfer from child and adolescent services to adult mental health services is a general problem but the transition can be particularly problematic in forensic services.

3.3. About children and young offenders’ data / info, how is it handled?

What about regulations on professional confidentiality?

All data collected by the Youth Justice Board is covered by the Data Protection Act. The following principles for collecting this information must be abided by; • All information must be obtained and processed fairly and lawfully • held for the lawful purpose described in the registration • used only for those purposes, and disclosed only to appropriate people • adequate, relevant and not excessive in relation to the purpose for which they are held • accurate and where necessary, kept up-to-date • held no longer than is necessary • accessible to the individual concerned who, where appropriate, has the right to have information about themselves corrected or erased properly • safeguarded (http://www.yjb.gov.uk/en-gb/practitioners/Prevention/Mentoring/Mentoringmanagementguidance/ SettingUpaProject/Policies+and+Procedures/Confidentiality/ )

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The issue of professional confidentiality may become a barrier when it comes to interagency working (e.g. between YOTs and CAMHS), and is not always in the best interest of the child. Good working relationships between agencies at a local level certainly helps matters, but there still needs to be clearer guidelines on this matter rather than a reliance on local arrangements and ‘good will’.

The degree to which confidentiality may compromise the care of a young person was highlighted by a number of interviewees in a Youth Justice Board report: ‘Confidentiality issues come up again and again. As an agency, we need to spell out what we mean by confidentiality, and how it benefits the customer when there could well be mental health needs that are not being identified. Do we just give ourselves an easy time by hiding behind that? That would be my worry. It feels that, with confidentiality, a polarisation takes place, and it’s moving us from our position of comfort into one where you are confronted with situations that you’re not familiar with; some can then say: ‘It’s nothing to do with me, confidentiality.’ End of story. (http://www.yjb.gov.uk/publications/Resources/Downloads/MentalHealthNeedsfull.pdf)

In this context, there is also a continuing problem arising from the existence of both formal and informal professional hierarchies and the bearing that this can have on information sharing and decision making. It is still the case that certain categories of staff are regarded as less important in the case work process than others and whose views are less likely to influence decision making. This is the case with all categories of residential staff (including prison officers) and foster carers despite these professionals being more closely involved with young offenders than other professionals whose contact with young people is usually on an appointment or sessional basis.

The screening processes for young offenders are detailed in following sections of this report. However, completion of these screening interview schedules can only be completed with the cooperation and consent of the young person. The YJB guidelines contain the following points on confidentiality to be borne in mind by workers completing the interviews: • Clear statements need to be made about who has access to information and where information is recorded.

• Explain that information obtained will not be used against the young person in any way, and forms part of the health assessment as part of the multidisciplinary assessments within the YOT or secure setting.

• Clarify that you are required to share information if a young person is at risk to themselves or others or if they are at risk of abuse by others.

• Information may also need to be shared if the young person becomes subject to

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a formal assessment under the Mental Health Act. The YJB guidance recognises that it is important that each young person is given the opportunity to discuss all issues raised by the Screening Tool. It should be made clear to them that they are not required to disclose any information that they do not want to discuss during the screening interviews.

A young person can opt out of the The Mental Health Screening Interview for Adolescents (SIFA); a detailed interview to be completed by YOT health staff, at any time if they decide they do not want to participate. While it is preferable that the screening process is completed to enable the best decision on the most appropriate support package and/ or referral to be made, in all cases the decision to put in place appropriate services is not dependant on a completed interview. The best interests of the young person should be paramount at all times during the screening process. In terms of good practice and information sharing reference should be made to the following documents for further information: •

YJB and Department of Health joint best practice guidance When to share information

•

The Nacro good practice guide: The YOT Health Practitioner: Identifying and sharing good mental practice

3.4. What kind of specialized training is received by juvenile justice and health professionals who are in contact with mentally ill young offenders in your country?

The Youth Justice Board during the course of its existence has worked to develop a comprehensive training programme relevant to all staff working in youth justice. These training programmes have been developed alongside the more general reforms of training for all staff working with children and young people overseen by the Children’s Workforce Development Council with an emphasis on the youth justice system and the needs of young offenders and in the framework of what is described as a Youth Justice National Qualification Framework which aims to: •

promote practice proven to be effective in reducing youth offending

•

be flexible, straightforward and accessible

•

be aligned with the common core and Youth Justice national occupational standards

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•

be comprehensive and contributes to the recruitment and retention of youth justice workers

•

support the continuing development of effective practice skills across the youth justice sector.

Much of this training is system focused rather than on direct work with children and young people. In YOTs there is an expectation of staff being qualified in their own professional discipline, i.e. social work, education, nursing or psychology although none of these initial training qualifications will necessarily include consideration of the mental health needs of young offenders.

Allied to this overall scheme for training staff in the youth justice sector is specific training for staff working in the secure estate. The Juvenile Awareness Staff Programme (JASP) is intended to address a lack of specialist training for staff working with children and young people in custody. It encompasses Prison Service Order 4950, and has been informed by training needs analysis in the juvenile estate and YJB research into effective practice. JASP is part of the national qualifications framework and is mandatory training for all staff working with children and young people in custody.

JASP is a seven day modular programme and is broken down into two phases as follows: Phase 1 1 day – child protection 2 days – training delivered by Trust for the Study of Adolescence Phase 2 ½ day – mental health ½ day – substance misuse 1 day – vulnerability assessment 1 day – resettlement and training planning ½ day – managing difficult behaviour ½ day – safeguarding As may be seen there is a requirement for ½ days training on mental health and substance abuse.

According to a survey commissioned by the Health Care Commission, 10% of Youth Offending Teams have no mental health workers in their team (Actions Speak Louder, 2009) and there are inadequate numbers of specially trained staff working in these teams. However, although Harrington and Bailey identified good examples of YOTs working together with the local CAMHS staff which did mean that young offenders were in contact with trained health workers, there were still a majority of cases in which staff

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allocated to the YOT were not trained to deal with young people with mental health needs.

Initial training for the vast majority of staff working with young offenders in both custodial and community settings has relatively little focus on the needs of the mentally ill young offender. Whilst there are health care professionals working in youth justice (psychiatrists, psychologists, mental health nurses) who obviously provide a more specialist service, they are relatively few in number and their availability is variable from area to area. There is a national shortage of specialist child and adolescent psychiatrists and this extends more acutely into forensic work with these groups.

3.5. What kind of multidisciplinary teams, if any, are assigned the duty of dealing with these minors? Can you please describe the professionals that form part of this team? What is their intervention procedure?

Across England and Wales local authority Youth Offending Teams provide the framework for multi-agency community work with young offenders (see Part B â&#x20AC;&#x201C; The Youth justice Board).

The Crime and Disorder Act 1998 places a duty on every local authority to establish a Youth Offending Team (YOT). It is mandatory for YOTs to have at least one Probation Officer, Social Worker, Police Officer, Education Officer and a nominated health worker.

Whilst in a number of YOTs the nominated health worker is a specialist CAMHS nurse, there are no guidelines that stipulate that the health worker should be from a CAMHS background. The Youth Justice Board has indicated a preference for health practitioners to focus on mental health issues and a review by the Healthcare Commission 2006, (Letâ&#x20AC;&#x2122;s Talk About It) supports this view, finding 18% of young offenders going through YOTs have a physical health need, 42% have substance misuse needs and 44% have emotional or mental health needs.

The surveys and research cited in this report agree that the provision of good interagency work for this group of young offenders, i.e. those with mental health problems, remains patchy and often dependent on local partnerships based on good working relationships and good practice, (see above, examples of joint working).

In those cases where Child and Adolescent Mental Health Services and Youth Offending Teams work closely together, the chances of young people with mental health difficulties receiving a high level of service are greatly enhanced. However, problems still remain as such collaborative working is not a statutory requirement and except in some where the YOT may have a seconded CAMHS worker as part of their team , in which case

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although the seconded worker carries out the assessments, young people still have to be referred to the main stream CAMHS for ongoing treatment. This process of referral is often cumbersome with long delays between referral and treatment (see Harrington and Bailey).

3.6 Assessment The Asset documentation provides a common, structured framework for assessment of all young people involved in the criminal justice system. It is a standard assessment of the factors contributing to a young person’s offending based on the research commissioned by the Youth Justice Board that has sought to establish the main risk factors that lead to youth offending and also the protective factors that can prevent it.

Asset must be completed at the beginning and end of all interventions, and at the midpoint of Detention and Training Orders. It should inform the completion of assessment and planning documentation within the secure estate.

Youth Offending Team workers must complete Asset before reports for external audiences are written (e.g. Pre-Sentence Reports, or reports for Referral Order Panels).

These reports should be informed by the Asset assessment.

The Onset referral and assessment framework was designed by the Centre for Criminological Research, University of Oxford for the YJB and was piloted by the 13 pilot youth inclusion and support panels (YISPs)...

Common Assessment Framework The Common Assessment Framework (CAF) is a standardised approach to assessing the needs of children and young people who may need additional help in order to meet the five priority outcomes set out in the Every Child Matters programme. It has been designed for practitioners in all agencies to allow effective communication and collaboration, and it plays an important role in providing early intervention.

Asset Mental Health Screening Tool As part of the YJB’s commitment to improve access to mental health services for young people within the youth justice system, they commissioned the University of Manchester and Salford NHS Trust to develop a child and adolescent Mental Health Screening Tool to be attached to Asset.

The Asset Mental Health Screening Tool is triggered by section 8 of the Asset Core

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Profile and consists of: •

SQIFA - The Mental Health Screening Questionnaire Interview for Adolescents (SQIFA) is a short screening tool attached to Asset to be completed by all YOT staff.

•

SIFA - The Mental Health Screening Interview for Adolescents (SIFA) is a detailed interview to be completed by YOT health staff.

•

Screening Manual - This manual provides youth justice practitioners with supporting notes on the screening process and local training.

The aim of this tool is to improve the ability of youth justice services to identify young people with mental health needs and to provide both appropriate support and referral to a range of Tier 1 to Tier 4 CAMH services.

Asset Mental Health Screening Tool - Screening Pathway The Screening Pathway is intended to improve the process for identification of young people within the youth justice system who have mental health needs. It is important that these young people are supported by youth justice services to access the appropriate level of Child and Adolescent Mental Health Tier 1 to 4 services that they require.

It is important to note that, in any situation where it is clearly evident that a young person has mental health needs that require urgent assessment by specialist Child and Adolescent Mental Health Services, an immediate referral should be made to the appropriate local CAMH service. In these cases there is no requirement to complete the screening pathway before making a referral.

Where specialist assessment and treatment resources are not available to meet a young person’s needs as identified by the screening pathway, and/or long waiting lists exist, the best possible alternative support package which should have already been considered, should be put in place while waiting for access to specialist CAMHS. The following sets out the steps in the screening pathway: 1) Asset: Section 8 - Emotional and Mental Health If a young person scores 2 or more in Section 8 of Asset then SQIFA should be completed.

2) SQIFA 0 or 1 = no problem in this area.

2 = consider repeating the questionnaire in 4-6 weeks or if circumstances change.

3 or 4 = possible problems, full screening interview SIFA should be carried out.

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3) SIFA a. Complete full SIFA interview. b. Provide support and make the appropriate referral to CAMHS. Note: All decisions regarding action taken or decisions not to proceed with further screening must be recorded on a young person’s case file.

4. INTERVENTION APPROACHES: WHAT IS WORKING AND WHAT IS NOT Harrington and Bailey (2005) in summarising what works with young offenders in addressing antisocial behaviour and mental health needs state: • An initial structured assessment of risk and mental health needs of the young person is an important basis for planning interventions. It was also clearly evidenced that the most common reason for unmet need was the failure to assess and review the needs of a young person adequately.

• Interventions should be tailored to the young person’s needs and abilities (a quarter of offenders were found to have learning difficulties), with a focus on the dynamic aspects of risk.

• Cognitive behavioural and problem-solving skills therapies are most effective, particularly multi-modal approaches that include the individual, peer group and family.

• There is limited evidence for brief uni-modal interventions such as anger management or social skills training.

• There is evidence to support a number of interventions for treating child and adolescent mental health problems, but not all have been fully evaluated on samples of young offenders.

• There is empirical support that cognitive behavioural therapy programmes and problemsolving skills training designed to reduce anti-social behaviour may also have a beneficial effect on mild-to-moderate emotional symptoms (anxiety and depression).

• Young offenders with moderate-to-severe mental health needs should be identified by a structured screening process, and referred to the appropriate professional or agency, as co-existing mental health problems are likely to influence the success of any offence reduction work.

And in their Conclusions and recommendations they summarise as follows: • There should be tailored interventions using a cognitive behavioural and problem-solving skills training approach based on assessment of risk, needs and learning abilities.

• There should be a multi-modal approach focusing on the individual, family and peer

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• • • •

group.

Interventions should be evaluated for effectiveness with young offenders and accredited by the Youth Justice Board.

Those with moderate and severe mental health problems should be identified and referred to the appropriate professional or agency.

There should be prioritisation at both national and local level for mental health screening with the development of a local mental health strategy.

It is essential that all interventions are delivered by fully trained staff.

(Harrington and Bailey 2005)

The Youth Justice Board has identified elements of effective practice in key areas for developing and improving youth justice services and promoting effective practice across the whole of the youth justice system to ensure that work with young people is as effective as possible, and based on research evidence and promising practice.

The Key Elements of Effective Practice (the ‘what to do’) describe the features of effective interventions, using the best evidence available. They are intended to be used as the primary tool by youth justice services for evidence-based self-assessment and quality assurance, providing the benchmark for effective practice. In Key elements of Effective Practice – Mental Health, the YJB note the following Key indicators: • Assessment Identification of early indicators for potential mental health problems will help to provide effective mental health care. Practitioners should use standardised protocols and early intervention systems to provide adequate and effective care pathways. Asset, in particular Section 8 of Asset – Core Profile: Emotional and mental health, should be used as the starting point for constructing safe and accurate mental health assessments.

• Individual needs Individual needs, such as gender, ethnicity, cultural background and complex cases of cooccurring substance misuse, should be taken into account when developing individual tailormade intervention plans. Mental health diagnosis can affect intervention success and therefore should be considered when planning an intervention.

• Communication Protocols and standardised procedures across a broad range of practitioners and agencies should be used to ensure effective practice. Practitioners should refer to their professional guidelines when obtaining informed consent from a young person. Young people, where possible, should be involved in the decisions that affect them.

• Service delivery The intervention plan must be matched to the individual needs of a young person. Practitioners should aim to engage families and young people to increase the level of social support and create

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a positive mutual regard to increase the likelihood of the successful completion of an intervention.

• Transition Multi-disciplinary plans should be developed to aid the transition and monitoring of a young person’s care from one service to the next. Practitioners should aim to reduce risk of relapse by including family members, integrating and co-ordinating services and involving significant others such as parents/carer, guardians and other specialist staff.

• Training Skills-based training should be available to practitioners to allow them to rehearse and reflect on everyday practice. Practitioners should be given the opportunity to maintain skills and relevant mental health knowledge to enable them to work across a number of different partners and multidisciplinary teams.

• Management Managers should ensure that clear management systems with high-quality supervision and appraisal systems are in place to ensure that a young person’s mental health problems are managed in a safe and appropriate manner. Managers should have a coherent approach to dealing with, and managing, individuals in a mental health crisis or emergency situation.

• Service development Inter-agency protocols should be developed with all relevant external agencies when dealing with high-profile cases. An integrated mental health and substance misuse strategy should be established to ensure that a young person’s needs are met across a range of different dimensions.

• Monitoring and evaluation Monitoring data and evaluating the interventions delivered is essential to ensure effective service delivery of mental health care. Managers should ensure that appropriate audit data is collected in order to conduct meaningful evaluations of service delivery.

4.1. What kind of standardized resources are available for developing psychiatric diagnoses and assessments for juvenile detainees with mental disorders?

• See previous section on Asset and Mental Health Screening.

It should be acknowledged that whilst screening is not the same as psychiatric diagnosis of mental illness, it has an important role in the early identification of mental health problems in children and young people. The basic screening processes as described previously are intended to alert non-specialist youth justice professionals to potential mental health problems for a young person and to act as a catalyst for referral to more specialist resources and services. Since many children and young people often do not have the cognitive and linguistic sophistication needed to accurately describe their symptoms, clinicians must rely very heavily on direct observation, corroborated by observations of other people, such as parents and teachers and in youth justice services by YOT workers and secure estate staff.

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Only medically qualified psychiatrists are able to make formal diagnoses of mental illness in children and young people and the difficulties of diagnosing mental illness in children and adolescents is well documented and considerably more complex than in adults.

As well as relying heavily on observations by other adult figures in a child’s life, evaluation of mental complaints or symptoms in children and adolescents differs from that in adults in two important ways: • Developmental context is critically important in children. Behaviours that are normal at a young age may indicate a serious mental disorder at an older age.

• Children exist in the context of a family system, and that system has a profound effect on children’s symptoms and behaviours; normal children living in a family troubled by domestic violence and substance abuse may superficially appear to have one or more mental disorders.

In many cases, developmental and behavioural problems (e.g. poor academic progress, delays in language acquisition and deficits in social skills) are difficult to distinguish from those due to a mental disorder. In such cases, formal developmental and neuropsychological testing are an important parts of the evaluation process.

The content of the above paragraphs reinforces previous statements about the difficulties of defining mental disorder in the young offender population and in identifying appropriate treatment modalities. However, research is clear that early identification of these problems is critical and that early intervention can prevent later onset of formal mental illness.

4.2. What kind of therapeutic interventions do youth offenders receive in detention and community based sanctions? Are there any rules or particular treatment for them?

The three types of secure accommodation for young offenders, Young Offender Institutions (YOIs), Secure Training Centres (STCs) and Local Authority Secure Children’s Homes (LASCHs) offer a wide range of regimes and resources for the young offenders in their care (see Part A and Rose 2009).

Although of variable quality and effectiveness, every custodial establishment focuses its routine daily programme for young people on an education based curriculum.

Alongside or within this daily educational programme there are a number of more specific programmes for young people focusing for the most part on addressing

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antisocial or offending behaviour, social and life skills development and substance abuse.

In Mapping Mental Health Interventions in the Juvenile Secure Estate - Report for the Department of Health (Jo Tunnard, Mary Ryan and Zarrina Kurtz October 2005) cluster the programmes available in YOIs under five headings: • Psychological treatments or psychotherapies • Medication and complementary therapies • Skills training • Systemic, multi-level and psychosocial interventions • Provision for children deemed vulnerable on the wings Examples of the above include; specific offending behaviour programmes such as the .Enhanced Thinking Skills programme; cognitive behaviour therapy; use of complimentary therapies, e.g. reflexology and massage; a range of counselling programmes; creative arts therapies; life skills programmes; group work (see Tunnard et al pages 43-45). However as the researchers note: ‘In interviews it became very evident that staff availability determined whether services were available and, if so, to what extent.’

With particular regard to mental health, the questionnaire used by the researchers asked custodial establishments across the secure estate for a brief description of what they were able to provide for this group of young people. They found, ‘a wide variety of sources of support, advice and guidance, activities, and education and training were listed.

Many of the interventions or types of support reported were the same as those given as examples of particular mental health interventions, emphasising the clear link between mental health promotion and responding to specific mental health problems. (Tunnard 2005:43) Examples included: An independent adult to confide in Most sites mentioned the IMB and the Samaritans, and over half listed the chaplaincy.

A number of sites referred to staff in Healthcare, MHIRT, education or the YOT, and a small number referred to advocacy projects. One site referred to personal officers on the wings.

A befriending service The majority of sites listed the chaplaincy and the IMB and a smaller number the Samaritans. Two sites referred to peer support.

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An advocacy service A majority of sites had independent advocates for young people: this was provided in six sites by VCC, in five by NYAS, in one by the local MIND organisation, and in another

by Connexions advisors. The remaining sites referred to MHIRT staff fulfilling this role to a certain extent, or to chaplains or the IMB. Two sites said there was no provision.

To help children manage their behaviour A majority of sites referred to the work of mental health professionals in Healthcare or the MHIRT or to the offending behaviour programmes described earlier in the report.

Also listed were prison officers, incentive schemes, and drug and alcohol awareness sessions provided by the Juvenile Substance Misuse Service (JSMS) or gym staff.

To help children take part in decision making A majority of sites referred to young people attending their DTO reviews and also to offending behaviour programmes such as ETS or MORE. Others referred to work done by a range of staff in the prison, including Healthcare and MHIRT, chaplains, the YOT, and education. Four sites referred to trainee/staff committees.

To help children engage in activities Key here were gym and education staff, mentioned by a majority of sites, and wing staff.

Other relevant staff or activities included YOT workers, the MHIRT and Healthcare. A couple of sites mentioned the Duke of Edinburgh award and one referred to enrichment groups (walking, camping, music, drama).

To help children improve their self-care A range of staff and services were mentioned here. A majority referred to the role played by prison officers in giving advice and guidance. Health and hygiene advice is given by a range of different staff. Substance misuse information and advice was mentioned, as were various specific health services such as dental, optical and sexual health.

To improve their physical health The majority of sites referred to gym and education staff, followed by the Juvenile Substance Misuse Service (JSMS). Next in frequency were health services such as the GP and nursing staff. Two sites referred to the role of kitchen staff in producing a healthy diet.

To enhance their sense of identity The majority of sites referred to the importance of the chaplaincy which in many, but not all, sites was described as multi-faith. Others referred to access to interpreters, and one site to Mapping MH Interventions in the Juvenile Secure signers for the deaf. Three

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sites referred to “diversity awareness”, and one to family contact. A number of sites at interview referred to halal food being available.

To continue with education or training now All sites listed education. A number also mentioned vocational courses, NVQs, and basic skills training. A few sites referred to Connexions and two to the YOT. To help children prepare for education, training, work later Education was listed by all sites and half referred to Connexions too. Two sites referred to release on temporary licence for work placements, and three to interviews for jobs or work experience.

To help children prepare for life after custody A majority referred to Connexions and the YOT. In addition, they referred to advice and information from a range of staff and from outside organisations - about health, substance misuse, parenting, benefits, and accommodation.

4.3. Community based interventions The principles for effective intervention with young offenders in the community are outlined above. There are unsurprisingly a wider range of agencies and services available to young offenders in the community than in custody, although many are dependent on local resources rather than being part of a nationally coordinated set of provisions.

Some services are national, e.g. the National Treatment Agency for Substance Abuse and the associated programmes delivered by local Drugs Advisory Services.

One of the most innovative and increasingly well evidenced interventions for young offenders in the community is Multisystemic Therapy which is an intensive familyand community-based treatment programme. The Brandon Centre in London has been running the first randomised controlled trial of Multisystemic Therapy (MST) in the UK in partnership with Camden and Haringey Youth Offending Services. They describe MST as follows: ‘MST adopts a social-ecological approach to understanding anti-social behaviour or emotional problems. The underlying premise of MST is that young people’s difficulties are multi-causal; therefore, effective interventions would recognise this fact and address the multiple sources of influence. These sources are found not only in the young person (values and attitudes, social skills, biology, etc) but also in the young person’s social ecology: the family, school, peer group and neighbourhood. It is a key premise of MST that community-based treatment informed by an understanding of the young person’s

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ecology will be more effective than costlier residential treatment. Research has shown that treating the young person in isolation of the family, school, peer and neighbourhood systems means that any gains are quickly eroded upon return to the family, school or neighbourhood. Custody stays could also be counter-productive because an already troubled young person is immersed in a peer culture where antisocial values predominate.

MST uses the family-preservation model of service delivery in that it is home-based, goal-oriented and time-limited. It is present-focused and seeks to identify and extinguish behaviours that are of concern not only to referring agents but also to the family itself.

In fact the entire family is involved with MST, in contrast to the many interventions that define the young person as the â&#x20AC;&#x153;identified client.â&#x20AC;? MST involvement will typically be between three and five months.

Collaboration with community agencies is a crucial part of MST. The school is a key player and workers may be in daily contact with teachers and administrators. MST Therapists will also work in close partnership with referrers. The MST Team will work closely with youth justice officers, social workers or mental health workers to ensure that MST is implemented to maximum effect in the context of the requirements of the referring agency. There may be a need to involve the young person in substance abuse treatment or seek a psychiatric consultation about a parent, for example.

While the initial MST involvement may be intensive, perhaps daily, the ultimate goal is to empower the family to take responsibility for making and maintaining gains. An important part of this process is to foster in the parents the ability to be good advocates for their children and themselves with social service agencies and to seek out their own supports. In other words, parents are encouraged to develop the requisite skills to solve their own problems rather than rely on professionals.â&#x20AC;&#x2122; (http://www.brandon-centre.org.uk ) Initial research on the outcomes achieved by MST are encouraging including the first randomised controlled trial of MST in the UK run by the Brandon Centre in partnership with Camden and Haringey Youth Offending Services.

4.4. Pupil Parent Partnership (PPP) As a therapeutic not-for-profit organisation, PPP supports young people by offering individual support; group and family counselling; mentoring; therapeutic residential work; crisis intervention; access to supported applied education and accredited key skills and GCSE programmes. The focus is on keeping the problem in perspective and not ignoring it or over-exaggerating. 15 years of experience in the young social

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exclusion working and a European Commissioned project carried out in collaboration with European partners culminated in the creation of a Framework that underpins the way in which we work. It is a model that emphasises the ‘Why’ and ‘How’ rather than the ‘What’. We feel that an enormous amount of ideas are generated around different types of interventions in an effort to initiate changes of behaviour in this client group. An equal focus is placed on our motives and on devising more effective ways of delivering services would generate greater success. This multi-systemic way of working is carried out with the following principles in mind: 1. Nurture; a nurturing relationship is the key to rebuilding a young person’s self confidence and ability to positively negotiate their environment. Initiatives taking place around the country to deal with vulnerable young people are valuable but can be improved by including nurture and attachment learning.

2. Empathy and integrity; Mentoring is the best way of tackling criminal behaviour in young people, however it was stressed that mentoring must at all times be honest.

3. Family work; supporting parents properly is absolutely key to helping young people move away from the influences of crime and offending.

4. Community; working with young people in isolation will have limited success if the entrenched problems within their wider community are not properly taken into account.

5. Mental health; must be taken into account in any strategy that deals with their behaviour.

6. Legacy of oppression; PPP believe that the legacy of oppression, of any form and to any community, must be adequately understood and explored when dealing with young people who are involved in crime.

7. Specific Learning Difficulties; At least 60 % of young people involved in serious crime have specific learning difficulties.

8. Remain optimistic; crime among young people is extremely complex, emotive and causes immeasurable suffering for the people who are involved. However in London, of the 1.8million young people, less than 1% is involved in crime.

4.5. Are there any specific mental-health units for young offenders with MH needs in your country? What are the results of this intervention?

There are just 6 in-patient forensic medium secure settings offering around 200 placements to young people in England and Wales. In terms of identified need, a report in 2006 by Zarrin Kurtz, THE NEEDS OF YOUNG PEOPLE FOR SECURE FORENSIC MENTAL HEALTH SERVICES AS CURRENTLY COMMISSIONED BY NSCAG (The National Specialist Commissioning Advisory Group) identified that on the basis of the research

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studies considered the likely numbers of young people in England alone requiring secure forensic mental health services could range from 568 to as many as 1,256.

(Kurtz 2006:9) Given that the population of young people in these secure settings are not only young offenders but include admissions of the most high risk young people in the community but not necessarily convicted offenders, the extent of the shortage of in-patient facilities is apparent. As commented on above, the YJB figures showing the numbers of young people in custody do not include those placed in these settings.

4.6. What are the possibilities for working in terms of family therapy?

What would be the outcomes and results?

The assessment, planning and review processes for young offenders provide the opportunity for Youth Offending Team workers to routinely involve parents and young people in addressing offending and anti-social behaviour together. The Involving Young People in Parenting Programmes (IYPP) project was designed to develop this joint approach go further, and to learn more about linking work with parents directly with work with young people to prevent youth offending, anti-social behaviour and truancy.

Working with families has been proven to reduce reoffending (see Monitoring and evaluation of family intervention projects to March 2010, Department for Education (DfE), 2010).

Family intervention services provide intensive support using evidence-based programmes targeted at the most challenging and chaotic families, who may have high levels of anti-social behaviour or be involved in youth crime. They also work to address needs such as education and provide positive activities for parents and children. The core principle is the utilisation of a key worker who organises services and proactively engages the family using a more assertive approach to providing support. Family intervention services also reduce the risk of siblings being influenced by offending behaviour.

Some YOTs have family intervention in-house while others link with partners to provide support and referrals. Family intervention key workers lever in support from a number of statutory and voluntary services. An evaluation of early family intervention projects in 2008 found that families appreciated the emotional support and practical assistance above other types of support they received through the intervention (see Family Intervention Projects: An Evaluation of their Design, Set-up and Early Outcomes - Brief, Department of Children, Schools and Families, 2008).

A Department of Education (DfE) research document provides a measure of family

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intervention outcomes up to March 2010 from 21 pathfinder projects, finding that almost 50 per cent of families involved in crime at the referral stage did not reoffend during the intervention (See the full report at Monitoring and evaluation of family intervention projects to March 2010 ).

4.7. Evidence-based programmes It is recognised that parenting skills can be learnt and evidence-based interventions with parents are effective in reducing the offending rates of young people work. A range of evidence-based programmes is available. The Children’s Workforce Development Council (CWDC) has launched a commissioning toolkit for evidence-based parenting interventions and many YOT practitioners have completed the Council’s other evidence-based training programmes such as Strengthening Families, Strengthening Communities and Triple P. These approaches are having promising results. International evidence from more intensive family interventions, such as multi-systemic therapy and functional family therapy, also shows significant reductions in recidivism as well as reductions in the use of custody and use of care. Both are being piloted in YOTs with promising results and practitioners working in Family Intervention Projects with families with multiple and complex needs are seeing positive results so far.

4.8. Are there any prevention programmes (early intervention) concerning young people with behavioural disorders?

As indicated throughout this report the targeting of children and young people showing early signs of antisocial behaviour is a critical factor in preventing later onset of more serious delinquent behaviours (Rutter and Giller, 1999). The YJB have introduced a number of schemes designed to intervene with children and young people to prevent their involvement in the youth justice system. Youth Inclusion Programmes (YIPs), established in 2000, are tailor-made programmes for 8 to 17-year-olds who are at high risk of involvement in crime or anti-social behaviour. YIPs generally work with either the 8-12 age range (Junior YIPs) or the 13-17 (Senior YIPs).

YIPs target young people in a neighbourhood who are considered to be most at risk of offending, but are also open to other young people in the local area. The programme operates in 110 of the most deprived/high crime neighbourhoods in England and Wales.

YIPs aim to reduce youth crime and anti-social behaviour in the neighbourhoods in which they work. Young people on the YIP are identified through a number of different agencies, including the YOT, police, children and family services, local education

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authorities or schools, neighbourhood wardens and anti-social behaviour teams.

The programme gives young people somewhere safe to go where they can learn new skills, take part in activities with others and get support with their education and careers guidance. Positive role models – the workers and volunteer mentors – help to change young people’s attitudes to crime and anti-social behaviour, and address those factors that put young people at risk of involvement in offending or anti-social behaviour.

The evaluation of the YIP scheme has shown mixed results in terms of their effectiveness against the 4 target areas of the evaluation (Evaluation of the Youth Inclusion Programme, Phase 2 2008): ‘Engagement − 82% of the core 50 were engaged by projects at some stage in Phase 2. This exceeded the target of engaging 75%.

Contact − over Phase 2 as a whole, just 17% of the core 50 attended interventions for an average of five hours per week, well short of the target that all of the core 50 should receive this level of contact.

Arrest rates − for the core 50 who were engaged at any time, there was a decrease in the average rate of offending of 66.5%, which is very close to the programme’s target of 70%.

Education, training or employment (ETE) − 59% of the core 50, engaged in Phase 2, were in full-time ETE, which was 31% short of the 90% target.

In overall terms, one of the targets (engagement) was easily met, one was nearly met (arrest rates) and achievement fell well short on the remaining two targets (contact and ETE).’

Nurture Groups provide another example of early intervention that have an increasingly well researched evidence base as to their effectiveness, whilst the model of practice and the principles that underpin this are interestingly applicable to other settings and to the development of a supportive and facilitating organisational culture (Rose 2010:64-89).

Using a standardised assessment tool, The Boxall Profile (or with young people 11-14, The Boxall Profile for Young People) children are placed in a nurture group for up to 4 school terms. The Profile identifies key presenting elements in a child’s behaviour and links these to deficits in their early learning experiences. Problems with behaviour are therefore linked to delayed development rather than regarding as reflecting any underlying pathology. The groups are staffed by 2 adults (usually a teacher and a learning support assistant) and learning is based on the relationships developed between the adults and the children in the group, reflecting the early learning principles of attachment theory.

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A standard day in a nurture group sees the group’s children register with their ‘base’ class. Collected by group staff, these children spend most of their day in the special nurture group room, keeping in contact with the rest of the school by joining them for midday lunch and at playtime, and then returning to their ‘base’ class for the last part of the day. It is recommended that nurture group staff should have one afternoon session for recording and planning, training or for meetings with parents. On average, children spend up to four terms in the nurture group before re-joining their mainstream class.

In many schools there are variations on the above, usually in terms of the length of time spent in the group each day or by increasing involvement with their mainstream class in certain subject areas; but nurture groups always work to the core principles encapsulated in the above description, i.e.

• Children’s learning is understood developmentally • The classroom offers a safe base • Nurture is essential for the development of self-esteem •Language is a vital means of communication – more than a ‘tool’; it is a vehicle for expressing feelings and emotions •All behaviour is communication • Transitions are important in children’s lives Along with operational characteristics required for effective practice, the principles encapsulate the ideas that provide for extended application into other areas of practice, as well as for the management and organisation of services. A form of the nurture group model has been developed by education staff in one Young Offender Institution to such good effect that it was commended by the Prison Service Inspectorate, who noted the influence of the work in the group on other aspects of the regime (Bourne 2008). Nurture groups have also been adapted for residential special schools where the influence is not only on the ‘school’ part of the establishment, but also in the residential units.

Two main research programmes for the evaluation of nurture groups have published their findings. The national research programme at the University of Leicester, lead

by Paul Cooper and David Whitebread, was published in 2007; and the study of the successful introduction and development of nurture group provision in the city of Glasgow detailed its outcomes in a report to Glasgow City Council in February 2007.

Both of these reports are available at the Nurture Group Network website, www. nurturegroups.org, They draw similar conclusions as to the overall value of nurture groups and to the difference that nurture groups make to children’s progress in school in terms of such criteria as attendance, behaviour in school and at home, and academic attainment. Of considerable interest are the common findings that indicate nurture groups make a substantial difference to both the overall ethos of a school and

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to the relationships that a school has with children’s parents. Indeed, the comments and views of parents about nurture groups make them amongst their most powerful advocates (Bennathan, M. Rose, J. 2008).

With specific reference to children and young people with mental health needs early identification and diversionary intervention strategies are amongst the best forms of support for young people at risk of entry into the youth justice system. Lord Bradley in his review of people with mental health problems and learning disabilities in the Criminal Justice System (Bradley 2009) emphasised the importance of early identification of health needs and diversion away from the Criminal Justice System.

As part of the ‘Supporting Young Peoples Mental Health Project’, the YJB, Department of Health and the Sainsbury Centre for mental health are conducting 6 pilots across England called ‘Youth Justice Liaison and Diversion Pilots’. The objective of these two year pilots is to: o plan to introduce a system of identification and diversion for young people with mental health, learning, communication difficulties or other vulnerabilities at the earliest possible opportunity in the youth justice system o place a Youth Justice Liaison and Diversion worker in the custody suite to screen as many young people passing through the police custody suite as possible for vulnerabilities o ensure, where fuller assessment is needed, the Youth Justice Liaison and Diversion worker has strong links within the community for referrals as they will have already mapped all services in the area for referrals.

4.9. What is the regulation or process regarding a psychiatric treatment?

Who is in charge of it? Are minors obliged to follow the treatment decided by professionals?

The Mental Health Act 2007 is the encompassing legislation for the treatment of mentally ill people including children and young people and orders under this legislation are overseen by a medically qualified psychiatrist. In the case of children and young people under the age of 18 years, the diagnosis of a mental illness would also be made by a medically qualified psychiatrist who would also supervise treatment. If the severity of the illness necessitates in-patient admission on a voluntary basis, then there would be involvement by local children’s services in subsequent reviews of the admission and in the planning of support for the child and their family. In terms of consent to treatment this may be given by parents or those holding parental responsibility for a child and

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although there is no specified age at which a child / young person under the age of 18 years becomes eligible to make their own decisions, the weight of case law is that if a child is deemed competent to act in their best interests then the wishes of the child must be taken into account in the decision making process.

There are clear and statutory review mechanisms in place for children detained in local authority secure accommodation and whilst mental health per se is not covered by the Children Act 1989, placement can be made in a secure unit if a child is deemed to be ‘a danger to themselves or others’. After an initial 72 hour placement a child or young person (10-17 years), must be brought before the courts for the placement to continue and reviewed at a maximum of 3 monthly intervals.

Such interventions almost always occurs within the context of family and multi-agency involvement including social workers and school staff, together with youth offending team staff if the young person is involved in the youth justice system.

As already identified involuntary admission to a hospital setting for psychiatric treatment, (a Hospital Order), is rarely used for young offenders facing the courts on a criminal charge.

4.10. What legal and medical measures are foreseen in cases of noncompletion of treatment in outpatient or semi-open systems? When the minor fails to complete outpatient treatment, even when there is no situation to justify admission to a closed centre, if there is a risk of reoffending, do the Courts decide upon involuntary-admission measures?

As already described, both a Youth Rehabilitation Order and the terms of a post-release licence under a Detention and Training Order may include a requirement for treatment of a mental disorder. This is also the case for a young person released on licence having served a custodial sentence under Section 90/91.

It is possible to breach a young person who fails to comply with the conditions of their order and in fact around a fifth of sentenced young offenders serving a custodial sentence have been imprisoned for breaching conditions of community sentences, of antisocial behaviour orders, of licences following earlier release from custody or for failing to surrender to bail.

It is highly unlikely that a breach order would be sought solely on the grounds of a failure to comply with a treatment requirement, given the alternative of a likely placement

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in an unsuitable secure facility. However, if the failure to comply were associated with further offending behaviour then a return to court would be more likely, although it is to be expected that if a mental disorder was deemed to be the primary root cause of the continuing offending, a placement in a more suitable secure setting offering treatment would be sought.

4.11. Are laws and action protocols foreseen that would provide for mixed systems of closed and outpatient treatment? Please describe them if so The opportunity for continuing out-patient treatment following a period of in-patient treatment is pretty much standard within the general field of child and adolescent mental health services. For young offenders the terms of the licences for post-release supervision as described above allow for the provision of continuing care and treatment in the community. However, the problems associated with delivery of post-custodial care as referred to previously should be noted.

5. RECOMMENDATIONS AND PROPOSALS FOR GOOD PRACTICES Concerning young offenders with MH problems and according to your knowledge and professional approach what actions should be implemented with respect to the following aspects?

5.1. The training and role of professionals and actors Attention has been drawn throughout this report to the importance of having appropriately qualified and trained staff to undertake initial screening of young offenders for the purposes of identifying mental health issues and to provide support to other staff in the care and management of young people with these problems.

Staff seconded from health services to Youth Offending Teams should have relevant qualifications in work with mentally disordered young people and opportunities provided for them to share this expertise in staff training programmes.

In custodial settings the arrangements for the presence of CAMHS workers as part of the reach-in programme should be extended across all YOIs and continuing funding available to support these initiatives.

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The national shortage of qualified psychiatrists and psychology professionals for forensic work with children and adolescents should be addressed through more targeted recruitment.

Whilst there have been considerable improvements in the basic and initial training provided to the core residential staff across the secure estate there need to be more focus in this training on the needs of the children and young people with particular reference to their development, the principles of nurture and the relevance of attachment theory.

5.2. Community-based intervention and prevention The overwhelming weight of available evidence suggests that the earlier the processes of assessment and intervention occur for a child or young person, the more effective it is likely to be and models of effective practice in the community have already been highlighted. A continuing shift of resources from the secure estate, to community based programmes should continue with clear monitoring and evaluative measures in place.

5.3. Cooperation and interchange between mental-health and justice systems A serious problem in the provision of community based resources for young offenders is the continuing disjunction between youth justice and other children’s services in the local authority. Whilst there are examples of good collaborative working across agencies and departments, these are still heavily reliant on local relationships and working practices rather than prescribed by regulation and enforced through legislation.

5.4. Key facts from partnership Conference in Rome • Presentations from various countries throughout Europe, Latin America and the USA all highlighted the same worrying subject of the suffering of large numbers of young people who find themselves within the juvenile justice system. Causal factors of youth offending were discussed within the group and links with poverty, drug and alcohol abuse and family difficulties all arose.

• There is a need to regularly assess the impact of mental health needs on young offenders and professional approaches on the subject. Alongside there is the need for staff training to gain an understanding of psychological and systemic therapies.

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• Recognition of the need for early intervention with families identified and known within the juvenile justice system. The balance of human rights around these issues is essential.

• Investment in the aforementioned points - every £1 invested into drug treatment saves £3 in the Criminal Justice System.

• The conference was useful in highlighting the problems of different countries and some of the similarities we all face. The task being how first identify and then support a young person with mental health needs within the juvenile justice system to access the right interventions for them and their family. This can only be done if there is the belief and understanding that they are in fact ill rather than bad. This will, in turn, influence how we approach these key issues.

Support of professionals working with young people with mental health needs and dealing with the behaviour that they present is central to their development and understanding and as such, the effectiveness of their interventions.

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References Bennathan, M. and Rose, J. (2008) All About Nurture Groups, London: The Nurture Group Network.

Boswell, G. (1995) Violent Victims. The Prevalence of Abuse and Loss in the Lives of Section 53 Offenders, London: The Prince’s Trust.

Bourne, S. (2008) Helping young offenders to learn, Nurture, Issue 10, Summer 2008.

Bullock, R., Little, M. and Millham, S. (1998) Secure Treatment Outcomes, Aldershot: Ashgate Publishing.

Cooper, P., Whitebread, D. (2007) ‘The Effectiveness of Nurture Groups on Student Progress: Evidence from a National Research Study’, Emotional and Behavioural Difficulties, 12:3, 171–190.

Frühwald, S., and Frottier, P. (2005) Suicide in prison, The Lancet, vol 366, issue 9493.

Glover, P., and Hibbert, P. (2009) Locking up or giving up? Why custody thresholds for teenagers aged 12, 13 and 14 need to be raised. An analysis of the cases of 214 children sentenced to custody in England 2007-8, London: Barnardo’s.

Gopnik, A. (2009) Angels and Ages, London: Quercus.

Lerner, R. M., & Galambos, N. L. (1998). Adolescent development: Challenges and opportunities for research, programs, and policies. Annual Review of Psychology, 49, 413-446.

Reynolds, S., MacKay, T., Kearney, M. (2009) ‘Nurture groups: a large-scale, controlled study of effects on development and academic attainment’ British Journal of Special Education.

Rose, J. (2002) Working with Young People in Secure Accommodation - From Chaos to Culture, London: Brunner – Routledge.

Rose, J. (2008) Types of Secure Establishments in Children and Young People in Custody: Managing the risk Editors: Maggie Blyth, Chris Wright and Robert Newman. Bristol: The Policy Press.

Rose, J. (2010) How Nurture Protects Children: Nurture and narrative in work with children, young people and families London: Responsive Solutions UK Ltd. Rutter, M., Giller, H. and Hagell, A. (1998) Antisocial Behaviour by Young People, Cambridge: Cambridge University Press.

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Youth Justice Board (http://www.yjb.gov.uk ) Reports: Evaluation of the Youth Inclusion Programme – phase 2.

Key elements of Effective Practice – Mental Health (2008).

Accommodation needs and experiences (2007).

Prof Richard Harrington and Prof Sue Bailey (2005) Mental Health Needs and Effectiveness of Provision for Young Offenders in Custody and in the Community, Risk and Protective Factors (2005).

Mental Health Needs and Effectiveness of Provision for Young Offenders in Custody and in the Community (2005).

Hazel N, Hagell A, Liddle M, Archer D, Grimshaw R and King J (2002) Assessment of the Detention and Training Order and its impact on the secure estate across England and Wales.

Office for National Statistics: National Statistics Online (2004) Mental Disorder More Common In Boys.

Singleton et al (2000) Psychiatric Morbidity among young offenders in England and Wales.

Other References The Bercow Report (2008) A Review of Services for Children and Young People (0-19) with speech, language and communication needs.

The Bradley Report (2009) Lord Bradley’s review of people with mental health problems or learning disabilities in the criminal justice system.

The Brandon Centre - (http://www.brandon-centre.org.uk).

Department for Education (2010) Monitoring and evaluation of family intervention projects to March 2010.

Department for Education and Skills (2004) Common Assessment Framework (CAF) http://www.education.gov.uk/consultations/downloadableDocs/ACFA006.pdf

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Department of Children, Schools and Families (2008) Family Intervention Projects: An Evaluation of their Design, Set-up and Early Outcomes.

Department of Health (2009) Healthy children Safer Communities - A strategy to promote the health and well-being of children and young people in contact with the youth justice system.

Department of Health (2005) Mapping Mental Health Interventions in the Juvenile Secure Estate.

The Health Care Commission and Her Majesty’s Inspectorate of Probation (2009) Actions Speak Louder - a second review of health care in the community for young people who offend.

The Independent Commission on Youth Crime and Antisocial Behaviour (2009) Time for a fresh start.

HM Chief Inspector of Prisons for England and Wales Annual Report 2006/7 (London: HM Inspectorate of Prisons).

Kurtz, Z. (2006), The Needs of Young People for Secure Forensic Mental Health Services as Currently Commissioned by NSCAG (The National Specialist Commissioning Advisory Group).

Laming J, Lord (2003) ‘The Victoria Climblié Inquiry: Report of an Inquiry by Lord Laming’.

Mental Health Foundation (2005) Mental health in children and young people in Great Britain: Lifetime Impacts: Childhood and Adolescent Mental Health, Understanding The Lifetime Impacts.

Nacro (2006) Getting Disclosures Right: A review of the use and misuse of criminal record disclosures, with a guide to best practice and assessing risk http://www.nacro.org.uk/ data/files/getting-disclosures-right-847.pdf.

National CAMHS Review (2008) final report, Children and young people in mind.

National Children’s Bureau (2009) Managing Transitions from Secure Settings.

The Prison Reform Trust (2009) Punishing Disadvantage - a profile of children in custody

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Review by the Forensic Faculty, Royal College of Psychiatrists 6 March 2008 University of Oxford, Criminology Department for the youth Justice Board (2006) Onset referral and assessment framework. http://www.justice.gov.uk/guidance/youth-justice/ assessment/onset.htm.

Youth Justice Board, Mental Health â&#x20AC;&#x201C; Asset Mental Health Tool. http://www.justice.gov. uk/guidance/youth-justice/health/mental-health.htm.

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Comments As referred to throughout this report a key change for the improvement of services for young offenders with mental health problems would be to collapse the youth justice system into the universal services for children and young people, i.e. social care, education and health. As stated previously: ‘To achieve this shift in thinking would require a paradigm change in the way in which government and society as a whole regards young offenders and organises services to address their needs in collaboration with universal children’s services, such as health and education. It is still the case that young offenders are responded to primarily in terms of their offending behaviour rather than in the wider context as children in need.’

A further statement in the report is worth repeating here: ‘One of the notable features of the youth justice system in England and Wales is a lack of a coherent theoretical model for understanding the needs of the children and young people involved in the system and this has implications for the way in which mental health is viewed in this context. As indicated in Part A and Part B of this report the youth justice system is constructed with an emphasis on antisocial and offending behaviour by young people and the need to control and change this behaviour in the context of demonstrating that public protection is secured and proportionate punishment administered.’

In custodial settings it is important to emphasise the key role played by the residential staff (including prison officers) that have day-to-day responsibility and contact with the young people. Unless the culture of the residential units is focused on the needs of the young people and their experience of the adults caring for them is positive, engendering feelings of safety and security and a sense that someone is attending to their particular needs, the impact of any specific programme or treatment intervention will be considerably lessened. (Rose 2002) Please also visit the following website to download copies of: The Mental Health Screening Interview for Adolescents SIfA and The Mental Health Screening Questionnaire Interview for Adolescents SQIFA http://www.yjb.gov.uk/en-gb/practitioners/Health/Mentalhealth/

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Biographies of experts COLLABORATOR’S NAME JIM ROSE MA (CANTAB.) BIOGRAPHY Jim Rose has worked in various social care settings with children, young people and their families since 1975. This has included appointments in the local authority and independent sectors. During his career he has been Principal of two local authority residential centres with secure accommodation as part of their provision. As the first Principal of Leverton in Essex he was instrumental in establishing the ethos and practice of the Unit drawing upon the tradition of therapeutic communities and adapting this for a secure setting.

From 1998 – 2001 Jim was Professional Adviser to HM Prison Service on the placement and management of young people sentenced to long-term custody for serious offences and also advised on the development of facilities for juveniles in the prison estate. Following this he moved to Medway Secure Training Centre as Director.

Since 2004 Jim has worked as an independent consultant. From January 2004 – December 2008 he worked part-time as Executive Director for The Nurture Group Network, taking the lead in developing the organisation to its current position as a thriving and independent charity, promoting and supporting nurture groups across the UK. His other main area of work has been as a senior consultant with The Fostering Foundation, an independent fostering agency in London, Bristol and the South West. He is also Chair of Foundation’s three Fostering Panels.

Jim is the author of the well-reviewed book, Working with Young People in Secure Accommodation – From Chaos to Culture, (Brunner - Routledge – 2002) He also contributed a chapter to Children and Young People in Custody: Managing the risk Editors: Maggie Blyth, Chris Wright and Robert Newman, The Policy Press, November 2008 In 2010 Jim wrote How Nurture Protects Children – Nurture and narrative in work with children, young people and families (Responsive Solutions UK Ltd, 2010) How Nurture Protects Children is partly a critique of the current prevailing professional culture but it is also an attempt to describe alternative ways of thinking about the nature of work with vulnerable children, young people and their families. The book has been well received and described as ‘a book to make you think, to challenge your ways of working, to force you to revisit what you believe about children and how best to help them’ (Sir Paul Ennals)

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COLLABORATOR’S NAME PROF. GARY O’REILLY BIOGRAPHY University College Dublin (UCD), School of Psychology Gary O’ Reilly is a senior lecturer at the UCD School of Psychology. He is also the deputy director of the Doctoral Programme in Clinical Psychology. He has a parttime appointment as a principal clinical psychologist at the Children’s University Hospital Temple Street, Dublin. He has developed a Cognitive Behavioural Therapy Workbook for children and adolescents which is available free-of-charge to people working in clinical settings. It can be accessed by e-mail request.

Please see www.juvenilementalhealthmatters.com for further details. He has coedited a number of books including: The Handbook of Intellectual Disability and Clinical Psychology Practice (2007) and The Handbook of Clinical Intervention with Young People who Sexually Abuse (2004).

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Youth justice and Mental Health: Intercontinental Challenges and best practices

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Chapter X Mental Health and Child Justice in Africa: A brief appraisal of the law and practice .......................................................................................................................................

by Lucyline Nkatha Murungi LLB, LLM (Human Rights and Democratisation in Africa), Doctoral Researcher, Community Law Centre, University of the Western, Cape South Africa

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Table of Contents

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Introduction 1. PREVALENCE OF MENTAL ILLNESS OR MENTAL DISABILITY IN AFRICA 2. CONTEXTUAL REALITIES 3. LEGAL FRAMEWORK ON JUSTICE FOR YOUNG OFFENDERS WITH MENTAL ILLNESS IN AFRICA 3.1. The African Charter on Human and People´s Rights (ACHPR) 3.2. The African Charter on the Rights and Welfare of the Child (ACRWC) 3.3. African Youth Charter 3.4. Non-binding legal instruments

4. REGIONAL INSTITUTIONS AND SPECIAL MECHANISMS 4.1. African Commission on Human and People´s Rights 4.2. Special Rapporteur on Prisons and Prison Conditions in Africa 4.3. African Committee of Experts on the Rights and Welfare of the Child, ACERWC 4.4. Convention on the Rights of Persons with Disabilities, CRPD

5. EMERGING FRONTIERS 6. ENTRY POINTS FOR INTERVENTION References

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Introduction Children with mental illness or intellectual disabilities often come into conflict with the law for reasons either directly related to the disability or not. Just like all other children, when children with mental disabilities are in conflict with the law, they are prone to experience an abuse of their rights. But, the potential that their welfare could be compromised is amplified by the disability. There are various legal guarantees at the international and regional levels that are geared towards ensuring that such abuse does not occur. There are also contextual factors in the African region that have an effect on the protection of such rights.

This paper gives a general overview of the legal framework on the rights of children with mental health problems or disabilities in the African context. The region is vast, meaning that it is not possible in this short paper to delve in detail into the various domestic circumstances or laws in African countries. As far as possible, the paper collates common themes on this issue as can be deciphered from the legislation of the different states.

1. PREVALENCE OF MENTAL ILLNESS OR MENTAL DISABILITY IN AFRICA It must be indicated at the beginning that the issue of juveniles with mental health problems falls between two disciplines, that is, medical and legal. It is not possible to dichotomize the two areas when addressing the rights of the persons concerned.

Mental illness is a medical concept meaning that its definition could be found in medical as opposed to legal sources.202 There is however longstanding recognition of the legal implications of mental illness in the context of criminal justice. The distinction between mental illness and mental or intellectual disability is based on the interaction between the person with mental illness and social attitudes towards people who suffer the illness. In the absence of environmental and attitudinal barriers in society, mental illness is largely a medical concern. In the same manner, where mental illness limits the participation of an individual in society solely as a result of the illness, then persons with mental illness would be deemed to have a disability. In practice, the distinction is often blurred.

In terms of the UN Convention on the Rights of Persons with Disabilities, a person with a disability includes someone who has a ‘long-term physical, mental, intellectual or

202 Henry Weihofen ‘The Law and the Mentally Ill: the definition of mental illness’ Ohio State Law Journal Vol 21 Winter 1960 Number 1, 1.

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sensory impairment which in interaction with other barriers may hinder their full and effective participation in society on an equal basis with others.’203 This definition neither expressly mentions mental illness as constituting a disability, nor excludes it from the definition. The definition creates a margin of appreciation for states to determine what constitutes a disability in their context. It means that while mental illness may be considered a disability in some countries, it may not be equally classified in others.

Whether or not a person falls within the definition has implications for the regime of and scope of rights applicable to them.

Dealing with child offenders with mental health problems is a complex process that demands taking into account issues of human development, behaviour, individual variation and non-specific concepts such as intelligence and moral development.204 Consequently, the scope of potential cases is very broad, making an adequate response doubtful in the context of inadequate resources. Proper assessment is critical to determination of criminal capacity, and to understanding the experiences of the child in the criminal justice process up to the point of sentencing. Mental health care is also critical in the post-sentence phase of child justice as part of the child offender’s right to the highest attainable standard of health. There are however few mental health professionals with the required qualification for forensic assessment of criminal capacity.205

2. CONTEXTUAL REALITIES Global statistics indicate that on average, ten percent of the world’s population lives with one or more forms of disability. Of this number, eighty percent live in the developing world, such as Africa. In his 2011 report on the status of the Convention on the Rights of the Child, the UN Secretary General noted that accurate data on disabilities is lacking, especially in developing countries.206 In effect, it is difficult to corroborate or contest the global statistics.207 However, some contextual African realities lend credence to the estimate of large numbers of persons with disabilities in the region.

203 CRPD Article 1 204 Ann Skelton and Charmaine Badenhorst ‘The Criminal Capacity of Children in South Africa: International Developments and Considerations for a Review’ Child Justice Alliance (2011) 22.

205 Ann Skelton and Charmaine Badenhorst ‘The Criminal Capacity of Children in South Africa: International Developments and Considerations for a Review’ Child Justice Alliance (2011) 22. Though this statement is made in respect of South Africa, lack of adequate qualified professionals pervades the entire region.

206 UN Secretary General Status of the Convention on the Rights of the Child Report 3 August 2011 A/66/230, paragraph 16 207 Recent statistics on national census results in some African countries such as Kenya and South Africa point to much lower numbers than the ten percent global estimate.

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These include the poor standard of healthcare in the region which means that illnesses with the potential to cause disability are not accorded proper treatment. The prevalence of armed conflict in many African countries results in disabilities, mainly physical but also mental as a result of trauma particularly for the children and young persons. Very low standards of living characteristic of the majority of African people means that lack of proper nutrition and access to early intervention services results in more cases of children and young persons with disabilities. Some detrimental cultural beliefs, practices and attitudes and intense social stigma associated with disability may also exacerbate or otherwise make it difficult to address the needs of children with disabilities in African communities.

The inadequacy of resources in the region also compromises the capacity of African states to implement their international human rights commitments.208 In effect, the volume of such commitments notwithstanding, effective and consistent translation of the rights of children in the justice system into practice cannot be guaranteed.

3. LEGAL FRAMEWORK ON JUSTICE FOR YOUNG OFFENDERS WITH MENTAL ILLNESS IN AFRICA 3.1. The African Charter on Human and People´s Rights (ACHPR) The ACHPR is the principle regional human rights instruments in Africa.209 In article 16, the Charter recognizes the right of every individual to enjoy the best attainable state of physical and mental health, and the duty of State Parties to take necessary measures to protect the health of the people, and to ensure that they receive medical attention when they are sick. In article 18(4), the Charter recognises the right of persons with disabilities to special measures of protection in keeping with their ‘physical and moral’ needs. The ACHPR however lacks an explicit prohibition of discrimination on the basis of disabilities, and does not expound on the guarantees of persons deprived of liberty. As discussed further below, the African Commission on Human and People´s Rights has, through case law, expanded the grounds of discrimination under the article 2 thereof to include disability. Also, the needs of persons with disabilities are more than ‘physical and moral’ as envisaged under the provision. In the present context, medical or psychological support may be equally needed.

208 Ann Skelton and Charmaine Badenhorst ‘The Criminal Capacity of Children in South Africa: International Developments and Considerations for a Review’ Child Justice Alliance (2011) 10.

209 Viljoen, F International Human Rights Law in Africa (2007) Oxford University Press 235.

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3.2. The African Charter on the Rights and Welfare of the Child (ACRWC) The Africa Children’s Charter is the principal children’s rights instrument in the region. It complements and supplements the provisions of the CRC in the African context. Though the rights established in the ACHPR apply to children as well, the Charter does not have a specific focus on children. Rather, it requires states to ensure the rights of the child ‘as stipulated in international declarations and conventions.’210 Such declarations and Conventions include the CRC and the ACRWC. The Children’s Charter addresses the issue of juvenile justice in article 17. In terms thereof, a child accused of or found guilty of having infringed the penal law is entitled to special treatment in a manner consistent with their sense of dignity and self-worth. Particularly, the provision requires that such child is not subjected to torture, inhuman or degrading treatment or punishment, that they are separated from adults in detention, that they are presumed innocent until recognized as guilty, and that where the child is accused of having infringed the law, they are promptly informed in detail of the charge against them and are entitled to an interpreter if they cannot understand the language used.

The framing of the provision raises some concerns on the rights of child offenders with disabilities. It is argued that the provision is susceptible to abuse because a child’s sense of dignity and self-worth is a subjective standard.211 In addition, unlike article 37(b) of the CRC, the ACRWC excludes the guarantee that a child may not be deprived of their liberty unlawfully or arbitrarily or that the arrest, detention or imprisonment of a child shall be a measure of last resort and for the shortest time possible. Moreover, The ACWRC neither prohibits life imprisonment for children, nor provides for legal remedies for children deprived of their liberty in similar terms with the CRC.212 In addition, article 17 of the ACRWC is limited to children ‘accused or found guilty of having infringed the penal law’. In view of the rampant criminalization of disability-induced conduct as well as the designation of children with disabilities as being in need of care and protection in terms of domestic legislation, the foregoing omissions disproportionately affect these children.

In article 13, the Charter recognises the rights of children with mental disabilities to special measures of protection in keeping with their ‘physical and moral’ needs and in environments that respect their dignity, promote self-reliance and active participation in community.

The framing of this provision also raises some concerns. The article’s scope is limited to ‘mentally or physically disabled’ children. As the body mandated with the interpretation of

210 ACRWC Article 18(3) 211 Michael Gose The African Charter on the Rights and Welfare of the Child (2002) Community Law Centre 70 212 Michael Gose The African Charter on the Rights and Welfare of the Child (2002) Community Law Centre 71

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the ACRWC, the African Committee of Experts on the Rights and Welfare of the Child could expand the interpretation of this provision in tandem with the CRC Committee’s General Comment No. 9 or the UN Convention on the Rights of Persons with Disabilities. Secondly, though article 13 is exclusively on children with disabilities, it does not reiterate their equal right to benefit from the rights established under the Charter. Also, the criterion for access to special measures under the article is too stringent and subjective, thereby diminishing the potential benefits of the measures for the target children. Significantly for this work, the envisaged support measures exclude support to facilitate access to justice.213

3.3. African Youth Charter The African Youth Charter sets out the rights and freedoms of the youth, defined as persons between the age of 15 and 35, and the corresponding duties of states in that regard.214 The Charter reiterates the guarantees in the ACRWC with respect to children accused of committing crimes.215 It specifically addresses the right of ‘mentally and physically challenged youth’, particularly their need for special care and the duty of the state to ensure access to education, training, health care services, employment, sport, physical education and cultural and recreational activities.216

3.4. Non-binding legal instruments Several non-binding instruments have also been adopted at the regional level. These include the Guidelines on Action for Children in the Justice System in Africa which provide guidance for action on implementing international and regional instruments on child friendly justice by states and other role players in the region. These guidelines call for the consideration of the special needs of, inter alia, children with disabilities.217 They do not however, prescribe specific measures for children with disabilities, preferring rather to address the needs of ‘vulnerable groups of children’ generally. The Guidelines provide that, ‘in developing systems for the protection and advancement of justice for children, priority attention shall be given to children in need of special protection including ......children with disabilities’.218 They also emphasize the need to take into account the right of children with disabilities to have access to information in the development and provision of information about the

213 In terms of article 23(3), assistance extended to a child with disabilities is designed to ensure that the child has access to education, training, healthcare services, rehabilitation services, preparation for employment and recreation opportunities. The need to extend special assistance to children with disabilities to facilitate their access to justice was not highlighted at all during the negotiating process on article 23 of the CRC. 214 African Youth Charter, Adopted in Banjul 2006 and entered into force in August 2009. There are 28 ratifications of the instrument so far.

215 Article 18 216 Article 24.

217 Guidelines on Action for Children in the Justice System in Africa, paragraph 3(k).

218 Guidelines on Action for Children in the Justice System in Africa paragraph 26.

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justice system to children.219 The Guidelines further require traditional courts to respect international standards on the right to fair trial and children’s rights.220 This is significant because in Africa, children with disabilities are often the subject of discriminatory traditional attitudes which are likely to be endorsed and or perpetuated by such traditional institutions.

The Kampala Declaration on Prison Conditions in Africa which was adopted at a meeting of African stakeholders in the context of prisons in Africa in 1996, recognized the vulnerability of certain groups of prisoners particularly those with mental or physical illness, and prisoners with disabilities, and called for special procedures and treatment in accordance with their needs during arrest, trial and or detention.221 Similarly, the Robben Island Guidelines222 require measures to ensure that when deprived of their liberty, members of ‘vulnerable groups’ are held in appropriate and separate facilities.223 A common and recurrent feature of these instruments is that they all recognize the need for a special response to the needs of persons with disabilities or mental illness. However, they fail to identify or prescribe tailored measures that have the potential to clearly guide action in response to these needs. The implications of this omission ought to be understood in the context of growing evidence that the mere proscription of discrimination does not guarantee appropriate and adequate responses to the rights of marginalized groups including persons with disabilities.

4. REGIONAL INSTITUTIONS AND SPECIAL MECHANISMS 4.1. African Commission on Human and People´s Rights The Commission is established under article 30 of the ACHPR to promote and protect human rights in Africa in various ways including formulation of principles and rules on human rights that can guide African governments in formulating their legislation.

The Commission also receives and considers cases alleging violation of any of the rights established thereunder.

Thus far, the Commission has heard and determined one case on the violations of the rights of prisoners with disabilities. In Purohit and Moore v The Gambia224 the complainants

219 Guidelines on Action Paragraph 33.

220 Paragraph 37(a).

221 Kampala Declaration on Prison Conditions in Africa Paragraph 5(d).

222 Guidelines and Measures for the Prohibition of Torture, Cruel, and Inhuman or Degrading Treatment or Punishment in Africa (The Robben Island Guidelines).

223 Paragraph 36.

224 Purohit and Moore v The Gambia 16 Annual Activity Report 241/01.

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were mental health advocates acting on behalf of patients detained in a psychiatric unit of the Royal Victoria Hospital as well as ‘future’ mental health patients detained under the Mental Health Acts of the Gambia, including the Lunatics Detention Act. They alleged violation of articles 2, 3, 5, 7(1) (a) and (c), 13(1), 16 and 18(4) of the Charter which include the right to inter alia, non-discrimination, equality before the law and equal protection of the law, respect for human dignity, and the right to health. The Commission admitted the complaint and considered it on merit.

Several issues raised in this case are significant to the rights of child and young offenders with mental illness. First, the Commission readily accepted ‘disability’ as one of the prohibited grounds of discrimination under the ACHPR. Secondly, the Commission readily applied international law and standards on the rights of persons with disabilities such as the Vienna Declaration and Program of Action, and the UN Principles for the Protection of Persons with Mental Illness and the Improvement of Mental Health Care.225In this way, the Commission opened an avenue for the application of international standards on mental health and mental disabilities in assessing the actions of states in the region. Further, the Commission was of the opinion that the language of the Lunatics Detention Act which referred to persons with mental illness as ‘lunatics’ and ‘idiots’ was dehumanizing and denying them their dignity, hence violating article 5 of the Charter.226 The Commission stated that persons with mental disability or illness, like all other human beings, ‘have a right to enjoy a decent life, as normal and full as possible, a right which lies at the heart of the right to human dignity,’227 and which ought to be ‘zealously guarded and forcefully protected by all States party to the African Charter’ according to the principle that all human beings are born free and equal in dignity and rights as stipulated in the Universal Declaration of Human Rights.228 In the Commission’s opinion, the automatic detention of persons considered ‘lunatics’ under the Lunatics Detention Act violated article 6 of the ACHPR on the right to liberty and security of the person, because whereas the detention was authorized by law, as required under article 6, it fell short of internationally laid down norms and standards for detention.

The Commission also set out the responsibility of the state with respect to health, nothing with regard to persons with mental disability that ‘as a result of their condition and by virtue of their disabilities, mental health patients should be accorded special treatment which would enable them to not only attain

225 UN Doc A/CONF.157/23, and UN General Assembly Resolution 46/119, 46 UN General Assembly ORSupp. (No. 49), UN Doc A/46/49 (1991) respectively.

226 Purohit and Moore v the Gambia para 59.

227 Purohit and Moore v the Gambia para 61.

228 Article 1 of the Universal Declaration of Human Rights.

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but also sustain their optimum level of independence and performance in keeping with article 18(4) of the African Charter …..and the UN Principles for the Protection of Persons with Mental Disabilities and Improvement of Mental Health Care.’229 While recognizing the scarcity of resources that could hamper the pursuit of optimum healthcare, both generally and specifically for persons with disability, the Commission nevertheless emphasized that ‘persons with mental illnesses should never be denied their right to proper health care, which is crucial for their survival and their assimilation into and acceptance by the wider society.’230 The Commission interpreted mental healthcare as ‘........analysis and diagnosis of a person’s mental condition and treatment, care and rehabilitation for a mental illness or suspected mental illness. The Principles envisage not just ‘attainable standards’, but the highest attainable standards of health care for the mentally ill at three levels. First, in the analysis and diagnosis of a person’s mental condition; second, in the treatment of that mental condition and; thirdly, during the rehabilitation of a suspected or diagnosed person with mental health problems’231 This case is highly significant because it shows that even in the absence of an elaborate clause on disability in the ACHPR, the protection of the rights of persons with disabilities can be read into the existing rights. The Commission’s attitude to the application of other international instruments also indicates that the gains made in the international human rights sphere may, courtesy to article 60 of the ACHPR, be actualized in the African context.

4.2. Special Rapporteur on Prisons and Prison Conditions in Africa The Special Rapporteur is a special mechanism of the African Commission established at the 21st session of the Commission in 1997. In exercise of her mandate, the Special Rapporteur has undertaken some country visits to assess the conditions of prisons and places of detention in African countries. The Countries visited so far include Ethiopia, South Africa, and Cameroon.232 Though this is a negligible number relative to the size of the region, it is nevertheless an important highlight of some of the trends in African countries with respect to detention of juveniles with mental disabilities or illness. In Ethiopia for instance,

229 Purohit and Moore v The Gambia para 81.

230 Purohit and Moore v The Gambia para 85.

231 Purohit and Moore v The Gambia para 82.

232 The reports of these visits are available at http://www.achpr.org/english/_info/prison_mis....html (accessed 27 December 2011).

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the Special Rapporteur reported that there were no prisoners with mental illness in the prisons as at the time of the visit. Where persons with mental illness were convicted, they were sent to a mental hospital instead.233 In South Africa, the Special Rapporteur visited the Letengeur Mental Hospital to which accused persons may be referred in terms of the Criminal Procedure Act for determination of the existence of mental illness.234 She noted that due to the vague definition of mental illness in the Mental Health Act of 1973,235 there was a broad range of people held at the facility.236 In addition, she argued that it was often overlooked that these ‘inmates’ had never been tried or convicted of the original offence yet once in the hospital, their release was a prerogative of the Attorney General.237 In her assessment, the Special Rapporteur was of the opinion that the standards of prisons and places of detention in South Africa are satisfactory and in line with the internationally established minimum standards on conditions of detention.238 On Cameroon, the Special Rapporteur noted appalling conditions in the places of detention, which were generally under resourced, inadequately stuffed and overcrowded.239 Though she did not report specifically on the circumstances of young offenders or offenders with mental illness, she nevertheless indicated that due to the acute shortage of facilities, even prisoners who were meant to be separated from the others, which would ordinarily include prisoners with mental illness, were not so separated.240 The foregoing reports highlight some endemic and almost universal issues in African prisons, and which have a potential impact on the rights of young offenders with mental disabilities.

Primary among these is the lack of or inadequate health facilities in the prisons. Though the degrees of availability may vary, it is nevertheless a significant issue in this regard. The second is the lack of trained staff with the necessary capacity to respond to the challenges of prisoners with mental health needs. Thirdly, the overcrowding characteristic of most of

233 Report of the Mission of the Special Rapporteur on Prisons and Conditions of Detention in Africa to the Federal Democratic Republic of Ethiopia 15 – 29 March, 2004 p26.

234 Report of the Special Rapporteur on Prisons and Conditions of Detention in Africa Mission to the Republic of South Africa 14 – 30 June 2004 .

235 The Mental Health Act was repealed by the Mental Health Care Act of 2002 which only applies to persons found to have mental illness.

236 Report of the Special Rapporteur on Prisons and Conditions of Detention in Africa Mission to the Republic of South Africa 14 – 30 June 2004 p16.

237 Report of the Special Rapporteur on Prisons and Conditions of Detention in Africa Mission to the Republic of South Africa 14 – 30 June 2004 16.

238 Report of the Special Rapporteur on Prisons and Conditions of Detention in Africa Mission to the Republic of South Africa 14 – 30 June 2004 p37.

239 Prisons in Cameroon Report of the Special Rapporteur on Prisons and Conditions of Detention in Africa 2 to 15 September 2002.

240 Prisons in Cameroon Report of the Special Rapporteur on Prisons and Conditions of Detention in Africa 2 to 15 September 2002 p13.

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the facilities means that the standard of living of the inmates is definitely compromised and has the potential to exacerbate or trigger mental illness or distress. The reports also highlight a trend in Africa where mental institutions have traditionally been maintained to ‘keep’ people with mental disabilities or illness. Generally, no distinction is made as to those referred thereto as a result of infringing the law and those admitted solely for the purpose of accessing medical care.

4.3. African Committee of Experts on the Rights and Welfare of the Child, ACERWC The ACERWC is established in article 32 of the ACRWC to promote and protect the rights and welfare of the child. In exercise of its mandate, the Committee may formulate and lay down principles on the rights and welfare of the child in Africa. Since the commencement of its work in 2002, the Committee has received initial reports from eleven countries and given observations in respect of eight of those. In all these reports, the Committee considered the efforts the state had made towards ensuring the rights of children with disabilities, and in the administration of juvenile justice. The Committee however did not address itself to the circumstances of juvenile offenders with mental health problems. The ACERWC has thus far received two communications on violation of rights established in the Charter, and rendered its decision on one of those. The cases did not however address the issue of children with disabilities or mental illness, or those deprived of liberty.

4.4. Convention on the Rights of Persons with Disabilities, CRPD Several African countries were actively represented by state and non-governmental organisations in the drafting process of the CRPD. A number of countries in the region have also signed and/or ratified the Convention.241 As a result, these countries have embraced the duty to take up measures to ensure the rights of persons with disabilities including those with mental disabilities. The adoption of the CRPD has triggered a wave of legislative review to align with the international obligations of the respective states. One of these rights is the right to health, particularly the duty to provide health services needed by persons with disabilities specifically because of the disabilities, including early identification and intervention as appropriate.242 As indicated at the beginning, when mental illness interacts with social attitudes and environment that bar effective and unhindered participation of the patient in society, it translates into a disability. The CRPD remains the single most elaborate document on the responsibilities of states towards persons with mental disabilities.

241 Thus far 22 African Countries have ratified the Convention and many more are signatory thereto.

242 CRPD Article 25.

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5. EMERGING FRONTIERS A recent case in South African courts highlights an emerging issue on the situation of children with ‘debilitating conduct disorder’ in the criminal justice process. The case highlights the inadequacy of the justice system in responding to the circumstances and or needs of children with mental health issues. It is also a good example of the challenges of borderline cases.

Unlike the more developed jurisdictions like the United States of America, Little is known about conduct disorder in South Africa,243 or other African countries for that matter. Children with conduct disorder, especially those who are severely affected, display violent outbursts and wayward behaviour. As a result, ordinary care facilities are either unable or unwilling to admit them. Consequently, the children are often referred to psychiatric institutions.

However, admission to such institutions requires a finding of mental illness by a mental health practitioner. The difficulty with these children however is that conduct disorder is not associated with a pathological disease of the mind, and the mental health practitioners are therefore unwilling to make a finding of mental illness.244 As a result, children with debilitating conduct disorder are unable to access appropriate responses and are often moved from one institution to another.

Children with conduct disorder are inherently predisposed to criminal conduct due to the violent behavioural patterns. In South Africa, courts are unwilling to find them to prima facie fit to stand trial. They are therefore often referred to the psychiatric hospitals for evaluation in terms of sections 77, 78 and 79 of the Criminal Procedure Act, or refereed to children’s courts as children in need of care and protection in terms of sections 50 and 64 of the Child Justice Act.245 In the latter case, the Children’s Court is likely to find these children to be in need of care and protection in which case they ought to be referred to appropriate care facilities, which as earlier mentioned, are not adequately resourced to deal with such children. The problem therefore becomes cyclic.

This case is significant in showing the shortcomings of chronological determination of capacity. Conduct disorder affects a child’s conative ability, meaning that whereas they may have capacity for reason, intellect, insight, perception or memory, which constitute cognition, they are nevertherless, unable to control their behaviour in line with such

243 Nicole Breen ‘Between the Cracks; How the State fails to provide for and Protect children with debilitating form of conduct disorder’ in Article 40 Vol 13 No.1 May 2011, 5.

244 Nicole Breen ‘Between the Cracks; How the State fails to provide for and Protect children with debilitating form of conduct disorder’ in Article 40 Vol 13 No.1 May 2011, 6.

245 Child Justice Act No. 75 of 2008

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cognition.246 Therefore, it is improper to presume capacity of a child with a conduct disorder simply because they are above the minimum age of criminal responsibility.

The case is also significant because it brings to the fore a lacuna in the law and practice relative to child and youthful offenders with mental health problems in South Africa. It has the potential for a ripple effect in the region where very little is known about conduct disorder.

6. ENTRY POINTS FOR INTERVENTION It is apparent from the discussion above that while a lot has already been achieved in terms of establishing an appropriate legal framework, there is a lot more to be done to ensure protection of children with mental disabilities in the justice system. There are a number of opportunities emanating from the foregoing discussion that can be further explored for this purpose. These include collaboration with and support for the regional human rights institutions, and the special mechanisms of the African Human Rights Commission, particularly the mandate of the Special Rapporteur on Prisons and Conditions of Detention.

Also, as above mentioned, the process of implementing the CRPD is still in the early stages in most African countries. It is therefore an opportune moment to ensure incorporation of legal safeguards relative to child and young offenders with mental disabilities. The trend of generic standards applicable to all on the basis of non-discrimination ought to be revised to specifically identify measures that ensure fundamental guarantees.

The practice of restorative justice has gained some impetus in the African context, partly due to its cultural legitimacy as a practice long associated with African values. Restorative justice has great potential to reduce the cases of children with disabilities sent to prison.

Engaging with the framework within which restorative justice is exercised in African countries can help identify opportunities for meaningful resolution of disputes and to accommodate the developmental needs of young offenders with mental illness.

246â&#x20AC;&#x201A; Nicole Breen â&#x20AC;&#x2DC;Between the Cracks; How the State fails to provide for and Protect children with debilitating form of conduct disorderâ&#x20AC;&#x2122; in Article 40 Vol 13 No.1 May 2011

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References Ann Skelton and Charmaine Badenhorst ‘The Criminal Capacity of Children in South Africa: International Developments and Considerations for a Review’ Child Justice Alliance (2011) Henry Weihofen ‘The Law and the Mentally Ill: the definition of mental illness’ Ohio State Law Journal Vol. 21 Winter 1960 Number 1.

Michael Gose The African Charter on the Rights and Welfare of the Child (2002) Community Law Centre.

Nicole Breen ‘Between the Cracks; How the State fails to provide for and Protect children with debilitating form of conduct disorder’ in Article 40 Vol. 13 No.1 May 2011 UN Secretary General Status of the Convention on the Rights of the Child Report 3 August 2011 A/66/230.

Viljoen, F International Human Rights Law in Africa (2007) Oxford University Press Purohit and Moore v The Gambia 16 Annual Activity Report 241/01.

Report of the Mission of the Special Rapporteur on Prisons and Conditions of Detention in Africa to the Federal Democratic Republic of Ethiopia 15 – 29 March, 2004 Report of the Special Rapporteur on Prisons and Conditions of Detention in Africa Mission to the Republic of South Africa.

Prisons in Cameroon Report of the Special Rapporteur on Prisons and Conditions of Detention in Africa 2 to 15 September 2002 .

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Chapter XI Juvenile Justice and Mental Health in Brazil: context, perspectives and challenges ....................................................................................................................................... by Aline Yamamoto Adriana Padua Borghi Daniel Adolpho Daltin Assis Gabriela Gramkow Maria Cristina Gonรงalves Vicentin

United Nations Latin American Institute for the Prevention of Crime and the Treatment of offenders (ILANUD)

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Table of Contents

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Introduction 1. LEGAL FRAMEWORK

1.1. Comprehensive Protection Doctrine of the Rights of Children and Adolescents 1.2. Psychiatric Reform 1.3. Juvenile Justice and Mental Health

2. A BRIEF PORTRAIT OF THE SOCIO-EDUCATIONAL SYSTEM IN BRAZIL AND THE DEMAND FOR MENTAL HEALTH CARE 3. PROBLEMATIC DIMENSIONS OF THE INTERFACE BETWEEN THE JUSTICE SYSTEM AND MENTAL HEALTH

3.1. The pathologisation of the offence and the psychologicallegal continuum as resistance to the guarantee of rights 3.2. The judicialisation of mental health care and the extension of the pathologising perspective to other sectors of adolescence

4. ADVANCES, EXPERIENCES AND CHALLENGES 4.1. Final Considerations

References

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Introduction Juvenile Justice and Mental Health in Brazil: context, perspectives and challenges247 The present article aims to contextualise the situation of juvenile offenders in Brazil with regards to the demand for mental health during the compliance with socioeducational measures248. Due to the fact that this is a problematic field, in which innumerable tensions emerge, in addition to introducing the legal framework that governs this interface, we will also touch upon its context and the main challenges that are involved in the integration of the Juvenile Justice System with the Mental Health System. Finally, we will present some proposed initiatives that leads to a new horizon for this field.

1. LEGAL FRAMEWORK 1.1. Comprehensive Protection Doctrine of the Rights of Children and Adolescents With the redemocratisation of the country in the 1980s, the promulgation of a new Federal Constitution in 1988 introduced to the Brazilian legal order a judicial and social conscience that recognises children and adolescents as subjects of full rights, with responsibility given to the State, the family and society to guarantee their rights with absolute priority249.

247 This article was prepared under the partnership between the OIJJ and the United Nations Latin American Institute for the Prevention of Crime and the Treatment of Offenders (Ilanud Brazil), with the authorship of: Adriana Borghi, master’s student in Philosophy of Law at Catholic University of São Paulo (drica.b@gmail.com), Aline Yamamoto, project coordinator of Ilanud, masters degree in Criminology and Criminal Law at Autonomous University of Barcelona and postgraduated in Women’s Human Rights at the University of Chile (alineddhh@gmail.com), Daniel Adolpho, lawyer at the Centre for Defence of the Rights of the Child and Adolescent Interlagos (Cedeca Interlagos, Sao Paulo) (danieladolpho@gmail. com), Gabriela Gramkow, Ph.D student at Programme of Postgraduate Studies in Psychology at Catholic University of São Paulo (gabigkw@hotmail.com) and Maria Cristina G. Vicentin, Ph.D professor at the Program of Post-Graduate Studies in Social Psychology at Catholic University of São Paulo (crisvic1@uol. com.br), all members of the Interagency Group on Mental Health and Juvenile Justice. This group brings together professionals from the judiciary, the Public Defender’s Office of the State of São Paulo, civil society organisations and research centres linked to universities, in the fields of law, psychology and health, with the aim of promoting advances in the mental health policy for juvenile offender in São Paulo.

248 In accordance with the Statute of the Child and Adolescent, socio-educational measures are applied to adolescents between 12 and 18 years old, who have committed one or more acts described as a crime or misdemeanour by the Brazilian Penal Code. The applicable measures are, in increasing order of severity: admonition, obligation to make reparations for damages, community service, probation, semiliberty and internment. Cf. Brazil. Statute of the Child and Adolescent. Federal Law 8,069 of July 13, 1990.

249 Cf. art. 227, Constitution of the Federative Republic of Brazil (Federal Constitution), “it is the duty of the family, society and the State to assure with absolute priority the rights of children and adolescents to life, health, food, education, leisure, occupational training, culture, dignity, respect, freedom, and family and community life, and in addition to protect them from all forms of negligence, discrimination, exploitation, violence, cruelty and oppression”.

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When specifically referring to health, the constitutional text includes, in addition to a general recognition of health as a universal right and duty of the State250, a specific provision that establishes the State’s obligation to promote comprehensive health assistance for children and adolescents, through the creation of specialised prevention programmes and services for those with physical, sensorial, or mental disabilities and for those addicted to drugs, as well as social integration for adolescents and the facilitation of access to collective goods and services, along with the elimination of prejudices and structural obstacles251.

This “new order,” founded on the Comprehensive Protection Doctrine and formalised by the Statute of the Child and Adolescent (Estatuto da Criança e do Adolescente – ECA)252, breaks with the Doctrine of the Irregular Situation253, which was imbued with the ideas of “protection,” “assistance,” and “surveillance” of those persons, then defined as “minors,” targets and objects of State legal and social intervention, within a correctionalrepressive lens that led to institutionalisation (and consequently exclusion) of an important segment of children and adolescents who were at risk and/or in conflict with the law.

The advent of this law, which regulates diverse facets of the lives of its subjects, thus ushered in important advances in guaranteeing the rights of and implementing public policies directed to children and adolescents. It is under these circumstances that efforts have been made to improve the policies for juvenile offenders in Brazil, so as to strengthen the System of Guarantees of the Rights of Children and Adolescents (Sistema de Garantia de Direitos da Criança e do Adolescente) (SGD)254.

As it specifically concerns involvement with illegal conduct, the ECA creates a special

250 Cf. articles 6 and 196 of the Federal Constitution.

251 Cf. article 227, par. 1, clause II and par. 3, clause VII of the Federal Constitution.

252 This change of orientation is in accordance with international norms that deal with the subject, to which Brazil is a signatory, such as the International Convention on the Rights of the Child (UN) and other guiding instruments of the Global Human Rights System, such as the United Nations Standard Minimal Rules for the Administration of Juvenile Justice (the Beijing Rules) and the United Nations Rules for the Protection of Juveniles Deprived of their Liberty.

253 The 1979 Minors Code provides in its art. 2: “For the purposes of this Code, a minor will be considered in an irregular situation if he or she is: I – deprived of conditions essential to his or her subsistence, health, and obligatory education, even as an occasional situation, due to a) the absence, action or omission of the parents or guardian; b) the manifest impossibility of the parents or guardian to provide evidence of those essential conditions; II – a victim of mistreatment or excessive punishment at the hands of his or her parents or guardian; III – in moral danger, due to a) finding him or herself habitually in environments that are contrary to good habits; b) exploration of activities that are contrary to good habits; IV – deprived of legal representation or assistance due to the occasional absence of the parents or guardian; V – deviant in conduct, by virtue of serious family or community inadequacy; VI – responsible for committing a penal infraction”.

254 According to art. 1 of resolution 113 of April 19, 2006, of national Council of Children and Adolescents, the SGD consists of the interconnection and integration of public governmental agencies and civil society, the application of normative instruments and the functioning of mechanisms of promotion, defence and control for the effectuation of the rights of children and adolescents, at the federal, state, district and municipal level.

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system of accountability for adolescents (between 12 and 18 years old255), taking into account the principle of their peculiar condition of development256. This law also carries a specific provision for cases of juvenile offenders who have mental illnesses or deficiencies, which stipulates that they should receive individual and specialised attention in an adequate facility for their conditions257. However, this instrument does not define the manner of care for these adolescents, which has been done by regulations in the area of health.

1.2. Psychiatric Reform Parallel to these changes in childhood and youth field, the mental health field movement in favour of Health and Psychiatric Reforms began to gain strength in Brazil during the 1970s. Thus, in the 1980s, within the constituent movement and its political motives for the recognition of human dignity, mental health was also reevaluated, especially by questioning the therapeutic effectiveness and quality of psychiatric internment and its various manifestations (judicial insane asylums, custodial hospitals, etc.).

Various experiences in de-hospitalisation and the creation of alternative services to psychiatric hospitals were undertaken in several cities and states during this period, setting up a broad movement of workers and patients under the banner of the AntiAsylum Fight.

In 1990, Brazil signed the Caracas Declaration of the World Health Organisation, based on the principle of deinstitutionalisation and promulgated its Organic Health Law. This law created the Unified Health System (Sistema Único de Saúde - SUS), formed by the interaction of federal, state and municipal management, subject to social control (exercised by “Health Councils”) and giving rise to changes in this area with a democratic and participatory perspective258.

However, only 11 years later, Brazil promulgated Federal Law 10.216/2001, known as the Psychiatric Reform Law, with the purpose of redirecting the model of mental health care in the country. The law is to be implemented by giving preference to non-hospital and community facilities (internment being indicated only when those resources prove insufficient and to be undertaken with the ultimate goal of the patient’s

255 The Brazilian Federal Constitution envisions, in its article 228, the non-imputability of persons under 18 years of age, i.e. if a person under 18 commits an act that is considered a crime or misdemeanour (an infractional act), he or she should be held accountable in accordance with the provisions of the ECA, not the Penal Code. As for infractions committed by children (person under 12 years of age, art. 2 of the ECA), the Statute envisions the application of protective measures (as provided in article 101), which do not possess a punitive character.

256 Cf. article 227, par. 3, clause V of the Federal Constitution and article 121of the ECA. 257 Cf. article 112, par. 3 of the ECA. 258 Federal Law 8.080/1990.

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social reintegration into his or her home environment), with explicit respect for the fundamental rights of people with mental disorders and their family members259 and within the federal structure of management pacts and intersectoral cooperation rooted in the principles of deinstitutionalisation and dehospitalisation260.

1.3. Juvenile Justice and Mental Health Historically, the interconnection of the justice system with the health care system has been a subject referred to the National Mental Health Conferences261. Since 1987, when the First Conference took place, until today, with the recent realisation of the Fourth Conference262, numerous proposals have been approved263, reflecting the constant

259 Among the patient’s rights provided for are: I – to have access to the best treatment in the health care system, consistent with his or her needs; II - to be treated humanely and with respect, and for the exclusive purpose of improving his or her health, aiming to achieve his or her recovery by integration into his or her family, work and community; III – to be protected against all forms of abuse and exploitation; IV – to have confidentiality guaranteed for all information he or she provides; V – to have the right to a medical consultation, at any time, to clarify the necessity or non-necessity of his or her involuntary hospitalisation; VI – to have free access to available means of communication; VII – to receive all information with respect to his or her illness and treatment; VIII – to receive treatment in a therapeutic environment by the least invasive means possible; IX – to receive treatment preferably through community mental health services; Cf. art. 2 of Federal Law 10.216/2001.

260 “The promulgation of this Law imposes a new impetus and new rhythm on the process of psychiatric reform in Brazil. It is in the context of the promulgation of Law 10.216 and the realisation of the Third National Mental Health Conference that the mental health policies of the federal government, aligned with the guidelines of psychiatric reform, have been consolidated, thereby achieving greater sustainability and visibility. Specific lines of funding are created by the Ministry of Health for open services and alternatives to psychiatric hospitals, and new mechanisms are created for the monitoring, management and scheduled reduction of the number of beds in psychiatric hospitals in the country. From this point, the daily mental health care network is experiencing an important expansion, reaching regions with a strong hospitalisation tradition, where community assistance for mental health has been practically non-existent.” (Brasil. Ministério da Saúde. Secretaria de Atenção à Saúde. Departamento de Ações Programáticas e Estratégicas. Coordenação Geral de Saúde Mental. Reforma Psiquiátrica e Saúde Mental no Brasil - Documento apresentado à Conferência Regional de Reforma dos Serviços de Saúde Mental: 15 anos depois de Caracas. OPAS. Brasília, novembro de 2005 (b), p. 8-9) 261 Present at the core of the discussions about social and cultural policies, the Conferences are carried out in a way that is both intersectoral and decentralised (politically and administratively), with the participation of members of civil society, government, and the State. The purpose of the Conferences is to produce proposals that are capable of improving the Brazilian political system, in accordance with the subject (rights) and the sector (policies). Documents are used to evaluate and monitor the policies, so that their decisions lead to effective mechanisms for guaranteeing rights. With a genuinely deliberative character, the Conferences issue Resolutions that bind the branches of government to their compliance.

262 The Second Conference took place in 1992, the Third was carried out in 2001, and the Fourth occurred in June of 2010.

263 At the First Conference, it was decided: 1. To adopt legal regulations that limit the psychiatric internment of “minors” and that remain under control; 2. That minors, from age 16 on, may contest their internment; 3. To guarantee, to hospitalised minors, formal or specialised education, professional training, and the right to recreational space; 5. That the therapeutic measures to be used on minors will be carefully reviewed, limiting or prohibiting the use of psychotropic drugs and other procedures (electroconvulsive therapy, for example) of dubious utility or of potential harm to the developmental process and the physical and mental integrity of minors; 6. That the psychiatric internments ordered by a Juvenile Judge will be required to be submitted for evaluation by a mental health team; 7. That minors subjected to internment

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concern of health care professionals with guaranteeing the rights of juvenile offenders and with monitoring the political policies that tend to segregate and exclude this segment of the population.

In spite of the existing legal framework in the area of childhood and youth (Law 8.069/90) and mental health (Law 10.216/2001), in 2002 a study by the Institute for Applied Economic Research revealed the fragility of health care for juvenile offenders incarcerated in socio-educational facilities in Brazil, reinforcing the necessity of implementing the reformative legislation264.

In response to the situation triggered by that study (and others265), which demonstrated, in various Brazilian states, all the problems caused by the socio-educational measure of internment, the federal government (through the Ministry of Health, the Secretariat of Human Rights and the Special Secretariat of Women’s Policies) created regulatory mechanisms for the development of guidelines regarding the comprehensive health of juvenile offenders subjected to deprivation of liberty and pre-trial detention.

Thus was enforced the Interministerial Ordinance 1.426/2004 and SAS/MS Ordinance 340/2004 (currently SAS/MS Ordinance 647/2008), urging the Secretaries of Health and those in charge of the socio-educational system to create a State Operating Plan for the health care of these adolescents. In terms of mental health, the SAS/MS Ordinance establishes that adolescents deprived of their liberty have guaranteed access to outpatient facilities in the Unified Health System and requires the creation of social reintegration programmes and, in cases of health hazards due to the use of alcohol and other drugs, the promotion of care includes the perspective of harm reduction.

Also in 2004, the National Forum on Child and Juvenile Mental Health266 was instituted, bringing together representatives from different sectors in equal numbers, both governmental and non-governmental, and organised by the National Mental Health Coordination of the Ministry of Health. Having already held eight meetings at this point,

will be guaranteed protection rights similar to those of adult patients, by studying mechanisms of control and protection that avoid collateral discrimination against them due to their minority and status as wards of the state. At the Second Conference, the monitoring of current mental health policies was defended by: creating, within the Ministry of Health, a Commission for the Protection of the Citizenship Rights of Children and Adolescents with Mental Illness, based on the Statute of the Child and Adolescent. At the Third Conference, it was resolved that “children and adolescents may not be treated by services that do not guarantee the rights recognised by the Statute of the Child and Adolescent.” At the Fourth National Mental Health Conference (in June of 2010), the debate and the construction of guidelines and resolutions was based on the relation of the justice system to mental health policies for children and adolescents.

(Conselho Regional de Psicologia de São Paulo. Medicalização da Infância é tema de manifesto do CRP-SP. Publicada no dia 08/06/2010. Available at http://www.crpsp.org.br/crp/midia/noticias/medicalizacao_ infancia.aspx) 264 Rocha, E. Mapeamento nacional da situação das Unidades de execução da medida socioeducativa de privação de liberdade ao adolescente em conflito com a lei. Brasília: IPEA/DCA-MJ, 2002.

265 Vicentin, M. C. G. Interfaces psi-jurídicas: o caso da psiquiatrização do adolescente em conflito com a lei.

Relatório de pesquisa-doutor - Pontifícia Universidade Católica de São Paulo, São Paulo, 2005 (b). Mimeo.

266 Ordinance GM 1.608, August 3, 2004.

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the Forum has become an important space for dialogue, cooperation and deliberation on the issue. According to a decision of the Forum, a pilot research project was carried out in 2005 in the State of Paraná regarding mental health care of juveniles deprived of their liberty267, whose results showed the fragility of intra-institutional care, the network and its coordination and highlighted the need for further studies on the use of alcohol and other illegal drugs, as well as on mental disorders268.

In the same year and in that context, the Mental Health Technical Department of the Ministry of Health proposed guidelines269 on mental health care in adolescence that situate juvenile offenders within the scope of any health service, in the direction of universal attention270.

At the same time, in the socio-educational field, it was found that even after more than 10 years of the ECA being in force, the national scene pointed to a lack of clear parameters for the execution of socio-educational measures involving deprivation of liberty (statewide), a fragility (and in most cases, nonexistence) of municipal programmes for the execution of socio-educational measures involving alternatives to incarceration271, and a lack of coordination among the different governmental bodies involved in the development of comprehensive policies to protect the rights of juvenile offenders. In that framework, after a long process of consultation with specialists and civil society organisations, the National System of Socio-educational Measures (Sistema Nacional de Atendimento Socioeducativo - SINASE) was developed to serve as the federal guidelines for carrying out socio-educational measures272.

267 The survey included 16 juvenile facilities for detention and/or pre-trial detention in 13 municipalities in Paraná.

268 Brasil. Ministério da Saúde e Secretaria de Direitos Humanos da Presidência da República. Levantamento Nacional da Atenção em Saúde Mental aos Adolescentes Privados de Liberdade e sua Articulação com as Unidades Socioeducativas – Relatório Preliminar. Brasília, 2009.

269 Brasil. Ministério da Saúde. Secretaria de Atenção à Saúde. Departamento de Ações Programáticas e Estratégicas. Caminhos para uma política de saúde mental infanto-juvenil. Brasília: Editora do Ministério da Saúde, 2005 (a).

270 In this regard: “All public health services aimed at children and youth should be open to anyone who arrives, i.e., each and every demand brought to the health service system according to the territory, should be attended, which means received, heard and answered.” Moreover, in the context of an intersectoral and territorial logic, “a clinical study cannot prevent itself from expanding its services, out of its gates, to the network which includes other services of a clinical nature (other Psycho-social Care Centers, outpatient programmes, hospitals, Family Health programmes etc.), but also to other non-clinical social agencies that permeate the lives of children and young people: school, church, children and youth justice system institutions, the guardianship council, sports, leisure, and culture institutions, among others.” (Ibidem, p.

12-14).

271 The Statute of the Child and Adolescent (articles 87 and 88) assigns responsibility to the municipalities’ executive power for the articulation and management of execution programmes of socio-educational measures without deprivation of liberty, as a part of a broader guideline of the municipalisation on the System of Guarantees of the Rights of Children and Adolescents.

272 Brasil. Presidência da República. Secretaria Especial dos Direitos Humanos. Conselho Nacional dos Direitos da Criança e do Adolescente. Sistema Nacional de Atendimento Socioeducativo – SINASE. Brasília: CONANDA, 2006c. There is a bill (PLC 134/2009) pending in Congress to turn SINASE into law.

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SINASE coordinates federal entities and their various bodies (on education, health, security, social assistance, etc.) to undertake programmes of socio-educational care, by taking into account intersectoral cooperation and sharing responsibility with the family, community, and State, by defining the responsibilities of the different actors in the financing, implementation, monitoring and evaluation of the system and by mapping out pedagogical guidelines that reaffirm the predominantly educational nature of the measures (prioritising those implemented without depriving the juvenile of his or her liberty).

At a time of overcoming the hegemonic practices of discipline and segregation, SINASE reinforces that the promotion and comprehensive health care of juvenile offenders, especially in regards to mental health, has become a guarantee of: non-confinement in wards or special areas as well as access to outpatient treatment; inclusion of health data and statistics on this segment of the population in the SUS information systems; reform and acquisition of equipment in health care units; and establishment of minimum health teams at socio-educational internment facilities, all of which emphasise the need to guarantee specialised care for adolescents in psychological distress or with alcohol and other drugs dependencies through the formulation of special policies that respect intersectoral and coordinated network services, particularly from the perspective of Psychiatric Reform.

In this sense, the parameters suggested by SINASE are consistent: the detention facilities must have a health plan established in partnership with the municipal, state and federal policies, in order to combine and coordinate their different competencies.

The facilities should ensure, in a combined and complementary manner, access to the specialised service that is appropriate for each case (whether it be a Therapeutic Community, Psychiatric Ward or Psycho-social Care Center), as necessary, and should ensure the participation of its health care team (clinician, psychologist, psychiatrist, social worker and others) in the treatment process, each with defined roles in the referred plan.

In parallel, and in order to reinforce these actions, in 2006, the National Plan for the Promotion, Defence and Guarantee of the Right of Children and Adolescents to Family and Community Life emerged273. This Plan represents an important instrument for breaking with the culture of institutionalisation of vulnerable or at-risk children and adolescents274. It strengthens the paradigm of full protection and preservation of family

273 Brasil. Presidência da República. Secretaria Especial dos Direitos Humanos. Conselho Nacional dos Direitos da Criança e do Adolescente. Plano Nacional de Promoção, Proteção e Defesa do Direito de Crianças e Adolescentes à Convivência Familiar e Comunitária. Brasília: CONANDA, 2006 (a).

274 The expressions “socially vulnerable” and “socially at risk” are used by the Unified Social Assistance System to name situations where children and adolescents have weak or nonexistent families ties, as well as where they have suffered various violations of rights. Such situations include the imposition of socio-

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and community ties advocated by the Statute of the Child and Adolescent.

During this same year, Interministerial Ordinance 1.055/2006 was instituted, which gave rise to a Working Group designed to create the Brazilian Centre for Human Rights and Mental Health (Núcleo Brasileiro de Direitos Humanos e Saúde Mental). Established by Interministerial Ordinance 3.347/2006 of the Ministry of Health and the Secretariat of Human Rights, it has a deliberative, consultative and supervisory function.

Currently, Ordinance SAS/MS 647/2008 is in force, which, combined with SINASE, was designed to support the “Guidelines for Deployment and Implementation of the Policy of Comprehensive Health Care for Juvenile Offenders in Detention or Pre-trial Detention”. These guidelines emphasise the physical and human structure in the readjustment of the health care system in facilities of deprivation and restriction of liberty, as well as furthering the development of the State Operating Plans for Comprehensive Care of these juveniles. Thus strengthening the federal alliance is envisioned, which involves, in reality, the state and municipal health networks.

Issued in 2009, the report of the Eighth Regular Meeting of the National Forum on Child and Juvenile Mental Health, reiterated: i) the guarantee of care in the public mental health network for adolescents under social-educational measures, as legitimate users; ii) the need for dialogue between health managers and the System of Guarantees of Rights in order to effectuate health initiatives within the SINASE and SUS principles; iii) the rejection and abhorrence, henceforth, of practices that are abusive or violative of rights, such as compulsory internment in specialised facilities and/or psychiatric hospitals.

Finally, it is worth noting that The Mental Health Reform in Brazil has increased its thematic and programmatic agenda, having absorbed the issue of alcohol and drug abuse into mental health policy with the relocation of the part of the drug and alcohol policy that until then had been classified strictly as within the area of justice, and the reconceptualisation of care with an emphasis on harm reduction strategies, as well as with the creation of the CAPS ad (Centre for Psycho-social Care – Alcohol and Drugs).

Despite having established all of these regulations and parameters for the structuring of a public policy that respects the human rights of children and adolescents, even after 20 years of the ECA being in force, numerous violations of its provisions are observed in practice. It is acknowledged that the System of Guarantees of Rights is still not fully institutionalised and has been carried out in a disjointed manner, with problems with the training of its operators, causing great damage to the implementation of public policies that guarantee the rights assured by the ECA. Not only that, it is the interface between the two areas, Juvenile Justice and Mental Health,

educational measures, a judicial consequence for committing an infraction.

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where the tension is established, verifiable by the divergent views/interpretations about juvenile offenders. Sectors of the Judiciary, supported by previously explained legal framework but still rather deficient in implementing the Doctrine of Comprehensive Protection, position themselves, within the logic of penal thought, as pro-society, adopting the concept of the dangerousness of the juvenile offender and labelling him a public enemy275 in order to justify the deprivation of his or her liberty276. To support this understanding, they conscript psychological knowledge, not to use it from a perspective of multidisciplinary care or the right to health, but to subject those who occasionally need mental health care to practices of institutionalisation and abuse of medication, as will be explained in depth in chapter 3 of this article.

2. A BRIEF PORTRAIT OF THE SOCIO-EDUCATIONAL SYSTEM IN BRAZIL AND THE DEMAND FOR MENTAL HEALTH CARE

Brazil is a country that faces high rates of violence and criminality. Nevertheless, these numbers do not affect everyone in the population in the same way: young people from 12 to 29 years old, who represent 35% of the Brazilian population, are both the main victims and main perpetrators of violent acts277.

The violence is selective in its victimisation and particularly affects young people who live in the peripheral areas of large cities, are black, have little education and are in highly socially at-risk situations278. Adolescents, inserted in this context of violence279,

275 It is worth contextualising this designation at the core of criminological line entitled “Enemy Criminal Law”.

276 The great tension in the integration of the Juvenile Justice System with Mental Health is especially evident in cases of adolescents deprived of their liberty. Those under a socio-educational measure without deprivation of liberty are easily directed to the outpatient network of SUS. 277 There are only a few studies which analyse the authorship of infractions committed in Brazil. In the penitentiary system, it appears that over half of the prisoners are young adults up to 29 years old. A survey conducted by SENASP based on incidents registered by the Civil Police points out that the adolescents are the authors of about 10% of the homicides, robberies, drug trafficking and rapes, 6% of personal injuries and 8% of extortions through kidnapping – Cf. Brasil. Ministério da Justiça. Secretaria Nacional de Segurança Pública. Perfil das vítimas e agressores das ocorrências registradas pelas polícias civis: janeiro de 2004 a dezembro de 2005. Brasília, agosto de 2006.

278 In this regard, one of the conclusions drawn by the Map of Violence in Brazil (2010) indicates that the rates of youth victimisation by homicide are abnormally high if compared to the international standards.

Proportionally today there are two and a half times more homicides of young people (ages 15 to 24) than people out of this age range, from which we can conclude that the increase in violence in Brazil has the youth as its major target, and the rates increasingly grow. Between the ages 12 and 15, each additional year of life almost doubles the number of homicides and homicide rates – Cf. Waiselfisz, J. J. Mapa da violência 2010: anatomia dos homicídios no Brasil. São Paulo: Instituto Sangari, 2010.

279 According to a survey conducted by Datafolha, in 2009, it was possible to verify that over a third of Brazilian adolescents and young people are constantly exposed to violence in their daily life - Cf. Brasil.

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have many of their human rights disrespected and experience a process of progressive exclusion which culminates, when they commit an offence, with the Justice System.

From his seizure by police until his completion of a socio-educational measure, the adolescent passes through a system where, in practice, repressive and educational objectives overlap and where mistreatment and torture are still constantly present. It is through this process that approximately 60,000 adolescents under social-education measures, which correspond to far less than 1% of the total population of adolescents in the country, see their chances of escaping the circle of violence and creating a different trajectory for their life becomes even more distant.

According to the National Survey on the Socio-educational Treatment of Juvenile Offenders in 2009280, Brazil has approximately 18,000 incarcerated adolescents, which corresponds to around 30% of adolescents subjected to socio-educational measures.

Another research study, conducted by Ilanud281, identified that 93% of the adolescents in compliance with socio-educational measures were male. The offences they committed were most part (53%) against property (drug offences accounted for 16% and homicides only 5%); 44% were between 16 and 17 years old and 34% were between 18 and 21, most of whom had not completed elementary school. This profile does not differ substantially from the youth which is sentenced to deprivation of liberty, since according to the National Survey on the Situation of Facilities for Juveniles Deprived of their Liberty, 90% were male, 97% were of African descendent, 76% were between 16 and 18 years old, 51% did not attend school, 90% had not completed primary education, and 85.6% were drug users282.

Regarding the percentage of adolescents suffering from mental illness who were under a socio-educational measure involving deprivation of liberty, there are no national studies that allow one to know the effective demand for these specific health services. On the other hand, the existing studies at the regional level present very different results and do not clearly expose their methodologies283, thus hampering their use as scientific studies.

Ministério da Justiça; Pronasci; Fórum Brasileiro de Segurança Pública; ILANUD; Instituto Sou da Paz; SEADE. Projeto Juventude e Prevenção da Violência: primeiros resultados. Brasília, novembro de 2009..

280 Brasil. Presidência da República. Secretaria de Direitos Humanos. Secretaria Nacional de Promoção dos Direitos da Criança e do Adolescente. Levantamento Nacional do Atendimento Socioeducativo ao Adolescente em Conflito com a Lei. Brasília, 2009. Available at: http://www.obscriancaeadolescente.org.br/observatorio/ pesquisas/index.php?pg=pesquisa&id_submenu=148&id_categoria=2.

281 Ilanud; Secretaria Especial de Direitos Humanos da Presidência da República.Mapeamento Nacional de Medidas Socioeducativas em Meio Aberto. Relatório Resumido, São Paulo, 2007. Available at: http://www.ilanud. org.br/midia/doc/relatorio_resumido_mapeamento_mse_abr2009.pdf.

282 Rocha, E., op. cit.

283 An example of this situation can be illustrated based on the results of local research developed in São Paulo and in Bahia. In São Paulo, the Centre for Studies and Research on Forensic Psychiatric and Legal Psychology (NUFOR) identified that approximately 27% of the 2400 young offenders under socioeducational measures involving deprivation of liberty presented some mental health problem. Between June 2008 and June 2009, 38% developed disorders related to abusive use of alcohol or drugs, 12% had

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In 2008, through an initiative of the Ministry of Health and the Secretariat of Human Rights of the Presidency, the first study was carried out on a national scale with the objective of describing and analysing the condition of mental health care for incarcerated adolescents in order to subsidise the promotion of public policies.

The National Survey on the Mental Health of Incarcerated Adolescents and its Connection with Socio-educational Facilities was performed in 272 detention or pre-trial detention facilities (out of 288 total facilities) in 147 municipalities of the country284. The final results of this survey pointed out key elements for improving the mental health policies for juvenile offenders, like the following relevant data285: Concerning the care of adolescents with problems associated with the use of alcohol and other drugs, it was observed that, despite the significant proportion of socio-educational facilities that refer these adolescents for external mental health care services, there’s a high prevalence of referrals to therapeutic communities and psychiatric hospitals (40%) or simply in-house care (i.e. within the facility) (33%), while fewer use external and open health services, such as CAPS ad (25%). That is, the adolescents are moved between similar institutions: from socio-educational internment facilities to psychiatric hospitals and therapeutic communities and then back to the internment facilities. This pattern, although it could be related to the provision of fewer public services in the area of drugs and alcohol, also demonstrates a viewpoint that use/abuse and chemical dependency are still approached by the detention facilities staffs (including the health care team) as an issue to be dealt with through discipline or medication, resulting in minimising the need for an approach through external health care services. It also points to a model of care focused on abstinence and institutionalisation (already encouraged by the total deprivation of liberty imposed by the accountability model of

behaviour disorders, 10% had profound depression, 8% had Attention-Deficit Hyperactivity Disorder, and 6% had anxiety disorders. There were fewer cases of major complexity: 4% were mentally retarded, 3% had bipolar disorder, and 3% had a psychotic condition, such as schizophrenia (source: http://www.estadao. com.br/estadaodehoje/20090824/not_imp423599,0.php). In Bahia, a study conducted in 2003 in a detention facility for adolescents reached the following result: out of the 290 individuals, 24.8% did not have a mental disorder and 75.2%, fulfilled the criteria for one ore more psychiatric disorders, according to the tenth review of the International Classification of Diseases (ICD-10). Among the 218 who had pathologies, 47.7% presented disorders in comorbidity. The most common associations were between behaviour disorders and disorders involving the abusive use of psychoactive substances (13.4%). Hyperkinetic disorders were only frequent when associated with other conditions (10.7%). The abusive use of psychoactive substances was identified in combination with the various psychiatric conditions. (source: http://www.scielo.br/scielo. php?script=sci_arttext&pid=S0047-20852006000200006).

284 Two instruments for gathering information were sent, one directed towards the administrative and functional characteristics of the detention facilities (or pre-trial detention facilities), including their actions in the mental health field, to be answered by the person responsible for managing the establishment, and another one that focused on the types and characteristics of the mental health services and actions offered to children and adolescents in the municipalities, to be answered by the municipal administrators of the public health network. In fact, 236 facilities and 125 municipalities answered the questionnaires.

285 Brasil. Ministério da Saúde e Secretaria de Direitos Humanos da Presidência da República. Levantamento Nacional dos Serviços de Saúde Mental no Atendimento aos Adolescentes Privados de Liberdade e sua Articulação com as Unidades Socioeducativas – Resumo executivo. Brasília, 2010.

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the internment measure), to the detriment of territorially-based approaches.

Regarding the prescription of psychiatric medications, the existence of a high proportion of extensively medicated adolescents in the detention facilities was noted, including with antipsychotics, anxiolytics, antidepressants and anticonvulsants. There were strong indications of the significant use of chemicals as a means of control in some facilities, where the proportion of adolescents using antidepressants reached 80%. It should be evaluated whether the profile of adolescent offenders is strongly associated with the prevalence of mental disorders or whether there is a pattern in the socio-educational facilities of medicating the adolescents at high rate regardless of any universally accepted clinical criteria.

More than half of the facilities reported that they use restraint and 60% use isolation as procedures related to mental health. The use of restraint and seclusion procedures in these institutions has damaging physical and psychological effects, both for the patients as well as for the staff, and should be regulated by specific standards and clinical protocols. In the detention facilities, the determination to use restraint and isolation could also be authorised by both health professionals as well as other professionals, such as those in security, thus signifying a hybrid characterisation of the procedures, a mix of health and safety measures.

Regarding the information of an epidemiological character provided by the local managers of the socio-educational system, such information can be controversial depending on the parameters used to define mental disorder, especially in the context of incarceration of adolescents. In this sense, there remains a lack of knowledge about the relation of mental health with the care strategies aimed at adolescent offenders, which justifies investment in new research on the subject.

In relation to the data submitted by the municipalities, almost all of them have pointed out that they have a mental health manager and 71% affirmed that they have a manager responsible for youth and adolescent health. It was confirmed that, of the municipalities that offer outpatient services (78%), a minority have spaces available for children and adolescents. In terms of the treatment of juveniles in psychiatric hospitals, of those that had such facilities (72%), only a minority provides services for children and adolescents, and this number drops even more when dealing with juvenile offenders. In general hospitals, half of the municipalities reported providing services for children and adolescents, including juvenile offenders. Another interesting finding is that the majority of health managers (64%) reported receiving court orders mandating compulsory internment, and 40% comply with them without attempting a dialogue with the Courts.

The research points to a lack of cooperation between the facilities for deprivation of liberty and the public health services network. While the former concentrate their treatment on the premises of their own facility, the latter needs to be better structured

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to provide services to children and adolescents. It is important to avoid the compulsory internment of adolescents who need mental health care by fostering dialogue between the professionals in the socio-educational system (including actors from the Judicial Branch) and health providers.

3. PROBLEMATIC DIMENSIONS OF THE INTERFACE BETWEEN THE JUSTICE SYSTEM AND MENTAL HEALTH The advances in Mental Health Reform and in the System of Guarantees of the Rights of Children and Adolescents in Brazil as described in item 1, have been gradually pushing towards significant changes in the mental health care of juvenile offenders.

However, two trends are observed, in practice, in which the social reality deviates from the established national principles and regulations, those being: a) the use of mental health knowledge and practices in the juvenile justice system from the perspective of social defence rather than from an ethic of care and health promotion; and b) the judicialisation of mental health care extending to other areas of adolescence.

3.1. The pathologisation of the offence and the psychological-legal continuum as resistance to the guarantee of rights A set of elements that connect “mental disorders” with juvenile criminality in various ways has been set up during the last ten years in Brazil as an increasing response to the demands of risk management286 that arise in the relationship of the society with the conflicts carried out by adolescents. Among these elements, we can highlight: a) Proposals to modify the legislation in force (the ECA) centred on the argument linking mental disorders with dangerousness. An example of this is the Bill that proposes: the “obligatory separation of juvenile offenders considered psychopaths or with severe personality disorders, considered difficult or impossible to cure, to be evaluated periodically by a multidisciplinary team; and the provision of security measures within the Statute of the Child and Adolescents including the specification of facilities adequate to its compliance (custodial or psychiatric hospitals) and the periodic evaluation by a multidisciplinary team”287; b) Increasing referral of juvenile offenders for psychiatric evaluations aiming to measure their degree of dangerousness and diagnose anti-social personality disorders, principally verified in the state of São Paulo288;

286 Castel, R. A gestão dos riscos. Rio de Janeiro: Francisco Alves, 1987.

287 Bill 2.599 proposed by Federal Deputy Vicente Cascione, November 2003.

288 Vicentin, M. C. G., op. cit.

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c) The emergence of a model custodial hospital for psychiatric treatment in the area of Juvenile Justice, similar to that established for adults who commit crimes and are subjected to security measures289, with the creation of the Experimental Health Facility by the state of São Paulo290. This facility is designed to offer treatment to offenders who have complied with socio-educational measures in the CASA Foundation291 and who have a diagnosis of a personality disorder and/or dangerousness292. The justification is that such treatment could not be given in the public health services network, because their facilities comply with the guidelines of the SUS mental health policy, which is characterised by services that do not have physical restraint spaces293; and d) The use of psychotropic medication as a form of control over adolescents under socio-educational measures, identified in at least four states of the country: Minas Gerais, Paraná, Piauí and Rio Grande do Sul294.

These elements have arisen in a context in which there was a small contingent of juveniles under socio-educational measures with various diagnoses of mental disorders and without the required health care. This finding has been diagnosed nationally, as well as in some states, particularly São Paulo where 37% of the total population of incarcerated adolescents in Brazil is concentrated295.

289 In Brazil, adults who commit crimes and have a mental illness that prevents them from understanding the illicit character of their conduct are not criminally responsible. It means that the person cannot be punished with prison, but the Penal Code provides the imposition of security measures, which are implemented in an outpatient or internment regime. These measures do not have a defined length of time and are subject to periodic medical evaluations.

290 According to the extract from the Technical Cooperation Agreement published in the official journal of the State of São Paulo, in April 1st, 2008, the objective of the creation of this facility is to provide adolescents/young adults with adequate treatment for the diagnosed pathology while they are sentenced to custody as determined by the judge.

291 The Foundation Centre for Adolescent Socio-educational Care (CASA) is the governmental institution responsible for carrying out socio-educational measures involving deprivation of liberty (pre-trial detention, incarceration, and semiliberty).

292 The young people are there, for the most part, because of sentences of compulsory internment handed down by civil judges. This occurs, in general, when the release of a young person who is under a socio-educational measure involving deprivation of liberty becomes imminent due to one of the causes of compulsory release provided in art. 121 of the ECA (i.e. three years of detention and/or 21 years of age).

The internment orders originating from these competency hearings are characterised by their absolutely indeterminate length. In other cases, judges may issue protective orders for medical, psychological or psychiatric treatment in a hospital setting (art. 101, V of the ECA) during the course of a socio-educational internment measure (art. 121 § 3 of the ECA), suspending such measure for an indeterminate period.

293 Frasseto, F. A unidade experimental de saúde – mais um triste capítulo da história paulista no tratamento de jovens infratores. São Paulo, 2008. Mimeo.

294 Conselho Federal de Psicologia; Comissão Nacional de Direitos Humanos do Conselho Federal da OAB. Direitos Humanos – um retrato das unidades de internação de adolescentes em conflito com a lei. Relatório da Inspeção Nacional às unidades de internação de adolescentes em conflito com a lei. Brasília, 2006. The researchers detected that in Rio Grande do Sul around 80% of those juveniles deprived of their liberty were medicated, and that the diagnoses as well as the medications prescribed were identical, which is evidence of the abusive use of the substances by the institutions.

295 Brasil. Presidência da República. Secretaria de Direitos Humanos. Secretaria Nacional de Promoção dos Direitos da Criança e do Adolescente, op. cit.

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In this state, prosecutors and judges responsible for monitoring the implementation of socio-educational measures initiated procedures to investigate irregularities in the care of adolescents with mental disorders by the public health services network, calling on various governmental bodies to take actions and formulate policies in this area. During the first period (1999-2001), these procedures were dominated by a concern with issues relating to the care of more classic mental disorders, such as drug addiction, psychotic episodes and mental disabilities, which gave way, during another period (20022008), to the treatment of anti-social personality disorders and to the evaluation of dangerousness, inserting the adolescents into other treatment contexts, notably heirs of a clearly psycho-criminological perspective. The concept of the personality disorder then took centre stage in the analysis of the intersection of mental health issues with the justice system, thereby creating a problematic new field.296 In addition, the institutional management difficulties at the socio-educational facilities for deprivation of liberty contributed to that discourse. According to the understanding of the directors of the Foundation responsible for carrying out these measures, the juveniles “do not understand, do not benefit from or subjectively resist the socioeducational plan”. That became clear when the Foundation’s superintendent of health affirmed that the aforementioned health facility would not house the mentally ill, but rather adolescents with “anti-social behaviour,” which she defined as “juvenile inmates who have the tendency to depredate internment facilities, who do not take care of their things, are questioning and do not follow rules, the agitated ones”297.

These allegations came in the wake of intense confrontations and resistance by adolescents to the repressive mechanisms and biopolitics of power298 present in the detention facilities, as evidenced by several rebellions and riots in response to torture, humiliation and mistreatment299. Thus, it is from these institutional routes that this “new dangerous” youth emerges: what is presented as ungovernable and unmanageable is, therefore, dangerous. In this sense, “danger” seems to be a concept linked to “uncontrollable,” as in “what escapes institutional management”300. This provides a renewed discourse of dangerousness: the adolescent with a personality disorder will be seen as being a “risk/danger,” which must be treated in a specialised facility – and which could be seen as conforming to the paradigm of comprehensive protection (which assures their right to mental health care).

296 Vicentin, M. C. G., op. cit.

297 Frasseto, F., op. cit.

298 Foucault, M. Microfísica do poder. Rio de Janeiro: Graal, 1988.

299 Anistia Internacional. Brasil. Desperdício de vidas. Febem-SP. Crise de direitos humanos e não questão de segurança pública. Londres: Secretariado Internacional, julho de 2000; Vicentin, M. C. G. A vida em rebelião.

Jovens em conflito com a lei. São Paulo: Hucitec/Fapesp, 2005 (a).

300 De Leonardis, O. “Estatuto y figuras de la peligrosidad social. Entre psiquiatría reformada y sistema penal: notas sociológicas”. Revista de Ciencias Penales, Montevideo, nº 4, p. 429-449, 1998

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According to various experts on the socio-educational and justice systems, the lack of a socio-educational plan in some facilities, the continuous facility transfers that some adolescents experience (especially in periods of rebellion), and the violations of rights to which they are subject are situations that collaborate in the construction of young people that are either profoundly helpless or deeply angry; the latter is very close to a profile easily “converted” into an anti-social personality.

Actors in the field of health, such as the Project Quixote team at the Federal University of São Paulo, which in 2000 carried out a “diagnostic” of mental health in the juvenile detention facilities of São Paulo, alert us to the fact that this anti-social personality disorder is absolutely compatible with the institutional logic: The most notable, among these, are traits of an “anti-social personality” (we refer to the concepts conveyed by the official psychiatric classification systems), which helped the juveniles as much in deprivation of liberty situations as in a life of crime, and which were, to a certain extent, cultivated by the institution: the best (read: “the most anti-social”) survive better and are more respected, both by the boys as well as by the professionals. So the institution itself is perverse, the rules are not clear and are not shared by everyone, since they depend on subjective criteria.301

A diagnostic done by the Ministry of Health and the Secretariat of Human Rights on this same subject argues that: Despite the advances coming from the Psychiatric Reform, we have a large gap in understanding the condition of adolescents as subjects of rights, as at risk and as having the special condition of being a person in development, since the system of juvenile accountability still perpetuates custodial hospital models based on asylums and total institutions. These models greatly undermine the quality of care offered to juvenile offenders by forcing correctional-repressive action, when not masquerading as a therapeutic-psychiatric purpose, including recent proposals aimed at maintaining compulsory hospitalisation of adolescents over 21 years old.302

Essentially, this combining of the offence with a mental disorder has been producing practices that are directly contrary to the paradigms of the ECA and the current national Mental Health policies. The pathologisation of adolescents, i.e. the reduction of complex processes of social vulnerability to a problem of mental illness, leads in the direction of the radicalisation of segregationist policies as a response to issues of violence and insecurity, to the detriment of investment in social policies.

The concept of dangerousness seems to acquire connotations that facilitate the

301 Sarti, C. A. A saúde mental na “nova Febem”. Projeto Quixote. Relatório interno de trabalho apresentado à Febem-SP. Departamento de Psiquiatria - Universidade Federal de São Paulo, São Paulo, 2000. Mimeo.

302 Brazil. Ministry of Health and Secretariat of Human Rights of the Presidency of the Republic, op. cit, p. 33.

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extension and diffusion of its use, increasingly more subordinated to the demands of “social defence.” This pathologisation prevents the recognition of the phenomena of social exclusion and vulnerability, which are also factors in the commission of an offence, and deprives the subject in question of the possibility of creating social bonds.

Finally, it is worth highlighting a third period (2008-2010) that is emerging in this interface between mental health and juvenile justice, in which the focus is on the issue of “drug addiction” and sending juvenile offenders for drug and alcohol treatment in specialised clinics. It is observed that the Court is imposing socio-educational measures that do not involve internment along with protective measures that include treatment programmes for “drug addicts” to be carried out in recovery houses and therapeutic communities that do require the internment of the adolescent. This sort of “Therapeutic Justice” applies a model of compulsory treatment in which the adolescent, in order to complete the sanction for his transgression, is subjected to treatment imposed as a duty and not as a right to health. Under this formulation, treatment and punishment tend to take on the same form when their limits are conditioned upon cure or recovery.

Moreover, emphasising internment as the “gold standard” for the treatment of drug addiction is part of the belief that considers the drug as the agent of addiction and reduces the practice of substance abuse to the physical manifestations of intoxication.

It is known, however, that there is no default treatment and that one must work to create a demand, a minimum consent of the adolescent to the treatment. If the clinical work does not manage to move beyond the formal imperatives of the law decreed by the State, it will be doomed to failure303.

These elements create a direction in the mental health care of juvenile offenders that is marked by a custodial-correctional viewpoint to the detriment of a philosophy of care and the right to health. Such a viewpoint affects not only the perpetrators of the infractions, but also extends to other sectors of youth/adolescence as well.

3.2. The judicialisation of mental health care and the extension of the pathologising perspective to other sectors of adolescence Together with the situation presented above, we can observe the growth in the psychiatric internment of adolescents by court order in the largest psychiatric hospitals for adolescents (research shows similar data in three major capital cities: Rio de Janeiro, São Paulo and Porto Alegre). Such psychiatric internment is marked by being compulsory, by having its length based on judicial determinations (the average length

303 Bittencourt, L. “Orientações básicas para a atenção à saúde mental de adolescentes em conflito com a lei e/ou privados de liberdade”. Seminário Mais Juventude na Saúde. Brasil: Ministério da Saúde, 2009.

Mimeo.

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of internment being greater than that of other people hospitalised by other procedures) and by the increased presence of conditions related to behavioural disorders (therefore, not psychotic) or the use of psychoactive substances304.

In a survey conducted by the Integrated Centre on the Psychosocial Treatment of Children and Adolescents of the Psychiatric Hospital of São Pedro, in the city of Porto Alegre, Rio Grande do Sul, Scisleski and others verified that the issue of drug addiction has been the youth “pathology” that has had the highest demand for services at that institution, with youth being commonly sent there by court order. The authors found that, in such cases, the court order seems to play a dubious role: on the one hand, it is a procedure that provides a strategy of access to health care services for young people, yet on the other hand, it is sometimes used as a type of punishment, in the sense that internment is used as an additional disciplinary measure for juveniles. Psychiatric internment works both as a response that gives legitimacy to a “failed individual” and reaffirms the position of social marginality of these youth305.

A study developed by Federal University of Rio Grande do Sul306 in the aforementioned Psychiatric Hospital of São Pedro (HPSP) in Porto Alegre shows that, since the hospital’s foundation, at the beginning of the 20th century, young offenders were taken there for the treatment at the institution. Therefore, their “misconduct” has always been related to a hygienist strategy of controlling all deviant behaviour.

Since the 1980s, the description of deviant behaviour ceases to be only a reason for internment and assumes the status of a codified pathology in various psychiatric manuals as a behavioural disorder. With the emergence of crack in Porto Alegre at the end of the 1990s, and because of its highly addictive chemical effect, the association between chemical addiction and behavioural disorders has acquired greater visibility, creating direct correlations in the profile of the drug-user population: young, poor, “delinquent”. Therefore, a connection is established between the use of drugs, social inadequacy and psychiatric disorders. It is a connection that gained popular legitimacy, driven by the local medical discourse, aiming at the centrality of the Psychiatric Hospital in the treatment of such demand, since, in accordance with this perspective, the crack user certainly will commit an infraction and develop a pathology or vice versa. Due to

304 Bentes, A. L. S. Tudo como dantes no quartel d’Abrantes: estudo das internações psiquiátricas de crianças e adolescentes através de encaminhamento judicial. Dissertação de Mestrado. Escola Nacional de Saúde Pública Fundação Osvaldo Cruz, Rio de Janeiro, 1999; Joia, J. A interface psi-jurídica: estudo de internações de adolescentes por determinação judicial no Hospital Psiquiátrico Pinel. Relatório final de pesquisa de Iniciação Científica Conselho de Ensino e Pesquisa, Pontifícia Universidade Católica de São Paulo, São Paulo, 2006.

305 Scisleski, A. C. C.; Maraschin, C.; Silva, R. N. “Manicômio em circuito: os percursos dos jovens e a internação psiquiátrica”. Cadernos de Saúde Pública, Rio de Janeiro, vol. 24, no. 2, pp. 342-352, February 2008.

306 56 The survey: “The problematisation of the normal and pathological standards in the ways of being of children and adolescents” is linked to the Post-Graduation Programme in Social and Institutional Psychology. We thank the Ph.D Professor Rosane Neves da Silva for providing information contained in the next paragraph for the development of this text.

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epidemic demand, the opening of 500 new beds in psychiatric hospitals in 2008 in Rio Grande do Sul’s public health system was seen as justified307.

A new field of work, therefore, was opened to psychiatry, which had languished with the Psychiatric Reform movement. The object of study and sentencing has been relocated, however, to the young “delinquent,” who is poor and addicted to crack. And, in fact, evidence has shown a massive influx of such people into mental health care services.

In the case of HPSP, out of the referrals made since 2000, about 50% were under the above-specified profile. The referrals come basically from families and the judiciary as a “protective” strategy: court orders replace the referrals made by the police to the hospital in an earlier era. Currently, most young people are submitted to the treatment as a requirement of the socio-educational measures imposed by a judge and experience the contiguity of the institutions of control which runs through this institutional space, mixing the functions of the hospital and prison, physician and judge, psychologist and lawyer, nurse and security guard. Spending 30 days in the CIAPS (Integrated Centre on Psycho-social Treatment), for example, is a common situation that points to the lack of division between justice and mental health facilities for a large number of young people in the city of Porto Alegre.

We have currently noticed a delicate relationship between protective and/or socioeducational measures and the demands on mental health, with treatments (most times compulsory) being differently understood by the legal and health fields, when often the protection is based more on the need to segregate than on health care. This delicate connection is very evident, as seen above, on the occasions when therapy is confused with punishment or when the treatment and punishment assume the same form, mainly in the case of imposed treatment for drug use.

Consequently, there is an increasing presence of the justice system in the health care field, which could result in the growing judicialisation of care or which could be reversed in favour of intersectoral and in-network cooperation, depending on how it is handled, as suggested by Barreto. She indicates that the entrance to mental health services, unlike in the past, may be the field of justice, and highlights the importance of investigating the internment orders without losing the opportunity to receive and treat the referred adolescents, but at the same time, reconfiguring bureaucratic limitations to be able to take care of cases through a different approach308.

Besides the proposal to rethink the ways of funnelling people into the health care system through the judicial system (focusing on intersectoral and geographic cooperation), other researchers call attention to the risk that such demands directed at the mental

307 57 News available at: http://www.simers.org.br/cms/arquivos/noticias/noticia_527.pdf 308 58 Barreto, C. “A adolescência, as medidas e a saúde mental: uma cota de liberdade”. Em: Ribeiro, E. L.; Tanaka, O. Y. (orgs.). Saúde mental de crianças e adolescentes. Contribuições ao Sistema Único de Saúde. São Paulo: Hucitec, 2010.

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health field accompany a growing trend of medicalising and pathologising other sectors of youth living in poverty.

ANCED in the document “Analysis of the Rights of Children and Adolescents in Brazil: Preliminary Report” indicates that, even if the new policy on mental health is responsible for a significant improvement in health indicators, we can identify features of psychiatrisation and medicalisation in the social and political needs of those young people who suffer from the inability to have their cases attended to. The document suggests the need for integrated action of social and legal actors towards the implementation of the right to health guarantee during childhood and adolescence309.

This set of elements shows that it is necessary to lead a discussion about therapeutic guidelines when they are tied to an individualist logic, which prevents the expansion of a broader approach to the complex and sometimes limited network in which these young individuals are socially inserted, or when such guidelines seek to respond to the demands of social defence.

In this regard, no institution on its own – even the ones in mental health – will be capable of offering alternatives to young people so that they can overcome the circumstances of vulnerability which combine to create these legal and medical needs.

Only collective coordination between the different actors and institutions that attend to these adolescents can create other alternatives to this asylum circuit310.

4. ADVANCES, EXPERIENCES AND CHALLENGES In chapter 1 of this article, we demonstrated how Brazil has changed its regulations in order to guarantee rights to children and adolescents, especially juvenile offenders, and established intersectoral mental health policies based on the Psychiatric Reform movement, characterised by deinstitutionalisation. In item 2, we presented a general picture of the socio-educational system in Brazil. In item 3, we described how, in practice, at the intersection of Justice and Mental Health, more conservative discourses about the criminalisation of juveniles and the normalisation of subjects make it so that juvenile offenders who have any serious mental disorder or drug addiction must endure experiences of exclusion and segregation in various states of the country. This demonstrates the difficulty of effectively creating a fully democratic state in Brazil,

309 Associação Nacional dos Centros de Defesa da Criança e do Adolescente (ANCED). Análise sobre os direitos da criança e do adolescente no Brasil: relatório preliminar. São Paulo: março de 2009. Available at: http:// www.anced.org.br/cyberteca/publicacoes/relatorio-alternativo-cdc/relatorio-preliminar/view 310 61 Bentes, A. L. S., op. cit.; Joia, J., op. cit.; Scisleski, A. C. C. et al, op. cit; ; Vicentin, M. C. G.; Rosa, M. D. “Transtorno mental e criminalidade na adolescência: notas para uma análise crítica da patologização do adolescente autor de ato infracional”. Revista Brasileira de Ciências Criminais, ano 17, vol. 78, p. 320-349, 2009.

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since forces acting under the aegis of social protection have impeded the widespread realisation of human rights.

Under these circumstances, innovative practices and proposals have emerged which demonstrate the possibility of effectively implementing the rights of children and adolescents in this interface between mental health and juvenile justice. Below, we will present two emblematic experiments, one carried out nationwide and the other undertaken in a Brazilian city.

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The implementation of a National Policy of Child and Adolescent Human Rights: Contributions of the National Secretariat for the Promotion of the Rights of Children and Adolescents Carmen Silveira de Oliveira311 Concerning the mental health of children and juveniles, the guiding framework of this policy should consider the issue of guaranteeing the rights indicated in art. 227 of the Federal Constitution. In addition to this, the policy should include the guidance coming from the Brazilian psychiatric reform movement, which recommends replacing the custodial hospital model in favour of the creation of community treatment instruments, residential services, and care that guarantees the rights and autonomy of its users.

The mental health and the human rights of children and adolescents policies converge and interact with one another because both require consideration of the scope and contributions of various disciplines, without which the System of Guarantees of the Rights of Children and Adolescents (Sistema de Garantia de Direitos - SGD) will not be secured.

The SGD consists in the interconnection and integration of public governmental bodies and civil society who work together to apply the relevant laws and regulations and to enforce the mechanisms of promotion, protection and control in order to realise the human rights of children and adolescents. Therefore, it is a framework to implement rights at the federal, state, district and municipal levels, which should be seen as a strategic player in strengthening mental health policies.

311â&#x20AC;&#x201A; National Secretary for the Promotion of the Rights of Children and Adolescents of the Secretariat of Human Rights of the Presidency of Brazil.

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Regarding adolescents under socio-educational measures, it is essential to ensure that the multidisciplinary teams in the local health and mental health care networks are qualified to attend to and monitor adolescents with mental disorders in an individualised manner, while respecting the principles of psychiatric reform. In this way, it is important to guarantee that adolescents, including those in situations of deprivation of liberty, have access to quality care through the public services network while also ensuring that those with mental disorders are not confined in special wards or spaces, considering that the fundamental goal of the socio-educational measures, as well as of the health teams, is the (re)integration of these adolescents into society.

As a result, within the several intersectoral actions aimed at consolidating the policy of comprehensive health care for juvenile offenders, we point out the following significant guidelines: • the review of Interministerial Ordinance 340/2004, which resulted in SAS Ordinance 647/2008, which provides guidelines for the implementation of health care for juvenile offenders under a regime of detention and pre-trial detention in male and female facilities; • the creation of the Brazilian Centre for Human Rights and Mental Health composed of governmental, university and civil society institutions through Interministerial Ordinance 3357 of December 29, 2006, an initiative of the Ministry of Health and the Secretariat of Human Rights. This initiative aims to expand the avenues of communication between the government and society by creating a mechanism for receiving complaints and externally monitoring institutions that deal with people with mental disorders, including children and adolescents, drug and alcohol abusers, and incarcerated persons; • the realisation in 2008 of the First Workshop for the Construction of Operational Flowcharts regarding Mental Health Care of Adolescents Deprived of Liberty, in the city of Belo Horizonte, which allowed for the systematisation of a methodology, which had a contribution of actors from the SGD as well as actors resulting from the partnership between the Secretariat of Human Rights, the Ministry of Health, the National Council for the Rights of Children and Adolescents and the Brazilian Association of Child and Youth Magistrates, Public Prosecutors and Public Defenders; • the accomplishment of the National Survey on the Mental Health Care of Incarcerated Adolescents and its Connection with Socio-educational Facilities, which presented information about the manner that the health care services are being offered to incarcerated juveniles and in which way

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they are recognised as legitimate users by professionals of the public health services; • the Final Report of the Eighth Ordinary Meeting of the National Forum on Child and Juvenile Mental Health held in March 2009, and in particular, the part referring to Axis III – the Socio-Educational System, Mental Health, Alcohol and Other Drugs, which had the participation of representatives of both civil society and the government; • the participation of various actors from the System of Guarantee of Rights in the construction of the Flowchart of the Mental Health Care of Adolescents in Conflict with the Law. Therefore, in light of the challenges and strategies presented to overcome the rights violations in the field of the comprehensive health care of children and adolescent citizens, the National Secretariat for the Promotion of the Rights of Children and Adolescents of the National Secretariat of Human Rights contributes, along with other government institutions, to the coordination and implementation of various national policies, guided by the overall purpose of establishing public policies that take into account national and international norms in order to guarantee with absolute priority the fundamental rights of children and adolescents.

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The Probation Programme and Mental Health in Belo Horizonte Cristiane Barreto312 e Raquel Marinho313 Humanity has, for the first time in history, a majority of its population living in cities. It is estimated that by 2030, this number will represent more than 60% of the world’s population. In an urban world, we construct various forms of solitude and connection. How do we or should we communicate, organise, meet, associate, circulate?

There are plenty of difficulties. In some of them, it is common to see the end of the conversation forced, the end of the line imposed, and, as a consequence, we run the risk of seeing “public security through warrior language, which never dreams of cities… but has nightmares of citadels”.314 According to a 2007 survey by the Brazilian Institute of Geography and Statistics (IBGE), Belo Horizonte is the sixth most populous city in Brazil with 2,412,937 inhabitants, of which 412,000 are between 10 and 19 years of age. And it has not managed to escape one of the major urban problems: violence involving adolescents, from the commission of crimes to premature death.

According to data from CIA-BH (the Integrated Centre for the Treatment of Juvenile Offenders), out of a total of 9,605 incidents involving adolescents, 3,759 of them had passed through the justice system in 2009 because of involvement with narcotics.

In June of 2010, according to Mônica Brandão (Manager of Socio-Educational Measures involving Alternatives to Incarceration, of the Deputy Municipal Secretary of Social Welfare of Belo Horizonte), 874 juvenile were performing community service and 805 were on probation.

From the data on adolescents serving sentences of semi-liberty and incarceration,

312 Psychoanalyst, member of the Brazilian School of Psychoanalysis of Minas Gerais; Clinical Supervisor of the Mental Health Services Network for the municipality of Belo Horizonte; Clinical Supervisor for CAPS-I of Sete Lagoas for the Ministry of Health; Coordinator and Clinical Supervisor of the Probation Program of Belo Horizonte (1998 – 2006).

313 Psychoanalyst, correspondent of the São Paulo section of the Brazilian School of Psychoanalysis; Masters in Social Psychology from PUC-SP; Director of the Centre for Preparation for Semi-Liberty; Specialist in the Probation Program of Belo Horizonte (2001 – 2006).

314 Fragment of the synopsis of the debate “Do Desejo de Cidade à Topografia do Terror”, from the 22nd National Meeting of AMPUR (National Post-Graduate and Research Association in Regional Urban Planning), Florianópolis, May 2009.

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including pre-trial detention, we can only point to a numerical estimate, due to the absence of officially published data and differing information among sources.

According to the official data provided to the Municipal Health Secretary by the State Secretary for Social Protection, who is responsible for the execution of incarceration, pre-trial detention and semi-liberty measures, an amount of 400 adolescents were incarcerated in April 2009. And, considering the semi-liberty facilities located in the city – seven “semi-liberty houses” and one “centre for preparation for semi-liberty” – around 135 adolescents are under one of these sentences in Belo Horizonte.

Belo Horizonte’s Experience In 1998, the city of Belo Horizonte put in place a Probation Programme. It was the first time that a municipal government had assumed responsibility for the care of juvenile offenders, guided by the recommendations of the Statute of the Child and Adolescent (ECA) that freedom should be taken as a basic principle, and it is therefore an essential priority to have socio-educational measures without deprivation of liberty.

Also in this vein, the Probation Programme invited the participation of civil society by creating the position of “Volunteer Social Advisor”, who can be an ordinary citizen willing to mentor an adolescent during his compliance with the measure.

This position created another person who was involved in the monitoring and reintegration of each adolescent.

By promoting a meeting point between the community and the adolescent, the ECA introduced a political-cultural shift, in the sense of basing the socio-educational measure on the adolescent and his social ties. Thus, the novelty of a resident of Belo Horizonte interested in mentoring a troubled adolescent led to an opening of perceptions, both for the resident and the adolescent, in terms of ways of co-existing in the city.

It is worth clarifying that each adolescent was obligatorily supervised by a Programme Specialist as well. The Programme Specialist was responsible for administering the sentence through cooperation with the judiciary and for thinking of all the possible ways in which the mentor could get involved in the social and educational aspects of the adolescent’s life: school, family, leisure, culture, and bringing him to specific places in the city, such as health facilities.

The Probation Programme required, within the context of municipal policies, transportation around the city and access to various services in different political sectors. The concept of intersectoral cooperation inaugurated a logical and effective way of guaranteeing the rights of adolescents.

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Intersectoral Public Policies: Brief considerations regarding the partnership with mental health Two things stood out in the inaugural connection of the justice system with mental health: the issue of cases of psychosis, based on the idea that only the mental health system can treat them, and the issue of drug use.

We will start with the current context. Seeing that the justice system reported that almost 40% of offences committed in 2009 in Belo Horizonte were related to youth involved with drugs, this figure should not be looked at uncritically.

What is being considered use or abuse?

The approach taken by the judiciary to the situation of the adolescents involved with drugs diminishes the reliability of its numerical records. There is generally no minimum consensus on the distinction between use and abuse of drugs since both are more or less associated with the previous moral judgment such as “drugs lead to crimes”, and are in this manner seen as the “great evil” to be fought.

This way of dealing with drug use appears to be, most of the time, a defence mechanism, because of the horror or seriousness of the cases; however, it is also a sign of retreat when faced with the enormous difficulty of developing solutions to the issue of the violence surrounding the drug trade, which is a well-known cause of adolescent deaths.

At this point, it seems that the problem is related to the position adopted by the judiciary, which tends to require from the health system a different focus than it has been structured for.

After all, the health system in Brazil adopts, for example, “harm reduction” as a policy and a subjective responsibility of any potential treatment – seeing that what matters is treating the adolescent’s issues rather than blaming the drugs. These guidelines are opposed to solutions of a punitive and/or biological character.

Our view, in the Probation Programme, considers drug use as a symptom to be treated, carefully, without deviating from our responsibility to take in and deal with the adolescents’ issues, even when they involve serious mental suffering.

In Belo Horizonte about ten years ago, through an initiative of the programmes that implement socio-educational measures and the Child and Youth Public Prosecutor’s Office, a group was formed that meets monthly in order to discuss the main obstacles faced by programmes that provide alternatives

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to incarceration, juvenile internment facilities and semi-liberty measures.

All the programmes that perform the measures, as well as their partners, participate in this “network meeting”, as it is called, including representatives from Education, Health, the Prosecutor’s Office, Juvenile Court, the Council of Rights, the Public Defenders’ Office and other occasional guests according to the specific themes of the meeting. It is important to highlight that, as part of its constitutive strategy, the meeting functions mainly as a place to bring together the programmes’ workers and supporters. It is important to note that it is not a “pro-forma” administrators meeting (even though such meetings may perform great contributions), but a space that functions as a workshop for ideas. Political or administrative circumstances may interfere with the progress of the work, but laudably, the meetings continue without interruptions and are an essential tool for the programmes.

To deal with issues involving mental health, this network proposed, from the beginning, the formation of sub-groups to deal with specific cases. Through these groups, they managed to minimise the effects of the assertion that “all serious cases were psychosis,” “were mental health”. A different dialogue was established with the presence of a clinical supervisor; much more than the diagnosis was discussed, since the goal was not to “classify,” but to formulate guidelines for handling the case and to define the participation and responsibilities of the various partners and parts of the network. And, secondly, the most important task of the groups was to work on the specifics of certain cases, which were in fact quite serious, as the link among the various providers and services.

The experiment of the Probation Program benefited from the mental health care structure that already existed in the municipality and was known to be efficient; however, this structure existed, as is historically found in Brazil, with less resources provided for the health care of adolescents. And here another positive point stood out, since awareness of the work and problems faced by each sector of the networks was shared, they supported the decision to improve, enhance and build together. The proposals developed in cooperation between the management of mental health and the Probation Program allowed guideline clearance to be provided to professionals, who day by day, acquired more confidence in their jobs.

As a matter of fact, the dialogue between these fields made it clear that many young people only had access to treatment trough their socio-educational measure and that, without this path, the health care system still could not fully reach them. This shows how building a network is crucial to dealing with the true complexity of the cases.

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This network would not exist if it did not constantly confront preconceived ideas.

The concepts of dangerousness and risk which surround the young offender, at the border with mental health, reveal both a fear of him and a desire to accommodate him and provide him with opportunities to preserve his freedom and create a better way of life.

And the Probation Program is still going strong!

4.1. Final Considerations In June 2010, the Fourth National Mental Health Conference was held under the topic “The Mental Health Right of and Commitment to All: Reinforcing Advances and Facing Challenges”, which invested in building guidelines and practices with respect to the relationship between justice and the mental health policies for children and adolescents in the country.

At the Fourth Conference, the participants approved guidelines that aim to confront the processes of pathologisation and criminalisation, which use the psycho-legal alliance to strengthen the paradigm of correctional protection while disregarding the implementation of comprehensive policies that guarantee the rights of children and adolescents. Likewise, the internment model applied to young offenders diagnosed with Anti-Social Personality Disorder has been renounced because it violates their guaranteed right to health, to the extent that it segregates and guards the person instead of promoting comprehensive and intersectoral health care.

The implementation of policies to build a national consensus against juvenile internment is considered the key to the success of this important political movement that defends care as opposed to segregation and stigmatising treatment.

Psychiatrisation, in this context, works against the idea of making youth accountable for themselves, since seeing oneself as a “bearer of a personality disorder unlikely to be cured” situates the person as “incapable and without the judgement” to be the author of his own actions and the actor in his own story.

It is also urgent that we review the role of health care providers and their function in the treatment context, since the ideology and strategy of contemporary health policies have helped us to reconsider the use of a diagnosis of anti-social personality disorder on adolescents and the use of control through medication as a standard treatment.

The policies in this area should primarily focus on the pedagogical needs, choosing ones that aim to strengthen family and community ties as provided in the Statute of the Child and Adolescent.

It is therefore highly recommended that such issues be incorporated into the collective

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discussion and intersectoral construction of public policies on mental health. As such, it is necessary to invest in the training of professionals who work with juvenile offenders in order to create opportunities for these professionals to rethink their beliefs and daily practices. It is the responsibility of the managers of socio-educational system and health providers to offer permanent, ongoing training in mental health, emphasising the particular cultural traits of this population. Ultimately, improving the quality of the care provided to children and adolescents within the socio-educational system also requires supervision, knowledge production and research, as well as tools to conduct follow-up assessements and to aid in the construction and reinvention of the professional practice315.

315â&#x20AC;&#x201A; Bittencourt, op. cit; Vicentin, M. C. G., op. cit.

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References Anistia Internacional. Brasil. Desperdício de vidas. Febem-SP. Crise de direitos humanos e não questão de segurança pública. Londres: Secretariado Internacional, julho de 2000.

Associação Nacional dos Centros de Defesa da Criança e do Adolescente (ANCED).

Análise sobre os direitos da criança e do adolescente no Brasil: relatório preliminar. São Paulo: março de 2009. Disponível em: http://www.anced.org.br/cyberteca/publicacoes/ relatorio-alternativo-cdc/relatorio-preliminar/view. Acesso em: 19.jun.2010.

Barreto, C. “A adolescência, as medidas e a saúde mental: uma cota de liberdade”.

Em: Ribeiro, E. L.; Tanaka, O. Y. (orgs.). Saúde mental de crianças e adolescentes.

Contribuições ao Sistema Único de Saúde. São Paulo: Hucitec, 2010.

Bentes, A. L. S. Tudo como dantes no quartel d’Abrantes: estudo das internações psiquiátricas de crianças e adolescentes através de encaminhamento judicial. Dissertação de Mestrado.

Escola Nacional de Saúde Pública - Fundação Osvaldo Cruz, Rio de Janeiro, 1999.

Bittencourt, L. “Orientações básicas para a atenção à saúde mental de adolescentes em conflito com a lei e/ou privados de liberdade”. Seminário Mais Juventude na Saúde.

Brasil: Ministério da Saúde, 2009. Mimeo.

Brasil. Constituição da República Federativa do Brasil, de 1988. _____. Estatuto da Criança e do Adolescente. Lei Federal nº 8.069, de 13 de julho de 1990. _____. Ministério da Justiça; Pronasci; Fórum Brasileiro de Segurança Pública; Ilanud; Instituto Sou da Paz; SEADE. Projeto Juventude e Prevenção da Violência: primeiros resultados. Brasília, novembro de 2009. _____. Ministério da Justiça. Secretaria Nacional de Segurança Pública. Perfil das vítimas e agressores das ocorrências registradas pelas polícias civis: janeiro de 2004 a dezembro de 2005. Brasília, agosto de 2006. _____. Ministério da Saúde. Secretaria de Atenção à Saúde. Departamento de Ações Programáticas e Estratégicas. Caminhos para uma política de saúde mental infanto-juvenil.

Brasília: Editora do Ministério da Saúde, 2005 (a). _____. Ministério da Saúde. Secretaria de Atenção à Saúde. Departamento de Ações Programáticas e Estratégicas. Coordenação Geral de Saúde Mental. Reforma

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Psiquiátrica e Saúde Mental no Brasil - Documento apresentado à Conferência Regional de Reforma dos Serviços de Saúde Mental: 15 anos depois de Caracas. OPAS. Brasília, novembro de 2005 (b). _____. Ministério da Saúde e Secretaria de Direitos Humanos da Presidência da República. Levantamento Nacional da Atenção em Saúde Mental aos Adolescentes Privados de Liberdade e sua Articulação com as Unidades Socioeducativas – Relatório Preliminar. Brasília, 2009. _____. Ministério da Saúde e Secretaria de Direitos Humanos da Presidência da República. Levantamento Nacional nos Serviços de Saúde Mental no Atendimento aos Adolescentes Privados de Liberdade e sua Articulação com as Unidades Socioeducativas – Resumo Executivo. Brasília, 2010. _____. Presidência da República. Secretaria de Direitos Humanos. Secretaria Nacional de Promoção dos Direitos da Criança e do Adolescente. Levantamento Nacional do Atendimento Socioeducativo ao Adolescente em Conflito com a Lei. Brasília, 2009.

Disponível em: http://www.obscriancaeadolescente.org.br/observatorio/pesquisas/ index.php?pg=pesquisa&id_submenu=148&id_categoria=2. Acesso em: 19.jun.2010. _____. Presidência da República. Secretaria Especial dos Direitos Humanos. Conselho Nacional dos Direitos da Criança e do Adolescente. Plano Nacional de Promoção, Proteção e Defesa do Direito de Crianças e Adolescentes à Convivência Familiar e Comunitária.

Brasília: CONANDA, 2006 (a). _____. Presidência da República. Secretaria Especial dos Direitos Humanos. Conselho Nacional dos Direitos da Criança e do Adolescente. Resolução 113, de 19 de abril de 2006 (b). _____. Presidência da República. Secretaria Especial dos Direitos Humanos. Conselho Nacional dos Direitos da Criança e do Adolescente. Sistema Nacional de Atendimento Socioeducativo – SINASE. Brasília: CONANDA, 2006 (c).

Castel, R. A gestão dos riscos. Rio de Janeiro: Francisco Alves, 1987.

Conselho Federal de Psicologia; Comissão Nacional de Direitos Humanos do Conselho Federal da OAB. Direitos Humanos – um retrato das unidades de internação de adolescentes em conflito com a lei. Relatório da Inspeção Nacional às unidades de internação de adolescentes em conflito com a lei. Brasília, 2006.

De Leonardis, O. “Estatuto y figuras de la peligrosidad social. Entre psiquiatría reformada

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y sistema penal: notas sociológicas”. Revista de Ciencias Penales, Montevideo, nº 4, p. 429449, 1998.

Foucault, M. Microfísica do poder. Rio de Janeiro: Graal, 1988.

Frasseto, F. A. A unidade experimental de saúde – mais um triste capítulo da história paulista no tratamento de jovens infratores. São Paulo, 2008. Mimeo.

Ilanud; Secretaria Especial de Direitos Humanos da Presidência da República.

Mapeamento Nacional de Medidas Socioeducativas em Meio Aberto. Relatório Resumido. São Paulo, 2007. Disponível em: http://www.ilanud.org.br/midia/doc/relatorio_resumido_ mapeamento_mse_abr2009.pdf. Acesso em: 20.jun.2010.

Joia, J. A interface psi-jurídica: estudo de internações de adolescentes por determinação judicial no Hospital Psiquiátrico Pinel. Relatório final de pesquisa de Iniciação Científica - Conselho de Ensino e Pesquisa, Pontifícia Universidade Católica de São Paulo, São Paulo, 2006.

Rocha, E. Mapeamento nacional da situação das unidades de execução da medida socioeducativa de privação de liberdade ao adolescente em conflito com a lei. Brasília: IPEA/DCA-MJ, 2002.

Sarti, C. A. A saúde mental na “nova Febem”. Projeto Quixote. Relatório interno de trabalho apresentado à Febem-SP. Departamento de Psiquiatria - Universidade Federal de São Paulo, São Paulo, 2000. Mimeo.

Scisleski, A. C. C.; Maraschin, C.; Silva, R. N. “Manicômio em circuito: os percursos dos jovens e a internação psiquiátrica”. Cadernos de Saúde Pública, Rio de Janeiro, vol. 24, nº2, p. 342-352, fev. 2008.

Vicentin, M. C. G. A vida em rebelião. Jovens em conflito com a lei. São Paulo: Hucitec/ Fapesp, 2005 (a). _____. Interfaces psi-jurídicas: o caso da psiquiatrização do adolescente em conflito com a lei.

Relatório de pesquisa-doutor - Pontifícia Universidade Católica de São Paulo, São Paulo, 2005 (b). Mimeo. _____; Rosa, M. D. “Transtorno mental e criminalidade na adolescência: notas para uma análise crítica da patologização do adolescente autor de ato infracional”. Revista Brasileira de Ciências Criminais, ano 17, vol. 78, p. 320-349, 2009.

Waiselfisz, J. J. Mapa da violência 2010: anatomia dos homicídios no Brasil. São Paulo: Instituto Sangari, 2010.

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Conclusions .......................................................................................................................................

by Prof. Gary Oâ&#x20AC;&#x2122;Reilly. Dept. of psychology, University College Dublin CĂŠdric Foussard and Agustina Ramos. International Juvenile Justice Observatory

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This volume is a unique document on the current status of mental health in young people in conflict with the law in the following nations: France; Italy; the Netherlands; Poland; Portugal; Spain; and the UK. Each of the participating nations can identify that very significant numbers of young people who come into conflict with the law also have mental health problems. This volume also reminds us that international law and standards require nations to deal appropriately and effectively with young people in the criminal justice system to ensure their mental health status is identified and where indicated that they receive appropriate care.

Some general conclusion can be drawn from the nations described in detail in this volume. There is variability in the availability of empirical studies across nations on the national mental health status of young people in general and young offenders in particular. Countries should consider the merit of establishing these rates to support them in adequately planning for the mental health needs of juveniles with and without criminal behaviour. Nevertheless, the available data indicates that in all nations evidence is found whether through formal research, or review of the records of centres of detention or in the criminal justice system, that juvenile offending and mental health difficulties go hand in hand. Furthermore, the level of involvement of a young person within the criminal justice system correlates with greater rates of mental health difficulty. Higher rates of mental health difficulty are found in juvenile offenders on community sanctions compared with young people in the general community who do not offend, and higher rates again are found among young people in detention.

Detention centres can expect that up to as many as 8 out of 10 young people in their care will have a diagnosable mental health problem. The types of mental health difficulty identified are also consistent. Externalising mental health diagnoses (such as Conduct Disorder), and alcohol and drug addiction are identified at extremely high rates among young people in conflict with the law. Internalising difficulties (such as depression and anxiety) and associated features such as suicidal ideation are also found at high frequencies. These difficulties are likely to be exacerbated by experiences of detention. Other aspects of problem behaviour linked to mental health status and associated with the traumatic and socially disadvantaged histories of young people

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CONCLUSIONS

in detention will include risky sexual behaviour, aggression, and violence. Specific learning difficulties and intellectual disability will also be more common. These are without a doubt complex mental health and psycho-social problems. However, we do have effective approaches that allow us to appropriately screen, assess, formulate and intervene when young people experience each of these difficulties. Furthermore, there is a human rights imperative ensuring we do so.

The current democratic nations described in this volume have each to varying degrees sought a solution that brings together inter-twining aspects of government: the juvenile justice system; the civil rights of citizens within a nation with particular reference to child welfare and protection systems; the health service; and the educational system.

Each of these arms of government are complex and often more progressive in their capacity to generate policy than to see it effectively implemented. They rarely work in a collaborative manner. The mental health needs of young people are seen by the various nations covered in this report as best met within the regular National Health Service rather than in specialist health services within centres of detention. Although this principal is espoused by all, the reality in most nations is that the provision of good quality mental health services for young people in conflict with the law are few and far between. The reason for this is in part due to their lack of provision for the general population, but also due to a lack of integration between juvenile justice, health and educational services.

However, the nature and content of the kind of cooperation and services required is increasingly clear and evidence based. The nations described here universally recognise that young people in conflict with the law require a response from the criminal justice system that is not simply punitive but which also strives to restore wellbeing in society by redirecting the development of young people who engage in criminal behaviour.

A practice of screening the mental health status of all young people within the juvenile justice system, particularly those in detention is recommended and there are structured clinical tools to assist staff in this process. Evidence-based interventions that assist young people who offend are available and are characterised by multisystemic approaches which include family work, parent training, and individual development designed to target problem behaviours and addictions, and approaches informed by Cognitive-Behavioural principals to assist young people with mood disorders or trauma. It is also clear from this report that many young people who find themselves in conflict with the law may be assisted prior to their involvement in crime.

That is, within their homes, schools and communities effective preventative work may be valuable in assisting their development. Each national report in this volume clearly indicates that training for staff is a key ingredient in this successful integration of these arms of government. In some instances, this requires more training of certain types of staff such as child and adolescent psychiatrists or clinical psychologists. A need

MHYO VOLUME I

for training of existing staff is also identified, particularly training that supports legal professionals in understanding mental health issues, and mental health professionals in understanding the legal system of their respective nation. Furthermore, there is also an identified need to promote the merits within legal and mental health professions of working with young people who engage in criminal behaviour to ensure its value to all of society is evident.

Ultimately, we face a choice about the type of society in which we wish to live. Perhaps itâ&#x20AC;&#x2122;s one where we leave things as they currently stand? Where young people become involved in crime, face a legal sanction and if they are lucky may access services when required if these happen to be available in their locality. Or we may endeavour to bring to maturity the human rights principal of supporting the development of a young person vulnerable to a life of crime (with its associated distress for the future victims of their crime) by achieving a truly just and rehabilitative response that appropriately acknowledges the harm of their behaviour while humanely supporting them towards a good life and good mental health. Thus restoring the young person to a developmental pathway that leads away from criminality and towards responsible and crime free citizenry. It would appear that to do so require us to find a mechanism where aspects of the judicial, education, and health systems combine to work co-operatively and effectively together for the good of all citizens. In most nations, this would appear to be something these systems have rarely succeeded in previously. However, it is possible and will bring benefits to all.

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INTERNATIONAL JUVENILE JUSTICE OBSERVATORY (IJJO) INTERNATIONAL INTERNATIONAL INTERNATIONAL JUVENILE JUVENILE JUVENILE JUSTICE JUSTICE JUSTICE OBSERVATORY OBSERVATORY OBSERVATORY (IJJO) (IJJO) (IJJO) Rue Mercelis, 50.

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With the support of the Prevention of and Fight against Crime Programme European With With theCommision-Directorate-General With support the support the of support the of Prevention theofPrevention the Prevention of and of and Fight of Fight and against Fight against Crime against Crime Programme Crime Programme Programme European European European Justice, Freedom and Security With the support of the Prevention of and Fight against Crime Programme European Commision-Directorate-General Commision-Directorate-General Commision-Directorate-General Justice, Justice, Freedom Justice, Freedom Freedom andand Security Security and Security Commision-Directorate-General Justice, Freedom and Security

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With the support of the Prevention of and Fight against Crime Programme European Commision-Directorate-General Justice, Freedom and Security