Comorbid Psychiatric Disorders in Youth in Juvenile Detention Karen M. Abram, PhD; Linda A. Teplin, PhD; Gary M. McClelland, PhD; Mina K. Dulcan, MD

Objective: To estimate 6-month prevalence of comor- bid psychiatric disorders among juvenile detainees by demographic subgroups (sex, race/ethnicity, and age).

Design: Epidemiologic study of juvenile detainees. Mas- ter’s level clinical research interviewers administered the Diagnostic Interview Schedule for Children Version 2.3 to randomly selected detainees.

Setting: A large temporary detention center for juve- niles in Cook County, Illinois (which includes Chicago and surrounding suburbs).

Participants: Randomly selected, stratified sample of 1829 African American, non-Hispanic white, and His- panic youth (1172 males, 657 females, aged 10-18 years) arrested and newly detained.

Main Outcome Measure: Diagnostic Interview Sched- ule for Children.

Results: Significantly more females (56.5%) than males (45.9%) met criteria for 2 or more of the following disor- ders: major depressive, dysthymic, manic, psychotic, panic, separation anxiety, overanxious, generalized anxiety, ob- sessive-compulsive, attention-deficit/hyperactivity, con-

duct, oppositional defiant, alcohol, marijuana, and other substance; 17.3% of females and 20.4% of males had only one disorder. We also examined types of disorder: affec- tive, anxiety, substance use, and attention-deficit/ hyperactivity or behavioral. The odds of having comor- bid disorders were higher than expected by chance for most demographic subgroups, except when base rates of dis- orders were already high or when cell sizes were small. Nearly 14% of females and 11% of males had both a ma- jor mental disorder (psychosis, manic episode, or major depressive episode) and a substance use disorder. Com- pared with participants with no major mental disorder (the residual category), those with a major mental disorder had significantly greater odds (1.8-4.1) of having substance use disorders. Nearly 30% of females and more than 20% of males with substance use disorders had major mental dis- orders. Rates of some types of comorbidity were higher among non-Hispanic whites and older adolescents.

Conclusions: Comorbid psychiatric disorders are a ma- jor health problem among detained youth. We recom- mend directions for research and discuss how to im- prove treatment and reduce health disparities in the juvenile justice and mental health systems.

Arch Gen Psychiatry. 2003;60:1097-1108

M ANY OF our nation’syouth are involved inthe juvenile justicesystem. The US De-partment of Justice es- timates that each year there are 2.5 mil- lion juvenile arrests.1 Moreover, nearly 1.8 million cases are referred to juvenile courts.2 On an average day in the United States, approximately 109 000 youth younger than 18 years are incarcerated3; nearly 15% of these are youth housed in adult facilities that may lack mental health services for youth.4 African American and Hispanic youth are overrepresented in the juvenile justice system, accounting for more than 60% of young offenders in ju- venile justice facilities.5 The number of fe- males in the juvenile justice system is in-

creasing at an even faster rate than the number of males.5

Many detained youth have psychiat- ric disorders.6-9 Teplin et al8 found that even after excluding conduct disorder (symptoms of which include delinquent behaviors), approximately 60% of males and 70% of females had a psychiatric dis- order. These rates of disorder far exceed those of youth in the community.8,10

Advocacy groups and public policy experts believe that many youth in the ju- venile justice system have comorbidity: more than 1 alcohol, other drug, or men- tal (ADM) disorder.11 The Surgeon Gen- eral’s report12 on children’s mental health notes that youth with comorbidity may be arrested because our fragmented mental health system has little to offer them. Re-

ORIGINAL ARTICLE

From the Department of Psychiatry and Behavioral Sciences, Feinberg School of Medicine, Northwestern University (Drs Abram, Teplin, and McClelland), and Children’s Memorial Hospital (Dr Dulcan), Chicago, Ill.

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lated research suggests that ADM comorbidity among ju- venile detainees is common. Comorbidity is prevalent among youth in the community,13-16 adolescent treat- ment samples,17,18 and adult jail detainees.19,20 Rates of comorbidity among detained adolescents may be even higher than rates among detained adults.15,21,22

Despite its importance, there have been few empiri- cal studies of ADM comorbidity among juvenile detain- ees and no large-scale investigations, to our knowledge.23

Three studies found high rates of comorbidity24-26; how- ever, their samples were too small to estimate its true preva- lence or how patterns of comorbidity vary by sex, race/ ethnicity and age.

Data on ADM comorbidity among juvenile detain- ees are needed for 2 reasons:

1. To improve treatment of detained youth. De- tention centers are legally mandated to treat detainees with major mental disorders.27 However, treating detain- ees who have ADM comorbidity is far more complex than treating youth who have only one disorder.28,29 Sound epi- demiologic data on comorbidity will help us target youth with the most common diagnostic profiles.

2. To improve treatment for high-risk youth in the community. Although committed (sentenced) juve- niles stay an average of 5 months,5 juveniles in deten- tion have an average stay of 2 weeks.5 Moreover, many high-risk youth (eg, substance abusers, abused and ne- glected youth) eventually cycle through the juvenile jus- tice system. Without treatment, disorders are likely to persist and worsen, contributing to negative social out- comes and recidivism.30 Data on ADM comorbidity among detainees are needed to develop more effective interven- tions for high-risk youth in the community and to tailor services for special populations, such as females and mi- norities.

We present findings on the prevalence and pat- terns of ADM comorbidity from the Northwestern Juve- nile Project, a large-scale study of psychiatric disorders in detained youth.

METHODS

PARTICIPANTS AND SAMPLING PROCEDURES

Participants were 1829 male and female youth, 10 to 18 years old, randomly sampled at intake into the Cook County Juve- nile Temporary Detention Center (CCJTDC) from November 20, 1995, through June 14, 1998. The sample was stratified by sex, race/ethnicity (African American, non-Hispanic white, His- panic), age (10-13 years or �14 years), and legal status (pro- cessed as a juvenile or as an adult) to obtain enough partici- pants to compare key subgroups (eg, females, Hispanics, and younger children).

The CCJTDC receives approximately 8500 admissions each year (John Howard Association, Chicago, unpublished data, 1992) and is used solely for pretrial detention and for offend- ers sentenced for fewer than 30 days. All detainees younger than 17 years are held at the CCJTDC, including youth processed as adults (automatic transfers to adult court). Youth up to 21 years may be detained in the CCJTDC if they are being pros- ecuted for an arrest that occurred when they were younger than 17 years. Like juvenile detainees nationwide, approximately 90% of the CCJTDC detainees are male, and most are racial/ethnic

minorities.5 The CCJTDC’s population is 77.9% African Ameri- can, 5.6% non-Hispanic white, 16.0% Hispanic, and 0.5% other racial or ethnic groups. The age and offense distributions of the CCJTDC detainees are also similar to detained juveniles na- tionwide.5

We chose the detention center in Cook County (which includes Chicago and surrounding suburbs) for 3 reasons. First, nationwide, most juvenile detainees live in and are detained in urban areas.31 Second, Cook County is ethnically diverse and has the third largest Hispanic population in the United States.32

Studying Hispanics is important because they are the largest minority group in the United States33 and they are overrepre- sented in the justice systems.5 Third, the detention center’s size (daily census of approximately 650 youth and intake of 20 youth per day) ensured that enough participants would be available.

No single site can represent the entire country because dif- ferent jurisdictions have different options for diversion.34,35 Nev- ertheless, Illinois’ criteria for detaining juveniles are similar to those of other states.34 All states allow pretrial detention if the youth needs protection, is likely to flee, or is considered a dan- ger to the community.34,35

Detainees were eligible to participate, regardless of their psychiatric morbidity, state of alcohol or other drug intoxica- tion, or fitness to stand trial. Within each stratum of sex, race/ ethnicity, age, and legal status, we used a random-numbers table to select names from the CCJTDC’s intake log. Throughout the study, we tracked how many participants were needed to fill each cell. Project staff sampled the rarest categories first. When more than one participant was available for a cell, a random- numbers table was used. The final sampling fractions ranged from 0.018 to 0.689. (Additional information on the sample is available from the authors.)

Studying detained youth requires special procedures be- cause they are minors, they are detained, and many do not have a parent or guardian who can provide appropriate consent.36

Project staff approached participants in their units, explained the project, and assured them that anything they told us (ex- cept acute suicidal or homicidal risk) would be confidential. Participants signed an assent form (if they were younger than 18 years) or consent form (if they were 18 years or older). Fed- eral regulations allow parental consent to be waived if the re- search involves minimal risk (45 CFR §46.116(c), 45 CFR §46.116(d), and 45 CFR §46.408(c)).36,37 The Northwestern Uni- versity Institutional Review Board, the Centers for Disease Con- trol and Prevention Institutional Review Board, and the US Of- fice of Protection from Research Risks waived parental consent. However, as ethicists recommend, we nevertheless tried to con- tact parents to provide them an opportunity to decline partici- pation and to offer them additional information (45 CFR §46.116(d)[4]).38,39 Despite repeated attempts to contact the parent or guardian, none could be found for 43.8% of partici- pants. In lieu of parental consent, youth assent was overseen by a participant advocate who represented the interests of the participants. Federal regulations allow for a participant advo- cate when parental consent is not feasible (45 CFR §46.116(d)).38

Of the 2275 names selected, 4.2% (34 youth and 62 par- ents or guardians) refused to participate. There were no sig- nificant differences in refusal rates by sex, race/ethnicity, or age. Some youth processed as adults (automatic transfers) were coun- seled by their lawyers to refuse participation; in this stratum, the refusal rate was 7.1% (26 of 368 youth). Twenty-seven youth left the detention center before we could schedule an inter- view; 312 were not interviewed because they left while we were attempting to locate their caretakers for consent. Eleven oth- ers were excluded: 9 became physically ill during the inter- view and could not finish it, 1 was too cognitively impaired to be interviewed, and 1 appeared to be lying. The final sample size was 1829. This sample size allows us to reliably detect (ie,

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distinguish from zero) disorders that have a base rate in the general population of 1.0% or greater with a power of 0.80.40

The final sample comprised 1172 males (64.1%) and 657 females (35.9%), 1005 African Americans (54.9%), 296 non- Hispanic whites (16.2%), 524 Hispanics (28.7%), and 4 oth- ers (0.2%). The mean age of participants was 14.9 years, and the median age was 15 years.

Participants were interviewed in a private area, almost al- ways within 2 days of intake. Most interviews lasted 2 to 3 hours, depending on how many symptoms were reported. We used both male and female interviewers. Female participants were always interviewed by female interviewers. Interviewers were trained for at least a month; most had a master’s degree in psy- chology or an associated field and experience interviewing high- risk youth. One third of our interviewers were fluent in Span- ish. We maintained consistency throughout the study by monitoring scripted interviews with mock participants.

PSYCHIATRIC DIAGNOSES

We used the Diagnostic Interview Schedule for Children (DISC) Version 2.3,41,42 the most recent English and Spanish versions then available. The DISC 2.3 assesses the presence of DSM- III-R disorders in the past 6 months. The DISC is highly struc- tured, contains detailed symptom probes, has acceptable reli- ability and validity,41,43-46 and requires relatively brief training.

As in our previous work,8 2 of the diagnoses required spe- cial management. The DISC psychosis module, a broad symp- tom screen, does not generate a specific diagnosis. Instead, this module flags participants if they endorse any “possible” or “prob- able” pathognomonic symptoms or at least 3 nonpathogno- monic symptoms of psychosis. More than one quarter of our participants scored positive on this screen. To be conserva- tive, we counted these participants as psychotic only if (1) their symptoms persisted for at least 1 week; (2) they had not used alcohol, other drugs, or medication during this time; and (3) a project clinician (a child and adolescent psychiatrist or clini- cal psychologist) judged that the symptoms were “probably in- dicative of psychosis” after reviewing the protocol and discuss- ing the case with the interviewer. Twelve participants met these criteria. Project clinicians classified another 8 participants as psychotic who, although they denied symptoms, were judged by the research interviewer to have auditory hallucinations, de- lusions, or thought disorder during the interview.

Attention-deficit/hyperactivity disorder (ADHD) is diffi- cult to assess via self-report47 and is even more challenging to diagnose among delinquent youth.48 In addition, the DSM- III-R requires that symptoms of ADHD be present before the age of 7 years. In many studies, age of onset is reported by the caretaker. Most of our participants who reported symptoms of ADHD could not remember when these symptoms began. To avoid underreporting, we calculated rates of ADHD in 2 ways: in the conventional manner (requiring that symptoms be pres- ent before the age of 7 years) and counting the disorder as pres- ent regardless of the reported age of onset. (We present only the latter; the former rates are available from the authors.)

We determined rates of disorders in 2 ways. As most in- vestigators have done, we report rates using the standard DISC computer algorithms to calculate rates using DSM-III-R crite- ria. We also calculated more conservative (less inclusive) rates for diagnoses that met both DSM-III-R criteria and diagnosis- specific impairment criteria, reported by participants.41 Al- though youth are poor reporters of their own impairment,41,49

we calculated these latter rates because psychiatric diagnoses are best determined by the presence of both symptoms and func- tional impairment.41,50-52 These more conservative estimates, sub- stantially similar to those reported herein, are available from the authors.

STATISTICAL ANALYSIS

Because we stratified our sample by sex, race/ethnicity, age, and legal status, we weighted all prevalence estimates to reflect the distributions of these variables in the detention center’s popu- lation. All reported SEs and tests of significance have been cor- rected for design characteristics with Taylor series lineariza- tion.53,54 We used 2-tailed tests; our level of significance for all tests was .05. We report disorders for males and females sepa- rately, because combining them masks important differences.

RESULTS

COMORBIDITY OF PSYCHIATRIC DISORDERS

Specific Disorders

Significantly more females (56.5%) than males (45.9%) met criteria for 2 or more of the following disorders: ma- jor depressive, dysthymic, manic, psychotic, panic, sepa- ration anxiety, overanxious, generalized anxiety, obses- sive-compulsive, ADHD, conduct, oppositional defiant, alcohol, marijuana, and other substance (t1812=3.13, P=.002); 17.3% of females and 20.4% of males had only 1 disorder. (The DISC 2.3 did not include posttrau- matic stress disorder; posttraumatic stress disorder di- agnoses, available on a subsample, will be presented in future articles.) These analyses are available from the au- thors; analyses of single disorders are available else- where.8 Even after excluding conduct and substance use disorders, which are common among delinquent youth, significantly more females (33.6%) than males (24.2%) had 2 or more disorders (t1813=2.81, P=.005).

Types of Disorders

Figure 1 and Figure 2 show substantial comorbidity for females and males. (We omitted psychoses from this analy- sis because there were so few cases.) Patterns of overlap differ somewhat by sex. Nearly one third of females (29.5%) and males (30.8%) had both substance use disorders and

Anxiety 31.5%

Substance 44.5%

Substance 44.5%

2.6%

2.0% 4.8%

6.7%

3.9%

2.0%

2.3%

4.9%

6.0%

14.0% 7.6%

9.6%

2.9%

ADHD or Behavioral

46.3%

None of the Listed Disorders

27.2%

Affective 26.4%

1.2% 2.2%

Figure 1. Comorbid types of disorder among females. ADHD indicates attention-deficit/hyperactivity disorder.

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ADHD or behavioral disorders; approximately half of these also had anxiety disorders, affective disorders, or both.

Significantly more females (47.8%) than males (41.6%) had 2 or more of the following types of disor-

ders: affective, anxiety, substance use, and ADHD or be- havioral (t1813=2.56, P=.02). Again, even when exclud- ing conduct and substance use disorders, significantly more females (25.1%) than males (18.0%) had 2 or more types of disorders (t1812=2.64, P=.01). Significantly more females (22.5%) than males (17.2%) had 3 or more types of disorders (t1813=2.09, P=.04). These analyses are avail- able from the authors.

Racial/Ethnic Differences. Among females, signifi- cantly more non-Hispanic whites (63.1%) had 2 or more types of disorders than African Americans (42.6%; t639= 3.21, P = .002). Among males, signifi- cantly more non-Hispanic whites (53.1%) had 2 or more types of disorders than African Americans (40.7%; t1142=3.92, P�.001). These analyses are avail- able from the authors.

Table 1 and Table 2 give the prevalence of comorbidity by race/ethnicity among females and males with affective, substance use, anxiety, and ADHD or behavioral disorders. The odds of having comorbid disorders are higher than expected by chance for most racial/ethnic subgroups, except when base rates of disorders were already high or when cell sizes were small.

Anxiety 21.1%

Substance 49.8%

Substance 49.8%

6.9%

2.1% 2.1%

4.3%

16.4% 6.7%

3.2%

1.4%

14.6%

1.1%

1.2% 2.0% 0.7% 1.6%

1.0%

ADHD or Behavioral

41.7%

None of the Listed Disorders

34.8%

Affective 17.9%

Figure 2. Comorbid types of disorder among males. ADHD indicates attention-deficit/hyperactivity disorder.

Table 1. Prevalence and Odds Ratios (ORs) of Comorbidity Among Female Juvenile Detainees With Affective, Substance Use, Anxiety, and ADHD or Behavioral Disorders by Race/Ethnicity*

Disorder

Total (n = 656)

African American (n = 430)

Non-Hispanic White (n = 89)

Hispanic (n = 136)

Prevalence of Comorbidity, % (95% CI)

OR (95% CI)

Prevalence of Comorbidity, % (95% CI)

OR (95% CI)

Prevalence of Comorbidity, % (95% CI)

OR (95% CI)

Prevalence of Comorbidity, % (95% CI)

OR (95% CI)

Affective disorders (n = 144) Substance use disorders 56.4 (47.8-64.7) 1.8† (1.2-2.6) 51.0 (40.6-61.2) 1.6 (1.0-2.5) 60.9 (37.5-80.2) 1.0 (0.3-3.2) 75.9 (57.8-87.8) 4.5† (1.7-12.2) Anxiety disorders 64.2 (55.7-71.9) 6.3‡ (4.1-9.6) 63.4 (52.9-72.8) 5.7‡ (3.5-9.5) 60.9 (37.5-80.2) 6.2† (2.0-19.3) 69.4 (50.9-83.2) 9.2‡ (3.4-25.1) ADHD or behavioral

disorders 71.2 (62.4-78.6) 3.9‡ (2.5-6.1) 70.9 (60.7-79.4) 5.0‡ (3.0-8.4) 70.8 (46.2-87.3) 1.7 (0.5-5.6) 72.3 (44.7-89.4) 2.8 (0.8-10.3)

Substance use disorders (n = 303)

Affective disorders 25.7 (20.8-31.3) 1.8† (1.2-2.6) 25.8 (19.8-32.8) 1.6 (1.0-2.5) 18.8 (10.3-31.8) 1.0 (0.3-3.2) 30.9 (19.0-46.0) 4.5† (1.7-12.2) Anxiety disorders 34.1 (28.5-40.1) 1.3 (0.9-1.9) 36.6 (29.8-44.1) 1.5 (1.0-2.3) 22.6 (12.9-36.4) 0.5 (0.2-1.4) 35.2 (22.5-50.3) 1.6 (0.6-4.4) ADHD or behavioral

disorders 65.2 (59.0-70.9) 4.4‡ (3.1-6.4) 60.3 (52.9-67.3) 4.2‡ (2.8-6.3) 79.6 (66.3-88.5) 7.7‡ (2.7-22.2) 69.0 (50.5-82.9) 3.2§ (1.1-9.2)

Anxiety disorders (n = 206) Affective disorders 42.8 (35.8-50.1) 6.3‡ (4.1-9.6) 42.4 (34.2-50.9) 5.7‡ (3.5-9.5) 41.1 (24.4-60.2) 6.2† (2.0-19.3) 45.4 (27.8-64.3) 9.2‡ (3.4-25.1) Substance use disorders 49.8 (42.5-57.1) 1.3 (0.9-1.9) 48.5 (40.1-57.1) 1.5 (1.0-2.3) 47.8 (30.0-66.2) 0.5 (0.2-1.4) 56.0 (35.9-74.3) 1.6 (0.6-4.4) ADHD or behavioral

disorders 58.9 (51.6-66.0) 2.2‡ (1.5-3.2) 57.9 (49.4-66.0) 2.8‡ (1.8-4.3) 62.5 (43.2-78.6) 1.1 (0.4-3.2) 60.8 (39.8-78.4) 1.6 (0.6-4.5)

ADHD or behavioral disorders (n = 317)

Affective disorders 32.1 (26.9-37.7) 3.9‡ (2.5-6.1) 36.9 (30.0-44.3) 5.0‡ (3.0-8.4) 21.2 (12.2-34.2) 1.7 (0.5-5.6) 26.4 (17.6-37.6) 2.8 (0.8-10.3) Substance use

disorders 64.7 (58.6-70.4) 4.4‡ (3.1-6.4) 62.3 (54.9-69.3) 4.2‡ (2.8-6.3) 78.5 (65.3-87.6) 7.7‡ (2.7-22.2) 60.8 (45.6-74.2) 3.2§ (1.1-9.2)

Anxiety disorders 39.9 (34.2-45.9) 2.2‡ (1.5-3.2) 44.9 (37.6-52.4) 2.8‡ (1.8-4.3) 28.6 (17.6-42.9) 1.1 (0.4-3.2) 33.9 (22.5-47.5) 1.6 (0.6-4.5)

Abbreviations: ADHD, attention-deficit/hyperactivity disorder; CI, confidence interval. *Participants may have more than one disorder. Each cell is weighted to reflect the population of the detention center. Statistically significant ORs indicate that

comorbidity exceeds the level expected by chance, given the prevalence of that disorder in the sample. Affective, substance use, anxiety, and ADHD or behavioral disorders are missing for 1 participant. This participant is excluded from all analyses in this table. All available data from the 656 remaining participants are used for each cell. Of these, 3 participants are missing for affective disorders, 13 are missing for substance use disorders, and 8 are missing for anxiety disorders. Because 1 participant of “other” race/ethnicity is included only in the Total column, racial/ethnic subcategories sum to 655, not 656.

†P�.01. ‡P�.001. §P�.05.

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Age Differences. Significantly more males aged 16 years and older had 2 or more types of disorders (41.2%) than males aged 13 years and younger (27.0%; t1158=3.57, P�.001). Similarly, significantly more males aged 14 and 15 years had 2 or more types of disorders (45.3%) than males aged 13 years and younger (t1158=3.75, P�.001). Among females, there were no significant age differ- ences in the overall prevalence of types of disorder. These analyses are available from the authors.

Table 3 and Table 4 give the prevalence of co- morbidity by age among females and males with affec- tive, substance use, anxiety, and ADHD or behavioral dis- orders. These tables show that the odds of having comorbid disorders are higher than expected by chance for most age groups.

SUBSTANCE USE DISORDERS AND MAJOR MENTAL DISORDERS

More than one tenth of males (10.8%) and 13.7% of fe- males had both a major mental disorder (psychosis, manic

episode, or major depressive episode) and a substance use disorder. We examined these disorders in depth because detention centers are mandated to treat major mental dis- orders and because comorbidity complicates treatment.

Rates of Substance Use Disorders Among Youth With Major Mental Disorders

What are the odds that participants with major mental disorders had co-occurring substance use disorders? Table 5 shows that compared with participants with no major mental disorder (the residual category), both fe- males and males with any major mental disorder had sig- nificantly greater odds (1.8-4.1) of having substance use disorders. We also examined 2 subcategories of major mental disorder: psychosis or manic episode (combined because there were too few cases to analyze separately and because these disorders present similarly) and ma- jor depressive episode. Most odds ratios for these sub- categories were statistically significant, except when cell sizes were small.

Table 2. Prevalence and Odds Ratios (ORs) of Comorbidity Among Male Juvenile Detainees With Affective, Substance Use, Anxiety, and ADHD or Behavioral Disorders by Race/Ethnicity*

Disorder

Total (n = 1170)

African American (n = 574)

Non-Hispanic White (n = 207)

Hispanic (n = 386)

Prevalence of Comorbidity, % (95% CI)

OR (95% CI)

Prevalence of Comorbidity, % (95% CI)

OR (95% CI)

Prevalence of Comorbidity, % (95% CI)

OR (95% CI)

Prevalence of Comorbidity, % (95% CI)

OR (95% CI)

Affective disorders (n = 150)

Substance use disorders