Journal of Child and Family Studies, Vol. 8, No. 2, 1999, pp. 193-204

Mental Health and Incarcerated Youth. I:Prevalence and Nature of Psychopathology

D. Lanette Atkins, M.D.,1 Andres J. Pumariega, M.D.,2,8 KennethRogers, M.D.,3 Larry Montgomery, M.D.,4 Cheryl Nybro, Ph.D.,5

Gary Jeffers,6 and Franklin Sease, B.S.7

The incarceration of mentally ill youth is a serious problem not receiving the sameattention as in adults. In this study, we examine the prevalence of psychopathologyand level of behavioral symptomatology in Incarcerated youth versus youth receiv-ing community mental health services or hospitalization. We randomly recruitedyouth from middle South Carolina served by a local CMHC (n = 60), youth servedby the state adolescent inpatient program (n = 50), and youth in the S.C. Dept.of Juvenile Justice facilities from the same region (n = 75). We used the DISC-PC2.3 to evaluate DSM-III-R diagnoses and the CBCL and YSR to evaluate behav-ioral symptomatology. On the DISC, incarcerated youth had significantly highermean number of diagnoses and symptoms than CMHC youth, but lower numbersthan hospitalized youth. Level of "caseness " (at least one diagnosis) was 86% inhospital youth, 72% in incarcerated youth, and 60% in CMHC youth. The groupsdiffered in CBCL mean total T, internalizing T, and externalizing T scores as wellas mean YSR internalizing T scores. Our results indicate the comparability in levelof psychopathology in incarcerated and community-treated populations of youth,

1 Medical Director, New Hope Midlands Residential Treatment Center, West Columbia, South Carolina.2 Professor and Chair, Department of Psychiatry and Behavioral Sciences, James H. Quillen College

of Medicine, East Tennessee State University, Johnson City, Tennessee.3 Assistant Professor, Department of Neuropsychiatry and Behavioral Science, University of SouthCarolina School of Medicine, Columbia, South Carolina.

4 Director of Inpatient Facilities, South Carolina Department of Mental Health, Columbia, SouthCarolina.

5 Engineer, KHAFRA Engineering, Columbia, South Carolina.6 Research Assistant, Department of Neuropsychiatry and Behavioral Science, University of SouthCarolina School of Medicine, Columbia, South Carolina.

7 Psychiatry Resident, Department of Neuropsychiatry and Behavioral Science, University of SouthCarolina School of Medicine, Columbia, South Carolina.

8 Correspondence should be directed to Andres J. Pumariega, East Tennessee State University, P.O. Box70567, Johnson City, Tennessee 37614.

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1062-l024/99/0600.0193$l600/0© 1999 Human Sciences Press, Inc.

Atkins, Pumariega, Rogers, Montgomery, Nybro, Jeffers, and Sease

The problems of juvenile crime and the incarceration of youth are receivingincreasing attention politically, socially, and clinically on a national level. In spiteof this recent attention, little time has been devoted to the issue of mentally illincarcerated youth. Some authors have suggested that a large proportion of youthbeing incarcerated are emotionally disturbed and mentally ill. The fact that emo-tionally disturbed and mentally ill youth are being incarcerated at all brings upserious concerns about the failure of community services designed to prevent suchoutcomes (Duchnowski, Johnson, Hall, Kutash, & Friedman, 1993).

Studies reported thus far in the U.S. addressing the problem of incarcera-tion of youth with emotional disorders/mental illness have had significant flaws.Most studies have not used systematic, random epidemiological sampling. Youthinvolved have only been evaluated for single diagnoses for each youth, despite thefact that research is indicating a high rate of comorbidity of mental disorders inchildren and adolescents (Anderson, Williams, McGee, & Silva, 1987; Caron &Rutter, 1991; Kashani et al., 1987; Otto, Greenstein, Johnson, & Friedman, 1992).Most studies conducted have not used systematic structured diagnostic instrumentsto evaluate such disorders (Davis, Bean, Schumacher, & Stringer, 1991) and havenot examined demographic variables associated with incarceration.

The most systematic studies available to date on the prevalence of mentalillness in incarcerated youth have been as part of the study by Teplin (1990, 1994)on male urban jail detainees in Cook County, Illinois, using random stratifiedsampling methods as well as the National Institute of Mental Health DiagnosticInterview Schedule (NIMH-DIS; Robins, Helzer, Ratcliff, & Seyfried, 1982). Shecompared the current rates of severe disorders with those found in the NIMHEpidemiological Catchment Area study (ECA; Eaton, Regier, Locke, & Taube,1981) and found significantly higher rates of severe disorders (major depression,schizophrenia, and mania) in the 18-22 year old sub-sample (4.36%) than foundin the ECA study (1.94%) for the comparable age group (Teplin, 1990). She lateranalyzed the data for a younger cohort in the same study and found that the rates ofpsychiatric disorders assessed (schizophrenia, manic episode, major depression,dysthymic disorder, substance abuse disorder, and anxiety/somatoform disorder)were lower in 16-21 year olds than in the older age groups (Teplin, 1994).

Otto et al. (1992) reviewed thirty four (34) epidemiological studies of youthwithin the juvenile justice system and found a prevalence rate for at least oneDSM-III-R diagnosis of up to 91%. Lower prevalence rates of mental disorderswere generally reported by those studies that did not use direct interviews of thesubjects but employed record review or clinical assessment interview. Structuredinterviews may be more reliable than clinical interviews because subjects of clinical

194

and the need to develop diversionary programs to prevent the entry of such youthinto the juvenile justice system.

KEY WORDS: Adolescents; incarceration; psychopathology; symptomatology; co-morbidity.

interviews are often less than honest, even when in non-threatening research situ-ations (Otto et al., 1992). The fact that subjects may be less than honest was sup-ported by a study which used urinalysis to confirm self report of substance abuse.The results of this study indicated that some youth were likely to minimize or denysubstance abuse (Dembo et al., 1990) and may do so for other symptoms as well.Research conducted so far indicates that the prevalence of mental disorders amongincarcerated youth is higher than estimated for the general population (Costello,1989) and that a major proportion of incarcerated juvenile offenders have signif-icant mental/emotional disorders (Hollender & Turner, 1985; McManus, Alessi,Grapentine, & Brickman, 1984).

Studies have shown that hospitalized and incarcerated youth were psychi-atrically similar (Lewis, Shanok, Cohen, Kligfeld, & Frisone, 1980), and that theincidence of mental disorders among incarcerated youth exceeded communityprevalence rates (Davis et al., 1991; Lewis, Shanok, & Balla, 1979). One studyof juvenile murderers indicated that up to 96% of incarcerated youth met criteriafor at least one DSM-III-R diagnosis (Myers, Scott, Burgess, & Burgess, 1995).Youth who are seriously delinquent show a disproportionate prevalence of somethought disorder symptoms, hyperactivity, affective disturbance, and neurocogni-tive impairment (Barnum, Famularo, Bunshaft, Fenton, & Bolduc, 1989).

High rates of comorbidity of mental disorders have been reported in youth inthe juvenile justice system, which may be explained by a number of common riskfactors which predispose them to multiple forms of disturbance and psychopathol-ogy (Otto et al., 1992). For example, the discord associated with broken homes isassociated with both incarceration and emotional disturbance (Westendorp, Brink,Roberson, & Ortiz, 1986). Characteristics of social, economic, and educationaldisadvantage (school problems, drug and alcohol abuse, and family discord) arerisk factors for developing delinquent and criminal careers in addition to beingfactors that influence psychiatric referral (Barnum et al., 1989).

Comorbidity associated with disruptive behavior disorders has been found tobe prevalent amongst youth in the juvenile justice system. Approximately half ofyouth with conduct disorder had at least one other diagnosis (Otto et al., 1992).There are high rates of comorbidity between conduct disorder and affective disor-ders (Davis et al., 1991; Fergusson, Lynskey, & Horwood, 1996). This co-morbiditymay also be due to the fact that the risk factors that predispose youth to affectivedisorders are associated with the same risk factors that predispose to conductdisorders (Fergusson et al., 1996).

Another form of prevalent comorbidity reported in youth in the juvenile jus-tice system is associated with psychotic symptomatology. For example, a studyof juvenile murderers indicated that almost three fourths (71%) had a historyof psychotic symptoms. Although the youth had multiple psychotic symptoms,none met criteria for a DSM-III-R diagnosis (Myers et al., 1995). This increasedprevalence of comorbidity with psychotic symptoms may be due to PTSD typedissociative phenomena. This theory is supported by the fact that many youth

Psychopathology in Incarcerated Youth 195

involved with the juvenile justice system have histories of serious physical abuse,sexual victimization, and/or serious neglect (Dembo, Williams, & Schmeidler,1993; Lewis et al., 1979; Myers et al., 1995). There is also speculation that someyouth classified with conduct disorder may be pre-schizophrenic and manifestthis by disruptive, unusual or eccentric behavior (Davis et al., 1991). In addi-tion, individuals with borderline personality disorder often exhibit transient psy-chotic symptoms and show extreme variations in mood and behavior (Davis et al.,1991).

Minority youth, particularly African-American and Latino males, are over-represented within the incarcerated juvenile population (Cohen et al., 1990; Kaplan& Busner, 1992). Possible factors involved in the over-representation of minorityyouth in incarcerated populations include: the failure of mental health and socialservices to address the needs of minority youth (Mason & Gibbs, 1992) and biasesin assessment (Fabrega, Ulrich, & Mezzich, 1993; Kilgus, Pumariega, & Cuffe,1995; Lewis et al., 1980) which may predispose the entry of minority youth intothe juvenile correctional system (Westendorp et al., 1986).

We address a number of important questions underlying the incarceration ofyouth with mental/emotional disorders. These include: (a) What is the prevalenceof major psychiatric diagnoses amongst incarcerated versus community-treated orpsychiatrically hospitalized youth? (b) What is the caseness (prevalence of anydisorder) amongst these three groups? (c) What is the symptomatic prevalence(mean symptom count) across the three groups? (d) What are the levels of behav-ioral symptomatology (as measured by CBCL and YSR) across the three studygroups?

METHOD

Participants

The study included three groups of youth ages 13 to 17 from the "Midlands"region of South Carolina, consisting of eight counties which cover the centralpart of the state. The three groups were comprised as follows: (a) Incarceratedyouth were recruited from the South Carolina Department of Juvenile Justice(SCDJJ) central detention facility in Columbia (n = 75). These youth came fromthe whole Midlands region and were randomly selected from the monthly rostersof the SCDJJ facility. Youth who had been incarcerated over six months wereexcluded from the study in order to control for the psychological impact of longterm incarceration/ institutionalization. They represent a balance of rural and urbanpopulations in the Midlands region, with 42.7% coming from an urban settingsand 57.3% from rural settings. The non-participation rate in this group (includingrefusal to participate, inability to contact, and lack of follow-through) was quite low(17 percent). (b) Youth being treated at the Columbia Area Community MentalHealth Center (CMHC youth, n = 60). They were randomly selected from the

196 Atkins, Pumariega, Rogers, Montgomery, Nybro, Jeffers, and Sease

Psychopathology in Incarcerated Youth

case rosters at the Columbia Area CMHC and represented a mostly urban sample(83.3% urban and 16.7% rural). The rate of non-participation in this sample was50%. (c) Youth hospitalized at the state inpatient program for adolescents at theWilliam S. Hall Psychiatric Institute (n = 50). This group was recruited from serialadmissions from the whole Midlands region during a period of slightly over a year.They also represent a balance of rural (44.0%) and urban (56.0%) populations. Thenon-participation rate in this sample was 44%. Youth with an IQ of 65 or belowwere excluded from the study.

Table 1 summarizes the demographic profile of the three study groups. Bycomparison, according to data from the 1990 U.S. Census, the population of theMidlands region is 39.5% rural, 60.5% urban, and 39.1% African-American (withno more than 2 percent Hispanic and Native American combined and the restbeing white). Four of the counties in the region (including Richland, the main ur-ban county) having a majority of African-American population. The three groupsdiffered significantly in their gender, racial, rural/urban, and age composition(Table 1). Interestingly, CMHC youth have a similar racial distribution as incarcer-ated youth. This is largely a result of the poorer, predominantly African-Americanpopulation of children and youth served by community mental health centers inthe Midlands region.

Instruments

The instruments used in this study include: (a) The Diagnostic InterviewSchedule for Children, version 2.3 (DISC 2.3; Shaffer et al., 1996). The DISC2.3 was developed by the National Institute for Mental Health for the systematic

197

Table 1. Demographic Characteristics of Incarcerated, Hospitalized, and CMHC Youth

DemographicVariable

GenderMaleFemale

RaceAfrican-Amer.White

RuralityRuralUrban

Age

Incarcerated(n = 75)

n

714

5817

4332

M

15.5

%

94.75.3

77.322.7

57.342.7

SD

1.0

Hospitalized(n = 50)

n

2723

2228

2228

M15.1

%

54.046.0

46.056.0

44.056.0

SD1.4

CMHC(n =60)

n

3624

4613

1050

M14.2

%

60.040.0

76.721.7

16.783.3

SD

1.0

Significance

X2

31.72

21.22

23.08

F20.46

P

.00

.00

.00

P.00

Notes: One way ANOVA's performed with Bonferroni corrections for repeated measures;df= 2 for between group comparisons, df= 182 for within group comparisons; df = 2 for chisquare analyses.

assessment of major diagnoses found under the Diagnostic and Statistic Man-ual of the American Psychiatric Association, Third Edition, Revised (DSM-III-R;American Psychiatric Association, 1987), especially in epidemiological studies.The instrument includes modules for anxiety disorders, mood disorders, psychosis,disruptive disorders, substance abuse disorders, and miscellaneous disorders suchas eating disorders, tics, and elimination disorders. The youth version of the in-strument was used in used to determine diagnoses as well as symptoms of mental/emotional disorders. We analyzed the frequency of different diagnostic categories,the number of diagnoses met by participant, and the number of symptoms whichcontributed to meeting diagnostic criteria. (We did not include psychotic symp-toms in the symptom count totals since the psychosis module was designed as a"screen" and not a diagnostic module, so many of the symptoms could overlapwith the symptoms of other modules.) (b) Child Behavior Checklist and YouthSelf-Report (CBCL and YSR; Achenbach, 1991), which are rating instrumentsused to obtain parent and youth ratings respectively of behavioral and emotionalsymptoms and social competence. Both of these instruments have well establishedreliability and validity data in field studies as well as clinical settings. We analyzedthe total, internalizing, and externalizing T scores for each instrument.

Procedure

The youth selected, and their respective parents/guardians, were recruited us-ing a written parental consent and youth assent procedure after they were identifiedby the random selection procedure. Parent rating scales were first completed inperson or by mail, with phone assistance provided if parents were unable to read.Youth were interviewed in their respective residential setting by trained interview-ers (social workers, nurses, and medical students) once the parent rating scaleswere completed.

RESULTS

Table 2 summarizes the percent of youth in each of the three groups (incar-cerated, hospitalized, and community-treated) who met criteria for different levelsof caseness. Using the DISC 2.3, 72% of incarcerated youth, 60% of community-treated youth, and 86% of hospitalized youth in our sample met criteria for atleast one psychiatric disorder (X2(2, 185) = 9.12, p = .010). Using the CBCL,69.3% of incarcerated, 81.6% of CMHC youth, and 94% of hospitalized youthwere at or above the established clinical cut-off T score of greater than or equal to60 (X2(2, 185) = 11.56, p = .003). A similar cut-off score was used for the YSRtotal T score, with no significant difference across the percentages of youth meet-ing this criterion (41.3% incarcerated, 58.0% hospitalized, and 40.0% CMHC;X2(2, 185) = 4.41, p = .110. We combined DISC positive diagnosis and CBCL

198 Atkins, Pumariega, Rogers, Montgomery, Nybro, Jeffers, and Sease

Psychopathology in Incarcerated Youth 199

cut-off score criteria to calculate an overall caseness estimate. This providesa multi-informant criterion which combines diagnostic and behavior rating ap-proaches. We found that 53% of incarcerated, 56.6% of CMHC youth and 80.0%of hospitalized youth met this combined criterion, which were not significantlydifferent (X2(2, 185) = 5.58, p = .061).

Table 3 summarizes the frequencies of different DSM diagnostic categorygroupings across the three participant groups. The rates of anxiety (X2(2, 185) =22.42, p = .033), mood (X2(2, 185) = 23.82; p = .001), disruptive (X2(2, 185) =9.63, p = .047), and substance abuse disorders (X2(2, 185) = 18.19, p = .006)

Table 2. Prevalence of Diagnoses and Clinically Significant Disturbance inIncarcerated, Hospitalized, and CMHC Youth

Incarcerated(n = 75)

Variable

Positive DISC DiagnosisCBCL Total T > 60YSR Total T > 70Positive Diagnosis and

CBCL Total T > 60

n

54523140

%

72.069.341.353.3

Hospitalized(n = 50)

n

43472940

%

86.094.058.080.0

CMHC(n =60)

n %

36 60.049 81.624 40.034 56.6

X2

9.1211.564.415.58

P

.010

.003

.110

.061

Note: df = 2 for chi square analyses.

Table 3. Frequencies of Diagnostic Categories Measured in Incarcerated,Hospitalized, and CMHC Youth

Diagnostic Category

Anxietya

Moodb

Psychosisc

Disruptived

Substance Abusee

Miscellaneousf

Incarcerated(n = 75)

n

25183432158

%

33.324.045.342.720.010.7

Hospitalized(n = 50)

n

27262622192

%

54.052.052.044.038.04.0

CMHC(n = 60)

n

219

2121110

%

35.015.035.035.018.30.0

X2

22.4223.822.079.63

18.197.96

P

.033

.001

.355

.047

.006

.093

Notes: Percentages add up to more than 100 percent due to comorbidity of disorders;df = 2 for chi square analyses.

aAnxiety: includes obsessive-compulsive disorder, panic disorder, separation anxietydisorder, simple phobia, social phobia, overanxious disorder, avoidant disorder, andgeneralized anxiety disorder.

bMood: includes major depression, dysthymia, and bipolar disorder.cPsychosis: includes positive psychosis screen.dDisruptive: includes conduct disorder, oppositional-defiant disorder, and attention

deficit hyperactivity disorder.eSubstance Abuse: includes alcohol, marijuana, and other illegal drug abuse and/ordependence.

fMiscellaneous: includes eating disorders, movement disorders, and enuresis/enco-presis.

Atkins, Pumariega, Rogers, Montgomery, Nybro, Jeffers, and Sease

were significantly different across the three groups, but the rates of psychosis(X2(2, 185) = 2.07, p = .355) and miscellaneous disorders (X2(2, 185) = 7.96, p =.093) were not. However, the rates found in incarcerated youth were in betweenthose found for hospitalized and CMHC youth, with the exception of higher sub-stance abuse disorders in the incarcerated youth sample. On Table 4, which sum-marizes the frequencies of disruptive disorder sub-types, we find that a higherpercentage of incarcerated and hospitalized youth met criteria for conduct dis-order (40% versus 15% for CMHC youth; X2(2, 185)= 11.67, p = .003), butfew of these did not have another concurrent Axis I disorder (10.0% for hos-pitalized, 4.0% for incarcerated, and none for CMHC youth; X2(2, 185) = 6.62,p = .036).

Table 5 summarizes the mean DISC co-morbidities, DISC symptoms, CBCLscores, and YSR scores for incarcerated, hospitalized, and CMHC youth, as wellas ANOVA's performed for each variable across the three groups. We found ahigh level of comorbidity across all three groups, with a mean of 2.4 diagnosesin incarcerated youth, 4.2 diagnoses in hospitalized youth, and 1.5 diagnoses inCMHC youth (F(2, 182) = 12.63, p = .0000). Levels of symptomatology were

200

Table 4. Frequencies of Disruptive Disorders Measured in Incarcerated, Hospitalized, andCMHC Youth

Diagnostic Category

Conduct DisorderOppositional-Defiant DisorderADHDConduct Disord. Alone

Incarcerated(n = 75)

n

3011

13

%

40.014.7

1.34.0

Hospitalized(n = 50)

n

20945

%

40.018.08.0

10.0

CMHC(n = 60)

n

9540

%

15.08.36.70.0

X2

11.672.323.506.62

P

.003

.313

.173

.036

Note: df = 1 for chi square analyses.

Table S. Diagnosis and Symptom Comparison: Incarcerated, Hospitalized, and CMHC Youth

Variable

Number DISC Dx...Number DISC sympt..CBCL Total TCBCL Int. TCBCL Ext. TYSR Total TYSR Int. TYSR Ext. T

Incarcerated(n = 75)

M

2.4030.4963.0858.5965.4357.9255.3260.08

SD

2.7323.2211.0411.4010.9312.1511.8112.92

Hospitalized(n = 50)

M

4.2046.6273.6870.3871.4459.5658.9858.82

SD

3.9632.348.778.759.99

11.2411.7713.35

CMHC(n = 60)

M

1.4718.8368.0763.1767.3754.6552.4556.90

SD

1.7317.6310.7312.5710.8613.7412.2114.23

F

12.63 .17.64 .15.77 .16.74 .4.81 .2.27 .4.09 .0.93 .

P

00000000000000000092106601843959

Note: One way ANOVA's performed with Bonferroni corrections for repeated measures; df = 2 forbetween group comparisons, df = 182 for within group comparisons.

high in all samples, with a mean of 30.5 positive symptoms in incarcerated, 46.62 inhospitalized, and 18.8 symptoms in CMHC youth (F(2, 182) = 17.64, p = .0000).Again, the levels of co-morbidity and symptomatology for incarcerated youth werebetween those found for hospitalized and CMHC youth. The mean CBCL totalT(F(2, 182) = 15.77, p = .0000), internalizing T(F(2, 182) = 16.74, p = .0000),and externalizing T(F(2, 182) = 10.86, p = .0092) scores were significantly dif-ferent for the three groups, with incarcerated youth having lower scores than theother groups. The YSR internalizing T scores were significantly different betweenthe three groups (F(2, 182) = 4.09, p = .0184), while the YSR total (F(2, 182) =2.27, p = .1066) and externalizing T scores (F(2, 182) = 0.93, p = .3959) wereequivalent across the three groups.

DISCUSSION

This study has a number of limitations which restrict the conclusions whichcan be drawn from it. The sample size is relatively small and confined to thepopulation of one region of a small state, which limits the statistical analyseswhich can be performed on the data. The diagnostic and clinical symptom datarelies on the reliability report of the youth and his/her parent. Although we didhave parent and youth reports factored in the combined caseness rates, we werenot able to obtain parent structured interviews given the available resources for thestudy. On the other hand, this is the first study of psychopathology in incarceratedyouth to use random sampling and structured diagnostic instruments, which is aconsiderable strength compared to other studies to date.

The levels of psychopathology and symptomatology found in our sample ofincarcerated youth are comparable to those at the higher end of previous studies(Otto et al., 1992). They were also comparable to those we found in youth be-ing treated in community mental health centers, with incarcerated youth possiblyhaving even higher levels of psychopathology. The latter is indicated by the highlevel of co-morbidity found in the incarcerated group as well as the prevalencerates for anxiety and depressive disorders as well as the high prevalence of youthhaving experienced significant psychotic symptoms. It is also important to notethat relatively few incarcerated youth met criteria for a solitary conduct disorderdiagnosis, disproving the commonly-held belief that incarcerated youth primarilyhave solitary conduct disorder. On the other hand, the prevalence of substanceabuse and dependence disorders was lower than expected given the high numberof youth incarcerated for drug-related offenses. This could indicate some difficultywith self-disclosure on the part of youth around these problems, perhaps for fearof further legal repercussions. On the other hand, many of the youth we surveyedspontaneously indicated during the administration of the substance abuse modulethat they casually used substances and even dealt drugs, but they were not heavyusers.

Psychopathology in Incarcerated Youth 201

These results strongly supports observed trends towards the incarcerationof mentally ill and emotionally disturbed youth. The lack of community-basedand preventive mental health services for youth, particularly in rural areas, allowsmany youth with emotional mental disorders to go undetected and untreated. Theycan then escalate in their symptoms to the point that they suffer from co-morbiddisruptive behavioral symptoms. At that point, they then come to the attentionof juvenile authorities and the courts. It is not by accident that the proportionof African-Americans in the hospitalized group was significantly lower than thatfor both the incarcerated group and community-treated sample representative ofthe catchment area from which the inpatient units draw their admissions. As thestudies by Lewis et al. (1980), Kaplan and Busner (1992), and Cohen et al. (1990)have pointed out, white youth with serious disturbances access hospitalizationmuch more readily than African-Americans, who are tracked towards the juvenilejustice system. The patterns of service utilization and diagnostic bias which leadto the incarceration of emotionally disturbed and mentally ill youth require closestudy.

Our results also support the appropriateness of high levels of mental healthservices to address the needs of incarcerated youth., as well as the need fordiversionary programs to prevent the incarceration of youth at risk for men-tal illness/emotional disturbance. The success of community-based interventionssuch as multisystemic therapy (Henggeler, Melton, Smith, Schoenwald, &Hanley, 1993) in the prevention of incarceration of emotionally disturbed youthis promising. However, we cannot ignore the mental health needs of youth whoare currently incarcerated. The current political climate generates much pressureto punish incarcerated youth rather than rehabilitate them. However, given thealready high prevalence rates of psychopathology amongst incarcerated youth,the integration of treatment services within youth correctional facilities com-bined with effective follow-up and case management services upon release may bethe most clinically and cost-effective means of preventing future criminality andrecidivism.

ACKNOWLEDGMENTS

Study funded through a grant by the Fullerton Foundation, Gaffney, SouthCarolina, through the University of South Carolina School of Medicine; Andres J.Pumariega, M.D., Principal Investigator.

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