Young people with serious antisocial behaviour Systems issues

At any one time there are approximately 7500 boys (aged under 21 years) in the 28 male young offender institutions in the United Kingdom, and approximately 2500 boys and girls aged under 18 years in what is now called the Secure (Juvenile) Estate provision which includes the following:

• secure care units provided by the local authority (500 places)

• youth treatment centres (40 places)

• young offender institutions (1800 places, of which 300 are for 15- and 16-year-olds)

• secure training centres (200 places)

• secure psychiatric adolescent units provided by the National Health Service and the independent sector (70 places).

It is also likely that, at any one time, between 2500 and 5000 young people with a similar level of risk, need, and antisocial behaviour are being dealt with in the community by youth justice services and the probation service.

There is still a lack of systematically collected data about the whole of this high-need population. There is also poor planning of the transition of care as serious young offenders serving long sentences move back into the community.

In the United Kingdom new Secure Training Orders for the 12- to 14-year-olds admitted to Secure Training Centres emphasize education, avocation, and rehabilitation, and contain automatic follow-up and supervision since half the order is served after return to the community. Although these Secure Training Centres raise major ethical issues, being viewed by many as child prisons, the introduction of aftercare and sentence planning has the potential for involving families and for local community initiatives.

There is increasing research evidence that the rate of mental disorder is high among young offenders, particularly persistent offenders. A diagnosis of primary mental disorder can be made in a third of young men aged between 16 and 18 years who have been sentenced by a court (1°6) and in 26 per cent of male remand prisoners aged 21 years and over (excluding substance misuse). A third of those supervised by a large probation service had a history of deliberate self-harm. Mental health problems are more frequent amongst young offenders before, during, and following incarceration. The most serious example of this increase is the high rate of suicide or attempted suicide amongst young offenders.(109)

High levels of psychiatric and physical morbidity, including learning difficulties, mood disorder, epilepsy, frequent use of alcohol and illicit drugs, and frank mental illness, were found among 10- to 17-year-olds attending a United Kingdom city centre youth court. (I10) Similar findings have been reported in Canada. ^.l1 In the specialist secure care provisions of the Youth Treatment Service, mental health problems that justified specialist clinical assessment were reported in 50 per cent of the population. ^J.2

Factors strongly associated with mental health problems, such as childhood abuse and/or loss, were found in 91 per cent of young people who had committed serious crimes such as violence, arson, or rape.(l i13 Similar high rates of disorder have been found among young people who have an increased risk of delinquency. (114) The mental health needs of young people under the age of 18 years who display high levels of antisocial behaviour, are psychologically disturbed, and present a danger to themselves and others, and who offend, are not well recognized or provided for. (H5)

A survey of youth justice services in England and Wales (H6) reported that the various agencies involved have different objectives and pursue their own key agendas. Most resources are invested in the investigative process and few in changing behaviour. The Crime and Disorder Act 1998 is set to overhaul the United Kingdom youth justice system. It is always stressed that community interventions work better than residential methods, but the latter are required for more seriously disturbed young people and are hampered by poor co-ordination with aftercare and family support. The setting up in the United Kingdom of young offender teams, in which all agencies have a statutory duty to be involved, and a National Youth Justice Board to review and monitor the functioning of these teams, has created a new opportunity for co-ordination.

Violence

Grave acts of violence carried out by adolescents are seen as one of the most important problems in both Europe and the United States, not least because of the economic, social, and emotional costs.

In the United States the arrest rate of those under 18 years of age for murder and manslaughter rose by 60 per cent between 1981 and 1991 compared with a 5 per cent rise for those aged over 18.(H7) These figures are greatly influenced by the ready availability of firearms in the United States and the concentration of juvenile homicide within the African-American subpopulation. (H8) The rate of grave offences committed by children and young adolescents in the United Kingdom, particularly juvenile homicide, has not risen to any significant extent. (H9) Nevertheless, fear of violent crime at the hands of young people is an important and debilitating problem.(120)

Common disorders that may result in displays of violent aggressive, sadistic, or destructive behaviour inevitably involve serious malfunction of individuals in their social setting. To understand how this arises there is a need to understand the process of individual development and social conditions. Violent offenders commit offences of many types, and nearly all chronic offenders have committed a violent offence. Delinquent young people are as much at risk of injury and other victimization as they are of committing offences. Important preventative strategies include understanding early predictors, the availability of early family support, and preschool education. A public health approach to violence has the advantage that it focuses on injury rather than crime. A focus on revictimization suggests that rapid short-term prevention initiatives are most likely to prevent further domestic violence.

Transition of aggression into violence

Violence is particularly subject to rhetoric, born largely out of factual ignorance and understandable fear. In the United Kingdom, Europe, and the United States sadistic violent acts by adolescents lead to a surfeit of public and media interest which at times becomes voyeuristic. Violence occurs within a social system and in the context of individual differences. The development of violent behaviour often involves a loss of sense of personal identity, uniqueness, and personal value; the adolescent engages in actions without concern for future consequences or past commitments.

Loeber*1..21.) has argued convincingly that a developmental approach to violence in children and adolescents 'can open many avenues to knowledge'. The onset of aggression in boys is often in the preschool period. Throughout childhood and into adolescence increasing numbers of boys begin to experience of aggression. (122) More serious violence tends to increase with age, especially during adolescence. Loeber and Hay (123) argue that prevalence rates of aggression and violence from preschool age to young adulthood actually represent four diverse groups of young people:

• those who desist from aggression

• those whose aggression is stable and continues at the same level

• those whose aggression escalates and makes the transition to violence

• those who become persistently aggressive.

Olweus(124) found that the average correlation between aggression in childhood or adolescence and aggression in later life is as high as that for intelligence over time. Longitudinal studies have confirmed this finding.

Sexually inappropriate behaviour in adolescents

Juvenile sexual offending constitutes a substantial health and social problem. Abusers often come from disadvantaged backgrounds with a history of victimization and many suffer from psychiatric disorders. Victims of abuse also suffer high rates of psychiatric disorder. Child mental health services are increasingly being asked to assess and provide treatment not only for victims but also for perpetrators, especially as young abusers are now considered under the United Kingdom child protection framework.

Prevalence rates for sexual offending in the United Kingdom are remarkably similar to those in the United States: 1.5 per 1000 12- to 17-year-olds based on official cases.(!25) The majority of abusers are male, with a history of neglect, physical and/or sexual abuse, below average ability, and high rates of behavioural and psychological problems. In a series of 121 male juvenile sex offenders, the sexual acts were not isolated incidents in normally developing adolescents. (126) Many had a previous record of similar or less serious offences, but previous assessments had not explored the presence or evolution of rape fantasies. The authors stressed the need, in a psychiatric interview, to enquire about rape fantasies and other concurrent violent behaviours in addition to paraphilias. Vizard et al. (127) highlight the necessity to balance the need to take into account the wishes and feelings of the child with the needs of others when the young person has 'wishes and feelings' directed towards abusing others. A model is suggested of a multidisciplinary team that can use the resources of several agencies for the young sexual abuser, following child protection procedures but also arranging early preventative measures.

Most adult sexual abusers of children started their abuse when in adolescence, and yet neither ICD-10 nor DSM-IV has a diagnostic category for paedophilia for those under the age of 16. Vizard et al. (!27) suggest the creation of a new disorder, 'Sexual arousal disorder of childhood', to help identify this vulnerable group who can in turn place vulnerable others at risk. There is currently a lack of epidemiological surveys, using standardized instruments and interviews, in the United Kingdom. Prospective studies using good baseline data are needed to inform the planning of treatment programmes tailored to the needs of adolescents and not just be taken from existing programmes for adults.

Young arsonists

Fire-setting and arson are devastating behaviours impacting on the victim and wider society. There is a paucity of literature that facilitates a consistent view regarding the emergence, maintenance, or promotion of fire-setting behaviour (see Chapteriii11.4:.1).

Fineman(128) stressed the interaction of personal and familial factors predisposing the young person to the behaviour. Vreeland and Levin (129) suggested that fire-setting is the culmination of difficulty/fear of direct expression of aggression, and Patterson (!3°) suggested that it occurs at the end of a continuum of antisocial behaviours. Kolko and Kazdin(l31) highlighted the key features of attraction to fire, heightened arousal, impulsivity, and limited social competence.

In addition to the comprehensive assessment of development, social/family problems, educational history, personal/family history, health history, and offence history, the following specific domains should be explored:

• history of fireplay

• history of hoax telephone calls

• nature of behaviour—fires set alone, with peers, or combination

• where set—open/green space, occupied/unoccupied dwelling

• previous threats/targets

• type of fire—single, multiple seats of fire, ritualistic

• motivation—anger resolution, boredom rejection, cry for help, thrill-seeking, fire-fighting, crime concealment, no motivation, curiosity, peer pressure.

Treatment

Adolescent arsonists are not a homogenous group. They have a wide range of familial, developmental, social, interpersonal, clinical, and 'legal' needs. Thus, as with other serious antisocial behaviours, no single standard treatment approach will be appropriate for all individuals. (132)

The following should be considered for recidivistic fire-setters.

1. Psychotherapy to promote the adolescent's understanding of the behaviour, including antecedents, defining the problem behaviour, and establishing what the reinforcers of the behaviour are.

2. Skills training—promoting the adolescent's ability to use adaptive coping mechanisms as an alternative to fire-setting.

3. Understanding environmental factors to provide strategies to manage or avoid trigger situations such as alcohol use and stressful social situations.

4. Counselling to reduce psychological distress.

5. Behavioural techniques to extinguish the behaviour.

6. Education to promote the adolescent's understanding of the cause and effect of his or her behaviour and to establish acceptance of responsibility for his or her actions.

7. Supervision and support for the staff caring the adolescent.

Treatment resistance is most likely to occur in adolescents whose life experiences have included those listed in Tables.

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Table 3 Life experiences associated with treatment resistance

Juvenile homicide

A United Kingdom study of 50 juvenile murderers (10-17 years) assessed (133) and given long-term treatment by an adolescent forensic service(134) revealed that many had pre-existing conduct disorder and emotional difficulties with adverse family and social circumstances. A smaller group had learning difficulties and neuropsychological problems. Alcohol was a significant contributory factor in older adolescents. However, none of 76 variables studied stood alone as causing the young person to act as he or she did. These findings mirror those obtained in the United States (135) when use of firearms is taken into account. The characteristics of this group also mirrored those of young people referred to the service with less serious antisocial behaviour and highlights the need for the assessment of the individual health needs of all delinquent young people offered cognitive-behaviourally based programmes by social services and probation.

Psychodynamic therapy with young people who have committed sadistic acts of violence has to be tailored to the demands of the external environment and approached cautiously. Motivational dynamics are complex.

Given the frequent distortion of perception of self and others, the emergence of a true sense of guilt and shame can be, and often is, a slow, difficult, painful, and angry process. Within the United Kingdom this group is liable to periods of lengthy incarceration. Irrespective of the treatment model, the parallel process of education, vocation, avocation-consistent role models, and continued family contact is of critical importance. This requires a warm and harmonious setting with clear organization, practical aims, and high expectations, allowing positive relations between the staff and the adolescent, between staff, and between adolescents. (136)

Against the inevitable background of public pressures before, during, and after the trial, the adolescent has to move safely through the process of disbelief, denial, loss, grief, anger, and blame. Post-traumatic stress disorder, arising from participation in the sadistic act, has to be treated, as does trauma arising from previous experience of emotional, physical, and/or sexual abuse. Characteristics such as previous frequent and severe aggression, low intelligence, and a poor capacity for insight weigh heavily against a safe long-term outcome. The possibility of emerging mental illness, in particular depression, is very real.

Adolescents with sadistic behaviour have a depth of sensitivity and reaction to perceived threat not seen in other young people. They may see threat and ridicule in many ordinary daily events. A related theme is saving face. As the young person starts to discuss his sadistic act, he may have to confront past loss, trauma, and abuse. This leads to disclosure of fears of being vulnerable, and fears that therapy may bring about change he neither likes nor can control. His past sadistic acts have been attempts at maladaptive control over the outside world that he is reluctant to relinquish. A combination of verbal and non-verbal therapies, in particular art, has much to offer this group of adolescents. With disclosure and understanding comes empathy for the victim, saying sorry, and reattribution of blame. This process is often accompanied by expressions of anger and distress within sessions, often sexualized in form and content. Emotions engendered in treatment can spill outside the sessions, leading to disruptive behaviour. In the closed institution, this is difficult not only for the adolescent but for the carers, and both may become collusively rejecting and dismissive of the therapists. Combining within the institution a consistent regime based on cognitive-behavioural principles, together with individual psychotherapy, offers the best chance of safe resolution and halting of a trajectory into adult antisocial personality disorder.

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