Mental Health: The Influence of Mental Health on Juvenile Justice System Involvement

Definitions

Mental health includes a person's psychological, emotional, and social well-being (CDC, 2023; SAMHSA, 2023c; Westerhof and Keyes, 2010).

• Psychological well-being refers to positive individual functioning that promotes self-realization (Westerhof and Keyes, 2010).
• Emotional well-being refers to feelings of happiness and satisfaction with life (Westerhof and Keyes, 2010). Emotional health (or emotional wellness) is an individual's ability to cope with both positive and negative emotions (National Institutes of Health, 2022; WebMD, 2024).
• Social well-being refers to positive societal functioning and value, such as building and maintaining healthy relationships and having meaningful, authentic interactions with others (Boston University, n.d.; CDC, 2022; Westerhof and Keyes, 2010).

Mental health affects how a person feels, thinks, and acts (CDC, 2023; SAMHSA, 2023c; Westerhof and Keyes, 2010) and is more than just the absence of mental illness (Fusar-Poli et al., 2020). However, the definition of mental health varies depending on the source (Galderisi et al., 2015; Stein et al., 2010; Stein, Palk, and Kendler, 2021). For example, the World Health Organization defines mental health as a state of well-being in which the individual realizes his or her own abilities, can cope with the normal stresses of life, and can work productively and fruitfully (Fusar-Poli et al., 2020). The American Psychological Association (2018a) defines mental health as a state of mind characterized by emotional well-being, good behavioral adjustment, relative freedom from anxiety and disabling symptoms, and a capacity to establish constructive relationships and cope with the ordinary demands and stresses of life.

Behavioral health is a general term that encompasses the promotion of emotional health; the prevention of mental illnesses and substance use disorders; and treatments and services for mental and/or substance use disorders (SAMHSA, 2023a).

Mental disorders relate to issues or difficulties a person may experience with his or her psychological, emotional, and social well-being. Mental illnesses are disorders that affect a person's thoughts, moods, and/or behaviors. Mental illnesses can range from mild to severe (SAMHSA, 2023c).

The Diagnostic and Statistical Manual of Mental Disorders (DSM) is a standard classification tool for mental disorders used by many mental health professionals in the United States. The most recent DSM is the fifth edition with text revision (DSM–5–TR>) [First et al., 2023].

Mental health problems can be categorized in different ways. For example, they can be viewed as either internalizing or externalizing disorders. Internalizing disorders are negative behaviors focused inward, such as depression, anxiety, and dissociative disorders. Externalizing disorders are characterized by behaviors directed externally toward a youth's environment, such as conduct disorders, oppositional defiant disorder, and antisocial behaviors (Cosgrove et al., 2011; Eisenberg et al., 2001; Kimonis, Frick, and Fleming, 2019; Loyd et al., 2019). Mental health disorders can also be organized into five types: 1) mood disorder (e.g., depression, bipolar disorder), 2) anxiety disorder (e.g., generalized anxiety disorder, panic disorder), 3) behavior disorder (attention-deficit/hyperactivity disorder [ADHD], conduct disorder, oppositional defiant disorder), 4) substance use disorder, and 5) other (e.g., eating disorder, psychosis) [Center for Behavioral Health Statistics and Quality, 2016].

Neuropsychiatric disorder is a medical term that encompasses a broad range of complex conditions with both neurologic and psychiatric symptoms (Bray and O'Donovan, 2018). These disorders are characterized by behavioral, cognitive, and emotional disturbances rooted in brain malfunction. Neuropsychiatric disorders include schizophrenia, bipolar disorders, major depressive disorder, psychopathy, autism spectrum disorder, and ADHD. Their underlying biological mechanisms are largely unknown (Bray and O'Donovan, 2018; Mathee et al., 2020).

Psychopathology is the scientific study of mental disorders, including their theoretical underpinnings, etiology, symptomatology, progression, diagnosis, and treatment (American Psychological Association, 2018b). Psychopathology is a broad discipline that draws on research from fields such as psychology, psychiatry, biochemistry, pharmacology, neurology, and endocrinology.

Serious emotional disturbance (SED) refers to diagnosable emotional, mental, or behavioral disorders resulting in functional impairment that substantially limits a child's functioning in school, family, or community activities (Center for Behavioral Health Statistics and Quality, 2016; Mayhew, 2018; SAMHSA, 1993). This term was defined by the Substance Abuse and Mental Health Services Administration (SAMHSA) in 1993 to assist states in measuring the prevalence of children with SED for their applications for Community Mental Health Block Grant funding (SAMHSA, 1993; SAMHSA, 1998). Although the DSM–5–TR does not employ the term SED, it provides criteria for diagnosing disorders that can constitute SED (e.g., posttraumatic stress disorder, bipolar disorder, conduct disorder). Substance use disorders and developmental disorders are not considered a SED unless they co-occur with another diagnosable SED (Center for Behavioral Health Statistics and Quality, 2016; SAMHSA, 1993).

Given the various ways that mental health is defined in research (McCormick, Peterson-Badali, and Skilling, 2017), it is sometimes difficult to compare results across studies. Studies may use different diagnostic tools for identifying mental health needs. Also, some conditions may be categorized differently depending on the study. Additionally, there is more empirical research on preventing poor mental health than on strengthening mental health (Fusar-Poli et al., 2020).

Types of Mental Health Interventions

Interventions to improve mental health outcomes generally fall somewhere on the continuum of prevention, treatment, and recovery (SAMHSA, 2016; Perlman and Jordan, 2017; Stanojlović and Davidson, 2021). Two broad categories of mental health and substance misuse interventions are psychosocial and psychotropic (TDMHSAS, 2013).

• Psychosocial interventions are interpersonal or informational activities, techniques, or strategies that address biological, behavioral, cognitive, emotional, interpersonal, social, or environmental factors to improve health functioning and well-being (Institute of Medicine, 2015). The two primary categories of psychosocial interventions are therapeutic and preventative. Therapeutic interventions typically are for individuals or smaller social systems (such as families and peers), and they generally seek to address diagnosable mental health problems (Borduin, Schaeffer, and Heiblum, 2009). Psychosocial prevention programs typically are broad efforts for large groups (such as schools or neighborhoods), and they generally are designed for specific subgroups of high-risk children and youth (Sawyer, Borduin, and Dopp, 2015).
• Psychotropic interventions use medications to treat mental health disorders (Lyons et al., 2013; Shahidullah et al., 2023; TSMHSAS, 2013). The five main types of psychotropic medications are: 1) antidepressants, to treat depression; 2) anti-anxiety medications; 3) stimulants, to manage ADHD and certain other conditions; 4) antipsychotics, to manage psychosis; and 5) mood stabilizers, to help regulate extreme emotions (Ghaemi, 2015; Shahidullah et al., 2023; WebMD, 2023). The use of psychotropic interventions is sometimes called pharmacological treatment or pharmacotherapy, which is the treatment of a disorder by the administration of drugs (American Psychological Association, 2018; Shahidullah et al., 2023).

The relationships between mental health problems and involvement in the juvenile justice system are complex. It is possible that 1) mental health problems contribute to delinquency, or that 2) delinquency contributes to mental health issues, or that 3) a bi-directional relationship exists between the two, or that 4) certain risk factors can increase both mental health issues and problem behaviors in young people (e.g., exposure to violence can increase posttraumatic stress and delinquent behaviors) [Finkelhor et al., 2009; Lalayants and Prince, 2014].

Key Findings

Research has been able to elucidate some of these relationships. For example, multiple studies have found that substance use disorders and externalizing disorders increase the likelihood of delinquency and recidivism (e.g., Baglivio et al., 2014; Barrett et al., 2014; Constantine et al., 2013; Hoeve et al., 2013; McReynolds, Schwalbe, and Wasserman, 2010; Schubert and Mulvey, 2014; Yampolskaya and Chuang, 2012).

Researchers have determined that some mental health diagnoses, such as depression and anxiety, do not increase the likelihood of offending (Armstrong-Hoskowitz et al., 2020; Wibbelink et al., 2017). Instead of being considered risk factors for delinquency, they are viewed as responsivity factors, affecting a youth's ability to fully engage in treatment, programming, and other interventions that focus on reducing problematic behaviors (Latessa, Listwan, and Koetzle, 2015; McCormick, Peterson-Badali, and Skilling, 2017).

The influence on delinquency of other disorders—such as posttraumatic stress disorder (PTSD) [Amatya and Barzman, 2012; Modrowski and Kerig, 2019; Vitopoulos et al., 2019] and autism spectrum disorder (ASD) [Cheely et al., 2012; Slaughter et al., 2019]—is unclear, as studies have yielded conflicting results.

Some evidence also suggests that delinquency may precede mental health problems in certain circumstances. Examining data from a sample of girls in the National Survey on Child and Adolescent Well-Being II, Lalayants and Prince (2014) found that, compared with girls who self-reported little to no delinquency, girls who reported the highest frequency of engaging in delinquent acts were nearly three times more likely to be depressed 18 months later. Engaging in minor theft appeared to have the greatest influence: compared with girls with little to no engagement in minor theft, girls who reported a higher frequency of engaging in minor theft were four times more likely to be depressed 18 months later. Researchers analyzing the data of 500 boys from the Pittsburgh Youth Study discovered that theft and serious violence were associated with later increases in anxiety and depression (Jolliffe et al., 2019). Involvement in the juvenile justice system (such as being arrested, going to court, being detained, and being confined) may also affect mental health (e.g., Dmitrieva et al., 2012; Gilman, Hill, and Hawkins, 2015; Gilman et al., 2021; Powell, 2022; Valentine, Restivo, and Wright, 2019). For more information, see the Model Programs Guide (MPG) literature review How the Juvenile Justice System Addresses Mental Health.

Despite challenges establishing directionality, it is widely recognized that young people's mental health needs should be addressed, regardless of whether these needs contributed to delinquent behaviors.

Externalizing and Internalizing Disorders

Researchers have determined that some externalizing disorders and problems (e.g., conduct disorder, oppositional defiant disorder, antisocial behaviors) increase the likelihood of delinquency, violence, and contact with the justice system (e.g., Barrett et al., 2014; Commisso et al., 2024; Hawkins et al., 2000). In their meta-analysis of predictors of youth violence, Hawkins and colleagues (2000) found evidence that aggression, restlessness, hyperactivity, concentration problems, and risk-taking consistently correlated with youth violence, although to varying degrees. However, some internalizing disorders and problems—such as anxiety disorders, worrying, and nervousness—were unrelated to later violence or reduced the likelihood of engaging in later violence. In other words, internalizing disorders and problems either had no statistically significant effect on later violence or they had a statistically significant effect on reducing the likelihood of later violence.

A meta-analysis by Wibbelink and colleagues (2017) examined the relationship between psychological disorders (including internalizing, externalizing, and comorbid disorders) and recidivism in youth. As did Hawkins and colleagues (2000) in their meta-analysis, Wibbelink and colleagues (2017) found that externalizing disorders were significantly related to recidivism, while internalizing behaviors were unrelated to recidivism (and in some cases, internalizing behaviors reduced the likelihood of recidivism).

Later studies continue to find a relationship between externalizing problems and delinquency. A study of 361 first-time justice system-involved youth, ages 12–18, found that youth with higher levels of clinically significant externalizing symptoms were more likely to have new charges in the next 2 years, compared with youth who had fewer challenges with externalizing symptoms or alcohol (Tolou-Shams et al., 2023). Additionally, a study of 567 youth in Portugal examined four types of aggression—proactive overt, proactive relational, reactive overt, and reactive relational—and their associations with delinquency and conduct disorder (Pechorro et al., 2021). The authors found that higher levels of each type of aggression predicted higher levels of delinquency and conduct disorder. They also discovered that high levels of self-control lessened the associations between the four types of aggression and delinquency/conduct problems.

Later studies continue to find that internalizing behaviors, such as depression and anxiety, are not predictors of delinquency or juvenile justice system involvement (e.g., Armstrong–Hoskowitz et al., 2020; Commisso et al., 2024; McCormick, Peterson-Badali, and Skilling, 2017), although youth in the juvenile justice system may report high levels of these behaviors (Armstrong-Hoskowitz et al., 2020).

Substance Use Disorders

Substance use disorders (SUDs) are classified as mental disorders because they affect a person's brain and behavior. SUDs often co-occur with other mental health disorders (Habersaat et al., 2018; National Institutes on Drug Abuse, 2020) and are associated with increased involvement in the mental health system (Doran et al., 2012). A large body of literature links substance use to engaging in delinquency and violence, coming into contact with the justice system, and reoffending (Baglivio et al., 2014; Dowden and Brown, 2002; Goodley, Pearson, and Morris, 2022; Hawkins et al., 2000; Holloway et al., 2022; Lalayants and Prince, 2014; Quinn, Walsh, and Dickson-Gomez, 2019; Rocca, Verde and Gatti, 2019; Tolou-Shams et al., 2023). For more information about youth substance use, see the Model Programs Guide (MPG) literature reviews Substance Use Prevention Programs and Substance Use Treatment Programs.

Attention-Deficit/Hyperactivity Disorder

The prevalence of attention-deficit/hyperactivity disorder (ADHD) is high among youth in the juvenile justice system (e.g. Baggio et al., 2018; Beaudry et al., 2021; McGee et al., 2022). Various studies have attempted to isolate the effect of ADHD on delinquency and juvenile justice system involvement. Many of the studies have identified ADHD as a "robust risk factor" (Wojciechowski, 2021); they conclude that findings have "consistently confirmed" that children with ADHD are at an increased risk for the development of antisocial, delinquent, violent, and criminal behaviors (Retz et al., 2021; Wojciechowski, 2021). Also, meta-analytic research studies have determined that having ADHD increases the likelihood of juvenile justice system involvement (Mohr-Jensen and Steinhausen, 2016) and recidivism (Wibbelink et al., 2017).

For example, a study used longitudinal data to examine the association between childhood ADHD and engagement in delinquency among a sample of about 500 boys (Sibley et al., 2011). The study authors found that, compared with boys who were not diagnosed with ADHD in childhood, boys with ADHD displayed earlier ages of delinquency initiation, a greater variety of offending behaviors, and higher prevalence of severe delinquency. The study also found that boys with both ADHD and conduct disorder had the greatest risk for delinquency (compared with boys who had only ADHD, had ADHD and oppositional defiant disorder, or did not have ADHD).

Another longitudinal study of about 200 individuals compared those who had been diagnosed with ADHD as children (but had not used psychostimulants before adolescence) with those who had not been diagnosed (Koisaari et al., 2015). The authors found that, by age 40, the individuals who had been diagnosed with ADHD as children engaged more frequently in violent behavior and/or financial criminality, compared with individuals not diagnosed. The individuals in the ADHD group were also more often victims of crime.

Studies in other countries yield similar results. A small study of 135 Italian youth ages 14–18, who were adjudicated in juvenile court, determined that youth who had committed crimes against people showed more ADHD symptoms than adolescents who had committed property or drug-related crimes (Margari et al., 2015). A longitudinal study of about 150,000 individuals in New Zealand found that young adults diagnosed with ADHD (at any age) were significantly more likely to have interactions with the criminal justice system, including police proceedings, court charges, court convictions, and incarceration before their 25th birthday (Anns et al., 2023).

Psychopathy

Psychopathy is a neuropsychiatric disorder marked by deficient emotional responses, poor behavioral controls, egocentricity, grandiosity, manipulativeness, and a lack of empathy (Anderson and Kiehl, 2014; Hare, 2006; Hare, 2003). This disorder is strongly associated with persistent antisocial deviance, criminal behavior, and involvement in the criminal justice system (Altikriti, Theocharidou, and Sullivan, 2020; Geerlings et al., 2020; Hare, 2003; Hare, 2006; Reidy et al., 2015). Although psychopathy is more commonly diagnosed in adults than in children and youth, research has been conducted with youth samples (e.g., Andershed et al., 2002; Brazil and Forth, 2024; Caldwell et al., 2007; Delisi et al., 2021; Frick, 2009; Lee and Kim, 2021; Ray, 2022; Rojas and Olver, 2022). A meta-analysis of studies involving 21 different samples of youth found that psychopathy was significantly associated with general and violent recidivism (Edens, Campbell, and Weir, 2007).

Psychopathy was included in the first two editions of the DSM but not in the fourth or fifth editions (DeAngelis, 2022; Strickland et al., 2013). The closest DSM-V diagnosis to psychopathy for adults is antisocial personality (DeAngelis, 2022; Strickland et al., 2013); the closest diagnosis for youth is conduct disorder with callous unemotional traits, which manifest as a callous lack of empathy, a lack of guilt and remorse, a lack of concern about one’s performance on important activities, and a general lack of emotional expression (DeAngelis, 2022). Studies of psychopathy sometimes examine one or more dimensions of psychopathy to isolate their unique influences, including 1) narcissistic or grandiose-manipulative, 2) callous-unemotional, and 3) impulsive or impulsive-irresponsible (e.g., Geerlings et al., 2020; Jambroes et al., 2018). Other studies attempt to isolate the influence of one or more of the three psychopathic symptom clusters: 1) interpersonal, 2) affective, or 3) behavioral (Corrado et al., 2004); or one of the four facets of psychopathy: 1) interpersonal (grandiosity, deceitfulness, superficial charm), 2) affective (lack of empathy, lack of remorse, failure to accept responsibility), 3) lifestyle (impulsivity, irresponsibility, lack of realistic long-term goals), and 4) antisocial (poor behavioral controls, antisocial behavior) [Braga et al., 2023; West et al., 2023].

Several studies have investigated psychopathy using data from the Pathways to Desistance longitudinal study, which followed youth with a record of serious offenses from two U.S. counties for several years. For example, research examining data from 726 boys in the Pathways to Desistance study found that having psychopathic personality traits was among the most important predictors of offending trajectories (Altikriti, Theocharidou, and Sullivan, 2020). Additional research, which analyzed data for more than 1,000 boys from the same study, concluded that youth with psychopathic traits perceived and internalized their environments differently from others and that this difference guided their own violent behaviors (Baskin-Sommers and Baskin, 2016). Meta-analytic research of more than 53 studies involving more than 10,000 individuals found that psychopathy was "moderately associated" with delinquency, general recidivism, and violent recidivism (Asscher et al., 2011).

A study of 159 adolescents with severe conduct problems in a closed treatment institution in Amsterdam determined that both the callous-unemotional dimension and the impulsive-irresponsible dimension of psychopathy were associated with higher levels of aggression (Jambroes et al., 2018). Additionally, a meta-analysis of 87 studies conducted in the United States, Europe, and other countries found that psychopathy was moderately and positively associated with delinquency (which means that higher levels of psychopathy are related to higher levels of delinquency), and that the effects were stronger for youth with impulsivity traits than for youth with callous-unemotional traits (Geerlings et al., 2020).

A meta-analysis examined the usefulness of the Psychopathy Checklist: Youth Version (PCL:YV) in predicting recidivism by isolating the influence of each of the four facets (Braga et al., 2023). In their analysis of 16 independent samples from longitudinal studies, the authors discovered that only the lifestyle and the antisocial facets were significantly related to both violent recidivism and general recidivism (Braga et al., 2023). An earlier study that tested the usefulness of the PCL:YV in predicting recidivism with 182 male adolescents in Vancouver, Canada, found that although psychopathy symptoms were associated with both general and violent recidivism, the associations were explained primarily by behavioral psychopathic symptoms rather than interpersonal or affective traits related to psychopathy (Corrado et al., 2004). The authors suggested that professionals be careful not to overstate the extent to which psychopathic personality features are associated with misbehavior. They concluded that impulsive, stimulation-seeking behavioral traits, which are characteristic of most disruptive behavior disorders in adolescents, were the most predictive of recidivism, and that these traits can be considered separate from psychopathy.

Posttraumatic Stress Disorder

The American Psychiatric Association (2022) defines posttraumatic stress disorder (PTSD) as a psychiatric disorder that may occur in people exposed to a traumatic event, series of events, or set of circumstances involving actual or threatened serious injury, sexual violence, or death. Examples of traumatic events and circumstances include natural disasters, serious accidents, war, rape/sexual assault, historical trauma, domestic violence, and bullying. Direct or indirect exposure to the traumatic event may affect the individual's emotional, mental, physical, social, and/or spiritual well-being. Unlike most psychiatric disorders, PTSD requires an initiating stressor (American Academy of Child and Adolescent Psychiatry, 2023; American Psychiatric Association, 2013; Copeland et al., 2007).

Researchers often disagree about the nature, strength, and directionality of the relationship between trauma and offending (Amatya and Barzman, 2012; Begle et al., 2011; Kerig and Becker, 2010; Marsiglio et al., 2014; Vitopoulos et al., 2019). PTSD is not considered a risk factor for engaging in crime and delinquency in the risk-need-responsivity (RNR) model, which was designed to guide effective intervention strategies for preventing recidivism (Andrews and Bonta, 2010; Latessa, Listwan, and Koetzle, 2015; McCormick, Peterson–Badali, and Skilling, 2017). Instead, PTSD is considered a responsivity factor, meaning that it may hinder a youth's ability to learn from an intervention designed to reduce other risk factors. Mental health conditions like depression and anxiety are also considered responsivity factors, since suffering from these internalizing conditions may prevent effective engagement in treatment and programming (Andrews and Bonta, 2010; Latessa, Listwan, and Koetzle, 2015; McCormick, Peterson-Badali, and Skilling, 2017; National Institute of Corrections, n.d.; Skeem, Steadman, and Manchak, 2015).

However, some researchers, especially those examining crime and delinquency among girls and women, have identified trauma and PTSD as potential risk factors for engaging in delinquent and criminal behaviors (i.e., as criminogenic risk factors) [Ardino, 2012; Paulino et al., 2023; Ruchkin et al., 2007; Vitopoulos et al., 2019]. A longitudinal study of more than 900,000 youth in Finland found that trauma-related disorders, such as PTSD, adjustment problems, and acute stress disorder, were associated with violent offending (Peltonen et al., 2020). Also, a small study of 83 boys in secure detention found that the severity of the boys’ PTSD symptoms was associated with the severity of their delinquent behavior (as measured by official arrest records) [Becker and Kerig, 2011].

A longitudinal study analyzed the relationship between violence exposure and psychopathology in a sample of more than 1,000 urban youth (Ruchkin et al., 2007). This study also examined the mediating role of posttraumatic stress. In other words, the study examined whether posttraumatic stress, after exposure to violence, affected the relationship between violence exposure and psychopathology. The researchers found that posttraumatic stress fully explained, or "mediated," the relationship between victimization and depression and anxiety in girls and partially explained that relationship in boys. In addition, posttraumatic stress partially explained the relationship between being exposed to violence and committing violent acts in boys.

Some studies show mixed findings. Examining a sample of 400 adolescents involved in the Utah juvenile justice system, Modrowski and Kerig (2019) found that posttraumatic risky behavior was not related to official records of offending. However, youth who evidenced high levels of posttraumatic risky behavior demonstrated significantly higher levels of exposure to trauma, higher posttraumatic stress symptom severity, and higher levels of self-reported offending compared with youth who evidenced low levels of posttraumatic risky behavior (Modrowski and Kerig, 2019). Another longitudinal study of 166 girls in the juvenile justice system examined the relationship between traumatic events and delinquency (Marsiglio et al., 2014). The results suggested that experiencing trauma increased the likelihood of future delinquency for girls who had not yet started high school. However, for older girls, previous trauma experiences did not predict future delinquency.

Although findings regarding the relationship between a PTSD diagnosis and delinquency are limited and somewhat mixed, research on relationships between childhood exposure to violence (which can result in PTSD) and delinquency is much clearer: childhood exposure to violence is a strong predictor of engagement in delinquency, crime, and justice system involvement. Analyzing data from the National Longitudinal Study of Adolescent to Adult Health (Add Health), Farrell and Zimmerman (2018) found that exposure to violence in grades 7–12 increased the likelihood of current and future violent offending. Another study of 349 youth ages 9–15 residing in public housing in an eastern metropolis found that youth who were involved in gangs were significantly more likely to have been victims of violence and to have witnessed violence against others, compared with youth who were not involved in gangs (Li et al., 2002). A small study of adolescent mothers and their children found that children exposed before age 10 to higher levels of violence in their homes, neighborhoods, or schools were more likely to subsequently exhibit delinquent and violent behaviors (Weaver, Brokowski, and Whitman, 2008). For more information, see the MPG literature review Childhood Exposure to Violence.

Autism Spectrum Disorder

There is a small but growing body of literature examining the influence of autism spectrum disorder (ASD) on violence and delinquency (e.g., Farmer et al., 2015; Mouridsen, 2012; Richman, Karuse-Jensen, and Rodogno, 2022), but the findings are inconsistent. For example, a study of juvenile justice system-involved youth in South Carolina found that those with ASD had higher rates of crimes against persons but lower rates of crimes against property than those without ASD (Cheely et al., 2012). However, a study of more than 300 court-involved youth from Connecticut found no significant differences between youth with ASD and youth without disabilities with respect to aggression, detention stays, or reoffending (Slaughter, 2022). Another study from the Netherlands found that autistic symptoms were more prevalent in children who were arrested, compared with children in the general population, and that these symptoms were uniquely associated with future delinquent behavior (Geluk et al., 2012). 

Some of the research literature focuses specifically on aggression. A study of 189 children and adolescents in France found that those with ASD were more likely to engage in injurious behaviors directed against people or objects, compared with children and adolescents not diagnosed with autism (Bronsard, Botbol, and Tordjman, 2011). The authors explained that in a stressful situation, children and youth with autism were more likely to release their stress through aggression or violence, whereas typically developing individuals were able to use self-regulation skills such as mental coping strategies, social interaction, and verbal or nonverbal communication.

A systematic overview of the literature on autism among adults and youth in the justice system concluded that there was not enough evidence to state that individuals with ASD were more likely to offend than the general population (Rutten, Vermeiren, and Van Nieuwenhuizen, 2017). The authors' analysis covered research published between 1990 and 2016.

A meta-analysis of studies examining young people’s use of mental health services determined that schools and outpatient settings were the most common places for youth to access mental health care (Duong et al., 2021). This finding was true for youth overall and for youth with elevated symptoms or clinical diagnoses. Of the youth in the general population, 7.3 percent received school mental health services, and the remainder obtained care as follows: 7.3 percent, in mental health outpatient settings; 1.8 percent, in primary care offices; 1.8 percent, in inpatient facilities; 1.4 percent, in child welfare settings; and 0.9 percent in juvenile justice settings. Of the youth with elevated mental health symptoms or diagnoses, 22.1 percent received school-based mental health services, and the remainder obtained care as follows: 20.6 percent, in outpatient settings; 9.9 percent, in primary care offices; 9.1 percent, in inpatient facilities; 7.9 percent, in child welfare settings; and 4.5 percent, in juvenile justice settings.

Need for Services Exceeds Availability and Usage

Many researchers have found that the rates of mental health service availability and use by youth are too low, given their needs (e.g., Bagley et al., 2021; Martin et al., 2024; Miodus, 2023; SAMHSA, 2023b; Wasserman et al., 2021). According to the 2022 National Survey on Drug Use and Health (NSDUH), 30 percent of adolescents ages 12–17 received mental health treatment in the past year (23 percent in an outpatient setting, 14 percent by means of telehealth, 3 percent in an inpatient setting, and 1 percent in a prison, jail, or juvenile detention center) [SAMHSA, 2023b]. Additionally, 13 percent of youth reported that they took medication prescribed for their mental health. However, the survey also found that more than 40 percent of adolescents with a major depressive disorder did not receive mental health treatment in the past year.

The survey asked the respondents who did not receive mental health treatment whether they sought treatment or thought they should get treatment for their mental health. The NSDUH classified nearly half of the 2.1 million adolescents who had a past-year major depressive disorder and did not receive mental health services as having an "unmet need for mental health treatment." Reasons the youth provided for not receiving mental health treatment included the following (SAMHSA, 2023b):

• They thought they should have been able to handle their mental health, emotions, or behavior on their own (86.9 percent).
• They were worried about what people would think or say if they got treatment (59.8 percent).
• They were worried that information they shared would not be kept private (57.8 percent).
• They did not know how or where to get treatment (55.5 percent).
• They thought no one would care if they got better (53.9 percent).
• They did not think treatment would help them (51.5 percent).

According to a study surveying youth with alcohol, other drug, and mental health disorders in detention, the most frequently cited barrier to accessing services was that youth believed their problems would go away without their getting any help (Abram et al., 2015). Other reported perceived barriers were that youth were unsure whom to contact or where to go for help, or believed it was too difficult to obtain help. A qualitative study of individuals who had been in juvenile detention and received mental health services in the justice system before age 24 found that the participants wished they could have accessed services prior to being detained, instead of needing to experience incarceration (Miodus, 2023).

Racial and Ethnic Differences

Some studies have found differences in access to mental health services by race and sex. Analysis of a nationally representative sample of more than 50,000 youth ages 5–17 found significant differences in mental health care use for Black and Latino youth, compared with white youth, even after adjusting for mental health needs (Rodgers et al., 2022). The authors also determined that between 2010 and 2017, rates for Black youth receiving mental health care use decreased from 9 percent to 8 percent, while rates for white youth increased from 13 percent to 15 percent. Rates for Latino youth increased from 6 percent to 8 percent. Additionally, the authors identified differences in public mental health expenditures for Black and white youth.

A systematic review of the literature on mental health misdiagnoses found evidence supporting the possibility that misdiagnosis occurs of ethnic minority youths' emotional and behavioral problems (Liang, Matheson, and Douglas, 2016). Because the evidence was limited, a determination could not be made as to whether racial and ethnic differences in mental health diagnoses were due to differences in psychopathology, biases, or inaccurate diagnoses.

Researchers also have found differences in service access among foster care, child welfare, and Medicaid populations (Bilaver, Sobotka, Mandell, 2021; Garland and Besinger, 1997; Horwitz et al., 2012; Villagrana, 2017). For example, a study of more than 100,000 Medicaid-enrolled children with autism spectrum disorder found that Black, Asian, and Native American/Pacific Islander children received fewer outpatient services, compared with white children, and Black and Asian children received more school-based services than white children (Bilaver, Sobotka, and Mandell, 2021). Additionally, this study discovered large differences in case management/care coordination services in each racial and ethnic minority group. Another study of more than 400 youth 1 year after exiting foster care determined that Latino youth used fewer services than Black and white youth (Villagrana, 2017).

Finally, among youth served by mental health systems, racial and ethnic minority youth are more likely than white youth to be referred to the juvenile justice system (Cauffman et al., 2005; Evens and Vander Stoep, 1997; Scott, Snowden, and Libby, 2002; Vander Stoep, Evens, and Taub, 1997). For example, an examination of data on youth placed in residential treatment centers found that Black and Latino youth were more likely than white youth to incur new arrests and to be charged with crimes during and after treatment (Javdani et al., 2023).

Researchers have identified many programs and practices that can improve outcomes related to youth mental health and delinquency. Evaluations of these interventions have found statistically significant effects on a variety of outcomes. The effects include improvements in youth’s social connectedness, emotional regulation, self-control, problem-solving, school behaviors, and relationships with their families and teachers. The interventions have also demonstrated reductions in aggression and other externalizing behaviors, internalizing symptoms (including depression and anxiety), posttraumatic stress disorder (PTSD), rule-breaking, and delinquency.

Selected prevention and diversion interventions are highlighted in this section. Most of the highlighted programs do not concentrate on substance use specifically. For more information about interventions addressing substance use, see the MPG practice profile on juvenile drug courts and the Model Programs Guide (MPG) literature reviews Substance Use Prevention Programs and Substance Use Treatment Programs. Interventions designed for youth already involved in the juvenile justice system are discussed in the MPG literature review How the Juvenile Justice System Address Mental Health.

Prevention

Prevention programs include a wide array of activities, initiatives, and interventions designed to enhance child and youth development; educate and support individuals, families, and communities; increase protective factors; and decrease risk factors. These efforts attempt to prevent negative outcomes, often by preventing, reducing engagement in, or delaying initiation of, risky behaviors. Prevention programs usually seek to reach large groups (such as a school's entire student body) or specific, high-risk groups (Colizzi, Lasalvia, and Ruggeri, 2020; Deković et al., 2011; SAMHSA, 2016; Nation et al., 2003; Sawyer, Borduin, and Dopp, 2015). Most prevention initiatives are broad in scope, incorporating many approaches. Described below are examples of five approaches: 1) school based, 2) family based, 3) cognitive-behavioral therapy, 4) trauma-focused treatment, and 5) multi-system.

School-Based Programs

Sources of Strength (SOS) is a school-based, suicide prevention program for the entire student population that uses a socioecological approach to build protective factors through multiple sources of influence (e.g., trained peer leaders, trusted adults). The program focuses on changing the norms and behaviors of students through youth opinion leaders. Youth opinion leaders are trained by certified trainers and supported (by adult advisers) in preparing and conducting suicide prevention-messaging activities. The activities are designed to accomplish the following: change unhealthy norms involving seeking help and trusting adults, encourage students to connect suicidal friends with a trusted adult, improve communication between students and adults, and promote the use of interpersonal and formal coping resources. An evaluation of this program found that peer leaders demonstrated statistically significant improvements in perceptions and behaviors pertaining to suicide and social connectedness, compared with nonparticipating youths (Wyman et al., 2010).

Behavioral, Emotional, and Social Training: Competent Learners Achieving School Success (BEST in CLASS) is a classroom-based intervention, delivered by teachers, which is designed to prevent emotional and behavioral disorders in high-risk children. Evaluations of BEST in CLASS have found that intervention-group children showed statistically significant improvements in student behaviors, social and behavioral competence, and student-teacher relationships compared with control-group children (Conroy et al., 2015; Sutherland et al., 2018a; Sutherland et al., 2018b).

Family-Based Interventions

Promoting First Relationships for Native Families is a home-visiting program to foster positive caregiver-child relationships in Native families. An evaluation of this program found that participating families had higher quality caregiver-child interactions. The evaluation also determined that caregivers increased their understanding of their children’s social-emotional needs and reported fewer depressive symptoms, compared with nonparticipating families (Booth-LaForce et al., 2023a). However, there was no statistically significant difference in child externalizing behaviors between participating and nonparticipating families.

Family Check-Up for Children is a preventive, family-based program for families with young children who have behavioral misconduct risk factors. In this brief intervention, a professional therapist conducts three meetings in the family's home, using motivational interviewing. A longitudinal evaluation of more than 600 high-risk families found that children who participated in the program demonstrated statistically significantly reduced problem and externalizing behaviors, compared with children in the comparison group who did not participate (Dishion et al., 2008).

The Risk Reduction Through Family Therapy for Adolescents program is an exposure-based, integrative intervention designed to reduce substance use and mental health problems in adolescents who have experienced trauma. Evaluations of this program have found statistically significant impacts on depressive and internalizing symptoms, family cohesion, and family conflict among participants. There were mixed results for PTSD symptoms and substance use. There was no statistically significant impact on externalizing symptoms (Danielson et al., 2020; Danielson et al., 2012).

For more information about family-based interventions and engagement, see the MPG literature reviews Family Engagement in Juvenile Justice and Family Therapy.

Cognitive-Behavioral Therapy

Cognitive-behavioral therapy (CBT) is designed to help youth make positive changes in their thinking and in behaviors related to delinquency, crime, and violence (Little, 2005; Beck, 1999). Research has shown that CBT programs are effective in reducing recidivism rates (Jeong, Lee, and Martin, 2014). Two meta-analyses examined the usefulness of CBT for anger-related problems in children and adolescents, concluding that it was effective for reducing aggression and dysregulated anger, and for improving self-control, problem-solving, and social competencies (Hoogsteder et al., 2015; Sukhodolsky et al., 2004).

Bounce Back is a cognitive-behavioral intervention for children in grades one through five who have been exposed to traumatic events, and their parents. The goal is to help children reduce their symptoms of posttraumatic stress, depression, and anxiety; and improve their functioning in school. The program consists of 10 group sessions, lasting 50–60 minutes each; 2 to 3 individual sessions, lasting 30–50 minutes each; and 1 to 3 parent sessions. All sessions occur during the school day. The intervention uses a combination of therapeutic elements, including psychoeducation, relaxation training, cognitive restructuring, social problem solving, and trauma-focused intervention strategies. An evaluation of Bounce Back found that children who participated in the program demonstrated statistically significant improvements on measures of posttraumatic stress, anxiety symptoms, and emotional regulation; however, there was no impact on measures of depression or coping efficacy (Langley et al., 2015).

Alternatives for Families: Cognitive Behavioral Therapy (AF-CBT) is a family therapy program designed to reduce the effects of child abuse. AF–CBT teaches parents and children intrapersonal and interpersonal skills to enhance self-control, promote positive family relations, and reduce violent behavior. The intervention consists of 3 phases of treatment organized into 17 or 18 sessions. Phase 1 fosters engagement in treatment, provides psychoeducation, teaches how to identify feelings, and discusses abuse. Phase 2 teaches new ways of thinking, healthy strategies for managing emotions and behavior, and how to get along with others. Phase 3 consists of sessions on verbalizing healthy communication, enhancing safety through clarification, problem-solving, and graduating from the program (AF–CBT, n.d.). An evaluation of the program found statistically significant reductions in family conflict, parent-child violence, physical punishment, and child abuse risk, along with improvements in discipline, cohesion, and child acceptance. There were also statistically significant reductions in child internalizing and externalizing symptoms. However, there were no significant differences between groups in re-abuse rates (Kolko, 1996).

Trauma–Focused Cognitive-Behavioral Therapy (TF–CBT) is for children who have been victims of traumatic life events (such as sexual abuse). TF–CBT is designed to treat serious emotional problems such as posttraumatic stress, fear, anxiety, and depression by teaching children and their parents new skills for processing thoughts and feelings resulting from traumatic events. Evaluators found that children who participated in TF–CBT showed a statistically significant lower number of PTSD and depressive symptoms and problematic behaviors, compared with nonparticipating children. Also, parents had a statistically significant lower number of depressive symptoms, compared with nonparticipating parents. For more information about outcomes related to participation in trauma-focused treatment, see Trauma-Focused Treatment (below). 

Trauma-Focused Treatment

Using meta-analytic techniques, Hoogsteder and colleagues (2022) analyzed the effect of trauma-focused treatment for juveniles and young adults (ages 11–21). The treatments were developed specifically for individuals exposed to traumatic events, such as physical or sexual violence or severe accidents. The authors meta-analyzed 8 studies involving 566 youth and young adults. Trauma-focused interventions to reduce PTSD symptoms were grouped into two types: 1) trauma-focused cognitive-behavioral therapy (TF–CBT) [see below] and 2) eye movement desensitization and reprocessing (see below). The researchers found that youth who received trauma-focused treatment experienced reductions in both trauma symptoms (such as disassociation and withdrawal) and externalizing behaviors (such as aggression and criminal behavior), compared with youth in the control group who did not receive treatment (Hoogsteder et al., 2022).

Eye movement desensitization and reprocessing (EMDR) is designed to help children recover from PTSD through short imaginal exposure to the memory followed by brief exposure to stimuli that triggers eye movement. The goal of EMDR is to alleviate distress associated with traumatic memories by enabling the participant to access and process these memories in brief doses while focusing on an external stimulus (usually therapist-directed eye moments) [de Roos et al., 2017; Rodenburg et al., 2009]. A meta-analysis of seven studies published between 2001 and 2008, reporting on 109 children treated with EMDR and 100 children in the comparison group, found that EMDR had a positive, statistically significant effect on reducing trauma (Rodenburg et al., 2009). However, other meta-analyses have not found significant effects from this type of treatment (Washington State Institute for Public Policy, 2016).

Multisystem Approaches

SNAP Under 12® is for boys younger than 12 who display aggression and antisocial behavior problems. The program combines interventions that aid the child, the family, the school, and the community. An assessment is conducted to determine the unique treatment needs of boys and their families. Interventions include training in cognitive problem-solving, cognitive self-instruction, skills training, self-control strategies, family management skills training, and parent training. Evaluators have found that participation in SNAP Under 12^® results in a statistically significant decrease in delinquency, aggression, rule-breaking, and conduct problems (Augimeri et al., 2007; Lipman et al., 2008).

Diversion

Diversion programs allow youth who commit offenses to be directed away from more formal juvenile justice system involvement (Bolin, 2018; Kutcher and McDougall, 2009; Mental Health America, 2015; SAMHSA, 2019). Some programs occur before a trial or court disposition, which means that youth are diverted away from system processing at the outset (Models for Change, 2011).

Originally implemented in four probation departments in Texas, the Front-End Diversion Initiative was designed to divert youth with mental health needs away from the juvenile justice system. The program used specialized juvenile probation officers, each of whom had a caseload of no more than 15 youth with mental health needs. The officers were trained in motivational interviewing, family engagement, crisis intervention, and behavioral health management (Colwell, Villarreal, and Espinosa, 2012; Spriggs, 2009). An evaluation found that participants were statistically significantly less likely to face adjudication compared with youth who only received traditional supervision while on probation (Colwell, Villarreal, and Espinosa, 2012).

For more information about diversion, see the MPG literature review Diversion from Formal Court Processing.

The relationship between mental health problems and involvement in the juvenile justice system is complex, and it can be hard to disentangle correlational variables from causal ones (Schubert and Mulvey, 2014). However, several studies have found that some externalizing disorders (e.g., conduct disorders, oppositional defiant disorder, antisocial personality disorder, aggressive disorder), attention-deficit/hyperactivity disorder, substance use disorders, and psychopathy increase the likelihood of delinquency, violence, and contact with the justice system (Altikriti, Theocharidou, and Sullivan, 2020; Barrett et al., 2014; Hawkins et al., 2000; Lalayants and Prince, 2014; Habersaat et al., 2018; Retz et al., 2021; Rocca, Verde, and Gatti, 2019; Wojciechowski, 2021). To reduce the likelihood of juvenile justice system involvement, it is important for interventions to address these specific risk factors. Additionally, mental health conditions such as depression, anxiety, posttraumatic stress disorder (PTSD), and sleep disorders must be addressed for youth to fully benefit from programs and other interventions.

A variety of programs are known to have statistically significant effects on outcomes related to preventing or reducing mental health disorders in youth. Among the outcomes are improvements in youth’s social connectedness, emotional regulation, self-control, problem-solving, school behaviors, and relationships with their families and teachers. The interventions have also demonstrated reductions in aggression and other externalizing behaviors, internalizing symptoms (including depression and anxiety), PTSD, rule-breaking, and delinquency.

Examples of programs include Sources of Strength (SOS), a school-based, suicide prevention program that uses a socioecological approach to build protective factors through multiple sources of influence (e.g., trained peer leaders, trusted adults). Participation in SOS was associated with improvements in social connectedness and reductions in suicide-related behaviors (Wyman et al., 2010). The Risk Reduction Through Family Therapy for Adolescents program is an exposure-based, integrative intervention for youth who have experienced trauma. Participation in this program is associated with improvements in depression, internalizing symptoms, family cohesion, and family conflict (Danielson et al., 2020; Danielson et al., 2012).

Meta-analytic research has identified practices that improve youth outcomes. Participation in trauma-focused treatment, designed specifically for individuals who have been exposed to traumatic events, has been shown to reduce both internalizing trauma symptoms (such as disassociation and withdrawal) and externalizing behaviors (such as aggression and criminal behavior) [Hoogsteder et al., 2022]. Meta-analyses examining the usefulness of cognitive-behavioral therapy (CBT) for anger-related problems found that it was effective for reducing aggression and dysregulated anger, and for improving self-control, problem-solving, and social competencies, in children and adolescents (Hoogsteder et al., 2015; Sukhodolsky et al., 2004).

Suggested Reference: Development Services Group, Inc. September 2025. Mental Health: The Influence of Mental Health on Juvenile Justice System Involvement. Model Programs Guide. Literature review. Washington, DC: U.S. Department of Justice, Office of Justice Programs, Office of Juvenile Justice and Delinquency Prevention. https://ojjdp.ojp.gov/model-programs-guide/literature-reviews/influence-of-mental-health-on-juvenile-justice-system-involvement

Prepared by Development Services Group, Inc., under Contract no. 47QRAA20D002V.