Is there a correlation between mental health and youth violence?
Research - including the findings of the landmark Surgeon General's Report on Mental Health (1999) - strongly demonstrates that the overwhelming majority of people with mental illness are not violent. And, notwithstanding the publicity that surrounds cases such as the Virginia Tech tragedy; most acts of violence in America are not committed by people with mental illness. In fact, youth and adults with serious mental illnesses are far more often the victims of violence than the perpetrators.
When acts of violence linked to mental illness occur, it is usually an indication that something has gone terribly wrong. Mental illnesses are treatable, and individuals with these illnesses can and do recover with appropriate services and supports. Yet sadly, these services are frequently not available when youth need them the most.
The most recent study on mental illness and violence once again shows that mental illness alone does not predict or increase the risk of violence. This study, published last month in the Archives of General Psychiatry, shows that it is only when mental illness is combined with other risk factors such as substance use that the risk of violence increases. Other risk factors for increased violence include a history of juvenile detention or physical abuse, having witnessed domestic violence, a recent divorce and serious family conflict, unemployment, and living in poverty. Other risk factors include being young and male.
Youth are not violent by nature. Rather, youth violence is nearly always a symptom of other factors in a young person's life. It may be living in poverty, family conflict, or a host of other life circumstances. It may also be undiagnosed and untreated mental illness, especially when combined with a substance use disorder.
Youth with undiagnosed and untreated mental illnesses are more likely to use and abuse illicit substances and to have their young lives derailed, often with serious consequences.
We can do a far better job in this nation of identifying youth with emerging mental illnesses early and intervening with effective services and supports. We know a lot about the consequences of undiagnosed and untreated mental illnesses in our nation's youth and the news is not good. We also know that treatment works if youth can get it.
What do we know about youth and mental illness in our nation?
In June 2005, the National Institute of Mental Health (NIMH) released the findings of a landmark study with a headline that read "Mental illness exacts heavy toll, beginning in youth." The study found that half of all lifetime cases of mental illness begin by age 14 and that, on average, the delay between the onset of mental illness and treatment is 8 to 10 years. In the life of a young person, that represents the loss of critical developmental years that cannot be recaptured.
Research shows that 10% of children and adolescents in the United States live with mental illness serious enough to cause significant functional impairment in their day-to-day lives at home, in school and with peers. Yet, only between 20 and 30 percent of these youth are identified and receive services, leaving 70 to 80 percent behind. We cannot ignore these alarming statistics because early-onset mental illnesses that are left untreated are associated with school failure, substance use, homelessness, poverty in adulthood, incarceration, and the ultimate tragedy - suicide.
Suicide remains a serious public health concern and is the third leading cause of death in youth aged 10 to 24. More than 4,000 youth die every year from suicide. More youth die from suicide than from cancer, heart disease, AIDS, birth defects, stroke, pneumonia, influenza, and chronic lung disease combined (National Strategy for Suicide Prevention, 2001). Research shows that 90% of people who die by suicide suffer from a diagnosable and treatable mental illness at the time of their death (Mental Health: A report of the Surgeon General, 1999)
Untreated mental illness also has a profoundly negative impact on educational achievement among youth. Approximately 50% of students with a mental illness age 14 and older drop out of high school -- the highest dropout rate of any disability group (U.S. Department of Education, 2001). Education is the foundation for a stable and productive adult life. Without it, young lives are often defined by poverty and despair. Schools are not meeting the needs of students with mental illnesses, often because school professionals have not been trained in effective services and supports that meet the behavioral and academic needs of these students. Many families contact NAMI to express concern that schools appear to want their kids out of the school rather than working to address their functional and academic needs. Students with mental illnesses get frustrated, fall behind and drop out. The impact - including lost productivity - on American society is profoundly negative.
There is also a school to prison pipeline in a number of communities in our nation. This pipeline includes students with serious mental health treatment needs. When school personnel are not trained in how to address a psychiatric crisis and effective de-escalation in the face of a crisis, they too often rely on law enforcement to remove a student from the school. The media has reported on cases involving children as young as eight years old who have been transported from school in police cruisers. A number of these cases have included students with mental illness.
We also must address the reality that far too many youth with mental illness are becoming entangled with the juvenile justice system. Research consistently shows that 70% of youth involved in state and local juvenile justice systems throughout the country have a mental illness, with at least 20% experiencing symptoms so severe that their ability to function is significantly impaired (Blueprint for Change, National Center for Mental Health and Juvenile Justice, 2006). Those with the most serious illnesses are suicidal, psychotic and require immediate psychiatric care.
Many youth with mental illness who become involved in the juvenile justice system are not a threat to public safety and have not committed serious offenses. Rather, they have not been identified as needing mental health services or been provided with easily accessible and critically needed services and supports. Families routinely report that their communities lack crisis intervention and response services for psychiatric emergencies. So when their child experiences a psychiatric crisis, all too often after hours at night, their only option for getting help is to call the police. If police are not trained in effective crisis intervention for a psychiatric emergency or crisis, it can lead to arrest and unnecessary entry into the criminal justice system.
Youth of color are disproportionately overrepresented in the juvenile justice system. African-American, Latino, Asian, Pacific-Islander, and American Indian youth represent a combined one-third of our nation's youth, yet account for over two-thirds of the youth in secure juvenile facilities. (Minority Youth in the Juvenile Justice System ~ Disproportionate Minority Contact, National Conference of State Legislatures, January 2009) Many of these youth have serious mental health treatment needs that have not been addressed.
Youth with mental illness in African-American and Latino communities receive less mental health care and poorer quality care. (The President's New Freedom Commission on Mental Health, July 2003) The stigma associated with mental health care runs high in racially and culturally diverse communities, along with many barriers to accessing effective mental health services and supports.
The good news is that these issues are receiving more attention; however urgent action is needed to improve the lives of our nation's youth and to reduce the risk of violence on a number of fronts.
What is needed to address these issues?
Early Identification and Intervention. We need to do a far better job of identifying youth with mental health treatment needs early and intervening with effective services and supports. We can no longer afford to wait eight to ten years to intervene. By addressing early identification and intervention, we can reduce youth suicide, the use of drugs and alcohol for self-medication, the number of youth with mental illness entering the juvenile justice system, and improve the school performance and future prospects for these young Americans.
As our nation takes on healthcare reform, we must ensure that mental health screening is routinely done in primary care practice. We screen children for a number of health conditions, yet mental health screening is the exception, despite the fact that we know that 10% of youth will develop serious mental health conditions. Screening instruments that effectively identify at-risk youth for mental health conditions are available and should be routinely used in pediatric practices.
Medicaid - under the Early, Periodic, Screening, Diagnosis, and Treatment (EPSDT) provision - mandates that screening be done for all Medicaid eligible individuals age 21 and younger. This includes a mental health assessment. Yet, we know that in most states, this mandate is not being followed. States should be held accountable for following the dictates of the law so that children with mental health treatment needs are identified early and receive appropriate services.
Also, important is that youth diagnosed with a mental illness and co-occurring substance use disorder receive evidence-based interventions that have been shown through research to produce positive outcomes.
Schools. Our nation's youth spend, on average, six hours a day in school. It is the environment in which they often first display the warning signs of early onset mental illness. Unidentified and untreated mental illness is a major impediment to learning. Schools must play a bigger role in the early identification of mental health related concerns. (The President's New Freedom Commission on Mental Health, July 2003). School professionals should be trained in the early warning signs of mental illness.
Effective links must be developed between community mental health systems and schools for those youth who require intensive services and supports that may not be available in schools. Schools cannot address the mental health of students alone, it will take leadership and collaboration in communities to bring together child-serving systems to ensure that mental health services are available where and when they are needed. Some school districts are effectively addressing the mental health needs of students, but we need far more to make that commitment.
We also need school resource officers, appropriate school staff, and community law enforcement to be trained in effective crisis intervention programs to allow them to become better equipped to address psychiatric crises when and where they occur -- in schools and communities. We can tackle the school to prison pipeline with these programs for students who do not pose public safety threats, but rather require effective mental health services and supports.
Juvenile Justice Reform. The juvenile justice system has become the defacto mental health system for far too many youth in our nation. This is especially true for youth of color who are disproportionately represented in this system and often fail to receive the mental health services they need in their communities. We are seeing this crisis addressed in a number of communities around the country but urgent reforms are still needed. Given the high prevalence of youth with serious mental health treatment needs in the juvenile justice system, all youth entering the system should be screened and those who do not pose a public safety threat and clearly require mental health services, should be diverted into effective intervention programs.
There are a number of evidence-based diversion programs that have been shown to produce positive outcomes for justice-involved youth, including multi-systemic therapy, functional family therapy, and more. Equally important is that we provide effective interventions for youth in communities as part of re-entry programs for youth with mental illness being discharged from juvenile justice facilities. Our nation's infrastructure for home and community-based mental health services and supports for children and youth with mental illness is weak and cannot support the need that exists in most communities. An investment in infrastructure will help to get young lives back on track and promises to produce positive outcomes for youth living with mental illnesses.
In closing, I would like to thank Representatives Towns and Davis for their leadership in organizing this briefing on this critically important topic.
There is an urgent need for reform to make the mental health of our nation's youth a priority which will in turn reduce youth violence and create a more promising future for our nation's youth.
As our nation embarks on health care reform, we must recognize the value of early identification and intervention which promises to help control our overall healthcare and social program spending.
Youth represent a fraction of the population in our country, but are 100% of our future. Ensuring the early identification of emerging mental illness and intervention with effective services and supports requires immediate action at every level of government - federal, state and local. Thank you again for this important opportunity to share NAMI's position on these critically important issues. We look forward to working with you to address these issues.