Improving the Health of Canadians: Mental Health, Delinquency and Criminal Activity Elizabeth Votta, PhD Canadian Institute for Health Information Presentation.

Improving the Health of Canadians: Mental Health, Delinquency and Criminal Activity

Elizabeth Votta, PhD

Canadian Institute for Health Information

Presentation at Helping Canadian Kids Thrive!

National Conference on Positive Youth Development

Kamloops, British Columbia

May 1-2, 2008

Presentation Outline

1. Overview of the Canadian Institute for Health Information (CIHI) and the Canadian Population Health Initiative (CPHI)

2. Overview of CPHI’s Work in the Area of Youth Health and Development

• Highlights from CPHI’s report, Improving the Health of Canadians: Mental Health, Delinquency and Criminal Activity

About the Canadian Institute for Health Information (CIHI)

HealthInformation

Research and Analysis

Health Indicators

Data Holdings

Standards

Laying a foundation for health information

Capturing the portrait of health care

Building new health knowledge

Taking health information further

Priv

acy,

Con

fiden

tialit

y an

d Se

curit

y

Com

mun

icat

ion,

Con

sulta

tion

and

Dis

sem

inat

ion

Canadian Population Health Initiative (CPHI)

CPHI’s Mission:

• To foster a better understanding of factors that affect the health of individuals and communities; and

• To contribute to the development of policies that reduce inequities and improve the health and well-being of Canadians.

CPHI’s Strategic Functions

Knowledge Generation

Policy Synthesis

Knowledge Transfer Knowledge Exchange

CPHI Council Members (as of February 2008)

Cordell Neudorf (Chair)

David Allison André Corriveau

Nancy Edwards Brent Friesen

Judy Guernsey Richard Massé

Deborah Schwartz Elinor Wilson

Ian Potter (ex-officio) Gregory Taylor (ex-officio)

Michael Wolfson (ex-officio)

Expert Advisory Group Members

Gregory Taylor (Chair), Public Health Agency of Canada

Carl Lakaski, Public Health Agency of Canada

Kathy Langlois, First Nations and Inuit Health Branch

Alain Lesage, Louis-H. Lafontaine Hospital

Dora Nicinski, Atlantic Health Sciences Corporation (Region 2)

Rémi Quirion, Canadian Institutes of Health Research

Margaret Shim, Alberta Health and Wellness

Phil Upshall, The Mood Disorders Society of Canada

Cornelia Wieman, Indigenous Health Research Development Program

and University of Toronto

CPHI’s Key Theme Areas: 2004-2007

Place and HealthHealthy Transitions to Adulthood Healthy Weights

Improving the Health of Young Canadians

• First in the series of reports for 2005–2006

• Canadian youth aged 12 to 19 years

• Explores links between adolescents’ social environment and their health

• Discusses themes from current research

• Reviews relevant programs and policies

Adolescent Health and Development

Themes from the Research:

1. Cluster: Positive & negative behaviours ‘cluster’ together

2. Engaging youth: Participation in meaningful & structured activities

3. Resilience: Youth’s ability to successfully cope in adversity

4. Assets: Positive relationships, opportunities, values and self-perceptions correlated with healthy development

Youth Health and Assets in the Social Environment

CPHI’s report, Improving the Health of Young Canadians, looked at the roles of family, schools, peers and communities in healthy adolescent development:

• Parental nurturance

• Parental monitoring

• School engagement

• Peer connectedness

• Community engagement

IHYC Report Findings: Summary TableParental

NurturanceParental

MonitoringSchool

EngagementVolunteerism Connected to

Peers

High self-worth

Exc. or VG Health Status

Low Level of Anxiety

Peers who commit crimes

Alcohol Use

Tobacco Use

Marijuana Use

Injuries

-

+++

+++

+++

++

-

-- -

-

- ---

--

- -

++

Multiple Assets and Health

Research (e.g. U.S. Search Institute) indicates that the more assets adolescents possess:

• The greater their likelihood of engaging in good health practices (e.g. wearing helmets when riding a bike, wearing seatbelts, higher levels of physical activity); and

• The less likely they are to engage in harmful health practices (e.g. tobacco/drug use, risky sexual activity)

Health Outcomes and Behaviours by Number of Positive Assets

0

20

40

60

80

100%

of Y

out

h (1

2-15

yea

rs)

0-1 Positive Asset 48 54 84 37 55 31 36

2-3 Positive Assets 68 74 88 23 44 22 24

4-5 Positive Assets 82 83 94 17 26 11 12

High Self-Worth

Exc. or VG Health

Low Level of Anxiety

Contact Peers - Crimes

Alcohol Use

Tobacco Use

Marijuana Use

*

*

*

*

*

* **

***

** **

*

*

*

* All pair-wise comparisons significantly different at p < 0.05. ** Significantly different from two or three assets and zero or one asset at p < 0.05.*** Significantly different from two or three assets and four or five assets at p < 0.05.

Source: CPHI analysis of NLSCY (Cycle 4, 2000-2001), Statistics Canada.

Promoting Positive Youth Health

• Many programs across Canada for youth but few formally evaluated

• More outcome research needed including research that assesses health outcomes of youth-based policies and programs

• Three characteristics of programs/policies that are linked to healthy youth development: Comprehensive interventions that address common factors

associated with multiple behaviours

Approaches that support healthy youth development

Initiatives that engage youth

CPHI’s Key Themes 2007-2010

Promoting Healthy WeightsMental Health and

Resilience Place and Health

Reducing Gaps in Health

Improving the Health of Canadians Report Series on Mental Health

Series of three reports on the theme of mental health and how mental health is linked to the determinants of health• Two reports will focus on segments of the population often

identified as ‘vulnerable’• Final report will focus on the construct of positive mental health

Report Release Date

Report #1: Mental Health and Homelessness August 30, 2007

Report #2: Mental Health, Delinquency and Criminal Activity

April 29, 2008

Report #3: Promoting Positive Mental Health (working title)

February 2009

(exact date to be determined)


Purpose of ReportExamines the links between mental health, delinquency, criminal activity and their various determinants

Released:

April 29, 2008


How the Report is OrganizedSection One • Looks at what factors related to mental health within the

individual, family, school/peer and community contexts are related to youth delinquency in either a protective or risk capacity

Section Two • Looks at people with a mental illness who were or are involved

with the criminal justice system (that is, in a mental health bed with a criminal history or in a correctional facility with a mental illness)

Delinquency Among Canada’s Youth

What Does the Data Tell Us?

Aggressive Behaviour: A score based on responses to the following six items:

i. I get into many fights,

ii. I react to accidents with anger,

iii. I physically attack people,

iv. I threaten people,

v. I bully or am mean

vi. I hit others my age.

Often 10%

Some 34% *

None 56% *

Self-reported Aggressive Behaviour Among Youth Aged 12-15, 2004-2005

Source: CPHI Analysis of NLSCY (cycle 6, 2004-2005).

Note: These rates are based only on the 86% of youth who responded.

* Significantly different from “often” at p<0.05.

Property Delinquency: A score based on responses to the following 6 items:

i. I destroy my own things

ii. I steal at home

iii. I destroy other people’s things

iv. I tell lies or cheat

v. I vandalize

vi. I steal outside my home.

Often 7%

Some 44% *

None 50% *

Self-reported Property DelinquencyAmong Youth Aged 12-15, 2004-2005


Note: These rates are based only on the 86% of youth who responded.

* Significantly different from “often” at p<0.05.

Self-reported Aggressive Behaviour Among Males and Females Aged 12-15, 2004-2005


Note: Only among n = 3,768 responses (excludes non-response).

* Significantly different from “females” at p<0.05.

13%* 37% 50%*

7% 31% 62%

0% 20% 40% 60% 80% 100%

% of youth (ages 12-15)

Males

Females

Often Some None

Mental Health, Delinquency and Criminal Activity:

Relationships at the Level of Individual, Family, School/Peer and Community

Mental Health, Delinquency and Criminal Activity: Individual Level

INDIVIDUAL LEVEL

Protective Factors

• High levels of optimism, life satisfaction and emotional capability • Trustworthiness• Sense of belonging• Greater self-efficacy / High self-esteem

Risk Factors • Low self-worth• Hyperactivity• Depression• Victim of bullying, assault, threats, theft

CPHI Analysis: Aggression and Individual-level Protective Factors

Source: CPHI Analysis of NLSCY (cycle 6, 2004-2005).* Significant difference between levels within each mental health factor at p<0.05.

44%

61%*

47%

63%*

53%

65%*

46%

73%*

48%

75%*

0%

20%

40%

60%

80%

100%

% o

f y

ou

th r

ep

ort

ing

no

a

gg

res

siv

e b

eh

av

iou

r

Self-Esteem SelfMotivation

Adaptability StressManagement

EmotionalCapability

Medium-Low High

CPHI Analysis: Aggression and Individual-level Risk Factors

Source: CPHI Analysis of NLSCY (cycle 6, 2004-2005)E: Coefficient of variation between 16.6% and 33.3%. Interpret with caution.

* Significantly different than same level of aggression for “all youth” at p<0.05

56% 34% 10%

27%* 48%* 25%*

23%*E 46% 31%*

25%* 48%* 27%*

0% 20% 40% 60% 80% 100%

% of youth (aged 12-15)

All Youth

Anxious

Indirectly Aggressive

Hyperactive

None Some Often

Mental Health, Delinquency and Criminal Activity: Family Level

FAMILY LEVEL

Protective Factors

• Nurturing parenting style• High level of parental monitoring• Feeling loved and wanted• Having at least one parent home during at least one of four times during the day• High sense of family connectedness; doing activities together as a family• Being able to discuss problems with parents

Risk Factors • Harsh or inconsistent parenting style• Lack of parental supervision• Having a parent who struggles with an addiction or a mental illness and/or had a criminal record

CPHI Analysis: Aggression and Parenting Style


* Significant difference between levels at p<0.05.

42%*

66%

50%*

62%

0%

10%

20%

30%

40%

50%

60%

70%

% o

f y

ou

th (

12

-15

)

rep

ort

ing

no

ag

gre

ss

ive

be

ha

vio

ur

ParentalNurturance

ParentalMonitoring

Medium-Low High

Mental Health, Delinquency and Criminal Activity: School and Peer Levels

SCHOOL AND PEER LEVELS

Protective Factors

• School environment in which youth feel involved• Feeling connected with one’s peers• Feeling teachers are fair• Academic achievement

Risk Factors • Lack of school involvement• Poor academic achievement• Negative peer influences (older or delinquent friends, friends who committed or tolerated illegal acts)• Bullying• Truancy, suspensions

Mental Health Among Children & Youth:Students Who Do Not Feel Confident

Source: PHAC, The Human Face of Mental Health and Mental Illness in Canada, 2006.

Proportion of students who do not feel confident, by sex and grade, Canada, 2002

0

5

10

15

20

Pe

rce

nt

Girls 4.7 9.4 11.2 12.8 17.5

Boys 5.5 3.5 6.7 8.1 5.9

Grade 6 Grade 7 Grade 8 Grade 9 Grade 10

Mental Health Among Children & Youth:Students Who Feel Left Out or Lonely


Proportion of students who often feel left out or lonely, by sex and grade, Canada, 2002

0

10

20

30

40

50

Pe

rce

nt

Girls 23.1 24.8 30.4 27.6 31.8

Boys 21.9 24 26.1 25.2 25.9


Mental Health Among Children & Youth:Students Who Feel They Do Not Belong


Proportion of students who feel they do not belong at their school, by sex and grade, Canada, 2002

0

10

20

30

40

50

Pe

rce

nt

Girls 14 14 17.3 18.2 15.3

Boys 17.4 15.3 23.8 22.9 18.3


CPHI Analysis: Aggression and School/Peer Risk Factors


* Significantly different than same level of aggression for “all youth” at p<0.05.

56%* 34% 10%

41%* 43%* 16%*

39%* 43%* 17%*

46%* 42%* 12%

0% 20% 40% 60% 80% 100%

% of youth (aged 12-15)

All Youth

Few Positive Peer Connections

Peers with Problem Behaviours

Feels like an Outsider

None Some Often

Mental Health, Delinquency and Criminal Activity: Community Level

COMMUNITY LEVEL

Protective Factors

• Feeling a positive bond to society• Strong pro-social values

Risk Factors

• High turnover of neighbourhood residents• High rates of violent crimes• Feelings of hopelessness• High levels of marijuana availability• High numbers of youth in trouble with the law• Living in high-poverty neighbourhoods

CPHI Analysis: Protective Factors Among Youth who are Not Aggressive

• Just over one half (56%) of 3,768 responding youth reported no aggression.

• Compared to these youth, youth with identified protective factors were significantly more likely to report not being aggressive.

Source: CPHI analysis of Statistics Canada’s, NLSCY (cycle 6, 2004-2005).

Top 5 Protective Factors % of Youth Not Aggressive

Emotional capability 75

Able to manage stress 73

Nurturing parents 66

Likes school 65

Adaptable 65

CPHI Analysis: Risk Factors Among Youth who are Often Aggressive

Source: CPHI analysis of Statistics Canada’s, NLSCY (cycle 6, 2004-2005).

Top 5 Risk Factors % of Youth Often Aggressive

Indirectly aggressive 31

Hyperactivity 27

Parental rejection 26

Anxious 25

Punitive parenting 21

• 10% of responding youth reported often being aggressive• Youth with identified risk factors were more likely to report

often being aggressive compared to these youth.

CPHI Analyses: Conclusions

The top five protective factors represent the presence of positive behaviours, such as:• Emotional capability, stress management, parental nurturance, liking

school and being easily adaptable

As opposed to the absence of these protective factors, the top five risk factors for aggressive behaviour represent the presence of a negative behaviour, including:• Indirect aggression, hyperactive, reporting parental rejection or punitive

parents and being anxious

Analyses highlight the value of both promoting protective factors and reducing risk factors as a means of addressing aggression in youth

Preventing Delinquency and Involvement with the Criminal Justice System:Policies and Programs

Preventing Delinquency: Policies and Programs (1)

There is a link between various skills-training programs within the family and school contexts with improved mental health outcomes and reduced delinquency among youth.

• Project Early Intervention

• The Banyan Community Services SNAP™ Under-12 Outreach Project

• Syracuse Family Development Research Project

• Seattle Social Development Project

• Montréal Longitudinal Experimental Study

Policies and Programs (2)

• Project Early Intervention (Ottawa)

o Children aged 6 to 12 living in neighbourhoods at risk for delinquency

o Life skills training with sports/recreation programs, counselling

• The Banyan Community Services SNAP™ Under-12 Outreach Project (Hamilton)

o Boys aged 6 to 12 who previously committed offences

o Self-control skills and child-management parenting techniques

Outcomes:

• Reduced aggressive behaviour among children and improvements in social behaviours with self-control training


• Syracuse Family Development Research Project (Syracuse)o 108 disadvantaged familieso Individualized daycare services, parental training, in-home support

• Strong Families, Strong Children (Moncton)o Families with children aged 5 to 12 who displayed risk factors for

crime and victimizationo In-home support, family nurturing program, parent support group,

social skills training, respite care

Outcomes:

• Increased self-efficacy and reduced juvenile delinquency with family-skills training in early childhood


• Seattle Social Development Project (Seattle) o Children from 18 schools in different neighbourhoods

o Teacher/parent training, child social & emotional skills development

o Improvements in school and work functioning, decreased involvement in criminal activities and fewer mental health problems among youth receiving a school-based intervention

• Bully Prevention Program (Norway) o 2,500 elementary and junior high school studentso Different anti-bullying messages delivered by different people in

different contextso Decreases in bullying behaviour, being the victim of bullying, and in

rates of fighting, vandalism, theft, and truancy. Improvements in positive social relationships and positive attitudes towards school


• Montréal Longitudinal Experimental Study (Montreal)

o Boys from families of low socioeconomic status

o Social skills training for children, parenting skills training, teacher support/information

o At 4-year follow-up, less delinquency, less aggression in school

o At 15-year follow-up, no differences in terms of having a criminal record

Mental Health and theCriminal Justice System

Characteristics of Patients with Criminal Involvement Admitted to a Mental Health Bed

New analyses of data from CIHI’s Ontario Mental Health Reporting System (OMHRS) database show that from April 2006 to March 2007:

• Of 30, 606 unique patients admitted to a mental health bed

9% had some current involvement with the justice system (forensic admissions)

28% reported a violent or non-violent criminal history

• Compared to non-forensic patients, forensic patients tended to be younger and a higher proportion were male, never married, and had lower education levels and less stable housing

Males were more than three times more likely to be forensic patients than females

Risk Factors at Admission Among Patients with a Criminal History

Compared to patients without a criminal history, patients in mental health beds with a criminal history reported significantly more risk factors at admission:

• Reported rates of substance use were nearly two times higher

• Significantly greater victimization rate (38% versus 26%)

• Patients with a criminal history were more likely to have failed or dropped out of an education program (41% versus 25% of non-criminal history)

• For 44% of patients with a criminal history, the patient, family or friends indicated the relationship between the patient and immediate family was dysfunctional (versus 34% of others)

Risk Factors at Discharge Among Patients with a Criminal History

Compared to patients without a criminal history, patients with a criminal history reported significantly more risk factors at discharge

Criminal History

No Criminal History

Reported being adherent to medication less than 80% of the time in the month prior to admission

31% 21%

No support person who feels positive about their discharge

23% 18%

Initial living arrangement expected upon release:

Private home

Homeless

Correctional facility

Unknown

66%

4%

3%

3%

77%

1%

<1%

2%

Source: CPHI analysis of Ontario Mental Health Reporting System (OMHRS), CIHI, 2006–2007.

All comparisons are significantly different between groups at p<0.05.

Mental Illness Among Youth in Correctional Facilities

Rates of some mental illnesses are higher among incarcerated youth than among youth in the general population, including:

• Depression

• Anxiety disorders

• Attention-deficit/hyperactivity disorder (ADHD)

• Substance abuse disorders

• Conduct disorder

• Post-traumatic stress disorder (PTSD)

• Schizophrenia

Mental Illness Among Adults in Correctional Facilities

Most people with a mental illness or compromised mental health do not commit crimes

However, information from various sources indicates there is a higher prevalence of certain types of mental illnesses among incarcerated adults compared to the general population, including:

• Psychotic disorders (schizophrenia)

• Major depressive disorder

• Anxiety disorders

• Antisocial personality disorder

• Substance abuse disorder

Mental Illness Among Aboriginal Peoples in Correctional Facilities

Aboriginal Peoples are over-represented in the Canadian prison system

• In 2002, 17% of males and 26% of female inmates were Aboriginal

• 92% of Aboriginal federal offenders required help for a substance abuse problem; 96% reported a personal or emotional issue that needed attention

• Compared to non-Aboriginal inmates, Aboriginal inmates tend to have lower rates of completed education, greater unemployment histories, higher rates of unstable housing, higher rates of repeat offending and higher rates of violent offences

Mental Illness and Suicidal Behaviour in Correctional FacilitiesAmong the general population, 12% of males and 19% of females (15 to 24 years) reported having suicidal thoughts at some point in their lifetime• 2% of males and 6% of females reported a suicide attempt

In 2002, the proportion of male federal inmates in Canada who reported a suicide attempt in the previous five years ranged from 10% in minimum security to 16% in maximum security• Proportion among female inmates ranged from 11% to 41%

Among incarcerated youth, published rates of suicidal thoughts range from 9% to 10% with a lifetime prevalence of 34%

• A British Columbia study found that 21% of incarcerated youth thought about killing themselves in the past year; 13% reported a past attempt

Programs for People Involved with the Criminal Justice System

Diversion Programs

• Aim to intervene during the various points at which persons with a mental illness may come into contact with the criminal justice system

• Participants in mental health diversion programs spend less time in jail and have more involvement with mental health professionals and community mental health services than individuals not involved in such programs

Programs in Correctional Facilities

Many jurisdictions offer mental health-related programming for offenders in institutional settings, including substance abuse treatment; violence prevention; and stress and anger management • Preliminary evaluations speak to the effectiveness of violence

prevention and anger management programs offered in correctional facilities

• Little is known about the long-term impacts on mental health–related outcomes or the accessibility of programs to offenders, particularly among those with mental health issues

Programs in Community Settings

Many jurisdictions offer mental health-related programming for offenders in supervised community settings. Successful community-based programs share the following features:

• They are intense, highly structured and contain multiple components targeting specific problems;

• Treating clinicians assume multiple roles, including treating patient’s mental disorder, preventing violence and crime, and taking responsibility for patient’s compliance with the program;

• Treating clinicians have the authority to re-hospitalize patients if they are judged to be at risk, to be committing other crimes, or to be in need of acute psychiatric symptom treatment; and

• Treating clinicians have the option to obtain court orders in order to ensure compliance with the treatment program.

Conclusions

Conclusions

• There is value in providing appropriate services and programs in order to prevent criminal activity.

• Within the individual, family, school/peer and community contexts, various factors may protect against or increase one’s risk for delinquency.

• Research suggests that no single program that targets only one risk or protective factor would be as effective as programming that targets the multiple factors associated with mental health, delinquency and criminal activity.

• There is value in providing offenders who have a mental illness with appropriate services and programs within correctional facilities and in the community.

CPHI Mental Health Current and Planned Reports and Activities

Complementary Products

• Workshops that reflect content of given mental health report

• Collection of Papers: “What Makes a Community Mentally Healthy?”

• Mental Health, Delinquency and Criminal Activity—Supporting Documents: Literature search methodology

Data and analysis methodology

Policy scanning methodology

Summary report

PowerPoint presentation

It’s Your Turn

[email protected] www.cihi.ca/cphi

Improving the Health of Canadians: Mental Health, Delinquency and Criminal Activity Elizabeth Votta, PhD Canadian Institute for Health Information Presentation.

Documents

health slide

adolescent health

alberta health

health of individuals

positive youth health

health outcomes of youth

area of youth health

mental health series