Charles L. Scott

Juveniles in Court

Nineteenth-century American reformers were concerned about the influence of immaturity and development in juvenile offenses. They responded to their delinquent youths through the creation of juvenile courts. This early American juvenile justice system sought to treat children as different from adults and to rehabilitate wayward youths through the states assumption of a parental role. Although these rehabilitative goals were never fully realized, the field of American child psychiatry was spawned from these efforts on behalf of delinquent youths. Early child psychiatrists began by caring for juvenile offenders. The function of a child psychiatrist with juvenile delinquents expanded beyond strictly rehabilitation, however, as juvenile courts evolved to resemble criminal adult courts-due to landmark Supreme Court decisions and also juvenile legislation between 1966 and 1975. In response to dramatically increased juvenile violence and delinquency rates in the 1980s, juvenile justice became more retributional, and society was forced to confront issues such as capital punishment for juveniles, their transfer to adult courts, and their competency to stand trial. In the modern juvenile court, child psychiatrists are often asked to participate in the consideration of such issues because of their expertise in development. In that context we review the role of psychiatrists in assisting juvenile courts.

Malingering in the correctional system: does incentive affect prevalence?

Incentives to malinger vary greatly dependent on the context, as does the prevalence. Malingering in the medico-legal context of the criminal courts is generally for one of two purposes: to present as incompetent to stand trial or to successfully plead not guilty by reason of insanity. Estimates of the prevalence of malingering in these contexts vary between 8 and 21%. The prevalence of malingering increases dramatically in a general offender sample, where the external incentive is likely to be substantially different. Malingering in this context can be as high as 56% and generally occurs to obtain a more desirable housing situation or desired medications. Our study examined data from two distinct samples to evaluate incentives to malinger: patients found incompetent to stand trial (IST) and sent to a state hospital for restoration and jail inmates seeking psychiatric services (JPS). Our results indicate that the rate of malingering in the IST sample was consistent with rates published in comparable samples (17.5%) and the rate for the JPS sample was substantially higher (64.5%). Only in the IST sample was rate of malingering associated with offense severity: patients found IST for murder and robbery evidenced malingering rates more than double the sample as a whole. Offense severity bore no relationship to malingering in the JPS sample.

Dual diagnosis among incarcerated populations: Exception or rule?

ABSTRACT Objectives: Over 2 million individuals were incarcerated in jails and prisons in the United States in 2004. Multiple studies indicate that the prevalence of mental illness and substance use disorders is substantially higher in correctional environments when compared with rates in the community. The objective of this paper is to provide information on the prevalence of dual diagnosis among those incarcerated and the importance of assessing comorbidity for determining treatment needs of inmates. For the purposes of this article, the definition of dual diagnosis includes mental disorders and coexisting substance use disorders, mental disorders and coexisting developmental disabilities, and developmental disabilities and coexisting substance abuse disorders. Methods: An extensive electronic literature search was conducted through PubMed, Medline, Department of Justice, and the National Commission on Correctional Health Care. Studies examining the prevalence of mental illness and substance use in jails and prisons, female inmates, and inmates with developmental disabilities were reviewed. Results: The literature reviewed indicated a high comorbidity of mental illness and substance use disorders in incarcerated individuals. Providers should be aware of issues regarding dual diagnosis in special populations among those incarcerated to include female offenders and offenders with developmental disabilities. Conclusion: Providers who work in correctional environments must understand the significant prevalence of comorbid mental illness and substance use disorders in those incarcerated to more effectively assess and treat inmates.

Child sex tourism: extending the borders of sexual offender legislation.

Child sex tourism, the act of traveling to engage in sexual acts with minors, plagues developing nations worldwide. Several laws have been passed internationally in recent years designed to curtail this practice. Government entities and human rights organizations have driven these efforts. United States citizens represent a significant proportion of participants in child sex tourism. The PROTECT Act of 2003 prohibits United States citizens from participating in sexual acts with minors while traveling, and establishes extraterritorial jurisdiction. The case of Michael Lewis Clark, the first United States citizen convicted under this legislation, is highlighted. Child sex tourism poses unique issues to courts that will require ongoing clarification as challenges arise. This article discusses potential future challenges, describes strategies to address this problem, and relates this issue to psychiatry. Mental health providers may have the role of evaluating both the victims and perpetrators of child sex tourism. The authors propose a classification system for offenses and an initial list of topics to discuss with victims. The authors also describe the proper mechanism for reporting United States citizens suspected of participating in child sex tourism.

Malingering and Mental Health Disability Evaluations

Mental health professionals often perform disability evaluations at the request of their patients. Although malingering of psychiatric symptoms during a disability evaluation is common, providers may be reluctant to report that their patient is a malingerer, even if they suspect that their patient’s symptoms may be consciously motivated by an external gain. When evaluating the possibility of malingering, evaluators should look for inconsistencies in their patient’s symptom presentation, reported symptoms atypical for a genuine mental disorder, psychological testing indicative of poor effort or feigned symptom presentation, and objective evidence that supports actual impairment. The clinician should also be familiar with common diagnoses that are often mistaken for malingering. This chapter reviews important assessment strategies when evaluating malingering to include both interview and psychological testing indicators of malingering. Common feigned or exaggerated presentations of various psychiatric disorders are highlighted to include malingered psychosis, depression, posttraumatic stress disorder (PTSD), and cognitive disorders.

Evaluating Amnesia for Criminal Behavior. A Guide to Remember

This article provides a guide that is important to remember in evaluating a criminal defendants amnesia claim. Important concepts to understand regarding memory formation, memory systems, proposed causes of amnesia, reasons why amnesia claims may be true or false, and important strategies to implement as part of the evaluation process are reviewed. Structured assessment approaches are critical components of amnesia evaluations and generally require detailed questioning, review of collateral records, medical and neurologic workups, psychological testing, neuropsychological testing, and specific malingering assessments.

Psychiatric education in the correctional setting: challenges and opportunities

Abstract As the need for mental healthcare services within correctional settings in the US increases, so does the need for a mental health workforce that is motivated to work within such systems. One potentially effective method by which to increase the number of psychiatrists working in jails, prisons, and parole clinics is to provide exposure to these environments during their training. Correctional settings can serve as unique training sites for medical students and psychiatric residents and fellows. Such training experiences can provide a host of benefits to both trainees and staff within the correctional mental health system. Alongside many potential benefits exist substantial potential barriers to coordinating correctional training experiences, including both programme directors’ and residents’ concerns regarding safety and enjoyment and negative perceptions of inmate and prisoner patients. The establishment of academic affiliations with correctional institutions and didactic instruction on commonly encountered clinical issues with inmate populations may be methods of diffusing these concerns. Improving residents’ and fellows’ training experiences offers a hope for increasing the attractiveness of a career in correctional psychiatry.

Teaching Psychological Assessments to Forensic Psychiatry Fellows: A Practical Guide

Structured assessment instruments are a standard component of forensic psychology and are increasingly used in forensic work, where errors in clinical judgment can carry enormous consequences. More recently, some have argued that it is imperative that forensic psychiatrists become well-versed in these instruments [1]. Although potential controversy may arise from the concept of having psychiatrists administer psychological assessments, there are a multitude of reasons why forensic psychiatry fellowship programs should consider educating their fellows in the ethical use and administration of structured assessment tools. Scientific evidence suggests that judgments about violence risk and malingering are improved with structured approaches to the evaluations, especially when the selected instrument is matched to the situation and presented concerns [2, 3]. Statutes and regulations are increasingly requiring specialized assessments to distinguish “high risk” individuals for detention and “low risk” individuals for release. Structured instruments are commonly utilized, and in some states required, to accomplish this goal. Forensic psychiatrists who collaborate with psychologists, either in a treatment setting or as part of a forensic evaluation, should have a practical working knowledge of the various assessment instruments in order to understand and incorporate the test results in their evaluations. Moreover, with the increasing use of these instruments in forensic psychology, forensic psychiatrists must necessarily be informed as to the appropriate—and inappropriate—use by other retained experts in order to challenge their findings. Forensic psychologists have been leaders in the research and development of risk assessment instruments and assessments of feigned psychological symptoms and cognitive deficits. Over the last several years, forensic psychiatrists have begun to incorporate many of the structured assessment approaches in their research and related publications. If forensic psychiatrists are to become leaders in forensic research such as risk assessment and management and/or malingering assessment, they must have an in-depth knowledge of appropriate tools to use in the conduct of such research. Furthermore, forensic psychiatrists play vital leadership roles overseeing the delivery of care in forensic settings. In this role, the psychiatric administrator must have an understanding of these assessment tools, to include both their strengths and weaknesses and appropriate populations for their use. Without such knowledge, the psychiatrist must either proceed blindly or delegate their responsibility to an informed surrogate. Finally, the forensic psychiatrist is likely to encounter other experts who have utilized structured instruments in their case analysis. The forensic psychiatrist must be trained in this subject area in order to understand the methodology and appropriateness of the assessment performed by other retained experts [1]. The increasing importance of teaching structured psychological assessments is reflected in the Accreditation Council for Graduate Medical Education and The American Board of Psychiatry and Neurology’s resource document for training titled “The Forensic Psychiatry Milestone Project.” The Milestones in this document were identified by national educators in the field of forensic psychiatry for the evaluation of forensic psychiatry fellows during their progression in an ACGME-accredited residency or fellowship programs. Each Milestone is rated on a scale of 1–5 (1 = lowest rating; 5 = highest rating) to reflect the level of proficiency achieved by the fellow in that area. A “Level 4” rating indicates that the * Charles L. Scott clscott@ucdavis.edu

Clinical assessment of psychotic and mood disorder symptoms for risk of future violence

This article reviews important components to consider when evaluating the relationship of psychotic and mood disorder symptoms to violence. Particular attention is given to assessing persecutory delusions and command auditory hallucinations. Clinical implications of research findings to evaluating violence risk in psychiatric patients are reviewed.

The Child and Adolescent Track in the Forensic Fellowship

Exposure to child and adolescent forensic issues is limited in general psychiatry residency and child and adolescent psychiatry residency programs. There is no Graduate Medical Education Program for child and adolescent forensic psychiatry that is approved by the American Council on Graduate Medical Education (ACGME). Forensic psychiatry residency directors can create a child-focused forensic training opportunity that meets the needs of the ACGME program in forensic psychiatry. By creating didactic, clinical, and research experiences relevant to child and adolescent forensic psychiatric issues, this much-needed training can be provided to qualified psychiatrists.