Thomas Grisso

The MacArthur Treatment Competence Study. I: Mental illness and competence to consent to treatment.

This is the first of three papers reporting the results of the MacArthur Treatment Competence Study, a project designed to develop reliable and valid information with which to address clinical and policy questions regarding the abilities of persons with mental illness to make decisions about psychiatric treatment. Four commonly applied legal standards for determining decision-making competence are described: abilities to communicate a choice, understand relevant information, appreciate the nature of the situation and its likely consequences, and rationally manipulate information. Previous research related to the capacities of persons with mental illness in relation to these standards is reviewed and critiqued. The principles underlying the design of the MacArthur Treatment Competence Study are described.

The MacArthur Treatment Competence Study. III: Abilities of patients to consent to psychiatric and medical treatments

Three instruments assessing abilities related to legal standards for competence to consent to treatment were administered to 6 groups: patients recently hospitalized for schizophrenia, major depression, and ischemic heart disease, as well as three groups of non-ill persons in the community who were matched with the hospitalized patients on age, gender, race, and socioeconomic status. Significant impairments in decisional abilities were found for only a minority of persons in all groups. Both the schizophrenia and depression groups manifested poorer understanding of treatment disclosures, poorer reasoning in decision making regarding treatment, and a greater likelihood of failing to appreciate their illness or the potential benefits of treatment. Deficits were more pronounced, however, among patients with schizophrenia. Implications are discussed for policy designed to protect the rights and welfare of patients with mental illness who are at risk of incompetent refusal or consent when making treatment decisions.

Adolescent Development and the Measurement of Juvenile Psychopathy

Researchers are currently seeking antecedents of psychopathy among children and adolescents. Instruments developed for this purpose are likely to be used in the future in ways that may have serious implications for youths in delinquency and criminal cases. In this regard, and because the concept and measurement of psychopathy have been developed in reference to adults, there is reason to be concerned about potential developmental sources of false positives when measuring psychopathic traits in juvenile offenders. We provide the basis for our concern, as well as standards regarding the types of research evidence that should be provided before psychopathy measures are accepted for use in juvenile forensic assessments.

A classification tree approach to the development of actuarial violence risk assessment tools

Since the 1970s, a wide body of research has suggested that the accuracy of clinical risk assessments of violence might be increased if clinicians used actuarial tools. Despite considerable progress in recent years in the development of such tools for violence risk assessment, they remain primarily research instruments, largely ignored in daily clinical practice. We argue that because most existing actuarial tools are based on a main effects regression approach, they do not adequately reflect the contingent nature of the clinical assessment processes. To enhance the use of actuarial violence risk assessment tools, we propose a classification tree rather than a main effects regression approach. In addition, we suggest that by employing two decision thresholds for identifying high- and low-risk cases--instead of the standard single threshold--the use of actuarial tools to make dichotomous risk classification decisions may be further enhanced. These claims are supported with empirical data from the MacArthur Violence Risk Assessment Study.

Police-Induced Confessions: Risk Factors and Recommendations

Recent DNA exonerations have shed light on the problem that people sometimes confess to crimes they did not commit. Drawing on police practices, laws concerning the admissibility of confession evidence, core principles of psychology, and forensic studies involving multiple methodologies, this White Paper summarizes what is known about police-induced confessions. In this review, we identify suspect characteristics (e.g., adolescence; intellectual disability; mental illness; and certain personality traits), interrogation tactics (e.g., excessive interrogation time; presentations of false evidence; and minimization), and the phenomenology of innocence (e.g., the tendency to waive Miranda rights) that influence confessions as well as their effects on judges and juries. This article concludes with a strong recommendation for the mandatory electronic recording of interrogations and considers other possibilities for the reform of interrogation practices and the protection of vulnerable suspect populations.

Massachusetts Youth Screening Instrument for mental health needs of juvenile justice youths

OBJECTIVE This report describes the development of the Massachusetts Youth Screening Instrument-Second Version (MAYSI-2), a brief screening measure to identify youths with potential mental, emotional, or behavioral problems at entry points in the juvenile justice system. METHOD This 52-item self-report measure, with content relevant to common mental health problems in delinquent populations, was administered to 1,279 male and female youths, aged 12 to 17, in Massachusetts juvenile justice facilities. A subsample of youths also received the Millon Adolescent Clinical Inventory (MACI) and the Youth Self-Report (YSR). The instrument was subsequently administered to 3,804 male and female youths in California Youth Authority custody. RESULTS Factor analyses of the 52 items identified seven scales that were conceptually associated with various mental, emotional, and behavioral problems of youths, which were generally confirmed by separate factor analyses with the California sample. The scales manifested adequate internal consistency and test-retest reliability. Most scales were substantially correlated with conceptually similar scales in the MACI and YSR, and they identified most youths who scored at clinically significant levels on those instruments. CONCLUSIONS The MAYSI-2 shows promise as a reliable and valid screening tool to assist juvenile justice staff in identifying youths who may need an immediate response to mental or emotional problems.

Mental Health Screening and Assessment in Juvenile Justice

The editors of Mental Health Screening and Assessment in Juvenile Justice start with the premise that every year an increasing number of children with associated mental health disorders enter the juvenile justice system. They note that an administrator of a juvenile justice correctional program stated that the “three most pressing issues in juvenile justice facilities today are mental health, mental health, and mental health.” When asked the same question 15 years earlier, another mental health administrator stated “public safety, public safety, and public safety.” The difference in these quotes highlights the shift in focus from juvenile crime prevention to the current crisis with, and recognition of, mental health disorders among incarcerated youths today. Mental Health Screening and Assessment in Juvenile Justice is a comprehensive book organized into six sections: Preparing for Screening and Assessment, Multidimensional Brief Screening Tools, Unidimensional Screening Tools, Comprehensive Assessment Instruments, Risk for Violence, and Recidivism and Forensic Assessment Tools. Each section reviews tools principally developed after 1990 in the context of increasing focus on juveniles and their mental health needs. The tests reviewed in the book were chosen for four basic reasons: (1) they are easily available through commercial test publishers; (2) they have been developed for use in juvenile justice settings; (3) their procedures satisfy basic test construction criteria; and (4) they have shown reliability and validity in juvenile justice settings. The book lends itself to a comprehensive and thorough review of each instrument because the developers of the tests are typically the authors of the chapters. The preface, citing a recent review by the U.S. House of Representatives subcommittee, states that 15,000 youth are incarcerated every year because of mental health-related disorders. In this context, detention centers have a “custodial obligation” to these children and must be prepared to identify them and to facilitate their treatment in a timely manner. Moreover, a child’s rights around “due process,” such as the rights to avoid self-incrimination and to waive or obtain representation by an attorney, may be placed in jeopardy if a mental health disorder goes untreated. Clearly, treatment of a child’s mental health needs is important on many levels, and a lack of appropriate screening and assessment tools within a detention center does not absolve the center of their responsibility to the child. Section I, Chapter 2 is entitled “A Developmental Perspective on Adolescent Personality, Psychopathology, and Delinquency.” In it the authors provide a comprehensive review of how developmental issues affect the understanding of child psychopathology. As an example, the authors introduce the concept of “instability of youth” or mental health-related phenomena that may reflect serious psychopathology as an adult but is seen as developmental and more ageappropriate for a juvenile. Issues surrounding the concept of developmental appropriateness come up again in Section V around the Hare Psychopathy Checklist: Youth Version. Also in Chapter 2, the authors discuss a juvenile’s risk for violence. While the literature is described as “largely inconsistent,” the authors state that youth who manifest disruptive disorders in combination with a lack of empathy and remorse are at higher risk for delinquency and violence. The authors report a 5 to 20 times greater likelihood that children involved with substances will exhibit violent and delinquent tendencies later in life. Mood disorders are also cited as a potential risk for violence. As an example, a sullen, depressed, irritable youth could elicit abrupt and aggressive responses from others. His depression may also result in a greater propensity to interpret annoyances as “direct threats,” thereby leaving him at risk for interpersonal discord and physical altercations. The functionality and practicality of screening devices are reviewed in Chapter 3. At a minimum, the authors state that screening tools must focus on depression and anxiety; provide an indicator around the likelihood of short-term aggression; have the capacity to identify suicidal youth; and indicate the likelihood of a substance abuse or dependence diagnosis. These elements allow for more effective decisionmaking and an increasingly efficient allocation of resources surrounding a child’s mental health and/or substance abuse needs.

Mental health assessments in juvenile justice: report on the consensus conference.

OBJECTIVE At national, state, and local levels, there is increasing recognition of the importance of identifying and responding to the mental health needs of youths in the juvenile justice system, as policymakers and practitioners struggle to find ways to address causes and correlates of juvenile crime and delinquency. The proposed guidelines for mental health assessment provide explicit information about how, why, and when to obtain mental health information on justice youths at each important juncture in processing. METHOD A national group of expert researchers and practitioners convened in April 2002. Experts derived six recommendations, following the expert consensus method, for conducting mental health assessments in juvenile justice settings. Experts had broad experience creating collaborations between juvenile justice, mental health, and child welfare systems and understood the policy and health implications of conducting such assessments in juvenile justice settings. RESULTS Consensus Conference recommendations regarding screening for emergent risk, screening and assessment of mental health service needs, comprehensive mental health assessment components, assessment before community re-entry, need for periodic reassessment, and staff training are presented. CONCLUSION Deriving specific recommendations that can be implemented systematically is a necessary first step toward policy changes that will optimize the standard of care for this vulnerable population.

Is it unethical to offer predictions of future violence

An examination of the nature, foundation, and consequences of predictive testimony about future violence does not support the assertion, sometimes heard, that such testimony is necessarily unethical. Certain types of predictive testimony about future violence may have adequate scientific support. Moreover, society does not require certainty about future violence in order to restrict various liberties. Proper performance of an evaluation related to certain types of predictive testimony can provide an adequate foundation for the testimony. Finally, a consideration of the consequences of legal proceedings that restrict liberty does not support the conclusion that predictive testimony is necessarily ethically improper merely because it uses probabilities that create the potential for a significant number of false-positive legal decisions. Therefore, we would not advise psychology, psychiatry, or the courts to conclude that “predictions of dangerousness” as a class are unethical.

Sex and Race Differences in Mental Health Symptoms in Juvenile Justice: The MAYSI-2 National Meta-Analysis

OBJECTIVE Studies have suggested a high prevalence of mental health symptoms among youths in the juvenile justice system, with the highest prevalence among girls and whites compared to boys and other races. This multisite, archival study examined whether sex and race differences, when they exist, were consistent across U.S. juvenile justice programs. METHOD Data included scores on the Massachusetts Youth Screening Instrument-Version 2 (MAYSI-2) for 70,423 youths from 283 juvenile justice probation, detention, or corrections programs. A meta-analytic technique investigated the consistency of effect sizes for sex and race/ethnic differences across sites in self-reported mental health problems; RESULTS Across sites, girls on average were 1.8 (95% confidence interval 0.98-1.10) to 2.4 (95% confidence interval 2.38-2.48) times as likely as boys to have clinical elevations on all applicable MAYSI-2 scales except the Alcohol/Drug Use scale. On the Alcohol/Drug Use scale, a sex effect existed but only among youngeryouths. Whites were more likely to have clinical elevations than blacks or Hispanics; but surprisingly disparities varied across mental health categories and varied considerably across sites. CONCLUSION At the aggregate level, 72% of girls and 63% of boys had a clinical elevation on at least one MAYSI-2 scale. Our meta-analytic technique indicated that the sex differences across sites were even larger than these numbers imply. Conversely and counter to existing evidence, race-related differences were generally small or nonexistent. Whites were more likely to have alcohol and drug problems and suicide ideation, but not more likely to have symptoms of depression, anxiety, or thought disturbance than blacks or Hispanics.