the role of an indigenous health worker in contributing to

Attachment A

Australian e-Journal for the Advancement of Menial Health (AeJAMH), Volume 6, Issue 1, 2007ISSN: 1446-7984

The role of an Indigenous Health Worker in contributing to equity of accessto a mental health and substance abuse service for Indigenous young people in

a youth detention centreStephen Stathis1, Paul Letters2, Eva Dacre2, Ivan Doolan2,

Karla Heath2 and Bee Litchfield3

/. Child and Family Therapy Unit, Royal Children's Hospital, Herston, Queensland, Australia2. Mental Health Alcohol Tobacco and Other Drugs Service, Fortitude Valley, Queensland, Australia

3. Iona College, Wynnum, Central Queensland, Australia

Abstract

Indigenous youth in detention have been identified as a priority category in national and statepolicies in relation to their mental health and drug and alcohol service needs. This articledescribes the development of the role of Indigenous Health Worker in the Mental HealthAlcohol Tobacco and Other Drugs Service (MHATODS) at a youth detention centre. Itprovides an account of the process as well the outcomes achieved to date. A retrospective anddescriptive account is given of the development of the role, and of strategies aimed atimproving access to MHATODS for Indigenous young people. Over a one-year period, datawere compiled on all young people admitted to a Queensland youth detention centre, whichwas then cross referenced with MHATODS' own service records to determine the proportion ofIndigenous young people who had been referred and subsequently received a service. TheIndigenous Health Worker has decreased barriers to access for Indigenous young people whorequire treatment for mental health or substance abuse problems while in detention. There wasno significant difference in referral or service provision rates for Indigenous compared to non-Indigenous youth. Indigenous young people were statistically more likely to refuse anassessment by MHATODS, though given the low rates of refusal the clinical significance wassmall. MHATODS' use of an Indigenous Health Worker significantly contributes to the needsof Indigenous young people in youth detention by reducing barriers to access for the assessmentof mental health problems and substance misuse. MHATODS has achieved equity in referraland service provision between Indigenous and non-Indigenous youth admitted into detention.Clinical and cultural supervision play an important part in the development and maintenance ofthe Indigenous Health Worker role.

Keywords

Indigenous mental health, substance misuse, youth detention, youth, Indigenous, equity

Introduction for mental health problems (Australian Health

The need for equity in accessing mental health Ministers, 1992b). In the following year, theand substance abuse services H u m a n R l 8 h t s a n d Ec*ual Opportunities

Commission (1993) addressed the serious issueIn 1992, the National Mental Health Policy of poor delivery of mental health services to theidentified young people, and Aboriginal and m o s t s o d a l l y a n d e c o n o m i c a l ] y disadvantagedTorres Strait Islanders as being at particular risk s e c t l o n g o f t h e c o m m u n i t y ; l n c i u d i n g those in

Contact: Associate Professor Stephen Stathis, Consultant Psychiatrist, University of Queensland, Child and Family Therapy Unit,Royal Children's Hospital, Herston, Queensland, Australia, 4029 Stephen [email protected]

Citation: Stathis, S., Letters, P., Dacre, E., Doolan, I., Heath, K., & Litchfield, B. (2007). The role of an Indigenous Health Worker incontributing to equity of access to a mental health and substance abuse service for Indigenous young people in a youth detentioncentre. Australian e-Journal for the Advancement of Mental Health, 6(1), www.auseinet.com/journal/vol6issl/stathis.pdf

Published by: Australian Network for Promotion, Prevention and Early Intervention for Mental Health (Auseinet) —

Received 29 September 2006; Revised 19 March 2007; Accepted 19 March 2007

1

Stathis, Letters, Dacre el al.

youth detention. National and State policies havealso recognised that mental health servicedelivery to socially marginalised children andyoung people was an important area of unmetneed. Collaborative ventures between theCommonwealth, State and Territorygovernments have since been developed,committing them to a process of major reform ofmental health services (Australian HealthMinisters 1992a, 1992b, 1998). These keystrategies in mental health provision wereparalleled in the National Drug StrategicFramework and the National Alcohol Strategy(Ministerial Council on Drug Strategy 1998,2001), both of which noted the high incidence ofdual diagnoses among Indigenous young people,and recommended that steps be taken tostrengthen the links between mental healthservices and drug treatment services in order toprovide better and timelier access to therapeuticinterventions.

Youth in detention rank among the most sociallydisadvantaged in the community, and are at anincreased risk of a broad range of mental healthand substance misuse problems (Abram, Teplin,McClelland & Dulcan, 2003; Abrantes, Hoffman& Anton, 2005; Bickel & Campbell, 2002;Wasserman, 2002). In Queensland, a highproportion of these young people identifythemselves as being of Aboriginal or TorresStraight Islander descent (Department ofCommunities, 2004). Longstanding deficienciesin the provision of health services to youngpeople in detention in Queensland werehighlighted in 1999 by the QueenslandCommission of Inquiry into Abuse of Children inQueensland Institutions, which noted the needfor a mental health service to youth in detentioncentres that would more adequately address theirneeds (Forde, 1999). The development of theMental Health Alcohol Tobacco and OtherDrugs Service (MHATODS) was part of a widerresponse to recommendations of the Inquiry andhas been detailed elsewhere (Forde InquiryImplementation Monitoring Committee, 2001).

The development of the role of an IndigenousHealth WorkerCreating a service that is equally accessible to allyoung people in detention has been a coreobjective in the development of MHATODS.

During MHATODS' initial planning phase, itwas anticipated that engagement of Indigenousyoung people in the assessment of mental healthproblems and substance misuse would be aconsiderable challenge. In line with theQueensland Health Indigenous workforcestrategy (Queensland Health, 1999) advertisingwas aimed to target Indigenous communitiesthrough the Indigenous press, local Indigenousagencies and community leaders in order toencourage Indigenous people to apply.Involvement of Indigenous psychiatrists andallied health professionals was considered theideal option, though the dearth of such qualifiedprofessionals made this impractical.

It was difficult to find consistent descriptions ofIndigenous Health Worker positions within childand youth mental health or drug and alcoholservices. This issue has been noted by Parker(2003) who observed that the descriptive term'Aboriginal mental health worker' is used in abroad range of people with a wide range ofqualifications and experience, working undermarkedly different circumstances for serviceswho have poorly defined expectations.MHATODS was fortunate in having the supportand advice of a Senior Indigenous ProjectOfficer in developing the role, recruiting for theposition, and subsequently providing culturalsupervision. Following consultation withIndigenous stakeholders, it was recommendedthat MHATODS establish guidelines for thedevelopment of the non-clinical role of anIndigenous Health Worker in order to facilitateengagement with Indigenous youth.

It was determined that the primary task of theIndigenous Health Worker would be to promotereferrals of Indigenous youth to MHATODS,engage and maintain young people in treatmentand provide cultural insight into appropriatemental health assessments and interventions.Secondly, the Indigenous Health Worker wouldnot act as the sole case manager of any patientbut would be involved in formal clinicalinterventions jointly with a MHATODSclinician. Thirdly, the Indigenous Health Workerwould receive clinical supervision from a seniorallied health professional and regular culturalsupervision from a senior Indigenous officer.Fourthly, as no specific training program existed

Stathis, Letters, Dacre et al.

in MHATODS prior to recruitment of theIndigenous Health Worker, it was recommendedthat the worker receive standard orientation andparticipate in a number of core clinical trainingprograms. It was recommended that a specificprogram that aimed not to provide training intherapy, but to assist in complementing theclinical work of other MHATODS clinicians, bedeveloped over time as the tasks of theIndigenous Health Worker became clearer.Finally, an advanced diploma in Primary HealthStudies or equivalent was set as the minimumselection criterion.

Unique characteristics of the IndigenousHealth Worker role

From its commencement, MHATODSrecognised that a different style of interventionwould be required when working withIndigenous young people. A growing body ofliterature (Bennett & Zubrzycki, 2003; Folds,1985) has noted that the practice of Indigenousstaff members frequently requires a differentapproach from their non-Indigenous colleagues.These include working in non-formal settings atirregular hours, or becoming involved in socialactivities as part of the process of engaging andworking with Indigenous people (Bennet &Zubrzycki, 2003). However, without aconceptual framework, it was initially unclearjust what the worker's daily role would entail.Indeed, the Indigenous Health Workers' positiondescription developed conceptually over time.Engaging Indigenous patients in therapy,especially those who had previously refusedtreatment, gradually became recognised as thecentral focus of work.

The delivery of appropriate psychologicalsupport is a core task of MHATODS. It isrecognised that trust in the treating professionaland a belief in their genuineness and personalauthenticity are key factors for favourabletherapeutic outcomes (Pervin, 2003). Themajority of Indigenous young people in youthdetention suffer from a prejudicial upbringing,frequently characterised by poverty, abuse andneglect, itinerancy and family disruption. Thesedisadvantages are compounded by what manywould view as ubiquitous discrimination towardsIndigenous people in Australian society,particularly within this social cohort (Swan &

Raphael, 1995). It was the team's perception thatthese factors contributed to Indigenous youth indetention lacking trust in non-Indigenous peoplegenerally and in non-Indigenous therapists inparticular. The link between communication andtrust forms a critical component in the well beingof Indigenous mental health patients (Hunter,2004). Given that culturally appropriateengagement is recognised as a barrier toeffective mental health services (Vicary, 2002;Westerman, 2004), building rapport withIndigenous young people was viewed as aprimary task for the Indigenous Health Worker.It was therefore planned that the IndigenousHealth Worker would spend time engaging withyouth in their living quarters and social orsporting activities, thus developing a mutualsense of trust and encouraging them to attendMHATODS appointments following a referral.This generated a positive view of the Service,created a belief for the young person in a non-judgemental reception by MHATODS staff, andcontributed to realistic expectations of therapy.Furthermore, it became evident that having ageneral presence with young people has turnedout to be more than a means of directingindividuals towards therapy. It has alsocontributed to a culture of acceptance ofMHATODS within the centre. Third personreferral is frequently seen as culturallyappropriate (Vicary, 2002); it is not uncommonfor young people to 'vouch' for MHATODS andinformally refer friends and relatives to theService for an assessment.

With increased experience of forensic mentalhealth issues, the Indigenous Health Workerbecame clinically adroit in assessing behavioursthat were culturally bound or appropriate,compared to those issues that were considered tobe more manipulative or oppositional in nature.The worker was also able to engage youngpeople in the concept of emotional and spiritualwellbeing, and form an opinion as to whatsymptoms were more culturally bound, asopposed to those symptoms that were morecharacteristic of a distinct mental illness. Thishas made an important contribution to the team'soverall assessments. Although the ultimatedecision on clinical intervention lies with theclinician, the Indigenous Health Worker's


assessment frequently added either a level ofconfidence in formulating a treatment plan, or anote of caution that resulted in an increased levelof monitoring and review.

Young people in detention suffer from high ratesof serious mental health problems and substancemisuse (Abram et al., 2003; Abrantes et al.,2005; Bickel & Campbell, 2002; Wasserman,2002) complicated by significant psychosocialstresses such as poverty, unemployment, abuseand neglect (Chitsabesen & Bailey, 2006). Theseissues frequently challenge the most experiencedclinician. However, given the assumption thatthe Indigenous worker would not be a qualifiedmental health therapist, the role's focusemphasised cultural brokerage rather than directclinical intervention. It was soon evident thatsuch boundaries can easily blur. As planned, theIndigenous Health Workers spent significantamounts of time with the young people, whoresponded to their care, warmth and interest anddid not immediately see the distinction betweenwhat the Worker had to offer, and what wasavailable from the primary therapists. Operatingat that boundary between culture and therapytherefore raised a range of issues for theIndigenous Health Worker. For instance, aclinician's training demands an understanding ofthe complex dynamic relationship which existsbetween therapist and patient. The IndigenousHealth Worker would establish close links withvulnerable young people without the training tomeet the emotional demands of such arelationship. As a consequence, there were timeswhen Indigenous Health Workers wereemotionally burdened by these relationships. It isan area that MHATODS had identified as beingimportant to monitor, and therefore providedsupport to the non-therapeutically trainedworker.

The Indigenous Health Worker is employed in arole where their own aboriginality is central tothe work task, and not just a personalcharacteristic. They often work with youngpeople with whom they shared much commonground and experience, which brings its ownemotional, philosophical, political and culturalchallenges. Additionally, not all young peoplewith whom the Indigenous Health Worker wasinvolved perceived their situation from a

traditional or Indigenous perspectiveInvolvement with emotionally disturbed youngpeople therefore highlighted the need for theIndigenous Health Worker not only to be intouch with cultural dimensions of youngpeople's lives, but also the importance ofmaintaining appropriate boundaries withinclinical interactions. Again, these issues wereclarified in supervision, which emphasised theneed of support for non-therapeutically trainedstaff in what is an emotionally demanding area.

It is difficult for concerned workers within thefield of adolescent forensic mental health tomaintain a balanced perception of a youngperson's character while attempting to buildrapport. For the sake of the therapeuticrelationship, there may be a tendency tominimise a young person's history of conductdisorder or the seriousness of their criminalbehaviour. However, there is an additionalcultural dimension for the Indigenous HealthWorker. Bennett & Zubrzycki (2003) noted thatthe dominant professional discourse acts tomaintain separateness between the personal andthe professional self such as not developingfriendships with clients or adopting aprofessional role with family members. ForIndigenous workers these identities coexist andconverge as a result of kinship ties, obligationsand the realities of living and working in thecommunity. This is an issue into whichIndigenous supervisors may have direct insightand of which non-Indigenous clinical supervisorsneed an understanding in order to appreciate thedifficulties Indigenous Health Workers face inworking in this role.

The Indigenous Health Worker frequently worksoutside regular clinic periods and spends muchtime with detention centre staff. This has broughtconsiderable advantages to MHATODS, such ascreating a positive expectation from detentioncentre staff regarding the services MHATODSprovides, and improving lines of communicationbetween MHATODS and centre management.However, working at the interface of twodifferent agencies is challenging. For theIndigenous Health Worker, this paradigm has attimes contributed to a sense of discontinuity ineffectively being part of two organisations thatsometimes have different outlooks, expectations


of service provision, and understandings ofyoung people (Casey, 2000). PresentingMHATODS in an appropriate and culturallyacceptable manner has developed as a key aspectof the Indigenous Health Worker's role not onlywith young people in detention but also withIndigenous staff within the detention centre andexternal Indigenous service providers. TheIndigenous Health Worker became a member ofthe centre's Indigenous Reference Group. Thecurrent worker has participated in culturalcelebrations, formed linkages with a range ofnon-government organisations, and hasrepresented MHATODS at a number of nationalforums and conferences.

Assessing outcomes

While MHATODS has spent much time indeveloping the Indigenous Health Worker role,the Service has also employed other initiatives toincrease referral rates for Indigenous youngpeople in detention with mental health andsubstance misuse problems. These haveincluded:

• automatic referral for young people whoacknowledge substance use difficulties onadmission into detention;

• detention centre staff workshops aimed athelping detention staff identify mental healthand substance use issues in young people;and

• Indigenous specific substance use pamphletsavailable to all young people.

These initiatives have been refiected in increasedreferral rates for both Indigenous and non-Indigenous young people. The percentage ofIndigenous young people referred to MHATODShas increased on an incremental basis,accounting for 41% of total episodes of servicein 2003/4 (MHATODS, 2004). Rates have sincecontinued to rise, with Indigenous young peoplenow accounting for 50% of all referrals (Figure1), with the implication that Indigenous youngpeople were increasingly willing to accept areferral for an assessment by the Service.

Despite these promising developments, little hadbeen formally done to evaluate if Indigenousyoung people were statistically equallyrepresented in referrals to MHATODS. The aimof this study was therefore to determine how

well Indigenous youth were accessing theService. Referral rates and service utilisationrates were used as indicators of access. Thefindings of this study utilised the horizontalequity model. As such, we assumed that anunderlying equality of need existed for bothIndigenous and non-Indigenous young peoplewithin the centre. Consequently, young peoplewere assumed to suffer from equal rates ofmental health and substance use problems.

2001-2002 2002-2003 2003-2004 2004-2005 2005-2006

Figure 1. Percentage of episodes of service: Indigenousyoung people

Method

Prior to July 2003, MHATODS collectedinformation regarding standard demographiccharacteristics of all referred patients, thoughwas unable to identify the proportion ofIndigenous young people admitted to detentionthat had both been referred to and had consentedto an assessment by the Service. With the co-operation of the detention centre, information inrelation to the total number of Indigenous andnon-Indigenous young people admitted intodetention was compiled over a one-year periodbetween 1 August 2003 and 31 July 2004. Inorder to assess access to the Service, this list wasthen cross referenced with MHATODS' ownrecords over this period to determine theproportion of Indigenous young people who hadbeen referred and subsequently received aservice. Young people are frequency admittedmultiple times into detention. Recidivistjuveniles were defined as those admitted intodetention more than once over the 12 monthscovered by this study.

Stalhis, Letters, Dacre et al.

Results

During the year, there were 840 admissions intothe centre. Of these, 61 (7.3%) were held brieflyovernight pending a court appearance the nextday, subsequently released from detention, andhave not been included in the study. Theremaining 779 admissions consisted of 527individuals. Indigenous young people were over-represented within the detention centre.Although 4.6% of young people aged 10-18 inQueensland identify themselves as being ofAboriginal or Torres Strait Islander descent(Australian Bureau of Statistics, 2001), 225 ofthe 527 individuals (42.7%) admitted into thecentre identified themselves as being Indigenous.Of these 225 young people, 128 (56.9%) werereferred to MHATODS. However, there was nosignificant statistical difference betweenMHATODS referrals for Indigenous comparedto non-Indigenous young people (Table 1).

Of the 527 young people, 357 (155 Indigenous;202 non-Indigenous) were admitted once overthe year, 93 (40 Indigenous; 53 non-Indigenous)were admitted twice, and 77 (38 Indigenous; 39non-Indigenous) were admitted three or moretimes. Recidivists were significantly more likelyto be referred to MHATODS than their non-recidivist peers (p<0.001). However, there wasno statistical difference in referrals betweenIndigenous and Non-Indigenous non-recidivistyoung people. The same was true for recidivists(see Table 2).

Over the same year, MHATODS received a totalof 428 referrals for 280 young people. Of these428 referrals, 125 (57 individuals) were releasedfrom detention prior to being assessed. Therewas no significant difference in the number ofIndigenous compared to non-Indigenous youngpeople who were referred to MHATODS, butreleased from detention prior to an assessmentbeing made (Table 3).

Table 1. Referrals to MHATODS of young peopleadmitted into detention

Table 3. Young people referred to MHATODS whowere released prior to being seen

Referred toMHATODS

Not referred toMHATODS

Total

X2(1) = 2.56, n.s.

Indigenous

128

97

225

Non-Indigenous

143

145

302

Total

280

247

527

Referred

Referred butreleased prior tobeing seen

Total

X2(1) = 2.64, n.s.

Indigenous

139

47

186

Non-Indigenous

162

78

242

Total

303

125

428

Table 2. Referrals to MHATODS by number of admissions into detention

Referred to MHATODS

Subtotal

Not referred to MHATODS

Subtotal

Total

1 admission

Indigenous Non-Indigenous

68 84

152

87 118

205

357

2 admissions

Indigenous

29

11

Non-Indigenous

35

128

18

42

170

3+ admissions *

Indigenous

32

6

Non-Indigenous

32

7

Total

280

247

527

# Recidivists defined as 2 or more admissions over the year

Non-Recidivist vs Recidivist: x2(1) = 49.5, p < 0.001Non-Recidivists (1 admission): Indigenous versus non-Indigenous: %(\) = 0.19, p > 0.05Recidivists (2+ admissions): Indigenous versus non-Indigenous: x2(1) = 0.66, p > 0.05


Table 4. Referrals of young people to MHATODS whorefused to be seen

Consented toassessment

Refused anassessment

Total

Indigenous

106

33

139

Non-Indigenous

147

17

164

Total

253

50

303

X (1) = 9.77, p< 0.01

Of the remaining 303 referrals, 50 (33Indigenous; 17 non-Indigenous) were initiallywilling to be seen but later refused anassessment. These 50 referrals represented 38individuals (27 Indigenous; 11 non-Indigenous).Indigenous young people were statistically morelikely to refuse an assessment following areferral than their non-Indigenous peers (p<0.01) (Table 4). Of those young peopleassessed by MHATODS, Indigenous youngpeople were seen by the Service on an average of4.4 times per referral. Non-Indigenous youngpeople were reviewed an average of 5.3 times,though this difference was not statisticallysignificant.

Discussion

These results indicate that MHATODS hasestablished equity of access in terms of referralrates for Indigenous and non-Indigenous youngpeople in detention. Compared to their non-Indigenous peers, there was no statisticaldifference in the numbers of Indigenous youngpeople admitted to detention and referred toMHATODS. While it is difficult to attribute thisequity to any one intervention, it may beaccounted for by a combination of factorsincluding the development of effective linkswithin the centre in relation to the types ofservices MHATODS provides, word of mouthreputation built up over three years of serviceprovision and the promotion of MHATODS bythe Indigenous Health Workers within theService. The focus of this article was not on thesuccess or otherwise of the clinicians, but theeffectiveness of the Indigenous Health Worker inmeeting the stated aims of that role. Those aimswere not only to increase Indigenous youngpeople's access to the service, but also to assist

in maintaining these young people in therapy.Data indicated that these goals were achieved, asthe differences in total number of clinicalsessions per referral for Indigenous and non-Indigenous patients was not clinicallysignificant. MHATODS therefore achievedequity in service provision for these two groupsas well as equity of access.

Indigenous young people are statistically morelikely to refuse an assessment by MHATODSthan are their non-Indigenous peers. Therefore,unlike referral rates, service utilisation rates haveyet to achieve equity. This is despite consistentincremental increases in referral rates ofIndigenous youth since MHATODS commencedin 2001. Reasons for this are unknown. It is to beexpected that a proportion of Indigenous youngpeople in detention come from extremelysocially deprived backgrounds, which has lead toa distrust of formal organisations and non-Indigenous services. There is much historic andcurrent evidence that Indigenous people feelstigmatised within the mental health system(Brown, 2001; Colborne & MacKinnon, 2006;Westerman, 2004). Our current assessment andmanagement strategies may therefore still fail toreflect culturally appropriate ways to solvemental health and substance use problems in aproportion of Indigenous youth; perhaps thereremains a core group of Indigenous youngpeople who remain resistant to mental health ordrug and alcohol interventions. Finally, althoughIndigenous youth were statistically less likely toaccept an assessment to MHATODS, the clinicalsignificance of this disparity is small. Over theyear, only 3 of 27 Indigenous young people whorefused an assessment would have needed toconsent to an assessment in order for thedifference to become statistically not significant.

Recidivistic juveniles were significantly morelikely to be referred to MHATODS than theirpeers, though there was no statistical differencein referral rates between Indigenous and non-Indigenous young people. Although youngpeople within the juvenile justice system havehigh levels of mental illness and substance useproblems, there is some evidence that those whoare recidivistic have even higher rates than theirpeers (Kataoka, Zima, Dupre et al., 2001; Quist& Matshazi, 2000). Our findings may simply


reflect this. Other reasons would include thatrecidivistic young people have a greateropportunity to be referred, given they have beenadmitted multiple times into detention and arebetter known by centre staff, have previouslyengaged with MHATODS on an informal basisand may therefore be motivated to address theirmental health or substance use problems.

Not all juveniles referred to MHATODS had theopportunity for an assessment, with 20.4% ofyoung people referred to the Service beingdischarged from detention prior to review.Young people on remand were frequentlyreferred on admission and discharged fromcustody by the courts very shortly afterwards.The mental health status of these young people isunclear. A number of juveniles entering thedetention centre would have no mental health orsubstance abuse problems, and hence would notrequire a service. Other young people whowould have benefited from a mental health ordrug and alcohol assessment may have refusedany referral to the Service. Allied health staffworking for MHATODS have a daily presencein the centre, and a consultant child andadolescent psychiatrist visits twice weekly.Nevertheless, a number of young people wereunable to be seen due to the rapid turnover ofjuveniles through the centre. It is unlikely thatthis is due to any unreasonable delay occurringbetween a referral and an offered appointment.MHATODS attempts to assess all non-urgentreferrals within two working days, a responselevel which exceeds the minimum standardsrequired of its district community child andyouth mental health services. Given the highturnover of young people within the detentioncentre, and as many may be in detention for abrief period of time, MHATODS reviewsexisting clients frequently, often once or twiceweekly. Where a referred young person has beenreleased from detention prior to being seen,MHATODS contacts the young person's youthjustice officer to ensure that they are aware ofthe referral and the potential need for communityfollow up.

Published results in the Australian Bureau ofStatistics' National Health Survey (ABS, 2001)do not give details of the mental health of

Indigenous Australians and there is currently nonational database of the prevalence of mentaldisorders in Indigenous youth. This was due inpart to concerns that the survey questions in thisarea may not have been culturally appropriate(ABS, 2001). A subsequent ABS publication(ABS, 2002) suggested that an indication of thehigh levels of mental health problems inIndigenous Australians may be extrapolatedfrom other health-related data in whichIndigenous Australians are reportedly diagnosedwith increased rates of mental disorders due topsychoactive substances, have higher hospitaladmissions for conditions classified as 'mentaland behaviours disorders' than the generalpopulation, and have higher suicide rates andmortality rates for intentional self injury thannon-Indigenous Australians. While the abovedata is far from comprehensive, it does suggestthat Indigenous young people in detention arelikely to suffer from higher rates of mentalhealth and substance use disorders than theirnon-Indigenous peers and as a consequencerequire a greater level of service.

There is a growing body of theoretical work onthe various types of equity relating to health andhealth care (Wagstaff & van Doorslayer, 2000).Almond (2002) noted, amongst other models, thedistinction between the concepts of verticalequity and horizontal equity. Horizontal equity isachieved when all patients or defined groups ofpatients with equal needs are treated similarly.By implication, it therefore assumes that eachpatient requires the same type of service. Unlikehorizontal equity, vertical equity acknowledgesthat different groups of people may havedifferent or unequal needs that ought to beaddressed in an appropriate manner.

We chose to define 'access' in terms of theavailability and utilisation of services, and used ahorizontal model to assess equity of serviceprovision. Equity of access may imply more thansimilar proportions of differing cohorts of youngpeople accessing the service. Young peopleshould expect to receive a service in proportionto their needs. To achieve true vertical equity,the group with the greater burden of mentalhealth and/or drug and alcohol difficulties wouldhave a proportionally greater referral rate than a


group with a lesser burden. MHATODS' use ofan Indigenous Health Worker has contributedtowards addressing the needs of Indigenousyouth within juvenile detention by reducingbarriers in the referral and assessment to theService. While MHATODS has demonstratedequity of access and service provision forIndigenous and non-Indigenous young people indetention (horizontal equity), it is uncertain ifvertical equity has been established and furtherresearch is required.

Finally, on reflection, MHATODSunderestimated the difficulty of the task of theIndigenous Health Worker and the high level ofskills required for the role. Engaging Indigenousyouth in the context of a seemingly unstructuredenvironment is demanding work. We wouldrecommend the following to other services thatare considering the development of a similarrole:

• Be flexible in defining the role of theIndigenous Health Worker.

' Although the role may be deemed as non-clinical in nature, quality clinical andcultural supervision is necessary and playsan important part in the development andmaintenance of the role.

• Our experience has been that staff in otheragencies are appreciative of the involvementof the Indigenous Health Worker and have atendency for unrealistically highexpectations in terms of their clinicalinvolvement. Addressing those issues iseasier when the limitations of role are clearlyidentified, as has been discussed elsewhere(Casey, 2000).

• The role is challenging. Consider hiringpeople at the highest pay level in order toattract and retain suitable applicants. Theemployment of Indigenous Health Workersat higher grades opens up the possibilities ofsome degree of clinical intervention, forexample running manualised substance useprograms. Finally, it is also important toconsider that Indigenous professionals areincreasing in number, albeit slowly, and it iswise to look to them for clinical expertise inthe first instance.

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Ministerial Council on Drug Strategy (2001).National Alcohol Strategy: A Plan for Action 2001 to2003-04. Canberra: Ministerial Council on DrugStrategy.

Parker, R. (2003). The Indigenous Mental HealthWorker. Australasian Psychiatry, 11(3), 295-297.

Pervin, L. (2003). The Science of Personality (2nded). New York: Oxford University Press.

Queensland Health (1999). Our Jobs, Our Health,Our Future: Queensland Health IndigenousWorkforce Strategy. Brisbane: Queensland

Quist, R.M. & Matshazi, D.G, (2000). The child andadolescent functional assessment scale (CAFAS): adynamic predictor of juvenile recidivism.Adolescence, 35(137), 181-92.

Human Rights and Equal Opportunities Commission(1993). Human Rights and Mental Illness. Report ofthe National Inquiry into Human Rights of Peoplewith Mental Illness (Burdekin Report). Canberra:Australian Government Publishing Service.

Swan, P. & Raphael, B. (1995). National ConsultancyReport on Indigenous and Torres Strait IslanderMental Health: 'Ways Forward', Part I & Part 11.Canberra: Office of Indigenous and Torres StraitIslander Health.

Vicary, D.A. (2002). Engagement and Interventionfor Non-Indigenous Therapists Working with WesternAustralian Indigenous People. Perth: CurtinUniversity, Department of Psychology.

Wagstaff, A. & van Doorslayer, E. (2000). Equity inHealth Care Finance and Delivery. In A.J. Culyer &J.P. Newhouse (Eds.), Handbook of HealthEconomics: Volume IB. (pp 1803-1862). Amsterdam:Elsevier.

Wasserman, G.A., McReynolds, L., Lucas, C , Fisher,P.W., & Santos, L. (2002). The Voice DISC-IV withincarcerated male youth: prevalence of disorder.Journal of the American Academy of Child &Adolescent Psychiatry, 41 (3), 314-321.

Westerman, T.G. (2004). Engagement of Indigenousclients in mental health services: What role docultural differences play? Australian e-Journal for theAdvancement of Mental Health, 3(3),\vww.auseinet.com/iournal/vol3iss3Avestermaneditorial.pdr

10

doi:10.1111/j.1440-1754.2008.01324.x

ORIGINAL ARTICLE

Use of the Massachusetts Youth Screening Instrument to assessmental health problems in young people within an Australianyouth detention centreStephen Stathis,1 Paul Letters,2 Ivan Doolan,2 Robyn Fleming,2 Karla Heath,2 Amanda Arnett2 and Storm Cory2

'University of Queensland and Child and Family Therapy Unit, Royal Children's Hospital, Herston and 2Mentai Health Alcohol Tobacco and Other Drugs Service,Spring Hill, Queensland, Australia

Aim: To screen for mental health problems in an Australian adolescent forensic population, evaluate the Massachusetts Youth Screening

Instrument Version 2 (MAYSI-2) in providing a preliminary assessment of those needs, and to explore the level of mental health problems in

vulnerable populations within detention.

Methods: Over a 6-month period, all young people admitted into detention were referred for screening by the MAYSI-2, a 7-scaied instrument

developed to identify young people within the youth justice system at greatest risk for serious mental, emotional or behavioural disorders.

Results: High levels of mental health problems and trauma were reported, with 75.0% of males and 90.0% of females, and 81.2% of Indigenous

and 75.0% of non-Indigenous youth screening above the clinical cut-off for at least one scale. Males screened highest on the Alcohol and Drug

Use (58.9%), Angry-Irritable (28.2%) and Somatic Complaints (28.2%). Females screened highest on the Alcohol and Drug Use (67.5%), Somatic

Complaints (45.0%), Depressed-Anxious (42.5%) and Suicide Ideation (30.0%) scales, with significantly higher rates than males on the Depressed-

Anxious, Somatic Complaints and Suicide Ideation scales. No significant differences in screening rates were reported between Indigenous and

non-Indigenous youth.

Conclusions: This study confirmed the high rates of mental health problems in adolescents within youth detention. Appropriate use of

screening tools improves our understanding and targets treatment of mental health problems in this cohort. We have reservations in recom-

mending the MAYSI-2 as a valid screening tool for Indigenous young people in youth detention and recommend the development of a more

appropriate screening tool.

Key words: adolescent; MAYSI-2; mental health; youth detention.

Adolescents held in youth detention rank among the mostdisadvantaged in the community1 and share a number ofvulnerabilities including chronic social, family or educationaladversity, and a history of traumatic life events.''"' It shouldcome as no surprise that a growing body of literature has dem-onstrated that these young people also suffer from high rates ofmental health problems, Compared to Australian communitysamples, where 19% of adolescents reported mental healthproblems/' a considerable majority of young people in youthdetention report some form of mental illness,'"'9 with over50% suffering from three or more mental disorders, excludingconduct disorder.1" Furthermore, up to 90% are reported touse substances at dangerous levels or have a substancedependency."

In Australia, Indigenous youth have historically been over-represented in juvenile detention centres in every state and

Correspondence: Associate Professor Stephen Stathis, University ofQueensland and Child and Family Therapy Unit, Royal Children's Hospital,Herston Road, Herston Qld 4029, Australia. Fax: +61 73636 5179; email:[email protected]

Accepted for publication 24 January 2007.

territory.1" However, despite high rates of mental health prob-lems and substance misuse within the adolescent forensic popu-lation, there is little data comparing the prevalence of mentalhealth or substance misuse disorders between Indigenous andnon-Indigenous young people in youth detention. This isdespite the Indigenous youth having been identified in NationalHealth policies as being at particular risk for mental illness."-14

Furthermore, there is currently no national database on theprevalence of mental disorders in the Indigenous population, asthe Australian Bureau of Statistics (ABS) does not report detailsof the mental health of Indigenous Australians. This was due toconcerns that past survey questions may not have been cultur-ally appropriate,15 though a subsequent ABS publication" sug-gested that high levels of mental health problems amongIndigenous Australians could be extrapolated from otherhealth-related data.17 While the available evidence is not com-prehensive, it does indicate that Indigenous youth in detentionare likely to suffer from higher rates of mental health issues thantheir non-Indigenous peers.

Few young people in detention lake advantage of availablehealth care in the community prior to admission."5 As a result,their mental health and substance misuse problems arefrequently undiagnosed. Numbers of young people passing

438 Journal of Paediatrics and Child Health 41 (2008) 438-443© 2008 The Authors

Journal compilation © 2008 Paediatrics and Child Health Division (Royal Australasian College of Physicians)

S Stathis ef al. Mental Health screening in youth detention

through detention centres are significant and the time availablefor a full psychological or drug use assessment is limited. Anappropriate screening tool is therefore attractive for cliniciansworking in these settings, as it should enable the majority ofyoung people with mental health problems to be identified andsubsequently offered treatment. Furthermore, validated screen-ing tools not only give a measured indicator for the level ofunmet, need, but also reduce the risk of under-diagnosingmental disorders in a setting where distress is to some degreeomnipresent and the consequential blunting of clinical sensitivi-ties is often a concern. However, despite these potential benefits,we are aware of no such measures routinely being used inAustralian youth detention settings or which have been stan-dardised for the Australian population.

The aims of this study were threefold. First, to provide a betterunderstanding of the mental health needs in an Australianadolescent forensic population. Second, to assess the usefulnessof the Massachusetts Youth Screening Instrument Version 2(MAYSI-2)" in providing a preliminary assessment of thoseneeds. Third, to explore the level of mental health problems inspecific vulnerable populations within detention, includingIndigenous youth. Given that females in detention have alsobeen identified as a priority group in National Mental HealthPolicies,"0 and are reported to suffer higher rates of behaviouralproblems and mental illness than males,21'22 it was hypothesisedthat they would screen higher than males for mental healthdisorders.

In America, the majority of states screen young people uponentry into youth detention.23 The MAYSI-2, a 52-item screen-ing tool, was developed in part to identify young people aged.12-17 years within the youth justice system at greatest riskfor serious mental, emotional or behavioural disorders. TheMAYSI-2 has been found a valid and reliable screening tool in theUnited States, with clinical 'cut-off scores having been normedin over 70 000 American young people in detention.2''24

The MAYSI-2 screens for 7 scales of mental health or behav-ioural problems. Although not directly correlated to specific asDiagnostic and Statistical Manual of Mental Disorders psychiat-ric diagnoses, these scales have good psychometric propertiesand correlate to the Child Behaviour Cheeklisl-Youth Self-Report.19 The 8-item Alcohol and Drug scale is intended toidentify youths who are at risk of substance misuse or depen-dence. A screening cut-off score of four positive responses out ofeight is used. The 9-item Angry-irritable scale (cut-oil: fivepositive responses) addresses explicit feelings of anger andvengefulncss, as well as a tendency toward tension, frustrationand irritability. The 9-item Depressed-Anxious scale (cut-off:three positive responses) assesses symptoms of depression andanxiety. A 6-item Somatic Complaints scale (cut-off: three posi-tive responses) screens for somatic-related complaints. The5-item Suicide Ideation scale (cut-off: two positive responses)assesses thoughts and intentions about self-harm, as well asdepressive symptoms that may present an increased risk forsuicide. A 5-item Thought Disturbance scale screens for percep-tual distortions that are frequently associated with psychoticdisorders, in addition, it screens for symptoms of derealisafionthat may be an early indicator for psychosis, but which alsooccurs in anxiety or dissociative states. The 4-item ThoughtDisturbance scale (cut-off: one positive response) is calculated

for males only because of its psychometric properties and factorstructure. Finally, a 5-item gender-specific Traumatic Experi-ence scale identifies young people who have been exposed tosignificant traumatic events. Unlike the other six scales thatscreen for mental health problems over the previous 'fewmonths', the Traumatic Experience scale screens for traumaticevents across the individual's life-span. It is gender-specific andunlike the other scales, specific cut-off scores have not beenpublished.19

Method

The study was carried out in a Queensland youth detentioncentre by the Mental Health Alcohol Tobacco and Other DrugsService (MHATODS). MHATODS is a dedicated multidisci-plinary dual diagnosis service providing mental health andsubstance assessment and treatment for young people aged10-17 years held in custody. With the exception of a very smallnumber of young people involuntarily treated under Queen-sland's Mental Health Act 2000, all attend on a voluntary basis.The history and nature of the service is detailed elsewhere.25

All young people admitted into the centre are reviewed formedical problems by resident nursing staff. Over a 6-monthperiod, all young people admitted into the detention centre wereautomatically referred to MHATODS for an assessment. AsMHATODS patients, all the young people referred were informedof the role of MHATODS, the voluntary nature of their involve-ment with the service and completion of the MAYSI-2, as well asthe relevant issues of confidentiality and consent. Young peopleread the questions themselves and circled 'yes' or 'no' whetherthe item had been true for them within the past few months.A fifth grade reading level is required; those that struggled hadthe questions read to them, MHATODS collected demographicdata, including indigenous status and gender, on all youngpeople referred. Young people readmitted into custody within a3-month period were referred to MHATODS but not asked tocomplete a further MAYSI-2. However, young people who hadbeen readmitted into detention afteran absence of over 3 monthswere asked to complete another MAYSI-2 in order to screen forchanges in their mental health or substance misuse status. Youngpeople who were subsequently screened as at risk for mentalproblems or otherwise assessed as suffering from mental healthor substance use issues were offered treatment.

Results

A total of 402 young people (298 male, 104 female; 212Indigenous, 190 non-Indigenous) were admitted into detentionand referred to MHATODS. Allied health staff working forMHATODS had a daily presence in the centre during theworking week, and a child and adolescent psychiatrist consultedtwice weekly. Nevertheless, because of the rapid turnoverthrough the centre, 170 young people (121 male, 49 female; 65Indigenous, 105 non-Indigenous) were released from detentionprior to assessment. There was no statistical difference betweenthe numbers of males and females referred but released prior toassessment. However, non-Indigenous adolescents were signifi-cantly more likely to be released prior to an assessment thantheir non-Indigenous peers (x2 = 24.9; P < 0.001).

Journal of Paediatrics and Child Health 44 (2008) 438-443© 2008 The AuthorsJournal compilation © 2008 Paediatrics and Child Health Division (Royal Australasian Coiiege of Physicians)

439

Mental Health screening in youth detention S Stathis et al.

^:'y;~>Any cut-off

Alcohol/Drug use f^-A «at*w.:< J. ..-, r** \ v-^,

Angry-Irritable i ^ " " ^ ^ — ^ ^ ^ - " - ^

Depressed-Anxious p ^ ^ ' B & ^ - ? - > - ' • '^-^—r- - J

Somatic Complaints y"' "^'^^ ""-ieM,£.:«•. ^ •<.'""'

Suicide Ideation

STJ^fBTI 06

0 10 20 30 40 50 60 70

Percentage

90 100

Fig. 1 Percentage of males (n = 124) andfemales (n - 40) scoring above screening cut-offon each scale, excluding Traumatic Experiences(to the nearest whole number).

Any cut-off ^ 6 ^ ^ -

Alcohol/Drug use

^ssm • >

Angry-Irritable S

Depressed-Anxious j-

Somatic Complaints

Suicide Ideation

Thought Disturbance (male only)

0 20 40 60

Percentage

80

n non-Indigenous

E3 indigenous

.—j

100

Fig. 2 Percentage of non-Indigenous (n = 68)and Indigenous (n = 96) young people scoringabove the screening cut-off on each scale,excluding Traumatic Experiences (to the nearestwhole number).

Of the remaining 232 referrals, 54 (44 males, 10 females; 39Indigenous, 15 non-Indigenous) refused an assessment. Therewas no significant difference between the numbers of males orfemales, or Indigenous and non-Indigenous young people whorefused to be seen. One young person became agitated and wasunable to complete the MAYSI-2. Thirteen young people werereadmitted into detention within 3 months of their last releaseand were not required to recomplcte the MAYSI-2. A total of164 young people (124 males, 40 females; 96 Indigenous, 68non-Indigenous) with a mean age of 14,9 years (±1.3 years)successfully completed the MAYSI-2; three of whom wereassessed twice over the study period.

High levels of mental health problems were reported, with75.0% of all males and 90.0% of all females (Fig. 1), and 81.2%of Indigenous and 75.0% of non-Indigenous young people(Fig. 2) scoring above the clinical cut-off on at least one of thescales, excluding Traumatic Experiences. Unfortunately, finalnumbers prevented multivariate comparisons between genderand race. Based on the five validated scales that males andfemales share in common, males screened highest for Alcoholand Drug Use (58.9%), Angry-Irritable (28.2%) and SomaticComplaints (28.2%). Females screened highest for Alcohol and

Drug Use (67.5%) and Somatic Complaints (45.0%), but inaddition had elevated rates on the Depressed-Anxious (42.5%)and Suicide Ideation (30.0%) scales (Fig. 1). Chi-squared analy-ses showed females screened for significantly higher mentalhealth problems than males across three scales (Depressed-Anxious, x i = 9.41; P<0.01: Somatic Complaints, / 2 = 3.89:P<0.05: and Suicide Ideation x2 = 6.24; P<0.05). No signifi-cant gender difference was found for the Alcohol and Drug Useor Angry-Irritable scales (Table 1), Large standard deviationsindicate a skewing of data to the left. Although rates remainedhigh, there was no significant difference between Indigenousand non-Indigenous youth across the five scales, with Indig-enous young people scoring lower on all scales exceptDepressed-Anxious (Fig. 2 and Table 2). The Thought Distur-bance scale was calculated for males only, with no significantdifference in positive screens reported between Indigenous(25.0%) and non-Indigenous males (32.1%) (Fig. 2).

As the Traumatic Experience scale is gender-specific, an accu-rate comparison between males and females was unable to bedetermined although an analysis was used to establish if therewere cultural differences in reported scores between males andfemales. Mean Traumatic Experience scores for non-Indigenous


Journal compilation © 2008 Paediatrics and Child Health Division (Royal Australasian College of Physicians)


Table 1 Mean scores and standard deviations on the Massachusetts Youth Screening Instrument Version 2 by gender

Females mean

(i: standard deviation)Cut-offscores

Males meant standard deviation)

Alcohol/Drug useAngry-Irritable**Depressed-Anxious*Somatic Complaints*Suicide Ideation

4 of 85 of 93 of 93 of 62 of 5

4,0 (2.4)3.2 (2.5)1.4 (1.8)1.7(1.8)0.5 (1.0)

4.00 (2.2!3.45 (2.5)2.65 (2.4)2.43 (1.9)1.15 (1.6)

*P < 0.05; **P< 0.01.

Table 2 Mean scores and standard deviations on the Massachusetts Youth Screening Instrument Version 2 by race

Cut-off scores Indigenous mean!~ standard deviation)

Non-Indigenous mean(± standard deviation)

Alcohol/Drug useAngry-IrritableDepressed-AnxiousSomatic ComplaintsSuicide IdeationThought Disturbance (male only)

4 of 85 of 93 of 93 of 62 of 51 of 4

3.9 (2.3)3.1 (2.4)1.7 (2.0)1.8(1.9)0.6(1.2)0.5 (0.9)

4,2 (2.4)3.5 (2.7)1,8(2.0!2.0 (1.8)0.8(1,2)0,6(1.0)

Table 3 Mean scores and standard deviations on the Massachusetts Youth Screening Instrument Version 2 by gender and race for Traumatic Experiences

*P < 0.0!. I, Indigenous; Nl, Non-Indigenous.

MalesFemales

Indigenousmean (— standard deviations

1.1 (1.8)2.5(1.8!

Non-Indigenousmean |± standard deviation)

1.9(1.4)2.5(2.1)

% age a !

!

57.6

82.1

Nl

83.9*

75.0

% age 2:3

1

17,650.0

Nl

30.453.6

males (1.9) was higher than Indigenous males (1.1), and non-Indigenous males were statistically more likely to report at leastone traumatic event than Indigenous males (83.9% vs. 57.6%);%' = 9.96; P < 0.01. Other studies have used a cut-off of three onthe Traumatic Experience scale as a measure for significanttrauma exposure.26 Using this cut-off, 30.4% of non-Indigenousmales and 17.6% of Indigenous males reached this threshold,although lower numbers meant thatthis difference now failed toreach statistical significance (Table 3). High Traumatic Experi-ence scores were reported in non-Indigenous (mean = 2.5)and Indigenous (mean = 2.5) females, with 75.0% of non-Indigenous and 82.1% of Indigenous females and screening atleast one traumatic event. Fifty per cent of non-Indigenous and53.6% of Indigenous females reported three or more events(Table 3). Unlike males, there was no significant difference inreported scores when a threshold of one or three was used.However, low numbers mean that these results should betreated with caution.

Discussion

This study confirmed the high rates of mental health problemsin the adolescent forensic population, with the vast majority ofyoung people screening for at least one mental health issue. Ofparticular concern were the high rates of alcohol and druguse, depression, anxiety and suicidal ideation, particularly infemales.

Although rnales are more likely to be admitted into youthdetention than females, there is good evidence to show that thisgap has narrowed over the last 10 years27 and may be associatedwith increasing violent behaviour and serious mental healthissues in these adolescent girls.28 This study clearly demon-strated that females in youth detention not only screen for highrates of menial health problems on the MAYSI-2, but do so atrates which are generally significantly higher than, males. Theseresults arc comparable to those reported in a large Americanstudy,2'1 where females screened for higher rates than males on

Journal of Paediatrics and Child Health 44 (2008) 438-443© 2008 The AuthorsJournal compilation © 2008 Paediatrics and Child Health Division (Royal Australasian College of Physicians)

441

Mental Health screening in youth detention S Stathis et al.

all but the Angry-Irritable scale, with significantly elevatedscores on the Depressed-Anxious, Somatic Complaints andSuicide Ideation scales, and is in keeping with other studieswhich have reported greater rales of mental illness for femalesin youth detention.8'2122 One possible explanation for suchgender differences could be that magistrates working within theyouth justice system are reluctant to remand females intocustody. Those remanded may therefore have higher rates ofbehavioural problems, psychological disturbance or delinquentbehaviours.

The high rates of reported traumatic events in this study areindicative of early vulnerability and the violence to which theseyoung people have been subjected during childhood. Femalesreported higher levels of trauma than males, A growing body ofliterature has shown that childhood trauma is associated witha range of mental health problems including mood disordersand suicidal plans2' and psychotic phenomena,""31 with femalesmore likely to be subject to abuse7 and oilier adverse lifeevents.12 It is not unreasonable to hypothesise thai the increasedprevalence of mental health problems reported by females wasassociated with their increased rates of previous trauma andabuse.

This study failed to demonstrate that Indigenous youth indetention screened for higher rates of mental health problemsthan non-Indigenous youth. This may reflect a true lack ofdifference in the prevalence of mental illness between Indig-enous and non-Indigenous youth within this forensic popula-tion, although a more likely explanation would be that theMAYSI-2 is not culturally appropriate for Indigenous Austra-lians. There is evidence that. Indigenous youth have difficultiesin self-reporting mental health problems, particularly with non-Indigenous clinicians."'4 Anecdotally, Indigenous young peoplefrequently appeared perplexed about the underlying concepts ofa number of questions asked, including their nature, structureand vocabulary. For instance, although Indigenous youth in thisdetention centre suffer from high rates of volatile substanceabuse (unpublished data), many failed to screen positive on theAlcohol and Drug use questions as they did not view volatilesubstances (i.e. glue, paint and petrol) as 'a drug'. Indigenousyoung people would frequently get confused when asked aboutsomatic complaints. They would often struggle to answer ques-tions concerning school attendance, given that high numbershad previously dropped out of schooling. A number of maleshad difficulty responding to the questions on thought disorder.However, on further assessment, those who screened over thecut-off on this scale frequently indicated that they had mis-understood the nature of the questions asked. Based on ourresults, we would therefore have reservations in recommendingthe MAYSI-2 as a valid screening tool for Indigenous youth,Nevertheless, it did highlight the alarming rates of mental healthissues in Indigenous young people in detention and indicatedthe need for the development of an appropriate screening tool.For instance, the Westerman Aboriginal Symptom Checklist-Youth" has already been validated in community samples,although further research is required to demonstrate whether itis suitable within a forensic cohort.

There are a number of limitations to this study. First, ourfindings should be confined to adolescents within the youthjustice system who have been admitted into detention, and it

is unknown if the results of this study may be extrapolated toyoung people within the system but not remanded into custody.Second, young people may have under-reported mental healthproblems because of the associated stigma, and our findingscould actually underestimate the true rate of mental healthissues in this population. Third, because of the rapid turnoverof young people through detention, over 40% referred toMHATODS were discharged from detention prior to review. Thecharacteristics and mental problems of this population areunknown. Although there was no gender difference, non-Indigenous young people were significantly more likely to bereleased prior to assessment, leaving a study population biastowards Indigenous youths. However, those young people whocompleted the MAYSI-2 were statistically representative of theavailable detention centre population. Finally, it is recom-mended that the MAYSI-2 be completed within 4 h of a youngperson entering detention.23 This was not possible because ofresource constraints particularly over the weekend, althoughmajority of adolescents admitted into detention on a weekdaywere assessed within 48 h. There is evidence that adolescentshave higher scores on screening the longer they remain indetention.26 However, it is uncertain if this reflected under-reporting of symptoms of those administered with the MAYSI-2within the recommended time, or whether later administrationleads to over-reporting of symptoms.

Despite the above limitations, these findings have contributedto our understanding of gender and cultural differences in theprevalence of mental health problems within the Australianyouth detention centres. Given the finding of high levels ofmental health problems and trauma in this population, it isevident that, there are advantages in providing mental healthassessments for all young people admitted to detention as amatter of course and this has consequently become standardpractice in MHATODS.

Although it is sometimes difficult to see beyond the prob-lematic conduct and serious offences committed by youngpeople in detention, this study demonstrated the very signifi-cant mental health needs of the adolescent forensic population.In Australia, paediatricians have been at the forefront of advo-cacy for health policies and initiatives that focus on the needsof young people. They have promoted awareness that success-ful programs in childhood and adolescence may lead to positiveoutcomes in multiple domains, ranging from improved healthcare and enhanced academic performance, to better social skillsand more successful relationships later in life. The psychologi-cal needs of adolescents within youth detention should causepaediatricians great concern because of the risk that theseyoung people pose to themselves through undiagnosed oruntreated mental illness and substance misuse, and to thecommunity through the cost of recidivism and lost opportuni-ties. However, as mental health problems are so widespread inthis population, the accurate identification of those youths inneed of mental health services is not in itself sufficient toimprove the effectiveness of treatment programs. With increas-ing interest in reducing juvenile recidivism al both state andfederal levels, the current challenge now is to develop appro-priate clinical interventions that address their levels of psychi-atric illness and significant abuse histories, preferably informedby evidence-based practice.


Journal compilation © 2008 Paediatrics and Chiid Health Division (Royal Australasian College of Physicians;


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