More youths are processed in adult criminal court than ever before. All 50 states and the District of Columbia have legal mechanisms to try juveniles as adults in criminal court (1,2,3). Historically, most states have transferred juveniles to adult criminal court primarily through judicial waiver. That is, juvenile court judges made decisions on a case-by-case basis, considering the characteristics of the charge and of the youth (1,4,5). An increasing number of juveniles are now transferred to adult criminal court by using automatic transfers (29 states) and prosecutorial direct file (15 states) (1). Automatic transfers exclude juveniles from the jurisdiction of the juvenile court solely on the basis of the type of offense, criminal history, and age of the youths; judges are not involved in this form of transfer. Prosecutorial direct-file mechanisms allow prosecutors to determine when to file certain juvenile cases directly in criminal court.

The increased availability of legal mechanisms to process juveniles in adult criminal court is largely responsible for the 366% increase between 1983 and 1998 in the number of juveniles held in adult jails (6). As of 2004, about 7% of the approximately two million arrests of youths eligible for processing in the juvenile justice system were cases in which the youth was transferred directly to adult criminal court (7). Given the substantial numbers of youths transferred to adult criminal court on an annual basis, accurate epidemiologic data on the prevalence of psychiatric disorders in this population are important. Youths with serious psychiatric disorders who are processed in adult criminal court have the right to receive needed treatment for several mental disorders (6).

Recent studies indicate that a substantial proportion of juvenile detainees need mental health services (8); between one-half and two-thirds of juvenile detainees have one or more psychiatric disorders (9,10). Yet, to our knowledge, no study has examined the prevalence of psychiatric disorders specifically among youths transferred to adult criminal court. Data on the prevalence of psychiatric disorders among youths processed in adult criminal court (referred to in this article as transferred youths) are needed for three reasons.

First, transferred youths are disproportionately from underserved sociodemographic groups. Numerous studies indicate that transferred youths are disproportionately male and from racial-ethnic minority groups (4,6,11,12,13,14,15,16). Although disproportionate confinement of members of racial-ethnic minority groups is found at all levels of the juvenile justice system, it is even greater among youths transferred to adult criminal court. One study in California found that youths from racial-ethnic minority groups who were arrested for a violent crime were 3.1 times more likely to be transferred and convicted than non-Hispanic white youths arrested for a violent crime (17). Males and youths from racial-ethnic minority groups were found to be significantly less likely than females and non-Hispanic white youths to receive needed mental health treatment after they are detained (18). Little, however, is known about racial-ethnic disparities in mental health needs among youths transferred to adult criminal court.

Second, youths transferred to adult criminal court typically wait substantially longer for their case to be adjudicated (that is, a finding of guilt or innocence) than their peers in the juvenile system (19,20,21). They are also less likely than adults to be released before adjudication (22). Because transferred youths are incarcerated for longer periods than youths processed in juvenile court, they may be at greater risk of developing psychiatric problems than those held in detention for shorter periods. For example, the conditions associated with extended detention, such as separation from loved ones, crowding, and solitary confinement, may increase the risk of suicidal behavior (23,24,25,26).

Finally, findings from an experimental study suggest that jurors may be biased against a youth being tried in an adult court, leading to a greater likelihood of a finding of guilt, higher confidence in the defendant's guilt, and a lower standard of proof for guilt (27). Indeed, youths processed in adult criminal court are more likely to be convicted and to receive more stringent sentences than those processed in juvenile court (20,22,28,29). Transferred youths are also more likely to receive more severe punishments than young adults charged with similar crimes in adult criminal court (30). Nearly 60% of all transferred youths charged with violent offenses are adjudicated to prison, compared with 26% of similarly charged adults (22). Approximately 5,400 convicted youths are housed in adult prison facilities (6), where they may not receive age-appropriate interventions (31). Before we can develop age-appropriate interventions and plan for their implementation in the adult correctional system, we need to know which psychiatric disorders are most prevalent.

Despite the importance of this issue, we could find only one study that examined mental health problems among youths processed in adult court (32). The study, which was based on one clinician's coding of 50 of his case records, investigated only posttraumatic stress disorder (PTSD) and learning disorders.

To our knowledge, our investigation is the first large-scale study of psychiatric disorders among youths transferred to adult criminal court. Using data from the Northwestern Juvenile Project (9), we compared youths processed in adult criminal court with youths processed in juvenile court. Specifically, we examined the following questions. Do the demographic characteristics of youths processed in juvenile court differ from those of youths processed in adult court? Are there differences in the psychiatric needs of youths processed in juvenile court and those processed in adult criminal court? Among youths processed in adult criminal court, are there differences in the psychiatric needs among those sentenced to prison and those who received less severe sentences?

Participants

Participants included 1,829 youths, ten to 18 years of age, who were randomly sampled from intake into the Cook County Juvenile Temporary Detention Center (CCJTDC) in Chicago from November 1995 through June 1998. The CCJTDC receives approximately 8,500 annual admissions (33) and is used solely for pretrial detention and for offenders sentenced for less than 30 days. All detainees younger than 17 years are held at the CCJTDC, including youths processed in adult criminal court. Youths up to 21 years of age may be detained in the CCJTDC if they are still being prosecuted for an arrest that occurred when they were younger than 17 years. Like juvenile detainees nationwide, approximately 90% of the CCJTDC detainees are male and most are from racial-ethnic minority group (77.9% African American, 5.6% non-Hispanic white, 16.0% Hispanic, and .5% other racial or ethnic group). The age and offense distributions of the CCJTDC detainees are also similar to those of detained juveniles nationwide (34).

Transfer to adult criminal court in Illinois

In Illinois the minimum age at which a juvenile can be transferred to adult criminal court is 13 years. The juvenile court has jurisdiction over all youths 16 years or younger, unless they have been transferred to adult criminal court. At the time the data were collected, an Illinois statute specified six felony offenses for which youths were automatically transferred to adult criminal court for processing. Four of these offenses (first-degree murder, aggravated criminal sexual assault, armed robbery committed with a firearm, or aggravated vehicular hijacking committed with a firearm) are violent offenses; the other two offenses (unlawful use of a weapon on or within 1,000 feet of school property and delivery of a controlled substance on or within 1,000 feet of school property or public housing property) are not.

Sampling and interview procedures

Youths were eligible to participate, regardless of psychiatric morbidity, drug or alcohol intoxication, or fitness to stand trial. Project staff explained the project to participants in their units and assured them that anything they told us (except for any indication of acute suicidal or homicidal risk) would be confidential. Project staff informed participants that all information is protected by a Federal Certificate of Confidentiality and Title 28 Code of Federal Regulations, Part 22. Participants signed an assent form or consent form, depending on their age. The Northwestern Institutional Review Board, the Centers for Disease Control and Prevention Institutional Review Board, and the U.S. Office of Protection From Research Risks (now the Office for Human Research Protections) waived parental consent, consistent with federal regulations. We nevertheless tried to contact parents; however, despite repeated attempts, none could be found for 44% of the participants. In lieu of parental consent, youths' assent was overseen by a participant advocate who represented the interests of the participants.

Participants were interviewed for two to three hours in a private area, almost always within two days of intake. Female participants were always interviewed by female interviewers. Interviewers were trained for at least one month; most had a master's degree in psychology or an associated field and had experience interviewing high-risk youths. One-third of the interviewers were fluent in Spanish. We maintained consistency throughout the study by monitoring scripted interviews with mock participants. Additional information on our methods can be found in a previous publication from this study (9).

Measures

To determine diagnoses we used English and Spanish versions of the Diagnostic Interview Schedule for Children version 2.3 (DISC-2.3) (35), which was the most recent version at the time of the study. The DISC-2.3 assesses DSM-III-R disorders in the past six months. We included the following disorders: affective (major depression, dysthymia, mania, and hypomania), anxiety (generalized anxiety disorder, separation anxiety disorder, obsessive-compulsive disorder, overanxious disorder, and panic disorder), psychosis, disruptive behavior (conduct disorder, attention-deficit hyperactivity disorder [ADHD], and oppositional defiant disorder), and substance use disorders (alcohol, marijuana, and drugs other than marijuana). Details of the special procedures associated with the determination of psychosis and ADHD have been reported previously (9).

Data collection for PTSD began 13 months after the study began because PTSD was not included in the DISC-2.3. PTSD was measured with the DISC-4.0, which provided 12-month rates using DSM-IV criteria for PTSD. Data on PTSD diagnoses were examined by using a subsample of 898 participants. The subsample was composed of 532 males (59%) and 366 females (41%). It included 490 African-American youths (55%), 154 non-Hispanic white youths (17%), 252 Hispanic youths (28%), and two youths of other race-ethnicity groups (<1%).

Data on arrest charges were obtained from intake records at the CCJTDC.

Sample stratification

The sample was stratified by gender, race-ethnicity (African American, non-Hispanic white, or Hispanic), age (ten to 13 years old or 14 years and older), and legal status (processed in juvenile or adult criminal court). Stratification by legal status was conducted only for males; not enough females were transferred to adult criminal court to make stratification feasible. Within each stratum, we used a random-numbers table to select names from the CCJTDC intake log. Some demographic strata (females, non-Hispanic whites, and ten- to 13-year-olds) were oversampled to obtain adequate numbers of participants in key subgroups. The final sampling fractions ranged from .018 to .689. (Additional information on the sample is available from the authors.) Because certain strata were oversampled, all statistics were weighted to reflect CCJTDC's demographic characteristics. The overall rate of refusal to participate was 4%; within the stratum of youths transferred to the adult criminal court, the refusal rate was 7%, largely because their lawyers advised that they not participate.

Statistical analyses

Unless otherwise noted, all descriptive statistics and model parameters were weighted by using sample weights derived from CCJTDC's demographic characteristics and the sampling fractions for each stratum. Taylor series linearization was used to estimate standard errors (36,37). Logistic regression, which estimates odds ratios (ORs), was used to assess differences in prevalence rates. Poisson regression, which estimates rate ratios, was used to assess differences for count data. Because we observed significant differences in transfer status by gender, race-ethnicity, and age, and these demographic factors have been shown to be associated with psychiatric disorders (9), we adjusted all analyses by gender, race-ethnicity, and age.

We restricted the final sample to participants 13 years and older (N=1,715) because juveniles younger than 13 are not eligible for processing in adult criminal court in Illinois. The PTSD subsample consisted of 840 participants who were 13 years and older. The final sample of youths processed in the adult criminal court (N=275) included 21 females and 254 males, 199 African Americans, 69 Hispanics, and seven non-Hispanic whites. The sample of youths processed in the juvenile court (N=1,440) included 616 females and 824 males, 727 African Americans, 429 Hispanics, 280 non-Hispanic whites, and four participants who self-identified as an "other" race or ethnicity. The unweighted mean±SD age was 15.7±.5 for youths processed in adult criminal court and 15.0±1.2 for youths processed in juvenile court.

Among the 275 youths processed in adult criminal court, 117 (43%) were charged with a felony-level violent crime, 213 (78%) were found guilty, and 139 (51%) were sentenced to prison. Among the 1,440 youths processed in the juvenile court, 281 (20%) were charged with a felony-level violent crime, 945 (65%) were "adjudicated delinquent" (the juvenile justice equivalent to being found guilty), and eight (1%) were sentenced to prison. Compared with youths processed in juvenile court, significantly more youths processed in adult criminal court were charged with a felony-level violent crime (OR=3.7, 95% confidence interval [CI]=2.5—5.6, p<.001), found guilty (OR=1.8, CI=1.2—2.7, p<.01), and sentenced to prison (OR=170.6, CI = 44.3—656.6, p<.001).

Table 1 presents the unweighted demographic characteristics of the sample and the weighted proportions of juveniles processed in adult criminal court compared with juvenile court by gender, racial-ethnic subgroup, and specific age group. As shown in Table 1, males, youths from racial-ethnic minority groups, and older youths had greater odds than females, non-Hispanic whites, and younger youths, respectively, of being transferred to the adult court. Furthermore, African-American youths had greater odds of being transferred than Hispanic youths. We examined whether the results changed when we controlled for who received a charge for a felony-level violent crime. The results did not change; males, youths from racial-ethnic minority groups, and older youths still had significantly greater odds of transfer to adult court than females, non-Hispanic whites, and younger youths, respectively.

We next compared the prevalence of specific psychiatric disorders (Table 2) and comorbid psychiatric disorders (Table 3) among youths processed in adult criminal court and those processed in juvenile court. No significant differences in the prevalence of specific disorders were found between the two groups; both had high rates of disorders. As shown in Table 3, no differences were found for any combination of comorbid psychiatric disorders. Furthermore, no differences between youths processed in adult court and youths processed in juvenile court were found in the number of specific disorders (2.15±.15 compared with 2.01±.11, rate ratio [RR]=1.09, CI= .90—1.31, p=.40) or the number of types of psychiatric disorders (1.40± .09 compared with 1.35±.06, RR= 1.05, CI=.89—1.23, p=.59).

We next examined data for only the 275 youths processed in adult criminal court to compare prevalence rates of psychiatric disorders among those who did and did not receive a prison sentence. Table 4 shows the prevalence rates of specific psychiatric disorders. Transferred youths who received a prison sentence had significantly greater odds of any disorder, any disorder except conduct disorder, any disruptive behavior disorder, oppositional defiant disorder, conduct disorder, any substance use disorder, alcohol use disorder, marijuana use disorder, and comorbid alcohol and drug use disorders.

Table 5 shows the prevalence rates of comorbid disorders among transferred youths by prison status (sentenced to prison or not). Transferred youths who received a prison sentence had significantly greater odds of nearly all combinations of comorbid disorders. Compared with transferred youths who did not receive a prison sentence, those who received a sentence had significantly greater odds of having two or more, three or more, and all four types of disorders. Finally, transferred youths who received a prison sentence had significantly greater numbers of specific disorders than those who did not receive a prison sentence (2.64±.23 compared with 1.66±0.20, RR=1.60, CI=1.19—2.14, p<.01) as well as significantly more types of disorder (1.68±.13 compared with 1.11±.11, RR=1.51, CI=1.18—1.93, p<.01).

Our findings indicate that the prevalence rates of specific and comorbid psychiatric disorders are as high or higher for youths processed in adult criminal court as for youths processed in juvenile court. These findings are consistent with the clinical data reported by Beyer (32), who found no differences on a clinical assessment between youths processed in adult criminal court and in juvenile court. To our knowledge, the study reported here provides the first evidence that many transferred youths, like their peers processed in juvenile court, have substantial need for psychiatric and substance abuse services.

These findings also suggest that transferred youths may have a greater need for psychiatric services than detained adults. Previous research indicates that less than 35% of detained adult males have a psychiatric disorder (excluding antisocial personality disorder) (38); in contrast, 64% of transferred youths have a psychiatric disorder, even when conduct disorder is excluded. This study found that the six-month prevalence rate of major depression for transferred youths (16%) was three times greater than the lifetime rate among adult male detainees (5%) (38).

Our study replicated previous findings that youths processed in adult criminal court are disproportionately male, African American, Hispanic, and older. Although these findings underscore the importance of addressing disproportionate confinement of individuals from minority groups (39), the findings also have implications for psychiatric services. The sociodemographic factors associated with greater odds of being processed in adult criminal court are the same factors associated with lower odds of receiving psychiatric services, regardless of need (18). This finding suggests an urgent situation in which the largest numbers of transferred youths in need of psychiatric services are also the least likely to receive them.

We also found that the odds of having a psychiatric disorder were greater among transferred youths sentenced to prison than those who received less severe sentences. The specific disorders associated with increased odds for a prison sentence were, not surprisingly, disruptive behavior and substance use disorders. Higher rates of disruptive behavior and substance use disorders may reasonably be expected among youths with greater antisocial traits, assuming that a sentence to prison is a proxy for greater antisociality. In other words, disruptive behavior and substance use disorders may reflect underlying antisocial traits. A parallel result has been found among adult male prisoners, of whom approximately half meet criteria for antisocial personality disorder (40).

The higher prevalence of comorbid disorders found among prison-bound youths, however, is not as easily explained by underlying antisocial traits. On average, youths transferred to adult criminal court and sentenced to prison had more than one psychiatric disorder, and 15% had all four major types of psychiatric disorders. Furthermore, the types of comorbid disorders were not limited to behavioral or substance use disorders; receiving a prison sentence was associated with greater odds of having comorbid affective and anxiety disorders. These findings suggest that transferred youths sentenced to prison not only have greater needs for behavioral rehabilitation to address disruptive behavior and substance use disorders than transferred youths receiving less severe sentences, but they also have greater needs for psychiatric treatment of major affective and anxiety disorders.

Limitations

This study has several limitations. Because our findings are drawn from a single site, they may pertain only to detention centers with a similar demographic composition and legal mechanisms for transfer to adult criminal court. For example, the generalizability of these findings may be limited to states that limit jurisdiction of the juvenile court to youths 17 and younger; most states extend jurisdiction of the juvenile court up to age 18. Differences in prevalence of disorder by transfer status may vary if diagnoses are based on DSM-IV instead of DSM-III-R. Because it was not feasible to interview caretakers (few would have been available), our diagnostic data are also limited by the reliability and validity of youths' self-report. This may result in underreporting of some disorders, such as disruptive behavior disorders. Despite oversampling within specific strata, the sample size for specific sociodemographic groups, such as non-Hispanic white females, may be too small to conduct reliable comparisons. Finally, transfer processes may have changed since these data were collected; the findings may have less applicability to areas with different mechanisms for transfer.

Future research

On the basis of findings from this study, we suggest the following directions for future research.

Studies of long-term functioning and outcome. Although several studies have examined recidivism among transferred youths (21,29,41,42,43), little is known about the long-term effects of being processed in adult criminal court on broader indices of functioning. Findings from this study suggest that youths processed in adult criminal court may experience worse long-term psychiatric outcomes than youths processed in juvenile court; however, few empirical studies are available. The longer preadjudication detention and stressors associated with processing in adult criminal court may increase the risk of psychiatric disorders and other adverse developmental, social, and functional consequences (44,45,46,47). Furthermore, previous studies have found that few youths receive needed psychiatric services before adjudication (18), and transferred youths have a low likelihood of receiving services after adjudication (48). Data on the long-term psychiatric and overall functioning of transferred youths are especially needed for those who are eventually released into the community, who represent the majority of transferred youths.

Studies of competency to stand trial. Future studies should investigate the influence of psychiatric disorders on competency to stand trial among youths transferred to adult criminal court. Some states are beginning to recognize cognitive and developmental immaturity as a basis for incompetence, similar to mental illness and mental retardation (49). Although the available research indicates that adolescents as young as 16 have, on average, abilities for judicial competency that are similar to those of adults (47,49), research is needed to understand how psychiatric disorders interact with developmental stage to influence youths' ability to participate in adult legal proceedings.

Implications for public policy

The findings of this study have several implications for public policy.

First, psychiatric services within correctional systems should address the unique characteristics of transferred youths. The correctional system is not prepared to identify and treat transferred youths with psychiatric disorders (31). Assessment and treatment approaches developed for use with adults cannot be applied automatically to transferred youths (31). Furthermore, because we know little about the effectiveness of treatments delivered to youths in correctional facilities (50), we cannot assume that assessment and treatment approaches developed for youths in the general population will be effective with transferred youths (31). Correctional psychiatric systems must use developmentally, culturally, and contextually appropriate assessment and treatment approaches (44). Rehabilitation of transferred youths is likely to be even more challenging if psychiatric disorders are not appropriately identified and treated.

Second, current legal mechanisms for transfer to adult criminal court should be reconsidered. Public health and criminal justice professionals have questioned the effectiveness of the transfer process in protecting the public (44). Available evidence indicates that transferred youths reoffend more quickly and are more likely to engage in violent crimes after release than youths processed in the juvenile justice system (21,29,41,42,43), calling into question whether current transfer mechanisms improve public safety. The substantial need for psychiatric services for transferred youths raises additional concerns with the transfer process. Psychiatric disorders may be important mitigating factors in determining transfer to adult criminal court. Although public opinion generally supports the inclusion of mitigating factors in transfer decisions (51), automatic transfers preclude their consideration.

Third, clinicians should help to determine when psychiatric disorders play a mitigating role in transfer decisions. Judicial processing, particularly the decision to process youths as adults or juveniles, represents a critical intervention point for youths (52). Clinicians can advise the court about which youths may benefit from alternative sentencing options and about which youths may be less likely to benefit from rehabilitation (53). If alternative sentencing options are made available, prison sentences may become less common (54). Clinicians and researchers must continue to refine juvenile assessment technology to assist the court with weighing mitigating psychiatric factors in transfer decisions (44,55).

Fourth, the field must address the racial-ethnic disproportionality associated with the transfer process. According to our findings and national statistics, more than 60% of transferred youths with psychiatric problems are from racial-ethnic minority groups (34); these youths are most likely to be underserved in detention and in the community (18). The disproportionate transfer of African-American youths to adult court is of particular concern. Although no national statistics are available, we found that 84% of youths processed in adult criminal court were African Americans but only 26% of Cook County's population is African American. Some states have already begun to address the influence of transfer processing on racial-ethnic disproportionality. Illinois recently repealed two laws established in 1989 that required automatic transfer of youths older than 14 years to adult criminal court if they were charged with selling drugs within 1,000 feet of a designated "safe zone," typically schools and public housing. Because of the concentration of both schools and public housing in urban areas where racial-ethnic minority groups make up a large proportion of the population, 99% of the youths transferred to adult criminal court for a drug crime were from racial-ethnic minority groups (56).

Transfer of youths to adult criminal court should be reserved for the most serious, chronic, and violent offenders (44). Clinicians can help to ensure this outcome by determining when and how mitigating psychiatric factors should be considered and which transferred youths may respond best to alternative sentencing. Correctional systems must be prepared to provide psychiatric services to youths transferred to adult criminal court and especially to youths sentenced to prison. Community health systems must also be prepared to provide services for these youths when they are released into the community. Psychiatric service providers need to consider the disproportionate representation of individuals from racial-ethnic minority groups in the transfer process when developing and implementing services.

This work was supported by grants R01-MH-54197 and R01-MH-59463 from the Division of Services and Intervention Research and the Center for Mental Health Research on AIDS of the National Institute of Mental Health and grants 1999-JE-FX-1001 and 2005-JL-FX-0288 from the Office of Juvenile Justice and Delinquency Prevention, U.S. Department of Justice. Major funding was also provided by the National Institute on Drug Abuse and National Institute on Alcohol Abuse and Alcoholism of the National Institutes of Health (NIH); the Center for Mental Health Services, Center for Substance Abuse Prevention, and Center for Substance Abuse Treatment of the Substance Abuse and Mental Health Services Administration; the National Center on Injury Prevention and Control and National Center for HIV, STD and TB Prevention of the Centers for Disease Control and Prevention; the NIH Office of Research on Women's Health; the NIH Center on Minority Health and Health Disparities; the U.S. Department of Housing and Urban Development; the NIH Office on Rare Diseases; the U.S. Department of Labor; the William T. Grant Foundation; and the Robert Wood Johnson Foundation. Additional funds were provided by the John D. and Catherine T. MacArthur Foundation, the Open Society Institute, and the Chicago Community Trust. The authors thank these agencies for their collaborative spirit and steadfast support. Many more people than the authors contributed to this project. This study could not have been accomplished without the advice of Ann Hohmann, Ph.D., Kimberly Hoagwood, Ph.D., Heather Ringeisen, Ph.D., Grayson Norquist, M.D., and Delores Parron, Ph.D. Celia Fisher, Ph.D., guided the human participant procedures. Leah Welty, Ph.D., provided assistance on analytic issues. The authors also thank Eugene Griffin, Ph.D., for review of an earlier version of this article.

The authors report no competing interests.