1. Improving the Health of Canadians: Mental Health, Delinquency and Criminal Activity Elizabeth Votta, PhD Canadian Institute for Health Information Presentation at Helping Canadian Kids Thrive! National Conference on Positive Youth Development Kamloops, British Columbia May 1-2, 2008

2. Presentation Outline 1.Overview of the Canadian Institute for Health Information (CIHI) and the Canadian Population Health Initiative (CPHI) 2.Overview of CPHI’s Work in the Area of Youth Health and Development Highlights from CPHI’s report, Improving the Health of Canadians: Mental Health, Delinquency and Criminal Activity

3. About the Canadian Institute for Health Information (CIHI) Health Information Research and Analysis Health Indicators Data Holdings Standards Laying a foundation for health information Capturing the portrait of health care Building new health knowledge Taking health information further Privacy, Confidentiality and Security Communication, Consultation and Dissemination

4. Canadian Population Health Initiative (CPHI) CPHI’s Mission: To foster a better understanding of factors that affect the health of individuals and communities; and To contribute to the development of policies that reduce inequities and improve the health and well- being of Canadians.

5. CPHI’s Strategic Functions Knowledge Generation Policy Synthesis Knowledge TransferKnowledge Exchange

6. CPHI Council Members (as of February 2008) Cordell Neudorf (Chair) David AllisonAndré Corriveau Nancy EdwardsBrent Friesen Judy GuernseyRichard Massé Deborah Schwartz Elinor Wilson Ian Potter (ex-officio) Gregory Taylor (ex-officio) Michael Wolfson (ex-officio)

7. Expert Advisory Group Members Gregory Taylor (Chair), Public Health Agency of Canada Carl Lakaski, Public Health Agency of Canada Kathy Langlois, First Nations and Inuit Health Branch Alain Lesage, Louis-H. Lafontaine Hospital Dora Nicinski, Atlantic Health Sciences Corporation (Region 2) Rémi Quirion, Canadian Institutes of Health Research Margaret Shim, Alberta Health and Wellness Phil Upshall, The Mood Disorders Society of Canada Cornelia Wieman, Indigenous Health Research Development Program and University of Toronto

8. CPHI’s Key Theme Areas: 2004-2007 Place and HealthHealthy Transitions to AdulthoodHealthy Weights

9. Improving the Health of Young Canadians First in the series of reports for 2005–2006 Canadian youth aged 12 to 19 years Explores links between adolescents’ social environment and their health Discusses themes from current research Reviews relevant programs and policies

10. Adolescent Health and Development Themes from the Research: 1.Cluster: Positive & negative behaviours ‘cluster’ together 2.Engaging youth: Participation in meaningful & structured activities 3.Resilience: Youth’s ability to successfully cope in adversity 4.Assets: Positive relationships, opportunities, values and self-perceptions correlated with healthy development

11. Youth Health and Assets in the Social Environment CPHI’s report, Improving the Health of Young Canadians, looked at the roles of family, schools, peers and communities in healthy adolescent development: Parental nurturance Parental monitoring School engagement Peer connectedness Community engagement

12. IHYC Report Findings: Summary Table Parental Nurturance Parental Monitoring School Engagement VolunteerismConnected to Peers High self- worth Exc. or VG Health Status Low Level of Anxiety Peers who commit crimes Alcohol Use Tobacco Use Marijuana Use Injuries - + + + + + + + + + + + - - -- - -- - - - - - - + +

13. Multiple Assets and Health Research (e.g. U.S. Search Institute) indicates that the more assets adolescents possess: The greater their likelihood of engaging in good health practices (e.g. wearing helmets when riding a bike, wearing seatbelts, higher levels of physical activity); and The less likely they are to engage in harmful health practices (e.g. tobacco/drug use, risky sexual activity)

14. Health Outcomes and Behaviours by Number of Positive Assets * * * * * * ** *** ** * * * * All pair-wise comparisons significantly different at p < 0.05. ** Significantly different from two or three assets and zero or one asset at p < 0.05. *** Significantly different from two or three assets and four or five assets at p < 0.05. Source: CPHI analysis of NLSCY (Cycle 4, 2000-2001), Statistics Canada.

15. Promoting Positive Youth Health Many programs across Canada for youth but few formally evaluated More outcome research needed including research that assesses health outcomes of youth-based policies and programs Three characteristics of programs/policies that are linked to healthy youth development:  Comprehensive interventions that address common factors associated with multiple behaviours  Approaches that support healthy youth development  Initiatives that engage youth

16. CPHI’s Key Themes 2007-2010 Promoting Healthy Weights Mental Health and Resilience Place and Health Reducing Gaps in Health

17. Improving the Health of Canadians Report Series on Mental Health Series of three reports on the theme of mental health and how mental health is linked to the determinants of health Two reports will focus on segments of the population often identified as ‘vulnerable’ Final report will focus on the construct of positive mental health ReportRelease Date Report #1: Mental Health and HomelessnessAugust 30, 2007 Report #2: Mental Health, Delinquency and Criminal Activity April 29, 2008 Report #3: Promoting Positive Mental Health (working title) February 2009 (exact date to be determined)

18. Improving the Health of Canadians: Mental Health, Delinquency and Criminal Activity Purpose of Report Examines the links between mental health, delinquency, criminal activity and their various determinants Released: April 29, 2008

19. Improving the Health of Canadians: Mental Health, Delinquency and Criminal Activity How the Report is Organized Section One Looks at what factors related to mental health within the individual, family, school/peer and community contexts are related to youth delinquency in either a protective or risk capacity Section Two Looks at people with a mental illness who were or are involved with the criminal justice system (that is, in a mental health bed with a criminal history or in a correctional facility with a mental illness)

20. Delinquency Among Canada’s Youth What Does the Data Tell Us?

21. Aggressive Behaviour: A score based on responses to the following six items: i.I get into many fights, ii.I react to accidents with anger, iii.I physically attack people, iv.I threaten people, v.I bully or am mean vi.I hit others my age. Often10% Some34% * None56% * Self-reported Aggressive Behaviour Among Youth Aged 12-15, 2004-2005 Source: CPHI Analysis of NLSCY (cycle 6, 2004-2005). Note: These rates are based only on the 86% of youth who responded. * Significantly different from “often” at p<0.05.

22. Property Delinquency: A score based on responses to the following 6 items: i.I destroy my own things ii.I steal at home iii.I destroy other people’s things iv.I tell lies or cheat v.I vandalize vi.I steal outside my home. Often7% Some44% * None50% * Self-reported Property Delinquency Among Youth Aged 12-15, 2004-2005 Source: CPHI Analysis of NLSCY (cycle 6, 2004-2005). Note: These rates are based only on the 86% of youth who responded. * Significantly different from “often” at p<0.05.

23. Self-reported Aggressive Behaviour Among Males and Females Aged 12-15, 2004-2005 Source: CPHI Analysis of NLSCY (cycle 6, 2004-2005). Note: Only among n = 3,768 responses (excludes non-response). * Significantly different from “females” at p<0.05.

24. Mental Health, Delinquency and Criminal Activity: Relationships at the Level of Individual, Family, School/Peer and Community

25. Mental Health, Delinquency and Criminal Activity: Individual Level INDIVIDUAL LEVEL Protective Factors High levels of optimism, life satisfaction and emotional capability Trustworthiness Sense of belonging Greater self-efficacy / High self-esteem Risk Factors Low self-worth Hyperactivity Depression Victim of bullying, assault, threats, theft

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

27. CPHI Analysis: Aggression and Individual-level Risk Factors Source: CPHI Analysis of NLSCY (cycle 6, 2004-2005) E: Coefficient of variation between 16.6% and 33.3%. Interpret with caution. * Significantly different than same level of aggression for “all youth” at p<0.05

28. Mental Health, Delinquency and Criminal Activity: Family Level FAMILY LEVEL Protective Factors Nurturing parenting style High level of parental monitoring Feeling loved and wanted Having at least one parent home during at least one of four times during the day High sense of family connectedness; doing activities together as a family Being able to discuss problems with parents Risk Factors Harsh or inconsistent parenting style Lack of parental supervision Having a parent who struggles with an addiction or a mental illness and/or had a criminal record

29. CPHI Analysis: Aggression and Parenting Style Source: CPHI Analysis of NLSCY (cycle 6, 2004-2005). * Significant difference between levels at p<0.05.

30. Mental Health, Delinquency and Criminal Activity: School and Peer Levels SCHOOL AND PEER LEVELS Protective Factors School environment in which youth feel involved Feeling connected with one’s peers Feeling teachers are fair Academic achievement Risk Factors Lack of school involvement Poor academic achievement Negative peer influences (older or delinquent friends, friends who committed or tolerated illegal acts) Bullying Truancy, suspensions

31. Mental Health Among Children & Youth: Students Who Do Not Feel Confident Source: PHAC, The Human Face of Mental Health and Mental Illness in Canada, 2006.

32. Mental Health Among Children & Youth: Students Who Feel Left Out or Lonely Source: PHAC, The Human Face of Mental Health and Mental Illness in Canada, 2006.

33. Mental Health Among Children & Youth: Students Who Feel They Do Not Belong Source: PHAC, The Human Face of Mental Health and Mental Illness in Canada, 2006.

34. CPHI Analysis: Aggression and School/Peer Risk Factors Source: CPHI Analysis of NLSCY (cycle 6, 2004-2005). * Significantly different than same level of aggression for “all youth” at p<0.05.

35. Mental Health, Delinquency and Criminal Activity: Community Level COMMUNITY LEVEL Protective Factors Feeling a positive bond to society Strong pro-social values Risk Factors High turnover of neighbourhood residents High rates of violent crimes Feelings of hopelessness High levels of marijuana availability High numbers of youth in trouble with the law Living in high-poverty neighbourhoods

36. CPHI Analysis: Protective Factors Among Youth who are Not Aggressive Just over one half (56%) of 3,768 responding youth reported no aggression. Compared to these youth, youth with identified protective factors were significantly more likely to report not being aggressive. Source: CPHI analysis of Statistics Canada’s, NLSCY (cycle 6, 2004-2005). Top 5 Protective Factors% of Youth Not Aggressive Emotional capability75 Able to manage stress73 Nurturing parents66 Likes school65 Adaptable65

37. CPHI Analysis: Risk Factors Among Youth who are Often Aggressive Source: CPHI analysis of Statistics Canada’s, NLSCY (cycle 6, 2004-2005). Top 5 Risk Factors% of Youth Often Aggressive Indirectly aggressive31 Hyperactivity27 Parental rejection26 Anxious25 Punitive parenting21 10% of responding youth reported often being aggressive Youth with identified risk factors were more likely to report often being aggressive compared to these youth.

38. CPHI Analyses: Conclusions The top five protective factors represent the presence of positive behaviours, such as: Emotional capability, stress management, parental nurturance, liking school and being easily adaptable As opposed to the absence of these protective factors, the top five risk factors for aggressive behaviour represent the presence of a negative behaviour, including: Indirect aggression, hyperactive, reporting parental rejection or punitive parents and being anxious Analyses highlight the value of both promoting protective factors and reducing risk factors as a means of addressing aggression in youth

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

40. Preventing Delinquency: Policies and Programs (1) There is a link between various skills-training programs within the family and school contexts with improved mental health outcomes and reduced delinquency among youth. Project Early Intervention The Banyan Community Services SNAP™ Under-12 Outreach Project Syracuse Family Development Research Project Seattle Social Development Project Montréal Longitudinal Experimental Study

41. Policies and Programs (2) Project Early Intervention (Ottawa) o Children aged 6 to 12 living in neighbourhoods at risk for delinquency o Life skills training with sports/recreation programs, counselling The Banyan Community Services SNAP™ Under-12 Outreach Project (Hamilton) o Boys aged 6 to 12 who previously committed offences o Self-control skills and child-management parenting techniques Outcomes: Reduced aggressive behaviour among children and improvements in social behaviours with self-control training

42. Policies and Programs (3) Syracuse Family Development Research Project (Syracuse) o 108 disadvantaged families o Individualized daycare services, parental training, in-home support Strong Families, Strong Children (Moncton) o Families with children aged 5 to 12 who displayed risk factors for crime and victimization o In-home support, family nurturing program, parent support group, social skills training, respite care Outcomes: Increased self-efficacy and reduced juvenile delinquency with family-skills training in early childhood

43. Policies and Programs (4) Seattle Social Development Project (Seattle) o Children from 18 schools in different neighbourhoods o Teacher/parent training, child social & emotional skills development o Improvements in school and work functioning, decreased involvement in criminal activities and fewer mental health problems among youth receiving a school-based intervention Bully Prevention Program (Norway) o 2,500 elementary and junior high school students o Different anti-bullying messages delivered by different people in different contexts o Decreases in bullying behaviour, being the victim of bullying, and in rates of fighting, vandalism, theft, and truancy. Improvements in positive social relationships and positive attitudes towards school

44. Policies and Programs (5) Montréal Longitudinal Experimental Study (Montreal) o Boys from families of low socioeconomic status o Social skills training for children, parenting skills training, teacher support/information o At 4-year follow-up, less delinquency, less aggression in school o At 15-year follow-up, no differences in terms of having a criminal record

45. Mental Health and the Criminal Justice System

46. Characteristics of Patients with Criminal Involvement Admitted to a Mental Health Bed New analyses of data from CIHI’s Ontario Mental Health Reporting System (OMHRS) database show that from April 2006 to March 2007: Of 30, 606 unique patients admitted to a mental health bed  9% had some current involvement with the justice system (forensic admissions)  28% reported a violent or non-violent criminal history Compared to non-forensic patients, forensic patients tended to be younger and a higher proportion were male, never married, and had lower education levels and less stable housing  Males were more than three times more likely to be forensic patients than females

47. Risk Factors at Admission Among Patients with a Criminal History Compared to patients without a criminal history, patients in mental health beds with a criminal history reported significantly more risk factors at admission: Reported rates of substance use were nearly two times higher Significantly greater victimization rate (38% versus 26%) Patients with a criminal history were more likely to have failed or dropped out of an education program (41% versus 25% of non- criminal history) For 44% of patients with a criminal history, the patient, family or friends indicated the relationship between the patient and immediate family was dysfunctional (versus 34% of others)

48. Risk Factors at Discharge Among Patients with a Criminal History Compared to patients without a criminal history, patients with a criminal history reported significantly more risk factors at discharge Criminal History No Criminal History Reported being adherent to medication less than 80% of the time in the month prior to admission 31%21% No support person who feels positive about their discharge 23%18% Initial living arrangement expected upon release: Private home Homeless Correctional facility Unknown 66% 4% 3% 77% 1% <1% 2% Source: CPHI analysis of Ontario Mental Health Reporting System (OMHRS), CIHI, 2006–2007. All comparisons are significantly different between groups at p<0.05.

49. Mental Illness Among Youth in Correctional Facilities Rates of some mental illnesses are higher among incarcerated youth than among youth in the general population, including: Depression Anxiety disorders Attention-deficit/hyperactivity disorder (ADHD) Substance abuse disorders Conduct disorder Post-traumatic stress disorder (PTSD) Schizophrenia

50. Mental Illness Among Adults in Correctional Facilities Most people with a mental illness or compromised mental health do not commit crimes However, information from various sources indicates there is a higher prevalence of certain types of mental illnesses among incarcerated adults compared to the general population, including: Psychotic disorders (schizophrenia) Major depressive disorder Anxiety disorders Antisocial personality disorder Substance abuse disorder

51. Mental Illness Among Aboriginal Peoples in Correctional Facilities Aboriginal Peoples are over-represented in the Canadian prison system In 2002, 17% of males and 26% of female inmates were Aboriginal 92% of Aboriginal federal offenders required help for a substance abuse problem; 96% reported a personal or emotional issue that needed attention Compared to non-Aboriginal inmates, Aboriginal inmates tend to have lower rates of completed education, greater unemployment histories, higher rates of unstable housing, higher rates of repeat offending and higher rates of violent offences

52. Mental Illness and Suicidal Behaviour in Correctional Facilities Among the general population, 12% of males and 19% of females (15 to 24 years) reported having suicidal thoughts at some point in their lifetime 2% of males and 6% of females reported a suicide attempt In 2002, the proportion of male federal inmates in Canada who reported a suicide attempt in the previous five years ranged from 10% in minimum security to 16% in maximum security Proportion among female inmates ranged from 11% to 41% Among incarcerated youth, published rates of suicidal thoughts range from 9% to 10% with a lifetime prevalence of 34% A British Columbia study found that 21% of incarcerated youth thought about killing themselves in the past year; 13% reported a past attempt

53. Programs for People Involved with the Criminal Justice System Diversion Programs Aim to intervene during the various points at which persons with a mental illness may come into contact with the criminal justice system Participants in mental health diversion programs spend less time in jail and have more involvement with mental health professionals and community mental health services than individuals not involved in such programs

54. Programs in Correctional Facilities Many jurisdictions offer mental health-related programming for offenders in institutional settings, including substance abuse treatment; violence prevention; and stress and anger management Preliminary evaluations speak to the effectiveness of violence prevention and anger management programs offered in correctional facilities Little is known about the long-term impacts on mental health– related outcomes or the accessibility of programs to offenders, particularly among those with mental health issues

55. Programs in Community Settings Many jurisdictions offer mental health-related programming for offenders in supervised community settings. Successful community-based programs share the following features: They are intense, highly structured and contain multiple components targeting specific problems; Treating clinicians assume multiple roles, including treating patient’s mental disorder, preventing violence and crime, and taking responsibility for patient’s compliance with the program; Treating clinicians have the authority to re-hospitalize patients if they are judged to be at risk, to be committing other crimes, or to be in need of acute psychiatric symptom treatment; and Treating clinicians have the option to obtain court orders in order to ensure compliance with the treatment program.

56. Conclusions

57. There is value in providing appropriate services and programs in order to prevent criminal activity. Within the individual, family, school/peer and community contexts, various factors may protect against or increase one’s risk for delinquency. Research suggests that no single program that targets only one risk or protective factor would be as effective as programming that targets the multiple factors associated with mental health, delinquency and criminal activity. There is value in providing offenders who have a mental illness with appropriate services and programs within correctional facilities and in the community.

58. CPHI Mental Health Current and Planned Reports and Activities

59. Complementary Products Workshops that reflect content of given mental health report Collection of Papers: “What Makes a Community Mentally Healthy?” Mental Health, Delinquency and Criminal Activity— Supporting Documents:  Literature search methodology  Data and analysis methodology  Policy scanning methodology  Summary report  PowerPoint presentation

60. It’s Your Turn cphi@cihi.ca www.cihi.ca/cphi