Prevalence of psychiatric disorders among juvenile offenders in Malaysian prisons and association with socio-demographic and personal factors S.A. Aida, H.H. Aili, K.S. Manveen, W.I.W. Salwina, K.P. Subash, C.G. Ng and A.Z.M. Muhsin

Dr S.A. Aida is a Psychiatrist and a Senior Lecturer, Professor C.G. Ng is a Consultant Psychiatrist and Dr A.Z.M. Muhsin is a Consultant Psychiatrist, all are based at Department of Psychological Medicine, Faculty of Medicine, University Malaya, Kuala Lumpur, Malaysia. Dr H.H. Aili is a Consultant Psychiatrist, Dr K.S. Manveen is a Senior Lecturer and a Child & Adolescent Psychiatrist and Professor K.P. Subash is a Psychiatrist, all are based at Psychiatry Adolescent and Child (PAC) Unit, Department of Psychological Medicine, University Malaya/Faculty of Medicine, Kuala Lumpur, Malaysia. Professor W.I.W. Salwina is a Child & Adolescent Psychiatrist, based at Department of Psychiatry, Faculty of Medicine, University Kebangsaan Malaysia, Kuala Lumpur, Malaysia.

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Abstract Purpose – The number of juvenile offenders admitted to Malaysian prisons is alarming. The purpose of this paper is to determine the presence of any psychiatric disorders and their association with personal characteristics of juvenile detainees in prisons across Peninsular Malaysia. Design/methodology/approach – Detainees were recruited from five different prisons in Peninsular Malaysia and interviewed by a psychiatrist using the MINI-Kid and FACES-IV, relevant personal and family information was also collected. Findings – A total of 105 detainees participated in the study. Almost all of the offenders (93.3 per cent) had at least one diagnosable psychiatric disorder and more than half (76.2 per cent) had two or more psychiatric diagnoses. Conduct disorder (CD) was the commonest disorder (59.0 per cent), while substance use disorders (SUD) was the commonest co-morbidity. A significant correlation was found between presence of CD, education level and SUD. Almost all (61/62, 98.4 per cent) of the detainees with CD, had not completed schooling (OR 8.03, 95 per cent CI 1.01-71.35), and detainees with this disorder were more likely to use substances than detainees without CD (OR 4.35, 95 per cent CI 1.90-9.99). Detainees with any psychiatric diagnosis were more likely to have four or more siblings in their families (OR 5.5, 95 per cent CI 1.1-26.9). Originality/value – There is a high prevalence of psychiatric disorders among juvenile offenders in Malaysian prisons, detection and intervention would be important. Keywords Malaysia, Offenders, Co-morbidity, Psychiatric disorders, Juvenile, Detainees Paper type Research paper

Introduction Over the past few years, Malaysia has seen an increase in the number of offences committed by juveniles (Hussin, 2005; Department of Social Welfare, 2006). The types of crime reported include theft, substance misuse, rape and even murder. Globally, the prevalence of mental illness among juveniles in the justice system is estimated to be three to four times higher than in the general population (Otto et al., 1992; Cocozza and Skowyra, 2000; McReynolds et al., 2008; Odgers et al., 2005; Wasserman et al., 2010). The presence of any mental disorder in these detained youths is a major concern as it is associated with elevated risk of aggression (Abram et al., 2003; Steiner et al., 2011) and recidivism (McReynolds et al., 2010). The prevalence of mental illness among juveniles has been estimated to be as high as 50 per cent (Brink, 2005; Teplin et al., 2002). Presence of psychiatric conditions have been associated with early and persistent offending behaviour (Vreugdenhil et al., 2004; Young et al., 2011) and these estimates includes for female offenders (Teplin et al., 2002; McReynolds et al., 2008). The most prevalent

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DOI 10.1108/IJPH-06-2013-0029

disorders are disruptive behavioural disorders (Wasserman et al., 2010), substance use disorder (SUD) and Attention Deficit Hyperactivity Disorder (ADHD) (Teplin et al., 2002; Brink, 2005). The family situation has been implicated as a major cause of offences in this population. Many juveniles who enter the justice system have multiple personal and family problems (Wasserman and Seracini, 2001; Dembo and Schmeidler, 2003), including coming from homes that are characterized by marital discord, poor family communication, unaffectionate parents, presence of high stress level and tension, and with lacking of parental cohesiveness and solidarity (Monahan, 1957; Ward et al., 2000; Starzyk and Marshall, 2003). The aims of this study were to determine the prevalence of psychiatric morbidity among juvenile detainees in Peninsular Malaysia and to examine any association with socio-demographic and personal factors to improve understanding of mental health problems among these juveniles.

Methods We conducted a cross-sectional study with universal and convenience sampling to recruit a non-duplicated sample of subjects. There are 30 prisons in Malaysia, which in 2010, had a total of 34,231 prisoners of whom o10 per cent were below the age of 21 (Prisons Department Malaysia, 2010), 148 persons (0.4 per cent ) were below 18 years of age, which was the targeted population. The sample size was 105 subjects at a confidence of 95 per cent, with the Z-value at 1.96 and d is set at 5 per cent (Naing et al., 2006). The study was conducted in February-June 2010 at five prisons in Peninsular Malaysia that are the designated detention centres for juvenile offenders. All 105 detainees below 18 years of age and who consented to participate in the study were included. The exclusion criteria were refusal or inability to cooperate in the interview, including inability to understand or communicate in Malay or English language; no detainees were excluded from the study and none refused to participate. The first author interviewed all the detainees and discussed the results with the team of five psychiatrists. The study was explained to the detainees and an information sheet was provided. The investigator assisted detainees who had difficulties in understanding any questions. The detainees could choose to obtain consent from either their parent’s (by telephone) or their legal guardian (at that time, the prison warden). The detainees were assured of their confidentiality. A questionnaire was devised to collect the relevant background information and the detainees were then interviewed using the MINI-Kid, which is a short structured diagnostic interview to determine the presence of any DSM-IV or ICD-10 psychiatric disorders (Sheehan et al., 1998) and FACES-IV which is a self-rated questionnaire on family cohesion and flexibility (Olson et al., 1979). Statistical analysis The data were anonymized with coding to identify individuals and were analyzed using the SPSS version 16. Descriptive statistics were used to summarize the data. Associations between any and specific psychiatric diagnosis and personal variables were analyzed as odds ratios. Ethical consideration The study protocol was approved by the Research Committee, Department of Psychological Medicine, and by the Research and Ethics Committee, University Malaya Medical Centre. Permission to conduct the study was also obtained from the Director of the Prisons Department of Malaysia.

Results The ages of the detainees ranged from 14 to 17 years, with most of the detainees being 17 years old (Table I). The commonest crimes were property-related offense (35.2 per cent) and 9.5 per cent of the detainees had a history of recidivism. Table IV shows that 16 per cent of the detainees were already convicted while 84 per cent were awaiting trial.

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Table I Personal characteristics of 105 juvenile detainees in five Malaysian Prisons Variables

n (%)

Mean age in years7SD (range) Gender Male Female Ethnicity Malay Chinese Indians Others Education level Never received formal education Primary Secondary Completed secondary Tertiary Employment status Employed Unemployed Income oRM1,000 RM1,000-RM2,000 4RM2,000 Marital status Single Married Co-habitating Living arrangement With parents Other Arrangements Alone With spouse With others Family structure Intact home with biological parents Broken home One step parent Foster parents Single parent Types of offense Homicide Violence Property related Substance related Sex related Others Recidivism 1 prior offense 2 prior offenses 3 prior offenses No recidivism Psychiatric history Prior psychiatric contact No past psychiatric contact Note: From February to June 2010

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16.770.64 (14.0-17.0) 102 (97.1) 3 (2.9) 81 (77.1) 6 (5.7) 14 (13.3) 4 (3.8) 6 (5.7) 20 (19.0) 73 (69.5) 4 (3.8) 2 (1.9) 67 (63.8) 38 (36.2) 55 (82.1) 10 (14.9) 2 (3.0) 102 (97.1) 2 (1.9) 1 (1.0) 63 (60.0) 4 (3.8) 3 (2.9) 35 (33.3) 49 (46.7) 21 (20.00) 8 (7.6) 27 (25.7) 10 (9.5) 14 (13.3) 37 (35.2) 25 (23.8) 16 (15.2) 3 (2.9) 10 (9.5) 8 (80) 1 (10) 1 (10) 95 (90.5) 4 (3.8) 101 (96.2)

Almost all of the detainees met the diagnostic criteria for one or more psychiatric disorder (Table II). Even when conduct disorder (CD) and adjustment disorders were not taken into account, the presence of any psychiatric disorder among the detainees remained high (89 and 88 per cent, respectively). The commonest disorder was disruptive behaviour disorders (66.7 per cent, n ¼ 70) followed by SUD (53.3 per cent, n ¼ 56). Two or more psychiatric disorders were found in 76.2 per cent (n ¼ 80) detainees, the commonest co-morbidity being SUD, mainly involving the use of stimulants (34.3 per cent, n ¼ 36), followed by marijuana (22.9 per cent, n ¼ 24). ADHD was the fourth commonest disorder with the combined subtype found in 50.0 per cent (n ¼ 13), the hyperactive-impulsive subtype in 30.8 per cent (n ¼ 8) and the inattentive subtype in 19.2 per cent (n ¼ 5) of the detainees with ADHD. One-quarter of the detainees diagnosed with CD had co-morbid ADHD, but the association was not statistically significant. SUD was analyzed in a non-parametric test to determine any association with other psychiatric diagnoses (Table III). Detainees with co-morbid CD were more likely to be using substance than detainees without co-morbid CD.

Table II The prevalence of psychiatric disorders among the juvenile detainees in five Malaysian prisons Diagnosis Any of the listed disorders Any except conduct disorder Any except adjustment disorder Any disruptive behaviour disorder Oppositional –defiant disorder Conduct disorders Substance use disorder Alcohol abuse Substance dependence Substance abuse Adjustment disorder ADHD Any affective disorders Major depression Dysthymia Hypomanic Manic Any anxiety disorders Psychotic disorders Tic disorder

n

(%)

98 94 93 70 8 62 56 16 30 22 30 26 18a 8 5 6 2 17a 9 2

93.3 89.5 88.6 66.7 7.6 59.0 53.3 15.2 28.6 21.0 28.6 24.8 17.1 7.6 4.8 5.7 1.9 16.2 8.6 1.9

Notes: From February to June 2010. aIn these groups of disorders, the total of subjects does not sum up because of overlaps within the disorders

Table III Association between substance use disorder (SUD) and conduct disorder (CD) among detainees with the two conditions SUD Yes n (%)

No n (%)

Conduct disorder Yes No

42 (75.0) 14 (25.0)

ADHD Yes No

11 (19.6) 45 (80.4)

Variables

OR

95% CI

20 (40.8) 29 (59.2)

4.35

1.90-9.99

15 (30.6) 34 (69.4)

0.55

0.23-1.36

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Education level was statistically significant associated with presence of CD (Table IV). Of the 62 (59.0 per cent) detainees diagnosed with CD, 61 (98.4 per cent) had not completed schooling, only one had completed his secondary school. In this study 46.7 per cent of the subjects came from intact homes, whereas more than half (53.3 per cent) came from broken homes (Table I). The family factor most strongly associated with the presence of any psychiatric disorder was number of siblings; most of the detainees (n ¼ 79, 80.6 per cent) with any psychiatric disorder came from a large family, with four or more siblings. In the assessment of family communication, 62.9 per cent of the subjects reported having moderate to high communication level in their family system, as opposed to 35.2per cent of subjects who reportedly having low communication in their family. In the assessment of family cohesion and flexibility, 77.1 per cent of the subjects reported having low satisfaction level with their family, while 21.4 per cent reported moderate-to-high satisfaction level. Nevertheless 59.0 per cent the detainees perceived their family to be a functional unit while 39.0 per cent reported their family as dysfunctional. Analysis of the family communication level, family satisfaction level, family cohesion and flexibility in those diagnosed with any psychiatric disorders from those without any psychiatric disorders showed no statistical significance although more detainees with specific psychiatric disorders reported having lower family satisfaction level.

Discussion Almost all 105 offenders in this study had at least one diagnosable psychiatric disorder, and more than a quarter, had two or more disorders. CD was the commonest psychiatric disorder present, followed by SUD, adjustment disorder, ADHD and mood disorder. Detainees with CD were more likely to take substances than detainees without CD, with one-third of the detainees with CD also had SUD. Detainees with CD were more likely not to have completed schooling. Although ADHD was a co-morbid condition in a quarter of the detainees with CD, this association did not record statistical significance.

Table IV Associations between conduct disorder and personal characteristics of the detainees Conduct disorder Yes No n (%) n (%)

Variables Race Malay Non-Malay Family structure Broken Intact Living arrangement With parents Others Education level osecondary Completed school Employment Yes No Income oRM1,000 4RM1,000 Legal status Convicted Remanded Recidivism Yes No

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50(80.6) 12(19.4)

31(72.1) 12(27.9)

33(53.2) 29(46.8)

23(53.5) 20(46.5)

38(61.3) 24(38.7)

25(58.1) 18(41.9)

61(98.4) 1 (1.6)

38(88.4) 5(11.6)

42(67.7) 20(32.3)

26(60.5) 17(39.5)

32(78.0) 9(22.0)

23(88.5) 3(11.5)

10(16.1) 52(83.9)

7(16.3) 36(83.7)

7(11.3) 55(88.7)

3(7.0) 40(93.0)

OR

95% CI

1.61

0.65-4.04

0.99

0.45-2.16

1.14

0.52-2.52

8.03

1.01-71.35

1.37

0.61-3.09

0.46

0.11-1.90

0.99

0.34-2.84

1.70

0.41-6.97

More than half of the detainees came from broken family unit, and reported presence of poor communication in the family and lower satisfaction level with their family, however, the only significant family characteristics was detainees with any psychiatric disorder had larger families, i.e. having four or more siblings, than those with no psychiatric disorder. In Malaysia, Sections 82 and 83 of the Malaysian Penal Code, provides protection for children under the ages of ten years and for children between the ages of ten and 12, with the presumption that children in these age groups are incapable of understanding the nature and consequence of his/her act (The Commissioner of Law Revision Malaysia, 2006). Under the Malaysian Penal Code, complete immunity is given to a child below the age of ten years (Section 82) and partial immunity when the child is between ten and 12 years old (Section 83) (The Commissioner of Law Revision Malaysia, 2006). For children above the age of 12 years, for the purposes of criminal liability they are treated as adults irrespective of the kind of crime they have committed. However, a different criminal procedure and court disposals apply to them (The Commissioner of Law Malaysia, 2001; The Commissioner of Law Revision Malaysia, 2006). The Section 91(1) of the Child Act 2001 (The Commissioner of Law Malaysia, 2001) provides that a special court, i.e. the Court for Children (previously known as the Juvenile Court) has the jurisdiction to impose punishment on a child whose offence has been proven in the Courts. The Prison Department of Malaysia is under the control of Ministry of Internal Security and is the final institution in the implementation of the Criminal Justice System by detaining those who are sentenced by the courts. For this study, the juvenile detainees were in the prisons as sentenced by the relevant courts. In the Malaysian prisons, the juvenile detainees are housed separately from the adult inmates; while basic medical care is available psychiatric care is provided only when necessary. Once ordered for detainment in the prisons, these juveniles live according to prescribed rules and regulations within the prisons, with their movements tightly controlled (The Commissioner of Law Revision Malaysia, 2009). With the Prisons Act 1995 (Act 537) (The Commissioner of Law Revision Malaysia, 2009), prisons are places where prisoners are detained, guarded and undergo various rehabilitation activities until their release. The duties of the Department are to guard them with the utmost humanity and to help them live productive and law-abiding lives during their time in prisons and after their release (The Commissioner of Law Revision Malaysia, 2009). In accordance to the Prison’s Act 2000 (Prisons Department Malaysia and Attorney General Chamber Malaysia, 2000), the Prisons Department is compelled to provide adequate education for these juvenile detainees. Thus detainees who have not completed schooling, they are given the opportunity to do so while in prison. We found a slightly higher rate of psychiatric disorders among detainees than in other studies (Ulzen and Hamilton, 1998; Teplin et al., 2002; Robertson et al., 2004; Vreugdenhil et al., 2004; Ajiboye et al., 2009). Harzke et al. (2012) found a much higher rate of psychiatric disorders (98.3 per cent) in their study of a larger population of youths committed to correctional facilities. Externalizing disorders were commoner than internalizing disorders with CD being the commonest diagnosis found. This is in keeping with the prevalence of 40-90 per cent reported in other studies (Otto et al., 1992; Ulzen and Hamilton, 1998; Teplin et al., 2002; Abram et al., 2003; Rosler et al., 2004; Vreugdenhil et al., 2004; Harzke et al., 2012; Domburgh et al., 2011). Co-morbidity in CD seems to be the rule rather than the exception (Lambert et al., 2001). An elevated risk for SUD in people with CD has been reported in many studies (Cohen et al., 1993; Greenbaum et al., 1996; Federman et al., 1997; Disney et al., 1999; Nock et al., 2006). The presence of CD increases the likelihood of SUD by five- to sixfold (Disney et al., 1999). The second commonest co-morbidity with CD was ADHD (25.8 per cent of detainees). The behavioural difficulties of a child with ADHD are often signals of worsening problems with no intervention made and the presence of CD complicates the picture (Loeber et al., 1992; Johnson et al., 2002; McReynolds et al., 2010; Loeber et al., 2000). Although the association was not statistically significant, other studies have found that ADHD is significantly associated with widespread co-morbidity in childhood, adolescence and in adulthood (Young et al., 2011). Many studies have concluded that the diagnosis of CD and ADHD in adolescents must be taken seriously as children with both conditions are at increased risk of aggression (Loeber et al., 2000) while others have noted the risk of becoming chronic offenders (Vreugdenhil et al., 2004; Young et al., 2011).

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Nearly 50 per cent of children with ADHD develop CD in adolescence and in early adulthood SUD occurs as a common co-morbid condition with a prevalence of 50 per cent in the cases studied (Rosler et al., 2004; Wasserman et al., 2010; Loeber et al., 2000). The study found close to 95 per cent of the detainees were not able to finish their education. The reasons given were that they had lost interest especially in their late childhood as the subjects in school became more difficult. Other factors that could contribute to the detainees not being able to finish their education includes for some having friends were a major distraction while a smaller proportion stated that their families faced financial constraints. Similar findings were noted in a study of Malaysian sex offenders where more than half of the offenders reported academic and behavioural difficulties during adolescence and having gravitated towards peers who often indulged in risky behaviours (Aili et al., 2012). Factors such as low cognitive ability, poor academic performance, weak attachment to school, little commitment to academic pursuits, dropping out of school are positively related to delinquency (Loeber et al., 1992; Foley, 2001; Baltonado et al., 2005; Christle et al., 2005) and later crime in both long and short term (Thornberry et al., 1985; Sander et al., 2012; Christle et al., 2005). The concept of out from school to the prison pipeline is a worrying trend as more students gradually become disengaged from their school and simultaneously move towards involvement in crime and delinquency (Sander et al., 2012; Christle et al., 2005). This is especially worrying as these adolescents are likely to associate with delinquent peers, who are often themselves drug-using peers (Kung and Farrell, 2000; Caldwell et al., 2006). Educational challenges of juvenile delinquent and the need for special education have been clearly noted in the literature (Sander et al., 2012). Presence of ADHD contribute to learning difficulties and academic underachievement (Loeber et al., 2000); ADHD was diagnosed in slightly more than a quarter of the detainees. The prevalence of ADHD in this study was similar to those in other studies (Oregon Youth Authority, 2002; Teplin et al., 2002). Besides academic underachievement, childhood ADHD represents a risk factor for later criminality (Mannuzza et al., 1998) and has been found to be a predictor of recidivism in crimes in early adulthood (Pratt et al., 2002; Rosler et al., 2004). The presence of ADHD in offenders is significant as ADHD symptoms characterized by problems with inattentiveness, impulse control and high levels of activity (Barkley, 2006) make it more difficult for these detainees to cope with the demands within correctional facilities (Young et al., 2011). Additionally, detainees are encouraged to complete their schooling while in prisons, and the undetected presence of ADHD may well interfere with their learning and aggravate their learning difficulties (McNamara et al., 2008). The prevalence of SUD in this study (53.3 per cent), is in keeping with those in other studies which showed that substance use is strongly associated with general offending behaviour (Teplin et al., 2002; Odgers et al., 2005; Wasserman et al., 2010; Welch-Brewer et al., 2011). Associations have been found between adolescent substance use and abuse with antisocial behaviour, rebelliousness, aggressiveness, crime, delinquency, truancy and school performance (Federman et al., 1997). Many studies have found high substance use among juvenile offenders (Vaughn et al., 2007; McReynolds et al., 2008; Hussey et al., 2007). We found that most of the detainees abused or were dependent to illicit drugs rather than alcohol. Almost all Malays are Muslims and are forbidden to ingest alcohol, as Malays were overrepresented in this study, this might explain why the rate of alcohol abuse was lower than in other studies (Federman et al., 1997). A high percentage of the detainees (49.5 per cent) were found to have illicit drug use and dependence. The study did not go into detail with regards to drug taking behaviour of the detainees as this was beyond the scope of the study. Currently, the number of drug users in the country is estimated to be at 250,000 and the number is predicted to reach 500,000 by 2015 (Rusdi et al., 2008). A great concern in Malaysia is that most cases of drug abuse involve young people in their productive years (Rusdi et al., 2008). Apart from SUD and CD, most co-morbid disorders in this study were not statistically significant although associations between concomitant substance use and other psychiatric disorders have been well documented (Deykin et al., 1992; Greenbaum et al., 1996; McReynolds et al., 2008). Family situations are important factors that influence delinquent behaviour (Murry et al., 2006) and even substance use (Caldwell et al., 2006; Kung and Farrell, 2000). More juvenile offenders come from broken homes than intact family systems (Gregory, 1965; Hoffman and Brown, 1998;

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Demuth and Brown, 2004) as seen in this study. Even though more than half of the detainees perceived their family to be a functional family system, from the assessment 77.1 per cent reported having low satisfaction level with their family, indicating presence of unbalanced family system (Olson et al., 1979; Olson, 2011). The FACES-IV is a scale which assesses the satisfaction of family members in regards to their family cohesion, flexibility and communication (Olson et al., 1979; Olson, 2011). A balanced level of cohesiveness and flexibility is favorable to healthy family functioning and greater family satisfaction (Olson, 2011). The scale has been found to discriminate between families with problems and families with no problems (Olson, 2011; Craddock, 2001); dysfunctional family systems are families with problems characterized by presence of family chaos, disengagement, enmeshed relationship, rigid family system, presence of higher levels stress thus lower levels of satisfaction (Craddock, 2001). Lower family satisfaction was reported by the detainees with specific psychiatric disorders, though no statistical significant was found between detainees with any psychiatric disorders and those without psychiatric disorder with regards to family characteristics. The majority of the detainees came from large families; more than three-quarters had four or more siblings. Disruptive behaviour disorders were found to be statistically significantly associated with family size, i.e. detainees from large families were twice more likely to have disruptive behaviour disorder than those from a smaller family. This is in keeping with other studies which has found that a large family predicts delinquency (Wasserman and Seracini, 2001; Farrington, 2002). As the number of children increases, the household tends to become overcrowded, possibly leading to frustration, irritation and conflict among the household members with decreased parental attention given to each child. This may be why the majority of the detainees while perceiving their family as not dysfunctional still reported low satisfaction level with their family. Hence it is just not enough for a family unit to be intact; there must be family communication, support, and nurturance to build positive impact on the behaviour of children.

Limitations Attempts were made to reach the suggested sample size, thus there were subjects not recruited into this study which may have influence on the results. It would have been ideal to assess all the detainees in the five prisons. Unfortunately at the point of recruitment, there were too few female subjects hence analysis between genders was not possible. This was a cross-sectional study, thus the results can only suggest associations; a case control study is strongly recommended for a formal comparison of psychiatric disorders in juvenile offenders and in the general adolescent population. As the place of detention was the prisons, detainees were interviewed in the presence of guards or warden as required; this might have impact on the detainees which could cause them to be cautious in their answers. Some other socio-demographic and familial characteristics that are known risk factors, such as childhood history, family history of imprisonment or offending, family history of psychiatric illness and history of abuse and neglect was not known or brought up by the detainees.

Strengths The study had an adequate number of participants for the statistical analysis with a power of 480 per cent. The psychiatric diagnoses were made on the basis of the gold standard DSM-IV criteria and its diagnostic tool, i.e. M.I.N.I-Kid. The participants identified during the interview, having any psychiatric disorder were referred to the prison’s medical officer for treatment, as proposed by the research team. Clinical implications Common mental disorders that first emerge in childhood can have disastrous consequences for the individual, family and community at large. This study supports the findings of other studies on juvenile offenders, that they are a psychiatrically morbid population in dire need of services. There is a need to offer interventions, including provision of psychiatric services to these detainees. Likewise, identifying delinquent adolescents with early appropriate diagnosis and intervention may well reduce the likelihood of contact with the justice system.

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Acknowledgment The team would like to thank the Health and Translational Medicine Cluster of the University Malaya, the Paradigm Research Group and the Department of Psychological Medicine for giving the authors the opportunity to carry out this research. The team would also like to thank Professor E. Heseltine.

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Corresponding author Dr H.H. Aili can be contacted at: [email protected]

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