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AMER. J. DRUG & ALCOHOL ABUSE, 2(2), pp. 197-213 (1975)
Psychiatric Evaluation Services to Court Referred Drug Users
LESLIE S. PRICHEP, Ph.D., MELVIN COHEN, Ph.D. JOEL KAPLAN, M.D. EUGENE KALIN, M.A. DONALD KLEIN, M.D. Hillside Division Long Island Jewish-Hillside Medical Center Glen Oaks, New York 11004
ABSTRACT This paper reports on the description and outcome of one hundred youthful drug abusers referred from family court for psychiatric evaluation and treatment recommendation. The average referral, both male and female, was a 16-year-old white Catholic from a middle class background who was diagnosed as having a personality disorder. Significantly more males than females showed pathology in early childhood such as behavior problems in school and hyperactivity. Follow-up data collected up to 6 months after evaluation and treatment recommendation indicated that approximately half of the clients showed improvement in terms of work and/or school adjustment, social relations, and drug use.
INTRODUCTION This paper is a report of a successful service program between the Hillside Division of the Long Island Jewish-Hillside Medical Center and the 197
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Probation Department of the Nassau County Family Court. Under a contract from the Nassau County Drug Abuse and Alcohol Commission, Hillside was to provide psychiatric and psychological diagnostic and evaluative services to adolescents with a history of drug use who were brought to the attention of the Family Court for any one of a variety of charges. Based on this evaluation a treatment plan was proposed when appropriate. The hospital, therefore, became a community resource agency to provide additional services to the Court. The program began in May of 1971 and is currently in its fourth year of operation. In this paper we will describe the evaluation and diagnostic program, give a description of the population, and present the preliminary results of a follow-up study t o determine the eventual outcome of each case.
EVALUATION PROCEDURE Adolescents and young adults between the ages of 13-21 are referred by the Probation Department of the Nassau County Court System to the Long Island Jewish-Hillside Medical Center, Hillside Division, for the purpose of diagnoses, evaluation, and treatment recommendations. In order for the client to be considered for referral there must be a history of drug use and impaired functioning as evidenced by deterioration in at least one of the following areas: social, school, work, or family behavior. The probation department has both investigatory and supervisory responsibilities. When a probation officer concluded that the regular investigation procedure did not provide sufficient information to make a recommendation or when additional information was necessary t o facilitate the supervision of a case, the possibility of a psychiatric evaluation was indicated. If there was also a history of drug use and impaired functioning, the probation officer presented the case t o the Mental Health Consultant of the Probation Department who gave final approval and scheduled the case for referral to Hillside. The evalution procedure is as follows: Clients and their parents are seen on the same day at Hillside Hospital. They are asked t o arrive at 9:00 AM. The client is first interviewed by a psychiatrist for approximately one hour. Simultaneously, the parents are seen by a master’s
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level case work interviewer in order to obtain a development and psychosocial history. Following the psychiatric interview, the client is seen by a psychometrician who administers a battery of psychological tests. The test battery consists of a Wechsler Intelligence Scale for Children (up t o age 15 years, 1 1 months) o r a Wechsler Adult Intelligence Scale, a BenderMotor-Gestalt Test, a Human Figure Drawing Test, a Sentence Completion Test, a Thematic Apperception Test, and a Rorschach Test (time permitting). Upon completion of the psychological testing, the client and his parents are taken to lunch at the hospital cafeteria. This allows an opportunity to observe the interaction between the client and his parents. In the afternoon, the client is given an electroencephalogram (EEG); both a sleep and wake record are recorded. This concludes the evaluation procedure. Following the evaluative procedures, the information is pooled and discussed by the Hillside team members. A diagnosis is made and a tentative recommendation for treatment is decided upon. Every Friday the members of the Hillside team meet at the Probation Department to discuss the cases seen that week. This meeting is attended by the Mental Health Consultant of Probation, the Probation Officer in charge of the case, and the Probation Officer’s supervisor. The information is presented and discussed and a final treatment plan is agreed upon. A complete written report follows within ten days. The written report consists of a Conference Summary, Psychiatric Evaluation, Psychological Evaluation, Psychosocial History, and an EEG report. Each section is described below: 1. Conference Evaluation-Summarized findings by the Hillside team, diagnoses, and final recommendations decided upon at the Friday conference. 2. Psychiatric Evaluation-Client’s present history, past history, computerized Mental Status Examination Record [ 1 I , and diagnosis. 3. Psychological Evaluation-Test behavior and observations, intellectual functioning, emotional functioning, and final summary and recommendations. 4. Psychosocial History-The Computerized Psychiatric Anamnestic Record [ 1I developed by Drs. Spitzer and Endicott and a psychosocial narrative history.
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EEG Report-EEG findings as determined by electroencephalographic recording in both the wake and sleep states. The records are read and interpreted by the Director of the EEG Laboratory of Hillside Hospital.
DESCRIPTION OF POPULATION The total sample consisted of 100 clients (64 males, 36 females) between the ages of 13 and 25. The mean age of males was 16.4 years, and the mean age of females was 15.9 years. They were predominantly white (84%), Catholic (53%), and all resided in Nassau County. In terms of socioeconomic status, 79% fall into Hollingshead Class 111 o r below and are equally distributed in Classes 111, IV, and V. IQ’s ranged from a Full Scale Score of 65 to 149, with 85% of the youths scoring within the normal range or higher.
Electroencephalograms EEG records were obtained for 79 (49 males, 30 females) of the 100 clients. Normal EEGs were found in 41% (N=20) of the males and 77% (N=23) of the females. Abnormal EEGs (omitting 14 and 6 positive spikes) were found in 12% (N=6) of the males and 13% (N=4) of the females. These abnormalities were fairly evenly distributed among the following types: 6/sec. spike and wave, minimally abnormal generalized slowing, nonspecific diffuse spike and wave discharges, and exceedingly fast activity. The remaining EEGs, 47% (N=23) of the males and 10% (N=3) of the females, showed the 14 and 6 sec. positive spike pattern (originally described by Gibbs and Gibbs [ 2 ] .) Comparing the incidence of the 14 and 6 pattern in our population with the average incidence (approximately 15%) reported by other investigators among “normal” controls of comparable age [ 3-51 , our population was found t o have a significantly higher incidence of the 14 and 6 pattern (corrected X z = 14.1280, p < 0.01). While present in a very large percentage of our male population, the clinical significance of this pattern is questionable [6, 71.
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However, when accompanied by episodic dyscontrol of temper a trial period of anticonvulsant medication was recommended as part of the treatment plan [8, 91.
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Drug Use In regard to drug use, 48% were soft drug users only (soft drugs include all drugs exclusive of narcotics and cocaine). Of this group, all were polydrug users, except two clients who had used marijuana only. The other 52% of the clients had used narcotics (on more than a one-time experimental basis, although only a small number were addicted to narcotics) in addition to other drugs. Drug use among the males indicated an approximately equal distribution of hard and soft drug use. However, among the females 61% (N=22) were hard drug users. The mean age of onset of drug use was 13.3 years for males and 12.8 years for females.
Impaired Functioning Impaired functioning was rated on a 4 point scale indicating the degree of deterioration in social, school and/or work functioning and family and social relationships. These ratings, made by the psychiatrist who interviewed the client, were based on a composite of data gathered through the evaluation procedure and the psychiatrist’s global impression of the client. Definitions and clinical illustrative examples of each category of impaired functioning follow: ( 1 ) Mild: Patient’s overall functioning is adequate, but there is evidence of a problem in at least one area (for example, the patient may have a history of drug abuse). Example: M.B. is a 16-year-old single, white Catholic male high school student whose experimentation with drugs was limited to occasional use of alcohol and the smoking of marijuana on two occasions. The first external indication of any problem was at age 14 when the client and his friends were charged with vandalism of their school and the client’s case was handled informally by the Family Court. One year later while experimenting with marijuana with a friend, the client was picked up by police and
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charged with possession of marijuana. After being charged with possession of marijuana, the client and his parents began sessions at a local mental health clinic and have had three sessions prior t o the client being evaluated. (2) Moderate: Patient is functioning adequately in at least one major area, but is experiencing difficulties in some other areas. Example: O.A. is a 16-year-old single, black female high school student, who began t o use drugs at the age of 12 (marijuana and hashish) and eventually progressed to the use of barbiturates and amphetamines. She and her older brother H. were charged with shoplifting and possession of marijuana. In O.’s case, the charges were handled informally. 0. began to associate with an older crowd, and a Missing Persons Alarm was filed in June 1971, after she ran away. However, during this time, the patient has continued to do very well in school, and is presently an 1 l t h grade student. Two months prior to her evaluation, she was arrested for the possession of a dangerous drug, namely, marijuana. At the present time, she is living at home and attending school. (3) Severe: Patient is doing poorly in most areas of functioning, but has shown some strength in at least one area. For example, patient may be attending school or has a part-time job. The patient may have a history of psychiatric care and an extensive history of drug use. Example: F.S. is a 17?h-year-old single, white, Catholic male high school student who began t o use drugs at the age of 14. He started with sniffing lighter fluid and progressed to the use of marijuana, hashish, amphetamines, barbiturates and LSD. F. would often stay out of school and miss classes completely. He received a total of four individual interviews in individual psychotherapy on an outpatient basis, but refused t o continue. F. has a history of impairment dating back to childhood. He was described as being hyperactive in class and unable to sit still. However, throughout the past few years he has continued to work on a parttime basis at a delicatessen. At the time of evaluation, he was charged with the possession of marijuana. (4) Very Severe: Patient doing very poorly in all areas of functioning. The patient may have a history of psychiatric hospitalization and/or outpatient psychiatric care. This is usually accompanied by a history of heavy drug abuse and difficulties in school and social functioning. Example: Patient D.W. is a 14?h-year-old single, white female Protestant 9th grade student who used drugs since the age of 10. She
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has used alcohol, marijuana, hashish, barbiturates, amphetamines, and narcotics. By the age of 13, D. was going out with men much older than herself and was extremely promiscuous. A PINS Petition was filed on D. by her father due to her excessive truancy, her drug use, and because she ran away from home on a number of occasions. Subsequently D. became pregnant and had an abortion. Following the abortion, she ODed on barbiturates in an apparent suicide attempt. She was hospitalized at a State Hospital facility but was discharged because of acting out behavior. At the time of her evaluation at Hillside Hospital, she was in Nassau County Children’s Shelter, where she was remanded for violation of probation. Table 1 shows the percentage of males and females in each category of impaired functioning. As indicated, most of the clients referred by the Family Court were in the “severe” category of impaired functioning. If one considers “severe” and “very severe” together, then it shows that 81% of the males and 7 1% of the females had a high degree of impaired functioning. Thus, this population was most likely selected for evaluation by the Family Court Probation personnel because they recognized the degree of impairment of these cases, and the possible need for some form of treatment.
Onset of Impairment The clients were divided into two groups, those who manifested problems in functioning in childhood and those whose childhood history was normal (reportedly symptom-free). It was found that significantly more males showed pathology in childhood than females (X2= 16.5001, p < 0.001). In
Table 1. Percentage of Males and Females in Each Category of Impaired Functioning
% Mild
Severity of Impairment % Moderate % Severe
Males (N=64)
3
16
65
16
Females (N=36)
3
26
53
18
% Verv severe
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83% (N=30) of the females, childhood histories appeared normal with no evidence of disorders until they reached puberty, at which time symptoms appeared and behavior changed. However, for the males, 61% (N=39) had a history of disorders in childhood. The most common childhood symptom in this group was behavior problems ir, school (38%, N=15), which was frequently accompanied by hyperactivity (3 1%, N = l 2 ) and learning difficulties (31%, N=12). There was also evidence of temper tantrums and poor socialization in both male and female clients who had problems in childhood.
Personality Characteristics
The outstanding traits of each client were rated by the team psychiatrist using the appropriate sections of both the P.A.R. and M.S.E.R. (computerized forms described previously). Table 2 shows those traits which were present in at least 50% of the male or female clients. “Impulsivity”, the tendency to act immediately without reflection, was the most outstanding descriptive characteristic of both the male and female populations. “Suspiciousness”, ranging from mild distrust to feelings of persecution (but not delusional in nature), “a tendency to blame others” for own difficulties, and an “inability to relax” were also common traits. Other descriptors were “emotional instability”, in which the individual reacts with excitability, ineffectiveness, and poor judgment when confronted with even minor stress, and “self-defeating” behavior marked
Table 2. Personality Traits Present in at least 50% of the Males or Females Trait
% Males (N=63)
% Females (N=35)
%Total (N=98)
Impulsivity Suspiciousness
90 71
100
94
57
66
Tendency to blame others Emotional instability
62 51
54
59
66
56
Inability to relax
51
53
Excitability
54 54
48
52
Self-defeating
46
51
48
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by a tendency to become involved in self-damaging situations (e.g., deliberate violations of probation by staying out all night o r shoplifting). Although “suspiciousness” was more common in males and “emotional instability” more common in females, there were n o significant differences in traits between the sexes. Thus, while the male and female clients have been shown t o differ in other respects (e.g., onset of impairment and drug use), they were seen as having similar personality characteristics.
Psychiatric Symptoms A symptom history check list from the Inpatient Multidimensional Psychiatric Survey (IMPS) was completed on each of the first 72 clients by the team psychiatrist. All symptoms were rated on a 3 point scale, (1 = none, 2 = mile/moderate, 3 = severe) and cover the period from the onset of drug use to the present interview. Table 3 shows the symptoms rated as mild/moderate o r severe during the “on drug” period in at least 50% of the males o r females. “Low self-esteem” is symptomatic of approximately 100% of the total population and is present to a severe degree in over 60% of males and females. “Psychopathy”, also present in approximately 100%of the population, was more severe in males than females. “Anger”, present in 100% Table 3. Psychiatric Symptoms Present in at least 50%of Males or Females
Symptom
Mild/Moderate % Males % Females (N=42) (N=30)
% Males (N=42)
Low self-esteem
36
33
62
67
Psychopathy
29
57
71
40
Anger
55
67
33
20
Chronic anxiety
72
77
14
13
Sexual inhibition
79
47
0
0
Depression
60
53
2
13
Social isolation
74
33
0
0
5
50
2
10
Histrionic behavior
Severe
% Females (N-30)
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of the females was seen in 88% of the males, and was rated as mild/moderate in most cases. “Chronic anxiety” was present in approximately 90% of the population and was rated as mild or moderate in most cases. Mild or moderate “sexual inhibition” was present in 79% of the males and 47% of the females. “Depression” was present most often t o a mild o r moderate degree in approximately 65% of the cases. Mild or moderate “social isolation” was present in approximately three-quarters of the males, but only one-third of the females. “Histrionic behavior” was seen t o a mild or moderate degree in 50% of the females and severely present in another 10% of the females, but was present in only 7% of the males.
Psychiatric Diagnosis A psychiatric diagnosis was made for each client, following his/her evaluation, according t o the Diagnostic & Statistical Manual of Mental Disorders (DSM 11, 1968). The diagnosis was made by the psychiatrist in consultation with the other evaluation staff members. An attempt was made to give a diagnosis based on the client’s behavior and symptomatology when not under the influence of drugs. Thus, queries were made as to the differences in the client’s behavior when drug free and when drug induced. Table 4 gives the frequency of the different diagnoses found for the court referred population. Sixty-nine percent of the clients were diagnosed as personality disorders, the predominant disorder group considered t o be passive aggressive personality (accounting for 39% of the total sample). The figures were similar for males and females. Table 4. Diagnoses by Sex % Total
Diagnoses
% Males (N=64)
% Females (N=36)
(N=100)
Personality disorders
66
75
69
Schizophrenia
4
3
3
Neuroses
6
9
7
Organic brain syndrome Psychophysiologic disorder
3
3
3
0
3
1
22
8
17
Adiustment reaction of adolescence
population
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Seventeen percent of the clients were diagnosed as “adjustment reactions of adolescence”. In this category, there was a much higher percentage of males (22%) than females (8%). Seven percent of the clients were diagnosed as neurotic, three percent as organic brain syndrome, three percent as schizophrenic, and one percent as having psychophysiological disorder gastrointestinal type.
Court History Forty-two percent (N=27) of the males and sixty-four percent (N=23) of the females were unknown to the Court prior to the present offense. The others were previously involved with the Court either through formal or informal charges. It was found that significantly more “hard” drug users had previous histories of formal court involvement than did the soft drug users (corrected X 2 = 6.6349, p < 0.05). The p:esent offenses were divided into four categories: ( 1 ) P.I.N.S. Petition (person in need of supervisiun). (2) J.D. Petition Guvenile delinquency) for sale and/or possession of a dangerous drug. (3) J.D. Petition for nondrug related offense (e.g., burglary). (4) Other (e.g., family offense). Twenty-eight percent of the males ( W l 8 ) were included in category 1, 28% (N=l8), in category 2, 27% ( W 1 7 ) in category 3, and 17% ( N = l l ) in category 4. The females were less evenly distributed between the first three categories with 67% (N=24) included in category 1, 14% (N=5) in category 2, none in category 3, and 19% (N=7) in category 4. Significantly more females than males were brought in on P.I.N.S. Petitions and significantly more males were brought in on J.D. Petitions.
RECOMMENDATIONS MADE BY EVALUATION TEAM There were no restrictions placed by the Family Court on the scope of the recommendations that could be made by the Hillside Team. Although recommendations could range from no therapeutic or court intervention through all forms of treatment modalities, and could have included
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a recommendation for placement in a reform school or jail, in no case was jail o r reform school ever recommended. Final recommendations were made only during a joint conference with probation personnel and were based on both our evaluation and additional information which was provided by the probation officer involved with the case. In almost all cases in conjunction with the primary treatment recommendation it was recommended that the client be placed on probation or, if already on probation, that the probationary period be extended. This was felt t o be an important tool both in the implementation of recommendations (a client may be considered in violation of probation if he did not follow the treatment plan) and in providing a structure and authority (outside the family) for the client. Also, a secondary recommendation for a 6 week trial period on anticonvulsant medication (Dilantin) was made when EEG and behavioral data so indicated. However, only primary recommendations are reported below. The majority of these recommendations can be divided into four major categories: ( 1 ) Outpatient therapy (2) Inpatient psychiatric treatment (hospitalization) (3) Drug programs (4) Special schooling Table 5 gives specific information on recommendations made. In 45% of the cases some form of outpatient therapy was recommended. Inpatient hospitalization was recommended in 12% of the cases. Drug programs were recommended in 15% of the cases, and special schooling was recommended in 22%. The final report was used by the probation department in the form of a recommendation to the presiding judge, o r as additional information to be used by the supervising probation officer in dealing with a problem client.
FOLLOW-UP INFORMATION Follow-Up Method and Ratings Follow-up information on the client’s progress at 1, 3, and 6 months after they were evaluated at Hillside was gathered via questionnaires
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Table 5. Treatment Recommendations by Sex
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Recommendation Outpatient therapy: Individual Family Group Day hospital Counseling Inpatient psychiatric hospitalization Day care drug program Community outpatient drug program Residential drug program Residential school Special education (BOCES, DVR, Remedial Reading, etc.) Neurological examination Other
% Males (N=64)
% Females (N=36)
25 9 5 0 5 13 3 6 2 17
22
9 2 4
0 3
11
3 3 8 11 6 3 14 14
2
% Total Population (N= 100) 24 10 4 1 6 12 4 5 6 16 6 2 4
distributed t o the Probation Officers. Through these questionnaires, information was supplied on the status of the recommendation made, the probationary status of the client, treatment information, familial adjustment, school and/or job status, and drug usage during follow-up period. Complete follow-up information was received on 83 clients. It was found that in 87% of the cases ( N = 7 2 ) the recommendation made by Hillside was accepted by the Probation Department and/or the court. The eleven cases in which the recommendations were not followed were of 3 types: ( 1 ) cases in which the status of the client had changed before he/she reached the court; for example, if the client violated probation, ( 2 ) cases in which the client refused t o accept the recommendation, but accepted an alternative plan, or ( 3 ) where probation felt a less structured treatment plan be attempted first. However, of the 7 2 cases in which the recommendations were accepted, there were 8 cases where the recommended treatment was not further implemented. The reasons for this vary from refusal of the client to accept treatment to an inability to place the client in the recommended treatment program. After the 1, 3 , and 6 month follow-ups were received on an individual,
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a judgment was made as t o the overall improvement during the 6 month period following the evaluation at Hillside. Ratings were made o n a 3 point scale where 1 = improved, 2 = no change, and 3 = worse. These ratings were made independently by the members of the evaluation team and reliability was significant at the p < 0.00 1 level (Kappa = 0.7 1, z = 7.32, unweighted). The follow-up scores are briefly defined below: 1. Improved: Client’s functioning has improved during the 6 month period. He/she has not violated probation, has been cooperative with the Probation Department, has improved his/her relationship with parents, is working o r in school (or both), and is receiving treatment (when treatment was recommended). Further, the client has not used any drugs. 2. No change: Client’s functioning has shown no real change during the 6 month period. He/she has been cooperative with the Probation Department, however, in some instances there were violations of probation. His/her relationship with parents has not improved, their school o r work status is unchanged, and treatment (when recommended) was frequently terminated after a short period or never entered into. Drug usage has continued. 3 . Worse: Client’s functioning has worsened during the 6 month period. He/she was uncooperative with the Probation Department and there were often violations of Probation. His/her relationship with parents has not improved and, in some cases, has worsened. Client is either unemployed and/or not in school. Treatment recommendations were not implemented and moderate to heavy drug usage is present. Table 6 shows the percentage of males and females in each followup category in those cases in which the recommendations were implemented. Approximately half of the male and female clients were considered as
Table 6. Percentage of Males and Females in each Follow-up Category (Implemented Cases Only, N=64) Follow-up Category % Improved
% No change
% Worse
% Insufficient information for rating
Males (N=40)
45
25
10
20
Females (N=24)
50
33
4
Total (N=64)
47
28
13 11
14
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“improved” in their overall degree of functioning six months after they were seen for evaluation and a recommendation was made for treatment. One-fourth to one-third of male and female clients showed “no change’’ and a much smaller percentage (10% for males and 13% for females) were considered as having become “worse”. In comparison, of the 19 cases in which Hillside’s recommendations were not followed ( 1 1 cases not originally accepted and 8 cases accepted but not implemented), only 4 were rated as improved. This represents 21% of the nonaccepted or not implemented cases as compared to the 47% rated as improved when our recommendations were accepted and implemented. This difference shows a trend, significant at the p < 0.10 level of significance (A? = 3.23), indicating that there was greater improvement in those cases in which the hospital recommendations were accepted and actually implemented. Possible characteristics which may distinguish between those clients in which treatment plans were implemented and those where they were not, are now being investigated.
SUMMARY In its first year and a half of operation, the Hillside diagnostic and evaluation services program for the Nassau Family Court System worked with a large number of adolescents and young adults for whom the Probation Department felt it needed additional help in developing a treatment plan or in the supervision of the client. Additionally, all those referred for evaluation had a history of drug use and evidence of impairment in some area of functioning. Each client seen at Hillside received a psychiatric interview, a complete battery of psychological tests, and a sleep and wake electroencephalogram. The client’s parents were also interviewed in order to supply a developmental and psychosocial history. The analysis of this information then served as the basis for a group conference between the Hillside Team and those in the Probation Department involved with the case. At this conference, a tentative treatment plan was outlined when appropriate. The average female client was 15.9 years old, white, Catholic, and from a middle class background. Her early childhood history was without apparent problems. She began using drugs at 12.8 years of age and her
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drug use history showed her to be a polydrug user who tended toward hard use. She was before the court on a P.I.N.S. Petition at the time of her Hillside Evaluation, but was previously unknown to the court. At the time of her evaluation she was seen as having severe functional impairment and was diagnosed as a Personality Disorder. The average male client was a 16.4-year-old white, middle class Catholic, who tended to have an abnormal EEG. Unlike the females, his early childhood history was marked with problems, usually manifest in behavior disorders in school. He began to use drugs at 13.3 years of age and while he also tended to be a polydrug user, his drug use was as likely to be primarily soft drugs as both soft and hard drugs. He was before the court at the time of his Hillside evaluation for either a Juvenile Delinquency Petition or a P.I.N.S. Petition and was previously known to the court. At the time of the evaluation he was seen as having severe functional impairment and was diagnosed as a Personality Disorder. The most outstanding personality descriptor of the overall population was “impulsivity”. Low self-esteem, psychopathy, anger, and anxiety were the major psychiatric symptoms presented by these clients. Diagnostically, the majority of these youths displayed characteristics of personality disorders, and most treatment plans were of an outpatient nature. Follow-up data collected from the Probation Department at 1 , 3, and 6 months after the client was seen at Hillside indicated that approximately half the clients showed improvement. There was a higher percentage of improvement in those cases where the recommendations were implemented than in those where they were not. One reason for this may be simply that the plans were in fact implemented; another may be a type of client and client situation (e.g., family acceptance of plan) for whom there is a better treatment prognosis. Still another possible explanation may be that in this type of population the authority of the court acts as a necessary external motivator for positive involvement in treatment. A similar observation to this was suggested in the report of a similar program between a court clinic and the Jewish Board of Guardians [ 101, We are presently investigating these and other possible indicators of treatment outcome.
ACKNOWLEDGMENT The authors wish to thank Thomas Castiglia, Elizabeth Brautigam, and the entire staff of the Nassau County Family Court Probation Department. We also thank
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Melvin Anderson and the staff of the Adult Division of the Nassau County Probation Department.
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REFERENCES
[ 11 Spitzer, R., and Endicott, J., Biometrics Research, New York State Department of Mental Hygiene. [2] Gibbs, E. L., and Gibbs, F. A., Electroencephalographic evidence of thalamic and hypothalamic epilepsy, Neurology I: 136-144 (1951). [3] Demerdash, A., Eeg-Olofsson, O., and Petersen, I., The incidence of 14 and 6 per second positive spikes in a population of normal children, Develop. Med. Child. Neurol. 10:309-3 16 (1 968). [4] Gibbs, E. L., and Gibbs, F. A., Atlas of Electroencephalography Neurological and Psychiatric Disorders, Vol. 3, Addison-Wesley, Reading, Mass., 1964. [5] Weiner, J. M., Delano, J. G., and Klass, D. W., An EEG study of delinquent and nondelinquent adolescents, Arch. Cen. Psychiat. 15: 144-150 (1966). [6] Loomis, S. D., Bohnert, P. J., and Huncke, S., Prediction of EEG abnormalities in adolescent delinquents, Arch. Gen. Psychiat. 17:494497 (1967). [7] Struve, F. A., Feigenbaum, E. S., and Farnum, C. D., Prediction of 14 & 6/sec. positive spikes in EEGs of psychiatric patients, Clin. EEG. 3:60-64 (1 972). [8] Metcalf, D. R., Behavioral and physiologic implications of six and fourteen per second spikes on the EEG, in Proc. 11th Western Institute on Epilepsy, Milwaukee, Wisc. (1959). [9] Poser, C. M., and Ziegler, D. K., Clinical significance of 14 and 6 per second positive spike complexes, Neurology 8:903-912 (1 958). [lo] Nir, Y., and Cutler, R., The therapeutic utilization of the juvenile court, Amer. J. Psychiat. 130: 1 112-11 17 (1973).
AMER. J. DRUG & ALCOHOL ABUSE, 2(2), pp. 197-213 (1975)
Psychiatric Evaluation Services to Court Referred Drug Users
LESLIE S. PRICHEP, Ph.D., MELVIN COHEN, Ph.D. JOEL KAPLAN, M.D. EUGENE KALIN, M.A. DONALD KLEIN, M.D. Hillside Division Long Island Jewish-Hillside Medical Center Glen Oaks, New York 11004
ABSTRACT This paper reports on the description and outcome of one hundred youthful drug abusers referred from family court for psychiatric evaluation and treatment recommendation. The average referral, both male and female, was a 16-year-old white Catholic from a middle class background who was diagnosed as having a personality disorder. Significantly more males than females showed pathology in early childhood such as behavior problems in school and hyperactivity. Follow-up data collected up to 6 months after evaluation and treatment recommendation indicated that approximately half of the clients showed improvement in terms of work and/or school adjustment, social relations, and drug use.
INTRODUCTION This paper is a report of a successful service program between the Hillside Division of the Long Island Jewish-Hillside Medical Center and the 197
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Probation Department of the Nassau County Family Court. Under a contract from the Nassau County Drug Abuse and Alcohol Commission, Hillside was to provide psychiatric and psychological diagnostic and evaluative services to adolescents with a history of drug use who were brought to the attention of the Family Court for any one of a variety of charges. Based on this evaluation a treatment plan was proposed when appropriate. The hospital, therefore, became a community resource agency to provide additional services to the Court. The program began in May of 1971 and is currently in its fourth year of operation. In this paper we will describe the evaluation and diagnostic program, give a description of the population, and present the preliminary results of a follow-up study t o determine the eventual outcome of each case.
EVALUATION PROCEDURE Adolescents and young adults between the ages of 13-21 are referred by the Probation Department of the Nassau County Court System to the Long Island Jewish-Hillside Medical Center, Hillside Division, for the purpose of diagnoses, evaluation, and treatment recommendations. In order for the client to be considered for referral there must be a history of drug use and impaired functioning as evidenced by deterioration in at least one of the following areas: social, school, work, or family behavior. The probation department has both investigatory and supervisory responsibilities. When a probation officer concluded that the regular investigation procedure did not provide sufficient information to make a recommendation or when additional information was necessary t o facilitate the supervision of a case, the possibility of a psychiatric evaluation was indicated. If there was also a history of drug use and impaired functioning, the probation officer presented the case t o the Mental Health Consultant of the Probation Department who gave final approval and scheduled the case for referral to Hillside. The evalution procedure is as follows: Clients and their parents are seen on the same day at Hillside Hospital. They are asked t o arrive at 9:00 AM. The client is first interviewed by a psychiatrist for approximately one hour. Simultaneously, the parents are seen by a master’s
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level case work interviewer in order to obtain a development and psychosocial history. Following the psychiatric interview, the client is seen by a psychometrician who administers a battery of psychological tests. The test battery consists of a Wechsler Intelligence Scale for Children (up t o age 15 years, 1 1 months) o r a Wechsler Adult Intelligence Scale, a BenderMotor-Gestalt Test, a Human Figure Drawing Test, a Sentence Completion Test, a Thematic Apperception Test, and a Rorschach Test (time permitting). Upon completion of the psychological testing, the client and his parents are taken to lunch at the hospital cafeteria. This allows an opportunity to observe the interaction between the client and his parents. In the afternoon, the client is given an electroencephalogram (EEG); both a sleep and wake record are recorded. This concludes the evaluation procedure. Following the evaluative procedures, the information is pooled and discussed by the Hillside team members. A diagnosis is made and a tentative recommendation for treatment is decided upon. Every Friday the members of the Hillside team meet at the Probation Department to discuss the cases seen that week. This meeting is attended by the Mental Health Consultant of Probation, the Probation Officer in charge of the case, and the Probation Officer’s supervisor. The information is presented and discussed and a final treatment plan is agreed upon. A complete written report follows within ten days. The written report consists of a Conference Summary, Psychiatric Evaluation, Psychological Evaluation, Psychosocial History, and an EEG report. Each section is described below: 1. Conference Evaluation-Summarized findings by the Hillside team, diagnoses, and final recommendations decided upon at the Friday conference. 2. Psychiatric Evaluation-Client’s present history, past history, computerized Mental Status Examination Record [ 1 I , and diagnosis. 3. Psychological Evaluation-Test behavior and observations, intellectual functioning, emotional functioning, and final summary and recommendations. 4. Psychosocial History-The Computerized Psychiatric Anamnestic Record [ 1I developed by Drs. Spitzer and Endicott and a psychosocial narrative history.
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EEG Report-EEG findings as determined by electroencephalographic recording in both the wake and sleep states. The records are read and interpreted by the Director of the EEG Laboratory of Hillside Hospital.
DESCRIPTION OF POPULATION The total sample consisted of 100 clients (64 males, 36 females) between the ages of 13 and 25. The mean age of males was 16.4 years, and the mean age of females was 15.9 years. They were predominantly white (84%), Catholic (53%), and all resided in Nassau County. In terms of socioeconomic status, 79% fall into Hollingshead Class 111 o r below and are equally distributed in Classes 111, IV, and V. IQ’s ranged from a Full Scale Score of 65 to 149, with 85% of the youths scoring within the normal range or higher.
Electroencephalograms EEG records were obtained for 79 (49 males, 30 females) of the 100 clients. Normal EEGs were found in 41% (N=20) of the males and 77% (N=23) of the females. Abnormal EEGs (omitting 14 and 6 positive spikes) were found in 12% (N=6) of the males and 13% (N=4) of the females. These abnormalities were fairly evenly distributed among the following types: 6/sec. spike and wave, minimally abnormal generalized slowing, nonspecific diffuse spike and wave discharges, and exceedingly fast activity. The remaining EEGs, 47% (N=23) of the males and 10% (N=3) of the females, showed the 14 and 6 sec. positive spike pattern (originally described by Gibbs and Gibbs [ 2 ] .) Comparing the incidence of the 14 and 6 pattern in our population with the average incidence (approximately 15%) reported by other investigators among “normal” controls of comparable age [ 3-51 , our population was found t o have a significantly higher incidence of the 14 and 6 pattern (corrected X z = 14.1280, p < 0.01). While present in a very large percentage of our male population, the clinical significance of this pattern is questionable [6, 71.
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However, when accompanied by episodic dyscontrol of temper a trial period of anticonvulsant medication was recommended as part of the treatment plan [8, 91.
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Drug Use In regard to drug use, 48% were soft drug users only (soft drugs include all drugs exclusive of narcotics and cocaine). Of this group, all were polydrug users, except two clients who had used marijuana only. The other 52% of the clients had used narcotics (on more than a one-time experimental basis, although only a small number were addicted to narcotics) in addition to other drugs. Drug use among the males indicated an approximately equal distribution of hard and soft drug use. However, among the females 61% (N=22) were hard drug users. The mean age of onset of drug use was 13.3 years for males and 12.8 years for females.
Impaired Functioning Impaired functioning was rated on a 4 point scale indicating the degree of deterioration in social, school and/or work functioning and family and social relationships. These ratings, made by the psychiatrist who interviewed the client, were based on a composite of data gathered through the evaluation procedure and the psychiatrist’s global impression of the client. Definitions and clinical illustrative examples of each category of impaired functioning follow: ( 1 ) Mild: Patient’s overall functioning is adequate, but there is evidence of a problem in at least one area (for example, the patient may have a history of drug abuse). Example: M.B. is a 16-year-old single, white Catholic male high school student whose experimentation with drugs was limited to occasional use of alcohol and the smoking of marijuana on two occasions. The first external indication of any problem was at age 14 when the client and his friends were charged with vandalism of their school and the client’s case was handled informally by the Family Court. One year later while experimenting with marijuana with a friend, the client was picked up by police and
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charged with possession of marijuana. After being charged with possession of marijuana, the client and his parents began sessions at a local mental health clinic and have had three sessions prior t o the client being evaluated. (2) Moderate: Patient is functioning adequately in at least one major area, but is experiencing difficulties in some other areas. Example: O.A. is a 16-year-old single, black female high school student, who began t o use drugs at the age of 12 (marijuana and hashish) and eventually progressed to the use of barbiturates and amphetamines. She and her older brother H. were charged with shoplifting and possession of marijuana. In O.’s case, the charges were handled informally. 0. began to associate with an older crowd, and a Missing Persons Alarm was filed in June 1971, after she ran away. However, during this time, the patient has continued to do very well in school, and is presently an 1 l t h grade student. Two months prior to her evaluation, she was arrested for the possession of a dangerous drug, namely, marijuana. At the present time, she is living at home and attending school. (3) Severe: Patient is doing poorly in most areas of functioning, but has shown some strength in at least one area. For example, patient may be attending school or has a part-time job. The patient may have a history of psychiatric care and an extensive history of drug use. Example: F.S. is a 17?h-year-old single, white, Catholic male high school student who began t o use drugs at the age of 14. He started with sniffing lighter fluid and progressed to the use of marijuana, hashish, amphetamines, barbiturates and LSD. F. would often stay out of school and miss classes completely. He received a total of four individual interviews in individual psychotherapy on an outpatient basis, but refused t o continue. F. has a history of impairment dating back to childhood. He was described as being hyperactive in class and unable to sit still. However, throughout the past few years he has continued to work on a parttime basis at a delicatessen. At the time of evaluation, he was charged with the possession of marijuana. (4) Very Severe: Patient doing very poorly in all areas of functioning. The patient may have a history of psychiatric hospitalization and/or outpatient psychiatric care. This is usually accompanied by a history of heavy drug abuse and difficulties in school and social functioning. Example: Patient D.W. is a 14?h-year-old single, white female Protestant 9th grade student who used drugs since the age of 10. She
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has used alcohol, marijuana, hashish, barbiturates, amphetamines, and narcotics. By the age of 13, D. was going out with men much older than herself and was extremely promiscuous. A PINS Petition was filed on D. by her father due to her excessive truancy, her drug use, and because she ran away from home on a number of occasions. Subsequently D. became pregnant and had an abortion. Following the abortion, she ODed on barbiturates in an apparent suicide attempt. She was hospitalized at a State Hospital facility but was discharged because of acting out behavior. At the time of her evaluation at Hillside Hospital, she was in Nassau County Children’s Shelter, where she was remanded for violation of probation. Table 1 shows the percentage of males and females in each category of impaired functioning. As indicated, most of the clients referred by the Family Court were in the “severe” category of impaired functioning. If one considers “severe” and “very severe” together, then it shows that 81% of the males and 7 1% of the females had a high degree of impaired functioning. Thus, this population was most likely selected for evaluation by the Family Court Probation personnel because they recognized the degree of impairment of these cases, and the possible need for some form of treatment.
Onset of Impairment The clients were divided into two groups, those who manifested problems in functioning in childhood and those whose childhood history was normal (reportedly symptom-free). It was found that significantly more males showed pathology in childhood than females (X2= 16.5001, p < 0.001). In
Table 1. Percentage of Males and Females in Each Category of Impaired Functioning
% Mild
Severity of Impairment % Moderate % Severe
Males (N=64)
3
16
65
16
Females (N=36)
3
26
53
18
% Verv severe
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83% (N=30) of the females, childhood histories appeared normal with no evidence of disorders until they reached puberty, at which time symptoms appeared and behavior changed. However, for the males, 61% (N=39) had a history of disorders in childhood. The most common childhood symptom in this group was behavior problems ir, school (38%, N=15), which was frequently accompanied by hyperactivity (3 1%, N = l 2 ) and learning difficulties (31%, N=12). There was also evidence of temper tantrums and poor socialization in both male and female clients who had problems in childhood.
Personality Characteristics
The outstanding traits of each client were rated by the team psychiatrist using the appropriate sections of both the P.A.R. and M.S.E.R. (computerized forms described previously). Table 2 shows those traits which were present in at least 50% of the male or female clients. “Impulsivity”, the tendency to act immediately without reflection, was the most outstanding descriptive characteristic of both the male and female populations. “Suspiciousness”, ranging from mild distrust to feelings of persecution (but not delusional in nature), “a tendency to blame others” for own difficulties, and an “inability to relax” were also common traits. Other descriptors were “emotional instability”, in which the individual reacts with excitability, ineffectiveness, and poor judgment when confronted with even minor stress, and “self-defeating” behavior marked
Table 2. Personality Traits Present in at least 50% of the Males or Females Trait
% Males (N=63)
% Females (N=35)
%Total (N=98)
Impulsivity Suspiciousness
90 71
100
94
57
66
Tendency to blame others Emotional instability
62 51
54
59
66
56
Inability to relax
51
53
Excitability
54 54
48
52
Self-defeating
46
51
48
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by a tendency to become involved in self-damaging situations (e.g., deliberate violations of probation by staying out all night o r shoplifting). Although “suspiciousness” was more common in males and “emotional instability” more common in females, there were n o significant differences in traits between the sexes. Thus, while the male and female clients have been shown t o differ in other respects (e.g., onset of impairment and drug use), they were seen as having similar personality characteristics.
Psychiatric Symptoms A symptom history check list from the Inpatient Multidimensional Psychiatric Survey (IMPS) was completed on each of the first 72 clients by the team psychiatrist. All symptoms were rated on a 3 point scale, (1 = none, 2 = mile/moderate, 3 = severe) and cover the period from the onset of drug use to the present interview. Table 3 shows the symptoms rated as mild/moderate o r severe during the “on drug” period in at least 50% of the males o r females. “Low self-esteem” is symptomatic of approximately 100% of the total population and is present to a severe degree in over 60% of males and females. “Psychopathy”, also present in approximately 100%of the population, was more severe in males than females. “Anger”, present in 100% Table 3. Psychiatric Symptoms Present in at least 50%of Males or Females
Symptom
Mild/Moderate % Males % Females (N=42) (N=30)
% Males (N=42)
Low self-esteem
36
33
62
67
Psychopathy
29
57
71
40
Anger
55
67
33
20
Chronic anxiety
72
77
14
13
Sexual inhibition
79
47
0
0
Depression
60
53
2
13
Social isolation
74
33
0
0
5
50
2
10
Histrionic behavior
Severe
% Females (N-30)
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of the females was seen in 88% of the males, and was rated as mild/moderate in most cases. “Chronic anxiety” was present in approximately 90% of the population and was rated as mild or moderate in most cases. Mild or moderate “sexual inhibition” was present in 79% of the males and 47% of the females. “Depression” was present most often t o a mild o r moderate degree in approximately 65% of the cases. Mild or moderate “social isolation” was present in approximately three-quarters of the males, but only one-third of the females. “Histrionic behavior” was seen t o a mild or moderate degree in 50% of the females and severely present in another 10% of the females, but was present in only 7% of the males.
Psychiatric Diagnosis A psychiatric diagnosis was made for each client, following his/her evaluation, according t o the Diagnostic & Statistical Manual of Mental Disorders (DSM 11, 1968). The diagnosis was made by the psychiatrist in consultation with the other evaluation staff members. An attempt was made to give a diagnosis based on the client’s behavior and symptomatology when not under the influence of drugs. Thus, queries were made as to the differences in the client’s behavior when drug free and when drug induced. Table 4 gives the frequency of the different diagnoses found for the court referred population. Sixty-nine percent of the clients were diagnosed as personality disorders, the predominant disorder group considered t o be passive aggressive personality (accounting for 39% of the total sample). The figures were similar for males and females. Table 4. Diagnoses by Sex % Total
Diagnoses
% Males (N=64)
% Females (N=36)
(N=100)
Personality disorders
66
75
69
Schizophrenia
4
3
3
Neuroses
6
9
7
Organic brain syndrome Psychophysiologic disorder
3
3
3
0
3
1
22
8
17
Adiustment reaction of adolescence
population
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Seventeen percent of the clients were diagnosed as “adjustment reactions of adolescence”. In this category, there was a much higher percentage of males (22%) than females (8%). Seven percent of the clients were diagnosed as neurotic, three percent as organic brain syndrome, three percent as schizophrenic, and one percent as having psychophysiological disorder gastrointestinal type.
Court History Forty-two percent (N=27) of the males and sixty-four percent (N=23) of the females were unknown to the Court prior to the present offense. The others were previously involved with the Court either through formal or informal charges. It was found that significantly more “hard” drug users had previous histories of formal court involvement than did the soft drug users (corrected X 2 = 6.6349, p < 0.05). The p:esent offenses were divided into four categories: ( 1 ) P.I.N.S. Petition (person in need of supervisiun). (2) J.D. Petition Guvenile delinquency) for sale and/or possession of a dangerous drug. (3) J.D. Petition for nondrug related offense (e.g., burglary). (4) Other (e.g., family offense). Twenty-eight percent of the males ( W l 8 ) were included in category 1, 28% (N=l8), in category 2, 27% ( W 1 7 ) in category 3, and 17% ( N = l l ) in category 4. The females were less evenly distributed between the first three categories with 67% (N=24) included in category 1, 14% (N=5) in category 2, none in category 3, and 19% (N=7) in category 4. Significantly more females than males were brought in on P.I.N.S. Petitions and significantly more males were brought in on J.D. Petitions.
RECOMMENDATIONS MADE BY EVALUATION TEAM There were no restrictions placed by the Family Court on the scope of the recommendations that could be made by the Hillside Team. Although recommendations could range from no therapeutic or court intervention through all forms of treatment modalities, and could have included
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a recommendation for placement in a reform school or jail, in no case was jail o r reform school ever recommended. Final recommendations were made only during a joint conference with probation personnel and were based on both our evaluation and additional information which was provided by the probation officer involved with the case. In almost all cases in conjunction with the primary treatment recommendation it was recommended that the client be placed on probation or, if already on probation, that the probationary period be extended. This was felt t o be an important tool both in the implementation of recommendations (a client may be considered in violation of probation if he did not follow the treatment plan) and in providing a structure and authority (outside the family) for the client. Also, a secondary recommendation for a 6 week trial period on anticonvulsant medication (Dilantin) was made when EEG and behavioral data so indicated. However, only primary recommendations are reported below. The majority of these recommendations can be divided into four major categories: ( 1 ) Outpatient therapy (2) Inpatient psychiatric treatment (hospitalization) (3) Drug programs (4) Special schooling Table 5 gives specific information on recommendations made. In 45% of the cases some form of outpatient therapy was recommended. Inpatient hospitalization was recommended in 12% of the cases. Drug programs were recommended in 15% of the cases, and special schooling was recommended in 22%. The final report was used by the probation department in the form of a recommendation to the presiding judge, o r as additional information to be used by the supervising probation officer in dealing with a problem client.
FOLLOW-UP INFORMATION Follow-Up Method and Ratings Follow-up information on the client’s progress at 1, 3, and 6 months after they were evaluated at Hillside was gathered via questionnaires
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Table 5. Treatment Recommendations by Sex
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Recommendation Outpatient therapy: Individual Family Group Day hospital Counseling Inpatient psychiatric hospitalization Day care drug program Community outpatient drug program Residential drug program Residential school Special education (BOCES, DVR, Remedial Reading, etc.) Neurological examination Other
% Males (N=64)
% Females (N=36)
25 9 5 0 5 13 3 6 2 17
22
9 2 4
0 3
11
3 3 8 11 6 3 14 14
2
% Total Population (N= 100) 24 10 4 1 6 12 4 5 6 16 6 2 4
distributed t o the Probation Officers. Through these questionnaires, information was supplied on the status of the recommendation made, the probationary status of the client, treatment information, familial adjustment, school and/or job status, and drug usage during follow-up period. Complete follow-up information was received on 83 clients. It was found that in 87% of the cases ( N = 7 2 ) the recommendation made by Hillside was accepted by the Probation Department and/or the court. The eleven cases in which the recommendations were not followed were of 3 types: ( 1 ) cases in which the status of the client had changed before he/she reached the court; for example, if the client violated probation, ( 2 ) cases in which the client refused t o accept the recommendation, but accepted an alternative plan, or ( 3 ) where probation felt a less structured treatment plan be attempted first. However, of the 7 2 cases in which the recommendations were accepted, there were 8 cases where the recommended treatment was not further implemented. The reasons for this vary from refusal of the client to accept treatment to an inability to place the client in the recommended treatment program. After the 1, 3 , and 6 month follow-ups were received on an individual,
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a judgment was made as t o the overall improvement during the 6 month period following the evaluation at Hillside. Ratings were made o n a 3 point scale where 1 = improved, 2 = no change, and 3 = worse. These ratings were made independently by the members of the evaluation team and reliability was significant at the p < 0.00 1 level (Kappa = 0.7 1, z = 7.32, unweighted). The follow-up scores are briefly defined below: 1. Improved: Client’s functioning has improved during the 6 month period. He/she has not violated probation, has been cooperative with the Probation Department, has improved his/her relationship with parents, is working o r in school (or both), and is receiving treatment (when treatment was recommended). Further, the client has not used any drugs. 2. No change: Client’s functioning has shown no real change during the 6 month period. He/she has been cooperative with the Probation Department, however, in some instances there were violations of probation. His/her relationship with parents has not improved, their school o r work status is unchanged, and treatment (when recommended) was frequently terminated after a short period or never entered into. Drug usage has continued. 3 . Worse: Client’s functioning has worsened during the 6 month period. He/she was uncooperative with the Probation Department and there were often violations of Probation. His/her relationship with parents has not improved and, in some cases, has worsened. Client is either unemployed and/or not in school. Treatment recommendations were not implemented and moderate to heavy drug usage is present. Table 6 shows the percentage of males and females in each followup category in those cases in which the recommendations were implemented. Approximately half of the male and female clients were considered as
Table 6. Percentage of Males and Females in each Follow-up Category (Implemented Cases Only, N=64) Follow-up Category % Improved
% No change
% Worse
% Insufficient information for rating
Males (N=40)
45
25
10
20
Females (N=24)
50
33
4
Total (N=64)
47
28
13 11
14
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“improved” in their overall degree of functioning six months after they were seen for evaluation and a recommendation was made for treatment. One-fourth to one-third of male and female clients showed “no change’’ and a much smaller percentage (10% for males and 13% for females) were considered as having become “worse”. In comparison, of the 19 cases in which Hillside’s recommendations were not followed ( 1 1 cases not originally accepted and 8 cases accepted but not implemented), only 4 were rated as improved. This represents 21% of the nonaccepted or not implemented cases as compared to the 47% rated as improved when our recommendations were accepted and implemented. This difference shows a trend, significant at the p < 0.10 level of significance (A? = 3.23), indicating that there was greater improvement in those cases in which the hospital recommendations were accepted and actually implemented. Possible characteristics which may distinguish between those clients in which treatment plans were implemented and those where they were not, are now being investigated.
SUMMARY In its first year and a half of operation, the Hillside diagnostic and evaluation services program for the Nassau Family Court System worked with a large number of adolescents and young adults for whom the Probation Department felt it needed additional help in developing a treatment plan or in the supervision of the client. Additionally, all those referred for evaluation had a history of drug use and evidence of impairment in some area of functioning. Each client seen at Hillside received a psychiatric interview, a complete battery of psychological tests, and a sleep and wake electroencephalogram. The client’s parents were also interviewed in order to supply a developmental and psychosocial history. The analysis of this information then served as the basis for a group conference between the Hillside Team and those in the Probation Department involved with the case. At this conference, a tentative treatment plan was outlined when appropriate. The average female client was 15.9 years old, white, Catholic, and from a middle class background. Her early childhood history was without apparent problems. She began using drugs at 12.8 years of age and her
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drug use history showed her to be a polydrug user who tended toward hard use. She was before the court on a P.I.N.S. Petition at the time of her Hillside Evaluation, but was previously unknown to the court. At the time of her evaluation she was seen as having severe functional impairment and was diagnosed as a Personality Disorder. The average male client was a 16.4-year-old white, middle class Catholic, who tended to have an abnormal EEG. Unlike the females, his early childhood history was marked with problems, usually manifest in behavior disorders in school. He began to use drugs at 13.3 years of age and while he also tended to be a polydrug user, his drug use was as likely to be primarily soft drugs as both soft and hard drugs. He was before the court at the time of his Hillside evaluation for either a Juvenile Delinquency Petition or a P.I.N.S. Petition and was previously known to the court. At the time of the evaluation he was seen as having severe functional impairment and was diagnosed as a Personality Disorder. The most outstanding personality descriptor of the overall population was “impulsivity”. Low self-esteem, psychopathy, anger, and anxiety were the major psychiatric symptoms presented by these clients. Diagnostically, the majority of these youths displayed characteristics of personality disorders, and most treatment plans were of an outpatient nature. Follow-up data collected from the Probation Department at 1 , 3, and 6 months after the client was seen at Hillside indicated that approximately half the clients showed improvement. There was a higher percentage of improvement in those cases where the recommendations were implemented than in those where they were not. One reason for this may be simply that the plans were in fact implemented; another may be a type of client and client situation (e.g., family acceptance of plan) for whom there is a better treatment prognosis. Still another possible explanation may be that in this type of population the authority of the court acts as a necessary external motivator for positive involvement in treatment. A similar observation to this was suggested in the report of a similar program between a court clinic and the Jewish Board of Guardians [ 101, We are presently investigating these and other possible indicators of treatment outcome.
ACKNOWLEDGMENT The authors wish to thank Thomas Castiglia, Elizabeth Brautigam, and the entire staff of the Nassau County Family Court Probation Department. We also thank
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Melvin Anderson and the staff of the Adult Division of the Nassau County Probation Department.
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