International Journal of Criminal Justice Sciences Vol 3 Issue 2 July - December 2008 Copyright © 2008 International Journal of Criminal Justice Sciences (IJCJS) July – December Vol. 3 (2): 129–137

ISSN: 0973-5089

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Psychiatric Disorders in Iraqi Delinquents during Sanction Period

Juvenile

Ali Abdurrahman Younis 1 Al Ain General Hospital, United Arab Emirates

Wasam Ibrahim Al-Admawi

2

Royal Oman Police Hospital, Muscat, Oman

Saeed Yousef 3 Faculty of Medicine and health Sciences, UAE University, United Arab Emirates

Hamdy Fouad Moselhy 4 Faculty of Medicine and health Sciences, UAE University, United Arab Emirates

Abstract The aim of this study was to investigate the prevalence of psychiatric disorders in a sample of delinquent adolescents in an Iraqi pre-trial detention during sanctions period. Participants were recruited from outpatient attendees at a psychiatric service in Babylon, Iraq, between July 2001 and September 2001. Delinquent adolescents aged between 11 and 18 years, with a history of index offence, who were referred by the juvenile court for psychiatric evaluation, were included in the study. Inclusion criteria comprised of a sample size of 100, all consecutive clinic attendees, with their guardian agreement to participate. Psychiatric disorders were high in delinquent Iraqi adolescents during the sanction period; the levels were less compared to other societies without community-level trauma. Further research in other countries is needed to replicate our results with respect to sociocultural influences. ________________________________________________________________________ Key Words: Delinquents; Iraq; Community; Psychiatric Disorders.

Consultant psychiatrist, Al Ain General Hospital, United Arab Emirates Specialist, Royal Oman Police Hospital, Muscat, Oman 3 Research Assistant, Faculty of Medicine and health Sciences, UAE University, UAE University, United Arab Emirates 4 Associate professor, Department of Psychiatry and Behaviors Sciences, Faculty of Medicine and Health Sciences, UAE University, United Arab Emirates Email: [email protected] (Corresponding Author) 1

2

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Younis et al., – Psychiatric Disorders in Iraqi Juvenile Delinquents during Sanction Period

Introduction Juvenile delinquency is a legal term for behavior of children and adolescents that in adults would be judged criminal by the law. In the United States, definitions and age limits of juveniles vary, with the maximum age being set at 14 years in some states and as 21 years in others (Columbia Encyclopedia, 2007). In the late 1800s several states began to adopt the practice of trying adolescents and children separately from adults (Roush, 1996). These practices stemmed from social attitudes that recognized adolescents as developmentally different from adults and changed criminal court procedures so that juveniles, instead of being punished for crimes, could be guided through state intervention into more mature and healthy pathways to adulthood (Lathrop, 1912). Young people may enter detention centers for several reasons. First, those who are perceived to be at high risk of committing new crimes are detained for the safety of the community. Second, certain charges, such as homicide or sexual assault, are serious enough to warrant automatic detention. Third, youths who might not make required court appearances are detained until the case can be adjudicated. Finally, many youths enter detention because they appear to be suitable alternatives. That is, courts and other decision makers are concerned that there is no suitable adult to supervise, or a suitable child in detention because they are unable to control their child’s behavior (Desai et al., 2006) In the field of research into delinquency, researchers have tried to identify the causes of delinquency. The most common research design compared groups of delinquent and nondelinquent youths on a variety of factors implicitly believed to reflect the causes of delinquency; factors such as intra- and interpersonal characteristics of the young, family and community characteristics (Aber et al, 1989). The impact of the longitudinal studies on the relationship between age and crime in both the UK and in the USA has proved twofold (Hollin, 1990). The first effect has been in highlighting the ‘normality’ of delinquency in adolescence, where finding suggests that a substantial number of adolescents have committed at least one criminal offence, and secondly, that most crimes committed by adolescents are relatively trivial. Majority of the minor delinquent acts go undetected, meaning that most young people do not come in contact with the criminal justice system, and by their late teens and early twenties the erstwhile delinquents have grown out of crime. A much smaller proportion of adolescents do commit both serious offences and a disproportionately high number of offences. This, in turn, has led to the dichotomy in conceptualization between exploratory delinquents, for whom a small number of petty offences are simply a part of the normal developmental adolescent pattern, and chronic offenders who because of their persistent serious offending appear set for a long-term recidivist career (Hollin, 1990). Such findings have sparked a new way of theorizing about delinquency, often called a developmental perspective, in which the emphasis is on understanding the dynamic, complex interaction between the maturing young person and their environment, which culminates a host of new behavior, including delinquency (Aber et al, 1989). It seems highly unlikely that delinquent behavior occurs independently of other adolescent problem behavior; rather, the more probable pattern is of a cluster of problems such as drug and alcohol use, family difficulties, and poor educational progress (Osuna & Luna, 1989). Severe aggressive behavior is mostly a part of delinquency and is very persistent if manifested at a young age (Robins, 1980). Aggression is an inborn human disposition that is shaped (modeled) by many environmental influences, of which education in a broad 130 © 2008 International Journal of Criminal Justice Sciences. All rights reserved. Under a creative commons Attribution-Noncommercial-Share Alike 2.5 India License

International Journal of Criminal Justice Sciences Vol 3 Issue 2 July - December 2008

sense is the most important (Remschmidt, 1990). Aggression is not a diagnostic category in the psychiatric classification schemes. Neither ICD nor DSM diagnostic categories refer explicitly to the term. However, there are different categories, the most important of which is ‘conduct disorder’ that include aggressive behavior as a frequent symptom (Remschmidt, 1990). The growth of violence in Iraq is no longer a question of statistics but a part of its population’s daily life (Howard, 2007). People are afraid of children who, instead of playing with toy guns, use real machine ones to kill them. This is, however, not a problem restricted to Iraq, but is one that affects other countries, even during peace (Andrade et al., 2004; Group for the Advancement of Psychiatry, 1999). Although extensive research has been done on juvenile delinquency, most of the studies tend to focus on countries with more favorable social and economic conditions. Little information is available on delinquency in community-level trauma, where material deprivation; poverty and fear of war are essential components of a person’s daily life. Less still is known about trauma in adolescents in war torn areas. The aim of this study was to investigate the prevalence of psychiatric disorders in a sample of delinquent adolescents in an Iraqi pre-trial detention during the sanction period. Iraq Juvenile Criminal Law, concerning minors between 9 and 18 years old is marked by its mandatory character. In all offences the juvenile court has to request a forensic psychiatric examination in order to be able to impose a measure of restraint (Mahmoud, 2004).

Methods Participants and Procedure Participants were recruited from outpatient attendees at a psychiatric service in Al Hila city, Babylon, Iraq, between July 2001 and September 2001. Delinquent adolescents aged between 11 and 18 years, with a history of index offence, who were referred by the juvenile court for psychiatric evaluation, were included in the study. A sample size of 100 was aimed for, and all consecutive attendees at the clinic were interviewed, until this number was reached. Patients were excluded from the study if they/or their guardian refused to participate. Twenty four guardians and 11 adolescents refused to participate in the study. All of these subjects were excluded and a total of 100 adolescents participated in the study. The interviews were conducted in quiet, comfortable settings and each interview lasted for about two hours. Measures A screening interview based on the first and second parts of the Schedule for Affective Disorders and Schizophrenia for School-Age Children-Lifetime (KSADS-PL) (4) was used. All interviews were carried out by a single researcher (AY) to avoid methodological bias. The nature and scope of the study was discussed with each adolescent or their guardian and a written informed consent was obtained from all of them before the interview. The local review board of Merjan Hospital approved this study. Clinical Setting The psychiatry in-patient and out-patient facilities in Al-Hilla city exists in the Merjan General Hospital site. It has an open referral policy completely free of charge, with 400 131 © 2008 International Journal of Criminal Justice Sciences. All rights reserved. Under a creative commons Attribution-Noncommercial-Share Alike 2.5 India License

Younis et al., – Psychiatric Disorders in Iraqi Juvenile Delinquents during Sanction Period beds including 20 psychiatric beds. It serves the population of the whole Babylon governorate (1,200,000 people). Because of the sanction, the members of the multidisciplinary team offered very limited varieties of treatment modalities. Data analysis Analyses were performed using the Statistical Package for Social Sciences (SPSS, version 14). Descriptive statistics were used to summarize socio-demographic and clinical characteristics of the sample. To examine non-parametric data χ2 were used. All statistical tests were considered significant at p<=0.05.

Results Study sample description The mean age of the sample was 17 years (range= 11-18 years). The most common age group was 18 years (31%, 27 males and 4 females). A majority of the sample was males 92 (92%), singles, with primary school level of education, living in rural areas, in big families, and working in unskilled jobs. Some of the relevant demographic and clinical characteristics of the sample are given in Table I. Table I. Baseline demographic characteristics Demographic Characteristics Marital status Married Single Education Illiterate Primary intermediate Secondary Residency Urban Rural Employment Unemployed Unskilled Skilled Student Family size Less than 5 More than 5

N

M

F

2 98

1 91

1 7

19 52 25 4

14 50 24 4

χ2

Df

P

4.891

1

0.154

10.771

3

0.013

5.158

1

0.026

42.455

3

0.001

0.039

1

0.603

5 2 1 0

58 42

51 41

7 1

17 60 9 14

9 60 9 14

8 0 0 0

28 72

26 66

2 6

132 © 2008 International Journal of Criminal Justice Sciences. All rights reserved. Under a creative commons Attribution-Noncommercial-Share Alike 2.5 India License

International Journal of Criminal Justice Sciences Vol 3 Issue 2 July - December 2008

Use of concurrent psychoactive substances Table II presents data on the concurrent use of psychoactive substances by the adolescents. A minority of the sample (n=23) smoked cigarettes, but there were no significant differences between the two genders of adolescents (χ2=2.59, df=1, p=0.10). In addition, there were no significant differences between the two genders, on either the use of drugs (χ2=0.17, df=1, p=0.17) or drinking alcohol (χ2=0.55, df=1, p=0.45). The few patients who abused alcohol (6%) or benzodiazepine (2%) used it infrequently and in relatively small amounts. Table II. Psychiatric disorders, drug abuse, and types of crimes

Disorders Conduct disorder Learning disability (mental retardation) Affective disorders Anxiety disorder Attention deficit hyperactivity disorder Cigarettes smoking Drug abuse Alcohol abuse Theft Fights Murder Sexual offence Vandalism

Total number 22

Male N (%)

Female N (%)

20 (90.9)

2 (9.1)

5

5 (100)

0 (0)

13

12 (92.3)

1 (7.7)

7

3 (42.1)

4 (57.9)

17

17 (100)

0 (0)

23

23 (100)

0 (0)

2 6

2 (100) 6 (100)

0 (0) 0(0)

39 37 12 8

38 (97.4) 34 (91.9) 12 (100) 4 (50)

1 (2.6) 3 (8.1) 0 (0) 4 (50)

4

4 (100)

0 (0)

Levels of psychopathology and committed crimes Table II shows that 64% of the patients suffered syndromal psychopathology, and no significant sex differences (χ2=3.15, df=4, p=0.37). None of these patients were on any prescribed psychotropic medication. Murder was purely a crime committed by males (12%), and theft crime was more significant in males than females (χ2=22.1, df=4, p=0.001). 133 © 2008 International Journal of Criminal Justice Sciences. All rights reserved. Under a creative commons Attribution-Noncommercial-Share Alike 2.5 India License

Younis et al., – Psychiatric Disorders in Iraqi Juvenile Delinquents during Sanction Period Impact of poverty on delinquency Table III shows the significant relationship of living in a low income family and some clinical characteristics of delinquency. The sample was divided into 3 groups according to the income of the family: poor (earnings less than one American dollar a day); medium (earnings around five dollars a day); and high earning (earnings of more than 20 dollars a day). Table III highlights those delinquents who lived in low income families were more likely to live in urban areas, are either illiterate or with primary school level of education, and involved mostly in theft or fighting crimes. Table III. The significant relationship of poverty (income) and some clinical characteristics of delinquency

Low Residency Rural Urban Crimes Theft Fights Murder Sexual offences Vandalism Education Illiterate Primary Intermediate Secondary

Middle

N

%

38 47

44.7 55.3

2 11

High

15.4 84.6

2 0

χ2

P

9.147

0.01

110.897

0.001

100 00

39 37 8 1

45.9 43.5 9.4 1.2

0 0 4 7

00 00 30.8 53.8

0 0 0 0

00 00 00 00

0

00

2

15.4

2

100

19 50 16 0

22.4 58.8 18.8 00

00

0 0 0 2

00 00 00 100

74.168 0 2 15.4 9 69.2 2 15.4

0.001

Discussion and Conclusion The current findings show that the prevalence of psychiatric disorders in Iraqi juvenile delinquents, during sanction period, is 64%. The findings are especially frequent for conduct disorders and ADHD participants. The findings also suggest that such behaviour is more likely amongst males, with low level of education, and live in low income families. The findings cannot be due to a clinical filter since this is a result of mandatory assessment for all juveniles who commit offences and present in front of juvenile court. One of the limitations of this study was the lack of a control group. As we only set out to characterize the psychopathological profile of delinquents. Future research is appropriate to compare with normal healthy controls. It seems reasonable to examine the correspondence between these and other studies (Andrade et al., 2004; Anckarsater et al., 2007) demonstrating a rate of 53-73% for different psychiatric disorders in a juvenile 134 © 2008 International Journal of Criminal Justice Sciences. All rights reserved. Under a creative commons Attribution-Noncommercial-Share Alike 2.5 India License

International Journal of Criminal Justice Sciences Vol 3 Issue 2 July - December 2008

delinquent population. The limited sample size and the inclusion of only pre-detention juvenile court referrals are potential limitations that could limit the validity and generalizability of the findings. A wide range of psychiatric disorders were reported by our sample of patients. They included conduct disorder (n=22, 22%), ADHD (17%), affective disorder (13%), anxiety disorder (7%) and learning disability (5%). Only few males reported drug or alcohol abuse (n=8, 8%) and nearly a quarter of the whole sample (n=23, 23%) smoked cigarettes. Results did not show any significant differences between sexes across the following parameters of demographic and clinical characteristics: marital status, living in big families, drug or alcohol use, and the distribution of mental illnesses. Anckarsater et al (2007) in a study of prevalence of mental disorders among institutionalized adolescents demonstrated pervasive developmental disorder in 15% of their sample and 39% of attention deficits/hyperactivity disorder. Our study found the rates to be 0% and 17% respectively. Possibly this could be due to the high level of vigilance in the community created by the state of war and sanction that will need a high level of organization to commit crimes, as it is deficient in these group of adolescents. The studies’ findings of psychiatric disorders in delinquency are inconsistent. The prevalence of major affective disorder in the studies varies from 5 percent to 88 percent and psychoses vary from 12 percent to 45 percent (Domalanta et al., 2003; Shelton, 2001; Pliszka et al., 2000). Such inconsistencies may arise from discrepancies in methodology or then the recruitment was at different points in the criminal justice system (pre-detention or already in prison). Our study found the rates to be 13 percent and 0 percent respectively. In addition, Andrade et al (2004) found 63% for illicit drug abuse and 58% for regular alcohol abuse. Contrary to the experience of Andrade et al (2004) and other (Hollin, 1990), there was a low level of alcohol abuse, as minority of males (6%) used it. Where the role of alcohol in the etiology of delinquency has been much researched and it has been concluded that there would appear to be some relationship (Hollin, 1990). It is interesting to note that this theory is not true in all circumstances, where communityrelated restrictions regarding alcohol and drugs might be responsible for the fact that there was no overall high prevalence of abuse. Furthermore, oppositional defiant disorder was reported between 2 percent to 41 percent (McCabe et al, 2002; Duclos et al, 1998; Rohde et al, 1997), however in our study it was nil. This is mainly because we considered oppositional behaviors during the sanction and war as often a normal part of coping with the community stress. However, this needs further evaluation, particularly when compared with other adolescents of the same age and developmental level. The plasma levels of testosterone hormones has not been estimated in our sample, hence it is difficult to comment on the possible etiological mechanisms for severe aggressive behaviors in the male group e.g. murder. However, some researchers (Steiner, 1997; Remschmidt, 1990) have proposed many possible explanations. Firstly, conduct disorders are predominantly male conditions. Secondly, there are also gender-specific features, with a tendency towards physical aggression among boys (Archer et al., 1988) and tendency towards covert crimes and prostitution among girls (Andrade et al., 2004). These differences cause boys to be more easily arrested than girls. In our study it seems that living in a low income family and hence poverty had an etiological role in delinquency. If indeed, the delinquency reported is likely to be a direct effect of poverty (whether mediated by psychiatric disorders mechanisms or not), it is striking that adolescents living in medium to high income families had significantly fewer 135 © 2008 International Journal of Criminal Justice Sciences. All rights reserved. Under a creative commons Attribution-Noncommercial-Share Alike 2.5 India License

Younis et al., – Psychiatric Disorders in Iraqi Juvenile Delinquents during Sanction Period problems compared to adolescents on low income. High income induced significantly fewer crimes than low income in areas of theft, fighting, murder, but not in cases of sexual offences or vandalism. Low income adolescents were also higher (though not statistically significant) to medium/high incomes in areas of living in big families and using drugs or alcohol. Not having evaluated the reasons of fighting of the low/medium income adolescents, it is not possible to reason whether poverty induces relatively less levels of activity, and more time spent in social interaction, hence causing more crimes. However, this is tempting to speculate, as physical activities such as sports (as opposed to social interaction) are a good release of both endorphins and serotonin, and hence is likely to induce a sense of wellbeing and less aggression toward others. However, this needs further evaluation before any firm and valid conclusions are drawn. A prospective clinical trial with random assignment would be the optimum way to evaluate differences in aggressive crimes between delinquent juveniles. In conclusion although results show that psychiatric disorders are high in delinquent Iraqi adolescents during the sanction period, the levels were less compared with other societies without community-level trauma. As there was no available data from the time before sanction, it is difficult to conclude if there are clear associations between delinquency and sanction. Further research in other nations is needed to replicate our results with respect to socio-cultural influences. References Aber, M.S., Orcutt, H., & Eitel, S. (1989). Recent trends in delinquency research: developmental and feminist perspectives. Current Opinion in Psychiatry, 2, 764-769. Ambrosini, P. J. (2000). Historical development and present status of the schedule for affective disorders and schizophrenia for school-age children (K-SADS). Journal of the American Academy of Child and Adolescent Psychiatry, 39, 49-58 Anckarsater, H., Nilsson, T., Stahlberg, O., Gustafson, M., Saury, J. M., Rastam, M., & Gillberg, C. (2007). Prevalences and configurations of mental disorders among institutionalized adolescents. Developmental Neurorehabilitation, 10(1), 57-65. Andrade, R. C., Silva, V. A. & Assumpcao, F. B. (2004). Preliminary data on the prevalence of psychiatric disorders in Brazilian male and female juvenile delinquents. Brazilian Journal of Medical and Biological Research, 37, 1155-1160. Archer, J., Pearson, M. A., & Westeman, K. E. (1988). Aggressive behavior of children aged 6-11: gender differences and their magnitude. British Journal of Social Psychology, 27, 371-384. th Columbia Encyclopedia, Six Editions. Columbia University Press. Retrieved on 25 July 2008 from www.encycopedia.com/doc/1E1-juvenil- d.html. Desai, R. A., Goulet, J. L., Robbins, J., Chapman, J. F., Migdole, S. J., & Hoge, A. (2006). Mental health care in juvenile detention facilities: a review. Journal of American Academy of Psychiatry and Law, 34: 204-214. Domalanta, D. D., Risser, W. L., Roberts, R. E., & Risser, J. M. H. (2003). Prevalence of depression and other psychiatric disorders among incarcerated youths. Journal of the American Academy of Child and Adolescent Psychiatry, 42, 477-484. Duclos, C. W., Beals, J., Novins, D. K., Martin, C., Jewett, C. S., & Manson, S. M. (1998). Prevalence of common psychiatric disorders among American Indian adolescent detainees. Journal of the American Academy of Child and Adolescent Psychiatry, 37, 866-873. 136 © 2008 International Journal of Criminal Justice Sciences. All rights reserved. Under a creative commons Attribution-Noncommercial-Share Alike 2.5 India License

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