Youth Gang Members : Psychiatric Disorders and Substance Use

Objective: Approximately 260,000 of youth in the United States are gang-affiliated. There is a paucity of data available to identify the prevalence of mental health disorders in this population. Gang members share many of the features of “at risk” or juvenile justice involved youth who deny gang membership. The authors identified rates of psychiatric disorders within a juvenile justice population delineated in three categories: gang members, friends of gang members, and non-gang members. Methods: A retrospective review of records obtained by a juvenile probation department. A large detention center conducted mental health screenings on 7,615 youth aged 13–17. The mental health screenings were performed by either a master level or doctoral level mental health professional. Odds ratios were computed as an effect size for gender, race/ethnic differences, and gang-membership associations with self-reported psychiatric and substance use disorders. Logistic regression was used to evaluate the risk for psychiatric and substance use disorders among gang-members and friends of gang members. Diagnostic information was generated through a clinical interview and flexible battery. Results: Of the 7,615 youth in this study, ~50% had contact with gangs; 11% were self-identified gang-members, and 38% acknowledged having at least one friendship with a gang member. Similar to other studies, being male was a risk-factor for gang-membership (2.31 odds). In this multi-racial and ethnic study, Latinos had a greater affiliation with gang membership and association with gang members as friends (1.44 odds). Gang members were found to have increased rates of post-traumatic stress disorder (1.77 odds), current substance abuse (2.58 odds), oppositional defiant disorder, (1.24 odds) and conduct disorder (4.05 odds); however, they were less likely to have an adjustment disorder than non-gang members (0.70 odds). Conclusions: Juveniles who received a mental health assessment in this study were found to have differences in rates of psychiatric disorders and substance use based upon gang-affiliation or association. Current data is limited and inconsistent in the delineation of individual, family, peer, school and community characteristics specific to gang members. These differences warrant further investigation for intervention and treatment.


Introduction
In the United States, there are an estimated 29,000 gangs and nearly 750,000 members; 260,000 of those are adolescents.Adolescents make up 30-40% of these members highlighting that many members continue involvement into adulthood.46% of members are Hispanic or Latino, 35% Black or African Americans, 11% White and the remaining 7% are of mixed races/ethnicities [1].In communities where gang activity is new, more members are White [2].Nearly 10% of gang members are female.[1] Gang involvement, gang proliferation and gang violence have become common features of 21 st Century America.[3] Yet, the mental health literature is sparse with respect to evidenced-based interventions to prevent gang entry or to effectively provide mental health care for this patient population [4,5].There are few articles about gang involvement in the mental health literature [6][7][8].The complexity of youth gang members' psychological well-being and cognitive capabilities are unappreciated by our field.This is especially true when comparing the mental health of gang versus non-gang members who have been detained for suspected criminal acts.
There are approximately 100,000 adolescents detained in the criminal justice system in the United States.Gang members share many of the features of "at risk" or juvenile justice involved youth who deny gang membership [9,10].Current data is limited and inconsistent in the delineation of individual, family, peer, school and community characteristics specific to gang members [8,11,12].These youth have been characterized as frequently poor, with poor academic involvement and performance.They have been described as having an early onset of substance use, having an affiliation with aggressive peers in early adolescence, and inconsistently residing in disadvantaged communities.
Alleyne and Wood (2010) reviewed previous research examining the contributions of psychological processes predisposing an individual to either join or exit a gang [13] Researchers have posited when there is a lack of environmental prosocial supports (i.e., home, school, and community), risk factors such as low self-esteem, impulsivity, risk-seeking and the use of cognitive strategies that justify and rationalize harmful behaviors towards others predispose youth to illegal activity and gang involvement.Their research findings supported previous work and found cognitive differences were found with respect to assigning 'blame' for criminal acts.Youth who were either peripherally involved with gangs or gang members were more likely to blame either superiors (peripheral) or victims (gang member) for the crime in comparison to the non-gang member.Youth gang members as a whole displayed a greater level of anti-authority than either peripheral youth or non-gang members.
Gang-affiliated youth are often outside the bounds of the traditional mental health services and have particular needs.Because of the increased risk to exposure to violence, these youth have increased rates of post-traumatic stress disorder symptoms [8,11,12].There are high levels of mental health disorders within the juvenile detention population as a whole, estimated to affect between 40-70%, including psychotic disorders, mood disorders, attention deficit hyperactivity disorder, disruptive behavior disorders, and substance use disorders [9].In the last few decades, researchers have taken a systematic look at the connection of these youth with the mental health care system and treatment of these conditions.The prevalence of psychiatric disorders in detained youth is greater in comparison to the counterparts in the community (60-70% versus 20-25%) [14,15].Youth who are detained have increased rates of psychiatric co-morbidity; ethnic and gender differences have been identified [14].Coid et al. (2013) conducted a recent study in the United Kingdom and identified differences in the prevalence of mental health disorders and service utilization among young adult gang members, violent men, and non-violent men.They identified higher rates of psychosis, anxiety, antisocial personality disorder, suicide attempts, alcohol dependence, and drug dependence in young adult gang members in comparison to violent and non-violent men; however, both gang members and violent men had a lower prevalence of depression.In addition, both gang members and violent men utilized mental health care services at greater rates than non-violent men [7].
The aim of this study was to compare the rates of psychiatric disorders in youth gang members, friends of gang members, and non-gang members and to identify any demographic trends in these populations.The authors hypothesized there would be increased rates of psychiatric disorders in gang members versus non-gang members.

Methods
The Institutional Review Boards at Baylor College of Medicine and the Harris County Probation Department (HCJPD) both approved this retrospective study.For the purpose of this study, the files from all Harris County Juvenile Detention mental health screenings were reviewed for individual information: age, ethnicity, languages spoken, medical history and psychiatric history and for predetermined variables to ascertain current/prior gang membership and or affiliation.To ensure patient privacy and for analytical purposes, the senior psychologist at HCJPD assigned an identification number to the file of each who received a mental health screening or assessment.The data from each file were entered and compiled into a computerized database in a coded format.
Between 2007-2011, all juveniles less than 18 years of age (n = 7,615) who were detained within the Harris County Probation Department Center for more than 24 hours received a mental health screening.Additionally, juveniles who were detained less than 24 hours but received a mental health referral or testing request also received a mental health screening.The mental health screenings were conducted by either a master or a doctoral level clinician.Each juvenile's mental health screening and diagnostic conclusions were generated primarily from the clinical interview, and a review of available medical records.This current study focuses on those participants who screened positive for current and previous substance use, and met criteria for post-traumatic stress disorder, conduct disorder, oppositional defiant disorder and adjustment disorder.During the assessment, the clinician also inquired about each juvenile's youth gang affiliation.They were asked which of the following three categories best described their gang affiliation: gang member, friend of gang members, or non-gang member.
Investigators entered data into a relational database file that was password protected and located on a secure computer in the psychiatry division of Baylor College of Medicine.The researchers maintained data integrity by restricting allowable input values on a standardized entry form.The investigators calculated descriptive statistics for demographic, and clinical or examination findings from structured interviews.All dependent and independent variables were dichotomized (e.g., 0 = no gang membership, 1 = gang membership) and odds ratios were computed as an effect size of predicted associations.Logistic regression was used to evaluate the risk for psychiatric and substance use disorders among gang-members and friends of gang members.Dummy codes were used to create ethnic categories that were compared to the White reference group.To investigate variation of gang membership across gender and ethnic/racial groups, interaction terms crossing ethnicity/race by gender were added to the main effects logistic model.

Descriptive Statistics
There were 6264 males and 1351 females including in analyses.Of those, 833 endorsed gang membership (11%), while 2911 endorsed having at least one friendship with a gang member (38%).
Descriptive statistics for demographic variables, gang membership, and mental health diagnoses are presented in Table 1.The authors evaluated the extent to which gang membership was associated with reported mental health diagnosis (see Table 2).Consistent with our hypothesis, results demonstrated that gang membership was associated with 1.77 greater odds of having a diagnosis of post-traumatic stress disorder (PTSD), 2.58 greater odds of a current diagnosis of substance abuse, 1.24 greater odds of a diagnosis of oppositional defiant disorder (ODD), and 4.05 greater odds of conduct disorder (CD).In contrast, gang members were less likely to have a diagnosis of adjustment disorder (OR = 0.70) than non-gang members.There was no difference between gang members and non-members on rates of past substance abuse.Individuals who identified at least one friendship with a gang member were also at increased odds of having a current diagnosis of substance abuse (2.24), ODD (1.31), and CD (2.57) compared to non-gang members.Conversely, friendship with a gang member was associated with lower rates of adjustment disorder (OR = 0.77) compared to non-gang members.There were no differences between friends of gang members and non-members on rates of PTSD or past substance abuse.

Associations between Gender and Ethnicity and Gang Membership
The authors also examined the gender and ethnic differences among gang members, friends of gang members, and non-gang members (Table 3).Results indicated that males had 2.31 greater odds of gang membership and 1.48 greater odds of friendship with a gang member than females.The odds of gang membership were significantly greater among Black (OR = 1.45) and Latino participants (OR = 1.89) as compared to White participants.The odds of having a friend in a gang were significantly greater among Latino participants (OR = 1.44) as compared to White participants.Two-way interaction effects were evaluated between gender and the four ethnic groups.Tests revealed no significant interaction effects among gender and ethnicity on gang-membership or gang friendships.

Conclusions
Our study's primary aim was to compare rates of psychiatric disorders and substance use in youth gang members, friends of gang members, and non-gang members.Similar to research conducted to identify the prevalence of psychiatric disorders in juveniles who are detained and in adult gang members, gang members in our study had higher rates of post-traumatic stress symptoms, current substance use, oppositional defiant disorder and conduct disorder.In our study, friends of gang members had similar increased rates of psychiatric disorders and substance use as gang members.Both gang members and friends of gang members had lower rates of adjustment problems; however, friends of gang members had lower rates than gang members.These findings will need further examination but could have occurred because they met criteria for more severe and persisting disorders.
Another aim of this study was to evaluate for gender and racial/ethnic trends in gang membership.The demographic patterns of youth gang members have varied over time and are reflective of the community's racial and ethnic composition [8,13].Males from Irish descent in prior decades participated in youth gang activity at rates higher than other groups in the United States [8,16].However, in more recent decades, males from Latino and African American communities have participated in gang activity in higher levels in comparison to their White and Asian peers [1,8,17] Consistent with more recent findings, in the current study, males were found to have higher rates of gang membership, and Latinos endorsed increased rates of gang membership and gang association in comparison to other ethnic groups.
Our study was limited by the lack of collateral reports and standardized evaluation methods (i.e., DISC-computerized diagnostic interview schedule for children) to confirm psychiatric diagnoses.While our study population was diverse, these were juveniles from one location in an urban area and may not be easily to generalize when considering other geographical areas.
This study is an important step in better appreciating the mental health of adolescent gang members.Although previous studies have identified the prevalence rates of youth who are detained, there remains limited data to assist with understanding any unique mental health needs of youth who are gang-affiliated including their prior histories and ongoing risk for trauma exposure.There is also a need for health and mental health professionals to be informed of evidenced-based interventions to either prevent or reduce gang-activity in youth, as well as established hospital protocols for the clinical management of youth who are gang-affiliated during hospitalization and in outpatient treatment settings [18,19].Strategies for health and mental health care providers to engage at-risk youth, families, and communities are essential in order to effectively provide informed health care and pro-social and viable alternatives to gang-activity.Future studies are warranted to continue efforts to examine individual, family, community and cultural risk and protective factors to best serve this population.

Table 1 .
Descriptive Statistics for Study Variables.

Table 2 .
Associations Between Gang Membership and Mental Health Diagnosis.

Table 3 .
Associations Between Gender, Ethnicity and Gang Membership.