Associations Between Childhood and Adolescence Adversity and Risk for Arrest Among Patients With First-Episode Psychosis

The marked overrepresentation of individuals with serious mental illnesses in the U.S. criminal justice system is a thoroughly documented national problem. An estimated one to two million persons with serious mental illnesses are booked into jails each year (1), and many have a history of repeated arrest (2). A small body of evidence has also documented the heightened risk for criminal justice involvement in samples of people with early psychosis. In a recent study, 9% of early psychosis patients had a recent history of legal involvement before treatment contact (3). Another report indicated that 29% of patients with first-episode psychosis (FEP) had a history of criminal offending before treatment (4). Jail detention is also not uncommon. In one study, 14% of first-admission patients with psychosis had been incarcerated before their hospitalization, and 9% were incarcerated in a 4-year follow-up period (with almost 4% having been incarcerated multiple times) (5). Given these issues, understanding the factors that affect the likelihood that a young person with FEP becomes entangled in the criminal justice system is critically important.

Several studies have shown substantial correlations between adverse childhood experiences and increased risk for arrest in adulthood. For example, Jung et al. (6) reported associations between childhood maltreatment from childhood welfare reports and adult crimes against property, persons, and society among both females and males. The association with crimes against society persisted even after controlling for childhood socioeconomic status, gender, racial-ethnic minority status, marital status, and education level. Maxfield and Widom (7) reported that childhood victims of abuse or neglect identified from court records were more likely than persons in a control group to have a juvenile or adult arrest for any nontraffic offense (49% vs. 38%, respectively).

Limited previous research has also suggested an association between adverse childhood experiences and increased risk for arrest among adults with serious mental illnesses (8). Many patients with a history of schizophrenia and criminal justice system involvement have experienced childhood adversity, such as physical and sexual abuse (8). Studies have not yet assessed associations between childhood adversity and arrest among young people with FEP, despite reports that they have high rates of childhood adversity (9) and arrests (5, 10, 11). Repeated, prolonged experiences of childhood trauma and adversity, called toxic stress, can increase the risk for a wide variety of maladaptive behaviors and poor health outcomes through both biological and psychological pathways (12). As such, it is critical to interrogate the relationship between different types of childhood adversity and arrests.

In this analysis, we used existing data from a cross-sectional and retrospective study of the impact of premorbid marijuana use on age at onset of psychosis and clinical characteristics, thereby providing a well-characterized, relatively large sample of hospitalized patients with FEP (13). The parent project thoroughly measured adversity in childhood and adolescence and also queried participants about arrest history. It was hypothesized that adversity in childhood and adolescence would be associated with an increased likelihood of arrest and a greater number of arrests. Another objective was to determine which domains of adversity had the greatest impact. Finally, we assessed whether associations differed by gender, given some evidence of differential associations among genders (14).

Methods

Eligibility criteria for study participants included the following: ages 18–40 years, English speaking, absence of a known or suspected intellectual disability, Mini-Mental State Examination (15) score of ≥24, absence of a major medical condition compromising the ability to participate, ability to give informed consent, having no previous treatment for psychosis lasting >3 months, and having no previous hospitalization for psychosis earlier than 3 months before the index hospitalization. The vast majority of participants were completely treatment naïve. Trained master’s- or doctoral-level assessors conducted the in-depth assessments for the parent study, focusing on premorbid marijuana use and age at onset of psychosis (13). All study procedures were approved by institutional review boards at Emory University and The George Washington University.

Potentially eligible patients with FEP were referred to the study from three inpatient psychiatric units in Atlanta and three in Washington, D.C. Among 549 patients referred between August 2008 and June 2013, 247 were eligible, interested in participating, and enrolled. The 247 enrolled did not differ from the 302 excluded in terms of age, race, or ethnicity; however, the enrolled sample had a smaller proportion of female patients than the excluded sample (N=63 [26%] vs. N=111 [37%], respectively; χ²=7.94, df=2, p=0.005). No other variables were collected from the excluded group.

Diagnoses made by the Structured Clinical Interview for DSM-IV Axis I Disorders included the following: schizophrenia, paranoid type (N=97, 39%); psychotic disorder, not otherwise specified (N=38, 15%); schizophrenia, undifferentiated type (N=33, 13%); schizophreniform disorder (N=29, 12%); schizoaffective disorder, depressive type (N=26, 11%); schizophrenia, disorganized type (N=11, 5%); schizoaffective disorder, bipolar type (N=5, 2%); delusional disorder (N=4, 2%); brief psychotic disorder (N=2, 1%); and schizophrenia, catatonic type (N=2, 1%).

As part of the assessment of sociodemographic characteristics, participants were asked about any history of arrest and, among those endorsing an arrest, the number of arrests. We thoroughly assessed adversity in childhood and adolescence by using the following seven instruments as described in a previous report (16): Childhood Trauma Questionnaire–Short Form, Trauma Experiences Checklist, Parental Nurturance Scale, Parental Harsh Discipline Scale, Violence Exposure Scale, Friends’ Delinquent Behavior Scale, and School Connectedness Scale. A previously conducted factor analysis with these seven instruments’ 14 subscales (16) was used to reduce the number of variables and to simplify the analysis in this sample. The resulting three factors included violence and environmental adversity (e.g., percentage of friends who had destroyed property, fought, or used drugs, as well as exposure to violence, such as witnessing threats and violence or experiencing a car accident), interpersonal abuse (including physical, emotional, and sexual abuse, as well as harsh parental discipline, such as being slapped or locked out of the house), and neglect and lack of connectedness (including physical and emotional neglect; lack of parental advice, praise, or affection; not trusting teachers; and feeling disconnected from people at school).

Binary logistic regression was used to determine the associations between the three childhood adversity factors and having ever been arrested. Negative binomial regression was used for the outcome of number of arrests. Pearson correlations were calculated to estimate the magnitude of the associations with the number of arrests.

Results

Among the 247 participants, complete data for the adversity scales were available for 201. Of these 201 participants, the mean±SD age was 23.7±4.8 years, and the mean years of educational attainment was 11.9±2.3. Most participants were male (N=153, 76%), African American (N=174, 87%), single and never married (N=172, 86%), living with parents or other family members (N=136, 68%), and unemployed (N=141, 70%). Nearly two-thirds (N=127, 63%) had been arrested. Among the 109 for whom we could ascertain age at first arrest, the mean age was 19.6±4.5. Less than one-third (N=31, 28%) had been arrested before age 18 and most (N=21 out of 31, 68%) at age 16 or 17.

As shown in Table 1, violence and environmental adversity was statistically significantly (p<0.001) associated with both a history of arrest (odds ratio [OR]=2.29, 95% confidence interval [CI]=1.62–3.23) and number of arrests (β=0.60). Interpersonal abuse was significantly associated with number of arrests (β=0.28, p=0.004). Neglect and lack of connectedness was not significantly associated with either arrest variable. The correlation coefficients between number of arrests and these three adversity factors were r=0.39, r=0.22, and r=0.01, respectively.

In testing for an effect of gender on violence and environmental adversity, we observed an interaction of gender with both history of arrest and number of arrests (both p=0.05). Specifically, the association was stronger among female than among male patients (OR=5.15, 95% CI=1.83–14.48 and OR=1.72, 95% CI=1.15, 2.56, respectively, and β=1.13, 95% CI=0.51–1.76 and β=0.47, 95% CI=0.28–0.67, respectively). The correlation coefficients between number of arrests and violence and environmental adversity were r=0.41 and r=0.36 among female and male patients, respectively.

Discussion and Conclusions

We observed a remarkably high rate of previous arrest in this sample of patients with FEP, perhaps in part because the sample was predominantly male, African American, and unemployed, all demographic characteristics known to be associated with disproportionate rates of arrest (17). Adversity in childhood and adolescence, especially adversity marked by extreme risk, danger, and violence exposure, increased the risk for arrest before initial treatment for FEP. Furthermore, this association appeared to be stronger among female patients than among male patients, echoing findings of other research that has indicated that female patients who have experienced childhood victimization are at greater risk for negative consequences such as substance use (18).

Although extensive research has documented links between childhood trauma and psychosis as well as links between childhood trauma and later criminal and legal involvement, there has been limited examination of the individual characteristics among patients with FEP that predict criminal justice system contact, such as arrest. In this sample of patients, violence exposure in the home, at school, or in the neighborhood had the greatest impact on the likelihood of an arrest. This finding is important because previous studies have focused primarily on childhood physical, emotional, and sexual abuse as drivers of later criminal and legal involvement and have paid less attention to consequences of violence in the environment more generally (19).

However, among those who had been arrested, both environmental adversity and interpersonal adversity (including physical, emotional, and sexual abuse) predicted the number of arrests before treatment, suggesting that several domains of childhood adversity are correlated with repeated arrests. Only neglect and lack of connectedness showed no significant association with arrest history or frequency of arrests before first hospitalization, although rates of physical and emotional neglect in this population of patients with FEP are known to be quite high. This finding suggests that it is critical to conceptualize trauma broadly and to better understand the role of its various facets in pathways to both care and to criminal justice entanglement among patients with FEP. Doing so might inform targeted interventions that could be developed to reduce arrest rates for such patients and enhance early treatment engagement that follows trauma-informed principles.

Several limitations are noteworthy. First, the arrest histories were based on self-reported data. Because of difficulty with recall of exact charges and exact dates, other approaches to collecting data on arrest history, such as state criminal background histories (from administrative data), would be useful. Second, lack of data on the timing of adversities relative to the timing of arrests means that temporality and causality cannot be clearly established. Given that about one-quarter of the participants in the present study were likely arrested before age 18 (28% among those for whom we had data), it is possible that for some, arrest preceded, and potentially even provoked, the reported adversities. Third, sociodemographic and clinical characteristics of the sample were narrow, with a mostly low-income, socially disadvantaged group of African American men, all of whom were hospitalized. This narrowness could limit generalizability to other groups, including those who have less severe illness. Fourth, although many participants had illness onset before the age of 18, only those ages ≥18 at hospitalization were included. Fifth, because childhood adversity can have gender-specific effects on behaviors in adulthood, future analyses should include larger numbers of women to more deeply investigate the relationships among childhood adversity, arrest, and FEP. Finally, this analysis exclusively focused on childhood adversity, and future analyses should examine how other predictors can influence the likelihood of arrest, including other early-life and clinical factors.

Our findings indicate a need to address, as part of the model of specialty care for early psychosis, both childhood adversity and criminal justice involvement in the specific context of specialty care for early psychosis in the same way that educational support and employment support are now widely offered as part of the service model (if not considered a standard of care within the model). Previously published research with this sample and another very similar one has indicated that arrest and incarceration delay access to treatment (11) and are markers of poorer prognosis at the time treatment is initiated (10). This study provides new evidence that childhood exposure to environmental and interpersonal adversities is a correlate of arrests before FEP treatment initiation, reaffirming the importance of screening for both trauma and criminal and legal involvement as part of the initial assessment for FEP.