The Mental Health of Gang Members

1. The Mental Health of Gang Members Jane Padmore Child and Adolescent Mental Health Consultant Nurse South London and Maudsley NHS Foundation Trust Doctorate in Healthcare King College London Florence Nightingale Foundation Travel Scholar Jane.padmore@slam.nhs.uk Jane.padmore@kcl.ac.uk

2. Mental health needs of Young people involved in street Gangs.

3. Reasons for applying for the scholarship • Area of interest • My clinical work • Gangs are not spoken about in clinical practice • Are those involved in gangs being seen but the gang related activity is not spoken about? • Are these young people being referred at all? • Gangs are rarely written about in the mental health literature • Serious Case Reviews and investigations into serious incidents • Doctoral studies • What works? • An exploration of what might work • Networking

4. What do I mean by a gang?

5. Definitions • The term ‘gang’ means different things to different people and it has become shorthand for the media when discussing youth crime. • What are we talking about? • Stereotypes • Misconceptions • Media portrayal • Many names for the same/similar/presumed the same phenomena • Cliques • Transnational organisations • Urban tribes • Informal youth organisations • Street gangs • Organised crime • Criminogenic families

6. Politics The Prime Minister announced he would declare "a concerted, all-out war on gangs and gang culture“ August 2011

7. ‘We don’t have a gang problem in our school’- What does a gang member look like? Black? Not in educationor employment? No father onthe scene? Male? American gangstyle clothing? Broken homes? Troubled families? No future? Intimidating?

8. For some this is what gangs mean Monkey Business Images/shutterstock.com

9. For others… ES James / Shutterstock.com

10. For others..

11. Definition • Both ‘Gangs’ and ‘Mental health.’ • Gang. • ‘Any durable, street-orientated youth group whose involvement in illegal activity is part of its group identity’ (Esbensen and Weerman, 2005). • ‘‘Durability’ means several months or more and refers to the group, which continues despite turnover of members. • ‘Street orientated’ means spending a lot of group time outside home, work and school and often on the streets, shops, parks, cars and so on. • ‘Youth’ refers to average age in adolescence or early twenties. • ‘Illegal activity’ generally means delinquent or criminal behaviour not just bothersome activity. • ‘Identity’ refers to the group, not individual self image.’ • Mental health. • ICD 10

12. Policy context • ‘Positive for Youth,’ Department for Education (Crown, 2012)- where it is ‘reasonable practicable,’ services should be offered that improve young people’s physical and mental health and emotional well-being and ‘help those young people at risk of dropping out of learning or not achieving their full potential to engage and attain in education or training.’ • ‘Groups, Gangs and Weapons report’ (Young et al., 2007)- recommended that YOTs and local services focus on strategies that aim to break the cycle which can lead from group offending to gang involvement. • ‘Safeguarding Children and Young People who may be affected by Gang Activity’ (Crown, 2010)- agencies need to be mindful of and report gang activity, emphasising the negative effect of gangs on young people. • ‘

13. Ending Gang and Youth Violence’ (Crown, 2011)- Whilst this paper was consulted on widely it lacks the evidence to support its strategy. This was mainly due to there not being a comprehensive needs analysis and the lack of evidence available from the UK or internationally to support specific interventions. • Mayor’s Office for Policing and Crime published its gang strategy (Crown, 2013)-For the first time Mental Health is included. the strategy tasks the Mayor’s Office for Policing and Crime as well as local authorities, to ‘engage with regional health leads to assess and address the issues relating to CAMHS provision for violent young offenders who are involved in gangs’

14. The starting point • What the literature says and what my research indicated…

15. The mental health of young people in the UK • 1 in 10 children between the ages of one and 15 has a mental health disorder. • (The Office for National Statistics Mental health in children and young people in Great Britain, 2005) • Estimates vary, but research suggests that 20% of children have a mental health problem in any given year, and about 10% at any one time. • (Lifetime Impacts: Childhood and Adolescent Mental Health, Understanding The Lifetime Impacts, Mental Health Foundation, 2005)

16. Rates of mental health problems among children increase as they reach adolescence. • Disorders affect • 10.4% of boys aged 5-10, rising to 12.8% aged 11-15 • 5.9% of girls aged 5-10, rising to 9.65% aged 11-15. • (Mental Disorder More Common In Boys, National Statistics Online, 2004)

17. The mental health of young offenders • Widespread agreement in the literature. • Young offenders are at risk of having higher than usual rates of mental health difficulties than the general population. • Prevalence rates range from 25 to 81%, highest for those in custody. • Generally rates are at least three times higher for offenders than the general population.

18. Mental health in gang specific research • Public Health • Genetics • General papers relating to gangs that mention mental health

19. Public Health- The main body of research in the health field • Drinking and drug use • (Vigil and Long, 1990; Curry and Spergel, 1992; Bjerregaard and Smith, 1993; Esbensen et al, 1993; Hill et al, 1999; Thornberry et al, 1993; Harper et al, 2008) • Early sexualised behaviour • (Hill et al, 2001; Kosterman et al, 1996; Bjerregaard and Smith, 1993) • Non accidental injury • (DCSF, 2010)

20. Acting in a daring, courageous way, especially in the face of adversity • (Moore, 1991; Vigil, 1988) • Aggression • (Campbell, 1984a, 1984b; Cohen, 1960; Horowitz, 1983; Miller et al, 1962; Sanchez-Jankowski, 1991) • Higher risk of suicide • (Knox and Tromanhousar, 1999)

21. Genetics • Little has been written about any genetic predisposition to gang involvement. • One study (Beaver et al, 2010) explored the link between the level of Monoamine Oxidase A [MAOA], gang membership and weapon use. • They found a lower level of MAOA correlated with gang membership in males but not females. • This low level has also been found, in other studies (Caspie et al, 2002; Kim-Cohen et al, 2006), to be linked with conduct disorder, autistic traits and criminal behaviour. • Child abuse is a key covariate. • Although the precise mechanisms leading from MAOA to gang membership are unknown, it is thought to be likely that it is the result of a gene-environment correlation(Jaffey and Price, 2004).

22. Relation to mental health • Mental health problems, even serious mental health problems, are mentioned as a risk factor leading to (Hill et al, 1999; Wood and Alleyne, 2010)and resulting from (Flannery, 2006) gang involvement. • It is universally not clear how this conclusion was drawn or what operational definition of mental health was used.

23. An increase in mental health problems? • Research comparing gang members to non-gang members from the same community showed gang members exhibited high levels of psychopathic traits, notably low empathy and poor impulse controls (Valdez et al, 2000). • Psychopathic traits in young people has been linked to • ADHD • hyperactivity • Low anxiety • Low pro-sociality or empathy

24. A decrease in mental health problems? • A close network of friends and family has been shown to protect against mental health problems in adolescence (Kim and Cicchetti, 2010). Gang members are at once offenders and part of a group, frequently described as ‘friends’ or ‘family.’ • A number of studies (Moffitt, 1993; Warr, 2002; Moore and Vigil, 1989; Moore, 2002) have shown gang membership offers status, identity and companionship for socially excluded, status-less individuals at a time in their development when peer group influence is strongest. • Offending is both tolerated by the group and exerts a cohesive, unifying effect through shared risks, loyalty and secrecy.

25. A different Mental Health profile from other offenders? • The literature suggests that offending behaviour is associated with an increase in mental health problems • It is not clear what the interplay between this and the protective group cohesiveness found in a gang is • How young people are defined and treated by society is an important part of the equation, and social exclusion is an underlying theme, particularly for the mental health of the 16-18 age group.

26. Summary of significant results from my research • Gang members had a significantly higher level of hyperactivity and inattention difficulties than non-gang members (p<.001) • Gang members had a significantly higher level of hyperactivity and inattention difficulties than the general population (p<.001) • Non-gang members had a significantly higher level of hyperactivity and inattention difficulties than the general population (p=.033) • Gang members had a significantly higher level of pro-social difficulties than non-gang offenders (p=.001) • Gang members had a significantly higher level of pro-social difficulties than the general population (p<.001) • Gang members have significantly more emotional difficulties than the general population (p=.002) but not non-gang offenders (p=.053). • Gang members had significantly more total difficulties than both the general population (p<.001) and the non-gang offenders (p=.001).

27. The study also found • Gang members who had committed serious offences frequently were more likely to score as borderline or abnormal for inattention and hyperactivity.

28. Next steps • If we have some indication of the possible difficulties what should we be doing about it? • If policy is supporting the need to do provide services for this group what services should we provide? • What might work? • What would be a sensible research strategy?

29. UK Reviews- Interventions • Two cochrane reviews: • Opportunities and provision for preventing youth gang involvement for children and young people (7-16) (Fisher et al, 2008) • Cognitive-behavioural interventions for preventing youth gang involvement for children and young people (7-16) (Fisher et al, 2008) • Both conclude no randomised controlled trials or quasi-randomised controlled trials were identified. • Neither specifically address the mental health of those young people involved with gangs or the work of mental health services with this group. • Reducing gang related crime: a systemic review of ‘comprehensive’ intervention. (Hodgekinson et al, 2009) • Review of interventions, no mention of mental health.

30. The Sandra Charitable Trust An alumni suggested applying-Florence Nightingale Foundation Travel Scholarship

31. Los Angeles

32. Academics • University of California, Irvine • University of Southern California • California State University

33. What I learnt • Definitional issues • Evidence base • Outcome measures • Politics

34. Los Angeles Mayor’s Office • Gang Reduction and Youth Development Program

35. What I learnt • Politics • Funding • Systemic approach • Families • Prevention and early intervention • Community approach

36. Homeboy Industries • Jobs not jail • Home girl’s café • Ex gang members • Father Greg • Gang’s anonymous

37. What I learnt- Trauma and Victimisation • Adolescents involved in gangs are not only the perpetrators of violence, but also victims. • They are exposed to violence and aggression, trauma and substance misuse, all likely to increase mental health problems. • Victimisation, when experienced by young people who exhibit high risk behaviours, has been associated with depression, generalized anxiety disorder, traumatic stress disorder, and conduct disorder. • ‘The trauma provoked [in gang members] by such violence does not receive sufficient policy attention, locally or nationally’ (Economic and Social Research Council, 2009).

38. What I learnt • Victims and/or perpetrator • People with stories • Gangs anonymous • The ‘right time’ • Success rates and expectation • Strong leadership and vision • Finance model • Research challenges • Mental health treatment vital

39. Norwegian academic • Trauma • Changing role of girls in gangs

40. Miami

41. Forensic Mental Health Services • Reasoning and Rehabilitation 2 • Challenges • Successes • Collaboration

42. American Association of Psychiatric Nurses • Contacts • Potential multiple site research projects

43. Outcomes from the scholarship

44. Preliminary conceptual model (Padmore, 2013)

45. Research and clinical practice developments • The Star Project • R and R 2 developments • Development of a clinical tool to measure type and extent of gang involvement with academics in California • Research with Sao Paulo University Brazil

46. To you for listening To the Florence Nightingale Foundation for awarding me the scholarship To the Sandra Charitable Trust for supporting the scholarship To South London and Maudsley NHS Foundation Trust for releasing me to be a scholar and continuing to support the work as it develops To the professionals that shared their knowledge and experience with me To the current and ex gang members who shared their life stories with me Thank you