Undiagnosed Yet Receiving Addiction Treatment: Racial & Ethnic Disparities in Care for Male Serious-Juvenile-Offenders
The juvenile justice system is the most widely used, publically funded, mechanism for substance use disorder treatment for adolescents. Importantly, treatment has been shown to reduce the likelihood of reoffending.
For the most serious offenders, does the chance of receiving treatment depend on the racial and ethnic background of the adolescent?
WHAT PROBLEM DOES THIS STUDY ADDRESS?
Research has shown that the likelihood of reoffending (i.e., committing another offense after receiving a sanction) in the juvenile justice system is reduced when youth with a substance use disorder are provided with treatment. Evidence from other sectors of court-ordered care (e.g., foster care) has shown that African American and Hispanic adolescents are less likely to receive court-ordered substance use disorder treatment.
However, it is unclear if the provision of substance use disorder treatment in the juvenile justice system is equal for all racial and ethnic groups. Given equal rates of substance use disorder among racial and ethnic groups, if treatment is disproportionately provided to certain groups, it can create both health disparities and disparities in the likelihood of reoffending.
This study by Mansion and Chassin (2016) tested whether youth in the juvenile justice system with a substance use disorder diagnosis were equally as likely to receive treatment regardless of their racial and ethnic background.
HOW WAS THIS STUDY CONDUCTED?
The researchers analyzed data from the Pathways to Desistance Study, a two-site longitudinal study of desistance (i.e., cessation of offending or other antisocial behavior) among serious juvenile offenders.
This analysis included a subset of the full Pathways to Desistance Study sample of 638 males selected on the following criteria:
- had complete data on self-reported service receipt at both the 6-and 12-month time-point interviews
- had complete data on self-reported substance use disorders at baseline
- identified themselves as non-Hispanic Caucasian, African American, or Hispanic at baseline
Service receipt was defined as seeking help from a range of professionals including psychologists, mental health treatment groups for drug and alcohol, partial hospitalization or day treatment program, in home counseling, sessions with a counselor or special teacher at school, or a special school program outside of class.
The average age of the final sample was 16 years. Substance use disorder diagnosis (yes/no) according to the DSM-IV and race/ethnicity were both measured at baseline. Authors investigated whether these variables predicted treatment receipt (yes/no) at 6 and 12 months after controlling for age and prior criminal behavior. More specifically, they were interested in whether the effect of substance use disorder diagnosis on treatment receipt was conditional on race/ethnicity: did it depend on whether participants were White, African American, or Hispanic? The researchers expected that Hispanic and African American adolescents with substance use disorder would receive fewer treatment services compared to their non-Hispanic Caucasian counterparts.
WHAT DID THIS STUDY FIND?
Counter to expectations, they found no difference in the likelihood of treatment receipt for Caucasian, African American, or Hispanic adolescents diagnosed with a substance use disorder.
However, results showed that among adolescents not diagnosed with a substance use disorder, Hispanic & African American adolescents were less likely to receive treatment compared to non-Hispanic Caucasians.
Consequently, it is possible that some undiagnosed adolescents may have had a sub-clinical threshold for substance use disorder at baseline that eventually grew into levels requiring treatment. Given the large number of undiagnosed adolescent prisoners who reported receiving treatment, the researchers did follow-up analysis using substance use problems instead of diagnosis (e.g., a potentially more sensitive predictor of treatment receipt due to its continuous format compared to a dichotomous yes/no diagnosis variable).
Specifically, they found that racial and ethnic differences in treatment receipt occurred only when adolescents exhibited low or moderate levels of substance use problems, but not when substance use problems were either absent or very low, or were clearly severe.
WHY IS THIS STUDY IMPORTANT?
The juvenile justice system is the most widely used publicly funded mechanism for substance use disorder treatment for adolescents.
It is critical to know for whom treatment is being provided (and not provided) from an empirical perspective. This study helps fill the knowledge gap in understanding if substance use disorder treatment services are provided equivalently across the racial and ethnic groups in the juvenile justice system.
- This study is limited in its generalizability to less serious juvenile offenders. Adolescent crimes eligible to be included in the analysis were all felony offenses (except those of less serious property crimes), misdemeanor weapons offenses, and misdemeanor sexual assault. Many young adolescents in the juvenile justice system are not the most serious offenders. Therefore, the degree to which substance use disorder diagnosis (or lack of diagnosis) is associated with treatment receipt may vary for less serious offenders.
These analyses suggest that it is within the ambiguous margin of sub-clinical substance use disorders that race/ethnicity may play a role in the provision of treatment services for juvenile offenders.
Future research should test if decision makers (judges, probation officers, etc.) are more likely to send Caucasian versus African American or Hispanic adolescent offenders to treatment when levels of substance use problems could be mild or moderate.
- For individuals & families seeking recovery: If you or a family member are in the juvenile justice system due to a serious offense, and are having problems with alcohol or other drug use, this initial study suggests a possibility that the race/ethnicity of males may play a role in the likelihood of receiving treatment when levels of severity are less clear to diagnose. There may be adverse consequences for treating adolescents who do not meet diagnostic criteria. More work is needed to understand the impact of treating serious juvenile offenders who are at sub-clinical thresholds of substance use disorder. Additionally, this was not a national study, participants were recruited from two specific sites in the US, so questions remain about the extent to which race/ethnicity plays a role in treatment receipt at other sites.
- For Scientists: The operational definition of “treatment receipt” may have implications for why Hispanic and African American youth who were not diagnosed with substance use disorder were less likely to report treatment receipt. Excluded from the definition of treatment receipt are participants who only endorsed the following services: 1) visit to emergency room, 2) session with a priest, minister, clergy or healer, and 3) community support groups or self-help groups. Perhaps there are cultural differences in the resources that serious male offenders use to address concerns about substance use, and they are more likely to use non-professional services when the need for treatment is unclear.
- For Policy makers: The juvenile justice system is the most widely used publically funded mechanism for substance use disorder treatment for adolescents. Therefore, it is critical to know if racial and ethnic minorities are receiving differential treatment provision, particularly given the large number of racial and ethnic minorities serviced by the juvenile justice system. This is the first analysis to explicate the role of race and ethnicity in the likelihood of receiving treatment among serious male offenders who do not meeting diagnostic criteria for a substance use disorder. Strong conclusions about the need for intervention cannot be based off a single study. The results suggest that more funding is needed to understand the impact (positive or negative) of providing treatment to individuals with borderline substance use problems. Additionally, prioritizing research that seeks to understand if and why racial and ethnic minorities are less likely to receive treatment when symptomatic levels may be less clear to interpret (e.g., not at extremely high or low levels) could be informative.
- For Treatment professionals and treatment systems: Treatment for substance use disorder has been shown to reduce the risk of reoffending in juvenile justice populations. The impact of providing treatment to juvenile justice populations whose symptoms are below the clinical threshold is unclear. This study has shown that race and ethnicity may play a role in treatment provision among the most serious male offenders who are not diagnosed with a substance use disorder, or whose symptoms are not as clear to interpret, however, this is the first study of this nature so strong conclusions cannot be drawn given the current body of research.
Mansion, A. D. & Chassin, L. (2016). The effect of race/ethnicity on the relation between substance use disorder diagnosis and substance use treatment receipt among male serious adolescent offenders. Children and Youth Services Review, 61, 237-244.
Photo by Jim Beckel, The Oklahoman