People working in all aspects of the criminal justice system frequently interact with individuals who have been diagnosed with mental disorders. Your specific work in the criminal justice field will determine how in-depth your knowledge of mental disorders needs to be. If you work in a position that has direct contact to people accessing services, the public, or court-mandated people, you will need a deeper understanding of these various mental disorders.

Mental and substance use disorders affect all people and all age groups. These disorders are common, recurrent, and often serious, but they are treatable and many people do recover. Mental disorders involve changes in thinking, mood, and/or behavior. These disorders can affect how we relate to others and make choices. Reaching a level that can be formally diagnosed often depends on a reduction in a person’s ability to function as a result of the disorder. For example:

• Serious mental illness is defined by someone over 18 having (within the past year) a diagnosable mental, behavior, or emotional disorder that causes serious functional impairment that substantially interferes with or limits one or more major life activities.
• For people under the age of 18, the term “Serious Emotional Disturbance” refers to a diagnosable mental, behavioral, or emotional disorder in the past year, which resulted in functional impairment that substantially interferes with or limits the child’s role or functioning in family, school, or community activities.
• Substance use disorders occur when the recurrent use of alcohol and/or drugs causes clinically significant impairment, including health problems, disability, and failure to meet major responsibilities at work, school, or home.

The coexistence of both a mental and a substance use disorder is referred to as co-occurring disorders. The National Institute for Mental Health’s Mental Health Information page has information about specific conditions and disorders as well as their symptoms.

2.2.1 Diagnostic and Statistical Manual of Mental Disorders

The Diagnostic and Statistical Manual of Mental Disorders (DSM) is a classification system utilized in the United States by most mental health professionals. The first edition of the DSM was published in 1952, and it has undergone numerous revisions and updates, indicated by the Roman numerals that follow the title. The most recent text revision, in 2022, resulted in the American Psychiatric Association’s (APA) publication of the DSM-5-TR. The DSM includes categories of disorders described in detail to include diagnostic criteria and the percentage of the population that is diagnosed with each disorder.

Each edition of the DSM that is published brings substantial change to the understanding and management of mental disorders. For example, every new DSM edition has an increased number of disorders from the previous edition. Other substantial changes relate to societal norms and updated research. For instance, homosexuality was listed as a disorder in the original DSM and it was not until 1986 that it was fully removed from the DSM.  In 2013, the DSM-V was published, which named the importance of recognizing gender and cultural differences as a way to not ‘overpathologize’ behaviors or beliefs into a mental disorder.

An example of a notable change in the DSM, for purposes of this text, was the expansion of guidelines for diagnosing post-traumatic stress disorder (PTSD). Previously, PTSD was only diagnosable in people, primarily men, who served in the military. By the time the DSM-III was published, however, professionals had observed many similarities between impacted members of the military and people, primarily women, who had experienced trauma in the form of sexual assault. These populations had experienced different forms of trauma, but members of the military and sexual assault survivors were experiencing similar symptoms, and both met criteria forPTSD. This expansion gave voice and clinical recognition to survivors of events such as sexual assault and abuse by recognizing that PTSD can impact people without needing to experience a universal traumatic event. We’ll discuss PTSD in its current diagnostic form later in the chapter.

According to the APA (2013), a mental disorder is a condition that consists of the following:

1. There are significant disturbances in thoughts, feelings, and behaviors. For instance, the person impacted must see their behaviors or cognitions as distressing and/or uncontrollable.
2. The disturbance reflects some kind of biological, psychological, or developmental dysfunction.
3. The disturbance leads to significant distress or disability in one’s life. This may include impacting a person’s life, socially.
4. The disturbances do not reflect expected or culturally approved responses to certain events (i.e. responses are socially unacceptable).

2.2.2 Psychotic Disorders

Psychotic disorders include schizophrenia, schizoaffective disorder and delusional disorders. These diagnoses often have an onset during early adulthood (i.e. early to mid-20s) and have some effective medications to lessen the symptoms that are common with these disorders. Antipsychotic medications have greatly improved over the past few decades, however some people diagnosed with a psychotic disorder still report significant side effects to some of these medications. Strong efforts have also been made to keep antipsychotic medications accessible to the people in need. For instance, many antipsychotic medications are offered through an injection, which allows for someone to obtain a shot once per month instead of relying on remembering to take a pill every day.

2.2.2.1 Schizophrenia

Schizophrenia is a psychological disorder that is characterized by major disturbances in thought, perception, emotion, and behavior. People with schizophrenia are usually diagnosed between the ages of 16 and 30, after the first episode of psychosis, or losing touch with reality. Hallucinations and delusions are the most common indicators identified with psychosis. Starting treatment as soon as possible following the first episode of psychosis is an important step toward recovery. However, research shows that gradual changes in thinking, mood, and social functioning often appear before the first episode of psychosis.

Symptoms of schizophrenia vary from person to person and may change over time. Hospitalization may be needed during a severe episode to ensure a person’s safety, proper nutrition, sufficient sleep, and other factors.

The signs of schizophrenia involve:

• Delusions: false beliefs that a person does not change, even when presented facts.
• Hallucinations: seeing or hearing things that do not exist, such as a voice making commands.
• Disorganized thinking and speech: impaired communication, including shifting from one thought to the next without a logical connection, or speaking in sentences that do not make sense to others.
• Disorganized or abnormal physical behavior: inappropriate or strange actions, a complete lack of movement or talking, acting with a childlike silliness, unpredictable agitation, repetitive or excessive movements.
• Negative symptoms: a reduced or lack of the ability to function normally, such as ignoring personal hygiene or not showing emotion. (Substance Abuse and Mental Health Services Administration, 2022)

2.2.2.2 Schizoaffective Disorder

Schizoaffective disorder has similar symptoms to schizophrenia, major depressive disorder and bipolar disorder. There are many overlapping symptoms with these three disorders.  However, the main difference is that schizoaffective disorder is defined as meeting criteria for schizophrenia and a mood disorder (i.e. bipolar, manic, or major depressive disorder). Symptoms of schizoaffective disorder often include hallucinations, delusions, disorganized thinking, mania, and/or depressed mood. Schizoaffective disorder is a chronic mental health condition characterized primarily by symptoms of schizophrenia, such as hallucinations (National Alliance on Mental Illness, 2015).

Delusional Disorder

A delusional disorder is defined by the American Psychiatric Association as a condition where a person has  at least one delusion that lasts at least a month. There are different types or categories of delusions described in the DSM, based on the type of belief that is involved in the delusion. An example of a “grandiose delusion,” for example, would be a person’s belief that they hold special powers in society, such as the ability to read the minds of others. Another type of delusion is a persecutory delusion. This type of delusion commonly causes someone to believe others are out to get them. Persecutory delusions often cause anxiety, disturbed sleep and increased worry (Freeman & Garety, 2014).  Someone experiencing persecutory delusions might think their thoughts are being removed (thought withdrawal) or thoughts have been placed inside one’s head (thought insertion). Another type of delusion is a “somatic delusion,” which involves a belief that something highly abnormal is happening to their own body.  This delusion generally presents with a belief that there is an infestation in one’s body, distorted body image, or imagining unpleasant odors secreting from their body (BrightQuest, 2022). An example may be a belief there are insects infesting the inside of one’s body with no medical diagnosis to support this belief.

2.2.3 Mood Disorders

Mood disorders are characterized by severe disturbances in mood and emotions – most often depression, but also mania (Rothschild, 1999). People without these disorders typically experience variations in their emotional states based on many factors that impact their life. People with mood disorders experience mood fluctuations to such an extreme in degree and/or length of time that it impacts their ability to function.

2.2.3.1 Depressive Disorders

Depression commonly refers to intense and persistent sadness, and it can include a broad spectrum of symptoms that range in severity from mild to more serious. Symptoms can include changes in sleep, appetite, and energy, as well as feelings of hopelessness and even suicidality (National Alliance on Mental Illness, 2017).

Many people may experience a bout of depression for various reasons, such as trauma or personal crisis, or due to specific medical reasons, such as childbirth in postpartum depression. The more common depression diagnosis found in the criminal justice system is Major Depressive Disorder (MDD). MDD is a loss of interest and pleasure in usual activities (i.e. hobbies, sports, sex, social events, family time, etc.) that reaches a defined severe level that warrants the diagnosis (Rothschild, 1999). An MDD diagnosis requires that a person  experience at least five symptoms of depression lasting for more than two weeks; these symptoms must cause significant distress or impair normal functioning, and they must not be caused by substances or a medical condition.

Major depressive disorder is considered episodic: its symptoms are typically present at their full magnitude for a certain period of time and then gradually abate. Although depressive episodes can last for months, a majority of people diagnosed with this condition (around 70 percent) recover within a year. However, a substantial number do not recover; around 12 percent show serious signs of impairment associated with major depressive disorder after 5 years (Boland & Keller, 2009). In the long-term, many who do recover will still show minor symptoms that fluctuate in their severity (Judd, 2012). Depression, like other mental disorders, carries certain stigmas, including the misconception that people who experience it are weak, or lazy, rather than struggling with a serious mental disorder. This stigma may be particularly harmful for men, who are socialized and expected to be “strong” in the face of adversity. See this first-person account from a person who experiences depression to better understand the shame that can occur when a person internalizes the stigmas associated with the disorder

2.2.3.2 Bipolar Disorders

Bipolar disorder is diagnosed where a person has both period of major depressive disorder and a period of mania. Mania is defined as a state of extreme elation and agitation. Some people who experience a period of mania may become extremely talkative, behave recklessly, or attempt to take on many tasks simultaneously.

During a manic episode, individuals may feel as though they are not ill and do not need treatment. However, the reckless behaviors that often accompany these episodes—which can be illegal or physically threatening to others—may require involuntary hospitalization (APA, 2013). Some people with bipolar disorder will experience a rapid-cycling subtype, which is characterized by at least four manic episodes (or some combination of at least four manic and major depressive episodes) within one year.

Another major concern in bipolar disorder is the risk for completed suicide. When someone is in the middle of a major depressive episode, they may be too depressed to take action on suicide behaviors or self-harm, however as they begin to come our of their depressive episode into the start of a manic state, they may have the energy to follow through with suicide.

Bipolar disorder is most often considered a severe and persistent mental illness. However, people diagnosed with bipolar can often manage this disorder successfully with a combination of medication management and therapy. Ongoing safety planning and suicide risk screening is essential for all mental health disorders, and these are particularly important for people diagnosed with bipolar disorder.

Stigma around bipolar disorder may arise, at least in part, from difficulty in treatment. Bipolar is episodic and the person may not recognize recurrence of symptoms. Additionally, bipolar is often misdiagnosed (as schizophrenia or a personality disorder), and it often co-occurs with other mental disorders such as ADHD (attention deficit hyperactivity disorder) that, if medicated, can actually make a person’s bipolar symptoms worse (National Alliance on Mental Illness, 2017). Together, these issues contribute to a public perception that a person with bipolar disorder is necessarily very impaired, when that is not true; the stigma can then be very harmful to the diagnosed person (Mileva et al., 2013).

2.2.4 Anxiety Disorders 

Anxiety disorders are characterized by excessive and persistent fear and anxiety, and by related disturbances in behavior (APA, 2013). Although anxiety is universally experienced, anxiety disorders cause considerable distress. These disorders appear to be much more common in women than they are in men (National Comorbidity Survey, 2007). Anxiety disorders are the most frequently occurring class of mental disorders and are often comorbid with, meaning occurring alongside,each other and other mental disorders (Kessler, Ruscio, Shear, & Wittchen, 2009). In other words, a person may have multiple types of anxiety disorders, and/or an anxiety disorder as well as other different mental disorders.

2.2.4.1 Obsessive-Compulsive Disorder

People with obsessive-compulsive disorder (OCD) experience thoughts and urges that are intrusive and unwanted (obsessions) and/or the need to engage in repetitive behaviors or mental acts (compulsions). A person with this disorder might, for example, spend hours each day washing their hands or constantly checking and rechecking to make sure that a stove, faucet, or light has been turned off.

Obsessions are characterized as persistent, unintentional, and unwanted thoughts and urges that are highly intrusive, unpleasant, and distressing (APA, 2013). For instance, concern about germs or concern that they forgot to turn off the stove after leaving home.

Compulsions are repetitive and ritualistic acts that are typically carried out primarily to minimize the distress that obsessions trigger or to reduce the likelihood of a feared event (APA, 2013). Compulsions often include such behaviors as repeated and extensive hand washing, cleaning, checking (e.g., that a door is locked), and ordering (e.g., lining up all the pencils in a particular way), and they also include such mental acts as counting, praying, or reciting something to oneself.

2.2.4.2 Posttraumatic Stress Disorder

Direct or indirect exposure to a traumatic event places the people who experience this event at an increased risk for developing posttraumatic stress disorder (PTSD). Throughout much of the 20th century, this disorder was called shell shock and combat neurosis because its symptoms were observed in soldiers who had engaged in wartime combat. By the late 1970s it had become clear that women who had experienced sexual traumas (e.g., rape, domestic violence, and sexual assault) often experienced the same set of symptoms as did soldiers (Herman, 1997). The term posttraumatic stress disorder was developed given that these symptoms could happen to anyone who experienced one or more severely traumatic events.

Symptoms of PTSD include intrusive and distressing memories of the event, flashbacks (states that can last from a few seconds to several days, during which the individual relives the event and behaves as if the event were occurring at that moment), avoidance of stimuli connected to the event, persistently negative emotional states (e.g., fear, anger, guilt, and shame), feelings of detachment from others, irritability, proneness toward outbursts, and an exaggerated startle response (jumpiness) (APA, 2013).  For PTSD to be diagnosed, these symptoms must occur for at least one month.

There are higher rates of PTSD diagnoses among people exposed to mass trauma and people whose jobs involve duty-related trauma exposure (e.g., police officers, firefighters, and emergency medical personnel) (APA, 2013).  However, there is stigma tied to law enforcement and front line duty employees to seek support for PTSD.  This group of people often need a great deal of support to manage symptoms of trauma, however seeking this support has historically been highly stigmatized.

2.2.4.3 Complex Trauma

Complex trauma is based on the impact of trauma experiences that are not time limited, but that occur repeatedly. Complex trauma is a way to recognize that PTSD diagnoses are not always defined by one traumatic event; rather, someone can experience traumatic events across a lifespan. Complex trauma was not added to the DSM-V as a separate diagnosis, and most people with complex trauma meet criteria for a PTSD diagnosis. However this term is utilized in the mental health field giving recognition to traumatic experiences that occur over and over again. Complex trauma survivors may have been held in a state of captivity, physically or emotionally and under control of a perpetrator in the following: concentration or prisoner of war camps, prostitution brothels, long-term domestic violence situations, or long-term child physical or sexual abuse,  including organized child exploitation rings (Herman, J., 1997).

2.2.6 Dissociative Disorders

Dissociative disorders generally involve an “involuntary escape from reality,” created when there is a disconnect between a person’s thoughts, identity, consciousness and memory. These disorders often develop as a response to trauma, where the brain seeks to control thoughts and memories. These disorders are fairly rare overall, with women more likely to have the diagnosis (National Alliance on Mental Illness, n.d.).

Dissociative identity disorder (DID) is the dissociative disorder that tends to get the most recognition in the media. This disorder was formerly called multiple personality disorder. People with DID exhibit two or more separate personalities or identities, each well-defined and distinct from one another. They also experience memory gaps for the time during which another identity is in charge (e.g., one might find unfamiliar items in their shopping bags or among their possessions).

DID has been a controversial diagnosis throughout the time it has been listed in the DSM. In the 1980s, rates of the disorder suddenly skyrocketed. More cases of DID were identified during the five years prior to 1986 than in the preceding two centuries (Putnam, Guroff, Silberman, Barban, & Post, 1986). Although this increase may be due to the development of more sophisticated diagnostic techniques, it is also possible that the popularization of DID—helped in part by Sybil, a popular 1970s book (and later film) about a woman with 16 different personalities—may have prompted clinicians to overdiagnose the disorder (Piper & Merskey, 2004). Casting further scrutiny on the existence of multiple personalities or identities is the recent suggestion that the story of Sybil was largely fabricated, and the idea for the book might have been exaggerated (Nathan, 2011).

Despite any media sensation, DID is a legitimate diagnosis that is often tied to complex trauma,  particularly a history of childhood trauma. Research by Ross et al. (1990) suggests that about 95 percent of people with DID were physically and/or sexually abused as children. There is strong evidence that traumatic experiences can cause people to experience states of dissociation, suggesting that dissociative states—including the adoption of multiple personalities—may serve as a psychologically important coping mechanism for threat and danger (Dalenberg et al., 2012). DID is one of multiple dissociative disorders that are identified in the DSM-V-TR.

Dissociation more generally is also seen as a coping mechanism for many who have experienced abuse or on-going trauma. For instance, children who have been exposed to trauma or abuse in the home may have learned to dissociate (i.e. ‘space out’) during abuse to bring their mind to a space that is outside of their current physical reality. This may help them during times of abuse, however it can be counterproductive in other areas of life. For instance, a child may have a hard time concentrating in school if they dissociate during times of distress.

2.2.7 Personality Disorders

A personality disorder is a mental disorder where a person’s atypical thinking and functioning cause them to have trouble understanding and relating to others – often causing them to have problems in many areas of life, including work and social relationships. A person with a personality disorder may be unaware of their problematic approaches, and they may place blame on others for their struggles (Mayo Clinic, 2016).

There are several personality disorders listed in the DSM-V, however we focus here on antisocial personality disorder and borderline personality disorder, the two most commonly seen in the criminal justice field, including correctional settings, forensic hospitals, and mandated treatment settings.

2.2.7.1 Antisocial Personality Disorder 

Antisocial personality disorder (APD) describes someone who is continuously violating the rights of others. This may include lying, fighting, and engaging in impulsive behavior. People with APD can be deceitful for personal gain and engage in reckless behavior. People with this disorder often struggle abiding by the law and have limited empathy towards others. Someone diagnosed with antisocial personality disorder often ends up in the criminal justice system as they often engage in illegal activities. In order to be diagnosed with antisocial personality disorder, there must be evidence of a conduct disorder prior to the age of 15 years old. Someone cannot be diagnosed with antisocial personality disorder until they are at least 18 years old.

Antisocial personality disorder has much higher rates in men than women. According to the U.S. Department of Justice, 50 to 80 percent of incarcerated men are diagnosed with antisocial personality disorder. Although maladaptive behaviors can be addressed in treatment, it is difficult to change long-standing thought patterns that support an antisocial lifestyle. Later in this textbook we will address types of treatment for this personality disorder.

2.2.7.2 Borderline Personality Disorder

Borderline personality disorder (BPD) involves someone experiencing challenges with all-or-nothing thinking. For instance, a person with this disorder often experiences challenges connecting with others as they can vacillate frequently on whether or not a person is “good” or “bad.” Someone with BPD often struggle with the following:

• an unstable self-image
• unstable and intense relationships with others
• strong feelings of emptiness
• impulsive behaviors
• self-harm and/or suicidal gestures
• intense changes in mood
• inappropriate or intense anger

People with BPD often struggle in social relationships as they have intense fear of abandonment and separation, either real or imagined. Their relationships with others tend to be intense and unstable even though they greatly yearn for stability. For example, a romantic partner may be idealized early in a relationship, but then later vilified at the slightest sign they appear to no longer show interest. Someone with BPD often struggles with thoughts of suicide and engage in self-harming behaviors such as cutting. People with BPD are survivors of trauma including abuse or abandonment. They may have been exposed to unstable, invalidating relationships or conflicts. BPD is more common in women than men. This disorder is often identified in emergency rooms after frequent emergency room visits from suicidal gestures, correctional settings, or treatment facilities. Later in this textbook, we will discuss certain treatment options for people with BPD. Significant progress has been made to treat those struggling with this diagnosis.

2.2.8 Disruptive Disorders

Disruptive disorders are diagnosed to children under the age of 18 years old. The most common that are seen in the criminal justice field include oppositional defiant disorder and conduct disorder. Oppositional defiant disorder (ODD) is a diagnosis that is more commonly seen in males rather than females. It is a pattern of anger and irritability, being argumentative or vindictive lasting at least 6 months. Examples of this may include arguing with authority figures, defying rules, and blaming others for misbehaving (2013). This disorder is often first recognized in the school system, foster care, or group homes for children or adolescents. Conduct disorder is defined as a pattern of behaviors where major age-appropriate societal norms and rules are violated. For instance, people with a diagnosis of conduct disorder tend to exhibit aggression towards people and animals, is destructive towards property, is deceitful or steals from others, and/or majorly violates rules.

Disruptive disorders are generally challenging to treat, however focusing on these disorders as targeted as possible while a person is still a child or adolescent decreases the chance that someone will continue down a path of disruptive behavior as an adult. Disruptive disorders are generally identified in adolescent years, however if not properly addressed and treated, a person can later be diagnosed with antisocial personality disorder if disruptive behavior continues across the lifespan.

2.2.9 Paraphilic Disorders

Paraphilic disorders are often identified in the criminal justice system after someone has already committed a crime of sexual violence. Once someone has sexually victimized a person and has had legal action taken against them, they are often mandated to sex offense specific treatment either during the legal process, while incarcerated, or post-conviction while on supervised release (i.e. probation).

Pedophilic disorder is defined as the intense sexual arousal, urge, or behavior involving sexual activity with a prepubescent child (generally 13 years or younger) (DSM-V, 2013). When someone has been diagnosed with a paraphilic disorder, sexual preference will be identified while in sex offense specific treatment to best categorize the person’s sexual interest and target treatment modalities accordingly.

2.2.10 Neurodevelopmental Disorders

Neurodevelopmental disorders are defined in the DSM-5 as disorders that first present earlier in someone’s life, often before someone enters grade school.  Neurodevelopmental disorders are often recognized when children are delayed or do not meet expected developmental milestones.  These developmental disorders “produce impairments of personal, social, academic, or occupational functioning” (American Psychiatric Association, 2013).  These disorders frequently co-occur, meaning people are often diagnosed with a neurodevelopmental disorder and another disorder, for instance a learning disorder or intellectual disability.  Below are some of the neurodevelopmental disorders that are most common to present in the criminal justice field.

2.2.10.1 Attention Deficit Hyperactivity Disorder

Attention-deficit/hyperactivity disorder (ADHD) is marked by an ongoing pattern of inattention and/or hyperactivity-impulsivity that interferes with functioning or development.

Many people experience some inattention, unfocused motor activity, and impulsivity, but for people with ADHD, these behaviors interfere with daily functioning. Examples of inattention may include overlooking details, making seemingly careless mistakes, difficulty sustaining attention, difficulty following through on instructions, and avoiding tasks that require mental concentration to complete. For a person to receive a diagnosis of ADHD, the symptoms of inattention and/or hyperactivity-impulsivity must be chronic or long-lasting, impair the person’s functioning, and cause the person to fall behind typical development for their age.

ADHD symptoms can appear as early as between the ages of 3 and 6 and can continue through adolescence and adulthood. Symptoms of ADHD can be mistaken for emotional or disciplinary problems or missed entirely in children who primarily have symptoms of inattention, leading to a delay in diagnosis. Adults with undiagnosed ADHD may have a history of poor academic performance, problems at work, or difficult or failed relationships.  The way ADHD often shows up in the criminal justice field is through impulsivity as a contributing factor to offending behavior.  Someone who is diagnosed with ADHD may struggle with impulse control, which can lead to engaging in actions that lead to interactions with law enforcement (Spielman et al., 2020).

2.2.10.2 Autism Spectrum Disorder

Autism spectrum disorder (ASD) is a neurological and developmental disorder that affects how people interact with others, communicate, learn, and behave. Although autism can be diagnosed at any age, it is described as a “developmental disorder” because symptoms generally appear in the first two years of life.

Autism is known as a “spectrum” disorder because there is wide variation in the type and severity of symptoms people experience. People with ASD may have difficulty with social communication and interaction, restricted interests, and repetitive behaviors. Social interaction examples may include making little eye contact, displaying facial expressions that do not match what is being said, and having difficulty adjusting behaviors to social situations. Repetitive behaviors may include repeating words or phrases, becoming upset with a slight change in routine, and being more sensitive or less sensitive than others to sensory input (i.e. light, clothing, sound, or temperature).

2.2.10.3 Intellectual Developmental Disorder (Intellectual Disability)

Intellectual disability is a term used when there are limits to a person’s ability to learn and function at a standard level in daily life. Levels of intellectual disability vary greatly. People with intellectual disability might have a hard time letting others know their wants and needs, and taking care of themselves.  Most people with intellectual disability experience a milder form of this disorder, and this may appear simply as difficulty making decisions or coping with stressful situations. Attempts to cope with distress may involve techniques like avoidance (Hartley & MacLean, 2008).

Intellectual disability is diagnosed based on a problem that starts any time before a child turns 18 years old. This disorder is evidenced by learning and development that is slower than that in other children; it may take longer for a child with intellectual disability to learn to speak, walk, or perform other daily activities, and they may have trouble learning in school. Intellectual disability can be caused by injury, disease, or a difference in the brain. For many children, the cause of their intellectual disability is not known. Some of the most common known causes of intellectual disability – like Down syndrome, fetal alcohol syndrome, fragile X syndrome, and other genetic conditions, – happen before birth. Others happen while a baby is being born,  soon after birth, or when a child is older; these might include injury, stroke, or certain infections.

People with intellectual disabilities are vastly overrepresented as both victims and offenders in the criminal justice system, and they are especially vulnerable to wrongful convictions and re-abuse within the system (Davis, 2009).

2.2.10.4 Fetal Alcohol Spectrum Disorders

Fetal alcohol spectrum disorders are diagnosed when a person was exposed to alcohol in utero.  A person born with fetal alcohol spectrum disorders may have neurodevelopmental impairments and/or physical impairments.  Some people with fetal alcohol spectrum disorders have slight to severe physical impairments.  One trait that is most commonly recognized with this disorder is smooth skin between someone’s upper lip and nose (Mayo Clinic, 2018). Neurological impairments commonly found in fetal alcohol spectrum disorders include: learning disabilities, impulsivity, hyperactivity and poor judgment.  These impairments can also increase one’s likelihood of being involved in the criminal justice system (Fast & Conry, 2009).

2.2.11 Neurocognitive Disorders

Neurocognitive disorders are defined in the DSM-5 as disorders that are “acquired rather than developmental” (American Psychiatric Association, 2013).  Symptoms that are attributed to these mental disorders listed below are ones that present throughout someone’s lifespan and do not appear to be indicative of a developmental disability.  For instance, a traumatic brain injury (TBI), dementia, and alzheimer’s disease all appear to develop later in someone’s life and not at birth or early in life.  Neurocognitive disorders indicate a “decline from a previously attained level of functioning” (American Psychiatric Association, 2013). Dementia and TBI will be discussed in this section as these neurocognitive disorders are often experienced by professionals working in the criminal justice field.

2.2.11.1 Traumatic brain injury

Traumatic brain injury (TBI) is a brain injury that occurs when a sudden trauma causes damage to the brain. A TBI can result if a person hits their head suddenly and violently hits an object, or when an object pierces the skull and enters brain tissue (National Institute of Neurological Disorders and Stroke). Symptoms vary depending on the severity of the TBI.

People in the criminal justice system have often survived multiple violent encounters, including childhood abuse, physical fights, and prison violent encounters. TBIs are commonly undiagnosed among people involved in the criminal justice system, which can greatly impact people getting the proper support needed to successfully exit the criminal justice system. For instance, agitation, confusion, behavioral changes, and mood changes can all be symptoms of a TBI. If not properly diagnosed, these symptoms can easily be misdiagnosed as someone being defiant or unwilling to follow societal norms (National Advisory Neurological Disorders and Stroke, 2022).

Luckily, it is common practice for a mental health clinician to ask during a clinical assessment if someone has ever experienced a loss of consciousness for a few seconds or a few minutes. Although this question is routinely asked in the behavioral health field, it is unfortunately not followed up with the most comprehensive care it deserves. Oftentimes, a person will go untreated for potential TBIs and be incorrectly diagnosed as a behavioral disorder.  There is a need to have more comprehensive screening tools for potential TBI diagnosis for people involved in the criminal justice system to more accurately diagnose and treat this disorder.

2.2.11.2 Dementia

Dementia is the loss of cognitive functioning — thinking, remembering, and reasoning — to such an extent that it interferes with a person’s daily life and activities. Some people with dementia cannot control their emotions, and their personalities may change. Dementia ranges in severity from the mildest stage, when it is just beginning to affect a person’s functioning, to the most severe stage, when the person must depend completely on others for basic activities of living.

Dementia is more common as people grow older (about one-third of all people age 85 or older may have some form of dementia) but it is not a normal part of aging. Many people live into their 90s and beyond without any signs of dementia (National Institute on Aging, 2021).