National Institute of Justice Journal Issue Number 228. Series: NIJ Published: November 1994 69 pages 163,064 bytes ---------------------------- A MESSAGE FROM NIJ'S NEW DIRECTOR Publication of this issue of the National Institute of Justice Journal gives me the opportunity to introduce myself to the Journal's many readers in criminal justice and allied fields. As you may know, I was recently nominated by President Clinton and confirmed by the Senate to serve as Director of the National Institute of Justice. It is a privilege to be selected to work with an agency that since its inception some 25 years ago has been responsible for many innovations in the way the criminal justice system operates. My background, covering several areas of the law and of criminal justice, gives me a perspective that I feel will be particularly useful for the Institute. As general counsel for the New York City Police Department, as the director of projects on bail reform and victim assistance with the Vera Institute of Justice, and as chief counsel for a congressional subcommittee on criminal justice, I had the opportunity to work with and for practitioners, policymakers, and researchers. Experience with several components of the criminal justice community will help me understand and meet the needs of NIJ's varied constituent groups. I feel especially fortunate in coming to NIJ at a time that parallels enactment of the Violent Crime Control and Law Enforcement Act of 1994 (PL 103-352). Like most other Americans, I followed the bill with great interest in its often difficult passage through the legislative process. Now that it has become law, I share the belief that we have been given an unparalleled opportunity to deter our young people from crime and to make our communities safer. It is gratifying that the law provides for new or stronger enforcement and prevention measures in a number of areas that have been and continue to be priorities for NIJ. NIJ research is bringing about greater understanding of such problems as family violence, gang crime, and juvenile access to firearms, and its evaluations are resulting in new insights into such innovative responses as community policing, drug courts, and boot camps. The intersection of health and justice concerns, a recently launched NIJ initiative that is the featured topic of this issue of the Journal, is given recognition particularly in the prevention components of the 1994 crime bill. They implicitly confirm the perspective of violence as a public health problem. In the months ahead, I will be seeking your ideas about ways to further strengthen NIJ's response to the needs of the criminal justice community. Building on the groundwork laid by my predecessors and on your partnership with NIJ, I have every confidence we can make a difference. Jeremy Travis Director National Institute of Justice --------------------------------------- Table of Contents Health and Criminal Justice: Strengthening the Partnership Doctors Focus on the Threat to Health From Violence Understanding the Roots of Crime: The Project on Human Development in Chicago Neighborhoods Adopting the Health Care Model To Prevent Victimization The Health-Justice Interface: A New Arena for Police Expanding the Role of the Local Prosecutor The Impact of Health-Related Issues on the Courts Health Care Needs in Corrections: NIJ Responds Questions Most Frequently Asked About the ADA by Criminal Justice Professionals Young People, Violence, and Guns--What NIJ Is Doing Now NIJ Grants and Other Awards in Health and Justice __________________________________________________________ HEALTH AND CRIMINAL JUSTICE: STRENGTHENING THE PARTNERSHIP by Lois Felson Mock and Cheryl A. Crawford The fields of criminal justice and health have long shared areas of common concern. Traditionally, substance abuse has been the area where the convergence of the two fields was most evident. For criminal justice, drug and alcohol abuse has been a concern because of its implications for social order, and for the medical community such abuse has been a concern because of its adverse effect on the health and well-being of individuals. Recently, the emphasis has shifted. The proliferation of violence in this country has caused the association of the health and justice fields to acquire greater currency. It is common knowledge that violent crime is more widespread in the United States than almost anywhere else in the industrialized world.1 In absolute numbers crime is high--more than 6.6 million violent victimizations occurred in 1992, the most recent year for which data are available.2 And while the trend in crime overall appears to be downward, violent crime shows few signs of abating.3 Violent crime is particularly virulent among young people. Between 1980 and 1990, arrests for violent crime by juveniles rose more than one-fourth.4 Today, the chance of being victimized by violent crime is greater than the chance of being injured in a traffic accident.5 The health-justice interface. Violent crimes take their toll in injuries and death. The well-known fact of homicide as the leading cause of death among young African-American men provides ample evidence.6 When a violent crime is committed, the risk of injury is high; for victims, the chance of being injured is more than one in four.7 However, it is not only when victims seek medical attention that violent crime becomes the concern of the health care profession. The pervasiveness of violence has helped lead to its recognition as a public health problem that should be addressed through preventive measures. Allies for criminal justice. The criminal justice community shares this outlook. Recently, solutions proposed at the Federal Government level have focused on legislation in the area of gun control. However, violent crime comprises a multiplicity of problems, many of which can be addressed only by transcending the traditional boundaries of the criminal justice field. Viewing crime from the health perspective offers one of the most promising means to do so. The administration supports this new direction and has urged the medical profession to design antiviolence strategies as part of health care reform. U.S. Department of Health and Human Services' Secretary Donna Shalala and Attorney General Janet Reno have joined forces to pursue the common goal of reducing the toll taken by violence and drugs. The Attorney General has emphasized the importance of collaboration between the two agencies on such issues of shared concern as substance abuse, family violence, and murder. Launching the initiative. In the context of that enjoinder from the Attorney General, NIJ last year created its initiative on health and justice. The groundwork had already been laid, as the Institute has long sponsored research in areas where crime and health intersect--those cited by the Attorney General, plus others, such as health care in correctional facilities and, more recently, environmental crime. Setting the initiative in motion, NIJ established a working group of professionals who represent a wide range of organizations involved in health and justice. They represent law enforcement, victim services, mental health, public health, medical, corrections, community corrections, the courts, Federal agencies, and judicial associations. The group will provide continuing guidance to the internal task force of NIJ staff who are working on health-related projects. At its first meeting, the working group identified emerging issues, indicated areas for consideration by NIJ in developing plans for research, and explored means to expand outreach. Working group members cited a number of their priority areas: o The need to handle cases of rape, sexual assault, and child abuse so as to minimize the psychological damage suffered by victims as a result of the crime and to prevent "revictimization" by the criminal justice system. o Continuum of care for offenders following release to the community, particularly for those infected with tuberculosis and HIV. o Development of strategies to meet the needs of offenders in the justice system who are diagnosed as having both physical and mental illnesses. o Improvement in the range and nature of treatments and preventive services offered to children who are maltreated and their families. o Ways to improve court handling of cases involving complex scientific and health-related questions (for example, the evaluation of evidence based on DNA testing). o Greater collaboration between health and justice professionals on violence prevention programs, especially those involving young people. Collaborative projects. Several projects in which NIJ works with health care agencies and organizations are now under way. (See box on page 4.) NIJ's work in progress. The new initiative on health and justice formalizes and expands on a substantial number of Institute projects currently being conducted in the area of violence and in other areas that span the two fields. Several of these projects are the subjects of separate articles in this issue. Violence Understanding violence. The Project on Human Development in Chicago Neighborhoods is an unprecedented program of long-term research designed to advance knowledge about the causes of antisocial behavior, including substance abuse and other crimes, and to identify opportunities for treatment and prevention. Indepth information about individuals and their families, peers, schools, and communities will be gathered over an 8-year period. Family violence/violence against women. In collaboration with the Centers for Disease Control and Prevention (CDC), NIJ will provide indepth national data on the violent victimization of women in this country. Patterned after a successful Canadian survey, the project will ask women aged 18 and older about victimizations that occurred recently and at other times in their lives and about the impact of violence on their physical and emotional health. Especially important in the survey will be a section on stalking. A survey of violence against men by their intimates will also be part of the study. The findings should be useful to criminal justice and public health professionals and victim service providers, as well as to policymakers. Researchers will benefit from the availability of this extensive data set. Several NIJ studies center on criminal justice processing of family violence cases. How prosecutors handle these types of cases is the subject of one of these studies. In the past, prosecutors were thought to be insensitive to the needs of family violence victims and negligent in consistently prosecuting their cases. NIJ is examining the obstacles prosecutors encounter, what their needs are, what accomplishments they have made in handling these cases, and what factors are the most important in prosecution success. The different approaches of three established prosecutorial programs will be reviewed. The study will also examine the experiences of the victims in the prosecutorial process. In cooperation with a domestic violence court, NIJ will study several strategies the court uses to reduce domestic violence, particularly when drug and alcohol abuse are involved. Previous research examining the effect of arrest and prosecution in limiting further domestic violence offenses has had mixed results. Part of the study will focus on the impact of an approach that integrates substance abuse treatment with violence reduction treatment. Researchers hope to determine whether offenders who receive substance abuse treatment in addition to treatment to reduce domestic violence will be involved in fewer violent incidents in the future. Although civil protection orders are one of the major remedies the justice system offers to victims of domestic violence, there has been little empirically based evaluation of their effectiveness. NIJ is examining the way in which protection orders are processed, the types of relief they provide, the ancillary services available to victims, the extent to which the court coordinates these services, and the ways in which protection orders are monitored and enforced. Cases will be reviewed to determine which terms of the orders, which services, and which monitoring and enforcement mechanisms are most effective. Research indicates that the children of battered women often suffer adverse effects, including somatic complaints, psychological disorders, and a propensity to resort to violence themselves as a primary conflict resolution strategy. In an expansion of previous research that was limited to children of battered women living in shelters, NIJ is studying the service needs of these children irrespective of residence. Children whose mothers applied for restraining orders from the court will be tracked for 1 year, and data will be collected on the medical, mental health, and social services they received. The adequacy of the services will be assessed in interviews with the mothers. The study will produce a comprehensive picture of the children's service needs and suggestions for interventions. Child abuse. Children and adolescents are at significant risk of being victims of violent crime. NIJ-sponsored research has revealed that children who are abused or neglected become caught in a "cycle of violence," which is manifested in a greater likelihood of arrest for violent crime on reaching adulthood. This research also revealed other long-term consequences for abused or neglected children, among them an increased tendency toward clinical depression, alcohol and drug problems, and occupational difficulties.8 NIJ studies now under way will further increase the understanding of child victimization. A longitudinal study will meet the need for nationally representative data and provide the most complete information to date about the extent, nature, and consequences of victimization of children and adolescents in the United States. Because it is based on interviews with adolescents and their parents, the study will avoid the methodological problems encountered using retrospective studies of adults, which depend on recall. Further research is being conducted on the "cycle of violence." The figures published to date on the association of child abuse with violence may actually have underestimated lifetime arrest rates for violent crime because some of the individuals studied had not yet reached their "peak" offending years (ages 20 to 25). While the initial study relied on official records of arrest, the current study is using information obtained from the individuals themselves to identify instances of offending, including sexual offenses. Information from the interviews will be used to document a number of other long-term consequences of childhood victimization, including social, emotional, cognitive and intellectual, occupational, psychiatric, and general health outcomes. Substance abuse (including alcohol abuse) will also be studied as a possible consequence of childhood victimization. How child abuse cases are processed through the justice system is the subject of an NIJ study that focuses on the victims and the perpetrators, as well as on the cases. Family and dependency proceedings and criminal cases, as well as abuse cases that may be handled via court-approved alternative dispute resolution will be tracked through to disposition. The study will include a review of what recent research has revealed about child abuse case processing and an indepth examination of a site where such cases are processed on a regular basis. The criminal justice decisionmaking process will be examined through studies conducted at several sites. Police use of excessive force. NIJ's study of the use of police psychologists in controlling the use of excessive force by the police was the first national assessment of this practice. Findings indicate that more than three-fourths of the police psychologists, in a sample of the country's largest police departments, provide counseling services. As part of their professional functions, psychologists also identify the types of officers who are "at risk" for use of excessive force, including officers with personal problems that destabilize their functioning on the job. The use of psychologists was generally not strategic, however. They were more involved with counseling and evaluating functions than with training and monitoring police officers' behavior, and counseling was more likely to take place as a response to excessive-force incidents rather than as a means of prevention.9 The researcher will conduct case studies of how police departments work with psychologists to improve their capacity to respond to officers who are at risk for using excessive force. Firearms. The association of firearms and violence, and the public outrage over this issue, lend urgency to the need for research in this area. With the Office of Juvenile Justice and Delinquency Prevention, NIJ recently completed a study of firearms acquisition and use among young people, focusing on incarcerated juvenile offenders and inner city high school students. The youths were found to be extremely well armed and to have few compunctions about carrying and using guns. Heavy exposure to guns was part of the environment of violence and victimization in which these young people lived. Like the adult felons studied previously, the incarcerated juveniles and high school students said they acquire guns for self protection and obtain them (cheaply and easily) through illegal and informal street sources. Involvement with gangs and drugs was somewhat related to increased involvement with guns, but there was no straightforward, one-to-one relationship.10 Half of the households in this country contain firearms. But since only one firearm in every six that are used in crimes is legally obtained, and since many firearms are acquired by theft--sometimes from residences11--it becomes important to understand the decision to acquire a firearm and other aspects of gun ownership. NIJ has just begun a study of private firearms ownership and use among the general (civilian) population. How, where, when, and why people acquire guns; the types of weapons they own; how they store, use, and dispose of their weapons; and whether they have ever been victimized by crime are some of the issues to be explored. The frequency of theft from legitimate owners makes the issue of storage important, and the assertion of self-defense as a commonly used reason for owning a firearm makes the issue of crime victimization important. The rationale for nonownership will also be part of the study. Health care in the correctional system Not only have prison and jail populations grown rapidly over the past several years, but inmate demographics have also changed. These developments and others--notably the high incidence of drug abuse among arrestees and the impact of AIDS and other infectious diseases--are creating new challenges in corrections. NIJ's program of research in this area is helping corrections officials and administrators meet the physical and mental health care needs of prisoners and do so in the face of rising costs. To track HIV/AIDS in the incarcerated population, NIJ has been conducting studies of its incidence since 1985. The most recent studies have been conducted in partnership with the Centers for Disease Control and Prevention. In addition to measuring the incidence of AIDS and HIV infection, the studies also examine the correctional policy response (e.g., how HIV-infected inmates are housed) and changes in that response. The recent resurgence of tuberculosis led to the coverage of this infectious disease in the study. Since these medical conditions create special problems for prison populations, the findings of this study should help correctional and public health officials to better plan prevention and treatment.12 The addition of information about juvenile correctional institutions is being considered. In cooperation with the National Institute on Drug Abuse, NIJ conducted a research, demonstration, and evaluation project on programs that educate jail inmates about HIV and AIDS. The study compared the effectiveness of three different levels of education in reducing risky sexual and substance-abuse behaviors. Women and older people, who constitute a growing proportion of the prison population, often have special health care needs. To help manage the needs of the elderly in prison, NIJ is studying the types of services available and reviewing existing programs, policies, and management strategies, particularly those that are innovative or show particular promise of success. A similar assessment of mental health care programs in the Nation's jails is also being conducted. The mental health needs of women offenders are being studied in a related project that expands on an earlier study of women in correctional institutions. Health care fraud Fraud by health care providers has emerged as a serious problem that particularly victimizes such vulnerable individuals as older people and the poor. Medicaid and Medicare are two mechanisms through which this type of fraud is perpetrated. For this reason, NIJ has placed a priority on conducting research addressing health care provider fraud. Current and emerging issues in prevention and response, structural problems in the health care delivery system that might facilitate fraud, law enforcement problems, and legislative and regulatory issues were discussed in a workshop sponsored by NIJ. The workshop brought together officials, from public and private agencies, and from all levels of government, who are involved in health care fraud regulation and control. Of special interest were discussions of problems that might arise under health care reform as a result of increasing reliance on electronic claims processing. To lay the groundwork for the development of an electronic (i.e., computer-based) fraud detection system, NIJ is investigating how to control health care fraud in the electronic era. Notes 1. Reiss, Albert J., Jr., and Jeffrey A. Roth, eds., Understanding and Preventing Violence, Washington, D.C.: National Academy Press, 1993:52. 2. Criminal Victimization in the United States, 1992: A National Crime Victimization Survey Report, Washington, D.C.: U.S. Department of Justice, Bureau of Justice Statistics, March 1994:4. 3. Ibid.:3. See also Federal Bureau of Investigation, press release, December 5, 1993, which indicates that as measured by reports to the police, violent crime registered a slight decline (3 percent) in the first half of 1993, although the number of murders showed no change from the previous 6-month period. 4. Federal Bureau of Investigation, Uniform Crime Reports for the United States 1991, Washington, D.C.: U.S. Department of Justice, August 30, 1992:279. 5. Violent Crime in the United States, Washington, D.C.: U.S. Department of Justice, Bureau of Justice Statistics, March 1991:2. 6. "Advance Report of Final Mortality Statistics, 1991," Monthly Vital Statistics Report, 42, 2 (supplement, August 31, 1993), Centers for Disease Control and Prevention/National Center for Health Statistics. As discussed also on pages 22-28, among young African-American men age 15 to 24, 4,208 died as a result of homicide and 1,499 died in accidents (motor vehicles, falls, drownings, and the like), which was the next leading cause of death in this age group. The leading cause of death for all young men in this age group was accidents, with homicide the second leading cause: 11,534 died in accidents and 6,923 from homicide. 7. Violent Crime in the United States:9. 8. Widom, Cathy S., The Cycle of Violence, Research in Brief, Washington, D.C.: U.S. Department of Justice, National Institute of Justice, October 1992. 9. Scrivner, Ellen M., The Role of Police Psychology in Controlling Excessive Force, Research Report, Washington, D.C.: U.S. Department of Justice, National Institute of Justice, April 1994. 10. Sheley, Joseph F., and James D. Wright, Gun Acquisition and Possession in Selected Juvenile Samples, Research in Brief, Washington, D.C.: U.S. Department of Justice, National Institute of Justice, and Office of Juvenile Justice and Delinquency Prevention, December 1993. 11. Reiss and Roth, eds., Understanding and Preventing Violence: 256, 269. 12. The most recent reports were published as Hammett, Theodore M., et al, 1992 Update: HIV/AIDS in Correctional Facilities--Issues and Options, Issues and Practices in Criminal Justice, Washington, D.C.: U.S. Department of Justice, National Institute of Justice, and U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, January 1994; and Hammett, Theodore M., and Lynne Harrold, Tuberculosis in Correctional Facilities, Issues and Practices in Criminal Justice, Washington, D.C., U.S. Department of Justice, National Institute of Justice, and U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, January 1994. ________________________________ The authors are co-chairs of NIJ's Health and Justice Task Force. Lois Felson Mock, M.A., also manages NIJ's programs dealing with violence, firearms and violence, community policing, organized crime, and white collar crime. Cheryl A. Crawford, M.P.A., J.D., in addition to managing projects dealing with health and justice, manages those dealing with correctional health care and its costs and the impact of infectious diseases on the criminal justice system. They may be contacted at the National Institute of Justice, 633 Indiana Avenue N.W., Washington, DC 20531, by phone at 202-307-0693 (Mock) and 202-513-6210 (Crawford), or by fax at 202-307-6394. ------------------------------ Putting the Partnership Into Action Partnerships have been formed between NIJ and several other organizations and Federal agencies to address various issues of mutual concern in health and justice. Among them are the following: o With the Centers for Disease Control and Prevention (CDC)-- NIJ will work with CDC to better understand and prevent violent crime and the injury and death it causes. The framework for this collaboration has been formalized in a memorandum of understanding, which established the partnership. Collaboration will begin with joint sponsorship of a single-focused project funded in fiscal year 1994, with a more broad-based joint program to follow. The first project, which is also sponsored by the Office of Juvenile Justice and Delinquency Prevention, will address firearms violence, injury, and death among young people. The goal of this project is to demonstrate and evaluate the utility of working partnerships between local law enforcement and public health agencies in understanding and preventing violence. Ultimately, NIJ hopes to expand this partnership to include the U.S. Departments of Education, Labor, and Housing and Urban Development, and other agencies that deal with health and criminal justice issues. NIJ and CDC are also cooperating in an ongoing study to assess the impact of HIV/AIDS and tuberculosis in correctional facilities. Information about the incidence of HIV in prisons and jails is obtained through an annual survey of correctional facilities, now in its seventh year. The survey also examines the policy issues raised in dealing with such conditions in a correctional setting. The survey of violent victimization and its effects on women is also being conducted in cooperation with the CDC. o With the American Medical Association (AMA)--NIJ and the AMA have formed a partnership to address issues of violence. In one expression of that partnership NIJ supported and in other ways contributed to the AMA's major conference on domestic violence, held in March 1994. o With the National Institute on Drug Abuse (NIDA)--NIJ and NIDA jointly sponsored an AIDS/HIV education project to determine how to get substance-abusing arrestees into treatment and how to change health-related attitudes and behaviors. Various education strategies were designed and then tested in jail booking facilities and lockups in Portland, Oregon, and Washington, D.C. The highest level of intervention, case management, was found to be effective in reducing drug use and criminal activity, but no strategy was effective in reducing risky sexual behavior. Case management tended to be effective to the extent that it combined traditional elements (e.g., needs assessment, referral, and advocacy) with nonjudgmental, supportive counseling. _______________________________________________________ DOCTORS FOCUS ON THE THREAT TO HEALTH FROM VIOLENCE Most incidents of family violence, including the abuse of children, spouses, and elderly family members, eventually come to the attention of members of the medical profession, who treat the victims. Family violence thus represents a longstanding concern of physicians and of their national organization, the American Medical Association (AMA). Today the AMA is working on many fronts with the criminal justice system to detect these incidents earlier and prevent their recurrence. A recent AMA conference focused on the links between violence in the family and escalating violence in the world at large and on continued collaboration between members of the justice and health communities in detecting and preventing violence. The AMA recognizes the importance of collaboration between the health and justice systems in addressing public health issues. It has a long history of supporting laws intended to protect the health of citizens, ranging from laws requiring the use of helmets by motorcyclists and seat belts in automobiles and laws restricting the marketing of tobacco products to the recently-enacted Brady legislation requiring a waiting period for the purchase of handguns. The AMA Division of Health Science includes departments that focus on several public health areas: preventive medicine, adolescent health, HIV, geriatric health, women's and minority health, and mental health. AMA's Campaign Against Family Violence In 1991, the AMA launched its Campaign Against Family Violence. Spearheaded by the AMA Department of Mental Health, the campaign has as its main goals: o To heighten all physicians' awareness of family violence as a public health problem. o To improve physicians' ability to recognize the risk factors and symptoms of abuse and neglect, to ask appropriate questions in a nonjudgmental manner, and to treat and refer patients for shelter and services when needed. As part of this campaign, the AMA encourages physicians to become familiar with State laws regarding family violence, to comply with State reporting laws, to document evidence of injury, and to maintain complete records. Physicians are often asked to testify in family violence cases; their recorded documentation is crucial to effective testimony. The AMA has published a set of diagnostic and treatment guidelines for physicians in the areas of child physical abuse and neglect, child sexual abuse, domestic violence, and elder abuse and neglect. Each contains information on symptoms, diagnosis, treatment, referral, confidentiality, reporting, documentation, and testimony. In addition, the AMA Council on Scientific Affairs has produced several reports on various aspects of family violence and physicians' responses. The AMA has also established a National Coalition of Physicians Against Family Violence, which has 5,000 members. A National Advisory Council to the Coalition, which is made up of representatives from 40 medical specialty societies, is working on projects in the areas of medical education, antiviolence legislation, and public information. Several State medical societies have formed State coalitions and have initiated such activities at the local level. Conference links family violence to other social problems An important event in the AMA Campaign Against Family Violence was the 1994 AMA-sponsored National Conference on Family Violence: Health and Justice, which was funded, in part, by the National Institute of Justice. More than 100 health, justice, social service, and advocacy organizations participated in this invitational conference, which focused on all types of family violence and their relationships to violence in the community. Plenary sessions highlighted the links between violence and firearms, substance abuse, and societal factors. Recommendations from the five work groups at the conference will guide health and justice professionals across the country in the areas of professional education, assessment, intervention/rehabilitation, prevention, and media relationships. Proceedings from the conference will be available by fall 1994. A coalition of health and justice professionals will continue to gather information and to monitor progress in each of these areas over the next several years. Martha Witwer Project Coordinator AMA Department of Mental Health ___________________________________________________________ UNDERSTANDING THE ROOTS OF CRIME: THE PROJECT ON HUMAN DEVELOPMENT IN CHICAGO NEIGHBORHOODS by Christy A. Visher Why do some communities and not others become the settings for high rates of delinquency, crime, substance abuse, and drug marketing? Why do some people and not others become habituated to a life of criminal behavior? What is the relationship among community structure, family functioning, and a person's own individual development as factors in influencing criminal behavior? If answers to these questions could be found, they would contribute greatly to our understanding of criminal behavior and could serve as the basis for prevention strategies. In a major National Institute of Justice (NIJ)-sponsored study now under way, researchers are seeking these answers, and others, in an attempt to achieve that understanding. The cornerstone of NIJ's health and justice initiative, the Project on Human Development in Chicago Neighborhoods,1 is an unprecedented, long-range program of research designed to study a broad range of factors at the level of the community, the family, and the individual believed to be important in explaining early aggression and delinquency, substance abuse, and criminal behavior, including violence. The Project is directed by Felton Earls of the Harvard School of Public Health and Albert J. Reiss Jr., of Yale University. A group of distinguished scientists has been involved in the planning and design of the study from its inception. The project's rationale A critical premise of the Project is that an individual's behavioral development is deeply rooted in multiple contexts. Moreover, the complex interactions among them--the relationships of individual traits, community characteristics, the school and family setting, and peer group relations (friends and acquaintances)--also affect that development. The program of research is also based on the theory that patterns of criminal behavior have a long gestation period. Because they develop over time, knowledge about what evokes, sustains, or alters this long-term development can be put to good use in devising means of prevention and intervention. It is difficult to know how much influence to assign to any one of these factors in contrast to the others; that is, to find out the extent to which someone is the product of neighborhood influences and the extent to which her or his behavior results from individual development. Previous research has been unable to disentangle these factors to help distinguish the effects of one from the others. The Project on Human Development in Chicago Neighborhoods will attempt to do this and will give equal attention to influences at the individual level and the community level that may affect development throughout the course of a person's life. Focus on prevention Because the Project was conceptualized with an eye to interventions that may deter criminal behavior, preventable conditions will receive particular emphasis. Thus, special attention will be given to conditions that develop before birth (during the mother's pregnancy), as well as in infancy and early childhood. The objective is to ascertain which elements of a child's development influence the pathways from behavioral problems in the early years to aggression and crime--particularly violent crime--later in life. If interventions are to be used to the best effect in preventing criminal behavior, it is essential to know at what points in a person's development they should be applied. Accordingly, the program of research will identify opportunities during childhood and adolescence when interventions are most likely to produce the greatest benefit. Testing various strategies that promise effective intervention will also be part of the Project. Such knowledge can promote the development of informed public policies and programs geared to prevention. How the study was designed Taken together, the elements of the study design constitute a unique approach: o Investigation of behavioral problems, by age, including early aggression, delinquency, substance abuse, and criminal behavior among both males and females. o Examination of how influences generated in the neighborhood, school, and family contexts interact with the strengths and vulnerabilities of individuals to affect the onset of antisocial behavior and its patterns from preadolescence to adulthood. o Comparison of these contexts and individual differences by group (African-Americans, Hispanics, and Caucasians) and further distinguishing the groups by social class and gender. o Use of an accelerated longitudinal approach, involving nine age cohorts spaced from birth to age 32, permits information-gathering in a relatively brief period of time that would otherwise take several decades. The startup phase Over the past 5 years, NIJ, in conjunction with the John D. and Catherine T. MacArthur Foundation, has supported the planning and design of the study. It is a major component of NIJ's research program and addresses NIJ's statutory mandate to study "the causes and correlates of crime and juvenile delinquency." NIJ and its funding partner, the MacArthur Foundation, have jointly invested $10 million in the development and design phase. More than 100 scientists with numerous theoretical perspectives, who represent several disciplines--among them pediatrics, biology, psychology, sociology, and criminology--have been involved thus far. Laying the groundwork. The early phases, under way since 1989, included exploring particular study topics and finding out which study methods would work best. Pilot studies were carried out to answer specific questions, and two volumes on the method used to conduct a study with an accelerated longitudinal design were produced. A series of reports presented in outlines the design of a comprehensive study of the roots of crime. These reports included exhaustive reviews of previous studies in relevant topic areas: early childhood development and conduct disorder, adolescent development and juvenile delinquency, the influence of family and community factors on crime and criminal behavior, and the development of criminal careers. The pilot studies, whose findings are summarized in a box on page 12, explored several specific issues, some of which will be studied in greater depth over the course of the project, including: o The amount of interaction fathers have with their infants and preschool children and the impact of that interaction. o The effect of endocrine influences on aggression (for example, the accuracy of measures of the hormone testosterone in saliva in aggressive and nonaggressive boys). o The influence of peer groups (friends and acquaintances) on delinquency. o The use of social services such as counseling by adolescents and their parents. The researchers also conducted pilots to find measurement tools that would be useful for the study. Thus, they developed and tested various psychological measures appropriate to the different age groups in the study. For example, they wanted to find out how best to measure stress and family interaction. They also wanted to make certain the measures they chose were appropriate to the various cultural groups being studied. How the information will be gathered Information will be collected over a period of 8 years on 11,000 people, male and female, and at three points during the project on approximately 40,000 additional individuals who live in the same community areas. An innovative study design, which essentially accelerates the pace of a long-term study, permits tracing in just 8 years how criminal behavior develops from birth to age 32. The acceleration occurs through the study of the nine groups of people (cohorts) whose ages overlap. Between now and the year 2002, the investigators will gather detailed information about each of the 11,000 individuals, as well as about the communities in which they live. The use of the accelerated longitudinal design and analytic methods developed during the 5-year planning phase will make this knowledge available many years earlier than it would be through a conventional longitudinal approach. Throughout the course of the Project, results will be disseminated widely. In addition, the data will be made available as quickly as possible to other researchers, policy planners, and the communities involved. Community focus At the heart of the study is the question of how the characteristics of a community affect the development of people who live there. The people studied, who represent the diverse ethnic and social class structure of Chicago, will be chosen through a process of random selection from 80 communities in the city. To examine the role of neighborhoods in behavioral development and to monitor the changes that will inevitably take place in these communities over the course of the study, a selected number of residents will be interviewed at the beginning, middle, and end of the 8-year period as part of a community survey. This aspect of the study will go beyond U.S. Census tract data and standard socioeconomic measures that help define high-risk populations in other longitudinal studies. Data will be collected from the 80 neighborhoods from which the subjects are being drawn. Some of these neighborhoods are in the high-risk category, while others reflect varying degrees of affluence as well as different cultural and ethnic compositions. Adults in these communities will be surveyed about their perceptions of each neighborhood's atmosphere, desirability, and livability; and resources, including educational, health, social services, economic and business, employment, and recreational. Each neighborhood's access to and use of wider community resources in Chicago will be explored. Recent developments The development and design phase, which is needed to ensure a carefully crafted research design, has been completed. Data collection began in Chicago in August 1994. In the past 3 years, the Project has accomplished several tasks in addition to the exploratory studies of topics and methods noted above. The investigators pretested the protocols to be used in studying individuals and neighborhoods, selected the Chicago neighborhoods, and put together the research staff. Creating tools for conducting the study. Interviews with the subjects and their families will be a major tool in conducting the study. The project staff compiled the individual and family interview instruments and pretested the complete protocol on a selected number of 100 subjects and the principal caregiver (usually the mother) across the nine age cohorts. A subset of the interviews was translated and administered in Spanish. The community resident survey was pretested among 150 residents in several Chicago neighborhoods. Selecting the city. Chicago was selected as the Project site after analysis of the demographic structure of the 100 largest cities in the country and extensive site visits to Baltimore, Los Angeles, and Chicago. In addition to demographic elements--population structure and mobility--the investigators took several other factors into account in choosing the city: availability and quality of health, school, and criminal justice records; extent of community support anticipated for the Project; and each city's research environment. Administration and management. Making sure that data collection runs smoothly requires top-notch administrative and managerial skills. A nationwide search for a site director who would have overall responsibility for the Chicago study resulted in the selection of Dr. John Holton, formerly executive director of the Chicago chapter of the National Committee for Prevention of Child Abuse. Dr. Holton's professional background is in human development and juvenile delinquency. Three Deputy Directors, who have also been selected, are responsible for the respective areas of subject assessment (i.e., cohort interviews), agency records, and data management. At full capacity, the staff will consist of about 75 people. Next steps The Project issued a competitive procurement announcement late last year requesting proposals to carry out several tasks in the community design part of the study. A research organization has been selected that is responsible for the surveys of residents in Chicago communities and will assist in developing a plan for selecting the sample of people to be interviewed. The survey of community residents is expected to be completed by January 1995. The initial interviews with the study participants and their families will be completed by the fall of 1995. The Project is seeking additional support from organizations whose interests lie in mental health, child development, and substance abuse. This additional assistance is needed to supplement data collection in these topic areas. Conclusion The Project on Human Development in Chicago Neighborhoods is a major step forward in the study of crime prevention and control. The multidisciplinary approach integrating community, family, school, peer, and individual influences will permit significant advances of our understanding of the causes of crime and in developing interventions to prevent crime and its consequences. NIJ expects to disseminate initial findings from the first year of data collection in late 1995. Notes 1. Formerly the Program on Human Development and Criminal Behavior. For More Information The Project on Human Development in Chicago Neighborhoods is directed by Felton Earls of the Harvard School of Public Health. Interim reports and results of pilot studies can be obtained from: The Project on Human Developmentin Chicago Neighborhoods Harvard School of Public Health Department of Maternal and Child Health 677 Huntington Avenue Boston, MA 02115 Christy A. Visher, Ph.D., senior social scientist in NIJ's Office of Planning and Management, manages the Project on Human Development in Chicago Neighborhoods at NIJ. _________________________________________________________ FINDINGS OF THE PILOT STUDIES Studying the development of the individual in the social context Before the study began, the research design, measurement strategies, and method of data analysis were examined and then refined. Sample sizes were set for the age cohorts and the neighborhoods. The researchers showed that continuity and change over time in behavior--aggression, delinquency, and criminal activity--could be revealed by linking the information, even when information from different age cohorts was used. They also developed a detailed analytic plan to study how the social context (family, school, or neighborhood) can affect individuals' behavior. Does testosterone affect aggression in children? The link between the male hormone testosterone and aggression has been demonstrated in animal studies and in some studies of adult men. Other research has shown that aggressive children continue to display this type of behavior into adulthood. But the results of the pilot study conducted for this project cast strong doubts on the possibility that testosterone levels explain aggression in young children or can be used as a marker for latter aggression in adolescence or adulthood. In a study of a small group of highly aggressive prepubertal boys, no significant difference was found between their testosterone levels and those of nonaggressive children. The father's role in child/adolescent development The involvement of fathers in their children's development was found to have positive effects, according to the findings of another pilot study. This study of fathers' interaction with high-risk infants revealed that three-fourths played with their children on a daily basis (although for one-third of these children the paternal figure changed during the 3-year period covered by the study). Another study involved interviews with fathers (both those who live with their children and those who do not). Researchers found that fathers furnished unique information about family processes, including child behavior. Effects of neighborhood characteristics on drug use and sales A large city in the Northeast was studied to examine the extent of neighboring, local personal ties, income level, participation in community organizations, and extent of deviant-criminal subculture. Researchers wanted to find out if the type of neighborhood affects the amount of criminal behavior that takes place in it. They found that differences by neighborhood in these community characteristics could account for the differences among certain neighborhoods in the amount of substance abuse and explained differences in substance abuse by individuals within a given neighborhood. This study is being expanded in Chicago. Peer social networks Conventional wisdom and previous research hold that friends and acquaintances exert strong influences on young people's behavior. The primary focus of pilot studies was the availability of reliable information about peer social networks. Researchers found that the peer associates of highly deviant adolescents could be interviewed, that information about gang activity can be obtained through studies of peer social networks, and that large numbers of students in a classroom can be sources of information about social status and social networks of their friends and acquaintances. Is delinquency related to child caretaking arrangements? Children in high-risk neighborhoods were found to have different caretaking provided for them than the caretaking arrangements for children in the overall sample: there were more single mothers and single fathers in the high-risk sample. However, the arrangements did not affect delinquency among high-risk children. By contrast, in the general, citywide sample, child caretaking arrangements were related to delinquency. For example, children in the larger, citywide sample who lived with single mothers were much more delinquent than those living with two parents. In the high-risk sample, children with single mothers were no more delinquent than those in two-parent families. This illustrates complex interactions between family structure, neighborhood characteristics, and behavior. __________________________________________________________ THE CONTEXTS AND THE FACTORS TO BE STUDIED The Community o Social, economic, and demographic structure. o Organizational/political structure. o Community standards and norms. o Informal social control. o Crime, victimization, and arrests. o Social cohesion. o Residential turnover. o Level of involvement in drug and gang networks. The School o Academic achievement expectations. o School policies regarding social control. o School conflict. o Teacher-student relationships. o Strengths and weaknesses of the school environment. Peer Relationships o Composition and size of social network. o Substance abuse and delinquency by peers. o Deviant and prosocial attitudes of peers. o Location of peer networks (school or community). o Changes in peer relationships over time. The Family o Family structure. o Parent-child relationships. o Parental disciplinary practices. o Parent characteristics. o Family mental health. o Family history of criminal behavior and substance abuse. The Individual o Physical and mental health status. o Impulse control and sensation-seeking traits. o Cognitive and language development. o Ethnic identity and acculturation. o Leisure-time activities. o Self-perception, attitudes, and values. _________________________________________________________ ADOPTING THE HEALTH CARE MODEL TO PREVENT VICTIMIZATION by Lucy N. Friedman In the 1970's, when the victim movement began, its primary goals were to help victims recover from the emotional trauma, practical problems, and physical injuries resulting from crime and to prevent a second victimization by ensuring that the criminal justice, health, and social service systems treat victims with dignity, respect, and compassion. In two decades great strides have been made. New laws spell out the rights of crime victims, and 14 States have amended their constitutions to guarantee victims' rights. A vast network of victim services (approximately 8,000 programs nationwide)1 has been created, and these are raising public awareness about victims and their needs. But sadly, what victims say they want most is for the crime never to have happened. Advocates and service providers who work daily to heal the wounds of victimization are also growing weary of helping only after the fact; they, too, want to figure out how to prevent crime. Looking at violence only as a criminal justice issue has limited crime prevention strategies, but now policymakers are recognizing that violence is a health issue as well. The U.S. Department of Justice reports that Americans are more likely to become victims of violent crime than to be injured in motor vehicle accidents.2 Domestic violence is the leading cause of injury to women in the United States,3 and murder is the leading cause of death among African-American males aged 15 to 24.4 Treating violence as a major problem in criminal justice and health suggests some new strategies for prevention. Public health campaigns to induce people to take responsibility for avoiding illness have led many to change their daily behavior. Safer sex practices are a dramatic and widespread personal response to the AIDS epidemic. While it is decidedly harder to protect oneself against violence than against a virus, the public health approach offers useful lessons in preventing and controlling violence. Three public health concepts especially germane to preventing violence are public education, control of contagion, and early detection. Public education Education forms the backbone of public health efforts. Over the past 20 years, full-scale public education campaigns have increased the use of seat belts and reduced the use of tobacco. Antismoking education has been successful not only in getting a large part of the smoking population to quit but also in preventing many young people from starting to smoke. An antiviolence campaign even half as effective as the antismoking campaign would dramatically reduce violent behavior. Such a campaign could target youth and could get at the roots of violent behavior (such as a lack of respect for women, in cases of sexual and domestic assault) and teach alternative ways to solve disputes (e.g., conflict resolution and communication skills). One example of the type of behavior that could be eradicated with such a campaign is the kind of incident that terrified young girls at some New York City public pools during the summer of 1993. Groups of boys encircled the girls, cutting them off from help, and then ripped off the girls' bathing suits. These boys considered taunting and humiliating the girls to be a game--not a violent assault. A public education campaign to teach boys and girls to respect each other and take responsibility for their actions, at the same time raising awareness of how the abuse of power can result in violence, might have made those boys think twice before playing such an abusive "game." Controlling contagion The health care model stresses control of epidemics by targeting persons at risk for disease, such as those living in crowded or unsanitary conditions. Who is at risk for violence? Through new research as well as anecdotal evidence, some profiles of at-risk populations are emerging. For instance, there is increasing evidence that a predilection towards violence can be transmitted from generation to generation. One research study found that youths who have been abused or neglected are 38 percent more likely to be arrested for a violent crime by the time they are adults than those who have not been mistreated.5 Those working with youths have observed this link as well. James Fisher, coordinator of a school violence prevention program conducted by Victim Services in New York City, has a simple way of dramatizing this possibility. He says to students: "If you blow up a balloon, and keep blowing, what happens? It pops. If you're a victim (say, of family violence) and you have to keep that pain inside over and over again, eventually you'll explode and lash out at someone." In addition, data indicate that a person who has been shot is more likely to be victimized again than someone who has not.6 And yet another recent study found that women who were raped or were victims of attempted rape as adolescents were more than twice as likely as other women to be the victim of rape or attempted rape during their first year in college.7 How do we inoculate those at risk? Counseling can provide victims of violence support and constructive ways to channel their rage, which would reduce the likelihood they would lash out at someone else, seek retribution, or continue to feel vulnerable. Counseling can also provide new coping and crime prevention skills to reduce fear as well as the chance of a repeat victimization. When a person comes to the emergency room with a gunshot or knife wound, the hospital staff must report the incident to the police so that the criminal justice system can intervene. Funding is needed for counseling to help victims prevent repeat victimization and guide them from becoming victimizers themselves. Early detection To treat people at risk for violence, one must identify who they are. The public health model teaches that the earlier one can detect an ailment, the better the chance of curing it. In cases of violence between strangers, detection is usually straightforward: the victim turns to the criminal justice system. When the victim and offender have a prior relationship, the criminal justice system may not be involved until the violence escalates into serious assault or murder. In these cases, early detection and intervention can be especially important--and tricky. The following examples show why this is true. A daughter brought her elderly mother to an emergency room in the Bronx. The older woman had a broken arm, and the daughter explained that her mother had slipped on the ice. But when a social worker was able to talk to the mother in private she learned that, in fact, the daughter had pushed her mother and that this was the third injury for which she had brought the mother to an emergency room that month. Michael fatally stabbed his classmate Derek. Derek had bullied Michael for several months and had once beaten him so badly that Michael needed treatment for a sprained arm. Another time Derek slashed Michael's leg, leaving a wound that required 20 stitches. A doctor who asked Michael the reason for the sprained arm or knife wound might have picked up clues and referred Michael to counseling before he stabbed Derek.8 The health care workers in these cases needed to be more aware of the warning signs of violence among acquaintances. Training doctors, nurses, and social workers to ask the right questions so that they can identify and intervene or obtain other help in these cases could be mandatory. Many States have adopted such protocols for domestic abuse, and last year the Joint Commission on Accreditation of Health Care Organizations added to its standards the caveat that every hospital must have a protocol and provide training on domestic violence detection and treatment. The protocols need to be followed and expanded to include detection techniques for violence among acquaintances. Promise for the future An opportunity exists to screen for violence by a medical community that increasingly emphasizes prevention and the family doctor approach to health care. Family doctors are well positioned to notice patterns that suggest a patient is at risk of violence. Twenty years ago doctors rarely asked patients about their sexual and drinking habits, but now most doctors routinely ask such questions. Asking, "Do you have trouble controlling your temper? What happens when you lose it?" could be just as routine. If a patient replies that he occasionally "takes a swipe" at his partner or "breaks furniture," the physician could tell him that this is a health problem and that the patient needs help. Treating violence as a health as well as a criminal justice issue opens the door to more resources. National Institute of Justice (NIJ)-sponsored research is studying violence, but the information that still needs to be collected is vast. Computerized records of reasons for injuries and sophisticated studies about prevalence will offer a better grasp of patterns. With data in hand, stronger arguments can be made for increased allocation of limited resources. A better balance is needed: the Federal Government spends on research about $794 per year per life lost because of cancer, but only $31 per year per life lost to violence.9 The value of the public health approach is that investing in detection, education, and counseling is cost-effective. It is less expensive to incorporate early identification into the health care system and provide services than to face the burden of escalating emergency room, law enforcement, court, child welfare, and prison costs. But what is truly unbearable is the cost in human lives that the Nation will pay if efforts to prevent violence fail. Ultimately, early intervention and treatment by the health care system, combined with criminal justice efforts, will start giving the victims of violence what they deserve: for the crime not to have happened. Notes 1. These estimates come from the National Victim Center. 2. Highlights From 20 Years of Surveying Crime Victims: The National Crime Victimization Survey, 1973-1992, Washington, D: U.S. Department of Justice, Bureau of Justice Statistics, p. 5. 3. Stark, E., and A. Flitcraft, "Violence Among Intimates: An Epidemiological Review," in Haslett et al., eds., Handbook of Family Violence, 1987. 4. "Advance Report of Final Mortality Statistics, 1991," Monthly Vital Statistics Report, 42, 2 (supplement, August 31, 1993), Centers for Disease Control and Prevention/National Center for Health Statistics. 5. Widom, Cathy Spatz, The Cycle of Violence, Research in Brief, Washington, D: U.S. Department of Justice, National Institute of Justice, October 1992:1. 6. Weissbeski and Sims, "Urban Terrorism: A Chronic Recurring Disease," Journal of Trauma, 1989: 940-947. 7. White, Jacqueline, and John Humphrey. From a study at the University of North Carolina at Greensboro. 1992. 8. Cases are from Victim Services. Names have been changed to protect identities. 9. Reiss, Albert J., Jr., and Jeffrey A. Roth, eds., Understanding and Preventing Violence, Washington, D: National Academy Press, 1993: 345-6. Lucy N. Friedman is Executive Director of Victim Services, a New York City not-for-profit organization that helps more than 100,000 victims each year. ________________________________________________________ THE HEALTH-JUSTICE INTERFACE: A NEW ARENA FOR POLICE The paradigm of violence as a public health problem gives rise to a number of issues, among them the question of what role the police should play. Law enforcement traditionalists would argue that the police should be society's "surgeons," wielding arrest like a scalpel to excise violent offenders who threaten the com-munity's health. Yet what is becoming clear--to the public and many police officials--is that this standard response is not working. New opportunities for policing Community policing allows the police to balance the more traditional, reactive response with proactive efforts encompassing early intervention, prevention, and treatment. Working in and with the community and its service providers--including those offering health care--as partners in problem solving is the core of community policing. Health issues can engage the police A wise man once offered the following advice for those who wished for a peaceful world: "Work for peace within your family, then in your street, then within the community." These words written some 200 years ago apply today. Within the family. Until the past decade or so, violence within the family setting--physical and sexual assaults, particularly against women and children--was considered a private affair and not a crime to be reported to the police. Recognition of the criminal nature of family violence represents a major advance. The response of the police and of the medical profession to family violence is increasingly collaborative. Police in many jurisdictions have formed partnerships with health care providers, advocacy groups, social service agencies, and the courts to establish a continuum of protection and care. As part of these initiatives, legal remedies for victims have been enhanced and police procedures improved. Recent protocols for health care providers also promote the holistic approach. The Joint Commission on Accreditation of Health Care Organizations now requires that all accredited hospitals implement policies and procedures to detect domestic abuse, provide appropriate treatment to victims, and refer them to shelters, advocacy groups, or other sources of assistance. The standards also require that educational programs be developed for hospital staff in the areas of domestic violence, as well as in the specific areas of elder abuse, child abuse, and sexual assault. On neighborhood streets. Under community policing, neighborhoods resist violence and crime by fully engaging residents, the police, health care providers, and community services. These efforts may include actions taken to remove the more visible symptoms of disorder, such as trash and graffiti. In the community policing model, patrol officers become familiar with the needs of the people they serve and act as brokers, directing residents to services such as health screening, drug and alcohol treatment, and mental health services. They also function as "eyes on the street," alerting the appropriate enforcement authorities to such matters as health code violations. In the larger community. The engagement of community resources cannot be limited to the most afflicted neighborhoods. Law enforcement's experience in combating drug trafficking, for example, has demonstrated that problems solved in one neighborhood may simply be displaced to another. Arguably, community policing might best be applied citywide rather than in a limited number of neighborhood areas. Wider application might be more effective in addressing issues that divide a community and in promoting police awareness of com-munitywide problems. A broader police role Budgetary constraints and the public's urgent demands for immediate solutions increase pressure on police departments to return to the narrower, traditional focus on rapid response to calls for service. Hopefully, the temptation can be resisted. Viewing crime--particularly violent crime--from the perspective of health care, and integrating that view with the holistic approach of community policing, offers a new perspective. This may mean an expanded role for the police, but community policing leverages resources already available, opening up more opportunities to enhance public safety. Drew Diamond Senior Research Associate Police Executive Research Forum _________________________________________________________ EXPANDING THE ROLE OF THE LOCAL PROSECUTOR by Donald J. Rebovich The local prosecutor is often perceived as the single most powerful individual in local government. The prosecutor's office is the nexus of the law enforcement and adjudication functions, and is unique in the criminal justice system because it interacts directly with all system components--the police, the courts, and corrections. Yet, as the role has evolved over the past two decades, the functions of the district attorney have expanded far beyond the conventional boundaries of the criminal justice system into what have long been considered nontraditional areas of responsibility. Nowhere is this development more apparent than at the intersection of criminal justice and health concerns. In recent years, prosecutors and their constituents have become more accustomed to the new roles of public managers and elected officials who command considerable resources. These roles include those of strategic investor and institution builder. As strategic investors, prosecutors have broadened their responsibilities to include areas previously untouched by the profession, but which they recognize as having the potential to build long-term strategies for reducing crime. As institution builders, local prosecutors have become more responsible for identifying community problem areas, seeking solutions, and improving the vitality of local institutions, including the family unit. It is at the point where justice and medical/health-related issues converge that these "new role" prosecutors face their most daunting challenges. Prosecuting "gray area" offenses In their quest to address nontraditional areas, local prosecutors throughout the country are increasingly responding to community demands to criminally prosecute what have been viewed historically as violations in legal "gray areas"; i.e., areas where there is uncertainty about how the justice system should process them. Until recently, many of these gray areas have been dealt with through State and Federal law enforcement agencies and civil or regulatory means rather than through the criminal justice system. In at least two of these areas--the local prosecution of health care fraud and the local prosecution of environmental crime--criminal justice and health concerns overlap. Health care fraud. Health care fraud typically involves unnecessary referrals for treatment or services received from health care providers that, in effect, constitute criminal victimization of both patients and insurance carriers. The costs to society are many, and can include the theft of Medicaid funds that would otherwise be available for providing health care legitimately, and a resulting erosion of public faith in the health care system. Historically, local prosecutors have not aggressively pursued these cases, citing difficulties in the effective prosecution of highly regarded professional groups and the perceived misgivings judges might have at the prospect of prosecuting physicians as criminals. Despite these obstacles, local prosecutors have identified health care fraud as one of the most critical justice problems they face today. This view has been expressed in focus group sessions and survey research conducted by the National Institute of Justice and the American Prosecutors Research Institute. Once prevalent largely in urban jurisdictions, health care fraud is also reported as becoming more common in suburban and rural areas where local prosecutors have little or no experience with these types of cases. Such experience is valuable particularly because effective prosecution at the local level depends on accomplishing a number of tasks: thoroughly understanding the technology related to the medical services involved and the specific medical conditions of the patients in each case, using expert witnesses to explain the technology and provide insight into the extent to which medical treatment is necessary, and conveying all this information in terms comprehensible to jurors. In these complex and specialized areas, research can be most useful. Empirical research can shed light on how the more proactive local prosecutors' offices overcome common obstacles to handling health care fraud cases and, specifically, on what methods are most productive in prosecuting these offenses. Such information could form the basis for training programs designed to enhance the health care fraud prosecuting skills of all prosecutors, regardless of the size of the jurisdictions they represent. Environmental crime. As the locally based prosecutor of environmental polluters, the district attorney has assumed the role of protector of the public health. In that role, he or she is compelled to become intimately familiar with a variety of areas that require technical expertise, such as environmental science, chemistry, waste sampling techniques, and regulatory enforcement. As community demands to stem environmental violations gain in strength, criminal prosecution is employed. Special appeals to control environmental crime at the local level are now emanating from low-income, urban areas where illegal dumping of hazardous wastes has been characterized as "environmental racism," exposing vulnerable groups to serious health threats. Through criminal prosecution, local prosecutors serve a crucial function in helping to improve the overall quality of life of these neighborhoods. Not all local prosecutors possess the requisite technical expertise, but in at least one respect they are well-equipped to handle environmental crime cases. This advantage stems from their intimate knowledge of the community's perception of the extent to which these cases are considered truly criminal. This knowledge is invaluable in guiding case handling, but it does not diminish the need for technical assistance. The admissibility of medical and scientific evidence An overarching issue in prosecuting offenses such as health care fraud and environmental crime--and one that promises to achieve greater currency in the near future--is the presentation of medical and scientific evidence in the courtroom. Local prosecutors have expressed growing anxieties about their ability to successfully prosecute cases in which medical test results and information about various medical syndromes are submitted as evidence. This evidence can include information and testimony about the battered wife syndrome and the abused child syndrome, which are used as defenses against criminal charges. The recent U.S. Supreme Court decision in Daubert v. Merrell Dow Pharmaceuticals, Inc. (113 S. Ct. 2786, 53 CrL 2313 [1993]), which in effect replaced the previous Frye standard (Frye v. The United States, 293 F. 1013 [D Cir. 1923])1 for the admissibility of scientific evidence in Federal courts, is viewed by some local prosecutors as potentially having a major impact on changing definitions of the "reliability" and "relevancy" of such evidence in State courts. Through the Daubert decision, the Supreme Court recognized the current proliferation of what it called "junk science" (i.e., expert witness testimony that has little or no basis in reliable or valid empirical evidence) and instructed trial courts to subject new scientific information to rigorous cross-examination, allow the presentation of opposing evidence, and carefully instruct the jury in deciding the burden of proof in such cases. These changes in the admissibility of scientific evidence can have special bearing on environmental crime prosecutions in which substantiating the level of public harm inflicted by illegally disposed wastes can be a key determinant of the severity of the punishment imposed. Changes in the standards of admissibility of medical and scientific evidence affect no area to a greater degree than in deoxyribonucleic acid (DNA) sample matching. Recent advances in DNA technology have resulted in high levels of reliability in linking DNA evidence from the crime scene or the victim with the suspected perpetrators in cases ranging from simple burglary to murder. While such evidence is in many cases admitted into trial, unprecedented defense challenges to its admissibility and the 1992 release of a National Research Council (NRC) report on forensic DNA technology have muddied the waters for criminal court judges. The NRC report endorsed the technology, but its recommendations about the method of calculating the statistical significance of DNA matches are viewed as overly conservative by the FBI and forensic laboratories. In some cases, the defense has used the NRC recommendations to challenge the standards used by local prosecutors based on statistical calculations that specify how closely the "marker" bands in two DNA prints must be aligned to be deemed a match. As a result of the criticism, the NRC announced that it would readdress this issue and convene a new panel comprising statisticians and human geneticists. Given these developments, it is clear that if local prosecutors are to hold a competitive edge, they will need high-quality technical assistance in seeking the best methods to present DNA evidence in ways that lead to successful case disposition. When cases involve mentally impaired victims and defendants A growing challenge for local prosecutors is determining the most effective methods to prosecute cases in which either the victim or the defendant is mentally impaired. Recent cases in New Jersey and North Carolina highlighted the difficulties that can arise in situations where mentally impaired victims of crimes such as sexual assault may be assessed as unreliable witnesses by jurors. Local prosecutors will typically encounter defense strategies that exploit the impairment in an effort to destroy the victim's credibility. The fear is that prosecutors may be inclined to reject these cases or accept undesirable plea agreements if they lack sufficient confidence in their ability to prosecute them successfully. Here too, research that identifies the best methods for prosecuting these types of cases would be beneficial. Local prosecutors are also concerned about the implications of deinstitutionalization for crime. The emphasis on providing community health care for individuals who once would have been institutionalized increases the chances that crime will be committed by people who are mentally impaired and have been released into the community. In handling these types of offenses, local prosecutors are also relatively inexperienced. They seek not only to improve the likelihood of conviction but also to be more certain about what types of penalties to recommend as appropriate for these offenders. Other areas These are only a few of the many criminal justice and health issues confronting today's local prosecutor. The following list highlights some other areas of developing concern: o Prosecutor and juror stress in high-profile trials. o The prosecution of physician-assisted suicide and the termination of life-sustaining medical treatment. o The prosecution of child abuse cases involving child fatalities. o The prosecution of cases in which AIDS transmission is used as a weapon. o Drug testing at all phases of criminal prosecution--including post-conviction monitoring--as it affects successful rehabilitation and recidivism. o The prosecution of violence against the elderly. FThe prosecution of cases in which pregnant women are known drug abusers. o Research into the medical effects of crack compared to powder cocaine and the implications of the findings for criminal prosecution and penalties. Notes 1. From the early 1920's until 1993, the Frye decision was the standard for the admissibility of scientific evidence in the courtroom. Under Frye, evidence derived from a novel scientific technology could be presented to a jury only if the court first determined that the technique had gained general acceptance in the relevant field of science. Donald J. Rebovich, Ph.D., is Director of Research with the American Prosecutors Research Institute, the research, technical assistance, and program affiliate of the National District Attorneys Association. For more information, contact Dr. Rebovich at the American Prosecutors Research Institute, 99 Canal Center Plaza, Suite 510, Alexandria, VA 22314 (phone 703-519-1675; fax 703-836-3195). ____________________________________________________________ THE IMPACT OF HEALTH-RELATED ISSUES ON THE COURTS by Thomas L. Hafemeister While much attention is being paid to health care reform proposals, a less visible development, but one whose effects may be just as pervasive, is taking place as the judiciary is being asked to play a major role in shaping the country's health care policy. Many significant biomedical and health care-related issues are being raised in the courts today. A number of these issues are evolving rapidly, and the cases frequently involve highly technical matters and questions of great interest to society in general. For these reasons, both these types of cases and a broad array that are somewhat more routine may strain the courts' ability to process them and to adjudicate the complex matters they raise. Some courts are aware of the potential problems these cases pose, but many are not, and few have been provided the assistance needed to help resolve them. In response, the National Center for State Courts (NCSC) has been actively involved in health-related issues. The overall mission of the NCSC, a private, not-for-profit organization, is to improve the administration of justice in the Nation's State courts by serving as their central resource for solving problems, improving operations, enhancing performance, and increasing knowledge and understanding. In conjunction with this mission, the NCSC has undertaken and continues to undertake a number of projects designed to help the courts respond to health-related issues. New areas of adjudication Cases involving biomedical and health care issues are increasingly challenging--and inundating--the courts. Included are a growing number of complex and perplexing cases that raise issues not previously addressed by the particular court or jurisdiction (i.e., cases of first impression), that fall outside the courts' traditional areas of expertise and that cannot easily be processed in the usual manner. Many of these cases have broad-ranging social and ethical implications, involve decisions affecting the allocation of limited health care resources, and are daunting in the value judgments they require. Traditionally, such decisions have been reserved for legislatures, but the courts, by default, are often forced to resolve them when lawmakers have been unable or unwilling to do so. Simultaneously, the courts must handle a growing number of more traditional health-care-related cases. These cases may raise difficult evidentiary questions, tax the courts' ability to maintain the expertise necessary to resolve the issues posed, and require substantial judicial resources. Such cases include medical malpractice actions, tort claims regarding toxic substances, suits filed under the Americans With Disabilities Act, judicial review of administrative decisions made under Medicaid and similar State-authorized health care programs, and class action suits challenging the level of health care provided to individuals who are under State care or control. In addition, litigation is increasingly focusing on the protection of victims of family violence, including victims of elder abuse and neglect and children who witness domestic violence. In all these cases, health issues are a major concern. The types of cases being handled A brief review of some of the developments reported in the media during only a 2-week period demonstrates the frequency with which health-related issues are brought before the courts as well as the breadth of the matters they concern. o A company attempted to drastically cut its insurance coverage for employees with AIDS. o A woman convicted of child abuse was required to accept implantation of a long-term birth control drug (Norplant) as a condition of parole. o A woman was sentenced for child endangerment after passing to her infant through her breast milk an illegal drug she was using that killed the child. o A petition was brought to drop criminal charges because of the deteriorating health of the 85 year-old defendant. o A petition was sought to prevent execution of a defendant who had a physical disability. o A suit was filed on behalf of a Chicago executive who lost his job after his employer learned he had brain cancer (the first lawsuit filed under the Americans With Disabilities Act). o The courts were asked to address the need for environmental cleanup of toxic wastes, including the question of whether the proposed cleanup could itself endanger the public health, and in another instance were asked to assess the toxic effects of lead paint. Opportunities for improved court functioning Increased judicial attention to evidentiary issues is needed in several types of litigation, as noted in a recent report of the Carnegie Commission. The Commission foresaw growing judicial difficulty in determining causality and damages in cases involving silicone gel breast implants, repetitive motion injuries (e.g., carpal tunnel syndrome), and possibly even claims of brain cancer attributable to electromagnetic currents in cellular telephones. The Commission recommended improvements in the courts' approach to procedural issues associated with such cases, including, among other things: the relative weight accorded to the testimony of expert witnesses; the establishment of appropriate standards for use in evaluating scientific and technological testimony and evidence; the resolution of scientific and technological questions in pretrial procedures; the use of impartial, court-appointed experts; and the use of alternative dispute resolution techniques. Challenges for case processing Health-related matters, whether raised in traditional or new types of cases, demand a great deal of the courts. In some instances, the courts must determine the proper use of scientific, medical, and biotechnology evidence (for example, evidence involving genetic research, including DNA typing and its admissibility). They must also decide what are acceptable professional and clinical practice guidelines, determine the appropriate use of medical and judicial resources, and assess the qualifications of experts and the admissibility of their testimony. Because these types of cases often involve issues of personal well-being (including matters of life and death), they may create unique challenges for court processing. For example, they may be raised on an emergency basis and therefore require an expedited decision. They may be presented in a relatively nonconventional manner, such as by an ex parte contact in a nonadversarial context or by an attempt to obtain injunctive relief or a declaratory judgment (i.e., a judgment in which legal rights are declared but no consequential relief is ordered). Because, in such cases, there tends to be greater reliance on expert witnesses, the judge may be compelled to spend a considerable amount of time and energy developing the requisite expertise. Expert opinion. The presentation of expert testimony is a fairly frequent occurrence in the courtroom. One study of civil trials held in Dallas (Texas) County district courts in a recent 3-month period revealed that expert testimony was presented in more than 60 percent of the cases.1 In many instances in which such testimony is presented, health-related issues are involved: almost half the experts who testified in the Dallas cases studied were physicians. Medical malpractice cases are an example of an area in which expert opinion is used. In these cases the courts typically give considerable weight to evidence regarding customary medical practice. But because there are at least two parties to these disputes, a "battle of the experts" often ensues. There is a widely held view that such experts are not representative and their testimony does not provide a reliable or useful basis for informing the decision of the judge. One alternative is greater use of neutral, court-appointed experts. However, almost no information is available about the types of cases in which they should be used, the point in the judicial process when such appointments can or should be made, or under what circumstances. Research could help fill these information gaps. Evidentiary issues. Questions regarding the proper use of complex scientific and technological evidence, especially involving DNA typing and the admissibility of DNA, continue to be raised in State criminal courts as well as civil courts. One issue involves the statistical probability that DNA evidence taken from a crime scene matches that from an assailant or whether the match is merely a random occurrence. Recently, the District of Columbia Court of Appeals questioned FBI statistics that predicted the probability of a random DNA match in a rape case to be 1 in 30 million. Relying on a National Academy of Sciences report that indicated the probability of a random match was closer to 1 in 100,000, the court remanded the case to the trial court. This was done to permit the defendant to contest the sufficiency of the government's demonstration of the existence of scientific consensus on the issue. Health issues the courts are addressing A number of health-related matters the courts are being called upon to address or that affect court functioning, including the following, could benefit from research and technical assistance. Life-sustaining medical treatment. Controversies centering on forgoing life-sustaining medical treatment (LSMT), which the courts continue to be asked to resolve, are typically presented to judges on an emergency or an expedited basis, with information often incomplete and potentially misleading. In addition, many judges report feeling uncomfortable handling these cases, which seem to require expertise they do not possess. An example of such a case was one recently brought before the Court of Appeals of Maryland, which issued its first opinion addressing the forgoing of LSMT. The case centered on an application to withhold nutrition and hydration to a patient who has been in a persistent vegetative state since 1983. The court ruled that because the evidence was inconclusive concerning any intent the patient had, or would have, about forgoing nutrition and hydration under these circumstances, Maryland law did not authorize withholding life support. To assist the courts, the NCSC recently published guidelines for decisionmaking in these types of cases.2 A question frequently raised is why these cases are brought before the courts when they might be more appropriately resolved elsewhere. In a followup to the development of the guidelines, the NCSC is attempting to answer this question, examining the factors that increase or decrease the likelihood that resolution of issues associated with forgoing LSMT will be sought in the courts. Recommendations and guidelines will be developed for health care facilities seeking to avoid unnecessary judicial involvement in LSMT decisions. New reproductive technologies. State courts are continuing to see a number of cases that address the application of new reproductive technologies. Various State legislatures are considering amending their codes to accommodate the growing practice of in vitro fertilization and surrogate parenthood. They are doing so in response to criticism that the laws regarding presumptions of parenthood lag behind advances in medical technology. Public attention focused on this issue following one couple's realization that under State law, the surrogate mother of their biological child (conceived using the couple's egg and sperm) could be recognized as the child's legal mother. For the couple to obtain legal custody of the child, the surrogate mother could have been required to relinquish her maternal rights and the couple required to formally adopt the child. However, a judge ruled in favor of the couple, recognizing their legal status as the child's parents and granting them full custody. Elder abuse and neglect. One of the most rapidly developing areas of the law involves elder abuse and neglect. Usually modeled after child abuse and neglect statutes, legislation to protect elderly citizens has been enacted in almost all States during the past few years. State courts typically play a key role in these protective schemes. They may serve, for example, as a reporting mechanism, as the issuer of search warrants (used, for example, to conduct an investigation of suspected elder abuse or neglect) and protective orders, and as the locus of guardianship/conservatorship proceedings. Concern has recently been voiced, however, that in the eagerness to protect elderly citizens and an associated willingness to adopt readily available child-abuse protection models, certain schemes have been implemented that are not accomplishing what they set out to do and that may also violate the rights of the elderly. Juror stress. The courts are also increasingly required to attend to the health care needs of the participants in the judicial process. The right to a trial by jury, an integral part of the American judicial system, is dependent on the willingness of citizens to serve as jurors. That willingness is influenced by their perceptions of jury service. The associated guarantee of an impartial jury relies on the ability of jurors to perform their duties. Recent media reports indicate that as a result of their service, jurors may experience elevated levels of stress, with possible adverse consequences for their physical and mental health and the integrity of the judicial process. Health care resources and costs. In the more traditional context, the judiciary is responsible for assessing and awarding health care-related damages and costs in resolving tort and contract litigation. Increasingly, the judiciary is called upon to resolve issues associated with the allocation of health care resources and costs. For example, the courts may be asked to determine the nature and scope of health care to which people under the care and custody of the State are entitled. These people may include indigent patients receiving care from State-funded public/teaching health care facilities, prison and jail inmates, clients of substance abuse programs, residents of mental health care facilities, students with disabilities who attend public schools, or wards under the protection of guardians. Decisions regarding the level of health care for these groups of people are perhaps more traditionally considered a concern of the legislature. Recently, however, a series of decisions dictating minimal levels has been made by the judiciary. At the same time, nearly all States have been compelled to take steps to control health care expenditures in general, as the costs of health care in particular spiral upward at a rate surpassing nearly all others. Arguably, in determining the level of health care to which people are entitled, the issues of costs and availability should never be a concern. Conversely, it may be argued that such considerations are an inevitable aspect of these decisions. The courts' task can be complicated by the fact that the cost estimates provided by the litigants may be inflated or premised on hidden assumptions that cause distortion or bias. Medical malpractice. Recently, medical malpractice litigation has been targeted for reform. Attorneys for both plaintiffs and defendants have expressed displeasure with the way these cases are handled. Many States have instituted medical review panels to provide initial examination of these cases, but ultimate responsibility for processing them remains with the State courts. A review of the various ways in which the States are handling these lawsuits would be beneficial. It could identify strengths and weaknesses of the States' practices, with a focus on the perspectives of the judiciary, and could generate recommendations on how best to process these cases. Family violence. The courts are often a major component of programs to address domestic violence. In response to a national symposium on issues related to courts, children, and families, 24 States developed action plans to address domestic violence. In many of these programs, the courts have a major role in coordinating victim services. Among those services are physical and mental health care to speed recovery and to strengthen the victim's resolve to disengage from the abusive relationship. Although courts have a pivotal role in ordering and monitoring these services, they often do not have sufficient resources or expertise to fulfill this role. Research could be of assistance in this area as well. Increased knowledge about service coordination models would shorten the learning curve for courts seeking to improve provision and coordination of health services to domestic violence victims and would facilitate the development of funding sources and staff expertise. The courts have also been proactive in related areas. Children who witness family violence often are indirect victims of it. At least one State--Connecticut--has a program that uses family relations counselors to assist the court in identifying children most at risk and that contracts for preventive services from community agencies. The goals are to provide emotional support for children, educate them about the risk of becoming victims of family violence, and reduce the likelihood that children exposed to violence in the home will develop violent behaviors as adults. The State funds this program from fees offenders pay for participation in a mandatory pretrial family violence education program. Identification and evaluation of programs with goals similar to Connecticut's could help other courts implement programs that would protect children from the immediate and long-term effects of family violence. On the horizon The role of the courts in health-related issues is likely to expand if proposals to overhaul the Nation's health care system are enacted. Major changes are likely to result in an onslaught of new litigation, bringing many additional health-care-related issues before the courts. This prospect highlights the benefits that additional research would bring. It could furnish information in several areas: the nature of the issues being presented to the courts; the frequency with which they are posed and within what framework; the form in which evidence is presented and whether judges and jurors find it understandable, useful, and sufficient; the factors that make health-related cases more (or less) difficult to resolve; and the strategies used by court officials to facilitate case processing and whether these strategies are considered successful. In addition to more comprehensive information, judges and court officials who handle health-related cases could benefit from practical assistance and guidance. Notes 1. Champagne, Anthony, Daniel Shuman, and Elizabeth Whitaker, "Expert Witnesses in the Courts: An Empirical Examination," Judicature, 76(1) (1992):5-10. 2. National Center for State Courts, Guidelines for State Court Decision Making in Life-Sustaining Medical Treatment Case, West: 1993. Thomas L. Hafemeister, J.D., Ph.D., is a Senior Staff Attorney/Research Associate with the National Center for State Courts. The points of view expressed in this article are those of the author and do not necessarily represent the official position or policies of the NCSC. For more information, contact Dr. Hafemeister at the National Center for State Courts, 300 Newport Avenue, Williamsburg, VA 23187-8798 (phone 804-253-2000; fax 804-220-0449). __________________________________________________________ HEALTH CARE NEEDS IN CORRECTIONS: NIJ RESPONDS by Cheryl A. Crawford The challenges facing correctional administrators in the course of running a prison or jail today are many and often daunting. Among the most problematic are substance abuse and violence, crowded and poorly ventilated facilities, and budgetary constraints amid ever increasing costs--all in combination with pervasive infectious diseases such as hepatitis B, tuberculosis (TB), and human immuno-deficiency virus (HIV). The health care needs of the incarcerated are expanding with the growing numbers of offenders involved in both substance abuse and criminal activity. The problem is exacerbated by the aging of an inmate population serving longer sentences, a rise in the percentage of pregnant female offenders, the increasing violence of youthful offenders, and the fact that some infectious diseases affect the jail and prison inmate population at rates far greater than in the general population. The National Institute of Justice (NIJ) is committed to helping correctional administrators deal with the difficulties they face. Projects in the correctional health care arena constitute a significant portion of NIJ's recently launched Health and Justice Initiative. Moreover, NIJ has for a number of years focused on the needs of incarcerated offenders in its research grants, publications, and technical assistance. Infectious diseases HIV/AIDS. It has been more than 10 years since the first cases of Acquired Immunodeficiency Syndrome (AIDS) were reported among correctional inmates. As of early 1993, there had been 11,565 cases of the disease among inmates and almost 3,500 inmate deaths attributed to AIDS.1 The rate of increase in correctional cases between 1990 and 1992/1993 was slightly above that in the total U.S. population for the same period.2 Since 1985, NIJ has conducted national surveys of the incidence and institutional management of HIV/AIDS in Federal and State prison systems, as well as in the Nation's largest jails. The Centers for Disease Control and Prevention (CDC) joined NIJ in sponsoring the 1992 and 1993 surveys. Information from the surveys is compiled in annual reports for the HIV/AIDS in Correctional Facilities series. Since 1985, some notable trends in the correctional policy response to AIDS have emerged. Particularly important is the growing collaboration between corrections professionals and public health officials, a critical step in bridging the gap between the orientations and goals of the two fields. Too often in the past such collaboration was not the norm, and conflict was the result. The cosponsorship of the annual HIV/AIDS report by NIJ and CDC represents an important step in developing constructive dialog and in developing a shared approach, thereby advancing both criminal justice and public health objectives. In inmate housing, the trend continues away from blanket segregation policies toward case-by-case or presumptive general population housing for inmates with HIV. Only two State systems now segregate all known HIV-infected inmates, compared with eight in 1985.3 Six correctional systems make condoms available to inmates. Psychosocial services for HIV-infected inmates are experiencing staff shortages, and drug treatment capacity in prisons continues to fall short of need. Tuberculosis. In the mid-1980's, as the AIDS epidemic accelerated among communities of poor, minority, and drug-abusing Americans, TB was making a comeback after several decades of steady decline. The resurgence in TB in the late 1980's and early 1990's is closely associated with the HIV/AIDS epidemic and particularly afflicts inner-city minorities, injection drug users, and the poor. Since these populations are overrepresented in correctional populations, TB has become a serious problem in prisons and jails. Not only do inmate populations contain concentrations of persons at high risk for both TB and HIV, but the facilities themselves are high-risk settings for TB transmission because of crowded conditions and poor ventilation. As concern with the dual epidemics of HIV and TB increased, NIJ expanded its national survey on the impact of HIV/AIDS on corrections to include coverage of TB issues and policies. One of the most ominous developments in the tuberculosis resurgence has been the appearance of multidrug-resistant TB (MDR-TB). In a widely publicized 1992 outbreak of MDR-TB, 36 New York State prison inmates and one correctional officer died. The vast majority of inmates with TB were also infected with HIV.4 Inmate education. Jails are a particularly important focus for education outreach in HIV/AIDS because many arrestees are confined for only a few hours at a time and simply move back through the criminal justice system, limiting the ability of the system to take proactive steps to reduce the spread of HIV. Large proportions of arrestees report a history of drug use, including injection drug use.5 Therefore, the criminal justice system is faced with many people who are at high risk of infecting themselves and others with HIV. A soon-to-be-completed 3-year effort cosponsored by NIJ and the National Institute on Drug Abuse (NIDA) was designed to demonstrate and evaluate the effectiveness of educational interventions with arrestees held less than 48 hours in lockups or jail booking facilities. A motivational videotape was developed for showing in jails and lockups--an inexpensive and well-suited intervention for the lockup environment. Preoccupation with more pressing life needs such as employment, housing or shelter, and drug treatment sometimes prevents people from changing health- threatening habits. Therefore, a referral intervention and a case management intervention were added to help clients deal with these primary needs. Researchers wanted to determine the effects of these interventions on high-risk sexual activity, drug use, criminal behavior, and entry into drug treatment. Participants in the education project were randomly assigned to one of the three groups representing increasing levels of intervention (video only, video and referral to community services, and video and case management). They were interviewed at 3- and 6-month intervals following program completion. These self-reports were supplemented by information from subsequent arrest and incarceration data and from the results of urinalysis to detect illicit drug use. Findings from the two sites (Washington, D, and Portland, Oregon) indicate that case management was effective in reducing drug use and criminal activity. The changes in sexual behavior did not differ across interventions, and no intervention was effective in reducing high-risk sexual behavior. When case management was effective, its impact was associated with a blend of traditional elements (needs assessment, planning, referral, and advocacy) together with nonjudgmental, supportive counseling aimed at motivating clients to seek further assistance from service providers. Case management was limited by weaknesses in the breadth and adequacy of primary services in the community (e.g., mental health care, HIV prevention counseling). The study suggests several opportunities for the improvement of case management services with an arrestee population.6 Mental health needs A large number of prison and jail inmates have mental health needs. One recent survey of a random sample of jail admissions in Cook County (Chicago), Illinois, revealed that 6.4 percent of the men admitted were severely mentally ill and in need of mental health treatment.7 Contributing to the problem are lack of coherent, consistent standards and policies for prison and jail mental health services; lack of formal procedures requiring development of discharge plans; and lack of economic incentives for community mental health services to admit mentally ill offenders. Once offenders with mental health problems are released, they need support services from the community and the correctional system. To improve the interaction between corrections and community mental health agencies, NIJ has entered into a partnership with the Center for Mental Health Services (U.S. Department of Health and Human Services) and the National Institute of Corrections. NIJ has also launched specific projects on the mental health needs of inmates and offenders released into the community. Better service coordination. Services provided to mentally ill offenders will be analyzed by NIJ and recommendations will be made on how mental health and criminal justice system administrators can coordinate their efforts to improve mental health services to criminal justice system clients. NIJ is currently conducting a national assessment of programs and practices on the management and supervision of offenders with mental health needs in the Nation's jails. Since jails do not operate in isolation, the study will take an interagency approach, looking at the links to a variety of other agencies and organizations such as law enforcement, the courts, State mental hospitals, community mental health centers, and other health and human service agencies. Project findings will be useful to State and local officials interested in pursuing collaborative solutions to improving services for the mentally ill who come into contact with the criminal justice system. Community-based services. Mentally ill persons who come into the criminal justice system often have needs beyond conventional supervision. In Milwaukee, a day-reporting program established by the Wisconsin Correctional Service, a private, nonprofit organization, takes an innovative approach to meeting these needs. This program combines daily reporting for surveillance and medication, and provides these offenders with two innovative services to stabilize them in the community: assistance in money management (usually disability stipends) and housing assistance and placement. The aim is to keep people with chronic mental illnesses out of local jails and hospitals and to help them live independently. An NIJ-sponsored study of this Milwaukee program concluded that such a program can be readily adapted to the needs of other jurisdictions and illustrates the utility of day reporting for a specific offender population.8 By creating a system for identifying mentally ill persons brought into the system prior to their being jailed and creating a programmatic alternative that the courts actually use, this program is reducing the number of mentally ill persons in jail. Program administrators report that in recent years the proportion of inmates diagnosed as mentally ill while in jail has been small--much smaller than before the program's inception. And due to the positive incentives offered to the clients in this day reporting center, some participants choose to remain in the program even after their legal obligation is over. These incentives take the form of substantial benefits in terms of medical, nursing, and other support services. Elderly offenders Older people constitute the fastest growing segment of the U.S. population. In part, this explains the increase in the number of elderly inmates, which is growing at a comparable pace. In addition, the percentage of older persons arrested for serious crimes is increasing, and offenders serving long-term sentences are aging.9 To help correctional administrators modify their practices to better meet the needs of older inmates, NIJ is conducting a three-phase study of the management of elderly offenders in the Nation's prisons and jails. Phase one will examine the needs and problems of elderly inmates and the types of services and management approaches now in use. In phase two, a national survey will be conducted to determine current correctional policies and program and management strategies (such as housing, classification, and medical services) related to elderly inmates. Phase three will include site visits to selected jurisdictions with promising programs and practices. Project findings will be of value to criminal justice professionals and policymakers in improving the management and supervision of elderly offenders. Female offenders In the past decade, the number of women in prison has grown dramatically, increasing 200 percent between 1980 and 1989--a rate double the increase for men during the same period. Part of this increase is due to a 300-percent growth in the number of women arrested for drug crimes, compared to a 150-percent increase for men.10 The increase in the number of women inmates in State prisons in the 5-year period from 1986 to 1991 was due largely to drug offenses, with nearly one in three serving a sentence for drug offenses in 1991 compared to one in eight in 1986.11 Responding to unique needs. In addition to their increasing numbers, female inmates bring with them a unique set of characteristics and problems. A high proportion of women in prison have been sexually or physically abused. A significant number of women are pregnant when they enter prison. The majority were not employed before arrest and have little or no work history or skills. As noted above, substance abuse plagues these women. In State prisons, proportionally more women than men used drugs in the month before the offense for which they were imprisoned, and women inmates were more likely than male inmates to have used drugs regularly.12 A majority of female inmates are arrested for drug offenses and crimes committed to support their drug habits.13 NIJ's Drug Use Forecasting program indicates that the percentage of female arrestees who test positive for drugs ranges from 42 to 83 percent, depending on the city.14 These characteristics and problems pose special challenges for prison and jail administrators. To date, there has been no systematic, national study of the best programs and management practices for female inmates. In response, NIJ is identifying promising approaches to meeting the needs of female inmates and exploring the conditions under which these approaches can best be implemented. Among the issues to be studied are methods of classifying female inmates--identifying innovative and useful methods that satisfy security requirements while meeting inmates' needs. Incarcerated mothers and their children. Responding to the needs of the children of incarcerated women is a key policy area because positive programming for both mothers and their children can improve a woman's chances of successful reintegration into the community and family responsibilities after release. More than three-fourths of women in prison have children. Of these women, almost 90 percent have children under the age of 18. Various arrangements are made for the care of the children: the largest proportion are cared for by a grandparent, others live with their father or other relatives, and still others are placed in foster care or some other institutional setting. The vast majority of female inmates intend to be reunited with their children upon release.15 To help ensure successful family reunification and break the cycle of intergenerational involvement in the criminal justice system, NIJ has been the sponsor of a unique demonstration project involving a Girl Scout program for the daughters of incarcerated women. The pilot project, established at the Maryland Correctional Institution for Women (MCIW) in Jessup, Maryland, is the first Girl Scout troop for incarcerated women and their daughters. The daughters, who range in age from 5 to 17, join their mothers twice monthly for troop meetings at MCIW. During the 2-hour meetings, the women spend supervised group and individual time playing with their daughters, working on troop projects and planning for future activities. On alternate weeks the girls meet in the community, just like traditional troops, at sessions run by Girl Scout volunteers. The program also includes joint mother-daughter education seminars focusing on issues of family life including self-esteem, substance abuse, relationships, family crises, and teenage pregnancy. The project focuses as much on the mothers as on the daughters. It offers traditional Girl Scout leadership and general adult development courses to improve the parental skills of the incarcerated mothers. The mothers are able to assume temporary responsibility for their daughters through the activities of this Girl Scout troop. With the program's success, correctional administrators from a number of other States have expressed interest in adopting the NIJ/Girl Scout model, as has the Federal Bureau of Prisons. Both Ohio and Florida began their replications of the NIJ/Girl Scout program early in 1994. The problem of substance abuse. An NIJ-sponsored study is examining treatment programs for drug-dependent female inmates to determine how these programs can reduce drug use and criminality and promote productive lives. The study will (1) identify and assess the characteristics and needs of drug-abusing female offenders, (2) identify features of selected treatment programs for women in correctional and community-based settings, and (3) develop an agenda for research to improve drug treatment. Costs of correctional health care All prison and jail administrators face the challenge of managing the costs of correctional health care. They must give careful consideration to the growing demand for services while dealing with the fiscal restraint often imposed by limited budgets and legislative oversight. Correctional administrators generally recognize that spending for health care is increasing faster than other correctional costs and that larger shares of their budgets will be devoted to health care in the future. In Texas, correctional health care expenditures increased 473 percent between 1982 and 1989,16 due in part to a U.S. Federal Court's demands in the Ruiz case, which found conditions in the State's prisons system, including health care, to be unconstitutional.17 For those jurisdictions under similar court orders, the necessity of bringing inmate health care up to constitutional levels will increase health care costs even faster. What works to contain costs. State and local correctional authorities have been developing a number of new strategies to control costs, none of which have been evaluated but all of which vary considerably. NIJ has commissioned a study of the strategies so that lessons learned at the State and local levels can be communicated to other correctional administrators. The study will include a review and evaluation of research literature from related fields to determine its relevance for correctional health administration. A survey of State departments of correction and some larger local departments will be conducted to develop an "inventory" of existing practices developed to manage health care delivery and costs. An assessment of existing information about these practices will also be undertaken to evaluate their relevance for different types of correctional systems and cost-control problems and to determine their effectiveness in controlling costs. Study findings will be released in late 1994. Through its Health and Justice Initiative, NIJ will continue its focus on the needs of inmates in 1994 and beyond. NIJ's FY 1994-95 Research Plan calls for proposals in the areas of elderly offenders, the mental health needs of offenders, female offenders, and innovative health care programs for inmates. For instance, NIJ seeks to fund research on the link between prison health care and aftercare services and programming. More specifically, the Institute is seeking information on the links between diagnoses and treatment provided during confinement and those provided under community supervision, as well as the effectiveness of these services. NIJ will fund studies to understand better the health and safety risks incurred by correctional officers and ways to minimize them. NIJ will also sponsor development of a holistic offender-based needs assessment both within correctional settings and in the community. Elements for consideration in the assessment include health, mental health, wellness and diet programs, and effective parenting issues. In the area of drug treatment, NIJ is soliciting proposals on aftercare programs that focus on female offenders. It is hoped that programs such as those described here will be helpful to correctional administrators and practitioners as they meet the challenges posed by the many and varied health care needs of inmates. Notes 1. Hammett, T., 1992 Update: HIV/AIDS in Correctional Facilities, Washington, D, and Atlanta: U.S. Department of Justice, National Institute of Justice, and U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, January 1994:xi-xii. 2. Ibid., 14. 3. Ibid., xii. 4. Hammett, T., Tuberculosis in Correctional Facilities, Washington, D, and Atlanta: U.S. Department of Justice, National Institute of Justice, and U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, January 1994. 5. Wish, E., et al., "Lost Opportunity To Combat AIDS: Drug Abusers in the Criminal Justice System," in AIDS and Intravenous Drug Use: Future Directions for Community-Based Prevention Research, Research Monograph 93, Rockville, Maryland: National Institute on Drug Abuse, 1990. 6. Gross, M., et al., "AIDS/HIV Education in Lockups and Booking Facilities," Briefing Paper, unpublished, December 3, 1993. 7. Teplin, L.A., "The Prevalence of Severe Mental Disorder Among Male Urban Jail Detainees: Comparison With the Epidemiologic Catchment Area Program," American Journal of Public Health, 80 (1990):663-669. 8. McDonald, D., and M. Teitelbaum, Managing Mentally Ill Offenders in the Community: Milwaukee's Community Support Program, Program Focus, Washington, D: U.S. Department of Justice, National Institute of Justice, March 1994. 9. "Trends and Patterns for Elderly Offenders," Journal of Offender Counseling, 13 (1989); and Walsh, C.D., "Aging Inmate Offenders: Another Perspective," in Correctional Theory and Practices, eds. Clayton A. Hartjen and Edward E. Rhine, Chicago: Nelson Hall Publishers, 1992. 10. Greenfeld, L.A., and S. Minor-Harper, Women in Prison, Special Report, Washington, D: U.S. Department of Justice, Bureau of Justice Statistics, March 1991:1, 4. 11. Snell, Tracy L., Women in Prison: Survey of State Prison Inmates, 1992, Special Report, Washington, D: Department of Justice: Bureau of Justice Statistics, March 1994:3. 12. Ibid., 7. 13. Hser, Y.I., C.P. Chou, and M.D. Anglin, "The Criminality of Female Narcotics Addicts: A Causal Modeling Approach," Journal of Quantitative Criminology, 6(2) (1990):207-228. 14. U.S. Department of Justice, National Institute of Justice, Drug Use Forecasting Annual Report 1993, forthcoming. 15. Greenfeld and Minor-Harper, Women in Prison:6. 16. Anno, B.J., Prison Health Care: Guidelines for the Management of an Adequate Delivery System, Washington, D: National Institute of Corrections, 1991. 17. Ruiz v. Estelle, 503 F.Supp. 1265 (S.D. Tex. 1980); aff'd in part and rev'd in part, 679 F2d 115 (1982), am. in part, vac. in part 688 F2d 266 (5th Cir. 1982), cert. denied, 460 U.S. 1042, 103 S.Ct. 1438 (1983). _________________________________________________________ QUESTIONS MOST FREQUENTLY ASKED ABOUT THE ADA BY CRIMINAL JUSTICE PROFESSIONALS by Paula N. Rubin The Americans With Disabilities Act (ADA) was signed into law in 1990, effecting the most sweeping change in civil rights law in nearly 30 years. A primary goal of the ADA is to integrate into the mainstream of society the estimated 43 million persons with disabilities in the Nation. Among other things, the ADA requires the elimination of barriers to equal access in employment opportunities and public accommodations such as hotels, restaurants, and shopping centers, and the programs, services, and activities provided by Federal, State, and local government agencies and facilities. The notion of ending discrimination against individuals with disabilities is not new to criminal justice. For the past 20 years the Rehabilitation Act of 1973 has prohibited discrimination against persons with disabilities by any agency receiving Federal funds. The ADA expands this antidiscrimination obligation to include private employers, public accommodations, and State and local government entities. The portion of the ADA most relevant to criminal justice agencies went into effect on January 26, 1992. Even before the law took effect, however, administrators and managers began to conduct self-analyses and inventories to determine what changes needed to be made to come into compliance with ADA requirements. As criminal justice professionals have implemented this law, questions have emerged. Here are some of the questions most frequently asked by criminal justice professionals about the ADA: Are public safety agencies exempt from the ADA? Often criminal justice professionals ask whether the ADA applies to law enforcement and corrections. The answer is yes. While certain agencies in the Federal Government such as the Federal Bureau of Investigation (FBI) are exempt from the ADA (the FBI is, however, subject to the Rehabilitation Act of 1973), State and local governments and the agencies they administer are covered by this law. Title I of the ADA addresses employment issues. This section explicitly states that State and local governments are included as covered entities. Moreover, while private employers with fewer than 15 employees are not covered by the ADA, there is no minimum employee requirement for State and local governments under Title II of the law. Title II of the ADA deals with programs, services, and activities of public entities and applies to State and local governments, including their departments and agencies. Under the ADA, criminal justice agencies may not discriminate against qualified individuals with disabilities. This antidiscrimination mandate applies to an agency's recruitment, hiring, and promotion practices. Likewise, agencies must eliminate discrimination in the delivery of programs, services, and activities. This includes law enforcement agencies as well as prisons, jails, detention centers, and other correctional facilities. Are persons with disabilities entitled to preference in hiring? No. The ADA is not an affirmative action law. The ADA simply requires that employers hire the most qualified person for the job. To be covered by the ADA, an individual must have a disability. This means that the individual: o Has a mental or physical impairment that substantially limits a major life activity. o Has a record of such an impairment. o Is regarded or perceived as having such an impairment. Persons with disabilities need not be considered unless they are otherwise qualified for the job. This means that the individual can perform the essential functions of the position with or without a reasonable accommodation. Essential functions are those that are fundamental, not marginal. Finally, employers will not be required to provide a reasonable accommodation where doing so causes an undue hardship (i.e., significant difficulty or expense) or poses a direct threat to the health and safety of others. Direct threat means a significant risk of substantial harm based on objective evidence. Who decides what accommodation to provide? The agency decides. There is no requirement that a person with a disability be given the accommodation requested. Likewise, accom-modations do not have to be state-of-the-art, the best, or the most expensive. All that is necessary is that the accommodation be effective in enabling a person to perform the essential functions of the job. Providing accommodations does not have to cost a lot of money. The March 1992 edition of the Americans With Disabilities Act Manual Newsletter reported that "80 percent of reasonable accommodation for persons with disabilities costs under $100." In determining what accommodation to provide, it is a good idea to start by talking to the person being accommodated. Often the person with the disability will know the most effective and least expensive way to obtain the accommodation. Another valuable resource is the Job Accommodation Network (JAN) of the President's Committee on Disabilities. JAN is an information and reference service that advises on accommodations and can be reached by telephone by dialing 800-ADA-WORK. Does the ADA require architectural renovations? Not necessarily. The ADA is not a law that requires "retrofitting" America. New construction and renovations to existing facilities, however, must conform to ADA requirements. On the other hand, criminal justice agencies should look at the program, service, or activity they are attempting to deliver. Is it accessible? That is, do persons with disabilities have physical access? Are there barriers to effective communication? Can the person participate in or enjoy it? If the answer to any of these questions is "no," then one should ask if there is a way to change the way the program, service, or activity is delivered. Achieving physical accessibility can include moving programs to an accessible part of the facility, such as the first floor, providing home delivery, or telephoning persons with mobility impairments. If physical access can be accomplished this way, then architectural construction or renovations to existing facilities may not be necessary. Agencies may also need to look at any eligibility requirements for program participation. If such criteria tend to eliminate qualified persons with disabilities, then reasonable modifications to the program, service, or activity may be required. Reasonable modifications are not required, however, if doing so would fundamentally alter the nature of the program, service, or activity. Does the ADA apply to prisoners, inmates, or those held in custody? Yes. Programs offered to inmates must be accessible. If, for example, a hearing-impaired inmate wished to attend Alcoholics Anonymous meetings, the corrections facility would need to make reasonable modifications that permit the inmate to participate in a meaningful way. This could include effective auxiliary aids, such as providing a sign language interpreter or, where appropriate, writing notes for short exchanges. Inmates with disabilities should not be segregated into one cell block unless they specifically request such an accommodation. Integration is a key component of the ADA. Inmates with disabilities should be classified and housed as inmates without disabilities unless doing so poses a direct threat to the safety of other inmates or staff. So, for example, while it may be permissible to place all inmates with mobility impairments on the first floor for safe evacuation in case of fire, it is probably a good idea to integrate these inmates with all inmates on the first floor. Finally, eligibility requirements that prevent prisoners with disabilities from participating in programs, services, or activities should be evaluated. For instance, programs that give credit toward early release in exchange for hard labor or boot camps may tend to screen out inmates with physical disabilities. Since early release is a fundamental benefit, prisons and jails offering such programs should consider developing comparable programs for inmates whose disabilities prevent them from participation. One solution may be to give credit toward early release for other tasks, such as allowing inmates with mobility impairments to serve as readers for inmates with vision impairments. ____________ Paula N. Rubin, a lawyer, is an NIJ Visiting Fellow currently coordinating the Institute's initiative to research, develop, and deliver publications and training for the criminal justice community on the Americans With Disabilities Act and other civil rights issues. ________________________________________________________ YOUNG PEOPLE, VIOLENCE, AND GUNS--WHAT NIJ IS DOING NOW by Lois Felson Mock Public concern with crime, notably violent crime, may be at an all-time high, and according to some polls surpasses the economy for top position on the Nation's agenda. The concern is well-founded. Although the Nation's overall crime rate declined in 1992 (for the first time since 1984), the rate of violent crime is holding steady1, and rates of violent crime in this country are among the highest in the world.2 The health community's recognition of violence as a public health problem is by now common knowledge, as is the possibility that given current trends, homicide may overtake traffic accidents as the leading cause of death by injury. Violence in which firearms are used may well embody the public's perception of the Nation's crime problem. Recent incidents of multiple deaths by firearms--an attack on children at a public swimming pool in Washington, D, and on commuters on the Long Island Rail Road--generated renewed interest in control mechanisms. The involvement of young people with violence--either as victims or assailants--may elicit the greatest concern, and even alarm. Among young people in general, the level of violence has been unprecedented in recent years. According to the FBI's Uniform Crime Reports for 1991, "The Nation is experiencing an unrivaled period of juvenile violent crime." In the 1980's, crimes of violence became a larger component of all crime committed by young people, and during that period arrests for violent crime by juveniles rose 27 percent.3 Firearms are playing a large part in these disturbing developments. The rise in juvenile violence extends even to murder, with the rate of arrests for this offense climbing much faster among people under 18 than among those age 18 and over.4 The highest rate of handgun crime victimization is among young men, particularly young African-American men,5 and homicide as the leading cause of death among young African-American men is a well-known fact.6 Immediate action is being demanded of law enforcement and other public officials and policymakers. They know that public safety requires no less. To assist criminal justice professionals in finding effective approaches, the National Institute of Justice (NIJ) is supporting a number of projects that address the issue of violence, with special emphasis on young people's involvement in it. Firearms and violence Review of research to date. Is there a causal relationship between firearms and violence? The National Academy of Sciences' Panel on the Understanding and Control of Violent Behavior reviewed what researchers know to date about violence in the United States,7 and in reporting the results, gave considerable attention to that question.8 The research reviewed by the Panel did not demonstrate that greater gun availability is associated with overall rates of violent crime.9 Firearms were found to potentially modify both the probability that certain violent events will occur and the severity of events. Thus, some correlation was found between gun availability and the specific crimes of felony gun use and felony murder. Injuries caused by guns were found to have more serious consequences than those caused by other weapons. For example, in robberies and assaults, victims are far more likely to die when the perpetrator is armed with a gun than when he or she has another type of weapon or is unarmed. Other findings of the Panel's review related to the accessibility of guns for committing crime: o Self-defense is the reason people cite most commonly for acquiring a gun, but it is unclear how often these guns are used for self-protection against unprovoked attacks. o People who use guns to commit violent crime rarely purchase them directly from licensed dealers; most guns used in crime have been stolen or transferred between individuals after the original purchase. The Panel's emphasis was on what can be done in response. Several strategies that can be used to reduce gun murder were analyzed, and the Panel concluded that they need to be subjected to rigorous evaluation to ascertain whether they are effective. Among the strategies are reducing firearms' lethality (e.g., by banning certain types of ammunition) and reducing unauthorized use (e.g., through combination locks on triggers). The law can be and has been used successfully in reducing gun murder rates. Certain types of laws have been tested through evaluations and found to sometimes be effective: prohibitions on carrying concealed weapons, extended sentences for robbery and assault when a gun is used, and restrictive licensing requirements for handgun ownership. In the area of enforcement of existing laws, the Panel suggested that priority be given to three objectives: o Disruption of illegal gun markets. o Close cooperation between the police and the community to set priorities and enforce laws, to reduce the fears that lead to gun ownership for self-defense. o Reduction of juveniles' access to guns. NIJ used the recommendations of the Panel to help shape its own research and evaluation agenda. A summary of the Panel's treatment of firearms and violence has been published by NIJ in its Research in Brief series and disseminated to professionals in criminal justice and allied fields.10 Juveniles and guns. Although young people are prohibited by law from purchasing guns, they are inordinately involved with them. In the 1980's, the number of juveniles who committed murder with guns increased 79 percent. By the end of that decade, the rate at which juveniles were arrested for weapon law violations reached the highest ever recorded.11 These facts help explain the call for reducing juveniles' access to guns. Young people's involvement with guns also extends to victimization: the gun homicide rate is higher for teenage victims (ages 15 to 19) than for the population as a whole.12 For some high-risk young people, firearms have become part and parcel of their lives. This finding was revealed in a recently completed NIJ/Office of Juvenile Justice and Delinquency Prevention (OJJDP) study of male, inner-city high school students and young male inmates. Many were found to be extremely well-armed, to have few compunctions about carrying and using guns, and to have been heavily involved in gun-related activities. Owning and carrying guns were fairly common among these young people as well as among their family members, friends, and associates. Heavy exposure to guns was part of the environment of violence and victimization in which they lived: o 84 percent of the inmates had been threatened with a gun or shot at; 45 percent of the students had been threatened with a gun or shot at while going to or from school in the past few years. o 79 percent of the inmates and 69 percent of the inner-city students came from families in which at least some of the men owned guns. o 90 percent of the inmates had friends and associates who routinely owned and carried guns. These young people were also very likely to own guns themselves. More than 80 percent of the inmates had at least one gun at the time they were incarcerated. Moreover, the firearms they owned were the type that could inflict considerable harm. Among the inmates who owned guns, more than half had automatic or semiautomatic weapons. Both groups tended to own larger-caliber guns rather than "Saturday-night specials." Guns were felt to be easily and cheaply obtained, with an informal network of family, friends, and "the street" the method of acquisition. Although theft was not noted prominently by either group as a way to obtain guns, it is likely that theft and burglary were the ultimate source of the weapons. The association of guns with crime was evident. Many inmates (60 percent) had committed crimes with guns, and many (40 percent) had obtained a gun specifically for use in crime. The acceptability of gun violence was also evident. When asked whether it is "okay to shoot some guy who doesn't belong in your neighborhood," 35 percent of the inmates and 10 percent of the students agreed. Given the pervasive climate of violence in which these young people live, it is no surprise that the most important factor in the decision to own or carry guns, for both groups, was self-protection. Among the inmates, 74 percent cited protection, and among the students, 70 percent gave this reason. The findings indicate that handguns of all types are readily available. They suggest that from the standpoint of policy, other steps are needed in addition to reducing juveniles' access to guns. Emphasis should be placed on changing young people's notions of the acceptability of guns and on reducing the motivation to be armed. These young people's rationale for carrying guns, self-protection, suggests steps also need to be taken to reduce the fear that leads to this type of thinking.13 Firearms ownership. As noted above, the relationship of gun availability to violent crime is complex. Some studies have shown an association, but the causal chain is not always clear.14 Guns are widely available: half the households in this country have some type of gun, but some citizens claim the reason they arm themselves is self-defense. On the other hand, only about one firearm in every six used in crimes is obtained legally.15 Widespread gun availability makes it important to understand what lies behind the decision to acquire a firearm and to study other factors in gun ownership. As the number of privately owned guns increases, so does their availability--through theft--for use in violent crime. Partly in response to the National Academy of Sciences' suggestion of the need for this type of information, NIJ is sponsoring a nationwide study of private firearms ownership and use. The researchers will study the reasons for gun ownership, how many and what types of guns are owned, and how they are acquired, stored, and disposed of. Previous victimization of gun owners will be studied to shed light on the relationship of gun acquisition to their fear of crime. Nonowners will be surveyed, as well, and queried about the reasons they do not own a firearm. The information should be useful in promoting safety and preventing accidents among legitimate gun owners and in educating them regarding secure storage to prevent theft and subsequent use in crime. It can also assist legislators and law enforcement agencies in designing and implementing effective regulatory and firearms control policies. Controlling illegal firearms. Criminals, juveniles, and other high-risk individuals are prohibited by Federal law and numerous State statutes from purchasing guns. However, as research has revealed, offenders obtain firearms through theft from legitimate owners, through other illegal means, or informally. The high rate of handgun murder in some cities that restrict access to guns suggests they are often obtained illegally.16 As noted above, evidence suggests that control of illegal markets can help reduce gun violence. NIJ has conducted several studies addressing criminal firearms acquisition, ownership, and use. One study of incarcerated adult felons showed that acquisition was primarily through informal channels and illegal means, a finding corroborated by the recently completed study of at-risk young people. As the researchers put it, "The criminal handgun market is overwhelmingly dominated by informal transactions and theft as mechanisms of supply." Half the men studied had stolen at least one gun at some time in their lives. The subjects believed that obtaining a gun was easy, feeling they would encounter no obstacles to doing so upon release from prison.17 NIJ is further responding in part through proposals to evaluate the effectiveness of current firearms regulations and to identify new and innovative State statutes that have the potential for replication elsewhere. An evaluation of the State of Virginia's Firearms Trafficking Task Force, which operates in conjunction with the Bureau of Alcohol, Tobacco and Firearms, is also planned. The task force is designed to identify and prosecute individuals and dismantle organizations involved in illegal firearms acquisition. To address the problem of juvenile firearms violence, NIJ, with the Centers for Disease Control and Prevention and OJJDP, is sponsoring a demonstration project that would reduce firearms injury and death among young people and illegal firearms possession among them. Notes 1. Between 1991 and 1992, the crime rate, as measured by reports to the police, dropped 3 percent. The 1992 figure was, however, 4 percent higher than 5 years ago and 19 percent higher than 10 years ago. Although for violent crime the rate remained virtually the same in the 2-year period, the number of offenses increased by 1 percent. The increase since 1983, however, has been 54 percent. Uniform Crime Reports for the United States, 1992, Washington, D: U.S. Department of Justice, Federal Bureau of Investigation, October 3, 1993:6, 11. For the first 6 months of 1993, serious crimes declined 5 percent compared to the same period in 1992, and violent crime decreased 3 percent. Press release, U.S. Department of Justice, Federal Bureau of Investigation, December 5, 1993. The overall victimization rate also declined slightly between 1991 and 1992. These rates are reported in Criminal Victimization in the United States, 1992: A National Crime Victimization Survey Report, Washington, D: U.S. Department of Justice, Bureau of Justice Statistics, March 1994: 5. 2. Reiss, Albert J., Jr., and Jeffrey A. Roth, eds., Understanding and Preventing Violence, Washington, D: National Academy Press, 1993:3. 3. Crime in the United States, 1991, U.S. Department of Justice, Federal Bureau of Investigation, Washington, D, August 30, 1991: 279. The FBI counts people ages 10 to 17 as juveniles. 4. Between 1983 and 1992 the number of people under 18 who were arrested for murder and nonnegligent manslaughter more than doubled, from 1,175 to 2,680. The rise was 128 percent. For people age 18 and over the increase was 8.6 percent in the same period. Crime in the United States, 1992, Washington, D: U.S. Department of Justice, Federal Bureau of Investigation, October 3, 1993:221. 5. Rand, Michael R., Guns and Crime: Handgun Victimization, Firearm Self-Defense, and Firearm Theft, Crime Data Brief, Washington, D: U.S. Department of Justice, Bureau of Justice Statistics, April 1994:1. 6. "Advance Report of Final Mortality Statistics, 1991," Monthly Vital Statistics Report, 42, 2 (supplement, August 31, 1993), Centers for Disease Control and Prevention/National Center for Health Statistics. Among young African-Amercian men ages 15 to 24, 4,208 died as a result of homicide and 1,499 in accidents (motor vehicles, falls, drownings, and the like), the next leading cause of death in this age group. The leading cause of death for all young men in this age group was accidents, with homicide the second leading cause: 11,534 died in accidents and 6,923 from homicide. (See pages 22, 29.) 7. Reiss and Roth, eds., Understanding and Preventing Violence. 8. The issues of weapons, crime, and violence and their interaction were also explored in an NIJ-sponsored study: Wright, James D., Peter H. Rossi, and Kathleen Daly, Under the Gun: Weapons, Crime, and Violence in America, New York: Aldine Publishing Company, 1983. 9. The Panel defined "availability" as the overall number of guns in society and the ease of obtaining them. 10. See Jeffrey A. Roth's Firearms and Violence, Research in Brief, Washington, D: U.S. Department of Justice, National Institute of Justice, February 1994 (NCJ 145533). The other two documents summarizing the Panel's report, also by Dr. Roth, are Understanding and Preventing Violence, Research in Brief, Washington, D: U.S. Department of Justice, National Institute of Justice, February 1994 (NCJ 145645), and Psychoactive Substances and Violence, Research in Brief, Washington, D: U.S. Department of Justice, National Institute of Justice, February 1994 (NCJ 145534). 11. Crime in the United States, 1991, U.S. Department of Justice, Federal Bureau of Investigation, Washington, D, August 30, 1991: 279, 283. 12. Reiss and Roth, eds., Understanding and Preventing Violence: 256-57. The gun homicide rate per 100,000 people was 8 for teenagers and less than 6 for the general population. 13. Sheley, Joseph F., and James D. Wright, Gun Acquisition and Possession in Selected Juvenile Samples, Research in Brief, Washington, D: U.S. Department of Justice, National Institute of Justice, and Office of Juvenile Justice and Delinquency Prevention, December 1993 (NCJ 145326). 14. On the relationship of gun availability to use, see Cook, Philip J., "The Technology of Personal Violence," in Crime and Justice: A Review of Research (volume 14), ed. Michael Tonry, Chicago: University of Chicago Press, 1991:37-63. The topic is also treated in Reiss and Roth, eds., Understanding and Preventing Violence. 15. Reiss and Roth, eds., Understanding and Preventing Violence: 256, 267-68, 269. 16. Reiss and Roth, eds., Understanding and Preventing Violence: 269. 17. A summary treatment of this research is in Wright, James D., The Armed Criminal in America, Research in Brief, Washington, D: U.S. Department of Justice, National Institute of Justice, November 1986. See also Wright, James D., and Peter H. Rossi, Armed and Considered Dangerous: A Survey of Felons and Their Firearms, New York: Aldine De Gruyter, 1986, for a discussion of the means by which criminal offenders acquire firearms. __________________________________________________________ NIJ GRANTS AND OTHER AWARDS IN HEALTH AND JUSTICE The grants, contracts, cooperative agreements, and interagency agreements listed below are a selection of current projects supported by NIJ in which the fields of health and justice intersect. The first line is the title of the award, the next line is the grant recipient, the next is the name of the principal investigator or contact person, and the last line is the award number, the first two digits of which indicate the year the award was funded. Violent Behavior and Criminal Behavior Longitudinal Effects of Crime and Signs of Disorder on Communities Temple University Ralph Taylor 93-IJ-CX-0022 National Research Council Report on Preventing Violence Abt Associates, Inc. Jeffrey Roth OJP-89-C-009 Private Ownership of Firearms in the United States: A National Study Police Foundation Anthony Pate 93-IJ-CX-0017 Program on Human Development and Criminal Behavior Harvard University School of Public Health Felton J. Earls 93-IJ-CX-K005 Sexual Assault Evidence: National Assessment and Guidebook University of New Haven R.E. Gaensslen 91-IJ-CX-0016 Violence and Threats of Violence against Women in America Center for Policy Research Patricia Tjaden 93-IJ-CX-0012 Domestic Violence and Child Abuse Adjusting the National Crime Victimization Survey's Estimate of Rape and Domestic Violence University of South Carolina Ann Coker 93-IJ-CX-0050 Child Victimization and Adult Violence Research Foundation of the State University of New York, Albany Cathy Widom 93-IJ-CX-0032 Children of Battered Women Education Development Center, Inc. Cheryl Vince-Whitman 93-IJ-CX-0033 Divorce Mediation and Spousal Violence Center for Policy Research Jessica Pearson 93-IJ-CX-k009 Divorce Mediation and Spousal Violence Center for Policy Research Jessica Pearson 93-IJ-CX-0036 Domestic Violence Research Project Boston Police Department Pamela Kelley 93-IJ-CX-K009 Effectiveness of Civil Protection Orders in Deterring Domestic Violence National Center for State Courts Susan Keilitz 93-IJ-CX-0035 Parental Drug Testing To Facilitate Judicial and Social Service System Collaboration in Child Abuse and Neglect Cases The Urban Institute Lisa Newmark 93-IJ-CX-0042 Prevalence and Consequences of Child Victimization: Longitudinal Study Medical University of South Carolina Benjamin Saunders 93-IJ-CX-0023 The Role of Alcohol and Drug Abuse in Domestic Violence and Its Treatment: An Integrated Approach in Dade County's Domestic Violence Court Crime and Justice Research Institute John Goldkamp 93-IJ-CX-0028 Study of Prosecution of Domestic Violence in Rural Counties Ann Taylor, NIJ Fellow 93-IJ-CX-0003 Violence in the Schools Building a Culture and Climate of Safety in Public Schools: School-Based Management and Violence Reduction in Philadelphia Temple University Jack Green 93-IJ-CX-0038 Evaluation of Violence Prevention Programs in Middle Schools Victim Service Agency Ellen Brickman 92-IJ-CX-K030 Reducing School Violence in Detroit Michigan State University Sue Morgan 93-IJ-CX-0046 Victimization Effectiveness of Alternative Victim Assistance Service Delivery Models San Diego Association of Governments Christine Curtis 92-IJ-CX-K025 Research and Development for Sheriffs-- The Triad Concept To Reduce Criminal Victimization of the Elderly National Sheriffs' Association Charles B. Meeks 92-IJ-CX-K001 Illicit Use of Drugs/Drug Prevention and Treatment Criminal Justice Drug Treatment Programs for Female Offenders Public Health Foundation of Los Angeles County, Inc. Gayle Chapman 92-IJ-CX-K018 Effects of Different Criminal Justice System Strategies Aimed at Increasing Rates of Completion of Mandated Drug Treatment Programs Vera Institute of Justice Douglas Young 93-IJ-CX-0025 Evaluation of Two Models for Treating Sentenced Federal Drug Offenders in the Community National Council on Crime and Delinquency James Austin 93-IJ-CX-0041 Evaluation of Youth Gang Drug Intervention/Prevention Programs for Female Adolescents Development Services Group, Inc. Alan M. Bekelman 93-IJ-CX-0051 The Correctional System AIDS/HIV Education in Lockups and Booking Facilities: Phases I to III Abt Associates, Inc. Michael Gross 89-IJ-CX-0060 The Americans With Disabilities Act: Implications for Criminal Justice Paula N. Rubin-NIJ Fellow 92-IJ-CX-0009 Management of Special Populations: Mentally Disabled Offenders Policy Research Associates, Inc. Henry J. Steadman 92-IJ-CX-K020 Managing Elderly Offenders Northeastern University Edith Flynn 93-IJ-CX-0015 Prosecution and Adjudication Coordinating Criminal and Dependency Proceedings in Child Maltreatment Cases Education Development Center, Inc. Cheryl Vince-Whitman 92-IJ-CX-K034 Court-Adjudicated and Court-Ordered Health Care State Justice Institute/George Washington University Franklin Zweig 93-IJ-CX-A017 ____________________________________________________________ SELECTED RECENT NIJ PUBLICATIONS IN HEALTH AND JUSTICE Violent Behavior and Criminal Behavior Keppel, Robert D., and Joseph G. Weis, Improving the Investigation of Violent Crime: The Homicide Investigation and Tracking System, NIJ Research in Brief, August 1993, NCJ 141761. Roth, Jeffrey, Firearms and Violence, NIJ Research in Brief, February 1994, NCJ 145533. Roth, Jeffrey, Psychoactive Substances and Violence, NIJ Research in Brief, February 1994, NCJ 145534. Roth, Jeffrey, Understanding and Preventing Violence, NIJ Research in Brief, February 1994, NCJ 145645. Sheley, Joseph F., and James D. Wright, Gun Acquisition and Possession in Selected Juvenile Samples, NIJ Research in Brief (published jointly with the Office of Juvenile Justice and Delinquency Prevention), December 1993, NCJ 145326. Domestic Violence and Child Abuse National Criminal Justice Association, Project to Develop a Model Anti-Stalking Code for States, NIJ Research Report, October 1993, NCJ 144477. National Institute of Justice, Office for Victims of Crime, Office of Juvenile Justice and Delinquency Prevention, Joint Investigations of Child Abuse: Report of a Symposium, NIJ Research Report, July 1993, NCJ 142056. New Approach To Interviewing Children: A Test of Its Effectiveness, NIJ Research in Brief, 1992, NCJ 135011. Whitcomb, Debra, et al., The Emotional Effects of Testifying on Sexually Abused Children, NIJ Research in Brief, April 1994, NCJ 146414. Whitcomb, D., E.R. Shapiro, and L.D. Stellwagen, When the Victim Is a Child, 2nd edition, NIJ Issues and Practices, 1992, NCJ 136080. Widom, Cathy Spatz, The Cycle of Violence, NIJ Research in Brief, October 1992, NCJ 136607. Illicit Use of Drugs/Drug Prevention and Treatment Goldkamp, John, Assessing the Impact of Dade County's Drug Court, NIJ Research in Brief, 1993, NCJ 145302. Drugs: Treating Offenders, NIJ Crime File Videotape, 1990, NCJ 123673, $17.00 plus postage and handling. Drugs: Youth Crime, NIJ Crime File Videotape, 1990, NCJ 123674, $17.00 plus postage and handling. Dunworth, Terence, and Aaron Saiger, Drugs and Crime in Public Housing: A Three-City Analysis, NIJ Research Report, March 1994, NCJ 145329. Finn, Peter, and Andrea K. Newlyn, Miami's "Drug Court": A Different Approach, NIJ Program Focus, June 1993, NCJ 142412. Hepburn, John R., et al., Maricopa County: Demand Reduction Program, NIJ Evaluation Bulletin, October 1994, NCJ 149016. Rosenbaum, Dennis P., et al., Community Responses to Drug Abuse: A Program Evaluation, NIJ Research Report, February 1994, NCJ 145945. Use of Force by the Police Scrivner, Ellen, The Role of Police Psychology in Controlling Excessive Force, NIJ Research Report, April 1994, NCJ 146206. The Correctional System Hammett, Theodore M., 1992 Update: HIV/AIDS in Correctional Facilities, NIJ/Centers for Disease Control and Prevention, NIJ Issues and Practices, January 1994, NCJ 143398. Hammett, Theodore M., Tuberculosis in Correctional Facilities, NIJ/Centers for Disease Control and Prevention, NIJ Issues and Practices, January 1994, NCJ 143399. Hammett, Theodore M., and Andrea L. Daugherty, 1990 Update: AIDS in Correctional Facilities, NIJ Issues and Practices, July 1991, NCJ 131004. Special Populations McDonald, Douglas C., and Michele Teitelbaum, Managing Mentally Ill Offenders in the Community: Milwau-kee's Community Support Program, NIJ Program Focus, March 1994, NCJ 145330. Rubin, Paula N., The Americans With Disabilities Act and Criminal Justice: An Overview, NIJ ADA Bulletin, Research in Action, September 1993, NCJ 142960. Rubin, Paula N., The Americans With Disabilities Act and Criminal Justice: Hiring New Employees, NIJ ADA Bulletin, Research in Action, October 1994, NCJ 147479. Rubin, Paula N., The Americans With Disabilities Act and Criminal Justice: Providing Inmate Services, NIJ ADA Bulletin, Research in Action, July 1994, NCJ 148139. These publications can be obtained free, except where indicated, from the National Criminal Justice Reference Service (NCJRS), at 800-851-3420. The NCJ number at the end of each citation will expedite order processing.