Forensic child & adolescent psychiatry and psychology in Europe

In collaboration with Ricardo Barroso (Organizing Committee EFCAP 2024 & EFCAP), Nélio Brazão (Organizing Committee EFCAP 2024), Richard Church (RCPSYCH & EFCAP), Annemiek Harder (EFCAP-NL), Riittakerttu Kaltiala (EFCAP-FI), Evi Koenekoop (LUMC Curium), Madleina Manetsch (EFCAP-CH), Kees Mos (EFCAP-NL), Eva Mulder (EFCAP-NL), Belinda Plattner (EFCAP), Daniel Rijo (Organizing Committee EFCAP 2024), Chijs van Nieuwenhuizen (EFCAP), Roberta Vacondio (EFCAP), Dirk van West (EFCAP), Marco Zanoli (EFCAP).

Forensic child and adolescent psychiatry is a relatively young field that has evolved as a specialized branch of child and adolescent psychiatry analogous to forensic psychiatry. Until now, in most countries, forensic child and adolescent psychiatry remains still in a niche. There are only very few journals with a focus on forensic psychiatry and psychology, and none in the field of forensic child and adolescent psychiatry. Therefore, the offer of Child and Adolescent Psychiatry and Mental Health (CAPMH) in 2011 to start a thematic series under the auspices of European Association for Forensic Child and Adolescent Psychiatry, Psychology and other involved Professions (EFCAP) was a tremendous chance to get forensic child and adolescent psychiatry out of its niche. CAPMH was founded in 2007 and was the first independent, open access, online journal in the field [31]. The journal is established in the field and currently holds a 2 year Impact Factor of 5.6 and a 5 year Impact Factor of 5.0 (2022 Citation Impact).

Traditionally, the primary function of forensic child and adolescent psychiatry has been, and continues to be, the forensic evaluation and treatment of children, and especially adolescents, who have been committed to mental health services and/or institutions on the basis of civil or criminal law. Therefore, forensic child and adolescent psychiatry is characterized by a high inter-institutional cooperation, especially with the legal system that entail a variety of challenges and opportunities.

The relative youth of forensic child and adolescent psychiatry is reflected in the fact that it was not until 1997 that the umbrella organization EFCAP was founded, followed by the establishment of active national groups in the Netherlands (EFCAP-NL; for more information: see Box 1), Finland (EFCAP-FI; for more information: see Box 2) and Switzerland (EFCAP-CH; for more information: see Box 3). EFCAP also cooperates closely with the Adolescent Forensic Psychiatry Special Interest Group of the Royal College of Psychiatrists (RCPSYCH) in the United Kingdom (For more information: see Box 4), and adolescent forensic psychiatrists and psychologists from various countries such as Austria, Belgium, Cyprus, Czech Republic, France, Germany, Hungary, Italy, Lithuania, Portugal and Spain support EFCAP and its goals.

Box 1: EFCAP NL (Kees Mos, Eva Mulder & Annemiek Harder)

The rate of juvenile delinquency in the Netherlands is now more stable after years of decline. However, there are concerns about increased use of weapons and involvement in organized (drug) crime at a younger age. We cannot yet confirm this through research, but the government is investing seriously in researching and improving both intervention and prevention of juvenile delinquency.

In 2015, plans were made to change the Dutch juvenile justice system with the aim of developing tailored care and security. One of the reasons for this change was the introduction of the Juvenile Criminal Act in 2015. Due to the increasing diversity in the age of the population of justice-involved young people, but also in the severity of psychopathology, it was felt necessary to ensure that the stay in detention was more in line with the needs of young people by offering tailored care and security during detention and after the stay in detention facilities.

In 2016, five research pilots were launched to study small-scaled, community-embedded facilities aimed at enabling youth to develop protective factors (regarding school, work, family, friends) outside of the facility. There are now five small-scaled facilities, designed for youth at low risk of running away. They have low levels of physical security (no walls and gates) and rely heavily on relational security (based on positive contact between youth and staff).

In 2019 also the five closed Juvenile Justice Institutions (JJIs) began implementing a system change to become Forensic Care Centers (FCCs): highly secure facilities where youth with a specific care profile receive specialized care and security. This development should improve the quality and continuity of care with the ultimate goal of reducing recidivism. However, there are some factors that hinder these developments. One is the lack of personnel: it is difficult to find qualified people for this kind of work. It is a general problem in the Netherlands to find enough personnel, also in other sectors, such as teachers, nurses, et cetera. For this reason, the JJI’s have been under increased supervision by the Inspection of Justice and Security. This supervision was lifted last year, which means that the process of implementing tailored care and security will continue.

Box 2: EFCAP FI (Riittakerttu Kaltiala)

In recent years there has been a lot of societal concern over juvenile delinquency in Finland. Statistics inform that police registered violent crime by under-aged youth, particularly by those aged less than 15 (which is the age of criminal responsibility in Finland) has been rising during past 5 years. Statistics are affected by numerous other influences than changes in criminal activity itself, for example police resources, prioritization and citizen’s activity in reporting. It is not yet known whether a national survey on adolescent delinquency, regularly repeated, will correspondingly reveal changes in criminal behaviors on population level. Particular concerns focus on gang activities and involvement of adolescents in organized crime. Another phenomenon of concern that has reached extensive publicity is the videotaping and posting on social media of violent abuse situations where a victim is seriously battered, often by peers known to him/her. Such group battering resulted in death of an under-aged victim in 2020, followed by ample expressions of public concerns and media attention. These developments have resulted in debate over lowering the age of criminal responsibility and claims of tougher penalties, obviously seriously considered by political decision-makers. EFCAP Finland organizes annual multi-disciplinary conferences with the ambition to focus on topics currently of concern in the society, such as the aforementioned ones. In line with this, the topics of the conferences (homicides committed by adolescents in 2021, bullying in 2022, violent street crime in 2023) attract quite a wide audience comprising professionals from health and social care, education and law enforcement.

Box 3: EFCAP CH (Madleina Manetsch)

The story of EFCAP-CH started more than 15 years ago during the first International EFCAP-congress in Amsterdam. During that time, Swiss child and adolescent forensic mental health professionals were organized in the Swiss Society of Forensic Psychiatry. Since 2016, the subgroup was responsible for further education in forensic child and adolescent health care for psychiatrists and psychologists. EFCAP-CH has been an independently organized and officially registered association with statutes, a board and members since then. The main tasks of EFCAP-CH consist of carrying through the comprehensive curriculum in Forensic Child and Adolescent Psychiatry and Psychology. The program runs for two years with 12 theory blocks (two days) and 8 practical inputs (one day). Currently, the third curriculum will be completed in autumn 2024. Criminal and civil law, forensic assessments, court reports, psychotherapeutic interventions and offense-oriented intervention are amongst the subjects being taught. Furthermore, regular mini-congresses throughout the year keep the national discussion going. After a decrease in criminal convictions of juveniles, illegal acts committed by children and adolescents are again on the rise. Reasons for this phenomenon are multi-layered and at present the focus of research. Another upcoming challenge for EFCAP-CH lays in the future of the forensic mental health offspring. Furthering the attraction of our job in all its facets will be demanding.

Box 4: RCPSYCH (Richard Church)

The minimum age of criminal responsibility in England and Wales is 10 years of age, markedly out of keeping with European neighbours. Most recent reporting in January 2024 by the Youth Justice Board indicated a continuing secular trend of reducing total numbers of children cautioned or convicted of an offence – a total of 13,743 in the year to March 2023. The majority of those were youth aged 15–17 (10,184) with a small but significant number of 10-year-olds (27) and 11-year-olds (118).

Most young people in conflict with the law are managed in the community, but individuals charged or convicted of more serious offences may be detained in Young Offender Institutions, Secure Training Centres, Secure Childrens’ Homes or at the new Secure School that opened in early 2024. The number of children detained in these secure settings has reduced from over 3000 in 2003 to under 500 in 2023, with increasing recognition of the psychosocial adversity and high rates of mental disorder in this group.

Child and adolescent forensic mental health services operate in the community and in the secure settings listed above. In addition, there is network of secure hospital settings that include Psychiatric Intensive Care Units (PICU), Low Secure Units (LSU) and Medium Secure Units (MSU) for those who require a hospital setting to manage high risks to themselves and others. In England and Wales, admission to hospital is required to enable treatment under the Mental Health Act.

This is a complex and challenging area of work. In the UK, the Adolescent Forensic Psychiatry Special Interest Group at the Royal College of Psychiatrists has been in existence for over 20 years and has 3678 members. The group provides a forum and structure for representing the sub-specialty and championing best practice, to help clinicians serve this particularly vulnerable group of young people and their families.

One goal of EFCAP is to bring together experts and various stakeholders (e.g., experts by experience, practitioners, scientists, policy makers) in the field of forensic child and adolescent psychiatry and psychology to learn from one another. In doing so, the scientific and political goal is a better understanding of young people in forensic settings so that services to these young people and their families can better meet their needs, protect their development, and prevent future offending behavior. To facilitate this exchange, EFCAP organizes a scientific congress every two years. After congresses in Amsterdam (2008), Basel (2010), Berlin (2012), Manchester (2014), Porto (2016), Venice (2018) and Eindhoven (2022), this year’s congress will be held in the Azores (See Box 5).

Box 5: 8th EFCAP Congress 2024 (Daniel Rijo, Ricardo Barroso & Nélio Brazão)

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EFCAP congresses have been an opportunity for EFCAP members to get in touch with different practices and research findings within the field of child and adolescent forensic psychiatry, psychology and related professions, contributing to create a community of practitioners and researchers interested in child and adolescent mental health issues in the forensic field. The main theme of the 2024 EFCAP Congress will be: In search for effective interventions with young offenders and victims. Research and intervention efforts have been gradually focusing on young offenders and victims’ intervention needs. Offering and delivering appropriate treatment constitutes a major goal, attuned with EFCAP aims. The last decades have made possible the development of different types of interventions (e.g., individual versus group format), based in different theoretical approaches (e.g., Cognitive Behavioral Therapy [CBT] versus family focused), and delivered in different settings (e.g., community-based versus detention settings). Despite these efforts, there is still a need to assess treatment efficacy in more accurate ways. The congress will offer the opportunity to share new ideas and findings, involving students, researchers, professionals, and stakeholders, around the need to offer appropriate treatments to children and adolescents in the areas of forensic psychiatry and forensic psychology. Presenting new approaches to prevention and rehabilitation will be encouraged, as well as different methods when assessing treatment efficacy. A group of invited Keynote speakers will address innovative issues related to young offenders, victims and treatment approaches. They will share new findings and bring new challenges to everyone attending the congress.

Besides the organization of congresses, the dissemination of forensic knowledge in scientific publications is a second foothold of EFCAP to foster the development of the field. The collaboration between EFCAP and CAPMH started first in the form of a thematic series [4, 9, 20, 21], and since the end of 2019 in the form of an ongoing series. Since then, 24 papers (excluding the editorials mentioned above) have been published [1,2,3, 5, 7, 8, 11,12,13,14,15,16,17,18,19, 22,23,24,25,26,27,28,29,30].

One publication in particular we would like to highlight is the commentary: Overview of European forensic youth care: towards an integrative mission for prevention and intervention strategies for juvenile offenders by Souverein and colleagues [24], that summarized the results of a panel held at the 6th EFCAP conference in Venice in 2018. This commentary concludes with an integrative mission statement for Europe:

• 1. Consider forensic care for juveniles in a broader socio-political perspective.

• 2. Invest sufficient financial resources (and demonstrate that the investment pays off).

• 3. Collaborate nationally and internationally.

• 4. Prevention is critical.

• 5. Involve expert youth and their parents/caregivers.

Based on the goals of EFCAP, the themes of the upcoming EFCAP Congress, and the integrative mission statement of Souverein et al. [24], Bronfenbrenner’s (1979) ecological model and Engel’s (1977) biopsychosocial model, the authors attempted to visually summarize the major themes of the field that could be of interest for publication in our ongoing series (see Fig. 1).

Fig. 1

Visual summary of important topics in the field of forensic child and adolescent psychiatry

Looking to the future, we hope to continue our biennial conferences. In addition, we hope to welcome new national groups (or new sister organizations for countries where a forensic child and adolescent psychiatric/psychological nexus already exist). Finally, forensic child and adolescent psychiatry is an evolving field. CAPMH provides a platform for scientific communication and welcomes submissions of high quality research to further advance science and practice in the field, to better understand the needs of our patients, their families and the stakeholders and to provide better interventions.