Gangs and Adolescent Mental Health: a Narrative Review

Abstract

This study presents a narrative review of the literature on gang culture and its association with mental health, including an in-depth overview of the topic area and reference to key systematic reviews and meta-analyses. This review will define gang culture, discuss the multiple interacting reasons (biological, psychological and social) why some young people may be attracted to gangs; and the psychiatric morbidities associated with being part of a gang. Gang culture and some adolescent mental health problems are intricately linked. This paper highlights ways in which research, practice and policy could be extended to minimise the injurious effects of gang culture on adolescent mental health.

On 23rd June 2018, police officers were called to a community centre in East London after a fight broke out. Initial reports stated that a birthday party in North Romford Community Centre had been gate-crashed, individuals were prevented from entering, and violence soon ensued (Sheppard and Dunne 2018). The first officers on the scene were confronted with up to 100 youths, many of whom were members of local gangs. Officers soon had to perform CPR on a 15-year-old boy who had sustained multiple stab wounds. Paramedics arrived but were unable to resuscitate the boy.

Gang culture is a topical issue. In 2017, the UK Office for National Statistics stated that in the past year, knife and gun crime – both associated with gang involvement – had increased by 22 and 11% respectively (“Office for National Statistics: Crime in England and Wales” 2017). Youth involvement in gangs is a complex topic, as is its link with social antecedents and criminal behaviour. In preparing this review, I have drawn upon a methodological paper which recommends the narrative review, defined as ‘a scholarly summary along with interpretation and critique’ for illuminating the multiple interacting influences in a complex topic area (Greenhalgh et al. 2018). These authors distinguish between

… puzzles or problems that require data (for which a conventional systematic review, with meta-analysis where appropriate, may be the preferred methodology) and those that require clarification and insight (for which a more interpretive and discursive synthesis of existing literature is needed). (Greenhalgh et al. 2018)

This study began with a search of the literature using key words (‘gangs’, ‘youth’, ‘psychiatric morbidity’, ‘mental health’, ‘recreational drugs’, ‘violence’) which thereby identified some key empirical studies and highly-cited commentaries on the topic of gang culture. From that initial sample, references of references were searched and citation-tracking (forward searching of key papers using Google Scholar) was used. The resulting review thus provides an overview of multiple aspects of a wide topic area and includes reference to a number of key systematic reviews and meta-analyses on narrower aspects of the topic (Fisher et al. 2008; Fowler et al. 2009; Harris and Barraclough 1997; Townsend et al. 2010).

Antisocial behaviour linked to gang culture is common in many countries today, with violence and other criminal activity commonly appearing in the media. Although the proportion of young people involved in gangs has not increased overall in recent years (Medina et al. 2013), we are becoming much more aware of the mental health complications that both arise from, and predispose to, such involvement (Coid et al. 2013). Until recently, research on gangs has been focused on sociological and criminological preconditions for gang culture, with a relative scarcity of data about the individual psychopathology surrounding it (J. Wood and Alleyne 2010). More recent studies have begun to address more comprehensively why young people may be prone to joining gangs (McDaniel 2012), and what the psychological implications of doing so are (Madden et al. 2013).

What Is a Gang?

Definitions of a gang vary, and findings from empirical studies on gangs seem to depend heavily on how restrictive the definition is (F. A. Esbensen et al. 2001). However, a leading group of American and European researchers forming a network known as Eurogang have proposed a definition that many contemporary authors are now citing, “A street gang is any durable, street-orientated youth group whose involvement in illegal activity is part of its group identity” (Weerman et al. 2009).

There are similarities between gangs and other social groups (such as cults). For example, both cults and gangs restrict members’ freedom of thought, have self-appointed authoritarian leaders and effect a situational dependence on group identity (Knox 1999). The main difference is that the former invokes a spiritual or ideological principle of organisation to espouse a particular belief system, whereas the latter typically lacks this, and instead exhibits features of delinquent behaviour, aggression and criminality.

It is estimated that 6% of young people aged 10–19 are affiliated to a gang in the UK (Madden et al. 2013). Young people are vulnerable to the effects of gangs on mental health, and females are particularly at risk of sexual abuse and exploitation (“Ending gang and youth violence: annual report” 2014). Gangs tend to be located in inner-city areas and are associated with high rates of violence (Fowler et al. 2009). A government report on gang violence in 2011 showed that in London, 50% of shootings and 22% of acts of serious violence were committed by gang members (“Ending gang and youth violence: cross-government report” 2011).

Males are around 12 times more prevalent in gangs, but there are growing numbers of female members (Alleyne and Wood 2010). In the US, law enforcement agencies reported a greater number of Hispanic/Latino (46%) and African American (35%) ethnicities as a percentage of gang demographics (“National Youth Gang Survey Analysis” 2011). Some authors have claimed that the ethnic composition of some gangs are homogeneous (F. Esbensen and Weerman 2005) while some found heterogeneity (Gatti et al. 2005). Other research has shown that gangs tend to represent, broadly, the ethnic makeup of the underlying neighbourhood (Bullock and Tilley 2008).

‘Pushes’ and ‘Pulls’ Towards Gang Culture

Joining a gang carries predictable dangers: increased risk of violence, isolation from family life and a predisposition for other long-term problems such as homelessness (Petering 2016). Given these dangers, what are the reasons for young people to join gangs? One theory is that gang participation is a result of ‘pushes’ from society and culture, and ‘pulls’ from within the gang itself (Decker and van-Winkle 1996). Push factors tend to drive young people away from their family life and into gangs (Decker and van-Winkle 1996). Risk factors can be divided into individual, peer group, school, family and community; these are likely to be interrelated. Individual risk factors for gang participation include male sex, certain ethnicities, prior delinquency and underlying mental health problems (Ang et al 2015)(McDaniel 2012). Prior delinquency is a strong predictor of gang involvement, and participation in gangs is highly likely to perpetuate delinquent behaviour (Dhungana 2009).

A wide variety of mental health problems are associated with gang culture. Young people who socialise with delinquent peers, have gang members in their class or friend group, or spend more time on the street are at increased risk of being ‘pushed’ into gang culture (The National Crime Prevention Centre (NCPC) of the Public Safety Canada 2016). Research has shown that aggressive children form friendships with congenial peers by the age of ten (Cairns and Cairns 1991). Even in individuals with no peer exposure to delinquency or gang life, feeling marginalised by friends can trigger young people to join gangs (Decker and van-Winkle 1996). These factors are compounded by problems at school: poor school performance, negative labelling by teachers, and few teacher role models, all of which are predictors of gang involvement (The National Crime Prevention Centre (NCPC) of the Public Safety Canada 2016), as well as educational frustration stemming from learning difficulties (defined as IQ below 70) (Madden et al. 2013).

Familial factors are amongst the strongest predictors or delinquency and gang involvement (McDaniel 2012). These include parental drug and alcohol abuse, violence at home, and parental criminality or gang membership (The National Crime Prevention Centre (NCPC) of the Public Safety Canada 2016), all of which are associated with a low socioeconomic status (Heimer 1997). Moderate levels of parental monitoring significantly decrease the risk of gang affiliation (McDaniel 2012), and one study indicates that there are three parental variables which negatively correlate with problem behaviour in gang-associated youth: behavioural control, psychological control, and warmth (Walker-Barnes and Mason 2004). Interestingly, parents who knew their children’s peers were less likely to have children who joined a gang (Medina et al. 2013), perhaps because this was a proxy for parental engagement. These psychosocial influences could be mediated via neurobiological changes as a result of childhood maltreatment and adverse experiences (Anda et al. 2006).

Community ‘push’ factors linked to joining gangs include: social disorganisation, availability of firearms, access to drugs and cultural norms supporting gang behaviour (The National Crime Prevention Centre (NCPC) of the Public Safety Canada 2016). Youth may be pushed towards gang culture to resist structural violence they experience in their own community (Giliberti 2016). Furthermore, the presence of pre-existing gangs correlates strongly with further gang involvement, as neighbourhood gangs can trigger fear in young people and either stimulate young people to join existing gangs or drive groups of youths to form new gangs (Decker 1996).

Predictably, young people with more risk factors are more likely to be involved in gangs (K. G. Hill et al. 1999). Statistical analyses show that the presence of risk factors in multiple categories carries more influence than multiple factors in one category (J. Howell 2004; Merrin et al. 2015). Furthermore, these risk factors are evident from an early age, long before youth join gangs (The National Crime Prevention Centre (NCPC) of the Public Safety Canada 2016).

When assessing the relative effect of risk factors, it is important to consider the interactions between them and appreciate that some may act synergistically. Elijah Anderson, a leading ethnographer from Yale University, gives an account of inner-city violence amongst black Americans in his book ‘Code of the Street’, and posits that rather than resulting from random unconnected events, gang violence represents a complex web of interrelated factors. The author argues that street culture governs ‘interpersonal public behaviour, particularly violence…[providing] a rationale allowing those who are inclined to aggression to precipitate violent encounters in an approved way’ (Anderson 1999, p.33). Thus, on a background of low socioeconomic status, familial criminality and poor educational opportunities, young people may develop a sense of cynicism and hopelessness towards society, perpetuating a street culture conducive to violence and gang involvement. Some authors claim that the street code is as important to youths as family values and can significantly shape individual beliefs, values and behaviours (Oliver 2006). Interpersonal violence in this setting is used to gain respect, especially in the context of gang culture (Stewart and Simons 2006).

Overall, against a backdrop of adverse individual, familial, educational and societal factors, at-risk youth are predisposed to undergo predictable psychological changes. Poor self-esteem (Alleyne and Wood 2010; Dmitrieva et al. 2014) and impulsivity (Egan and Beadman 2011) are coupled with feelings of hostility towards society and affected individuals seek out ways to escape this. This can manifest as externalising behaviours such as aggression, antisocial behaviour and delinquency, paving the way for gang involvement (Donnellan et al. 2005).

As well as the ‘pushes’ that drive young people away from family and society, Decker and van-Winkle (1996) also propose that gangs provide opportunities that draw vulnerable individuals in. Given a background of individual, familial and societal risk factors, certain adolescents may be particularly suggestible and thereby manipulated into participating in gang culture.

One way in which gangs do this is to provide youths with status, identity and companionship. A cross-sectional study of 797 London schoolchildren aged 12–18 reported that gang members valued social status significantly more than non-gang youth, with members often feeling a need to prove themselves to figures of authority (Alleyne and Wood 2010). Gangs also attract young people with ‘coercive power’ (Knox 1999). Violent threats and acts can trigger young people to join gangs through fear, and bullying within gangs has been well established (James Wood et al. 2009).

Extending the work of Decker and van Winkel, it seems that gangs do not just ‘pull’ vulnerable members of society in, but also foster continuing participation amongst current members by discouraging them from leaving. Members of a gang face a sense of moral dissonance between (on the one hand) the benefits of social identity, companionship and respect amongst peers and (on the other hand) the negative social impacts of gang-related activities. Sykes and Matza (1957) argue that this moral dissonance is dealt with through ‘cognitive neutralisation techniques’ (Table 1).

Table 1.

Cognitive neutralisation techniques

Technique	Example
Denial of Responsibility	‘it wasn’t my fault’
Denial of Injury	‘it wasn’t a big deal’
Denial of Victimization	‘they had it coming’
Condemnation of Condemners	‘you’ve been just as bad’
Appeal to Higher Loyalties	‘my boss told me to’

*Cognitive neutralisation techniques used by delinquents to justify illegitimate actions, with examples of arguments used (adapted from Sykes and Matza 1957)

Albert Bandura, a psychologist at Stanford University, extended the idea of cognitive neutralisation in his theory of ‘moral disengagement’ (Bandura 1999), which delineates the ways by which inhumane conduct is actively justified. Gang members readily employ moral disengagement methods (Table 2) to exonerate perpetrators, rationalise reprehensible conduct, and provide a means by which members can justify their continued participation in the gang (Alleyne and Wood 2010).

Table 2.

Moral disengagement strategies

Disengagement strategy	Description
Moral justification	The behaviour has a higher moral purpose
Euphemistic labelling	The behaviour is redefined to liberate perpetrators from guilt
Advantageous comparison	The behaviour is absolved from fault by comparison to a worse outcome
Displacement of responsibility	Blaming another party
Diffusion of responsibility	Spreading the blame
Disregarding injurious consequences	–
Dehumanisation	The victim is no longer seen as human and is morally excluded

*Moral disengagement strategies used to justify inhumane behaviour (adapted from Bandura 1999)

Empirical research suggests that youth involvement in gangs is the result of a complex combination of factors that both pressures individuals to detach themselves from society and lures them in through elaborate psychological tactics. A generic narrative offered by Craig et al. for gang membership is as follows: [1] from an early age, individuals exhibit behavioural problems and anxiety; [2] these individuals fail to learn ‘conventional prosocial alternatives to antisocial behaviour’ by associating with delinquent peers; and [3] once on a trajectory into gang life, there is a reciprocal influence between congenial individuals which perpetuates antisocial problems (Craig et al. 2002). As noted above, one of the key associations with the cynicism for society that is linked to gang culture is mental health problems – but are such problems a cause or consequence of gang culture?

How Do We Explain the High Prevalence of Mental Health Issues in Gang Members?

In 1987, Terence Thornberry, a professor in criminology and criminal justice, proposed his ‘Interactional Theory’ to explain why gang members exhibit significantly higher rates of violence compared to those not in gangs (Thornberry 1987). The theory states that three factors underlie this trend: [1] selection, whereby gangs recruit members who are already delinquent; [2] facilitation, whereby gangs provide opportunities for criminal behaviour, and [3] enhancement, whereby gangs recruit youth already at a high risk of crime, stimulating them to become more delinquent. These same processes may be at play with regard to gangs and mental health in young people: [1] gangs preferentially select those with underlying mental health issues; [2] gang membership facilitates the development of mental health issues; and [3] gangs enhance covert psychiatric morbidity to become apparent. Furthermore, as the name Interactional Theory implies, these influences are both inter-related and mutually reinforcing.

In general terms, it is likely that all three processes – selection, facilitation and enhancement – are responsible for the high prevalence of mental health issues in gangs. However, to get a better picture of the underlying reasons, it is worth looking in more detail at the specific psychiatric conditions that have been described in members of gangs.

Prevalence of Mental Health Conditions in Gang Members

Coid et al. (2013) carried out a cross-sectional survey of 4664 men in Great Britain, purposefully oversampling areas with high levels of violence and gang membership. The study was focused on men aged 18–34 years, and hence gathered information on adult psychiatric conditions.

This was the first study to investigate the link between gang participation, violence and psychiatric morbidity. Participants were invited to complete questionnaires regarding their use of mental health services, gang membership and views on violence. Table 3 compares the prevalence of different mental health issues in non-violent men, violent men who were not part of a gang, and gang members.

Table 3.

Prevalence of mental health issues in non-violent men, violent men and gang members

Psychiatric morbidity	Non-violent men (%)	Violent men (%)	Gang members %	Adjusted odds ratio (how much higher the rate is in gang members compared to non-violent non-members)
Psychosis	0.8	4.9	25.1	4.16
Anxiety	10..6	19.2	58.9	2.25
Depression	9.4	8.5	19.7	0.18
Alcohol dependence	6.0	14.2	66.6	3.04
Drug dependence	0.8	5.0	57.4	3.64
Antisocial personality disorder	3.6	29.2	85.8	23.94
Suicide attempt	2.9	9.7	34.2	7.74

*Table adapted from Coid et al. (2013) showing the prevalence of mental health issues in non-violent men, violent men and gang members

The study found that rates of psychiatric morbidity were higher in gang members and violent men compared to non-violent men, with the notable exception of depression, which seemed to have a strong protective effect against joining a gang. Although the data only demonstrate trends (and not causality), the link between various mental health conditions and gang membership/violence is now well established.

Overall, rates of psychiatric morbidity were significantly higher in gang members compared to violent individuals who were not part of a gang (Coid et al. 2013). Therefore, whilst gang membership seems to allow violent traits to escalate (Farrington and Loeber 2000) – which could explain the higher levels of reported mental health issues – it is clearly not the full picture. What is it in particular about gangs that allow mental health problems to thrive?

Aside from depression, the rates of psychosis, anxiety, alcohol and drug dependence, antisocial personality disorder and a history of attempted suicide in this study were all significantly higher in gang members (Coid et al. 2013). The reason for these figures may be explained through the Interaction Theory (selection, facilitation and enhancement) hypothesis previously discussed (Gatti et al. 2005), though the proportional contribution of each of these may differ in different conditions. However, in order to get a better picture of the psychological influence of gang culture, we may need to explore its effect on specific conditions in detail, as the underlying processes may differ.

Correlation of Psychological Factors and Gang Involvement

Psychosis, Anxiety and Post-Traumatic Stress Disorder (PTSD)

One consistent indirect link between gang membership and certain psychiatric morbidities is the use of recreational drugs. Cannabis – and ‘skunk’ in particular – seems to predispose to a plethora of mental health issues, including anxiety (Crippa et al. 2009) and psychosis (Arseneault et al. 2002). Rates of use are significantly higher in gang members (Coid et al. 2013), which may be because of ties with the local drugs economy (Bennett and Holloway 2004). Furthermore, cannabis seems to have a synergistic effect with childhood trauma on the development of psychotic symptoms (Harley et al. 2010), meaning that having both risk factors increases the probability of developing psychosis beyond the additive interaction of the two factors together.

Fowler et al. (2009) carried out a meta-analysis on the psychological effects of violent exposure on young people, and found that those who had witnessed community violence – which is much more likely in gangs – were significantly more at risk of developing PTSD, which is linked with psychotic symptoms (Berry et al. 2013). Furthermore, recent evidence has shown that PTSD does not just effect victims of traumatic events, but also the perpetrators, who suffer adverse psychological consequences as a result of inflicting harm (Kerig et al. 2016).

It seems that whilst adolescents react to an exposure of community violence through externalising behaviours (e.g. aggressiveness), children tend to internalise their experience of similar stimuli and develop anxiety disorders (Fowler et al. 2009). Coid et al. (2013) posit that both of these behaviours are a result of their ongoing attitudes to violence, including ‘ruminative thinking, violent victimisation and fear of further victimisation’.

Depression

Although data suggest that depression levels are actually lower in gangs (Coid et al. 2013), other research, especially from the USA, challenges this view (Petering 2016; Watkins and Melde 2016). In studies where depressive symptoms are lower in gangs, there may be various explanations. Firstly, violence – especially in the context of gangs – may be seen as a ‘displacement activity’ that disperses the injurious effects of a traumatic childhood (Madden et al. 2013). The data obtained by Coid et al. corroborate this: levels of depression are lower in violent men compared with non-violent men, so violence would act as a confounding variable when assessing depression rates in gang members (Coid et al. 2013). Secondly, depressed individuals may be less likely to join a gang through a diminished effect of the ‘pushing’ and ‘pulling’ factors previously discussed. These factors are hard to assess though, as the major studies in the UK so far have been cross-sectional rather than longitudinal so were not designed to follow changes over time.

Rates of depression in gangs on the other side of the Atlantic are significantly higher compared to the general population (Watkins and Melde 2016). The reasons are yet to be elucidated, but could be due to shared risk factors for both (early physical abuse and neglect (Chaffin et al. 1996), lower socioeconomic status (Link et al. 1993) and substance abuse (Armstrong and Costello 2002)) or because gang membership causes and exacerbates symptoms of depression. For example, exposure to violence may trigger internalising behaviours, as is shown to be a factor linking gang membership to anxiety (Fowler et al. 2009). Another explanation is that gang culture may harbour high levels of stigma for mental health issues, which are commonly viewed with negative attitudes amongst young people, preventing others from seeking help (Corrigan et al. 2005; Pinfold et al. 2003).

Two conclusions are supported by these conflicting international findings: [1] further epidemiological research on the prevalence of depression in gangs needs to be carried out, specifically comparing contrasting cultures and neighbourhoods; and [2] the relationship between gang culture and affective disorders like depression may be more complex than in other psychiatric morbidities. New research could use longitudinal designs and productively focus on how different risk factors influence the rates of depression in gang members (whilst taking account of other variables), and also how membership in a gang can affect depressive symptoms. Focus should be aimed at why gangs from different cultures seem to exhibit different psychiatric landscapes.

Conduct Disorder and Antisocial Personality Disorder (ASPD)

These two psychiatric conditions are related, with individuals exhibiting aggressive or deceitful behaviour and a propensity to violate rules. About 40% of children with conduct disorder go on to develop ASPD (Zoccolillo et al. 1992), and the high rates of both conditions in gangs can be largely explained through shared risk factors (Madden et al. 2013). For example, one of the DSM-5 criteria for diagnosing ASPD is that from the age of 15, the individual exhibits ‘aggressiveness as indicated by physical fights or assaults’ (American Psychiatric Association 2013). Violence is much more prevalent amongst gang members than those who are not part of a gang (Coid et al. 2013), hence the elevated rate of individuals with ASPD in gangs. As well as violence, other shared risk factors include being male (Alegria et al. 2013) and having a history of early behavioural problems (American Psychiatric Association 2013; G. Hill et al. 2001).

Individuals with antisocial personality traits may be more inclined to join gangs because their peers are more likely to reaffirm their values and attitudes about the wider world. In a study by Egan and Beadman, adult male prisoners were given psychometric personality tests which demonstrated that antisocial personality traits such as impulsive and aggressive behaviour were a strong predictor of gang membership (Egan and Beadman 2011). The authors hypothesised that those with such traits felt little attachment to peers who were supposedly a good influence, and instead found their social niche in gangs with peers who respected and praised antisocial behaviour.

Suicide and Attempted Suicide

Those in gangs were eight times more likely to have attempted suicide than non-violent individuals who were not in gangs (Coid et al. 2013). Although not a mental health condition per se, suicidal tendencies tend to reflect underlying psychiatric morbidities such as depression, anxiety and psychosis (Harris and Barraclough 1997). Indeed, a meta-analysis of ‘suicide as an outcome for mental health disorders’ found that – with the exception of dementia and mental retardation – all mental health disorders increased the risk of suicide (Harris and Barraclough 1997). This is particularly true of functional disorders and substance misuse disorders. The increased rates of suicide among gang members may reflect underlying psychiatric morbidity, but could also illustrate an externalisation of violent ruminations and fear of victimisation (Madden et al. 2013).

Attention Deficit Hyperactivity Disorder (ADHD)

Whilst research on the characteristics of younger people in gangs is limited, one cross-sectional study used parents to complete questionnaires about their children and found that levels of hyperactivity and inattention (key symptoms in ADHD), as well as oppositional behaviour (which can precede conduct disorder) were significantly higher in gang members aged 10–14 than non-gang members (Craig et al. 2002). However, one problem with this study is that parents are often unable to provide reliable reports of peer activities to which adults are not privy. Nonetheless, is seems that behavioural issues from a young age, particularly traits found in ADHD, are a key risk factor for gang participation.

The reasons for high levels of hyperactivity and inattention in gangs could be because gangs actively select for these traits, or that they become more apparent in gang culture (Craig et al. 2002). Given the known association between ADHD and learning difficulties (Mayes et al. 2000), there could be a link with educational impairment and frustration at school. Another link could be substance abuse – children with ADHD are more likely to misuse recreational drugs like cannabis (Upadhyaya et al. 2005), which is a risk factor for gang participation as discussed earlier.

Future Direction for Prevention and Harm Reduction

Reducing the Involvement and Impact of Young People in Gangs

Broadly speaking in medicine, there are two possible methods to target public health problems: prevention and treatment. With relation to gangs, prevention generally refers to reducing the number of young people joining gangs by focusing on the ‘pushes’ described by Decker and van-Winkel (1996). Treatment refers to targeting youth already in gangs and aiming to reduce the impact of an adverse social environment on their mental health.

Preventing People from Joining Gangs

Although there is no evidence that the total number of young people joining gangs has increased in recent years (Medina et al. 2013), we are nevertheless becoming more aware of the psychological problems that these individuals face. This dictates a need to reduce youth involvement in gangs, which can be done by targeting adverse individual, familial, educational and community factors.

Individual factors in gang membership are often hard to change, but there are still interventions that can be implemented. Identifying children with pre-existing mental health conditions and learning difficulties (K. G. Hill et al. 1999; The National Crime Prevention Centre (NCPC) of the Public Safety Canada 2016) and providing early therapy may theoretically delay the journey towards gang participation, although there is limited evidence on the efficacy of behavioural interventions in preventing youth gang involvement (Fisher et al. 2008). Substance abuse may be targeted by a variety of methods (Gray et al. 2005; Kaminer et al. 2002), although a multi-systemic approach is most effective for tackling this issue in young people (Henggeler et al. 2002).

One key factor that predicts the risk of gang involvement amongst young people is high neighbourhood crime rates with pre-existing gangs, and the local community has a large role to play in youth gang desistance (Gormally 2015). Di Placido, Simon, Witte, Gu & Wong (2006) carried out a retrospective study of gang members who had committed crimes and investigated the role of correctional treatment in the incidence of recidivism and institutional misconduct. They found that when gang members were at a high risk of offending, and the ‘responsivity principle’ was adopted (treatment effectiveness is maximised by ‘accommodating…idiosyncratic tendencies’), then correctional treatment was highly effective at reducing the risk of reoffending. The study also showed that ‘criminogenic needs’ – factors that contribute to an individual’s delinquency such as criminal attitudes and criminal associates – must be targeted for correctional treatment to be effective. If gang members in a community are given tailored correctional treatment, which involves multi-disciplinary teams providing cognitive behavioural therapy, relapse prevention skills and psychoeducational groups on substance addiction, then neighbourhood criminality can be lowered, and the likelihood that other young people in the community joining gangs will diminish (Henggeler et al. 2002).

Therapy aimed at restoring family communication and supportiveness (Dhungana 2009) may be a viable option for preventing children with adverse family environment from descending into gang culture. Identifying families with gang affiliated youth may be hard as parents are often not privy to their children’s social life (Craig et al. 2002), but one author has called for medical professionals to more readily identify gang-involved youth in hospitals following violent crime so as to provide timely familial therapy (Akiyama 2015). These include interventions like Functional Family Therapy (FFT), which is significantly more effective than probation services in reducing recidivism in young offenders (Sexton and Turner 2010). However, there is limited evidence on the impact on reoffending if both therapies are used concomitantly.

Finally, we need to also offer strategies for secondary prevention, by identifying youths who are highly likely to rejoin a gang based on previous gang membership (Hennigan et al. 2015).

Reducing the Incidence and Impact of Mental Health Problems of those in Gangs

Conventional forms of treatment for mental health conditions, such as cognitive behavioural therapy, are effective in young offenders, especially in affective disorders such as depression and anxiety (Townsend et al. 2010). However, one study has shown that young people may respond very differently to these forms of treatment, and formal therapy at a predefined setting is often ineffective (Lemma 2010). Children may respond better to informal and indirect psychosocial therapy, e.g. though shared physical activities, especially those who are too ashamed and/or threatened to seek help for emotional problems (Lemma 2010). Treatment should be in an environment that children feel comfortable in, and any health professionals working with children need to establish strong emotional connections to ensure maximal benefit.

The most difficult-to-reach young people typically have multiple psychiatric comorbidities, with a variety of social vulnerabilities, poor treatment compliance and very poor prognoses (Kessler et al. 2010). An underlying problem in these individuals could be in mentalisation, a concept espoused by psychologist Peter Fonagy, which refers to the ability to differentiate self from others, specifically with regard to intentional mental states (e.g. needs, desires and feelings) (Fonagy and Luyten 2009). Fonagy argued that certain mental health conditions, especially in children, were due to impairments in mentalisation as a result of neurodevelopmental changes (Fonagy and Luyten 2009).

A novel treatment approach, termed ‘Adolescent Mentalisation-Based Integrative Therapy (AMBIT)’ has been developed to target three aspects of these individuals’ mentalisation: [1] towards the child and their family, [2] towards peers, and [3] towards the wider team looking after the child (Bevington et al. 2013). This multifactorial approach is relatively new and hence there is little data on its efficacy but represents a promising new method to reaching high-risk individuals, particularly those who have suffered adversely as consequence of gang culture.

We should be aware that gang involvement significantly reduces the effect of mental health interventions in youth (Boxer et al. 2015), and that primary prevention of gang affiliation is likely to be a much more effective approach to tackling the associated psychosocial problems. This is because once young people become involved with gangs, they become ‘embedded’ in cycles of ‘incarceration, destitution, addiction, and mental health crises’, which shield them from protective factors such as employment or access to mental health services (Fast et al. 2017). Resultantly, research is now focusing on identifying young people who are at risk of gang involvement so that interventions can be more appropriately targeted. For example, Howell et al. (2017) have developed a predictive tool (‘the life course model of gang involvement’) based on longitudinal data from Hautala et al. (2016), which identify risk factors for gang involvement in different domains as discussed previously (family, school, peer and individual) (Hautala et al. 2016; J. C. Howell et al. 2017). This model showed that the presence of more risk factors at a younger age correctly predicted the increased likelihood of gang involvement and could identify young people who would most benefit from primary prevention.

These approaches for tackling the myriad psychological problems of young people in gang culture are far from comprehensive, but hopefully offer an insight into what methods could be used to confront this widespread problem.

Conclusion

There is a long tradition of research into gang culture, but only recently have we started to appreciate the degree to which gang membership correlates with individual psychiatric morbidity. This is especially true in young people, who are much more vulnerable to an adverse familial environment, antisocial peers and dysfunctional neighbourhoods. Various studies have quantified the extent of mental health issues in gang members compared to the community as a whole and offered insights into why mental health conditions are so high.

Given the complexity of the problem, it is not surprising that there are no simple solutions to the psychosocial ramifications of gang culture, or how to use these to change current practice. Given what we now know, research should now aim to focus on how to minimise the number of young people who join gangs, through individual, familial and societal intervention; as well as targeting those already involved in gangs to curtail the onset and/or deterioration of psychiatric sequelae.

Compliance with Ethical Standards

Conflict of Interest

Alastair Macfarlane declares that he has no conflicts of interest to report.

Ethical Standards and Informed Consent

As a narrative review, this article did not require any specific informed consent.