"If we build palaces for children we tear down prison walls."
--Julius Tandler, 1938
Juvenile delinquency continues to be a major worldwide social problem. A series of new findings in epidemiology, developmental psychiatry, and neuroscience offers the opportunity to recast the problems of this recalcitrant and difficult-to-access population and bring to bear the insights of modern psychiatry in the treatment and successful rehabilitation of juvenile offenders. Delinquency can be seen as one maladaptive pathway in development that may result in antisocial and criminal behavior. However, clustering delinquents by type of crime and other criteria has shown only limited success in remedying and preventing adverse outcomes and recidivism.1 This suggests the need for new approaches to the issue of maladaptive aggression in juveniles. The traditional criminologic view of delinquency has resulted in a very large, heterogeneous category that has poor predictive validity in assessing long- and short-term outcomes.2
Epidemiologic insights combined with developmental psychiatry and neuroscience provide a new perspective that can inform diagnosis and treatment and may even help to prevent delinquency. Maladaptive aggression and psychopathology may best be considered as a subset of overall antisocial behavior and delinquent patterns (ie, adjudicated antisocial behavior) (Figure 1). Isolated antisocial behavior is extremely prevalent, especially in adolescents but has only a small chance of persistence. As we add psychopathology, especially psychopathy, prevalence decreases but chances of persistence increase greatly. Thus, we argue that the rehabilitation of juvenile delinquents without modern psychiatric evidence-based treatment is not likely to be successful, extending the arguments of Raine3 to view criminality as a form of psychopathology and apply them to children and adolescents. One promising approach to understanding these phenomena comes from neuroscience and developmental psychiatry, which propose distinct subtypes of aggression based on different underlying neurophysiologic and psychological mechanisms and provide an understanding of these processes in both evolutionary and clinical terms. This approach may be used to link specific techniques and treatments.
High rates of diverse, comorbid, and severe psychopathology
Based on several studies that have shown extraordinarily high rates and wide-ranging forms of psychiatric morbidity, delinquents can be classified on the basis of underlying psychopathology and thereby brought into the purview of mental health.4-8 These high levels of psychopathology have been unequivocally established in several worldwide screening studies.5 High levels of morbidity are equally evident in juveniles on probation and in incarcerative settings.
Suffering from psychiatric disorders in certain psychosocial contexts (eg, impoverished, unstructured, or outright injurious environments) seems to facilitate the expression of maladaptive aggression, as evidenced by the exceedingly high levels of conduct disorder and antisocial personality disorder in delinquent populations.9 Results from the California Youth Authority survey of 850 incarcerated delinquents who were examined by structured interviews showed prevalence rates in excess of 90% for externalizing disorders (such as disruptive behavior disorders and substance use disorders) in boys and girls.9 In the same study, girls (64%) were found to be twice as likely to have internalizing disorders as boys (29%), with depression and anxiety as leading diagnoses. In addition to these findings, comorbidity was the norm, with more than 80% of both boys and girls having 3 or more mental health diagnoses.
Juvenile justice systems seem to detect certain forms of psychopathology (such as substance abuse and learning disorders) more reliably, while others (especially internalizing disorders, such as separation anxiety; posttraumatic stress disorder [PTSD]; and phobias) are less well-recognized and therefore often go untreated.10,11 The reasons for this underdiagnosis are complex, but it is partially driven by ethnicity, age, and socioeconomic effects.11 While these psychiatric syndromes are not necessarily direct pathways to delinquency, they can create a set of circumstances that increase the likelihood of certain behaviors and cognitions that put adolescents at risk for persistent delinquent behavior. Many forms of psychopathology (eg, attention-deficit/hyperactivity disorder [ADHD], bipolar disorder, and PTSD) interfere with and prevent the juvenile's participation in rehabilitative programs and thus contribute to adverse criminologic outcomes.
Using a psychopathologic perspective to address the rehabilitation and treatment of delinquents suggests the use of effective interventions including psychotherapy, psychopharmacology, and sociotherapy to address specific processes and symptoms. It seems obvious that we need to directly examine the present penal treatment system for predelinquent and delinquent populations. These epidemiologic findings help to explain why present punitive and treatment approaches often fail.
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