The juvenile justice system by and large treats all forms of aggression and antisocial behavior as if these were acts under rational control. Neuroscience teaches us that this is probably not so. In recent years, findings that aggression can be divided effectively into "hot" and "cold" show that "cold" instrumental aggression can be expected to be under some rational control.29 However, its counterpart, "hot" aggression, which is most commonly activated by emotional disorders as divergent as PTSD, bipolar disorder, and severe impairment of executive cognitive functioning, is much less so and very often has a kindled quality to it. Blair and colleagues30 have shown that these 2 types of aggression run on different neuroachitectures, both serve an evolutionary purpose (defense and acquisition), and both can be derailed during normal development.
Hot aggression in particular seems to be a common accompaniment of psychopathologies, such as PTSD, bipolar disorder, and ADHD. It has many of the characteristics of classic psychiatric symptoms (eg, beyond voluntary control, exhibiting with considerable force, kindling, need for medication to ameliorate response). The law has acknowledged such a distinction for years: murder versus manslaughter, for instance. There is also good reason to think that it is hot aggression that is predominantly responsive to medications, while cold aggression needs containment, punishment, and behavioral interventions. Most likely, these insights will find their way into the courtroom and once again shift the border between pure response and responsibility.
There are several important implications of the neuroscience of aggression for the treatment of delinquent populations. First, the detection of psychopathology by suitable screening instruments that take the special characteristics of this population into account is a mandatory step in meeting the needs of most of these youths. Second, a great deal of thought will have to be given to the successful treatment of these subtypes of aggression.
Most likely, effective interventions will be based on the integration of behavioral treatment, psychotherapy, sociotherapeutic structures, and psychoeducation, which together with differentiated and sophisticated psychopharmacology can successfully target all manifestations of maladaptive aggression. Third, the availability of novel interventions redefines the time of incarceration into a window of op- portunity during which complicated treatment packages can be fine-tuned and maximized in terms of synergistic efficacy.
Because delinquent youths require such sophisticated integrated treatments, the optimal time to set up these complicated programs is when these youths are in secure settings that provide maximum control over problematic behavior while fostering compliance with protocols. Rather than simply "doing time," incarceration is a window of opportunity for optimized treatment that, for a variety of reasons, was not previously possible. As confinement progresses, protocols can be defined and refined, so that at exit, youths stand a more realistic chance of avoiding the close to 80% relapse rate that is currently the result of punitive practices insufficiently integrated into the practice of modern psychiatry.
This process of repeatedly refined treatment most likely will not end with discharge, and innovative and effective wraparound services will need to be provided to ensure that the carefully crafted intervention packages remain intact and effective after release. These goals are not easily achieved, but they hold the promise that alignment with modern medicine opens new pathways for improvement of criminologic outcomes, benefiting all concerned: patients, their families and friends, and society at large.Conclusions and implications
Investigators are continuing to explore different ways of conceptualizing ju-venile delinquency based on findings from the current literature on developmental psychiatry, epidemiology, and neuroscience. We have reviewed the high prevalence rates of psychiatric morbidity among juvenile delinquents and have discussed the potential pathways and relationships with social and environmental factors. Based on these hypotheses, we suggest that delinquents should be considered from a psychopathologic perspective that strongly supports the need to approach delinquents from a therapeutic rather than a punitive perspective. Juvenile justice settings can be seen as the sociotherapeutic framework in which modern psychiatric treatment can be delivered to a very difficult-to-reach population that often has high failure rates in community settings. The need for appropriate juvenile justice services for these persons has been established beyond any doubt.
Dr Steiner is a professor of psychiatry and behavioral sciences, child psychiatry, and human development in the department of psychiatry and codirector of the Center for Psychiatry and the Law of the Stanford University School of Medicine. He reports that he has received research/educational grants from Abbott, Eli Lilly, Ortho-McNeil, and McNeil; in addition, he is a consultant for Abbott and a speaker for Eli Lilly.