Commentary on Border et al. (2018): The public health burden of conduct disorder, early mortality and criminal justice involvement.

Abstract

The most prevalent behavioral health disorder among youth involved in the criminal justice system is a conduct disorder. Given the high rate of early mortality found by Border and colleagues for youth with a conduct disorder, an expansion of evidence-based treatments for youth involved in criminal justice is a public health priority. There is clear recognition that disruptive behavior disorders, including conduct and oppositional defiant disorder, place a significant health burden on young people, particularly young men 1. Disruptive behavior disorders are among the most common behavioral health problems diagnosed among youth 2-4, with national prevalence estimates at consistently more than 6% of school-age children 4, 5. Disruptive behavior disorders are also remarkably prevalent among youth involved in the justice system, with more than 50% meeting the diagnostic criteria for conduct disorder 6. The paper by Border and colleagues in this issue supports previous findings that youth with conduct disorder are at unique risk for early mortality 7. As such, the research community should target youth with conduct disorders for intervention—both in the community and in the juvenile justice system. Despite the significant negative effects of conduct disorder, youth with behavioral health problems (especially justice-involved youth) 8 are rarely connected to evidence-based treatments 9. This is problematic, as utilization of evidence-based treatment has been shown to improve youth outcomes 10, 11. Justice-involved youth also tend to experience high rates of poverty, lack health insurance and live in violent neighborhoods. These conditions both perpetuate symptoms of behavioral health problems and limit their access to services. Thus, in order to improve outcomes related to conduct disorder for all youth, expansion of evidence-based treatment for justice-involved youth is desperately needed. Services designed to treat comorbid behavioral health disorders may be most appropriate for addressing treatment need among justice-involved populations. Border and colleagues reported that substance use-related causes accounted for the majority of deaths among study participants with conduct disorder. Like disruptive behavior disorders, substance use disorders are also over-represented among justice-involved youth when compared to the general population, and warrant consideration in treatment efforts 6. Indeed, juvenile courts are the most common referral to substance use treatment services 12, but existing community-based services have rarely targeted co-occurring problems. More promising interventions, such as that tested by Liddle and colleagues 13, appear to take a more holistic approach to behavioral health services by treating an adolescent's family as a single unit. Again, ensuring that justice-involved youth both have access to, and become engaged in, evidence-based interventions to treat comorbid behavioral health problems is a challenge for the field. Although Border and colleagues found that the most common cause of death within the sample was related to substance use, they found no significant direct effect of substance abuse/dependence vulnerability on mortality. This seemingly confounding effect may be due to common environmental and genetic factors that influence both conduct disorder and substance use 14. Disinhibitory processes, for instance, have been found to underlie multiple behavioral health disorders during adolescence 15. As such, disinhibition processes, as a predictor of early mortality, should be explored in future work. It follows that evidence-based interventions for youth with conduct and substance use disorders should address potential causes common to both disorders. Border and colleagues have highlighted that youth with a conduct disorder are at significant risk for early death. However, fostering adolescents’ connection to (and engagement in) appropriate, evidence-based care to reduce the effects of conduct disorder remains problematic. Justice-involved youth, who suffer high rates of conduct disorder, should receive special attention in future endeavors to address this public health problem. None. This study was completed with funding from the Agency for Healthcare Research and Quality (R01 HS024296).