Discussion

Arriving at a DSM diagnosis requires consideration of the extent of a youth’s impairment (i.e., deficits in functioning) across a number of different domains. Because the DISC uses the logic of the DSM–IV, it also provides an impairment score. For several reasons, the findings presented in this Bulletin are based on diagnostic criteria only and do not consider the level of impairment.⁶

Although its assessment of disorder criteria is straightforward, the self-administered nature of the Voice DISC relies on a youth’s awareness of the social and personal consequences of his or her disorder to determine impairment. Because the social judgment of youth found guilty of delinquent or criminal behavior may be particularly poor, the Voice DISC may substantially underreport the level of impairment in these youth. A clinician considering impairment for the purpose of making a diagnosis should rely on multiple informants and various pieces of information to determine the level of impairment.

Comparison With Other Studies

As shown in table 5, the rates of disorder found in the present study are somewhat lower than those reported by previous studies that used the DISC in juvenile justice populations. However, the earlier studies used earlier versions of the DISC. Consideration of four basic differences in instrumentation and sample characteristics between the present study and the previous investigations puts the differences in the results into context:

• Participants in the present study responded to questions about the month preceding the interview, a period considerably shorter than the 6-month reporting timeframe of most of the earlier studies. In some cases, the rates of disorder found in the present study were correspondingly somewhat lower than those found in the studies that used a longer timeframe (Atkins, Pumariega, and Rogers, 1999; Duclos et al., 1998; Randall et al., 1999; Garland et al., 2001; Teplin et al., 2002).
  
  
• The present study evaluated youth who recently had been sent to secure placement (likely after they had spent weeks in juvenile detention). The youth assessed by Teplin and colleagues (2002) were being held in detention—that is, they recently had been in the community, where they had the opportunity to offend. Garland and colleagues (2001) assessed “wards of the court” without regard to whether they were in the community or in custody. By intent, secure placement limits misbehavior. The more structured and controlled the setting, the less opportunity youth have to engage in the behaviors characteristic of conduct and substance use disorders. Therefore, rates for those disorders might be expected to be lower for the youth in the present study than for the youth evaluated in the earlier studies.
  
  
• The present study relied exclusively on self-report, whereas Garland and colleagues (2001) pooled diagnostic information received from parents as well as youth, a procedure that results in increased prevalence rates (Bird, Gould, and Staghezza-Jaramillo, 1992). Parental informants are more likely than youth to report symptoms of disruptive behavior disorders such as attention deficit/hyperactivity disorder (ADHD) and conduct disorder (Jensen et al., 1999), and this may account for the variability in the reported rates of disorder across the studies.
  
  
• Because many youth entering secure care will recently have been removed from their homes, their endorsement of separation anxiety symptoms may not reflect enduring disorder. Therefore, in contrast to the earlier studies, the present investigation did not inquire about separation anxiety disorder. This decision may have caused the rates for overall anxiety disorders observed in the present study to be somewhat lower than those in the earlier studies.

The rate of suicide attempts in the past month (2.7 percent) reported by youth in the present study is comparable to the rate of suicide attempts by youth in the past month that was reported by facilities in the Conditions of Confinement study (2.5 percent) (Parent et al., 1994), lending further support to the validity of the Voice DISC assessment.

Although the prevalence of conduct disorder in the study sample was high (31.7 percent), the prevalence rates for other disruptive behavior disorders—ADHD (2.3 percent) and oppositional defiant disorder (2.8 percent)—were lower than might be anticipated. In clinical samples, as many as 75–90 percent of children with conduct disorder have also been found to have ADHD (Abikoff and Klein, 1992). Other studies have reported a link between the impulsivity of ADHD and delinquency (Mannuzza et al., 1993; Masse and Tremblay, 1997; McGee, Williams, and Feehan, 1992; Tremblay et al., 1994).

The rates of self-reported ADHD in other studies of juvenile justice populations that used the DISC are similarly low—between 1 and 7 percent (Atkins, Pumariega, and Rogers, 1999; Randall et al., 1999; Teplin et al., 2002). In the study done by Garland and colleagues (2001), who combined information from parental and youth reports, almost 13 percent of the youth received a diagnosis of ADHD, but this rate is still lower than expected. However, the rates of mood and anxiety disorders are high in the present study (9.1 percent and 18.9 percent, respectively) and across all five of the other DISC studies in juvenile justice populations (10–35 percent). Zoccolillo (1992) noted a high rate of comorbidity between mood and anxiety disorders and conduct problems in community samples of youth. Further, studies that used the DISC–2.3 to assess clinic-referred children found associations between anxiety symptoms (“trait anxiety”) and both conduct problems and aggression (Frick et al., 1999) and between mania and conduct disorder (Biederman et al., 1999).

Although a determination of juvenile delinquency is not synonymous with a diagnosis of a disruptive disorder, the results of the present study and the existing research indicate systematic underreporting of ADHD symptoms by youth in the justice system. This suggests that self-reported information should be supplemented by reports from another informant (e.g., a parent or teacher), especially as parents’ reports are more consistent with other indicators of conduct disorder, such as school suspension and police contacts, than youth’s reports (Loeber et al., 1991).⁷

Assessing the Mental Health Status of Youth in Juvenile Justice Settings	OJJDP Bulletin • August 2004