Letter

To the Editor: As I was reading the report by Karnik and colleagues ( 1 ) in the June issue, I was surprised by the authors' surprise at finding that the incidence of psychiatric disorders among "delinquents" was high after nine months of incarceration. I too was "incarcerated" from the 1960s to the 1980s as a consultant in settings for youths who were called delinquents, despite efforts by many of us to change that term. I consulted to the California Youth Authority Parole Board, the Los Angeles County Probation Department, and the Camarillo School for Girls, where adolescents who had been charged with everything from murder to so-called status offenses were placed in various levels of care. Most were high functioning and had serious undiagnosed and untreated psychiatric illnesses. Depression, trauma, impulsivity, and somatic complaints were the norm. No psychiatric diagnoses were acknowledged. I was told by colleagues that "children don't get depressed."

My unscientific conclusion was that six to nine months was a critical time in a process. Before this time the effective interventions were structure and what is now called mentalization, and the outcomes were behavioral containment and diminished acting out. But when incarceration went beyond nine months, useful attachment began and with that, treatment. In fact, when attachment appeared, treatment became routine, whereas earlier attempts were usually explosive.

I recall a well-run and caring residential treatment facility where I cautioned the staff about fostering attachment unless the child could stay beyond six to nine months. Eerily, when they fostered attachment and had to terminate treatment before that critical point, girls often came back with gangs to steal or destroy property. Later when I found that the process of treatment and change with equally impaired youngsters was very different in nonresidential settings, I came to believe that the process and timing of treatment differ markedly depending on whether the door is open or closed. By this I mean that it is not only a matter of whether young patients can come and go—because the structure of the treatment setting should keep them engaged during treatment hours—but also a matter of whether some of their home and street routines are accessible and maintained.

Dr. Scott is affiliated with the Department of Psychiatry, Harvard Medical School, Cambridge, Massachusetts.