A study of neurodevelopmental findings in early adolescent delinquents

JOURNAL OF ADOLESCENT HEALTH CARE 3:151-159, 1982

A Study of Neurodevelopmental Findings in Early Adolescent Delinquents WALT M. KARNISKI, M . D . , MELVIN D. LEVINE, M . D . , F . A . A . P . , S I M O N CLARKE, M . D . , F . C . P . ( S . A . ) , JUDITH S. PALFREY, M . D . , F . A . A . P . , A N D LYNN J. MELTZER, P h . D .

Subtle deficits or delays in the development of the central nervous system in young children are associated with problems affecting learning, behavior, and social adjustment. Less is known about the impact of such neurodevelopmental dysfunction in adolescents. This study assesses the possible association between neurodevelopmental delays and juvenile delinquency. An adolescent neurodevelopment examination was devised and administered to 54 delinquents and 51 secondary school students. Six areas were assessed. There were no significant differences in the prevalence of minor neurologic signs (P = 0.37) or in gross motor function (P = 0.02) and temporal sequential organization (P = 0.04). The greatest differences were in visual processing (P = 0.0002) and auditory-language function (P = 0.0001). Eighteen percent of delinquents and 4% of the comparison group were deficient in two or more neurodevelopmental areas. Nine percent of the delinquents and none of the comparison group had three or more dysfunctions. A neurodevelopmental examination may be a useful diagnostic tool for identifying endogenous factors in behavior, learning, and adjustment problems of this age group. Such findings have implications for the formulation of individualized management strategies.

From The Children's Hospital Medical Center, Boston, Massachusetts. This study was supported by grant #780-0243 from The Ford Foundation, New York, New York, and was presented, in part, at the annual meeting of the Society for Pediatric Research, San Francisco, California in April, 1981. Requests for reprints should be addressed to: Melvin D. Levine, M.D., Division of Ambulatory Pediatrics, The Children's Hospital Medical Center, 300 Longwood Avenue, Boston, Massachusetts 02115. Manuscript accepted April 25, 1982.

KEY WORDS:

Juvenile delinquency Learning disabilities Neurodevelopmental examination In a single year, an estimated one million American youths below the age of 18 years appear before juvenile courts (1). For many, this is part of a long history of crime and social failure. The ultimate goal of professionals working with juvenile delinquents is to break this self-perpetuating cycle. A number of studies have suggested associations between delinquency and a complex cluster of developmental, emotional, socioeconomic, and health factors (2-7). Although these characteristics have been important epidemiologically, a more detailed exploration of specific traits is needed to further understand the progress and pattern of events in individual cases. Considerable controversy exists regarding the apparent association between learning disabilities and delinquency (8,9). After an extensive review of the literature, one investigator concluded that "the existence of a causal relationship between learning disabilities and delinquency has not been established" (8). On the other hand, a number of researchers have demonstrated evidence of delays in isolated areas of cognitive development in juvenile delinquents. Hurwitz et al. (10) found that the delinquents in their study "had specific difficulties in tasks demanding the sequential ordering of sensori-motor and verbal elements." They reported that deficits in delinquent boys were more likely to be manifested "in tasks of temporal sequencing than in tasks of perceptual restructuring."

© Society for Adolescent Medicine, 1982 Published by Elsevier Science Publishing Co., Inc., 52 Vanderbilt Ave., New York, NY 10017

151 0197-0070/82/030151 +09502.75

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Berman and Siegal (11) compared 45 adolescents in a juvenile residential correctional facility to 45 nondelinquent inner-city adolescents. They found that the delinquent sample was not retarded in "motor skills, attention abilites, or gross motor functioning, but did show delays in verbal, perceptual, and non-verbal conceptual spheres." In an uncontrolled study, Zinkus and Gottlieb (12) examined 44 delinquent boys and found performance in reading, spelling, and arithmetic to be below grade level. They judged 60% of the group to have significant deficits in auditory-sequential memory, and 55% with deficient visual-motor coordination. Tarnopal (13) found a substantial number of 102 delinquents with weaknesses in visual-motor integration and motor coordination. All subjects came from a nonwhite ghetto population, and no controls were used. Other perspectives have been explored. Pontius has proposed frontal lobe dysfunction due to a developmental delay as the basis for some forms of delinquency (14,15). Other investigators have suggested that delinquents display processing difficulties in auditory perception and language development. Some studies have used intelligence subtests to examine differences in cognitive function (16,17). The discrepancy between verbal and performance scores has, in the past, been used by some as a hallmark of learning disability (18), and this has been explored in delinquents (19). However, close analysis of intelligence tests shows that such a simplistic interpretation may not be valid (20,21). Thus, the literature seems to implicate several isolated areas of delayed development as part of the clinical picture in juvenile delinquents, but overall results have been inconsistent. These findings may suggest a need for examining clusters of deficits, as opposed to single areas of difficulty in a delinquent population. This study was designed, therefore, to assess in depth the prevalence of single and multiple areas of developmental dysfunctions in a group of delinquent adolescents.

Methods A group of 54 delinquent youths, newly committed to the Massachusetts Department of Youth Services, were selected randomly for study. The comparison group was recruited by three random mailings to parents of students ages 12-16.5 years in two junior high schools and one high school in Watertown,

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Massachusetts, a predominantly blue-collar community in the Boston metropolitan area. Approximately 30% of the families contacted agreed to be studied. Both groups were limited to nonbilingual, white males between the ages of 12 and 16.5 years. The delinquent range was from 12 years 1 month to 16 years 9 months and the comparison group from 12 years 11 months to 16 years 2 months. There were no delinquent youngsters in the comparison group. Informed consent was obtained from the adolescents and their parents, as well as the Department of Youth Services. Items for the neurodevelopmental examination were compiled from a careful search of the developmental, psychological, and medical literature. Test items were selected to assess six specific areas:

1. Neuromaturation: the presence of traditional minor neurologic signs, or "soft signs," such as synkinesias (mirror movements) or associated movements present in the younger, normal child, which usually disappear by 8-10 years of age; 2. Gross Motor Function: the ability to use the larger muscles of the body for balance and coordination; 3. Fine Motor Function: the planning and output of movements of the fingers and hands; 4. Temporal-Sequential Organization: the ability to process information in a sequence and to utilize that sequence. 5. Visual Processing: the interpretation, storage, and retreival of visually presented simuli; and 6. Auditory-Language Function: the ability to receive verbal information and to express oneself with words. Items traditionally employed in the assessment of younger children were modified to be more applicable to the early adolescent age group. The test battery required approximately 50 minutes to administer. Table 1 includes a description of the developmental tasks. Composite ratings were determined for each of the six neurodevelopmental areas. Pediatricians were trained and supervised in administering the examination. Interobserver reliability was assessed on specific items and found to be in the acceptable range. Scoring criteria were based on standards previously published or, when unavailable, were determined by an analysis of a frequency distribution of the performances of all of the adolescents as a group, without regard to whether or not they were delinquent. Items were scored on a 0 to 10 scale, with 0 indicating the worst possible performance. Some items were weighted more heavily

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T a b l e 1. T h e A d o l e s c e n t N e u r o d e v e l o p m e n t E x a m i n a t i o n Item ,7

Task and observations t' NEUROMATURAT1ON

1. Synkinesia (22,23)

Observation of synkinesias (mirror-movements) was made on the examination, specifically: Rapid Alternating Movements Movements-Doorknob (#11), Sequential Finger Opposition (#21). (See each item below for complete description of the

different tasks throughout (#10), Rapid Alternating (#13), Fist-Edge-Palm task.)

2. Associated movements (22,23)

Observations of associated movements (rhythmic movements of the tongue, lips or mouth) were made on the following items: Rapid Alternating Movements (#10), Rapid Alternating Movements-Doorknob (#11), Sequential Finger Opposition (#13), Nuts on Spindles (#15), Fist-Edge-Palm (#21).

3. Motor, Stance (22,25-27)

The adolescent stood with feet together, arms outstretched parallel with the floor, fingers outstretched, mouth open, tongue protruded and eyes closed. Observations were made for spooning of the fingers, downward drift, and choreiform movements of fingers or tongue.

4. Finger agnosia (22,24,29)

With the adolescent's eyes closed find both tiands on his thighs, the examiner touched one or two fingers and asked him to raise the respective finger(s) of the opposite hand.

5. Finger agnosia (22,24,29)

As a second test of finger agn.osia, the Sequential Finger Opposition Test (#13) was used. GROSS MOTOR FUNCTION

6. Balancing on tiptoes (24)

The adolescent balanced on tiptoes of each foot separately, for as long as possible.

7. Balancing vertical rod (24)

The adolescerit balanced an 18-in. wooden rod on the index finger of each hand, as long as possible.

8. Jump, clap, land on toes (24)

The adolescent jumped into the air, clapped three times, and landed on his toes.

9. Tapping with feet and fingers (24)

The adolescent tapped feet in right-left rhythm, and tapped the table with both fingers simultaneously with the tapping of his right foot 0nly. He was judged on the basis of speed, rhythm, and coordination. FINE MOTOR FUNCTION

10. Rapid alternating movements (22)

In a sitting position, with both hands on thighs, the adolescent slapped his thighs, first with palms, then with the dorsum of the hand, in alternating fashion, with each hand separately. Assessments of rhythm and speed were made.

11. Rapid alternating movements (doorknob)

In a standing position, with one arm flexed 90° at the elbow, the adolescent twisted his hands, as if twisting a doorknob, to assess overall coordination.

12. Finger agnosia (22,28)

On the Finger Agnosia Test (see #4), overflow and coordination were assessed and differentiated from finger agnosia.

13. Sequential finger opposition (22,29)

The adolescent imitated the movements of the examiner. He touched his thumb to his other fingers in an alternating sequence, and was judged for speed, number correct, and hesitancy.

14. Open-close hands (24)

To assess rhythm and coordination, the adolescent imitated a complicated maneuver. One hand ~vas closed in a fist while the other was pointing to it. He had to close the open hand while pronating the arm, and open the closed hand while supinating the other arm.

15. Nuts on spindles

The adolescent placed nuts on spindles using both hands, as fast as possible, to assess speed, coordination, smoothness and rhythm. TEMPORAL-SEQUENTIALORGANIZATION

16. Experiential Sequences

The adolescent was asked to name th~ months of the year, the days of the week backward, and the seasons of the year in the proper order.

17. Forward digit span (30)

The adolescent was asked to repeat a sequence of digits in proper order.

18. Reverse digit span

The adolescent was asked to repeat a sequence of digits in reverse order.

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Table 1.~ (Continued) Item

Task and observations

19. Imitative square tapping

The adolescent was shown a page with 6 squares on it and asked to imitate a sequence of taps of increasing difficulty on the squares in the proper order.

20. Motor sequencing (22,29)

Two tasks of motor sequencing were used. The first was #13, Sequential Finger Opposition, described above.

21. Motor sequencing (fistedge-palm)

The adolescefit was asked to imitate a complicated hand maneuver in the proper sequence. VISUAL PROCESSING

22. Geometric form copy (31)

The adolescent was given a page with 5 geometric forms to copy. He was to copy these on another page without erasing. Each drawing was scored using standardized criteria.

23. Paths (24)

The adolescent traversed a "path" with a pencil as fast as possible without hitting the side walls (approximately 0.2 cm. apart) for each hand.

24. Design extrapolation

The adolescent continued a rhythmic design with a pencil across a page and was judged on horizontal alignment, spacing and quality of design. AUDITORY-LANGUAGE

25. Sentence repetition

The adolescent repeated 6 sentences, word-for-word, to assess appreciation of verbal syntax.

26. Syntax comprehension

The adolescent responded to a question, following a sentence that was read to him.

27. Modified token test (32-34)

A form of the Token Test with 16 items was used. The adolescent performed manipulations with colored circles and squares. ("Place the red circle on the blue square.")

28. Verbal opposites (35)

The adolescent gave the opposites of a group of words of increasing difficulty.

29. Boston naming test (36)

The adolescent identified the names of pictured objects of increasing difficulty.

Composite scores

The items in each area were scored on a 1-to-10 scale, with higher scores indicating better performance. Six composite scores were computed by averaging all scores in each area.

~Reference numbers appear in parentheses. ~'Number in parentheses refers to item number in first column.

than others based on characteristics of the individual test items judged prior to the analysis of results. ~2_ Tests were applied to establish differences between the delinquent and comparison groups.

educated, and of lower occupational status. These differences were statistically significant, and were taken into account in the analysis of results.

Neurodevelopmental Findings Results

Sociodemographic Factors Fifty-four delinquent adolescents and 51 comparison adolescents were examined. Table 2 summarizes the sociodemographic characteristics of the two groups. The mean age of the delinquent adolescents was approximately 9 months greater than the comparison group. The proportion of single-parent families in the delinquent group was 74%, three times the prevalence in the comparison group. This represented primarily divorce in both groups. In addition, the delinquents' parents tended to be younger, less

The mean performances of the two groups on the neurodevelopment battery are compared in Table 3. On each test, the delinquent adolescents performed less well than the comparison group. Significant differences were not seen in neuromaturation (minor neurologic signs) or in gross motor function. However, the comparison group demonstrated significantly better fine motor function (P < 0.02) temporal-sequential organization (P < 0.04), visual processing, and auditory-language function with the latter two areas showing a high level of statistical significance. An attempt was made to ascertain the percentage

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NEURODEVELOPMENT IN ADOLESCENT DELINQUENTS

Table 3. Composite Ratings of Each Component of the Neurodevelopmental Battery

T a b l e 2. S o c i o d e m o g r a p h i c C h a r a c t e r i s t i c s o f t h e Delinquent and Comparison Populations Delinquent

Comparison

(n = 53) ~

(n = 51)

15.1

14.3 ~'

73.6

26.0 l'

10.0

12.7'

10.2

11.8 v

42.8

45.9 C

40.1

44.0 '~

M E A N ADOLESCENT AGE (years) SINGLE-PARENT FAMILIES

(%) FATHER'S EDUCATION (average grade) MOTHER'S EDUCATION (average grade) EATHER'S AGE (years) MOTHER'S AGE (years) OCCUPATION Professional, whitecollar Skilled, semiskilled Unskilled U n e m p l o y e d , in jail Unknown Homemaker

15S

FATHER (%)

MOTHER (%)

FATHER (%)

MOTHER (go)

18

11

218

37

47 5 11 19 0

41 0 0 7 42

44 0 0 8 0

12 0 0 4 47

aOne m o t h e r w h o gave consent to have her adolescent evaluated preferred not to be interviewed. bp < 0.001 cp < C.05 up < 0.01

of adolescents who had severe problems in each area. The mean scores of the comparison group were used as a reference norm for each area. Any adolescent scoring more than two standard deviations below this cutoff was considered severely delayed in that area. Using this strategy, the percentage of adolescents in each group meeting criteria for developmental delay was determined. Table 4 shows that in all six neurodevelopment areas the delinquent adolescents were more likely to exhibit delavs. Using the )(2 test Qf significance, these prevalences were significant only for visual p.rocessing and auditory !anguage function. Of the delinquent group, 22% were found to be delayed in visual processing compared with only 4~ of the comparison population (X2 = 12.83, P - 0.0003). The probability of obtaining differences in favor of one group in all six neurodevelopment areas by chance alone can be calculated by a binomial test (37,38). Such a pattern corresponds to a probability value of 0 - 0.016 (P - (½)~where n = the number of separate areas of comparison employed) indicating that the trend of consistently poorer perfor-

C o m p o n e n t of the neurodevelopment battery Neuromaturation Gross m o t o r function Fine m o t o r function Temporal-sequential organization Visual processing Auditory-language function

Sc°rea Delinquent (n = 54)

Comparison (n = 51)

7.50 5.65 7.35 6.75

7.55 5.90 7.90 7.45

_+ _+ _+ +_

1.39 2.24 L50 2.27

6.80 -+ 1.52 6.55 +- 1.3i

-+ _+ +_ +_

1.25 1.88 1.3& 1.91

7.60 +_ 1.11" 7.65 _+ 0.78 ~

°Mean scores were c o m p u t e d on a ten-p0int scale (10 = best possible performance to 0 = worst), vaIues given as m e a n - SD. l,p = 0.02. cp = 0.002. dp = 0.001.

mance in the delinquent group is not likely to occur by chance alone. In order to determine whether certain adolescents had multiple areas of delay, the number of delays for each adolescent was counted. Eighty-six percent of the comparison group showed n o area of deficit compared with 54% of the delinquent adolescents. Twenty-eight percent Of the delinquents and 10% of the comparison sample were delayed in a single area. Eighteen percent of the delinquents were delayed in two or more areas compared with only 4% of the comparison g r o u p (X2 = 13.35, P = 0.001). No ad 2 olescent in the comparison group had more than two areas Of delay, but 9°7o of the delinquent group were delayed in three or more areas. Therefore, the prevalence of multiple areas of delay was highest in the detinquentpopulation.

T a b l e 4. P e r c e n t a g e o f A d o l e s c e n t s S e v e r e l y D e l a y e d ~ Neurode~eelopment battery

Delinquent i' (n = 54)

Comparison ~' (n = 51)

Neuromaturation Gross m o t o r function Fine m o t o r function Temporal-sequential organization Visual processing Aud.itory-!anguage

7.4 1.9 9.3 9.3

5.9 0.0 2.0 3.9

21.6 29.6

3.9 c 2.0 a

"Determined by scores more than 2 SD below the mean. VGiven a s percent. cdf = 1; )(2 = 4.79; P = 0.03. ddf = 1; )(2 = 12.83; P = 0.0003.

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KARNISKIET AL.

Adjustment

for S o c i o e c o n o m i c

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Variables

T w o separate m e t h o d s w e r e used to measure the effects of socioeconomic status (SES). The first comp a r e d the p e r f o r m a n c e s of two subgroups m a t c h e d for several SES variables. Four variables were used: m o t h e r ' s and father's occupations and education. Occupations w e r e rated o n the scale devised by Hollingshead (39), a n d levels of education were placed on a similar scale. The four variables were combined to d e t e r m i n e an average SES rating for each family. Sixteen adolescents of the d e l i n q u e n t group were m a t c h e d w i t h 16 of the c o m p a r i s o n y o u t h with identical SES ratings. These two subgroups were comp a r e d on their n e u r o d e v e l o p m e n t examination performance. These findings are p r e s e n t e d in Table 5. The result of this analysis was similar to that based o n the entire sample. In all d e v e l o p m e n t a l areas except n e u r o m a t u r a t i o n , the c o m p a r i s o n group perf o r m e d better t h a n the delinquents. The deficiencies in fine m o t o r function (P = 0.045) and a u d i t o r y language function (P = 0.02) remained statistically significant. The second m e t h o d adjusted for SES differences by a series of regression analvses using all of the adolescents in b o t h groups. Six SES variables (father's-and m o t h e r ' s ages, education, and occupations) w e r e first e n t e r e d into the analysis separately. The differences between the two groups were tested after adjusting for these SES b a c k g r o u n d variables. Corrected significance v a l u e s are s h o w n in Table 6. It can be seen that a u d i t o r y - l a n g u a g e function in the d e l i n q u e n t g r o u p remains significantly delayed in r e f e r e n c e to the comparison group. H o w e v e r , SES variables s e e m e d to influence Other previous!y n o t e d deficiencies. The results of these two separate analyses of the effects of SES factors are generally consistent with results p r e s e n t e d earlier: the delinquent group perf o r m e d less well t h a n the comparison g r o u p on these tests of n e u r o d e v e l o p m e n t function.

Discussion The results of this s t u d y suggest that a substantial s u b g r o u p of adolescents c o m m i t t e d for delinquent b e h a v i o r manifests deficiencies in various areas of neurologic d e v e l o p m e n t . Ifi the current sample, 45% of the delinquents had at least one area of develo p m e n t a l lag, a n d 20% h a d ~Inultip!e dysfunctionsl In view of these findings, it is reasonable to consider the n a t u r e of the association b e t w e e n such observed d e v e l o p m e n t a l lags and delinquency. It is t e m p t i n g to h y p o t h e s i z e an etiological link

Table 5. Composite Ratings on the NeurodevelopmentaI Examination Comparison of Groups Matched for Socioeconomic Status

Scoresa Neurodevelopment battery

Delinquent (n = 16)

Comparison

Neuromaturation Gross motor function Fine motor function Temporal-sequential or:ganization Visual~ processing Auditory-language function

7.70 -4- 1.35 5.55 + 2.00 7.35 _+ 1.60 7.05 -4- 2.10

7.70 _+ 1.30 5.65 -+ 1.90 8.25 _+ 1.15# 7.85 + 1.60

7.20 _+ 1.60 6.85 + 1.20

7.65 _+ 1.10 7.80 _ 0.90"

(n = 16)

~Mean scores were based on a ten-point scale (10 = best possible performance and 0 = worst); values given as mean -4SD. .~P .= 0.045. cp = 0.009.

b.etween subtle d e v e l o p m e n t a l disabilities and delinquent behavior, invoking l o n g - t e r m academic struggles, continuing frustration in school, chronic inability to please adults, persistent success deprivation, c o n s e q u e n t loss of self-esteem, and ultimately, crime as a form of protest, a quest fo i peer adulation, or end-state alienation. To begin with, such children with u n d e r l y i n g d e v e l o p m e n t a l dysfunctions m a y be mislabeled early in life as unintelligent or as not m e a s u r i n g Up to potential. T h e y t e n d to receive too m u c h criticism and too little service. This hypothetical m o d e l is neither confirmed n o r r e f u t e d b y our data, for in this age g r o u p it is also possible to argue fhat developmental delays may result from failure rathei: than Cause it. Delinquent y o u n g s t e r s are apt ~to be less conscientious about

Table 6. Significance Values Corrected for

Socioeconomic Status ~,for the Developmental Assessment Neurodevelopment battery

Uncorrected P value

P value corrected for SES"

Neuromaturation Gross motor function Fine motor function Temporal-sequential organization Visual processing

NS NS 0.02 0.04

NS NS NS NS

Auditory-language

0.001

0.002

F P F P

= = = =

2.89 0.10 5.86 0.02

NS = Not significant. ~Correction for mother!s and father's age, education, and occupations using regression analysis.

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NEURODEVELOPMENTIN ADOLESCENTDELINQUENTS

school; they are also prone to have a higher dropout rate. Their disinterest in learning may be but one escape route in the context of a broader retreat from conventional adult expectation. Moreover, it is likely that a youngster who has seceded from academic endeavors will display developmental delays when compared with peers of the same age. For example, in the present study, language deficiencies were most prominent in the delinquent group. One might argue that children who consistently read and write are likely to develop better language skills including improved understanding of syntax, expanded vocabulary, and enhanced fluency. Thus, w h e n given a developmental language test, delinquents may show lags secondary to their abstinence from the written word. Any study of behavior or development is made more complex by a myriad of confounding variables. In this study, the sociodemographic differences between the two groups of adolescents warrant special comment. The delinquent youths were slightly older than the comparison group. Developmental tools are usually designed so that as the child matures, performance improves. Thus, differences between the two groups studied could have been diminished by the presence of the older delinquent cohort. The delinquent youths tended to come from single-parent families three times as often as the comparison group. In most cases, the delinquents were living with their natural mothers, and often with a step-father. This accounts for the high frequency (19%) with which the father's occupation was listed as unknown. Furthermore, 7% of the delinquents' fathers were in jail at the time of evaluation. Many more had spent time in jail at one time or another. One adolescent had witnessed the murder of his mother at age 3 years. Two adolescents claimed they had been raped, one by his father. Is it possible to control for all these differences? A subgroup of adolescents matched for socioeconomic status demonstrated a pattern of poorer performance in the delinquent group consistent with the larger, unmatched sample. But questions of matching remain. It is likely that there are multiple pathogenic pathways leading to delinquent behavior in adolescence. These include the synergistic interaction of developmental dysfunctions and environmental stresses and deprivations. In our study, a multiple risk picture prevailed in the delinquent group. The study of developmental dysfunction in adolescents is hampered by a relative paucity of evaluation tools. Neurodevelopment examinations have

157

been used to assess infants, preschool children, and elementary age students. Their application in adolescence is nearly nonexistent. For this reason, most studies focus on overall intelligence or academic achievement without systematically assessing individual areas of development. Because of a relative lack of normative data for this age group, the present study included a comparison sample selected from the same geographic region. It is likely, however, that some volunteer effects occurred within the comparison group. Because it was not possible to require a random sample of youngsters to undergo the neurodevelopment examination, parents (who were randomly selected) had to agree for their children to participate. It is likely that within a volunteer group there may be a higher prevalence of concerns and, therefore, of developmental dysfunctions than would have been encountered in a nonvolunteer sample. This might skew the comparison group's performance downward, thereby diminishing the apparent prevalence of developmental dysfunctions in the delinquent sample as criteria for the latter were derived from comparison group performance. One also might encounter volunteer parents who participate in order to "display" the many strengths of their children. The causal role of neurodevelopmental delays in delinquency requires further study. Longitudinal investigations of youngsters with learning problems may help isolate those at particular risk for antisocial behavior during adolescence. Studies of the early childhood histories of delinquent youth may help to distinguish causes from effects and shed some light on which came first (i.e., the learning problems or antisocial behaviors). We are currently engaged in this type of analysis on our sample.

Implications Although precise mechanisms remain to be elucidated, there appears to be a portion of early adolescent delinquents whose developmental struggles may have made them more vulnerable to the stresses of social disadvantage or, alternatively, whose environmental problems aggravate neurodevelopmental delays. Clinically, therefore, it may be important to identify this subgroup. We believe that intake evaluations before or after commitment should include a careful assessment of developmental strengths and weaknesses. The latter may constitute critical features of a delinquent's current plight, regardless of whether they are the cause or the result of their maladaptive behavior. Those youngsters whose cur-

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rent assessment suggests severe developmental disadvantage might benefit from enhanced special education services, individualized vocational training, and counseling to help them gain insight into their own deficits, strengths, and learning styles. They may need a better understanding of the sources of their present feelings of inadequacy. Moreover, in planning a rehabilitation program, it may be useful to seize upon the strengths of a delinquent youth in order to prescribe potentially successful experiences that are socially acceptable. It is possible that an enhanced understanding of the developmental dysfunction of delinquent youngsters might contribute to prevention by helping identify early risk factors. In particular, failing children in failing families may require specialized education and counseling to reverse their spirals of failure. It is likely that such preventive intervention would have to occur on several fronts through active collaboration of the physician, school, and appropriate mental health consultants. The authors acknowledge the collaborative efforts of Margaret Tomaselli, Edward Maroney, Terrence Tivnan, Laurie Racine, Jack Calhoun, and Carey Halsey. Invaluable assistance was granted by the Massachusetts Department of Youth Services and the adolescents involved in the study.

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