JUVENILE VIOLENCE

FORENSIC PSYCHIATRY

0193-953X/99 $8.00

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JUVENILE VIOLENCE Charles L. Scott, MD

The peak in juvenile crime during the early 1990s combined with media attention to “kids who kill” has heightened concerns regarding violent youth. Juveniles account for nearly one of every five persons arrested for a violent crime.7Responding to the mantra, “If you do the crime you do the time,” many state legislatures have lowered the age for transferring juveniles to adult court. Mental health professionals provide valuable input regarding the assessment of aggressive youth. An understanding of risk factors and current treatment approaches will assist the clinician in the evaluation and disposition recommendations of violent juveniles. RISK FACTORS FOR JUVENILE VIOLENCE

Demographics

Certain demographic factors are associated with increased rates of violence among juveniles. Male juveniles are arrested for violent offenses six times more often than are female juveniles.55After age 13 years, the rate of homicide increases sharply during each year of adolescence until age On the surface, race also seems to be associated with increased juvenile violence. The rate of violent-crime arrests for black youths is approximately five times the rate for whitesz6; however, these racial differences have been linked to difficult living conditions and lower socioeconomic status rather than race alone.

From the Division of Forensic Psychiatry, University of California, Davis, Sacramento, California

THE PSYCHIATRIC CLINICS OF NORTH AMERICA VOLUME 22 * NUMBER 1 * MARCH 1999

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Personal and Family History of Violence

As with adults, one of the most important factors in determining a juvenile’s risk for future violence is the past history of violence. Juvenile offenders characteristically exhibit a variety of law-violating behaviors rather than repeating one particular illegal act. This pattern has been described as one of “diversification not spe~ialization.”~~ The actual number of unlawful acts is more predictive of future criminal behavior than the specific acts committed in the Chronic offenders (juveniles who have had more than five police contacts) represent less than 20% of all juvenile offenders but commit more than half of all offenses.74Even more disturbing is the fact that more than 80% of the most frequent and serious juvenile offenders have no official police record.= Therefore, in addition to being asked about police contacts, juveniles being evaluated should be asked, “What illegal acts have you gotten away with?” The greater the number of illegal acts, the higher the likelihood the youth will eventually commit a violent act. Finally, the age of the first violent act helps determine the risk for violent crimes in adulthood. In the National Youth Survey, 45% of those youth who committed a serious violent offense before age 11 years continued to perform violent acts into their 20s.= The family history often provides useful information about the risk for juvenile violence. Children with aggressive parents are more likely to be violent in adolescence and young adulthood.25Witnessing adults using knives or guns against each other doubles the risk for children to become serious violent offender^.^^ Children whose fathers have been incarcerated and those who are victims of abuse or neglect also have an increased risk for committing a violent crime.13,73 Carrying of Weapons

Juveniles are carrying weapons at an alarming rate. In a national survey, one in five high school students reported that they had carried a weapon during the previous month; males carry weapons at a rate four times that of females. Knives and razors are the most common weapons carried by youth; the exception is black males who more often carry firearms.I4Among inner-city high school students, approximately one in three males and one in ten females carries a gun on the streets.66 The carrying of guns, with their lethality, has resulted in a tripling Most youth of gun homicides by juveniles during the past 15 initially carry a gun for protection. More than half of incarcerated youth have been stabbed, and 80% have been threatened or shot with a gun. Many have developed a belief system legitimizing the use of firearms. For example, nearly one third of incarcerated juveniles agreed with the statement, ”It is okay to shoot a person if that is what it takes to get something you want.”67 Most juveniles acquire their guns before age 15 years. Many obtain

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their first gun passively from a relative or peer. Youths who purposefully obtain their first firearm carry their guns more frequently than do passive recipients. Firearms are easily purchased on the streets, particularly from drug dealers. Other sources include stealing, borrowing, trading, buying from a pawn shop, and access to a ”community gun” (a hidden gun used by various people).2 Juveniles most frequently carry firearms in unknown areas and to clubs where they anticipate confrontation with peers.67Unfortunately, juveniles also bring their weapons (including guns) into the classroom. Approximately 1 in 10 high school students carries a weapon into school each month.I5 Factors associated with middle school students bringing weapons to school include being male, living with only one parent or having a distant relationship with parents, a history of destroying school property, alcohol abuse, and believing that other students bring weapons to scho01.~Consider the following questions when evaluating a juvenile’s weapon use: What weapons has the youth obtained or used over his lifetime? How old was the youth when the weapon was first acquired? How did the youth first obtain the weapon (active versus passive)? Has the youth been threatened with a weapon? Why does the youth carry a weapon, and under what circumstances would it be used? Where does the youth take the weapon? Does the youth share the weapon? Does the youth have knowledge of other students carrying weapons into school? Does the youth have family members who own a weapon?

Participation in Gangs A gang is defined as three or more individuals with an identified leadership. The members, or ”gangbangers,” have recurrent interaction with each other, claim a particular territory, use various symbols, and engage in violent behavior. As many as one third of urban youth join gangs.3 Gang members are typically males between the ages of 12 and 24 years. Males are involved in gangs at a younger age and are arrested for gang-related crimes nine times more frequently than are females; however, female gang violence is increasing.I6 During the past 20 years, gang activity has extended past the inner city of large metropolitan areas into smaller communities and suburbs. Approximately half of gang-related crime involves homicide or violence. Juveniles belonging to gangs are involved in more violent behavior than are those who are not. The violence associated with gangs is most commonly related to disputes over territory or competition for status between gangs.69Four major youth gangs include the Crips, Bloods,

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Folk Nation (aka Hoovers, Black Gangsta Disciples, and Shorty Folks) and People Nation (aka Vice Lords, P Stone Rangers, and Latin Kings).% The three Rs of gang culture are (1)reputation, (2) respect, and (3) retaliatiodrevenge. A gang member’s personal reputation includes the reputation of his or her entire gang. A youth may exaggerate his or her activities within the gang to achieve higher status, impress others, and acquire respect. The more power the youth has within the group, the more ”juice” he or she has 0btained.5~ Obtaining respect often requires showing disrespect for rival gangs. This display of disrespect is referred to as “dis” or “dissing.“ A gang member may ”dis” a rival gang with hand signs, graffiti, or staring down. A gang member who fails to show disrespect may be severely beaten by his or her own gang. -Once a gang member feels he or she has been disrepected, then retaliation is required to maintain the status of the gang. Such retaliations include drive-by shootings and other violent strikes. Murder in response to a stare represents an extreme reaction for such minimal provocation; however, the gang member’s code often demands such acti0n.5~Because violent reactive behavior may be considered normal within the context of the gang, the clinician should use caution before labeling such responses as psychotic. Important information when assessing gang affiliation includes: What is the name and history of the gang? What attracted the youth to the gang? When did the youth first become involved in the gang? Are there other family members involved in the same or competing gangs? What is the main function of the gang (drug trafficking, turf protection, and theft)? What rules and rituals are associated with the gang (specific hand signs, colors, clothing, graffiti, slang, initiations, tattoos, and jewelry)? What various roles has the youth had in the gang? How does the youth show disrespect for rival gangs? Does the youth fear any reprisals if he or she attempts to leave the gang? What is the most violent gang activity that the youth has witnessed? What is the most violent gang activity that the youth has perpetrated? What type of weapons are used by this gang, and what role has this youth had in the use or carrying of such weapons? DSM-IV DIAGNOSIS AND JUVENILE VIOLENCE

The most common DSM-IV diagnosis in violent juveniles is conduct disorder. More than 80°/0 of incarcerated male and female juvenile of-

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fenders meet the criteria for conduct disorder.24Juveniles who have an earlier onset of conduct disorder and meet multiple criteria for this condition are involved in more serious and persistent juvenile delinquency? Attention deficit hyperactivity disorder (ADHD) is frequently found in juvenile delinquents. The core symptoms include problems with impulsivity, inattention, and hyperactivity. More than half of children with ADHD have been adjudicated delinquent by age 13 years.” Nearly half of juveniles with ADHD also have conduct di~order.~ Arrest rates of juveniles with ADHD range from 5 to 26 times higher than those without ADHD62;however, long-term follow-up studies of these children indicate that the additional presence of conduct disorder, not ADHD alone, predicts future criminality. Thus, children with ADHD without conduct disorder symptoms are not at increased risk for later ~riminality.~~ Approximately 25% of delinquent children meet the criteria for a In children, depression often presents with major depressive di~0rder.l~ irritability rather than depressed mood. Although most delinquents do not commit violent crimes because of depression, the identification and treatment of a mood disorder may reduce antisocial behavior in this group.54 Delinquent youth have often been exposed to repeated traumatic events. They have frequently witnessed the killing of friends or family members, seen violence in their neighborhoods, or personally experienced victimization. One study found that as many as 30% of incarcerated juveniles met the criteria for posttraumatic stress Children experiencing chronic high levels of community violence are more likely to show impaired social relationships’*and peer aggression3compared with youth exposed to a single violent event. Children exposed to repeated trauma sometimes develop an emotional numbing and have decreased reactions to subsequent traumatic events. The juveniles who have ”seen it all” may present with an ”I don’t care” attitude. They often exhibit little empathy for their victims. The contribution of alcohol or drug abuse or dependence to aggression is well recognized. Alcohol, LSD, PCP and stimulants are all associated with violent behavior.22,40, 76 According to the 1995 Monitoring the Future Study,38the use of alcohol, marijuana, hallucinogens, amphetamines, stimulants, and inhalants is increasing among high school students. More students now use LSD than they do cocaine or crack. Inhalants are also commonly abused. The practice of ”snorting,” ”sniffing,” ”huffing,” or “bagging” inhalants produces an intoxication similar to that produced by alcohol. Extreme inhalant intoxication has resulted in hallucinations and disruptive behavior.65 One third of all juveniles test positive for at least one drug at the time they enter d e t e n t i ~ nMore . ~ ~ than 40% of juvenile murderers acknowledged that they were under the influence of alcohol or drugs at the time of their offense.8Juveniles who sell drugs are more likely than are drug users to commit a violent offense. Juvenile drug dealers often

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carry concealed weapons, which increases their potential for more serious aggression.' The issue of neuropsychiatric contributions to juvenile violence remains controversial. Lewis' research4246notes that a significant number of violent youth suffer from psychomotor epilepsy, abnormal electroencephalograms, and soft neurologic signs. The frequency of such neurologic deficits has not been replicated by other examiners. Neurologic examinations of juvenile offenders conducted by McMannus et ar7,48 found that gross neurologic disorders were uncommon and soft neurologic signs were not associated with the severity of violent behavior. 45,46 has also described a frequent association between paranoid Lewis42,43, thinking, hallucinations, loose associations, and juvenile violence; however, the review by Cornell et all9 of juvenile homicide found that only 7% were psychotic.19 The study by Myer et a151 of 25 juvenile killers noted that although 71% had paranoid ideation, none met DSM-11-R criteria for a psychotic disorder. SEXUALLY VIOLENT JUVENILES

Approximately 20% of rapesz8and 30% of child sexual abuse casesz9 are committed by juveniles. Half of adult sexual offenders report that their first sexual offense was committed during adolescence.21Although a third of juvenile sexual offenders have a previous conviction for a nonsexual delinquent act, these youths rarely have a prior conviction for sexual assault. The typical profile of the sexually abusive youth is a 14-year-old white male adolescent who lives with both parents. The typical victim is a 7- or 8-year-old, unrelated girl who is sexually assaulted by coercion or force. The juvenile sexual offender frequently repeats the abuse on the same victim. Finally, juvenile offenders have an average of seven victims, with some offenders perpetrating sexual offenses against 30 or more victims.61 Deviant sexual fantasies are often the first step in the development of sexually abusive behavior. Such fantasies incorporate themes of aggression coupled with sexual activity. Feelings of power and mastery emerge as the youth puts the fantasy into action. Initially, the youth may act out these thoughts as sadistic behaviors toward animals or children.56 During the assault, perpetrators focus on their needs and devalue the victim. The sexually abusive behavior becomes associated with arousal and thus reinforced. To compensate for feelings of isolation, these youth begin to rationalize or minimize their behavior.61The outcome for violent juvenile sex offenders is grim. Male juveniles convicted of a sexual assault commit significantly more adult sexual and violent nonsexual offenses compared with juveniles with a history of violent but nonsexual offenses.6o Juvenile sexual homicide represents an extreme form of sexual violence. Sexual homicide has been defined as "murders with evidence or observations that indicate that the murder was sexual in nature."56 Sexual homicide has been divided into organized and disorganized

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subtypes. Characteristics of the organized subtype include social and sexual competence, good intelligence, a precipitating situational stress, and a controlled mood during the crime. The offense is often planned and targeted toward a stranger. Aggressive acts precede the death. In contrast, the disorganized sexual murderer is generally socially immature, sexually incompetent, and of average intelligence. The offense is usually spontaneous against a known victim. Sexual acts occur after the murder.56 In a study of juveniles convicted of sexual homicide, two thirds reported the presence of violent sexual fantasies before their crime. More than 90% had displayed prior violent behavior and used a weapon (most commonly a knife or cutting instrument) to commit the homicide. The juvenile usually acted alone and perpetrated the crime against a known, low-risk victim. A total of 43% of these murders were classified as organized sexual homicides and 36% were classified as disorganized. The remaining 21% had features of both.50 Many juveniles who become adult sexual offenders were victims of unreported child sexual abuse. A history of sexual abuse in childhood is best obtained by asking questions such as, ”How old were you and your partner when you first had intercourse?” and “Have you ever had sexual relations with someone much older than you?”6o When assessing the juvenile sex offender, the clinician should inquire into the various types of behavior the youth has committed, progression of sexual behaviors over time, and any associated aggression. Other important questions include41: How did the juvenile elicit the victim’s cooperation? What did the juvenile say and do during the sexual act? What did the juvenile do immediately after the act? What was the most attractive aspect of the victim? How long had the youth thought about the sexual act prior to the incident? How was the victim chosen? What did the juvenile do or say to encourage the victim not to tell? At what point during the act did the juvenile become aroused? Was any item taken from the victim or was the act recorded in some way? How was the juvenile caught? In what ways was the victim threatened? Did the youth have a weapon? JUVENILE HOMICIDE Between 1984 and 1993, the rate at which juveniles were arrested for murder in the United States increased by nearly 170%. This trend reversed slightly between 1993 and 1995; a 20% decrease occurred in the juvenile murder arrest Most juvenile homicide offenders act alone and kill members of their own race; however, when juveniles kill in

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groups, they are more likely to murder across racial lines. Boys are 10 times more likely to commit homicide than are girls. Male juveniles most commonly kill male friends or acquaintances. Female juveniles kill family members nearly as often as they do friends or acquaintances. Although girls most commonly murder with guns, girls are more likely than are boys to kill with a k11ife.6~ Categorization schemes of juvenile homicide offenders are usually based on developmental causality or environmental circumstance. Lewis et a14 reported that homicidal adolescents had histories of violent fathers, seizures, suicidal tendencies, and psychiatrically hospitalized mothers. The profile developed by Busch et a19 described a tetrad of symptoms: (1)criminally violent family members, (2) gang membership, (3) severe educational difficulties, and (4)alcohol abuse. Finally, Cornell et all9 developed a typology scheme that classified juvenile murderers into one of three groups: (1)psychotic, clear signs of psychotic symptoms or disorganized behavior; (2) conflict, nonpsychotic adolescents involved in an interpersonal conflict with the victim; and (3) crime, adolescents who killed in the course of another crime, such as a robbery.I9 Although these classification schemes are useful in examining common characteristics of homicide offenders, no one schema fully describes an individual youth. When examining a juvenile homicide offender, the clinician should inquire as to the relationship (if any) of the youth with the victim, the type of weapon used, precipitants to the incident, involvement of other perpetrators in the crime, and the presence of any substance abuse or mental illness. A careful past history should include any previous delinquent offenses; history of physical or sexual abuse; exposure to family; school or community violence; and underlying medical issues, such as seizures or head trauma. The examiner should also explore the youth’s attitude toward the homicide. Nonempathic juvenile killers who murder without any apparent reason represent a particularly dangerous subgroup because their violence is predatory and sociopathic.” Particular attention has been given to youth who commit parricide, the murder of a parent. Although only a few juvenile homicides are parricide^:^ these murders are dramatic and receive a great deal of media attention. The clinician should carefully explore any history of family violence and physical abuse, family substance abuse, inappropriate family boundaries, and the relationship of the offender to other siblings. A small subset of juveniles commit mass homicide. To the outside observer, these youth appear to have ”snapped” without obvious warning signs. In these cases, feelings of isolation, rejection, involvement in gangs or cults, access to weapons, previous verbal threats to harm, and violent fantasies should be explored. EVALUATION OF THE VIOLENT JUVENILE

Before beginning the assessment, the practitioner should clarify the purpose of the evaluation and the requesting authority. In addition, the

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legal guardian responsible for consenting to the evaluation should be contacted. In cases involving the juvenile or family court, the youth may have a court-appointed attorney (i.e., guardian ad litem) with whom the examiner should communicate. Issues of confidentiality need to be addressed before interviewing the youth. Important contacts include family members and caretakers, juvenile court probation officers, mental health providers, school teachers, and previous therapists. Recommended collateral sources include medical and mental health records, academic records, educational and intellectual testing, listing of prior offenses, and police reports. Finally, in those cases where the youth is threatening a third party, the clinician should follow their state’s statute regarding any Turusofl duty to protect. Most commonly, this duty involves notification of the threatened party or notification of the police. TREATMENT OF THE VIOLENT JUVENILE

Most violent juveniles have an associated conduct disorder. The treatment plan should be matched to the needs of the individual youth. In violent adolescents, neither individual therapy33nor group therapy when used alone has proven to be effective. Family therapy, including behavioral training for parents, has produced positive outcomes in young, aggressive children, but similar success in violent adolescents has not been shown.34Cognitive behavioral approaches, such as aggression replacement training30 and problem-solving skills training?* have shown effectiveness in reducing violence in adolescents within a correctional facility; however, sustained effectiveness outside a secure setting has not been demonstrated.” Shock incarceration programs, such as boot camps, have not shown a consistent, positive benefit; in some cases, they have yielded higher recidivism rates.3I The most encouraging results for adolescents with conduct disorder have been demonstrated by Henggeler ’s multisystemic therapy (MST). MST uses intense case management involving the home, school, peers, and neighborhood. Services are provided within the home setting with targeted family interventi0ns.3~ Youths receiving MST have fewer arrests for violent offenses compared with youth receiving only individual therapy: The use of medications as a sole treatment is not recommended. Pharmacologic interventions should be considered if an associated psychiatric disorder is likely to respond to medication. In particular, stimulants, such as methylphenidate, have proven efficacy for the treatment of ADHD. Anecdotal evidence for the effectiveness of antidepressants in depressed children has not been demonstrated in double-blind, placebocontrolled studies. Studies examining the effectiveness of lithium to treat aggressiveness have yielded mixed results.ll Conduct-disordered children with explosive outbursts may have a better treatment response to lithium.’O, l2 Literature regarding the effectiveness of anticonvulsants in this population is sparse. Carbamazepine is the most studied anticonvulsant; however, its effectiveness in reducing aggression has not been

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proved.20,39 Although antipsychotics have been used to manage aggressive behavior in children and adolescents, potential long-term side effects raise concern regarding their use in the absence of a psychotic illness. SUMMARY

No one missing piece can solve the puzzle of juvenile violence. Although numerous risk factors have been identified, the implementation of successful preventive and treatment programs remains the greatest challenge. With children increasingly turning to gangs as substitutes for their families and using weapons to solve their problems, there is little alternative but to meet this challenge. The consequence of failing to do so is summarized by King’s prophetic statement, ”The choice today is no longer between violence and nonviolence. It’s either nonviolence or nonexistence.”

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Address reprint requests to Charles L. Scott, MD Division of Forensic Neuropsychiatry Tidewater Building-10th Floor 1440 Canal Street New Orleans, LA 70112