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Delinquency and Psychopathology
Book Reviews
Delinquency and Psychopathology. By Dorothy 0. Lewis a n d David A. Balla. New York: G r u n e & Stratton, 1976, 209 pp.,
$14.75.
Reviewed by &.e Mattsson, M.D. This concise, well-written volume on neuropsychopathology and social characteristics of contemporary delinquents and their families is a must in any child mental health teaching seminar. It can be viewed as a belated but logical continuation of the pioneering work of William Healy as a juvenile court psychiatrist in Chicago during the early years of this century. Foremost among Healy’s contributions to a humane, yet scientific study of young offenders was his emphasis on an individual approach to each delinquent, including information about the juvenile’s medical history and status, his intellectual and emotional development, and his family background. Lewis and Balla have used a similar approach in their study of a large group of children referred to the Juvenile Court of the Second District of Connecticut, located in New Haven. Their investigation utilized modern neurological, psychiatric, psychological, and epidemiologic techniques to obtain as broad a picture as possible of the “individual delinquent” and his family and sociolegal systems. T h e authors, a child psychiatrist and a research developmental psychologist, joined by a psychiatric social worker, were invited to organize and operate a psychiatric clinic as part of the New Haven juvenile court. Their original charge was to provide training to the probation staff, direct service to the clients of the court, and conduct research, the nature of which was not specified. T h e book describes their many years of clinical experience with the referred delinquents and their families. Early in their work they were impressed by the large number of clinic-referred delinquents who showed evidence of serious psychiatric and neurological problems. Furthermore, they quickly discerned that many of the parents also suffered from severe psychiatric impairment. These observations prompted the team to refine their systematic data collection and to engage in epidemiologic studies of delinquent youngsters and parents not referred to the psychiatric clinic-in order to gain broader, unbiased information about the extent of neuropsychopathology among the court population compared to various control groups. Readers will be moved and inspired by the authors’ dedicated, rigorous clinical work with the referred delinDr. Mattsson is Professor of Psychiatry and Pediatrics at the University of Pittsburgh, Pittsburgh, Pennsylvania.
173
174
Book Reviews
quents and their parents, work that in many instances involved roundthe-clock crisis intervention with these troubled families. T h e volume provides unique field work illustrations of the fertile interplay between solid clinical work and associated evaluative and branching-out epidemiologic research. The only major critical comment is in regard to the lack of a clear description by the authors of their served juvenile court population in terms of conventional demographic data, such as age range, numbers of patients seen, sex and race proportions, types of offenses, and family composition. An introductory chapter presenting the authors’ data base in table form would have been helpful. Questions also arise about confidentiality and informed consent issues in regard to children and parents interviewed, and about such mundane aspects as cost effectiveness and service accountability of the psychiatric court clinic. T h e first chapter reviews psychiatric and sociological viewpoints on delinquency and associated psychopathology. T h e authors rightly warn against labeling of delinquent youths that might he harmful for their rehabilitative futures as well as lead to self-fulfilling prophesies. In addition to the authors’ historical review, it seems pertinent to emphasize the early psychoanalytic contributions to the psychodynamic understanding of j u venile delinquents. Writers such as William Healy, August Aichhorn, John Bowlby, Adelaide Johnson, and Anna Freud emphasized various aspects of early ego and superego deviant development, often related to faulty mother-child bonding, as etiological factors of later childhood aggressive and delinquent psychopathology. These psychodynamic explanations of early antisocial behavior were well summarized by Rexford (1966). T h e history of the confusing diagnostic term “sociopathy” is dealt with separately, in chapter 3; it probably would have made clearer reading to include this section in the first chapter. T h e authors’ plea to discard the pseudoscientific, pejorative diagnosis of sociopathy in child psychiatry is well taken. It probably should be discarded in any clinical psychiatric work and only used as a descriptive modifier, as the authors suggest. Chapter 2, entitled “Diagnostic Evaluation,” is a straightforward description of the sound ingredients of a child psychiatric evaluation of juvenile court youngsters and their parents. Clinical case vignettes illustrate the thorough interviewing with the families and the importance of obtaining medical histories and a traditional mental status examination. With their large sample of referred delinquents, the authors might have provided the reader with numerical data on their positive and negative findings, for there is always a question of yield and cost of such assessment tools, especially crucial when precious service and research funds request accountability records. Chapters 4 and 5 deal with the evidence of central nervous system dysfunction in these delinquent children. Unfortunately, the authors give few figures on the extent of obvious and subtle brain pathology, but their well-documented case illustrations show that even the delinquent recidivists had never had careful neuropsychiatric evaluations that might have
Book Reuiews
175
disclosed clear signs of neurological dysfunction at an earlier age. T h e authors claim that the hyperactive child syndrome was “one of the most common central nervous system precursors of delinquency that we saw at our clinic.” It would be helpful to learn about the prevalence of this syndrome among the court-referred youngsters and its possible relationship to a history of perinatal trauma, as the authors rightly stress that early central nervous system dysfunction seems to predispose to later serious psychopathology such as antisocial behavior, alcoholism, and hysteria. In regard to the diagnostic finding of psychomotor or temporal lobe epilepsy among the delinquents, Lewis and Balla do provide lucid and startling data: of the 285 children referred during the first two years of their study, 18 (6%) showed evidence of temporal lobe epilepsy. Sixteen of these subjects experienced paranoid delusions, and 14 had histories of severely aggressive behavior toward others. Helpful tables on these 18 cases present medical and developmental background and findings of the neuropsychiatric examination. Lewis and Balla conclude that their finding of a high prevalence of psychomotor epilepsy associated with paranoid ideation suggests that this combination of symptoms may be more common among delinquents than has been recognized. T h e chapter on psychotic symptomatology weaves case vignettes of thought-disordered delinquents into a review of the literature on followu p of antisocial children, of whom many show serious adult psychopathology including schizophrenia. Lewis and Balla suggest that much delinquent behavior among youths, often labeled “sociopathy,” may manifest a “forme fruste” of a thought disorder related to the spectrum of schizophrenic illness. Chapter 7 presents epidemiologic correlates of the findings of psychopathology among the evaluated youngsters. T h e authors’ court clinicreferred population seemed the same as the general juvenile court population in regard to sex, age, race, and socioeconomic status. T h e clinicreferred children had committed significantly more offenses than the nonreferred court children. T h e parents of both clinic-referred and nonreferred children showed similar evidence of psychiatric disorders, based upon their records of psychiatric treatment at nearby state mental health facilities. However, the prevalence of such treatment in both groups was significantly greater than that in the general New Haven lower income population. T h e last two chapters, on psychopathology, criminality, and assortative mating among the parents of the court-referred delinquents, deserve a separate review because of the exemplary epidemiologic and statistical methodology, the provocative findings, and the authors’ judicious, constructive conclusions. These are some highlights of the findings: parents of children identified as delinquent had made significantly greater use of the nonprivate psychiatric facilities in the New Haven area than the general, same level SES population (this finding is an indirect, conservative underestimate of the psychopathology among the cohorts); there was a significant positive relationship between paternal criminality and paternal
176
Book Reviews
psychiatric treatment; psychiatrically treated parents of the delinquents tended to marry each other; criminal fathers had a greater likelihood to be married to a woman with a history of psychiatric treatment than noncriminal fathers. Two marital constellations seemed to emerge of parents of the delinquent youngsters: psychiatrically treated males married to similarly treated females, and criminal males married to psychiatrically treated females. There was no correlation between severity of juvenile delinquency and evidence of parental mental illness or parental criminality; however, the more seriously criminal the parent, the younger was the child at the first (known) offense. The authors’ impressive finding of common, serious psychopathology and of criminality among the delinquents’ parents can be viewed as different indications of these families’ global inability to provide socialization, protection, and discipline to their children and to themselves. From their combination of clinical and epidemiologic investigations, Lewis and Balla gathered convincing evidence of the complex interaction between delinquency and psychopathology both within the individual and in his or her family. Juvenile delinquency, childhood neuropsychopathology , adult criminality, and the need for psychiatric treatment often appear to be “different manifestations of a common underlying inability to adapt.” At times, society regards these adaptive failures as evidence of sickness; at other times, as evidence of criminal tendencies. Delinquency and Psychopathology is a convincing scientific plea that the legal and medical-psychiatric systems pull their investigative and treatment forces together and take advantage of the growing evidence that a substantial portion of delinquent youngsters and their parents suffer from treatable neurological and psychiatric disorders.
T h e Deaf Child and His Family. By Susan Gregory. New York: Halstead Press, 1976, 256 pp., $10.00. Reviewed by Hilde S . Schlesinger, M.D. Gregory has conducted a compassionate study of 122 mothers of deaf children between the ages of - 2 and ti +. The children’s hearing ranged from no response to sound to near normal responses, with or without hearing aids. The etiologies were varied, with 52 percent “unknown,” and the next highest incidence stipulated to be rubella (27 percent). The sample was chosen on referral by the Medical Officer of Health from required lists of handicapped children in several counties of England. Gregory’s work clearly indicates that deafness transcends national boundaries, since most of her findings corroborate prior American studies (including our own). Dr. Schlesinger is Associate Clinical Professor and Project Director, Mental Health Seroices f o r the DeaJ University of California, San Francisco.
Delinquency and Psychopathology. By Dorothy 0. Lewis a n d David A. Balla. New York: G r u n e & Stratton, 1976, 209 pp.,
$14.75.
Reviewed by &.e Mattsson, M.D. This concise, well-written volume on neuropsychopathology and social characteristics of contemporary delinquents and their families is a must in any child mental health teaching seminar. It can be viewed as a belated but logical continuation of the pioneering work of William Healy as a juvenile court psychiatrist in Chicago during the early years of this century. Foremost among Healy’s contributions to a humane, yet scientific study of young offenders was his emphasis on an individual approach to each delinquent, including information about the juvenile’s medical history and status, his intellectual and emotional development, and his family background. Lewis and Balla have used a similar approach in their study of a large group of children referred to the Juvenile Court of the Second District of Connecticut, located in New Haven. Their investigation utilized modern neurological, psychiatric, psychological, and epidemiologic techniques to obtain as broad a picture as possible of the “individual delinquent” and his family and sociolegal systems. T h e authors, a child psychiatrist and a research developmental psychologist, joined by a psychiatric social worker, were invited to organize and operate a psychiatric clinic as part of the New Haven juvenile court. Their original charge was to provide training to the probation staff, direct service to the clients of the court, and conduct research, the nature of which was not specified. T h e book describes their many years of clinical experience with the referred delinquents and their families. Early in their work they were impressed by the large number of clinic-referred delinquents who showed evidence of serious psychiatric and neurological problems. Furthermore, they quickly discerned that many of the parents also suffered from severe psychiatric impairment. These observations prompted the team to refine their systematic data collection and to engage in epidemiologic studies of delinquent youngsters and parents not referred to the psychiatric clinic-in order to gain broader, unbiased information about the extent of neuropsychopathology among the court population compared to various control groups. Readers will be moved and inspired by the authors’ dedicated, rigorous clinical work with the referred delinDr. Mattsson is Professor of Psychiatry and Pediatrics at the University of Pittsburgh, Pittsburgh, Pennsylvania.
173
174
Book Reviews
quents and their parents, work that in many instances involved roundthe-clock crisis intervention with these troubled families. T h e volume provides unique field work illustrations of the fertile interplay between solid clinical work and associated evaluative and branching-out epidemiologic research. The only major critical comment is in regard to the lack of a clear description by the authors of their served juvenile court population in terms of conventional demographic data, such as age range, numbers of patients seen, sex and race proportions, types of offenses, and family composition. An introductory chapter presenting the authors’ data base in table form would have been helpful. Questions also arise about confidentiality and informed consent issues in regard to children and parents interviewed, and about such mundane aspects as cost effectiveness and service accountability of the psychiatric court clinic. T h e first chapter reviews psychiatric and sociological viewpoints on delinquency and associated psychopathology. T h e authors rightly warn against labeling of delinquent youths that might he harmful for their rehabilitative futures as well as lead to self-fulfilling prophesies. In addition to the authors’ historical review, it seems pertinent to emphasize the early psychoanalytic contributions to the psychodynamic understanding of j u venile delinquents. Writers such as William Healy, August Aichhorn, John Bowlby, Adelaide Johnson, and Anna Freud emphasized various aspects of early ego and superego deviant development, often related to faulty mother-child bonding, as etiological factors of later childhood aggressive and delinquent psychopathology. These psychodynamic explanations of early antisocial behavior were well summarized by Rexford (1966). T h e history of the confusing diagnostic term “sociopathy” is dealt with separately, in chapter 3; it probably would have made clearer reading to include this section in the first chapter. T h e authors’ plea to discard the pseudoscientific, pejorative diagnosis of sociopathy in child psychiatry is well taken. It probably should be discarded in any clinical psychiatric work and only used as a descriptive modifier, as the authors suggest. Chapter 2, entitled “Diagnostic Evaluation,” is a straightforward description of the sound ingredients of a child psychiatric evaluation of juvenile court youngsters and their parents. Clinical case vignettes illustrate the thorough interviewing with the families and the importance of obtaining medical histories and a traditional mental status examination. With their large sample of referred delinquents, the authors might have provided the reader with numerical data on their positive and negative findings, for there is always a question of yield and cost of such assessment tools, especially crucial when precious service and research funds request accountability records. Chapters 4 and 5 deal with the evidence of central nervous system dysfunction in these delinquent children. Unfortunately, the authors give few figures on the extent of obvious and subtle brain pathology, but their well-documented case illustrations show that even the delinquent recidivists had never had careful neuropsychiatric evaluations that might have
Book Reuiews
175
disclosed clear signs of neurological dysfunction at an earlier age. T h e authors claim that the hyperactive child syndrome was “one of the most common central nervous system precursors of delinquency that we saw at our clinic.” It would be helpful to learn about the prevalence of this syndrome among the court-referred youngsters and its possible relationship to a history of perinatal trauma, as the authors rightly stress that early central nervous system dysfunction seems to predispose to later serious psychopathology such as antisocial behavior, alcoholism, and hysteria. In regard to the diagnostic finding of psychomotor or temporal lobe epilepsy among the delinquents, Lewis and Balla do provide lucid and startling data: of the 285 children referred during the first two years of their study, 18 (6%) showed evidence of temporal lobe epilepsy. Sixteen of these subjects experienced paranoid delusions, and 14 had histories of severely aggressive behavior toward others. Helpful tables on these 18 cases present medical and developmental background and findings of the neuropsychiatric examination. Lewis and Balla conclude that their finding of a high prevalence of psychomotor epilepsy associated with paranoid ideation suggests that this combination of symptoms may be more common among delinquents than has been recognized. T h e chapter on psychotic symptomatology weaves case vignettes of thought-disordered delinquents into a review of the literature on followu p of antisocial children, of whom many show serious adult psychopathology including schizophrenia. Lewis and Balla suggest that much delinquent behavior among youths, often labeled “sociopathy,” may manifest a “forme fruste” of a thought disorder related to the spectrum of schizophrenic illness. Chapter 7 presents epidemiologic correlates of the findings of psychopathology among the evaluated youngsters. T h e authors’ court clinicreferred population seemed the same as the general juvenile court population in regard to sex, age, race, and socioeconomic status. T h e clinicreferred children had committed significantly more offenses than the nonreferred court children. T h e parents of both clinic-referred and nonreferred children showed similar evidence of psychiatric disorders, based upon their records of psychiatric treatment at nearby state mental health facilities. However, the prevalence of such treatment in both groups was significantly greater than that in the general New Haven lower income population. T h e last two chapters, on psychopathology, criminality, and assortative mating among the parents of the court-referred delinquents, deserve a separate review because of the exemplary epidemiologic and statistical methodology, the provocative findings, and the authors’ judicious, constructive conclusions. These are some highlights of the findings: parents of children identified as delinquent had made significantly greater use of the nonprivate psychiatric facilities in the New Haven area than the general, same level SES population (this finding is an indirect, conservative underestimate of the psychopathology among the cohorts); there was a significant positive relationship between paternal criminality and paternal
176
Book Reviews
psychiatric treatment; psychiatrically treated parents of the delinquents tended to marry each other; criminal fathers had a greater likelihood to be married to a woman with a history of psychiatric treatment than noncriminal fathers. Two marital constellations seemed to emerge of parents of the delinquent youngsters: psychiatrically treated males married to similarly treated females, and criminal males married to psychiatrically treated females. There was no correlation between severity of juvenile delinquency and evidence of parental mental illness or parental criminality; however, the more seriously criminal the parent, the younger was the child at the first (known) offense. The authors’ impressive finding of common, serious psychopathology and of criminality among the delinquents’ parents can be viewed as different indications of these families’ global inability to provide socialization, protection, and discipline to their children and to themselves. From their combination of clinical and epidemiologic investigations, Lewis and Balla gathered convincing evidence of the complex interaction between delinquency and psychopathology both within the individual and in his or her family. Juvenile delinquency, childhood neuropsychopathology , adult criminality, and the need for psychiatric treatment often appear to be “different manifestations of a common underlying inability to adapt.” At times, society regards these adaptive failures as evidence of sickness; at other times, as evidence of criminal tendencies. Delinquency and Psychopathology is a convincing scientific plea that the legal and medical-psychiatric systems pull their investigative and treatment forces together and take advantage of the growing evidence that a substantial portion of delinquent youngsters and their parents suffer from treatable neurological and psychiatric disorders.
T h e Deaf Child and His Family. By Susan Gregory. New York: Halstead Press, 1976, 256 pp., $10.00. Reviewed by Hilde S . Schlesinger, M.D. Gregory has conducted a compassionate study of 122 mothers of deaf children between the ages of - 2 and ti +. The children’s hearing ranged from no response to sound to near normal responses, with or without hearing aids. The etiologies were varied, with 52 percent “unknown,” and the next highest incidence stipulated to be rubella (27 percent). The sample was chosen on referral by the Medical Officer of Health from required lists of handicapped children in several counties of England. Gregory’s work clearly indicates that deafness transcends national boundaries, since most of her findings corroborate prior American studies (including our own). Dr. Schlesinger is Associate Clinical Professor and Project Director, Mental Health Seroices f o r the DeaJ University of California, San Francisco.