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Race, Health, and Delinquency
Race, Health, and Delinquency DOROTHY OTNOW LEWIS, M.D., MARILYN FELDMAN, M.A.,
AND
ANN BARRENGOS, M.A.
This paper reports results of a study of medical histories of black and white delinquents and a matched sample of nondelinquents. Medical records were analyzed in terms of numbers and timing of hospital contacts, nature of services used, and reasons for contacts. Black delinquents made somewhat more hospital visits than white delinquents. White delinquents had significantly more hospital contacts and accidents, injuries, illnesses, and psychiatric problems than white nondelinquents. Black nondelinquents had almost as many hospital contacts as black delinquents. Findings are discussed in terms of the relevance of particular medical events to the development of maladaptive behaviors, the tendency of clinicians to dismiss as culturally expectable certain medical and psychological factors in black children and their families, and the failure of physicians to recognize the existence of severe family disorganization in black children with multiple hospital contacts. Journal of the American Academy of Child Psychiatry, 24,2:161-167, 1985.
The purpose of this paper is to report the findings of a study of the medical histories of black and white delinquents and nondelinquents and to explore their implications for understanding delinquency rates in different populations. In previous studies (Lewis and Shanok, 1977) we found that delinquents as a group had more adverse medical histories than did nondelinquents, and that severity of delinquency correlated in certain ways with severity of medical disturbance, particularly central nervous system trauma (Lewis and Shanok, 1979). We wondered whether within our delinquent and nondelinquent samples there existed any differences between the medical histories of black and white subjects that might shed light on reasons for the disproportionate representation of black youngsters in the delinquent population in the United States.
greater than expected numbers of accidents, injuries, and illnesses in the histories of delinquents (Carper, 1974; Gibbens, 1963; Lewis and Shanok, 1977). Although there is debate regarding the medical status of delinquents compared to nondelinquents, there is a consensus that socioeconomically deprived children fare worse medically than do their middle-class peers. For example, perinatal problems (Fraser and Wilks, 1959; Pasamanick et aI., 1956; Scott, 1975; Stott and Latchford, 1976) and early nutritional deficiencies (Cravioto and Delicardie, 1970) are well recognized as contributors to behavioral disturbances in later childhood. Prematurity, lead poisoning, otitis media, hearing loss, and a myriad of other medical problems are more prevalent among poor children and, what is more, their sequelae are more serious (Egbuono and Starfield, 1982). Accidents of all kinds, especially car accidents, the commonest cause of death in the adolescent population, are also more frequent in the lives of poor children. Whether or not this is a reflection of particular factors in the environment (e.g., living near busy streets) or a reflection of poor parental supervision, or both, is unclear (Mare, 1982). Comparison of black and white populations indicate that black individuals of all ages, from birth onward, have more adverse medical histories than whites (U. S. Dept. of Commerce, 1982-83). What is more, there is some indication that black adolescents suffer from many kinds of medical problems for which they do not receive care (Brunswick and Josephson, 1972). Although there have been many clinical and epidemiological studies comparing medical factors in black/ white populations, these studies rarely examine social and behavioral concomitants of medical status. For this reason we welcomed the opportunity to compare
The Literature There is debate in the literature regarding whether or not delinquents have more adverse medical histories than nondelinquents. Some investigators have reported that delinquents as a group are a healthy lot (Glueck and Glueck, 1950). Others have reported that the medical status of delinquents, while not grossly different from that of other children, is characterized by an inordinate number of minor medical problems (Eilenberg, 1961). There have been a few reports of This research was supported in part by the lttleson, KenworthySwift, and Hye/iff Foundations. Dr. Lewis is Professor of Psychiatry, New York University School of Medicine, Ms. Feldman is Research Assistant, New York University School of Medicine, and Ms. Barrengos is a graduate student, New York University. We would like to thonk Gillian and Eric Lewis for their assistance. 0002-7138/85/2402-0161 $02.00/0 © 1985 by the American Academy of Child Psychiatry. 161
162
LEWIS ET AL.
the medical histories of black and white delinquents and nondelinquents and explore possible implications of our findings for understanding some aspects of deviant behavior.
Method Samples
Our delinquent samples consisted of 41 black delinquents and 64 white delinquents chosen randomly from the roster of all youngsters referred to a juvenile court in the mid-1970s. Approximately two-thirds were boys, one-third girls. Our comparison samples consisted of 41 black nondelinquents and 64 white nondelinquents from the same geographic area as the delinquent samples and with demographic characteristics similar to those of the delinquents. Each delinquent youngster was matched for age, sex, and race with a nondelinquent youngster. Because socioeconomic status was not always clearly defined in court records but court referrals tended to come from poverty backgrounds, the comparison sample was picked from a population of which 75% would have been classified as coming from Classes IV and V according to the Hollingshead and Redlich scale (1958). Sources of Data
The assessment of medical histories was based on comprehensive reviews of each child's hospital records from the two general hospitals serving their area of residence. The choice of limiting the study to hospital records raises the issue of case loss. Although it would have been desirable to conduct interviews with subjects and their parents, issues of confidentiality precluded our doing this. Our own experience (Lewis et aI., 1979a, 1982) suggests that certain kinds of medical problems, particularly severe physical abuse, are underrecorded in hospital records. However, there is evidence that personal histories are often unreliable (Hoekelman et aI., 1976) regarding numbers of illnesses and dates of medical events. For these kinds of data, hospital records are far more accurate.
Data from private physicians were also not available. Since the great majority of subjects came from socioeconomically deprived environments, we assumed few would have used private practitioners. Furthermore, serious accidents, illnesses, or injuries would have been treated at one or the other of the hospitals studied. Medical records were assessed to determine numbers of visits, timing of visits, usage of different hospital services (e.g., emergency room, clinic, wards), and reasons for visits (e.g., accidents, head trauma, illnesses, psychiatric problems).
Findings (Tables 1-4)
We first compared black delinquents with white delinquents. As can be seen in Figure 1, although both groups were found to have adverse medical histories, as measured by numbers of hospital contacts, black delinquents had somewhat more adverse histories than white delinquents. When we considered the nature of medical problems we found no significant differences except for the finding that more black delinquents had had a skull x-ray before age 17 (6/36 (14.3%) vs. 1/61 (1.6%) xy = 4.546, P = 0.034). When we compared white delinquents with white nondelinquents (Fig. 2), we found that white delinquents had far more adverse medical histories than did white nondelinquents. They made significantly more hospital contacts of almost every kind and these differences were evident by 4 years of age. When we considered the nature of medical problems we found that significantly more white delinquents experienced accidents before age 17 years (40/63 (63.5%) vs. 24/ 61 (39.3%), xy = 6.302, p = 0.013), more had received head or face injuries before 17 years of age (20/63 (31.7%) vs. 12/61 (19.7%), xy = 1.771, p = 0.184), significantly more had records of having been abused (7/61 (11.1%) vs. 0, xY = 5.249, p = 0.023), significantly more had psychiatric symptoms recorded before age 17 years (10/64 (15.6%) vs. 1/60 (1.6%), xY =
TABLE 1 Hospital Use and Number of Accidents of Black Delinquents us. White Delinquents· Mean No. of Contact8
H08pital Service UBed and No. of AccidentB
Black delinquentB
White delinquentB
t te8t
P Value
Degree8 Freedom
Total Vi8it8 before 17 ER vi8itB before 17 Clinic vi8itB before 17 Ward admi88ion8 before 17 AccidentB before 17 Total vi8itB before 4 ER vi8itB before 4
12.643 6.220 5.707 0.488 2.390 4.548 2.095
9.635 2.825 6.206 0.571 1.742 3.079 0.746
-1.030 -3.322 0.217 0.402 -1.3b9 -1.005 -2.718
NS <0.005 NS NS NS NS <0.010
103 102 102 102 101 103 103
• Re8ultB of a two-tailed t te8t.
163
RACE, HEALTH, AND DELINQUENCY TABLE 2 Hospital Use and Number of Accidents of White Delinquents vs. White Nondelinquents· Hospital Service Used and No. of Accidents Total visits before 17 ER visits before 17 Clinic visits before 17 Ward admissions before 17 Accidents before 17 Total visits before 4 ER visits before 4
Mean No. of Contacts White delinquents
White nondelinquents
tTest
p Value
Degrees Freedom
9.531 2.781 6.156 0.563 1.714 2.734 0.734
2.934 1.148 2.484 0.197 0.869 0.918 0.246
3.056 3.518 1.798 2.252 2.490 1.997 2.209
<0.005 <0.001 0.10> p > 0.05 <0.050 <0.050 <0.050 <0.050
123 123 124 123 122 123 123
• Results of a two-tailed t test. TABLE 3 Hospital Use and Number of Accidents of Black Delinquents vs. Black Nondelinquents· Mean No. of Contacts
Hospital Service Used and No. of Accidents
Black delinquents
Black nondelinquents
t Test
p Value
Degrees Freedom
Total visits before 17 ER visits before 17 Clinic visits before 17 Ward admissions before 17 Accidents before 17 Total visits before 4 ER visits before 4
12.300 6.282 5.333 0.462 2.410 4.700 2.200
8.463 4.390 3.707 0.341 1.707 1.244 1.024
1.442 1.260 1.056 0.780 1.082 2.695 1.842
NS NS NS NS NS <0.010 0.10> P > 0.05
79 78 78 78 78 79 79
• Results of a two-tailed t test. TABLE 4 Hospital Use and Number of Accidents of Black Nondelinquents and White Nondelinquents· Mean No. of Contacts
Hospital Service Used and No. of Accidents
Black nondelinquents
White nondelinquents
t Test
p Value
Degrees Freedom
Total visits before 17 ER visits before 17 Clinic visits before 17 Ward admissions before 17 Accidents before 17 Total visits before 4 ER visits before 4
8.463 4.390 3.707 0.341 1.707 1.244 1.024
2.934 1.148 2.484 0.197 0.869
3.190 3.925 0.747 1.309 1.920 0.607 2.730
<0.010 <0.001 NS NS <0.050 NS <0.010
100 100 100 100 100 100 100
0.91~
0.246
• Results of a two-tailed t test.
5.969, p = 0.015), significantly more had social work or psychiatric consultations before age 17 years (8/64 (12.5%) vs. 0, xy = 6.193,p = 0.013), and significantly more had a parent with psychiatric disturbance noted in the chart or a parent with a history of psychiatric treatment (16/62 (25.8%) vs. 5/61 (8.2%), xy = 5.548, p = 0.019). Differences between black delinquents and black nondelinquents, however, were not as striking (Fig. 3). In fact, the only significant difference between the groups in terms of numbers of hospital contacts was numbers of hospital visits prior to 4 years of age. When we considered reasons for medical contacts,
similar proportions of black delinquents and black nondelinquents had been treated for accidents before age 17 years (66.7% vs. 51.2%), had psychiatric symptoms noted (23.1% vs. 19.5%), and had been referred to a social worker or psychiatrist (7.7% vs. 12.5%). Of note, very few of the parents of black children from either group were described as having received psychiatric treatment of any kind (2.6% vs. 2.4%). It is also interesting, in view of the high prevalence of accidents and injuries in the two black groups, that physical abuse was almost never recognized as having occurred in either group of black children (5.1% vs. 2.4%). The only significant difference in terms of
164
LEWIS ET AL.
12 10 8
6
.
4 2
Total' Visits Before 17
ER Visits Defore 17
Clinic Visits Before 17
I~rd Accidents Admissions Before 17 Before 17
Total Visits Before 'I
6~ sits
Defore 4
FIG. 1. Hospital use and number of accidents of black delinquents vs. white delinquents.
12 • 10 • D
6
4 2
Total Visits Before 17
ER Visits Uefore 17
Clinic Visits Defore 17
Ward Accidents Admissions Before 17 Before 17
Total Visits Before 4
E
Vi s its Before 'I
FIG. 2. Hospital use and number of accidents of white delinquents vs. white nondelinquents.
reasons for hospital contacts was the finding that more black delinquents than black nondelinquents were treated for a head or face injury before age 17 years (18/39 (46.2%) vs. 9/41 (22.0%), xy = 4.210, p = 0.041). The greater vulnerabilities of the black nondelinquent group compared to the white nondelinquent group can be seen best in Figure 4. They made almost 3 times as many hospital visits, almost 4 times as many emergency room visits, and had twice as many accidents before 17 years of age. They were especially
likely to require emergency services prior to 4 years of age.
Discussion Clearly both black delinquents and white delinquents have more adverse medical histories than do their nondelinquent counterparts. The most important findings of this study were 1) that black delinquents are only somewhat more vulnerable medically than black nondelinquents and 2) that black nondelinquents from socially disadvantaged environments
165
RACE, HEALTH, AND DELINQUENCY
12 10
8 6 4 2
Vi s its Before 17
ER Visits Before 17
Clinic Visits Before 17
lIard Accidents Admissions Before 17 Before 17
FIG. 3. Hospital use and number of accidents of black delinquents
Total Visits Before 4 VB.
[~
. V,S,tS Before 4
black nondelinquents.
12 10
8 6 4
2
Total Vi sits Before 17
ER Vi sits Before 17
Clinic Vis its Before 17
~Iard
Admi ss ions Before 17
Accidents Before 17
Total Vi s its Before 4
1\
FIG. 4. Hospital use and number of accidents of black nondelinquents and white nondelinquents.
have far worse medical histories than white nondelinquents from socially disadvantaged environments. These findings shed some new light on possible reasons why delinquency rates are higher among blacks than whites in our country. First, greater numbers of hospital contacts for black children may indicate that greater proportions of black than white youngsters suffer from the kinds of accidents, illnesses, and emotional disorders associated with subsequent poor impulse control and impaired judgment. We know, for example, that black nondelinquents
made almost 4 times as many emergency room visits as white nondelinquents and suffered twice as many accidents before 17 years of age. They were especially at risk prior to 4 years of age, if emergency room contacts are considered a reflection of probable trauma. These findings are consistent with U.S. statistics on infant mortality. For example, of every 100,000 white children under 1 year of age, 1330 died, whereas of every 100,000 black children under 1 year of age, 2830 died (U.S. Dept. of Commerce, 1982-83). Moreover, between ages 1 and 4 years, 66 white chil-
166
LEWIS ET AL.
dren per 100,000 died compared with 107 black children per 100,000. Given the high occurrence of accidents and injuries in our black samples, the finding that few were recognized as having been abused stands out. We know from previous studies (Lewis et al., 1979a, 1979b) that delinquent children, black and white, are often victims of abuse. It would seem that clinicians have special difficulty recognizing abuse in minority populations. National statistics indicate that physical abuse is recognized almost 5 times as often in poor white children as it is in poor nonwhite children (U.S. Dept. of Health and Human Services, 197980). It is, of course, conceivable that abuse is rare in the poor black population. Our own clinical and epidemiological studies suggest that, on the contrary, abuse occurs at least as frequently in the families of black delinquents as it does in those of white delinquents. It tends, however, to go unrecognized or to be dismissed as culturally acceptable behavior. Thus abused black children are less likely to receive protection than abused white children. This phenomenon alone probably contributes significantly to the vulnerabilities of black children to delinquency. The fact that black youngsters tended to have greater numbers of hospital contacts for all sorts of reasons, not just head trauma, may tell something about the disorganization of the families from which they come. Parental difficulty in providing necessary support and protection is reflected in the myriad different reasons that brought children to the hospital. Equally noteworthy was the finding that hardly any black mothers or fathers were described as having psychiatric problems and almost none had ever received psychiatric treatment. It is, of course, possible that the lack of documentation of family psychopathology was an indication that none existed. It is more likely that psychiatric problems in parents of black children were either overlooked or dismissed as culturally expectable. We know, for example, from previous studies of delinquent children from similar backgrounds, (Lewis et al., 1980), that behaviors in white delinquents that are recognized as indicators of psychopathology, in black delinquents are dismissed as simply antisocial. Perhaps this same tendency toward bias in the interpretation of black children's behaviors holds true when clinicians are confronted with the task of understanding the parents of these children. When we look at the history of psychiatry in America we find rationalization after rationalization for excluding troubled black individuals from treatment. From the assertions of O'Malley (1914) that visual hallucinations in blacks were culturally expectable, to the more recent sociological perspective of Fischer (1969) that sick behavior in whites could be adaptive
and normal in blacks, excuses have been made for dismissing psychopathology in the black population. If there is no psychopathology, then there is no need for treatment. Our findings are not simply academic. They have implications for the possible reduction of delinquency rates in black and white children. They suggest that multiple hospital contacts for a variety of different problems, especially emergency room visits, particularly during the first four years of life, are often associated with a child's future social maladaptation. They also suggest that frequent visits to different hospital services for a myriad of different kinds of problems may be important indicators of extreme family disorganization. Our findings also suggest that when black children present with this constellation of medical events, any needs beyond care of the immediate presenting problem are likely to be overlooked. The possibility of abuse is especially likely to be missed. Most important, severe disturbance in their familes, especially the existence of serious psychiatric illness, will usually be overlooked or ignored. Whereas in the case of black children the kind of intrafamilial disorganization, neglect, and abuse conducive to the development of delinquency is permitted to continue uninterrupted, in the case of white children, it is more likely to be recognized and treated. References BRUNSWICK, A. F. & JOSEPHSON, E. (1972), Adolescent health in Harlem. Amer. J. Public Hlth. Suppl., 10:1-62. CARPER, J. (1974), Medical care of delinquent adolescent boys. Pediat. Clin. N. Amer., 21:423-433. CRAVIOTO, J. & DELICARDlE, E. R. (1970), Mental performance in school age children. Amer. J. Dis. Child., 120:404-410. EGBUONO, L. & STARFIELD, B. (1982), Child health and social status. Pediatrics, 69:550-557. ElLENBERG, M. D. (1961), Remand home boys 1930-1955. Brit. J. Criminol., 2:111-131. FISCHER, J. (1969), Negroes and whites and rates of mental illness. Psychiatry, 32:438-446. FRASER, M. S. & WILKS, J. (1959), The residual effects of neonatal asphyxia. J. Obstet. Gynoecol. Brit. Emp., 66:748-752. GIBBENS, T. N. C. (1963), The effects of physical ill-health in adolescent delinquents. Proe. R. Soc. Med., 56:1086-1088. GLUECK, S. & GLUECK, E. (1950), Unraveling Juvenile Delinquency. New York: Commonwealth Fund. HOEKELMAN, M. D., KELLY, J. & ZIMMER, A. W. (1976), The reliability of maternal recall. Clin. Pediat., 15:261-265. HOLLINGSHEAD, A. & REDLICH, F. (1958), Social Class and Mental Illness. New York: John Wiley & Sons. LEWIS, D. O. & SHANOK, S. S. (1977), Medical histories of delinquent and nondelinquent children. Amer. J. Psychiat., 134:10201025. (1979), Perinatal difficulties, head and face trauma and child abuse in the medical histories of seriously delinquent children. Amer. J. Psychiat., 136:419-423. PINCUS, J. H. & GLASER, G. H. (1979a), Violent juvenile delinquents. This Journal, 18:307-319. BALLA, D. A. & SHANOK, S. S. (1979b), Some evidence of race bias in the diagnosis and treatment of the juvenile offender. Amer. J. Orthopsychiat., 49:53-61. SHANOK, S. S., COHEN, R. J., KLiGFIELD, M. & FRISONE, G.
RACE, HEALTH, AND DELINQUENCY (1980), Race bias in the diagnosis and disposition of violent adolescents. Amer. J. Psychiat., 137:1211-1216. - - - - PINCUS, J. H. & GIAMMARINO, M. (1982), The medical assessment of seriously delinquent boys. J. Adolesc. Hlth Care, 3:160-164. MARE, R. D. (1982), Socioeconomic effects in child mortality in the U.S. Amer. J. Public Hlth., 72:539-547. PASAMANICK, B., RODGERS, M. E. & LILIENFELD, A. M. (1956), Pregnancy experience and the development of behavior disorders in children. Amer. J. Psychiat., 112:613-618. O'MALLEY, M. (1914), Psychoses in the colored race. A mer. J. Insanity, 71:309-337.
167
Scon, P. D. (1975), Medical aspects of delinquency. In: Contemporary Psychiatry, ed. T. Silverstone & B. A. Baraclough. London: Headley Brothers Ltd., pp. 287-295. STOn, D. H. & LATCHFORD, S. A. (1976), Prenatal antecedants of child healthy development and behavior. This Journal, 15:161191. U.S. DEPT. OF COMMERCE (1982-83), Statistical Abstract of the U.S. Washington, D.C.: Bureau of the Census, pp. 73, 75. U.S. DEPT. OF HEALTH AND HUMAN SERVICES (1979-80), Executive Summary: National Studies of the Incidence and Severity of Child Abuse and Neglect. Washington, D.C.: Office of Human Development Services.
AND
ANN BARRENGOS, M.A.
This paper reports results of a study of medical histories of black and white delinquents and a matched sample of nondelinquents. Medical records were analyzed in terms of numbers and timing of hospital contacts, nature of services used, and reasons for contacts. Black delinquents made somewhat more hospital visits than white delinquents. White delinquents had significantly more hospital contacts and accidents, injuries, illnesses, and psychiatric problems than white nondelinquents. Black nondelinquents had almost as many hospital contacts as black delinquents. Findings are discussed in terms of the relevance of particular medical events to the development of maladaptive behaviors, the tendency of clinicians to dismiss as culturally expectable certain medical and psychological factors in black children and their families, and the failure of physicians to recognize the existence of severe family disorganization in black children with multiple hospital contacts. Journal of the American Academy of Child Psychiatry, 24,2:161-167, 1985.
The purpose of this paper is to report the findings of a study of the medical histories of black and white delinquents and nondelinquents and to explore their implications for understanding delinquency rates in different populations. In previous studies (Lewis and Shanok, 1977) we found that delinquents as a group had more adverse medical histories than did nondelinquents, and that severity of delinquency correlated in certain ways with severity of medical disturbance, particularly central nervous system trauma (Lewis and Shanok, 1979). We wondered whether within our delinquent and nondelinquent samples there existed any differences between the medical histories of black and white subjects that might shed light on reasons for the disproportionate representation of black youngsters in the delinquent population in the United States.
greater than expected numbers of accidents, injuries, and illnesses in the histories of delinquents (Carper, 1974; Gibbens, 1963; Lewis and Shanok, 1977). Although there is debate regarding the medical status of delinquents compared to nondelinquents, there is a consensus that socioeconomically deprived children fare worse medically than do their middle-class peers. For example, perinatal problems (Fraser and Wilks, 1959; Pasamanick et aI., 1956; Scott, 1975; Stott and Latchford, 1976) and early nutritional deficiencies (Cravioto and Delicardie, 1970) are well recognized as contributors to behavioral disturbances in later childhood. Prematurity, lead poisoning, otitis media, hearing loss, and a myriad of other medical problems are more prevalent among poor children and, what is more, their sequelae are more serious (Egbuono and Starfield, 1982). Accidents of all kinds, especially car accidents, the commonest cause of death in the adolescent population, are also more frequent in the lives of poor children. Whether or not this is a reflection of particular factors in the environment (e.g., living near busy streets) or a reflection of poor parental supervision, or both, is unclear (Mare, 1982). Comparison of black and white populations indicate that black individuals of all ages, from birth onward, have more adverse medical histories than whites (U. S. Dept. of Commerce, 1982-83). What is more, there is some indication that black adolescents suffer from many kinds of medical problems for which they do not receive care (Brunswick and Josephson, 1972). Although there have been many clinical and epidemiological studies comparing medical factors in black/ white populations, these studies rarely examine social and behavioral concomitants of medical status. For this reason we welcomed the opportunity to compare
The Literature There is debate in the literature regarding whether or not delinquents have more adverse medical histories than nondelinquents. Some investigators have reported that delinquents as a group are a healthy lot (Glueck and Glueck, 1950). Others have reported that the medical status of delinquents, while not grossly different from that of other children, is characterized by an inordinate number of minor medical problems (Eilenberg, 1961). There have been a few reports of This research was supported in part by the lttleson, KenworthySwift, and Hye/iff Foundations. Dr. Lewis is Professor of Psychiatry, New York University School of Medicine, Ms. Feldman is Research Assistant, New York University School of Medicine, and Ms. Barrengos is a graduate student, New York University. We would like to thonk Gillian and Eric Lewis for their assistance. 0002-7138/85/2402-0161 $02.00/0 © 1985 by the American Academy of Child Psychiatry. 161
162
LEWIS ET AL.
the medical histories of black and white delinquents and nondelinquents and explore possible implications of our findings for understanding some aspects of deviant behavior.
Method Samples
Our delinquent samples consisted of 41 black delinquents and 64 white delinquents chosen randomly from the roster of all youngsters referred to a juvenile court in the mid-1970s. Approximately two-thirds were boys, one-third girls. Our comparison samples consisted of 41 black nondelinquents and 64 white nondelinquents from the same geographic area as the delinquent samples and with demographic characteristics similar to those of the delinquents. Each delinquent youngster was matched for age, sex, and race with a nondelinquent youngster. Because socioeconomic status was not always clearly defined in court records but court referrals tended to come from poverty backgrounds, the comparison sample was picked from a population of which 75% would have been classified as coming from Classes IV and V according to the Hollingshead and Redlich scale (1958). Sources of Data
The assessment of medical histories was based on comprehensive reviews of each child's hospital records from the two general hospitals serving their area of residence. The choice of limiting the study to hospital records raises the issue of case loss. Although it would have been desirable to conduct interviews with subjects and their parents, issues of confidentiality precluded our doing this. Our own experience (Lewis et aI., 1979a, 1982) suggests that certain kinds of medical problems, particularly severe physical abuse, are underrecorded in hospital records. However, there is evidence that personal histories are often unreliable (Hoekelman et aI., 1976) regarding numbers of illnesses and dates of medical events. For these kinds of data, hospital records are far more accurate.
Data from private physicians were also not available. Since the great majority of subjects came from socioeconomically deprived environments, we assumed few would have used private practitioners. Furthermore, serious accidents, illnesses, or injuries would have been treated at one or the other of the hospitals studied. Medical records were assessed to determine numbers of visits, timing of visits, usage of different hospital services (e.g., emergency room, clinic, wards), and reasons for visits (e.g., accidents, head trauma, illnesses, psychiatric problems).
Findings (Tables 1-4)
We first compared black delinquents with white delinquents. As can be seen in Figure 1, although both groups were found to have adverse medical histories, as measured by numbers of hospital contacts, black delinquents had somewhat more adverse histories than white delinquents. When we considered the nature of medical problems we found no significant differences except for the finding that more black delinquents had had a skull x-ray before age 17 (6/36 (14.3%) vs. 1/61 (1.6%) xy = 4.546, P = 0.034). When we compared white delinquents with white nondelinquents (Fig. 2), we found that white delinquents had far more adverse medical histories than did white nondelinquents. They made significantly more hospital contacts of almost every kind and these differences were evident by 4 years of age. When we considered the nature of medical problems we found that significantly more white delinquents experienced accidents before age 17 years (40/63 (63.5%) vs. 24/ 61 (39.3%), xy = 6.302, p = 0.013), more had received head or face injuries before 17 years of age (20/63 (31.7%) vs. 12/61 (19.7%), xy = 1.771, p = 0.184), significantly more had records of having been abused (7/61 (11.1%) vs. 0, xY = 5.249, p = 0.023), significantly more had psychiatric symptoms recorded before age 17 years (10/64 (15.6%) vs. 1/60 (1.6%), xY =
TABLE 1 Hospital Use and Number of Accidents of Black Delinquents us. White Delinquents· Mean No. of Contact8
H08pital Service UBed and No. of AccidentB
Black delinquentB
White delinquentB
t te8t
P Value
Degree8 Freedom
Total Vi8it8 before 17 ER vi8itB before 17 Clinic vi8itB before 17 Ward admi88ion8 before 17 AccidentB before 17 Total vi8itB before 4 ER vi8itB before 4
12.643 6.220 5.707 0.488 2.390 4.548 2.095
9.635 2.825 6.206 0.571 1.742 3.079 0.746
-1.030 -3.322 0.217 0.402 -1.3b9 -1.005 -2.718
NS <0.005 NS NS NS NS <0.010
103 102 102 102 101 103 103
• Re8ultB of a two-tailed t te8t.
163
RACE, HEALTH, AND DELINQUENCY TABLE 2 Hospital Use and Number of Accidents of White Delinquents vs. White Nondelinquents· Hospital Service Used and No. of Accidents Total visits before 17 ER visits before 17 Clinic visits before 17 Ward admissions before 17 Accidents before 17 Total visits before 4 ER visits before 4
Mean No. of Contacts White delinquents
White nondelinquents
tTest
p Value
Degrees Freedom
9.531 2.781 6.156 0.563 1.714 2.734 0.734
2.934 1.148 2.484 0.197 0.869 0.918 0.246
3.056 3.518 1.798 2.252 2.490 1.997 2.209
<0.005 <0.001 0.10> p > 0.05 <0.050 <0.050 <0.050 <0.050
123 123 124 123 122 123 123
• Results of a two-tailed t test. TABLE 3 Hospital Use and Number of Accidents of Black Delinquents vs. Black Nondelinquents· Mean No. of Contacts
Hospital Service Used and No. of Accidents
Black delinquents
Black nondelinquents
t Test
p Value
Degrees Freedom
Total visits before 17 ER visits before 17 Clinic visits before 17 Ward admissions before 17 Accidents before 17 Total visits before 4 ER visits before 4
12.300 6.282 5.333 0.462 2.410 4.700 2.200
8.463 4.390 3.707 0.341 1.707 1.244 1.024
1.442 1.260 1.056 0.780 1.082 2.695 1.842
NS NS NS NS NS <0.010 0.10> P > 0.05
79 78 78 78 78 79 79
• Results of a two-tailed t test. TABLE 4 Hospital Use and Number of Accidents of Black Nondelinquents and White Nondelinquents· Mean No. of Contacts
Hospital Service Used and No. of Accidents
Black nondelinquents
White nondelinquents
t Test
p Value
Degrees Freedom
Total visits before 17 ER visits before 17 Clinic visits before 17 Ward admissions before 17 Accidents before 17 Total visits before 4 ER visits before 4
8.463 4.390 3.707 0.341 1.707 1.244 1.024
2.934 1.148 2.484 0.197 0.869
3.190 3.925 0.747 1.309 1.920 0.607 2.730
<0.010 <0.001 NS NS <0.050 NS <0.010
100 100 100 100 100 100 100
0.91~
0.246
• Results of a two-tailed t test.
5.969, p = 0.015), significantly more had social work or psychiatric consultations before age 17 years (8/64 (12.5%) vs. 0, xy = 6.193,p = 0.013), and significantly more had a parent with psychiatric disturbance noted in the chart or a parent with a history of psychiatric treatment (16/62 (25.8%) vs. 5/61 (8.2%), xy = 5.548, p = 0.019). Differences between black delinquents and black nondelinquents, however, were not as striking (Fig. 3). In fact, the only significant difference between the groups in terms of numbers of hospital contacts was numbers of hospital visits prior to 4 years of age. When we considered reasons for medical contacts,
similar proportions of black delinquents and black nondelinquents had been treated for accidents before age 17 years (66.7% vs. 51.2%), had psychiatric symptoms noted (23.1% vs. 19.5%), and had been referred to a social worker or psychiatrist (7.7% vs. 12.5%). Of note, very few of the parents of black children from either group were described as having received psychiatric treatment of any kind (2.6% vs. 2.4%). It is also interesting, in view of the high prevalence of accidents and injuries in the two black groups, that physical abuse was almost never recognized as having occurred in either group of black children (5.1% vs. 2.4%). The only significant difference in terms of
164
LEWIS ET AL.
12 10 8
6
.
4 2
Total' Visits Before 17
ER Visits Defore 17
Clinic Visits Before 17
I~rd Accidents Admissions Before 17 Before 17
Total Visits Before 'I
6~ sits
Defore 4
FIG. 1. Hospital use and number of accidents of black delinquents vs. white delinquents.
12 • 10 • D
6
4 2
Total Visits Before 17
ER Visits Uefore 17
Clinic Visits Defore 17
Ward Accidents Admissions Before 17 Before 17
Total Visits Before 4
E
Vi s its Before 'I
FIG. 2. Hospital use and number of accidents of white delinquents vs. white nondelinquents.
reasons for hospital contacts was the finding that more black delinquents than black nondelinquents were treated for a head or face injury before age 17 years (18/39 (46.2%) vs. 9/41 (22.0%), xy = 4.210, p = 0.041). The greater vulnerabilities of the black nondelinquent group compared to the white nondelinquent group can be seen best in Figure 4. They made almost 3 times as many hospital visits, almost 4 times as many emergency room visits, and had twice as many accidents before 17 years of age. They were especially
likely to require emergency services prior to 4 years of age.
Discussion Clearly both black delinquents and white delinquents have more adverse medical histories than do their nondelinquent counterparts. The most important findings of this study were 1) that black delinquents are only somewhat more vulnerable medically than black nondelinquents and 2) that black nondelinquents from socially disadvantaged environments
165
RACE, HEALTH, AND DELINQUENCY
12 10
8 6 4 2
Vi s its Before 17
ER Visits Before 17
Clinic Visits Before 17
lIard Accidents Admissions Before 17 Before 17
FIG. 3. Hospital use and number of accidents of black delinquents
Total Visits Before 4 VB.
[~
. V,S,tS Before 4
black nondelinquents.
12 10
8 6 4
2
Total Vi sits Before 17
ER Vi sits Before 17
Clinic Vis its Before 17
~Iard
Admi ss ions Before 17
Accidents Before 17
Total Vi s its Before 4
1\
FIG. 4. Hospital use and number of accidents of black nondelinquents and white nondelinquents.
have far worse medical histories than white nondelinquents from socially disadvantaged environments. These findings shed some new light on possible reasons why delinquency rates are higher among blacks than whites in our country. First, greater numbers of hospital contacts for black children may indicate that greater proportions of black than white youngsters suffer from the kinds of accidents, illnesses, and emotional disorders associated with subsequent poor impulse control and impaired judgment. We know, for example, that black nondelinquents
made almost 4 times as many emergency room visits as white nondelinquents and suffered twice as many accidents before 17 years of age. They were especially at risk prior to 4 years of age, if emergency room contacts are considered a reflection of probable trauma. These findings are consistent with U.S. statistics on infant mortality. For example, of every 100,000 white children under 1 year of age, 1330 died, whereas of every 100,000 black children under 1 year of age, 2830 died (U.S. Dept. of Commerce, 1982-83). Moreover, between ages 1 and 4 years, 66 white chil-
166
LEWIS ET AL.
dren per 100,000 died compared with 107 black children per 100,000. Given the high occurrence of accidents and injuries in our black samples, the finding that few were recognized as having been abused stands out. We know from previous studies (Lewis et al., 1979a, 1979b) that delinquent children, black and white, are often victims of abuse. It would seem that clinicians have special difficulty recognizing abuse in minority populations. National statistics indicate that physical abuse is recognized almost 5 times as often in poor white children as it is in poor nonwhite children (U.S. Dept. of Health and Human Services, 197980). It is, of course, conceivable that abuse is rare in the poor black population. Our own clinical and epidemiological studies suggest that, on the contrary, abuse occurs at least as frequently in the families of black delinquents as it does in those of white delinquents. It tends, however, to go unrecognized or to be dismissed as culturally acceptable behavior. Thus abused black children are less likely to receive protection than abused white children. This phenomenon alone probably contributes significantly to the vulnerabilities of black children to delinquency. The fact that black youngsters tended to have greater numbers of hospital contacts for all sorts of reasons, not just head trauma, may tell something about the disorganization of the families from which they come. Parental difficulty in providing necessary support and protection is reflected in the myriad different reasons that brought children to the hospital. Equally noteworthy was the finding that hardly any black mothers or fathers were described as having psychiatric problems and almost none had ever received psychiatric treatment. It is, of course, possible that the lack of documentation of family psychopathology was an indication that none existed. It is more likely that psychiatric problems in parents of black children were either overlooked or dismissed as culturally expectable. We know, for example, from previous studies of delinquent children from similar backgrounds, (Lewis et al., 1980), that behaviors in white delinquents that are recognized as indicators of psychopathology, in black delinquents are dismissed as simply antisocial. Perhaps this same tendency toward bias in the interpretation of black children's behaviors holds true when clinicians are confronted with the task of understanding the parents of these children. When we look at the history of psychiatry in America we find rationalization after rationalization for excluding troubled black individuals from treatment. From the assertions of O'Malley (1914) that visual hallucinations in blacks were culturally expectable, to the more recent sociological perspective of Fischer (1969) that sick behavior in whites could be adaptive
and normal in blacks, excuses have been made for dismissing psychopathology in the black population. If there is no psychopathology, then there is no need for treatment. Our findings are not simply academic. They have implications for the possible reduction of delinquency rates in black and white children. They suggest that multiple hospital contacts for a variety of different problems, especially emergency room visits, particularly during the first four years of life, are often associated with a child's future social maladaptation. They also suggest that frequent visits to different hospital services for a myriad of different kinds of problems may be important indicators of extreme family disorganization. Our findings also suggest that when black children present with this constellation of medical events, any needs beyond care of the immediate presenting problem are likely to be overlooked. The possibility of abuse is especially likely to be missed. Most important, severe disturbance in their familes, especially the existence of serious psychiatric illness, will usually be overlooked or ignored. Whereas in the case of black children the kind of intrafamilial disorganization, neglect, and abuse conducive to the development of delinquency is permitted to continue uninterrupted, in the case of white children, it is more likely to be recognized and treated. References BRUNSWICK, A. F. & JOSEPHSON, E. (1972), Adolescent health in Harlem. Amer. J. Public Hlth. Suppl., 10:1-62. CARPER, J. (1974), Medical care of delinquent adolescent boys. Pediat. Clin. N. Amer., 21:423-433. CRAVIOTO, J. & DELICARDlE, E. R. (1970), Mental performance in school age children. Amer. J. Dis. Child., 120:404-410. EGBUONO, L. & STARFIELD, B. (1982), Child health and social status. Pediatrics, 69:550-557. ElLENBERG, M. D. (1961), Remand home boys 1930-1955. Brit. J. Criminol., 2:111-131. FISCHER, J. (1969), Negroes and whites and rates of mental illness. Psychiatry, 32:438-446. FRASER, M. S. & WILKS, J. (1959), The residual effects of neonatal asphyxia. J. Obstet. Gynoecol. Brit. Emp., 66:748-752. GIBBENS, T. N. C. (1963), The effects of physical ill-health in adolescent delinquents. Proe. R. Soc. Med., 56:1086-1088. GLUECK, S. & GLUECK, E. (1950), Unraveling Juvenile Delinquency. New York: Commonwealth Fund. HOEKELMAN, M. D., KELLY, J. & ZIMMER, A. W. (1976), The reliability of maternal recall. Clin. Pediat., 15:261-265. HOLLINGSHEAD, A. & REDLICH, F. (1958), Social Class and Mental Illness. New York: John Wiley & Sons. LEWIS, D. O. & SHANOK, S. S. (1977), Medical histories of delinquent and nondelinquent children. Amer. J. Psychiat., 134:10201025. (1979), Perinatal difficulties, head and face trauma and child abuse in the medical histories of seriously delinquent children. Amer. J. Psychiat., 136:419-423. PINCUS, J. H. & GLASER, G. H. (1979a), Violent juvenile delinquents. This Journal, 18:307-319. BALLA, D. A. & SHANOK, S. S. (1979b), Some evidence of race bias in the diagnosis and treatment of the juvenile offender. Amer. J. Orthopsychiat., 49:53-61. SHANOK, S. S., COHEN, R. J., KLiGFIELD, M. & FRISONE, G.
RACE, HEALTH, AND DELINQUENCY (1980), Race bias in the diagnosis and disposition of violent adolescents. Amer. J. Psychiat., 137:1211-1216. - - - - PINCUS, J. H. & GIAMMARINO, M. (1982), The medical assessment of seriously delinquent boys. J. Adolesc. Hlth Care, 3:160-164. MARE, R. D. (1982), Socioeconomic effects in child mortality in the U.S. Amer. J. Public Hlth., 72:539-547. PASAMANICK, B., RODGERS, M. E. & LILIENFELD, A. M. (1956), Pregnancy experience and the development of behavior disorders in children. Amer. J. Psychiat., 112:613-618. O'MALLEY, M. (1914), Psychoses in the colored race. A mer. J. Insanity, 71:309-337.
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Scon, P. D. (1975), Medical aspects of delinquency. In: Contemporary Psychiatry, ed. T. Silverstone & B. A. Baraclough. London: Headley Brothers Ltd., pp. 287-295. STOn, D. H. & LATCHFORD, S. A. (1976), Prenatal antecedants of child healthy development and behavior. This Journal, 15:161191. U.S. DEPT. OF COMMERCE (1982-83), Statistical Abstract of the U.S. Washington, D.C.: Bureau of the Census, pp. 73, 75. U.S. DEPT. OF HEALTH AND HUMAN SERVICES (1979-80), Executive Summary: National Studies of the Incidence and Severity of Child Abuse and Neglect. Washington, D.C.: Office of Human Development Services.