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Some Types of Delinquent Behavior
Some Types of Delinquent Behavior CHARLES G. SOLKY, M.D. DAVID L. MILLER, M.D.
As the role of the pediatrician changes today, he is confronted more and more with the need to provide guidance for the emotional as well as the physical problems of children and their families. Parents look to the physician for guidance with their concerns about development, for advice about prophylaxis of emotional difficulties, and for help in the management of family crises involving the child. 4 Among the psychologic and psychosocial difficulties for which the pediatrician is asked to provide primary care, few may present with the sense of urgency which one can see in the families of children with socially deviant behavior (although in some cases one observes a facade of indifference or even pleasure). If the primary physician is to respond adequately in terms of advice, direct management or appropriate referral, he must understand certain basic facts about the social and cultural set of the child and his family, the pattern of intrafamilial relations, the physical and emotional development of the child, and the extent and breadth of the social problems of delinquency. He must have some knowledge of the complex and variegated causes of deviant behavior, as well as an appreciation of the variations of severity and meaning in delinquent acts.
!
EXTENT OF THE PROBLEM
We are informed that, on a national scale, delinquency has been increasing each year for the last decade. 2 In New York State the increase from 1963 to 1964 in court-adjudicated delinquency cases was 3.4 per cent. Boys outnumbered girls in these cases by 9 to 1, although in most other reports the ratio is approximately 4:1. For boys, burglary, assault, larceny other than auto theft, and auto theft were the most frequent reasons for delinquency petitions. For girls, ungovernability, running away and sexual promiscuity were most common. The age group covered by the New York statistics is six to 15 years. 3 459
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CHARLES
C.
SOLKY, DAVID
L.
MILLER
It should be noted that court-adjudicated cases of juvenile delinquent behavior are thought to represent only a small fraction of those situations in which socially deviant action is the predominant symptom. Long before a child comes to the attention of legal authorities, there are heralding signs which may be perceived by the alert parent, teacher, clergyman, physician, or others. We should like, in this communication, to consider a few of the more significant kinds of deviant behavior, comment on some of the etiologic factors, and describe a few of the early indicators of delinquency, together with the appropriate responses to them.
A TYPOLOGY OF DELINQUENT BEHAVIOR
Much of the confusion about delinquency has resulted from the misconception that all children showing deviant behavior have similar origins for their problems. We propose, following the suggestion of Adelaide Johnson,5 to divide deli;nquency into two main classes, sociologic delinquency and individual delinquency.
SOCIOLOGIC OR GANG DELINQUENCY
The sociologic or gang delinquent is part of a cultural subgroup which has been, to a greater or lesser degree, formed by consciously determined forces within the home or community. Although gang delinquency is not absent in middle or upper class areas (and may be even increasing there), its principal occurrence is in blighted, poverty-stricken and deprived urban areas. According to Cohen,l ".... it is a hallmark of subcultural delinquency that it is acquired and practiced in groups rather than independently contrived by the individual as a solution to his private problems." The disparity between home environment and the standards of middle-class society encountered in school and elsewhere has been offered as a partial explanation of the resentment and deviant behavior seen in such cultural subgroups. The complexity of gang delinquency is so great that much further research is required to elucidate its causes. It is important, however, for the pediatrician to distinguish this type of delinquent from the child whose deviant behavior is internally and unconsciously motivated. Although the management of gang delinquents requires a broadly based community social effort, the individual delinquent needs a type of personal and family treatment to be reached effectively. In some cases there will be both individual and sociologic components. For these children both individual and family psychiatric treatment, as well as environmental manipulation, will be required. Big-
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ger and better psychiatric clinics alone will not provide the answers for socially and culturally determined deviance.
INDIVIDUAL DELINQUENTS
We shall consider four types of individual delinquency based on the predominating etiologic factors. Delinquent Behavior Resulting from Developmental Retardation Occasionally a child whose cognitive development has been impaired and whose judgment is defective will engage in antisocial deviant acts because of his inability to assess their consequences. CASE 1. Duane H. is a seven-year-old boy who was referred to the Child Study Center at Strong Memorial Hospital after trying to strangle a neighbor's puppy. He had been known to the Pediatric service since age 13 months, having had a convulsive disorder since that time. At age 4* he had been referred for psychologic testing because of markedly delayed speech development. He was noted, at that point, to have a short attention span, emotional lability, hyperactive behavior, and poor tolerance to frustration, manifested in tantrum-like and aggressive behavior. His intelligence quotient at age 4* was 66. When seen at age seven, his Full Scale WISC score was 55, which was felt to be a valid estimate of his functioning. He seemed a sad and bewildered boy who, because of his cognitive defects, was unable to integrate and handle the stimuli from the world around him. His parents are warm, accepting people who felt in some ways responsible for Duane's difficulties and were determined to shelter him, keep him at home, and modify his environment as much as possible. In addition to the episode with the dog, the patient had been involved in some aggressive behavior toward the children of most of the neighbors, some of whom had been injured. The family was on poor terms with several formerly friendly neighbors because of arguments over Duane's behavior. The family pediatrician had suggested placement for Duane in a protected environment away from home, but the parents had refused adamantly. Over a period of 1* years the pediatrician, with the encouragement and support of the psychiatrist who had seen Duane, and the caseworker who had seen the parents, met regularly with the parents to talk over their feelings of responsibility for Duane's problems. He was able to talk with Mrs. H. about her feelings of guilt for having produced a defective child and to help her see and accept Duane's needs more realistically. When Duane was 8*, the mother suggested, during one of her sessions with the pediatrician, after an episode in which Duane had broken a number of windows, that perhaps he would not have to do these things if he could live in a less pressured environment. The pediatrician arranged to have the family visit the local State School, and, after three months, it was arranged for Duane to be admitted.
In this case the pediatrician was able to help the family effect an institutional placement. In other situations, families with more moderately retarded children can be helped to deal with anxieties over the
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CHARLES
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SOLKY, DAVID
L.
MILLER
child's behavior through appropriate reassurance by the pediatrician. Such families can be assisted in providing consistent guidance for their child and helped to make the child an integral part of the family. The calm pediatrician who avoids panic, when confronted by the retarded child's misbehavior, can be a strong support to the family. Delinquent Behavior in Response to Physical Handicap Some children with physical handicaps, resulting either from congenital defects or the residua of physical illness, utilize compensatory mechanisms involving deviant behavior to establish their emotional equilibrium. We do not include in this group children like the boy with hemophilia who insists upon getting involved in rough contact sports. Although the psychologic roots of the behavior may be similar, we are interested only in the child whose symptom pattern takes the form of antisocial acts. In these cases the pediatrician can serve an important prophylactic function by the ways in which he assists the parents to manage the handicapped child. CASE 2. Ronald P. is a lO-year-old Negro boy who was referred to the Child Study Center at Strong Memorial Hospital by both the Pediatric service and the school social worker. The presenting complaints about him were poor school performance, repeated truancy and, most prominently, the repeated theft of bicycles. The repetitive stealing, always of bicycles, had brought Ronald into contact with the police department on numerous occasions. Ronald lives at home with two brothers, ages 13 and 11, a sister age seven, and both parents. The family lives in a deprived neighborhood, but both parents have middle class strivings, are warm, affectionate people, and provide a good home for their children. The other siblings all appear to be doing well. Ronald's development was uneventful until age four, when he had an attack of poliomyelitis which left him with a partially paralyzed and cosmetically badly deformed right arm. His mother dates the beginning of his stealing to age seven, when, at school, other children began to call him "polio-head" and "cripple." She reports that at home Ronald frequently denies the existence of his handicap and states that he can "ride a bicycle, play ball and swim as good as anybody" if he is only given a chance. Both his brothers are excellent athletes, and physical skills are highly valued in the family. In her own interviews, Mrs. P. frequently berated herself for not having had Ronald immunized against poliomyelitis and, coupled with this, repeated concerns over her inability to intervene to stop Ronald's actions. The boy, during the sessions with the psychiatrist, after an initial period of sullen withdrawal, related well and told of his feeling isolated and different. He felt that no one would like him the way he was, that he had to try to be like everybody else, and that, in some ways, the world owed him compensation for his handicap. In this sense he seemed to have something of the psychology of the exceptional character described in the psychiatric literature. 8 It was recommended to the P. family that a period of psychotherapy be undertaken, in which Ronald could learn to re-evaluate his damaged self-esteem, begin to see some of the hostile meanings in his behavior, and adopt alternate modes for the gratification of his need for love and approval. At the same time the parents are being engaged in an attempt to help them accept, and help Ronald accept, the realistic limitations of his disability. They are also being helped to
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see the ways in which their own guilt prevents their intervening to limit Ronald's behavior. After six months of treatment there has been, to date, little alteration in the patient's behavior.
There are a number of things which can be done to recognize the potential development of such situations and to help avoid them. The pediatrician can anticipate not only feelings of guilt on the part of the parents, but also anger toward the child and impatience with him. 9 Helping the parents to realign their expectations, to encourage the child in the areas where his achievements can bring enhanced self-esteem, and, above all, to avoid unrealistic overprotection and lack of limit-setting are all within the compass of the pediatrician's function. In addition, the referral of parents to agencies where they may meet with and share experiences with the parents of other similarly handicapped children can often have a most salutary effect. Delinquent Behavior Resulting from Specific Defects of the Rearing Process Johnson and Szurek6 have described a type of antisocial behavior in which the actions of the child are fostered by the unwitting permissive sanctions of the parents. In these cases the parents' uncertainties about their own antisocial impulses are communicated subtly to the child, who then develops specific conscience defects which mirror parental problems. For example, one may see a child whose only antisocial act is stealing, with no other socially deviant behavior. The ways in which a parent can communicate ambivalent feelings about standards of behavior are manifold. When a father asks his young son to carry out the trash and then immediately checks to see whether it has been done, there is a clear implication that an alternative choice exists in the fathers mind. The mature father does not choose the role of warden. Ambiguous messages and inconsistent child-rearing practices in which a child is alternately punished and indulged, overprotected and the subject of premature demands are important factors in the evolution of conscience defects leading to antisocial behavior. The parent who tells the child, "Ill buy that toy for you, but don't tell you father," or, "It doesn't matter if I exceed the speed limit here because this road is never patrolled," is setting a model of duplicity for the child which can only result in the child's developing defective internal standards of behavior. The most helpful attitude in promoting growth and maturity is, as Johnson5 says, "neither the nagging, checking detective nor the lax, permissive condoner." There are a number of premonitory signs which are apparent to the person taking a careful history, even during the course of routine pediatric examinations. Parents who report deviant acts, e.g. stealing, may give clues to impending difficulty by the manner of the reporting. The mother who tells the pediatrician, with apparent concern, that Johnny
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CHARLES G. SOLKY, DAVID L. MILLER
has been taking money from her purse should be questioned carefully about both the circumstances surrounding the act and her responses to it. Is she able to state clearly, "Johnny, no one can take money from another person without asking for it"? Some parents, because of their own uncertainties, respond with paralysis and confusion and thereby convey to the child their own indecisiveness about what constitutes acceptable behavior. Others respond with great outbursts of rage which convey to the child the parental fright about the child's inability to control his behavior. (It should be noted that such concern is often a reflection of the parent's uncertainty about control of his own antisocial impulses.) Perhaps the most destructive way of handling such events, in terms of the ultimate formation of a responsible, defect-free conscience, is conveyed by the parent who vacillates between harsh, restrictive and punitive measures and ineffectual ignoring of the deviant behavior. Among the kinds of parental unconcern which should be a danger signal to the pediatrician is the report of the parents who say, "He only takes things at home, so we're not worried. He hasn't stolen anything outside." CASE S. Gary L. is a lS-year-old boy who was seen by one of the authors (C.S.) upon referral from the family pediatrician. He is the eldest of five children of a successful engineer and his wife, a high school teacher. Both parents are highly educated people with doctoral degrees, and the family lives comfortably in an upper-middle income suburb. Gary's difficulty began at age eight, around the time of the birth of twin brothers. At that time he began to take extra "school lunch money" from his mother's purse. This was discovered by the mother, who decided to talk with Gary, but felt that she could not tell her husband because he would "whip Gary severely." Mrs. L. herself came from a severely deprived family, had a highly punitive father, and was generally unable to set any effective limits for her children. Her original solution to Gary's problem was to fill a jar with coins from which he could take money whenever he wished. The jar was secreted in a dresser drawer to keep it hidden from Mr. L. In the next three years Gary was involved in a number of petty thefts at home. When his father discovered these episodes, he would respond with extreme anger and with threats to send the boy to reform school. On other occasions the father would try to cajole the boy with expensive presents to induce him to change his behavior. After Gary had taken 10 dollars from his father's wallet to buy some records, Mr. L. had bought him a new phonograph on which to play them. A short time after his thirteenth birthday Gary was found to be responsible for an epidemic of locker thefts in school. There was a total of four such thefts, although he initially denied heatedly all but the last of these. In that case he had been caught by a teacher in the act of rifling the locker. He did not seem outwardly disturbed at being discovered and explained that he needed some extra money which he was "borrowing temporarily" from a friend. The parents were called to school and, in a conference attended by Gary, his parents and the principal, Mrs. L. was tearful and incredulous, while Mr. L. told the principal, "I don't understand it. He's never taken anything before." At the school's suggestion the family consulted Gary's physician. Although the pediatrician had followed the boy's development with great care, the parents had never alluded to any of Gary's behavioral difficulties and even denied them when asked directly by the physician. The mother, when asked whether she had been
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troubled by her son's actions, said, "We thought he'd outgrow it. Mter all, all children take things." At this point the pediatrician felt that a psychiatric consultation would help to clarify the extent and depth of the family's problems. Both parents were uncomfortable during the initial interview with the psychiatrist. Mr. L. alternated between dismissing Gary's troubles as unimportant and blaming them on the school, the boy's friends, and his wife. He had a facade of determined bravado and insisted initially that they were there because the pediatrician had insisted upon it, but were actually capable of handling the situation. Mrs. L. spent most of the time trying to placate her husband openly, while giving the impression covertly that she disagreed with almost all his ideas on child rearing. A discussion of everyday household routine revealed some amazing inconsistencies. Mr. L. was frequently away from home on business trips. When he was at home, all the children, including Gary, were in bed at 8:30 p.m. When he was away, Gary and his ll-year-old brother often stayed up until midnight, watching television. Mother repeatedly encouraged the children to evade rules which father made, and he, in turn, responded to the evasions by making the rules more rigid and restrictive. The tenor of Gary's relation with his parents is perhaps best indicated by the fact that he called his father "Sir" and addressed his mother by her first name. It became clear that the parents were locked in a severe marital conHict which often used the children as the battleground. Gary, when first seen, was reticent and angry. By the third meeting, however, he had begun to talk of the impossibility of satisfying both parents simultaneously. His talk alternated between expressions of mounting frustration, anger and despair, and a kind of bland, casual indifference. It became clear that dealing with the depression, with the boy feeling that his parents really condoned his stealing, and with his use of the behavior as a means of punishing and embarrassing them, would require a prolonged psychotherapeutic effort. The psychiatrist recommended treatment for the parents with a social caseworker conjointly with Gary's treatment. They were at first extremely reluctant to undertake such a course, but an explanation that Gary's problem was in reality a situation involving the entire family helped them to accept the recommendation. The pediatrician was most useful in helping the family to follow the advice of the psychiatrist, having been continually apprised of the progress of the psychiatric consultation. Treatment has continued for over a year, twice weekly for the boy and once weekly for the parents. The course has been stormy, with several repeated episodes of stealing, especially in the first six months. These seemed to be associated with two things. First, they occurred whenever Gary had to confront the hostility toward his parents implicit in his behavior. Second, they occurred when the parents began to be able, as a result of their own treatment, to establish reasonable, firm, consistent limits for Gary which were mutually agreeable to them. It appeared that the boy had to test the new limits repeatedly in order to assure himself of their constancy. At present, treatment is continuing, and the prognosis, with the increasing stresses of adolescence, is guarded.
It is helpful to examine the factors in this case which led the pediatrician to make a psychiatric referral. First, there was a long history of stealing which appeared as an isolated symptom and seemed to be getting progressively worse. Second, there was the indication that the problem was occurring in a setting of considerable family conflict which might itself require intervention. Third, it was clear that the boy's behavior was not part of a general cultural phenomenon, but a highly idiosyncratic thing. Fourth, the pediatrician responded to the family's inability to deal with any of the patient's earlier behavior in a constructive
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MILLER
way. He assumed correctly that such ignoring indicated more deepseated pathology than would have been indicated by an earlier call for help. He was particularly impressed by the fact that external coercion was the initial force in bringing the family for help. Delinquent Behavior as a Manifestation of Psychotic Illness At times the schizophrenic or preschizophrenic child or adolescent first comes to the attention of the pediatrician because of antisocial acts. The behavior of such children has a number of features which should suggest the possibility of psychotic disorder. Frequently these children show periods of social withdrawal, characterized by isolation, daydreaming, and seeming unawareness of their surroundings. These periods alternate with episodes of intense, uncontrolled and destructive rage. During such a period of aggression in school, for example, a schizophrenic child may assault and bite other children, attack his teacher, smash furniture, urinate, defecate, or even attempt literally to kill his classmates. Kaufman7 reports one case in which, during a violent rage, a psychotic child tried to saw off his sister's arm. Another characteristic of the psychotic delinquent is that the motivation for his antisocial actions is rarely clear to an external observer. Unlike the deviance of the delinquent with a defective conscience, his acts seem to be purposeless. If there are goals to be secured in terms of environmental response, they are obscure and distorted. Inner fantasy and concern are the stimuli for the psychotic child. Such a child may perform the most bizarre or horrifying act with an air of bland indifference. He may assault a totally unknown person without remorse or even anger. The psychotic delinquent is almost always a «loner," and, if he should perchance be part of a gang, he is often regarded with fear by the other gang members. In group delinquent acts he goes far beyond the others in the losses of control in behavior and in the bizarre and savage quality of his acts. The specific acts themselves, like firesetting and even murder, are atypical for most delinquents. In addition, and this is particularly true of the prepsychotic child, there are often other severe emotional problems, e.g. incapacitating phobias or compulsions. It has been reported that the families of psychotic delinquents show certain characteristics which may be diagnostically helpful. One or both of the parents may be psychotic or overtly antisocial. The families often have bizarre and superficial patterns of relations within the community. Most important to the physician, the parents of these children tend to be unable to give connected and definite descriptions of events. Histories are vague and often slightly bizarre. When confronted with a child in whom he suspects psychosis, the pediatrician should make a concerted effort to obtain immediate psychi-
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atric help. The disorganization of the family and their intense anxiety about referral usually make the physician's role difficult. He is faced with the problem often of making the appointments for the family and, as in one particularly urgent case in our Child Study Center, may even have to accompany the family to its first meeting with the psychiatrist. If he has a good relation with such a family (most of their relations are tenuous), the pediatrician can be intimately involved in helping the family to accept treatment. Since treatment frequently involves in-patient care in a closed setting, and since such families often have great difficulties with separation, the role of the child's physician in effecting the transition can be vital. If it is possible to construct a hierarchy of treatment needs, then it can be said that of all delinquents, the psychotic is the most urgently in need of care, both for society's safety and his own improvement.
SUMMARY AND CONCLUSIONS
Some classification of delinquent behavior has been given with illustrations, through case reports, of their management. It is hoped that the pediatrician, by becoming aware of the pathogenic possibilities inherent in retardation, physical handicaps, defective rearing processes, and psychosis, can undertake some primary preventive measures. It is recommended that careful history-taking, which includes consideration of parental attitudes, examination of family routine, e.g. bedtime, feeding practices, expected standards of behavior, discipline, can uncover factors around which the pediatrician can center his prophylactic advice. Finally, it is hoped that the pediatrician's recognition of pathology can increase the possibility of early referral when such is indicated.
REFERENCES 1. Cohen, A. K.: Delinquent Boys: The Culture of the Gang. Glencoe, Ill., Free Press, 1955. 2. Daniels, L.: A Look at Juvenile Delinquency. Publication #380. Washington, D.C., Children's Bureau, 1964. 3. Data on Youth. Albany, New York, New York State Division for YouL'1, 1965. 4. Green, M.: Comprehensive Pediatrics and the Changing Role of the Pediatrician; in A. J. Solnit and S. A. Provence (Eds.): in Modern Perspectives in Child Development. New York, International Universities Press, 1963. 5. Johnson, A. M.: Juvenile Delinquency; in S. Arieti (Ed.): American Handbook of Psychiatry. New York, Basic Books, 1959. 6. Johnson, A. M., and Szurek, S. M.: The Genesis of Antisocial Acting Out in Children and Adults. Psychoanalyt. Quart., 21:323, 1952. 7. Kaufman, I., and others: Delineation of Two Diagnostic Groups Among Juvenile Delinquents: The Schizophrenic and the Impulse-Ridden Character Disorder. /. Amer. Acad. Child Psychiat., 2:292, 1963.
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L.
MILLER
8. Niederland, W.: Narcissistic Ego Impainnent in Patients with Early Physical Malformations; in R. Eissler et al. (Eds.): The Psychoanalytic Study at the Child. New York, International Universities Press, 1965, Vol. XX. 9. Work, H., and Call, J.: Handbook of Preventive Child Psychiatry. New York, McGraw-Hill Book Company, Inc., 1965. Strong Memorial Hospital 260 Crittenden Boulevard Rochester, N.Y. 14620
As the role of the pediatrician changes today, he is confronted more and more with the need to provide guidance for the emotional as well as the physical problems of children and their families. Parents look to the physician for guidance with their concerns about development, for advice about prophylaxis of emotional difficulties, and for help in the management of family crises involving the child. 4 Among the psychologic and psychosocial difficulties for which the pediatrician is asked to provide primary care, few may present with the sense of urgency which one can see in the families of children with socially deviant behavior (although in some cases one observes a facade of indifference or even pleasure). If the primary physician is to respond adequately in terms of advice, direct management or appropriate referral, he must understand certain basic facts about the social and cultural set of the child and his family, the pattern of intrafamilial relations, the physical and emotional development of the child, and the extent and breadth of the social problems of delinquency. He must have some knowledge of the complex and variegated causes of deviant behavior, as well as an appreciation of the variations of severity and meaning in delinquent acts.
!
EXTENT OF THE PROBLEM
We are informed that, on a national scale, delinquency has been increasing each year for the last decade. 2 In New York State the increase from 1963 to 1964 in court-adjudicated delinquency cases was 3.4 per cent. Boys outnumbered girls in these cases by 9 to 1, although in most other reports the ratio is approximately 4:1. For boys, burglary, assault, larceny other than auto theft, and auto theft were the most frequent reasons for delinquency petitions. For girls, ungovernability, running away and sexual promiscuity were most common. The age group covered by the New York statistics is six to 15 years. 3 459
u
I ~ !:
460
CHARLES
C.
SOLKY, DAVID
L.
MILLER
It should be noted that court-adjudicated cases of juvenile delinquent behavior are thought to represent only a small fraction of those situations in which socially deviant action is the predominant symptom. Long before a child comes to the attention of legal authorities, there are heralding signs which may be perceived by the alert parent, teacher, clergyman, physician, or others. We should like, in this communication, to consider a few of the more significant kinds of deviant behavior, comment on some of the etiologic factors, and describe a few of the early indicators of delinquency, together with the appropriate responses to them.
A TYPOLOGY OF DELINQUENT BEHAVIOR
Much of the confusion about delinquency has resulted from the misconception that all children showing deviant behavior have similar origins for their problems. We propose, following the suggestion of Adelaide Johnson,5 to divide deli;nquency into two main classes, sociologic delinquency and individual delinquency.
SOCIOLOGIC OR GANG DELINQUENCY
The sociologic or gang delinquent is part of a cultural subgroup which has been, to a greater or lesser degree, formed by consciously determined forces within the home or community. Although gang delinquency is not absent in middle or upper class areas (and may be even increasing there), its principal occurrence is in blighted, poverty-stricken and deprived urban areas. According to Cohen,l ".... it is a hallmark of subcultural delinquency that it is acquired and practiced in groups rather than independently contrived by the individual as a solution to his private problems." The disparity between home environment and the standards of middle-class society encountered in school and elsewhere has been offered as a partial explanation of the resentment and deviant behavior seen in such cultural subgroups. The complexity of gang delinquency is so great that much further research is required to elucidate its causes. It is important, however, for the pediatrician to distinguish this type of delinquent from the child whose deviant behavior is internally and unconsciously motivated. Although the management of gang delinquents requires a broadly based community social effort, the individual delinquent needs a type of personal and family treatment to be reached effectively. In some cases there will be both individual and sociologic components. For these children both individual and family psychiatric treatment, as well as environmental manipulation, will be required. Big-
SOME TYPES OF DELINQUENT BERAVIOR
461
ger and better psychiatric clinics alone will not provide the answers for socially and culturally determined deviance.
INDIVIDUAL DELINQUENTS
We shall consider four types of individual delinquency based on the predominating etiologic factors. Delinquent Behavior Resulting from Developmental Retardation Occasionally a child whose cognitive development has been impaired and whose judgment is defective will engage in antisocial deviant acts because of his inability to assess their consequences. CASE 1. Duane H. is a seven-year-old boy who was referred to the Child Study Center at Strong Memorial Hospital after trying to strangle a neighbor's puppy. He had been known to the Pediatric service since age 13 months, having had a convulsive disorder since that time. At age 4* he had been referred for psychologic testing because of markedly delayed speech development. He was noted, at that point, to have a short attention span, emotional lability, hyperactive behavior, and poor tolerance to frustration, manifested in tantrum-like and aggressive behavior. His intelligence quotient at age 4* was 66. When seen at age seven, his Full Scale WISC score was 55, which was felt to be a valid estimate of his functioning. He seemed a sad and bewildered boy who, because of his cognitive defects, was unable to integrate and handle the stimuli from the world around him. His parents are warm, accepting people who felt in some ways responsible for Duane's difficulties and were determined to shelter him, keep him at home, and modify his environment as much as possible. In addition to the episode with the dog, the patient had been involved in some aggressive behavior toward the children of most of the neighbors, some of whom had been injured. The family was on poor terms with several formerly friendly neighbors because of arguments over Duane's behavior. The family pediatrician had suggested placement for Duane in a protected environment away from home, but the parents had refused adamantly. Over a period of 1* years the pediatrician, with the encouragement and support of the psychiatrist who had seen Duane, and the caseworker who had seen the parents, met regularly with the parents to talk over their feelings of responsibility for Duane's problems. He was able to talk with Mrs. H. about her feelings of guilt for having produced a defective child and to help her see and accept Duane's needs more realistically. When Duane was 8*, the mother suggested, during one of her sessions with the pediatrician, after an episode in which Duane had broken a number of windows, that perhaps he would not have to do these things if he could live in a less pressured environment. The pediatrician arranged to have the family visit the local State School, and, after three months, it was arranged for Duane to be admitted.
In this case the pediatrician was able to help the family effect an institutional placement. In other situations, families with more moderately retarded children can be helped to deal with anxieties over the
462
CHARLES
G.
SOLKY, DAVID
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MILLER
child's behavior through appropriate reassurance by the pediatrician. Such families can be assisted in providing consistent guidance for their child and helped to make the child an integral part of the family. The calm pediatrician who avoids panic, when confronted by the retarded child's misbehavior, can be a strong support to the family. Delinquent Behavior in Response to Physical Handicap Some children with physical handicaps, resulting either from congenital defects or the residua of physical illness, utilize compensatory mechanisms involving deviant behavior to establish their emotional equilibrium. We do not include in this group children like the boy with hemophilia who insists upon getting involved in rough contact sports. Although the psychologic roots of the behavior may be similar, we are interested only in the child whose symptom pattern takes the form of antisocial acts. In these cases the pediatrician can serve an important prophylactic function by the ways in which he assists the parents to manage the handicapped child. CASE 2. Ronald P. is a lO-year-old Negro boy who was referred to the Child Study Center at Strong Memorial Hospital by both the Pediatric service and the school social worker. The presenting complaints about him were poor school performance, repeated truancy and, most prominently, the repeated theft of bicycles. The repetitive stealing, always of bicycles, had brought Ronald into contact with the police department on numerous occasions. Ronald lives at home with two brothers, ages 13 and 11, a sister age seven, and both parents. The family lives in a deprived neighborhood, but both parents have middle class strivings, are warm, affectionate people, and provide a good home for their children. The other siblings all appear to be doing well. Ronald's development was uneventful until age four, when he had an attack of poliomyelitis which left him with a partially paralyzed and cosmetically badly deformed right arm. His mother dates the beginning of his stealing to age seven, when, at school, other children began to call him "polio-head" and "cripple." She reports that at home Ronald frequently denies the existence of his handicap and states that he can "ride a bicycle, play ball and swim as good as anybody" if he is only given a chance. Both his brothers are excellent athletes, and physical skills are highly valued in the family. In her own interviews, Mrs. P. frequently berated herself for not having had Ronald immunized against poliomyelitis and, coupled with this, repeated concerns over her inability to intervene to stop Ronald's actions. The boy, during the sessions with the psychiatrist, after an initial period of sullen withdrawal, related well and told of his feeling isolated and different. He felt that no one would like him the way he was, that he had to try to be like everybody else, and that, in some ways, the world owed him compensation for his handicap. In this sense he seemed to have something of the psychology of the exceptional character described in the psychiatric literature. 8 It was recommended to the P. family that a period of psychotherapy be undertaken, in which Ronald could learn to re-evaluate his damaged self-esteem, begin to see some of the hostile meanings in his behavior, and adopt alternate modes for the gratification of his need for love and approval. At the same time the parents are being engaged in an attempt to help them accept, and help Ronald accept, the realistic limitations of his disability. They are also being helped to
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see the ways in which their own guilt prevents their intervening to limit Ronald's behavior. After six months of treatment there has been, to date, little alteration in the patient's behavior.
There are a number of things which can be done to recognize the potential development of such situations and to help avoid them. The pediatrician can anticipate not only feelings of guilt on the part of the parents, but also anger toward the child and impatience with him. 9 Helping the parents to realign their expectations, to encourage the child in the areas where his achievements can bring enhanced self-esteem, and, above all, to avoid unrealistic overprotection and lack of limit-setting are all within the compass of the pediatrician's function. In addition, the referral of parents to agencies where they may meet with and share experiences with the parents of other similarly handicapped children can often have a most salutary effect. Delinquent Behavior Resulting from Specific Defects of the Rearing Process Johnson and Szurek6 have described a type of antisocial behavior in which the actions of the child are fostered by the unwitting permissive sanctions of the parents. In these cases the parents' uncertainties about their own antisocial impulses are communicated subtly to the child, who then develops specific conscience defects which mirror parental problems. For example, one may see a child whose only antisocial act is stealing, with no other socially deviant behavior. The ways in which a parent can communicate ambivalent feelings about standards of behavior are manifold. When a father asks his young son to carry out the trash and then immediately checks to see whether it has been done, there is a clear implication that an alternative choice exists in the fathers mind. The mature father does not choose the role of warden. Ambiguous messages and inconsistent child-rearing practices in which a child is alternately punished and indulged, overprotected and the subject of premature demands are important factors in the evolution of conscience defects leading to antisocial behavior. The parent who tells the child, "Ill buy that toy for you, but don't tell you father," or, "It doesn't matter if I exceed the speed limit here because this road is never patrolled," is setting a model of duplicity for the child which can only result in the child's developing defective internal standards of behavior. The most helpful attitude in promoting growth and maturity is, as Johnson5 says, "neither the nagging, checking detective nor the lax, permissive condoner." There are a number of premonitory signs which are apparent to the person taking a careful history, even during the course of routine pediatric examinations. Parents who report deviant acts, e.g. stealing, may give clues to impending difficulty by the manner of the reporting. The mother who tells the pediatrician, with apparent concern, that Johnny
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has been taking money from her purse should be questioned carefully about both the circumstances surrounding the act and her responses to it. Is she able to state clearly, "Johnny, no one can take money from another person without asking for it"? Some parents, because of their own uncertainties, respond with paralysis and confusion and thereby convey to the child their own indecisiveness about what constitutes acceptable behavior. Others respond with great outbursts of rage which convey to the child the parental fright about the child's inability to control his behavior. (It should be noted that such concern is often a reflection of the parent's uncertainty about control of his own antisocial impulses.) Perhaps the most destructive way of handling such events, in terms of the ultimate formation of a responsible, defect-free conscience, is conveyed by the parent who vacillates between harsh, restrictive and punitive measures and ineffectual ignoring of the deviant behavior. Among the kinds of parental unconcern which should be a danger signal to the pediatrician is the report of the parents who say, "He only takes things at home, so we're not worried. He hasn't stolen anything outside." CASE S. Gary L. is a lS-year-old boy who was seen by one of the authors (C.S.) upon referral from the family pediatrician. He is the eldest of five children of a successful engineer and his wife, a high school teacher. Both parents are highly educated people with doctoral degrees, and the family lives comfortably in an upper-middle income suburb. Gary's difficulty began at age eight, around the time of the birth of twin brothers. At that time he began to take extra "school lunch money" from his mother's purse. This was discovered by the mother, who decided to talk with Gary, but felt that she could not tell her husband because he would "whip Gary severely." Mrs. L. herself came from a severely deprived family, had a highly punitive father, and was generally unable to set any effective limits for her children. Her original solution to Gary's problem was to fill a jar with coins from which he could take money whenever he wished. The jar was secreted in a dresser drawer to keep it hidden from Mr. L. In the next three years Gary was involved in a number of petty thefts at home. When his father discovered these episodes, he would respond with extreme anger and with threats to send the boy to reform school. On other occasions the father would try to cajole the boy with expensive presents to induce him to change his behavior. After Gary had taken 10 dollars from his father's wallet to buy some records, Mr. L. had bought him a new phonograph on which to play them. A short time after his thirteenth birthday Gary was found to be responsible for an epidemic of locker thefts in school. There was a total of four such thefts, although he initially denied heatedly all but the last of these. In that case he had been caught by a teacher in the act of rifling the locker. He did not seem outwardly disturbed at being discovered and explained that he needed some extra money which he was "borrowing temporarily" from a friend. The parents were called to school and, in a conference attended by Gary, his parents and the principal, Mrs. L. was tearful and incredulous, while Mr. L. told the principal, "I don't understand it. He's never taken anything before." At the school's suggestion the family consulted Gary's physician. Although the pediatrician had followed the boy's development with great care, the parents had never alluded to any of Gary's behavioral difficulties and even denied them when asked directly by the physician. The mother, when asked whether she had been
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troubled by her son's actions, said, "We thought he'd outgrow it. Mter all, all children take things." At this point the pediatrician felt that a psychiatric consultation would help to clarify the extent and depth of the family's problems. Both parents were uncomfortable during the initial interview with the psychiatrist. Mr. L. alternated between dismissing Gary's troubles as unimportant and blaming them on the school, the boy's friends, and his wife. He had a facade of determined bravado and insisted initially that they were there because the pediatrician had insisted upon it, but were actually capable of handling the situation. Mrs. L. spent most of the time trying to placate her husband openly, while giving the impression covertly that she disagreed with almost all his ideas on child rearing. A discussion of everyday household routine revealed some amazing inconsistencies. Mr. L. was frequently away from home on business trips. When he was at home, all the children, including Gary, were in bed at 8:30 p.m. When he was away, Gary and his ll-year-old brother often stayed up until midnight, watching television. Mother repeatedly encouraged the children to evade rules which father made, and he, in turn, responded to the evasions by making the rules more rigid and restrictive. The tenor of Gary's relation with his parents is perhaps best indicated by the fact that he called his father "Sir" and addressed his mother by her first name. It became clear that the parents were locked in a severe marital conHict which often used the children as the battleground. Gary, when first seen, was reticent and angry. By the third meeting, however, he had begun to talk of the impossibility of satisfying both parents simultaneously. His talk alternated between expressions of mounting frustration, anger and despair, and a kind of bland, casual indifference. It became clear that dealing with the depression, with the boy feeling that his parents really condoned his stealing, and with his use of the behavior as a means of punishing and embarrassing them, would require a prolonged psychotherapeutic effort. The psychiatrist recommended treatment for the parents with a social caseworker conjointly with Gary's treatment. They were at first extremely reluctant to undertake such a course, but an explanation that Gary's problem was in reality a situation involving the entire family helped them to accept the recommendation. The pediatrician was most useful in helping the family to follow the advice of the psychiatrist, having been continually apprised of the progress of the psychiatric consultation. Treatment has continued for over a year, twice weekly for the boy and once weekly for the parents. The course has been stormy, with several repeated episodes of stealing, especially in the first six months. These seemed to be associated with two things. First, they occurred whenever Gary had to confront the hostility toward his parents implicit in his behavior. Second, they occurred when the parents began to be able, as a result of their own treatment, to establish reasonable, firm, consistent limits for Gary which were mutually agreeable to them. It appeared that the boy had to test the new limits repeatedly in order to assure himself of their constancy. At present, treatment is continuing, and the prognosis, with the increasing stresses of adolescence, is guarded.
It is helpful to examine the factors in this case which led the pediatrician to make a psychiatric referral. First, there was a long history of stealing which appeared as an isolated symptom and seemed to be getting progressively worse. Second, there was the indication that the problem was occurring in a setting of considerable family conflict which might itself require intervention. Third, it was clear that the boy's behavior was not part of a general cultural phenomenon, but a highly idiosyncratic thing. Fourth, the pediatrician responded to the family's inability to deal with any of the patient's earlier behavior in a constructive
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way. He assumed correctly that such ignoring indicated more deepseated pathology than would have been indicated by an earlier call for help. He was particularly impressed by the fact that external coercion was the initial force in bringing the family for help. Delinquent Behavior as a Manifestation of Psychotic Illness At times the schizophrenic or preschizophrenic child or adolescent first comes to the attention of the pediatrician because of antisocial acts. The behavior of such children has a number of features which should suggest the possibility of psychotic disorder. Frequently these children show periods of social withdrawal, characterized by isolation, daydreaming, and seeming unawareness of their surroundings. These periods alternate with episodes of intense, uncontrolled and destructive rage. During such a period of aggression in school, for example, a schizophrenic child may assault and bite other children, attack his teacher, smash furniture, urinate, defecate, or even attempt literally to kill his classmates. Kaufman7 reports one case in which, during a violent rage, a psychotic child tried to saw off his sister's arm. Another characteristic of the psychotic delinquent is that the motivation for his antisocial actions is rarely clear to an external observer. Unlike the deviance of the delinquent with a defective conscience, his acts seem to be purposeless. If there are goals to be secured in terms of environmental response, they are obscure and distorted. Inner fantasy and concern are the stimuli for the psychotic child. Such a child may perform the most bizarre or horrifying act with an air of bland indifference. He may assault a totally unknown person without remorse or even anger. The psychotic delinquent is almost always a «loner," and, if he should perchance be part of a gang, he is often regarded with fear by the other gang members. In group delinquent acts he goes far beyond the others in the losses of control in behavior and in the bizarre and savage quality of his acts. The specific acts themselves, like firesetting and even murder, are atypical for most delinquents. In addition, and this is particularly true of the prepsychotic child, there are often other severe emotional problems, e.g. incapacitating phobias or compulsions. It has been reported that the families of psychotic delinquents show certain characteristics which may be diagnostically helpful. One or both of the parents may be psychotic or overtly antisocial. The families often have bizarre and superficial patterns of relations within the community. Most important to the physician, the parents of these children tend to be unable to give connected and definite descriptions of events. Histories are vague and often slightly bizarre. When confronted with a child in whom he suspects psychosis, the pediatrician should make a concerted effort to obtain immediate psychi-
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atric help. The disorganization of the family and their intense anxiety about referral usually make the physician's role difficult. He is faced with the problem often of making the appointments for the family and, as in one particularly urgent case in our Child Study Center, may even have to accompany the family to its first meeting with the psychiatrist. If he has a good relation with such a family (most of their relations are tenuous), the pediatrician can be intimately involved in helping the family to accept treatment. Since treatment frequently involves in-patient care in a closed setting, and since such families often have great difficulties with separation, the role of the child's physician in effecting the transition can be vital. If it is possible to construct a hierarchy of treatment needs, then it can be said that of all delinquents, the psychotic is the most urgently in need of care, both for society's safety and his own improvement.
SUMMARY AND CONCLUSIONS
Some classification of delinquent behavior has been given with illustrations, through case reports, of their management. It is hoped that the pediatrician, by becoming aware of the pathogenic possibilities inherent in retardation, physical handicaps, defective rearing processes, and psychosis, can undertake some primary preventive measures. It is recommended that careful history-taking, which includes consideration of parental attitudes, examination of family routine, e.g. bedtime, feeding practices, expected standards of behavior, discipline, can uncover factors around which the pediatrician can center his prophylactic advice. Finally, it is hoped that the pediatrician's recognition of pathology can increase the possibility of early referral when such is indicated.
REFERENCES 1. Cohen, A. K.: Delinquent Boys: The Culture of the Gang. Glencoe, Ill., Free Press, 1955. 2. Daniels, L.: A Look at Juvenile Delinquency. Publication #380. Washington, D.C., Children's Bureau, 1964. 3. Data on Youth. Albany, New York, New York State Division for YouL'1, 1965. 4. Green, M.: Comprehensive Pediatrics and the Changing Role of the Pediatrician; in A. J. Solnit and S. A. Provence (Eds.): in Modern Perspectives in Child Development. New York, International Universities Press, 1963. 5. Johnson, A. M.: Juvenile Delinquency; in S. Arieti (Ed.): American Handbook of Psychiatry. New York, Basic Books, 1959. 6. Johnson, A. M., and Szurek, S. M.: The Genesis of Antisocial Acting Out in Children and Adults. Psychoanalyt. Quart., 21:323, 1952. 7. Kaufman, I., and others: Delineation of Two Diagnostic Groups Among Juvenile Delinquents: The Schizophrenic and the Impulse-Ridden Character Disorder. /. Amer. Acad. Child Psychiat., 2:292, 1963.
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8. Niederland, W.: Narcissistic Ego Impainnent in Patients with Early Physical Malformations; in R. Eissler et al. (Eds.): The Psychoanalytic Study at the Child. New York, International Universities Press, 1965, Vol. XX. 9. Work, H., and Call, J.: Handbook of Preventive Child Psychiatry. New York, McGraw-Hill Book Company, Inc., 1965. Strong Memorial Hospital 260 Crittenden Boulevard Rochester, N.Y. 14620