Biological Causes of Delinquency - Rosner & Schwartz (1989)

JUVENILE
PSYCHIATRY
AND THE LAW
CRITICAL ISSUES IN
AMERICAN PSYCHIATRY AND THE LAW
was edited for
THE AMERICAN ACADEMY OF PSYCHIATRY AND THE LAW
(TRI-STATE CHAPTER)
Officers
Stephen Rachlin, M.D. President Michael H. Bell, M.D. Councillor
Henry C. Weinstein, M.D. Past President Stephen B. Billick, M.D. Councillor
Stanley Kern, M.D. Vice-President Ezra Griffith, M.D. Councillor
Harold I. Schwartz, M.D. Secretary Howard Owens, M.D. Councillor
Robert L. Goldstein, M.D. Treasurer Sheldon Travin, M.D. Councillor
Richard Rosner, M.D. Founding President Howard V. Zonana, M.D. Councillor
Volume 1 Edited by Richard Rosner, M.D.
Volume 2 Edited by Richard Rosner, M.D.
Volume 3 GERIATRIC PSYCHIATRY AND THE LAW

Edited by Richard Rosner, M.D., and Harold I. Schwartz, M.D.
Volume 4 JUVENILE PSYCHIATRY AND THE LAW

Edited by Richard Rosner, M.D., and Harold I. Schwartz, M.D.
Volume 5 CRIMINAL COURT CONSULTATION

Edited by Richard Rosner, M.D., and Ronnie B. Harmon, M.A.
Volume 6 CORRECTIONAL PSYCHIATRY

Edited by Richard Rosner, M.D., and Ronnie B. Harmon, M.A.
A Continuation Order Plan is available for this series. A continuation order will bring delivery of
each new volume immediately upon publication. Volumes are billed only upon actual shipment.
For further information please contact the publisher.
JUVENILE
PSYCHIATRY
AND THE LAW
Edited by
RICHARD ROSNER, M.D.
Clinical Associate Professor, Division 'Ii Child and Adolescent Psychiatry
Department 'Ii Psychiatry, New York University School of Medicine
Fellow, Amen"can Society for Adolescent Psychiatry
Diplomate, American Board 'Ii Forensic Psychiatry
and Medical Director, Forensic Psychiatry Clinic for the New York Criminal
and Supreme Courts (First Judicial Department), New York, New York
and
HAROLD I. SCHWARTZ, M.D.
Associate Professor 'Ii Clinical Psychiatry, Department of Psychiatry,
Mount Sinai School of Medicine, and Chiif, Psychiatric Outpatient Services,
and Chiif, Program in Psychiatry and Law, Department of Psychiatry,
Beth Israel Medical Center, New York, New York
PLENUM PRESS. NEW YORK AND LONDON

Library of Congress Catalog Card Number 88-657025
ISBN-13: 978-1-4684-5528-1 e-ISBN-13: 978-1-4684-5526-7
DOl: 10.1007/978-1-4684-5526-7
© 1989 Plenum Press, New York

Softcover reprint of the hardcover 1st edition 1989
A Division of Plenum Publishing Corporation
233 Spring Street, New York, N.Y. 10013
All rights reserved

No part of this book may be reproduced, stored in a retrieval system, or transmitted
in any form or by any means, electronic, mechanical, photocopying, microfilming,
recording, or otherwise, without written permission from the Publisher
To our parents
Contributors
Promise Ahlstrom • Division of Adolescent Medicine, Montefiore Medical

Center, Albert Einstein College of Medicine, Bronx, New York
Judith V. Becker • New York State Psychiatric Institute and Department of

Psychiatry, College of Physicians and Surgeons, Columbia University, New
York, New York
Fred S. Berlin • Department of Psychiatry, Johns Hopkins University School

of Medicine, Baltimore, Maryland
Eileen Bloomingdale • New York Medical College, Valhalla, New York
Lewis Bloomingdale • New York Medical College, Valhalla, New York
Judianne Densen-Gerber • Odyssey Institute Corporation of Connecticut,

Bridgeport, Connecticut
John R. Dugan, Jr. • Research Foundation of the City University of New

York, New York, New York
Everett Dulit • Department of Psychiatry, Montefiore Medical Center, Bronx,

New York; Department of Psychiatry, Albert Einstein School of Medicine,
Bronx, New York
Richard A. Ellison • William S. Hall Psychiatric Institute, Columbia, South

Carolina
Gloria Faretra • Queens Children's Psychiatric Center, Bellerose, New York
Donald S. Gair • Gaebler Children's Center, Massachusetts Department of

Mental Health, Waltham, Massachusetts; Department of Child Psychiatry
vii
viii CONTRIBUTORS
and Child Development, Boston University School of Medicine, Boston,

Massachusetts
Gary J. Grad • Queens Children's Psychiatric Center, Bellerose, New York
Richard J. Herrnstein • Department of Psychology, Harvard University,

Cambridge, Massachusetts
Sarla Inamdar • Department of Pediatrics, New York Medical College, Val-

halla, New York
Subhash C. Inamdar • Department of Psychiatry, New York University School

of Medicine, New York, New York
RichardJ. Kavoussi • Mount Sinai School of Medicine, New York, New York
Avron M. Kriechman • Division of Child Psychiatry, Schneider Children's

Hospital, Long Island Jewish Hillside Medical Center, New Hyde Park,
New York; Department of Psychiatry, State University of New York at
Stony Brook, Stony Brook, New York
Richard C. Marohn • Department of Clinical Psychiatry, Northwestern Uni-

versity Medical School, Chicago, Illinois
Robert B. Millman • Departments of Psychiatry and Public Health, New York

Hospital-Cornell Medical Center, New York, New York
Hart de Coudres Peterson • Departments of Pediatrics and Neurology, New

York Hospital, New York, New York; Departments of Pediatrics and Neu-
rology, Cornell University Medical College, New York, New York
Heidi M. Petersen • New York Academy of Medicine, New York, New York
Jacques M. Quen • Department of Psychiatry, New York Hospital-Cornell

Medical Center, New York, New York
Richard A. Ratner • Department of Psychiatry, George Washington School of

Medicine, Washington, DC; Department of Psychiatry, Saint Elizabeth's
Hospital, Washington, DC
Richard Rosner • Forensic Psychiatry Clinic of the New York Criminal and
Supreme Courts, New York, New York; Department of Psychiatry, New
York University School of Medicine, New York, New York
CONTRIBUTORS ix
S. Kenneth Schonberg • Division of Adolescent Medicine, Montefiore Medi-

cal Center, Albert Einstein College of Medicine, Bronx, New York
Larry H. Strasburger • McLean Hospital, Belmont, Massachusetts; Depart-

ment of Psychiatry, Harvard Medical School, Boston, Massachusetts
Sheldon Travin • Department of Psychiatry, Bronx-Lebanon Hospital Cen-

ter, Bronx, New York; Department of Psychiatry, Albert Einstein College
of Medicine, Bronx, New York
Alan J. Tuckman • Forensic Psychiatry Clinic, Rockland County, New York;

Department of Psychiatry, New York University School of Medicine, New
York, New York
Robert Weinstock • Department of Psychiatry, University of California-Los

Angeles, Los Angeles, California; Department of Medicine, University of
California-Irvine, Irvine, California
Foreword
I am not sure when a series of volumes becomes an "institution"; this is the

fourth annual volume of Critical Issues in American Psychiatry and the Law, and
each has been an extraordinary summary of important forensic topics. This
book makes the point that the interface of psychiatry and law is not merely a
legal one, but has a great deal to do with clinical issues such as diagnosis and
treatment.
Children and adolescents are not adults. This may come as something of a
shock to those who proselytize for equal rights for children, and to those adults
(including some psychiatrists, attorneys, and judges) who advocate giving the
child adult choices and/or responsibilities.
Children differ from adults in many ways. The specialist in child or adoles-
cent psychiatry knows not only that one must attend to special social and family
issues for juveniles, but that juveniles are more complex internally as well.
They attempt to survive in the world while rapidly growing and learning,
usually with physically and emotionally immature resources. They have had
few years in which to develop experience, and do not have the psyche with
which to integrate that experience in ways one would expect of a mature adult.
Sometimes this frightens the patient, as in the case of a physically large teen-
ager whose impulse control is impaired. Sometimes it is frustrating, as in the
case of a healthy child unable to escape from a dysfunctioning family. It is
always confusing, and usually uncomfortable.
The rights of the juvenile cannot be equal to those of the adult. Some
reasons for this are outlined in this book. Whether or not this is fair is immaterial.
It is simply foolhardy, and sometimes cruel, to award all the rights of adult-
hood-with their attendant burdens and responsibilities-to children.
The extent to which we give the child responsibility is traditionally gradu-
ated by families or courts in such a way as to balance, as nearly as possible, the
individual's ability to assume personal and social autonomy with the need for
protection and supervision. Some would have us protect the child more than
others, for example by not allowing lengthy prison sentences for even the most
heinous of juvenile crimes. It is interesting that many of these advocates state
their positions in the name of individual rights.
xi
xii FOREWORD
Read on, then, as Volume 4, juvenile Psychiatry and the Law provides fascinat-
ing insights into some of the most important clinical, legal, and social issues of
our professions.
WILLIAM H. REID, M.D., M.P.H.

President-Elect
American Academy of Psychiatry and the Law
San Antonio, Texas
Introduction
The impetus for this volume, Juvenile Psychiatry and the Law, can be dated back
to 1976, when the American Academy of Psychiatry and the Law established a
formal liaison with the American Society for Adolescent Psychiatry. That liai-
son effort produced a panel on "Adolescent Psychiatry for the Forensic Psychi-
atrist" at the AAPL convention in New York City and a reciprocal panel on
"Forensic Psychiatry for the Adolescent Psychiatrist" at the ASAP convention
in New York City. Derivative from the interest generated by those meetings,
the Psychiatry and Behavioral Science Section of the American Academy of
Forensic Sciences created a Committee on Adolescent Forensic Psychiatry and
produced its own panel on "Adolescent Psychiatry for the Forensic Psychia-
trist." Continued professional interest in the interface of forensic psychiatry
and adolescent psychiatry led to the Tri-State Chapter of the American Acade-
my of Psychiatry and the Law presenting two programs: "Sexual Offenses
against Minors" and "Juvenile Criminality," broadening the focus to include
issues in child forensic psychiatry as well as adolescent forensic psychiatry.
While the core of the present book is derived from the last two programs, the
editors have supplemented that core with chapters specifically developed for
this volume. The focus remains on teenagers, but with the understanding that
proper appreciation of the problems in adolescent forensic psychiatry calls for
understanding adolescence as part of the broader realm of childhood growth
and development and for understanding adolescent forensic psychiatry as part
of the broader realm of child psychiatry and the law.
As do the prior volumes in this series,juvenile Psychiatry and the Law pre-
sumes that all issues in forensic psychiatry can be understood by the application
of a four-step analysis:
1. What is the psychiatric-legal issue?

2. What are the legal criteria that determine the issue?
3. What are the relevant clinical data?
4. What is the reasoning process the underlies the psychiatric-legal opin-
ion regarding the issue?
xiii
xiv INTRODUCTION
A single child may be the focus of more than one psychiatric-legal issue. A
child who is the focus of a parental battle for custody may also be the focus of
an investigation as a possible person in need of supervision (PINS). An adoles-
cent may be the focus of evaluations regarding his competence to have made a
confession to a criminal act in the past and his competence to stand trial for that
criminal act in the present. There is no such thing as a general, all-purpose
forensic psychiatric examination; there are only a series of specific psychiatric-
legal examinations directed to specific psychiatric-legal issues.
The legal criteria that determine a given issue are context dependent; they
vary depending on the court having jurisdiction over the child or adolescent.
The statutes enacted by the various state legislatures are differently phrased, as
are the states' constitutions, their case law, and their administrative codes.
Thus, for example, the same offense may be initially under the purview of
family court in one state and initially the responsibility of criminal court in
another state. The factors that must be used to determine "the best interests of
the child" for custody determinations will differ from state to state, or will be
listed in a different prioritization, or will be set forth with different degrees of
imprecision. The expert who evaluates a child or adolescent for legal purposes
must obtain a clear statement of the specific legal criteria that will be used to
determine the specific psychiatric-legal issue(s) under consideration.
The relevant clinical data will vary with the issue. For the purposes of a
child custody determination, it may be important to assess the quality of a
juvenile's relationship with his mother and with his father. However, such
information may be irrelevant for an assessment of the juvenile's competence
to be a witness in a trial. Data about the past may be at issue in an assessment of
a juvenile's accusation of an alleged act of child molestation. Data relevant to
predicting the future may be at issue in a custody determination. Failure to
collect the relevant data may lead to an embarrassed witness during cross-
examination.
The complaints that psychiatric witnesses are incomprehensible and in-
credible, that psychiatry is "mostly theory" rather than based on "science," are
partially derived from the layperson's misunderstandings and partially derived
from the failure of some psychiatrists to clearly and cogently set forth the
reasoning process that underlies their opinions. The facts of a psychiatric
examination are the same as those in an orthopedic examination: what the
expert has directly seen, heard, felt, smelled (sometimes), or tasted (rarely).
The process of gathering those facts into a meaningful pattern, the interpreta-
tions of those facts, the premises and assumptions that guide the expert's
assessment, all these may need to be made explicit so as to permit the trier of
fact to understand the logical process that has led to the expert opinion.
While one may wish for an expert witness who is trained in both forensic
psychiatry as well as child and adolescent psychiatry, it is more likely that a
general psychiatrist will be asked to function as a child and adolescent forensic
psychiatric consultant, simply because there are so few practitioners trained in
both specialties. This book is designed to present materials that will be of value
INTRODUCTION xv
to the general psychiatrist called upon to function as an expert in juvenile

psychiatry and the law. It is our belief that most of the chapters will be of use to
the child and adolescent psychiatrist who is not trained in forensic psychiatry
and to the forensic psychiatrist who is not trained in child and adolescent
psychiatry. Even the dual-qualified superspecialist will find new perspectives
on familiar issues in the chapters that follow.
As in all of the prior volumes in the series Critical Issues in American Psychia-
try and the Law, it is our intention to stimulate constructive thought, rather than
to provide definitive answers.
Richard Rosner
Harold I. Schwartz
Contents
SECTION I JUVENILE CRIME
1. The Historical Challenge of Juvenile Criminality 3

Jacques M. Quen
2. Some Criminogenic Traits of Offenders 13

Richard J. Herrnstein
3. Biological Causes of Delinquency 29

Richard A. Ratner
4. A Psychodynamic Approach to Understanding Juvenile Criminality 45

Richard C. Marohn
5. Childhood Identification and Prophylaxis of Antisocial Personality

Disorder ..................................................... 65
Lewis Bloomingdale and Eileen Bloomingdale
SECTION II SEXUAL ISSUES
6. Psychiatric Aspects of Incest Involving Juveniles 85

Sheldon Travin
7. Intrafamilial Child Sexual Abuse and Forensic Psychiatrists 107

Alan J. Tuckman
xvii
xviii CONTENTS
8. Special Considerations in the Psychiatric Evaluation

of Sexual Offenders against Minors.. . . . . . .. . .. . .. . . . . . . .. . . . . . . .. 119
Fred S. Berlin
9. Diagnosis and Treatment ofJuvenile Sex Offenders 133

Judith V. Becker and Richard J. Kavoussi
10. The United States Age-of-Consent Laws Governing the Sexual Conduct of
Minors: A Rationale for National Uniformity; an Overview of the Present
Law; a Proposal for Reform ..................................... 145
Judianne Densen-Gerber and John R. Dugan, Jr.
SECTION III CLINICAL CONSIDERATIONS
11. Assessment of Juvenile Psychopathology for Legal Purposes 183

Richard Rosner
12. Emotional, Cognitive, and Moral Developmental Considerations in

Interviews of Adolescents for Forensic Purposes . . . . . . . . . . . . . . . . . . . . .. 199
Robert Weinstock
13. Adolescent Psychological Development: Normal and Abnormal 219

Everett Dulit
14. Substance Abuse among Juveniles. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 237

Heidi M. Petersen and Robert B. Millman
15. Issues in the Forensic Assessment of the Black Adolescent 257

Richard A. Ellison
16. A Reintroduction to Pediatric Medicine for Forensic Psychiatrists 271

Sarla Inamdar
17. Issues of Adolescent Medicine 289

Promise Ahlstrom and S. Kenneth Schonberg
18. An Introduction to Child and Adolescent Neurology for Forensic

Psychiatrists. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 307
Hart de Coudres Peterson
CONTENTS xix
SECTION IV HOSPITAL ISSUES
19. The Psychiatrically Hospitalized Adolescent as Victim: Forensic Psychiatric

Considerations . ............................................... , 319
Subhash C. Inamdar
20. Special Considerations in the Inhospital Treatment of Dangerously Violent

Juveniles .......... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 333
Gloria Faretra and Gary J. Grad
21. Psychiatric Restraint of Children and Adolescents: Clinical and Legal

Aspects . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 345
Donald S. Gair
SECTION V PUBLIC POLICY ISSUES
22. The Adolescent's Right to Psychiatric Care. . . . . . . . . . . . . . . . . . . . . . . . .. 381

Avron M. Kriechman
23. The Juvenile Transfer Hearing and the Forensic Psychiatrist 391
Larry H. Strasburger
Index............... . ....... ...... ..... .......... ......... .. . .. .. 405

JUVENILE
PSYCHIATRY
AND THE LAW
I
Juvenile Crime
1
The Historical Challenge of
Juvenile Criminality
JACQUES M. QUEN
INTRODUCTION
Juvenile criminality has been a problem for mankind since Biblical times, at
least. Those acts that threaten the community structure, be it family, tribe, or
nation, may be as destructive when committed by a child as by an adult. How-
ever, throughout time, human communities, as with other animal societies,
have distinguished between the acts of children or babies and mature orga-
nisms. This chapter shall present several historical aspects of juvenile crimi-
nality in the Western world and will discuss those factors, relative to criminal
law, to psychiatry, and to society.
DEFINITIONS
Black's Law Dictionaryl defines ')uvenile" as "A young person who has
not yet attained the age at which he or she should be treated as an adult for
purposes of criminal law. In some American states, this age is seventeen. Under
the federal Juvenile Delinquency Act, a )uvenile' is a person who has not
attained his eighteenth birthday .... In law, the terms )uvenile' and 'minor' are
usually used in different contexts; [juvenile] when referring to young criminal
offenders, [minor] to legal capacity or majority."
The period between birth and adulthood has varied in different cultures
and eras. In ancient Hebrew law boys became adults at the age of 13; girls at
the age of 12.2 In 7th-century England, the Saxons held that those above the
JACQUES M. QUEN • Department of Psychiatry, New York Hospital-Cornell Medical Cen-

ter, New York, New York 10021.
3
4 JACQUES M. QUEN
age of 10 could be guilty of theft. Three centuries later, it was decreed that
those above the age of 12, caught in the act, could be found guilty of theft.
Those under 15 were not subject to capital punishment. Those between 12 and
15 who were convincted of a capital crime were spared and had to swear that
they would do no more evil. If caught stealing again, they were executed,
regardless of age. 3
In 4th-century England, under Edward III, the emphasis was shifted from
age to functional capabilities and resembled earlier Roman law. Under the age
of seven, a child was unequivocally unable to have the necessary mental ability
to commit a crime. Between 7 and 14 years of age, it was a presumption of law
that a child did not yet have that capacity, but if sufficient malice was present, it
could make up for the lack of years ("malice supplements age"). From 14 on, a
child, though still a minor, was legally presumed to have sufficient functional
capacity to commit any crime. 5
The British jurist-scholar, Mathew Hale, is often misunderstood to have
required a near-impossible "perfect insanity" to hold the mentally ill non-
responsible. Hale did not mean the complete absence of any sane functioning,
or as Erskine misconstrued in the trial of Hadfield, that exculpable insanity
required "such a state of prostrated intellect, as not to know his name, nor his
condition, nor his relation toward others-that if a husband, he should not
know he was married; or if a father could not remember he had children; nor
know the road to his house, etc."5* In fact, Hale's suggestion for the distinction
between a "perfect insanity" that would excuse and a partial insanity that would
not, was the understanding ordinarily possessed by the ordinary 14-year-old.
By Hale's standard, an adult with the understanding of a 10-year-old could not
be guilty of a felony. However, a normal lO-year-old, with sufficient demon-
strated malice could be found guilty of a felony. Hale's standard excluded the
mentally ill from such a vulnerability.6 It provided far greater protection of the
law to them than have most subsequent standards.
For the purposes of this presentation, unless stated otherwise, "crimes"
will be refer to common law crimes-murder, assault, rape, robbery, burglary,
theft, and arson.
There has been and is still a category of offenses peculiar to children, such
as running away from home, being beyond the control of parents, truancy, etc.
They are called status offenses and do not apply to adults. It appears that these
were designed to facilitate the roles and authority of parents in raising and
acculturating their children. By active statutory support of parental authority
the state would minimize the likelihood of having to assume its parens patriae
obligations. That Latin term originates from the English common law where
the monarch had a royal prerogative to act as guardian to persons with legal
disabilities, such as "infants, idiots, and lunatics."l Although the dictionary
*Drs. Marlin Mattson and Leonard Lexier called to my attention that the article errs in stating
that the royal visitor who interviewed Hadfield backstage immediately after the incident was
King George III. It was not the King. It was the Duke of York.
HISTORICAL CHALLENGE OF JUVENILE CRIMINAUTY 5
definition uses the phrase "royal prerogative," it is generally viewed as a gov-

ernmental obligation in the United States.
Those legally disabled groups have functional impairments which are bio-
logically determined or imposed upon the individual and are subject to medical
care or intervention. Although disability is a legally accurate word-we should
recognize that these are legal incompetencies. In fact, although not mentioned
by Lord Coke in his classic discussion of Beverly v. Snow 7 , infancy was a fifth
class of non compos mentis or mental incompetence in his time as well.
It is this age group that perhaps most clearly demonstrates the factual
justification and precedent for specifying discrete incompetencies. Bouvier's
Law Dictionary of 1868 said that "at common law a male at 14 is of discretion,
and may consent to marry; and at that age he may disagree to and annul a
marriage he may before that time have contracted ... he may act as executor at
the age of 17 years. A female ... at 12 may consent or disagree to marriage;
and ... at seventeen she may act as executrix."8 We see here (and in other legal
codes as well) the recognition of differential psychosexual development and,
within the same individual, coexisting discrete competencies and incompeten-
Cies.
I have referred to the disabilities of the infant, idiot, and lunatic as biolog-
ically determined. However, the expression of those legal disabilities is psycho-
logical. What is disabled in these cases are not physical functions but mental or
psychological ones. It is because of the psychological nature of these disabilities
and because of the differential rate of development of competencies-as well
as different etiologies of incompetencies-that the law calls upon experts in
child development, mental retardation, and psychiatry to assist the juries and
the courts.
LEGISLATION AND THE CHILD
Throughout history, one finds legal penalties that are severe together with
concurrent mechanisms designed to weaken or discourage their implementa-
tion. So in the Bible, we find in Exodus 21: 15, "And he that smiteth his father or
his mother shall be surely put to death." Excessive? Harsh? But, further study
reveals that the ancient rabbis of the Old Testament determined that only some
smites are punishable (i.e., those that leave wounds).2
Puritan Massachusetts had a statute in 1648 that said,
If any child, ... above sixteen years old, and of sufficient understanding, shall
CURSE, or SMITE their natural FATHER, or MOTHER; he ... shall be put to
death: unless it can be sufficiently testified that the Parents have been very
unchristianly negligent in the education of such children; or so provoked them
byextream [sic), and cruel correction; that they have been forced thereunto to
preserve themselves from death or maiming.!1
No execution for a simple smiting or simple cursing of a parent is known.

It should be recalled that the Puritans had come from a society in which the age
6 JACQUES M. QUEN
of criminal discretion was 14, not 16. In effect, they added a full two years after
a child could legally contract a marriage, for the age of criminal discretion.
Furthermore, although 17th-century England allowed criminal conviction and
execution of those as young as the age of eight, this statute left no room for
such court action. We should note, also, the exculpatory factors of "negligent"
education by the parents or their use of "extream and cruel correction." This
suggests that the Puritans recognized the existence and undesirability of child
abuse by parents. In this regard, the colonial Puritan theocracy actually liber-
alized the punitive laws they had brought with them from their home country.
Another statute, in 1641, said: "If any person shall willfully and unrea-
sonably deny any Child, timely or convenient marriage, or shall exercise any
unnatural severity toward them; such children shall have liberty to complain to
Authority for redress in such cases."9 This statute is clearly a reaffirmation of a
recognition of the legal rights of children when faced with unacceptable paren-
tal actions.
No Orphan, during their minority, which was not committed to tuition or
service by their Parents in their life time, shall afterwards be absolutely disposed
of by any, without the consent of some Court, ... except in case of marriage, in
which the approbation of a major part of the Selectmen of that Town, ... shall
be sufficient, and the minority of women in case of marriage, shall be sixteen
yeares. [1646)9
This statute extended the need for oversight and approval of the Town Se-
lectmen by two years and provided further security for the orphan.
As was pointed out, although the capital punishment offense for striking
one's parents was on the lawbooks, there is no evidence that it was ever applied
in the colonies. The same nonimplementation of harsh penalties against chil-
dren is found in British legal history. One example relevant to child criminality
in non-intra-family crimes is found in a historical study of 19th-century
England.
In 1965, Knell reported that the records of the Old Bailey in London
between 1801 and 1836 contained 103 cases of children sentenced to be ex-
ecuted. He found that of these 103, not one was executed. It should be men-
tioned that in practically every case the offense was theft, none were for homi-
cide. Knell concluded that "the [capital punishment] law, therefore, in the case
of children where stealing was concerned, was for all intents and purposes a
dead letter."ll
However, it is true that some very young children were sentenced to peni-
tentiaries for particularly vicious crimes. In 1834, in Durham, Maine, a 9-year-
old boy, Major Mitchell, with a history suggestive of organic brain damage, was
found guilty of mutilating and performing a unilateral orchiectomy on an 8-
year-old neighbor boy. Initially, the case was brought to ajustice of the peace
who fined him one dollar. Two weeks later, in response to the public outcry,
the boy was tried in the State Supreme Court and found guilty of maliciously
and criminally attacking his victim. He was sentenced to 9 years in the Thom-
HISTORICAL CHALLENGE OF JUVENILE CRIMINALITY 7
aston State Prison, a penitentiary whose cells were cut into a rock floor, entered
by a ladder, and constructed for solitary occupancy. Recent research shows that
he survived that sentence and reappeared briefly in Durham, where he worked
and later married. 12
What about children who killed? What was society's attitude toward them?
In keeping with Knell's findings that London children were often sentenced to
be executed, but that the sentence was rarely carried out. Anthony Platt re-
ported that he could find few verified child executions in the early United
States. 13
Perhaps the most famous child capital punishment case in 19th-century
America was that of Jesse H. Pomeroy, a 14-year-old, who killed 4-year-old
Horace Millen in 1874, near Boston. Horace's throat had been cut, his body
had 15 stab wounds, and he had been so badly beaten that one eye had been
enucleated. McDade reports that:
When arrested, Pomeroy had been at liberty only 60 days after spending a year
and a half at Westboro Reformatory for sadistic beatings he had previously given
to small children [when he was about 12 years old). The public furor at his arrest
for the Millen murder was only a murmur when compared to that when it was
discovered (after he had been in custody three months) that five weeks before
the Millen murder he had killed nine year old Katie Curren and buried her in
the cellar of a shop.
Despite his age, Jesse was tried for the murder of Millen. His defense of
insanity was no avail, and he was sentenced to death .... Jesse remained in jail
for two years until the succeeding governor got a committee to recommend
commutation, but to stifle any criticism, the order provided that Jesse be kept in
solitary confinement for the rest of his life .... Not until 1916 was J esse, then a
man of fifty-four, released from solitary and permitted to mix with other pris-
oners at the Charlestown Prison.
McDade goes on to say "If he were mad when first confined, there was no
sign of it in the writings of his later years. He died in Charlestown Prison on
September 29, 1932, in the seventy-third year of his life and the fifty-eighth
year of his confinement."14
No study ofjuvenile criminality would be adequate without some presenta-
tion of the response of the "private sector" and the public. Perhaps the first
nongovernmental institution for juvenile delinquents was established by Pope
Clement XI in 1703 in Rome, the Hospice of St. Michel. This hospice held
youths, under 20, sentenced to it by the courts after being convicted for crimes,
and incorrigible boys who were not convicted of any crimes but who were
placed there under the Pope's care by parents.
In England, delinquent children were often kept in local jails. In the early
18th century, 75 delinquent boys and 25 delinquent girls were transported by
request of the colonists to the Colony of Virginia as indentured servants. Two
years later, a second boatload was sent at the request of the same colonists. It is
possible that these waifs may have been the ancestors of some of the first
families of Virginia.
8 JACQUES M. QUEN
CHILD PROTECTION ORGANIZATIONS
By the late 18th century, Americans had become sufficiently concerned

about the problem of pauperism, when it seemed so unnecessary and socially
destructive, that they formed local organizations to fight it and to improve
conditions in the jails. In Philadelphia, Benjamin Rush founded one such
society, and another was founded in New York City. The members of these
organizations soon turned their efforts to the prevention of criminality. They
found juvenile criminals housed in jail with older criminals teaching them the
tricks of the trade. Soon these societies established orphanages, Houses of
Refuge, and other residential shelters for wayward and neglected youth. The
wayward youth were often criminals, the neglected youth often merely pen-
niless, without a trade, or abandoned by their parents. Other institutions were
developed, including the Newsboys Lodging House, from which Horatio Alger
wrote his popular stories.
In 1874, The New York Society for the Prevention of Cruelty to Animals
was confronted with a case of cruelty to a child and the next year the New York
Society for the Prevention of Cruelty to Children was formed. This association
of animals and children was not peculiar to New York. The Colorado Bureau
of Child and Animal Protection stated that "the protection of children and
animals are combined because of their helplessness."
Foster home placement was also developed as a preventive for destitute or
neglected children. Then as now it was believed that the city was a hotbed of sin
and vice and that the healthiest place to raise a child was in rural and agrarian
America. Consequently, children were sent, en masse, to foster homes on farms
in the American midwest. One prominent organization in this movement was
the Children's Aid Society of New York, founded by Charles Loring Brace. He
and the Society were responsible for placing thousands of New York's under-
privileged children in small towns and farms in middle America.
By the end of the 19th century there were numerous "child-saving" orga-
nizations attempting to deal with the difficult problem of aiding under-
privileged and misguided youth. Notable among their concerns was the judicial
practice of sentencing young criminals to jails with hardened ones. Prison
improvement societies, child-saving societies, Charity Organization Societies (a
group that focused on the family), all were concerned with trying to solve this
knotty problem. Efforts to establish penitentiaries designed solely to reform
wayward youth who had been deprived of the opportunity to enjoy wholesome
family life, sage guidance from good parents, or the education of a trade,
finally bore fruit in the opening of the Elmira Reformatory in New York in
1876, for young first offenders between the ages of 16 and 30.
PRISON REFORMATORIES
The reformatory's approach was based on British and Irish penal pro-
grams derived from the "Mark" system originally devised by Alexander Mac-
onochie at the prison on Norfolk Island off the coast of Australia. The system,
as used in Elmira, had as its keystone the indeterminate sentence. The pris-
oners, on admission, were assigned to the middle of three graded groups. At
the end of 6 months of good conduct, the convict could be promoted to the first
grade, and with 6 more months of good conduct, could be paroled. Mis-
behavior was punished by demotion to third grade, where a month's good
conduct was required for restoration to the second grade. Incorrigible inmates
had to serve the maximum sentence provided by law for their offense.
In 1894, a British Inspector of Prisons, after visiting Elmira described the
regime there as one of mildness "where most of the comforts of a first-class
boarding house, ample diet, military music, the study of Plato, and instruction
of interesting handicrafts are utilized."15 Unfortunately, it appears that if that
system did in fact exist, it did so only briefly. Reformatories were quickly taken
up by other states and soon established their relatively depressing records.
Although originally intended as a place of education and rehabilitation,
reformatories, as with other penal institutions, were hampered by legislative
penury and exploitation, with a major emphasis on their being self-supporting
and costing the state treasuries nothing. rather than focusing on their original-
ly designed purpose. Unquestionably some reformatories had periods of good
management under good and dedicated administrations, but by and large, no
reformatory seems to have escaped, in its history, the pitfalls of severe cruelty,
emphasis on earning money, and treating the inmates in near criminal ways. 16
Some reformatories hired out their inmates as contract laborers, during which
time the employers were in charge of discipline, food, etc., with no supervision
or constraints.
In the early decades of the 20th century there was much ferment in the
country with many other experimental programs trying to prevent juveniles
from grwoing into criminals. There were groups such as the George Junior
Republic, Children's Village, the Wiltwyck School, and Hawthorne-Cedar
Knolls, as progressive, residential treatment centers for juveniles.
There was still a belief that if younger and less hardened criminals were
treated differently, with different standards, they might yet be saved. In the
decade between 1899 and 1909, juvenile courts were established in 10 states
and the District of Columbia. However, the early records suggest that these
agencies had no better results. It was about this time that the Chicago Juvenile
Protective League proposed that Illinois delinquents be studied scientifically in
an effort to understand the root causes of delinquency.
In 1909, the Juvenile Psychopathic Institute was founded and the neu-
rologist William Healy was appointed to head the project. This resulted in the
publication of his book, The Individual Delinquent, in 1915. In his effort to
determine which of the current theories about the causes of juvenile delin-
quency was correct, Healy collected a prodigious mass of data on each indi-
vidual. He finally determined that no one theory was adequate to all the indi-
vidual cases, but that one could be certain that all of the cases did have a largely
psychological etiology.
Healy saw the malfunctioning of mental mechanisms as the major force in
10 JACQUES M. QUEN
producing delinquent behavior. This view was also consistent with Adolf
Meyer's psychobiological approach. For Healy, as for Meyer, one needed to
look at all of the life experiences as significant factors in the development of the
individual. The penetration of this view (and here I do not distinguish between
Healy's and Meyer's) was so marked that one must consider that it was not the
product of any single mind, but rather a function of the coming together of the
experiences of the socially concerned, the young profession of social work, the
experiences of asylum psychiatry, of post-civil-war neurology, and of the major
social force developed by medicine as a result of the laboratory research and
progress made by Virchow, Pasteur, and others with its major impact on public
health.
This was also the period in which psychologically minded neurologists and
asylum psychiatrists began to overlap in their professional work and identities.
Psychotherapy and psychoanalysis were being enthusiastically adopted by many
in this country, and it was also about this time that the crime and the judicial
hearing of Nathan Leopold and Richard Loeb occupied the minds of the public.
It was here that the earlier theories of juvenile delinquency and deprived child-
hoods appeared to have their major confrontation. And it was here that the
lawyer Clarence Darrow brought William Healy into the courtroom, along with
the famed William Alanson White ofSt. Elizabeth's Hospital in Washington and
Bernard Glueck, the chief psyr:hiatrist at Sing Sing. These nationally known
psychiatrists were all agreed that the crime committed by Leopold and Loeb was
an outgrowth of their mental illness.
Kathleen W. Jones, a historian of child psychiatry, suggests that child
psychiatry had its roots in society's struggle with the problem of juvenile crimi-
nality.16 She suggests that it was Healy's work that played a major role in
bringing attention to the need for psychiatrists to study the psychological devel-
opment of children, as well as their psychopathology and sociopathology. Until
the work of Kanner with autism and Lauretta Bender and her colleagues with
childhood schizophrenia, there was not a significant body of knowledge of
child psychiatry.
The degree of misinformation currently in circulation about past social
and legal attitudes toward children who committed antisocial acts, or who were
in danger of becoming either antisocial or inadequately prepared for living as
autonomous adults, is in great need of reexamination. And equally important,
child psychiatrists interested in law and legislation must educate themselves in
the history of laws and social attitudes regarding childhood by reading the
original sources, if they wish to avoid the unwitting perpetuation of ignorance
of past professional and social experiences.
REFERENCES
1. Black HC: Black's Law Dictionary. St. Paul, MN, West Publishing Co, 1979.
2. Blackman P: Mishnayoth. New York, Judaica Press, 1963,7 Vols.
3. Sanders WB (ed): Juvenile Offenders for a Thousand Years: Selected Readings from Anglo-Saxon
Times to 1900. Chapel Hill, University of N Carolina Press, 1970.
4. Blackstone W: Commentaries on the Laws of England, (vol 4: Of Public Wrongs), 1765,
(Reprint-Boston, Beacon Press, 1962).
5. Quen JM: ''James Hadfield and the medical jurisprudence of insanity," NY State J Med
69:1221-1226, 1969.
6. Hale M: History of the Pleas of the Crown. London: E R Nutt and R Gosling, 1736.
7. Coke E: Institutes of the Laws of England. London, Robert H. Small, 1853.
8. Bouvier J: A Law Dictionary Adapted to the Constitution and Laws of the United States of America,
etc. ed 12. Philadelphia, George W. Childs, 1868.
9. Gray FC: Remarks on the early laws of Massachusetts Bay; with the Code adopted in 1641, and
called THE BODY OF UBERTIES, now first printed, in Collections of the Massachusetts Histor-
ical Society. 3rd Ser, 8:192-141, Boston, Little and Brown, 1843.
10. Knell BEF: Capital punishment: Its administration in relation to juvenile offenders in the
nineteenth century and its possible administration in the eighteenth. British J Delinquency
5: 198-207, 1965.
11. Walsh AA: The curious trial of "the Durham boy." Newport Magazine, 2(2):n.p., 1979.
12. Platt A: The Child Savers: The Invention of Delinquency. Chicago, University of Chicago
Press, 1969.
13. McDade TM: The Annals of Murder: A Bibliography of Books and Pamphlets on American
Murders from Colonial Times to 1900. Norman, Oklahoma, University of Oklahoma Press,
1961, pp 226-227.
14. Teeters NK, Reineman JO: The Challenge of Delinquency: Causation, Treatment, and Preven-
tion ofJuvenile Delinquency. New York, Prentice-Hall, 1951, pp 523-525.
15. Lundrigan NG: Development of the Florida Schools for Male Youthful Offenders, 1889-1969.
Dissertation. Tallahassee, FL, Florida State University, 1975.
16. Jones KW: "Straightening the twig": The professionalization of American child psychia-
try. Unpublished manuscript.
2
Some Criminogenic Traits of
Offenders
RICHARD J. HERRNSTEIN
Who commits crime? Depending on how broad the brush, the picture we
develop of the typical offender mayor may not reveal patterns of traits that
predispose certain people to break the law. With too fine a brush, only the
accidents of single lifetimes become salient; with too broad, it is only general
sociological forces that emerge. Between these two pictures-the one too spe-
cific, the other too general to be very useful-lies evidence showing offenders,
on the average, to be something other than a random sampling of the popula-
tion at large. This evidence, reviewed here, also makes clear that the dis-
tinguishing traits of criminals cannot be fully explained as the result of society's
treatment of them at home, in school, or in the workplace. Nor can they be
entirely explained by the operation of the criminal justice system. The average
offender is psychologically atypical in various respects, not necessarily to a
pathological degree, but enough that the normal prohibitions against crime are
in some measure ineffective. In designing public policy, it is helpful to under-
stand that a society that successfully deters crime in 80% to 90% of its citizens
may find it hard to deter it in the remaining 10% to 20% for reasons that have
more to do with individual differences than with defects in policy.
Individual traits that, under given circumstances, predispose certain peo-
ple to less internalization of standards of conduct, to greater resentment for
inequity, to shorter time horizons, to frustration in the competition for good
jobs or satisfying companionship, or to diminished sensitivity to criminal penal-
ties are traits that may be called criminogenic. The evidence, although not com-
RICHARD J. HERRNSTEIN • Department of Psychology, Harvard University, Cambridge,

Massachusetts 02138. Reprinted with permission from Wilson JQ (ed); Crime and Public Policy.
San Francisco, Institute for Contemporary Studies, 1983. Copyright 1983 by the Institute for
Contemporary Studies.
13
14 RICHARD J. HERRNSTEIN
plete in any sense, points toward a variety of criminogenic traits, which are
reviewed in the remainder of this chapter.
Sheldon and Eleanor T. Glueck, husband and wife, conducted what was,
and has remained, the most detailed and comprehensive longitudinal and
cross-sectional study of male delinquency.l,2 Starting in the late 1930s, they
gathered data on a sample of 500 delinquent boys incarcerated for serious
offenses and compared them with a sample of 500 nondelinquent Boston boys
of about the same age, ethnic background, and IQ, and from neighborhoods
equivalent in general quality and delinquency rates. Then they surveyed a
large number of variables describing the boys themselves, as well as their
homes, parents, and grandparents.
Note, to begin with, that any variable used for matching delinquent and
nondelinquent samples is thereby ruled out of consideration as a correlate of
delinquency in this study. For example, both groups came mostly from English,
Italian, and Irish family backgrounds, and from slum neighborhoods. The lack
of an ethnic or neighborhood difference between the samples reflects only the
way the study was designed, not an absence of ethnic or neighborhood corre-
lates of delinquency in the population at large. Similarly, the delinquents had
an average IQ of 92 and the nondelinquents, 94--an insignificant difference,
showing that this study succeeded in excluding IQ as a variable that might be
correlated with delinquency.
For numerous other variables, the two groups differed significantly. Al-
though both groups lived in comparably poor neighborhoods with matching
delinquency rates, and although their families paid about the same rental per
room, the delinquents' homes were more crowded, less clean, and less well
provided with sanitary facilities. Similarly, although both groups were drawn
from about the same (generally low) occupational levels, the delinquents' fami-
lies had lower average earnings, in terms of both per capita income and
number of breadwinners. In short, the two groups differed in general social
and economic conditions, even after the deliberate effort to match them. This
was further reflected in the educational backgrounds of the two samples, which
were poorer for the delinquents' parents and grandparents. The delinquents'
parents came from poorer homes than the nondelinquents' parents, and their
families had a history of more public welfare support. They also had a history
of more serious physical illness, mental retardation, emotional disturbance,
alcoholism, crime, and marital discord between parents.
INDIVIDUAL TRAITS
These differences suggest that even within a relatively narrow and under-
privileged sector of the population, still finer environmental gradations, at the
level of the individual home itself, playa part in predisposing certain indi-
viduals toward crime. But beyond even those finer gradations, the Gluecks
found differences among the boys themselves. They were about the same
height and weight and were judged to be approximately equally healthy, but
SOME CRIMINOGENIC TRAITS OF OFFENDERS 15
they had different physiques. 3 According to W. H. Sheldon's three-dimension-

al system of body-typing,4 the delinquent boys were markedly more meso-
morphic (muscular, squarish) on the average than the nondelinquent boys, and
markedly less ectomorphic (fragile, linear). On the third dimension of body
type, endomorphy (soft, round), the groups were about equal. The superiority
in mesomorphic development was "expressed especially in the shoulders,
chest, waist, and upper extremities, and outlining the picture of the masculine
physical type with tapering torso, heavy arms, small face, strong neck, and wide
shoulders."5 Not only were they more mesomorphic (and stronger in hand-
grip) on the average, but the delinquent boys as a group were more homoge-
neous in body guild than the nondelinquents, who represented a more typical
mixture of physiques.
The difference in build, as well as other individual differences to be de-
scribed, characterized not every delinquent but only the group average. Twice
as many of the delinquents as nondelinquents were primarily mesomorphic
(60% versus 30%), and more than twice as many of the nondelinquents were
primarily ectomorphic (40% versus 14%). The percentages imply a fair
number of nonmuscular delinquents and muscular nondelinquents, yet they
leave no doubt that the delinquents did not represent a random sample of the
ethnic or socioeconomic population of their origin. Other studies, including
Sheldon's own,6 have confirmed the association between physique and crimi-
nality, both juvenile and adult. 7 ,s Although methodological flaws mar Shel-
don's study on this point, the evidence overall cannot be denied. Exactly what
psychological links may obtain between the static fact of physique and the
dynamic facts about criminal behavior will be discussed later.
Although the two groups in the Glueck sample were almost equal in aver-
age IQ, their pattern of abilities differed. The delinquents were relatively
weaker in verbal ability than the nondelinquents, even though the nondelin-
quents were verbally weak compared to the population as a whole. The delin-
quents did worse in school than the nondelinquents by any measure-academ-
ic, attitudinal, or motivational. When nondelinquents were asked to give
reasons for disliking school, they tended to blame feelings of inadequacy as
students, In contrast, the delinquents were more likely to express resentment
toward the school routine or a sheer lack of interest. Delinquents' vocational
ambitions included more frequent references to adventurous occupations, like
aviation and going to sea. The delinquents misbehaved in school earlier, more
often, and more seriously than the nondelinquents. Almost 90% of the delin-
quents had misbehaved prior to the age of 11, several years before adolescent
male delinquent gangs tend to form.
U sing the Rorschach inkblot test, an effort was made to characterize the
boys' personalities. This projective test no longer enjoys the popularity it had in
the 1940s, having been largely supplanted by more objective psychological
inventories, but it distinguished the two samples in this instance. The written
Rorschach protocols were interpreted "blind," that is to say, by experts who
had no information about the boys other than their responses to the ink blots.
Table I presents the breakdown of traits, paraphrasing only slightly and for
Table I. Personality Traits in the Glueck Sample
Delinquents exceed Nondelinquents exceed No significant

nondelinquents delinquents difference
Self-assertive Submissiveness Feeling not being taken

Social assertion General anxiety care of
Defiance Enhanced insecurity Feeling not being taken
Ambivalence toward Feeling unloved seriously
authority Feeling helpless Resignation
Feeling unappreciated Fear of failure Depression
Feeling resentment Adequate contact with Kindliness
Difficulty in contact others Competitiveness
with others Cooperativeness Isolation
Hostility Dependence on others Suggestibility
Suspicion Concerns about others' Spontaneity
Destructiveness expectations Feeling able to cope
Narcissism Conventionality Introversion
Feeling others will take Masochism
care of one Self-control
Sadism Compulsiveness
Impulsiveness
Extroversion
Mental pathology
SouTce. Author's summary of data presented in Glueck S, Glueck E: Unraveling Juvenile Delinquency. New
York, Commonwealth Fund, 1950.
convenience the experts' own characterizations. The first two columns list de-
scriptions that significantly more often applied to delinquents and nondelin-
quents, respectively. In the third column are descriptions that did not differ
significantly for the two groups.
Table I conjures up an impression of two distinct personalities for the two
groups. The delinquents were assertive, unafraid, aggressive, unconventional,
extroverted, and poorly assimilated into the social milieu. The nondelinquents
were self-controlled, concerned about their relations with others, willing to be
guided by social standards, and rich in such feelings as insecurity, helplessness,
love (or its lack), and anxiety. Psychiatric interviews conducted independently
confirmed the major distinctions between the two samples.
The Gluecks were able to follow most of the two samples into adulthood
and later published a second account of them. 2 The differences in academic
and socioeconomic success and in personality endured into young adulthood,
and so did the differences in criminal behavior. Of the 442 nondelinquents
who were located in adulthood, 62 were convicted for crimes by the age of 31,
The crimes were, on the whole, minor, involving mostly drunkenness, vio-
lations of license laws, and offenses within the family, plus a few serious of-
fenses-an armed robbery, an assault with a dangerous weapon, and a case of
child abuse, to cite some examples, In contrast, the delinquent group proved
prolifically criminal. By the age of 31, they had committed 15 homicides,
hundreds of burglaries, hundreds of larcenies (greater than petty), hundreds
of arrests for drunkenness, over 150 robberies, dozens of sex offenses, and so
on. Four hundred thirty-eight of the original 500 in the delinquent sample
were located, of whom 354 were arrested between the ages of 17 and 25.
Between the ages of 25 and 31, only 263 were arrested, perhaps showing the
characteristic decline of crime with age, or perhaps only the shrinking numbers
not in prison. One hundred forty-seven men from the delinquent sample spent
5 or more years injails or prisons during the 8 years from ages 17 to 25, and 45
did so during the 6 years from ages 25 to 31. Despite spending thousands of
man-years in correctional institutions, the delinquent sample had ample time
outside for hundreds of arrests.
Although the Glueck study was internationally cited, it was also criticized
intensely, particularly by American sociologists. 9 ,10 In modern criminological
texts, it usually earns short shrift. Nonetheless, most if not all of the dis-
tinguishing traits of the Gluecks' delinquent boys have been repeatedly con-
firmed in other samples. In retrospect, the methodological criticisms appear
less decisive than they seemed to a criminological community whose theories
often ignored the individualistic variables considered by the Gluecks, such as
personality traits and physique. Moreover, to criticisms about the comparability
of the delinquent and nondelinquent samples and about the objectivity of the
measures of physique and personality, Sheldon Glueck offered what now seem
adequate answers.ll Less adequate was his defense of his attempt with his wife
to construct an index for predicting criminality on the basis of individual
characteristics; but that issue, although timely and interesting, is beyond the
scope of this chapter. For our purposes, the only relevant point is that other
workers have substantiated the existence of a special psychology of delinquents
and criminals.
CORROBORATING STUDIES
There is, for example, a sizable literature on delinquency in relation to

performance on the Porteus maze tests. Developed as a supplement to conven-
tional IQ, these tests consist of a graded series of pencil and paper mazes
progressing from very simple to exceedingly hard. I2 - I4 Two measures of per-
formance are usually taken. One is based on the highest level of difficulty
attained and on the amount of practice needed to learn successive mazes; the
other (the "Q" score) measures the quality of execution of the mazes-for
example, the number of times the pencil is lifted, a line crossed, or a corner cut,
all against the examiner's instructions. Both measures correlate at least slightly
with conventional IQ scores, the first more so than the Q score. However, the Q
score correlates better with delinquency in minors and crime in adults. Over a
dozen controlled studies in Hawaii, the continental United States, and Great
Britain have demonstrated significant deficits in Q scores for the criminal
population as a whole, and especially large deficits for criminal recidivists and
troublesome prisoners. The deficits in the other score among criminals are
marginal at most.I 5
What is there about delinquents that the Q score captures? The question
cannot be answered with certainty, but Porteus's own account seems plausible:
Delinquents and criminals are not markedly inferior to nondelinquents in plan-
ning capacity as reflected in Maze test quantitative scores (the first measure); but
in regard to quality of performance (Q scores), they had decided tendencies
towards careless, haphazard, and impulsive reactions. Overconfidence in action
was characteristic of many, but on the other hand, others were easily "rattled" or
"nervous." Many also are unable to keep in mind specific instructions. They have
good intentions but their tendency to impulsive reactions nullifies their plan-
ning .... Those who have not succeeded in setting up for themselves standards
of self-accomplishment exhibit their disorganization by slipshod or hasty execu-
tion of the task on hand. 16
Porteus pursued his hypothesis by asking school teachers to identify stu-

dents who displayed "carelessness, hasty and impulsive reactions, and un-
satisfactory disciplinary attitudes," but to "disregard intelligence as far as possi-
ble."17 Compared to an unselected sample of schoolmates, the selected
students had significantly poorer Q scores. He also noted, though without
presenting substantiating data, that the selected group later showed high delin-
quency rates. Later work by others found that subjects who delay gratification
poorly-for example, by taking an immediate and small reward rather than
waiting for a delayed, larger one-also earn deficient Q scores. 18
Eysenck and his associates have written extensively on the individual traits
associated with criminal behavior. I9 . 20 From his findings with standardized
questionnaires and rating scales, Eysenck has proposed an analysis of person-
ality into three dimensions, which he calls "neuroticism," "extroversion," and
"psychoticism." Each person's answers on a questionnaire define relative values
along each dimension, in effect locating a point in a three-dimensional space.
The extroversion dimension has outgoing, sociable, impulsive, adventuresome
types at one end and introverts at the other, where the traits include reflec-
tiveness, quietness, social reserve, and diffidence. The neuroticism dimension
has excitability or emotionality or changeability at one end and emotional
steadiness at the other. At the high end of the psychoticism scale people are
characterized by cruelty, aggressiveness, atypical tastes and appetites, and defi-
ciencies in social sensitivity. The three dimensions are said to vary more or less
independently in the population as a whole.
The data gathered by Eysenck and his associates generally show criminals
not to be a random sampling from the three-dimensional space defined by his
measurement of personality. Offenders tend to be unusually high on at least
one dimension and often on two or all three. High values for all three are
particularly diagnostic of criminal behavior. 21 Excitable (i.e., "neurotic"), so-
cially insensitive, or atypically motivated extroverts account for the highest
rates of criminally deviant behavior. Moreover, it is the impulsive, not the
sociable, side of extroversion that correlates with crime. 2o .22
Complementary results have been found by Megargee and his associates. 23
All of the male offenders incarcerated over a 2-year period in a federal prison
were given the Minnesota Multiphasic Personality Inventory (MMPI), a ques-
tionnaire comprising 556 true-false items for which there is a large body of
standardizing data, including evidence of an association with delinquency.24,25
A respondent's pattern of answers permits, first of all, a check on the question-
naire's internal validity and consistency. Secondly, it provides a relative position
on each of 10 clinical scales that have been developed on the basis of responses
from groups of people known to exemplify the traits named by the scales (see
below). A high score on, say, the schizophrenia scale (8) does not mean that a
person is clinically schizophrenic; it means that schizophrenics as a group also
earn high scores on the scale. The following descriptions are excerpted from
Megargee and Bohn:
1. Hypochondriasis: "abnormal concern over bodily functions and pre-
occupation with physical complaints."
2. Depression: "feelings of hopelessness and self depreciation."
3. Hysteria: "tendency to use physical or mental symptoms to avoid
stressful conflicts ... unwillingness to accept adult responsibilities."
4. Psychopathic deviate: "tendency toward conflicts with authority fig-
ures, disregard of social conventions and laws, inability to learn from
experience, and shallowness in personal attachments."
5. Masculinity-femininity: "masculine or feminine interests, attitudes,
and forms of self-expression" (high scores often correlate with homo-
sexuality).
6. Paranoia: "abnormal suspiciousness and sensitivity."
7. Psychasthenia: "tendency towards obsessive ruminations, guilty feel-
ings, anxiety, indecision and worrying."
8. Schizophrenia: "bizarre or unusual thinking and behavior, interper-
sonal withdrawal and alienation, inappropriate affect."
9. Hypomania: "high activity level often without productivity."
lO. Social introversion: "shyness, social withdrawal and insecurity.26
Based on the patterns of questionnaire answers, more than 95% of the
sample of 1,214 prisoners fell into 1 of lO characteristic profiles. Our interest
here is not in the practical benefits of the resulting classificatory system-which
may be substantial-but in patterns of personality traits. Figure 1 shows the
overall profile of prisoners, the most deviant of the 10 profile types (13.3% of
classified prisoners), and the least deviant type of profile (19.3% of classified
prisoners). On each clinical scale, almost 70% of the general population lies
between 40 and 60, and averages 50. In contrast, the sample of prisoners (as
well as other samples)27 is conspicuous for higher values for psychopathic
deviate (4), schizophrenia (8), and hypomania (9). The most nearly normal
scale for prisoners was social introversion (lO). Differences among the ten
profiles were associated with differences in offenses, institutional behavior and
adjustment, recidivism, and various other characteristics.
The most deviant profile defined a group of prisoners who had the high-
est probability of reincarceration and who comprised the highest fraction in
trouble during imprisonment, whose work in prison earned the lowest ratings,
whose siblings were most deviant, and who also had relatively severe problems
.
/
90
~V'
80
70
80
50
40
6 9 0
ainical Scale-
Figure 1. MMPI profiles of prisoners. • = General profile; 0 = least deviant profile; x =

most deviant profile. For each scale, the general population has a mean of 50 and a standard
deviation of 10. Source: Adapted from Megargee EI, Bohn MG Jr (with Meyer J Jr, Sink F),
Classifying Criminal Offenders. Beverly Hills, Sage, 1979.
of adjustment outside of prison, in school and on the job. In contrast, the least
deviant profile belonged to a group of prisoners who had good prison adjust-
ment, a history of relatively minor crimes (e.g., draft offenses, drug and liquor
law violations, and a variety of property offenses), relatively few problems in
school, and high ratings for dependability at prison jobs. They had the second
lowest rate of recidivism, with the lowest rate earned by another profile group
with a low level of personality deviance.
Although each of the 10 types in the Megargee-Bohn classification differs
somewhat, certain generalizations can be made. As a whole, prisoners deviated
from the population at large in showing deficient attachments to others and to
social norms, bizarre thinking, and hyperactivity-traits associated with high
scores on the psychopathy, schizophrenia, and hypomania scales of the MMPI.
Moreover, the more deviant groups of prisoners as measured on the MMPI
typically had more serious behavior problems, more serious crimes in their
past, poorer prognoses for future contact with the law, and more trouble while
in prison.
EFFECTS OF INSTITUTIONALIZATION
The data reviewed so far came mainly from institutionalized subjects. Not
surprisingly, this has been a point of contention for critics of the search for
individual differences. It is not unreasonable to wonder whether institu-
tionalization itself, or the biases in the criminal justice system, account for the
distinctive personalities of offenders, rather than anything having to do with

susceptibility to crime. The evidence, however, suggests otherwise. We cannot
review all of it here, but it can be represented by a carefully executed prospec-
tive study conducted by West and Farrington on a sample of 400 boys drawn
from a working-class district in London. 28 Gathered over a 14-year period,
self-report questionnaires, school and family protocols, and self-reports and
official records of offenses enabled the authors to examine "the extent to which
young adult delinquents differ from their social peers in personal circum-
stances, attitudes, and behavior. 29 The latest comprehensive report uses inter-
views at the ages of 18-19, but the official records carry them to the age of 21
or thereabouts.
About 30% of the sample had some sort of official record of delinquency
by then-a figure about twice the national average, but close to that for com-
parable urban districts in England at the time. From the 22% of the sample that
had been rated prior to the age of 11 as "troublesome" by teachers and peers,
came about 60% of the recidivists by the age of 18. A scale to measure "anti-
social" tendencies was based on various measures of attitude and such activities
as smoking, loitering, getting tattooed, heavy drinking and gambling, involve-
ment in such antiestablishment groups as gangs, and promiscuous sex. Of the
110 young men who scored the highest (e.g., the most antisocial), over 60%
were delinquents; of the 72 who scored the lowest, 4% were delinquents. Ac-
cording to the authors, "One could hardly imagine a clearer demonstration of
the close connection between officially recorded delinquency and particular
attributes of character and lifestyle-the delinquent way of life."3o This study
was concerned with criminogenic traits that surfaced well before a boy's ac-
tivities intersected the arm of the law, so institutionalization could not have
fostered them. Yet the offenders' characteristics were at least as distinctive as in
Glueck's or Eysenck's or other samples of prisoners. From this, and from other
corroborating studies, we must conclude that offenders in general, not just
institutionalized offenders, show a constellation of personality characteris-
tiCS. 31 ,32
The evidence does not say that criminals are necessarily, or even usually,
clinically abnormal, although some of them are. Most criminals are within
normal ranges of variation for objective measures of personality such as the
MMPI, but they do not constitute a merely random sample of the population at
large. Different taxonomic schemes, different populations of offenders de-
fined by different criteria of criminality, different points in a criminal career
from childhood to mature adulthood, and different vocabularies mask an un-
derlying uniformity in the predisposing traits for comparable samples. Sum-
marizing the delinquents and adult offenders in their sample, West and Far-
rington described in clear language the traits they found. They could have
been writing about many other samples of young adults with criminal records:
Virtually every comparison suggested that the convicted delinquents were more
deviant. They were less socially restrained, more hedonistic, more impulsive,
more reckless and distinctly more aggressive and prone to physical violence than
their nondelinquent peers. They smoked more, drank more, and gambled more.
They had a faster lifestyle, they went out more, they visited bars, discotheques
and parties more often, they had more contacts with girls, they were more
sexually precocious and sexually promiscuous, they avoided educational pur-
suits, evening classes, or reading books, they earned more from highly paid
unskilled jobs with poor future prospects, but they spent more, saved less, and
were more frequently out of work and in debt. On an attitude questionnaire the
delinquents frequently endorsed anti-establishment opinions, such as "School
did me very little good" and "The police are always roughing people up" and
agreed with statements favoring violent behavior such as "I enjoy a punch up."
Reports of conflicts with parents, and an expressed preference for living away
from the parental home, were common among the delinquents. But perhaps the
most striking characteristic of all was their high level of self-admitted aggressive-
ness. 30
By some accounts, the distinguishing characteristics of criminal popula-

tions reflect the same sociocultural forces that produce the crime itself. Thus if
criminals are, on the average, more impulsive than noncriminals, it is not
because a static personality trait-impulsiveness-predisposes people to crime,
but because society favors both impulsiveness and criminality in certain disad-
vantaged groups. The same is said to hold true if they are more aggressive or
more unfeeling or more antisocial, and so on through the list of distinguishing
traits. In effect, this approach assumes that every person is equally susceptible
to the forces that promote or inhibit criminal behavior, and to the accompany-
ing individual traits. Perhaps no one subscribes to this approach complf'tely
(for then it would be necessary to account in sociocultural terms not only for
correlations with personality, but also for the differences in offending between,
say, 7-year-olds and 25-year-olds), but the criminological community has long
been drawn to it, as any survey of criminological textbooks would show. The
evidence against the assumption of equal criminal potentiality is that crime
correlates with non sociological traits, by which is meant traits that are not
accounted for by society.
PHYSIOLOGICAL FACTORS
An example of such an individual trait is physique. One may believe that

society produces criminality, but hardly that it produces mesomorphy; yet
populations of offenders have often been found to be disproportionately meso-
morphic and nonectomorphic. The correlation probably arises through phy-
sique's connection with personality. Even in populations of nonoffenders,
mesomorphs tend to be adventurous, hyperactive, argumentative, and outgo-
ing, whereas ectomorphs tend to be self-controlled, cautious, sensitive, shy, and
reflective. 33 •34 The traits of mesomorphy unleavened with those of ectomor-
phy yield a configuration that unmistakably resembles that found in popula-
tions of offenders.
We do not know whether the correlation between physique and person-
ality is itself sociological-whether, in other words, society could make meso-
morphs meek and ectomorphs outgoing. Nor do we know whether the con-
stellation of typical personality traits among criminals-a sociality, impulsive-
ness, high psychological energy, etc.-is a sociological necessity, or whether a
society could recruit its criminals from the introspective, the conscientious, and
the empathic. But even without knowing what mayor may not be possible in
hypothetical societies, we can assert with confidence that in our society phy-
sique illustrates a constitutional, individual factor linked to the propensity to
commit crime.
Other lines of evidence further undermine the assumption of equal crimi-
nal potentiality among all persons. Personality traits themselves, as measured
by objective inventories, are significantly heritable. 35- 39 Although it may be
premature to quantify heritability of these traits, it is already clear that the
heritability is not negligible. If the predisposing traits are heritable, it follows
that the tendency to commit crime should itself run in families for genetic
reasons; and the accumulating evidence suggests that it does. 4o
In numerous laboratory studies, institutionalized and noninstitutionalized
"psychopaths" (often called "sociopaths") have shown diminished physiological
reactivity to certain kinds of stimuli. 41 - 49 Although definitions of psychopathy
or sociopathy vary from study to study, the condition approximately corre-
sponds to elevated scores on the psychopathic deviate scale of the MMPI,
sometimes also including an elevation of the hypomania scale. Experimental
techniques and results also vary, but in most cases psychopaths have been
found to have trouble learning anticipatory responses, especially to imminent
painful stimuli (such as a brief electric shock), to discount time unusually steep-
ly in such procedures, and to have a weaker then average reflexive change in
the electrical conductivity of the skin to sudden or stressful stimuli-which is
known to be associated with the autonomic nervous system and hence provides
a measure of emotional arousal.
Eysenck, who early recognized the bearing of findings like these on the
analysis of criminal behavior, suggested that psychopaths and other potential
offenders often have low levels of arousal of the cerebral cortex, and are
consequently in a continual state of hunger for stimulation, expressed as a
restless appetite for new and intense experience. According to Eysenck's theo-
ry, since the cerebral cortex is known to be at least as much an inhibitor as an
excitor of behavior, deficient cortical arousal would suggest a lowered thresh-
old for ordinarily inhibited activities, such as crime. Somewhat closer to the
data is Hare's characterization of the population in these studies:
The psychopath's apparent disregard for the future consequences of his behav-
ior may therefore be seen as reflecting the failure of cues (visual, kinesthetic,
verbal, symbolic, etc.) associated with punishment to elicit sufficient anticipatory
fear for the instigation and subsequent reinforcement of avoidance behavior.
Moreover, it appears that the psychopath's relative inability to experience antic-
ipatory fear may be especially marked when the expected punishment is tem-
porally remote, a reflection, perhaps, of an unusually steep temporal gradient of
fear arousal. 50
THE ROLE OF INTELLIGENCE
One significant dimension of human variation remains to be considered:

intelligence as measured by standardized tests like the IQ. The understanding
of intelligence as a correlate of crime may be completing a full swing of the
pendulum. In the early days of testing, it was taken as proven that it was the
major individual correlate of crime. By early estimates, the proportion of men-
tally retarded in American prisons was as high as 50%.51 But the earliest
estimates of retardation among criminals were the highest. As the tests them-
selves, the criteria of mental retardation, and the population sampled met
increasingly rigorous and reasonable standards, the proportion rapidly shrank.
Observing this change, many criminologists extrapolated it to the vanishing
point, arguing that by the the time research methods became genuinely valid,
the intelligence of criminals would be seen to be no different from that of the
population at large. The leading spokesman for this view was Sutherland,
whose 50-year-old paper on the subject is still cited by those few textbooks on
criminology in which intelligence is mentioned at all. 52 American crimi-
nologists seemed, judging from secondary sources, to have concluded that
intelligence was not a differentiating characteristic of the criminal population.
In fact, since the mid-1930s, the best estimates have converged on an
average IQ deficit of about lO points for the criminal population in at least the
United States and the United Kingdom. 53 - 56 For recidivists, the IQ deficit may
be even larger. 56 ,57 If the population at large averages an IQ of lOO, and the
criminal population accounts for 15% of the total, then a lO-point deficit
implies an average IQ for offenders of 91.5-which closely approximates the
more representative samplings in the literature. Not much is known about the
precise shape of the IQ distribution for offenders, but it is likely to be trun-
cated at the low end because even the most slapdash crimes usually require
some mental competence. The high end probably lacks comparable truncation,
although an average of 91.5 implies that the criminal population lies mainly in
the so-called low normal and borderline region between 65 and 100.
It seems clear that IQ, independent of race and class, contributes to the
risk of criminal behavior; indeed, IQ probably contributes more to the risk
than either race or class. Judging from indirect evidence and a small amount of
direct measurement, the intellectual level of the average prisoner represents
that of criminals at large reasonably accurately, although a small number of
very bright offenders may well be eluding imprisonment. 55 ,56 The bright ones
fascinate us, and fill both the fiction and much of the human-interest jour-
nalism about crime, but they are few enough to have only a negligible impact
on the overall average.
Not all samples of criminals show the average deficit. In Megargee and
Bohn's MMPI study, for example, the prisoners apparently had average intel-
ligence. Their presence in a federal prison may be a clue to their higher scores,
for an early study found different averages for different criminal categories.
Prisoners convicted for conspiracy, for violations of "blue sky" or securities
laws, or for forgery had significantly higher scores than those convicted for
homicide, rape, weapons offenses, and assaults. 58 Evidence suggests that low
scores are correlated with the more impulsive criminal acts. 59 The offenses that
lead to a medium-security federal prison, such as the one used in the Megar-
gee-Bohn study, are probably heavily weighted toward those correlated with
higher scores.
The connection between intelligence and criminality has been interpreted
in two ways, both of which may be right to a degree. Low test scores often mean
failure and frustration in school. In combination with certain personality traits
and particular social circumstances, the resulting alienation may start young-
sters on the road to crime. This view, expressed by Hirschi and Hindelang,
depicts low IQ as leading to crime when the legitimate paths to success, which
start at school, are closed. Gordon stresses a different connection. Inasmuch as
society's rules must be learned, a low IQ impairs mastering the legal norms of
conduct much as it does the rules of spelling or long division. Purely on the
basis of the learning deficiency, according to this theory, the average offender
probably learns social prohibitions less rapidly or fully than the average nonof-
fender and hence is more likely to break the law. Personality traits that favor
acting out frustrations or that retard learning about delayed consequences
magnify the risk of criminal behavior associated with low intelligence, by either
of these theories. Even more surely than personality, intelligence has a herita-
ble component. 60 It must, therefore, also count as a predisposing individual
characteristic, at least in the modern industrial societies where the data have
been gathered.
PREDISPOSITION FOR CRIMINALITY
From obvious differences in body build, through personality and intel-

ligence, to subtle differences in time discounting, the people most at risk for
criminal behavior constitute an atypical population. In light of these findings
the medical analogy is irresistible. Just as sickness afflicts some people more
than others, so also does the social pathology called crime. This is not to deny
the importance of social and economic conditions, any more than it denies the
importance of precipitating agents for disease; it is, rather, to pay due regard
to individual differences.
It is not hard to see why the predisposing traits for crime are what they
appear to be. The rewards that crime can offer are enhanced by traits that
minimize internalized prohibitions, inhibit learning social conventions, are as-
sociated with unconventional or extremely intense drives of various sorts, and
cause deficient empathetic response to others. Traits that block legitimate suc-
cess further strengthen the attractions of crime. The deterrent effects of legal
sanctions are minimized by steep time-discounting, by an insensitivity to
punishment, and by traits that reduce the opportunity costs of imprisonment,
such as the low earning ability associated with low intelligence. 61 In each case,
some populations of criminals have displayed the predisposing traits and, in
most cases, the traits are abundantly present.
Some of these traits are heritable. Even so, neither the data nor any theory
built around them justifies the Lombrosian conception of the born criminal, if
that means an inevitable descent into a life of crime. Individuals are not simply
criminals or noncriminals. Everyone acts according to laws of behavior that can
equally well produce crime as noncrime, depending upon circumstances and
predispositions. Poor law enforcement, long delays in the criminal justice sys-
tem, inadequate teaching of society'S standards of conduct, school systems that
fail to educate the less gifted, and socioeconomic inequities that exacerbate
feelings of alienation and resentment are among the factors that incubate
crime-particularly among those with special susceptibilities. Instead of a ty-
pology of wicked people, modern psychology deals with the sources of criminal
behavior, acting through our individual differences on all of us.
REFERENCES
I. Glueck S, Glueck E: Unraveling Juvenile Delinquency. New York, Commonwealth Fund,

1950.
2. Glueck S, Glueck E: Delinquents and Nondelinquents in Perspective. Cambridge, Mass, Har-
vard University Press, 1968.
3. Glueck S, Glueck E: Physique and Deli'YUJuency. New York, Harper, 1956.
4. Sheldon WH: The Varieties of Human Physique. New York, Harper, 1940.
5. Glueck S, Glueck E: Unraveling Juvenile Delinquency, New York Commonwealth Fund,
1950, p 196.
6. Shelden WH, Hartl EM, McDermott E: Varieties of Delinquent Youth. New York, Harper,
1949.
7. Cortes JB, Gatti FM: Delinquency and Crime. New York, Seminar Press, 1972.
8. Gibbens TCN: Psychiatric Studies of Borstal Boys. London, Oxford University Press, 1963.
9. Reiss AJ: Unraveling juvenile delinquency, II: An appraisal of the research methods. A]S
57:115-120,1951.
10. Rubin S: Unraveling juvenile delinquency, I: Illusions in a research project using method
pairs. AJS 57: 107-114, 1951.
11. Glueck S: Ten years of Unraveling Juvenile Deli'YUJuency: An examination of criticisms.
Journal of Criminal Law, Criminology and Police Science 51 :283-308, 1960.
12. Porteus SD: The Maze Test and Mental Differences. Vineland, NJ, Smith, 1933.
13. Porteus SD: Q scores, temperament, and delinquency.] Soc Psychol 21 :81-103, 1945.
14. Porteus SD: Maze Test quantitative aspects. Br] Med PsychoI27:72-79, 1954.
15. For a summary see Riddle M, Roberts AH: Delinquency, delay of gratification, recidivism,
and the Porteus Maze Tests. Psychol Bull 84:417-425, 1977.
16. Porteus SD: Q scores, temperament, and delinquency.] Soc PsychoI21:85, 1945.
17. Porteus SD: Q scores, temperament, and delinquency.] Soc PsychoI21:88, 1945.
18. Riddle M, Roberts AH: Delinquency, delay of gratification, recidivism, and the Porteus
Maze Tests. Psychol Bull 84:417-425, 1977.
19. Eysenck SBG, Eysenck HJ: Crime and personality: An empirical study of the three-factor
theory. British]ournal of Criminology 10:225-239, 1970.
20. Eysenck HJ: Crime and Personality. London, Routledge and Kegan Paul 1977.
21. Feldman MP: Criminal Behavior: A Psychological Analysis. London, John Wiley and Sons,
1970.
22. Eysenck HJ: Crime and personality reconsidered. Bulletin of the British Psychological Society
27, 1974.
23. Megargee EI, Bohn MJ J r: Classifying Criminal Offenders. Beverly Hills, Cal, Sage, 1979.
24. Hathaway SR, Monachesi ED: Analyzing and Predicting Juvenile Deliquency with the MMPl.
Minneapolis, Minn, University of Minnesota Press, 1953.
25. Monachesi ED, Hathaway SR: The personality of delinquents, in MMPI: Research Develop-
ments and Clinical Applications. New York, McGraw Hill, 1969.
26. Megargee EI, Bohn MJ Jr: Classifying Criminal Offenders. Beverly Hills, Cal, Sage, 1979, p
77.
27. Edinger JD, Reuterfors D, Logue PE: Cross-validation of the Megargee MMPI typology:
A study of specialized populations. Criminal Justice and Behavior 9: 184-203, 1982.
28. West DJ, Farrington PD: The Delinquent Way of Life. New York, Crane Russak, 1977.
29. West DJ, Farrington PD: The Delinquent Way of Life. New York, Crane Russak, 1977, pI.
30. West DJ, Farrington PD: The Delinquent Way of Life. New York, Crane Russak, 1977, p
158.
31. Dinitz S: Chronically antisocial offenders, in Conrad JP, Dinitz S (eds): In Fear of Each
Other. Lexington, Mass, Lexington Books, 1977.
32. Wolfgang ME, Weiner NA, Pointer WD: Criminal Violence: Psychological Correlates and
Determinants. Washington DC, US Department of Justice, National Institute of Justice,
1981.
33. Cortes JB, Gatti FM: Delinquency and Crime. New York, Seminar Press, 1972.
34. Sheldon WH: The Varieties of Temperament. New York, Harper, 1942.
35. Eaves LJ, Eysenck HJ: The nature of extroversion: A genetical analysis.] Pers Soc Psychol
32:102-112,1975.
36. Eaves LJ, Young PA: Genetical theory and personality differences, in Lynn R (ed):
Dimensions of Personality: Papers in Honor of H. J. Eysenck. Oxford, Pergamon Press, 1981.
37. Floredus-Myrehed B, Pederson N, Rasmuson I: Assessment of heritability for person-
ality, based on a short-form of the Eysenck Personality Inventory: A study of 12,898 twin
pairs. Behav Genet 10:153-162, 1980.
38. Loehlin JC, Nichols RC: Heredity, Environment and Personality: A Study of 850 Sets of Twins.
Austin, Tex, University of Texas Press, 1976.
39. Zonderman AB: Differential heritability and consistency: A reanalysis of the National
Merit Scholarship Qualifying Test (NMSQT) California Psychological Inventory (CPI)
data. Behav Genet 12:193-208, 1982.
40. Mednick SA, Christiansen KO (eds): Biosocial Bases of Criminal Behavior. New York,
Gardner, 1977.
41. Hare RD: Temporal gradient of fear arousal in psychopaths.] Abnorm Psychol 70:442-
445, 1965.
42. Hare RD: Psychopathy and physiological responses to adrenalin. ] Abnorm Psychol
79: 138-147, 1972.
43. Mednick SA, Pollock V, VolavkaJ, Gabrielli WF Jr: Biology and Violence, in Wolfgang
ME, Weiner NA (eds): Criminal Violence. Beverly Hills, Cal, Sage, 1982.
44. Hare RD, Craigen D: Psychopathy and physiological activity in a mixed-motive game
situation. Psychophysiology II: 197-206, 1974.
45. Hinton JW, O'Neill MT: Pilot research on pyschophysiological response profiles of max-
imum security hospital patients. Br] Soc Clin PsychoI17:103, 1978.
46. Lippert WW Jr, Senter RJ: Electrodermal responses in the sociopath. Psychonomic Science
4:25-26, 1966.
47. Lykken DT: A study of anxiety in the sociopathic personality.] Abnorm Soc PsychoI55:6-
10, 1957.
48. Sutker PB: Vicarious conditioning and sociopathy.] Abnorm Psychol 76:380-386, 1980.
49. Ziskind E, Syndulko K, Maltzman I: Aversive conditioning in the sociopath. Pavlov] Bioi
Sci 13:199-205,1978.
50. Hare RD: Psychophysiological studies of psychopathy, in Fowles DC (ed): Clinical Applica-
tion of Psychophysiology. New York, Columbia, 1975.
51. Goddard HH: Feeble-Mindedness: Its Causes and C~nsequences. New York, Macmillan, 1914.
52. Sutherland EH: Mental deficiency and crime, in Young K (ed): Social Attitudes. New York,
Holt, Rinehart and Winston, 1931.
53. Reviewed in Caplan NS: Intellectual functioning, in Quay HC (ed): juvenile Delinquency.
New York, Van Nostrand, 1965.
54. Gordon RA: Crime and cognition: An evolutionary perspective. Proceedings of the II Inter-
national Symposium on Criminology. Sao Paolo, Brazil: International Center for Biological
and Medico-Forensic Criminology, 1975.
55. Gordon RA: Prevalence: The rare datum in delinquency measurement and its implica-
tions for the theory of delinquency, in Klein WM (ed): The juvenile justice System. Beverly
Hills, Cal, Sage, 1976.
56. Hirschi T, Hindelang J: Intelligence and delinquency: A revisionist review. Am Sociol
Rev 42:571-587,1977.
57. West DJ: Who Becomes Delinquent? London, Heinemann, 1973.
58. Fox V: Intelligence, race, and age as selective factors in crime. journal of Criminal Law and
Criminology 37:141-152, 1946.
59. Heilbrun AB Jr: Psychopathy and violent crime.j Consult Clin Psychol47:509-516, 1979.
60. For a tally of the world's data on intra familial correlations, see Bouchard TJ Jr, McGue M:
Familial studies of intelligence. Science 212: 1055-1059, 1981.
61. Jencks C: Who Gets Ahead? New York, Basic Books, 1979.
3
Biological Causes of
Delinquency
RICHARD A. RATNER
INTRODUCTION
The study of juvenile delinquency is ultimately as complex as the study of

human behavior generally. Not only can we delineate somewhat distinct social,
familial, psychological, and biological roots of delinquent behavior, we must
then be prepared to examine the interactions of all of these factors with the
others and the degree to which each aggravates or mitigates the others. It
quickly becomes clear that any attempt to look for an ultimate cause for delin-
quency exclusively in anyone realm is futile.
Delinquency, defined by the Psychiatric Dictionaryl as "all offenses com-
mitted by young people under the age of 16 or 18," is certainly not synonymous
with violence, including as it does such other nonviolent offenses as sexual
promiscuity, drug abuse, and even computer "hacking." For the most part,
however, the history of research into the biological determinants of delinquent
behavior has been the history of research into violent behavior in young
people.
Over many years, clinical studies of individuals suffering from brain
damage, intoxications, and deliriums 2 , supplemented by considerable animal
research into selective ablations and stimulations of brain tissue 3 .4 have left no
doubt that certain structural and functional alterations in the brain can facili-
tate violent behavior or inhibit it. Indeed, evidence continues to accumulate
concerning the relationship of violent and delinquent behavior to biological
variables, as will be discussed in the following. Most recently, the growth in our
RICHARD A. RATNER· Department of Psychiatry, George Washington School of Medi-

cine, Washington, DC 20037; Department of Psychiatry, Saint Elizabeth's Hospital, Wash-
ington, DC 20032.
29
30 RICHARD A. RATNER
knowledge of the central nervous system, and in particular, neurotransmitter

and receptor theory, has enabled us to come a step closer to a more compre-
hensive understanding of the organic roots of violence, or what Lewis 5 refers
to as the neuropsychiatric "vulnerability" to violent behavior.
The intent of this chapter is to review briefly some of the correlations that
have been made between violent and aggressive behavior on the one hand and
a variety of genetic, physiological, and biochemical abnormalities on the other.
It will then focus on studies correlating violent behavior with physiological and
pharmacological abnormalities within the central nervous system. This will lead
to a consideration of how changes in neurotransmitters may be the common
mechanism by which various organic factors lead to the potential for violent
behavior. Finally, we will discuss some of the implications of this information
for clinical practice and treatment.
GENETIC STUDIES
Genetic studies include those correlating violent behavior in juveniles with

characteristics of biological and adoptive parents and those correlating such
behavior with abnormalities of the individual's chromosomal endowment. Ex-
amples of the former include the work of Hutchings and Mednick,6 Crowe,7
and Cadoret and Cain,s all of whom have found significant correlations be-
tween criminality in their adolescent and adult subjects and antisocial behavior
in the subjects' biological fathers. Table I summarizes the findings of the study
by Hutchings and Mednick, in which the rate of criminality was twice as high
for the natural children of criminal fathers as for the natural children of
noncriminal fathers, regardless of whether these children were adopted out
after birth. Although other twin studies do exist that have not found significant
differences in concordance rates for criminal behavior in identical versus fra-
ternal twins, which are summarized by Rutter and Giller,9 the weight of evi-
dence continues to suggest a role for genetic factors.
Some studies of individuals with abnormalities of the Y chromosome have
been re"iewed by Brown and Goodwin in a recent paper.!O "Supermales" who
possess an extra Y chromosome (XYY) have been shown to have a higher
incidence of aggression and impulsivity than would be expected in a normal
population. Furthermore, other studies cited in the same article indicate that
although few adult criminals have an altered Y chromosome, there was a
tenfold increase in abnormal V's in a criminal population when compared to
noncriminal groups. Among young institutionalized criminals, those with long-
er Y chromosomes have been found to possess a significantly higher propor-
tion of fathers with criminal records or psychiatric disorders than those with
shorter Y chromosomes.
Until recently, the significance ofthese findings was unclear,ll but there is
now some evidence to suggest that the Y chromosome may include a locus for
determining serotonin levels in the cerebrospinal fluid (CSF). As will be noted
later, there also appears to be an inverse relationship between serotonin levels
BIOLOGICAL CAUSES OF DELINQUENCY 31
Table I. Relationship of Commonality

in Male Adoptees to Criminality in Adoptive
and Biological Fathers
Biological father Adoptive father Incidence of

a criminal a criminal criminality
+ + 33%
+ 20%
+ 10%
10%
Note. Adapted from "Registered criminals in adoptive and biological

parents of registered male adoptees" in Mednick SA, Schulsinger JT,
Higgins B, Bell RA (eds): Genetics, Environment and Psychopathology.
Amsterdam, North Holland Publishing, 1980.
in the CSF and the propensity to violent behavior. Such observations provide a
hypothetical explanation for the correlations between abnormal Y's and ag-
gressive behavior, that is, that Y chromosomes mediate serotonin levels in the
CSF, and that serotonin plays a role in aggression.
BIOCHEMICAL STUDIES
Cholesterol
Finnish investigators 12 have documented an association between violent
behavior and low levels of serum cholesterol in studies of children suffering
from Attention Deficit Disorder (ADD) with aggressive conduct disorders.
Lowered serum cholesterol in itself may be a manifestation of enhanced levels
of active insulin secretion, which may in turn result in periods of reactive
hypoglycemia. Hypoglycemia is believed to inhibit the brain's uptake of tryp-
tophan, a precursor of serotonin. As noted previously, serotonin seems to be
related to aggressive behavior and may be pivotal in the mechanism by which
hypoglycemia is believed to induce aggression.
Testosterone
As may be imagined, a fair amount of research centering on the rela-

tionship between testosterone and aggression in adults has taken place.
Ehrenkranz et al. 13 have shown a significant positive correlation in adults be-
tween elevated plasma testosterone and aggression, and a history of antisocial
behavior in adolescents has also been correlated with increased testosterone
levels. A Scandinavian study,14 although not finding a significant correlation
between testosterone level and age of first offense, found that in delinquents,
as opposed to normal adolescents, the rise in testosterone production that
occurs at puberty did not occur in step with physical maturation but predated
it. Such a finding suggests that an "immature" nervous system, thought to be
characteristic of hyperactive children, may not be able to deal effectively with
the increased testosterone secretion occurring at puberty.
Cornwall et at., in their review of the neuropsychiatry of violent and ag-
gressive behavior,15 found that although existing studies do not demonstrate
"a direct cause-and-effect relationship between testosterone and aggressive or
violent behavior," there is rather solid evidence that the use of anti-androgenic
agents (medroxyprogesterone, cyproterone, oral stilbestrol) helps to decrease
sexual aggression. Castration too has proven effective where the criminality or
aggression was sexual in nature.
Premenstrual Changes
Yet another bit of evidence linking sex hormones in the periphery to
violent behavior concerns the disproportionate number of violent crimes com-
mitted by females during the premenstrual week (60%) as compared to the end
of menstruation (2%).1 6 Again, there is no direct evidence regarding the effect
of progesterone or other hormones on violent behavior, especially during ado-
lescence, but the speculation that decreased progesterone may contribute to an
increase in irritability cannot be dismissed.
Assuming some connection between levels of hormones in the body and
aggressive or violent behavior, what is the connection? We know that these
"effector" hormones are released at the end of a chain of control beginning in
the central nervous system (CNS) with release of central peptides and neuro-
transmitters, which in turn mediate the release of hypothalamic releasing fac-
tors. These substances travel to the pituitary where they stimulate the release of
ACTH (adrenal corticotropic hormone), FSH (follicle stimulating hormone),
and LH (luteinizing hormone), which mediate the release of peripheral hor-
mones in the system. The hormones themselves close the feedback loop by
influencing the brain. Thus, plasma levels of testosterone, progesterone, etc.,
are influenced and controlled by CNS processes that are mediated by various
centrally acting neurotransmitters. Further understanding the actions of these
neurotransmitters should help to elucidate the relationship of peripheral hor-
mone levels to aggressive behavior.
PHYSIOLOGICAL STUDIES
Rutter and Giller9 reviewed some physiological studies of delinquent boys

and grouped them into three categories. The first is of autonomic reactivity,
wherein delinquents have been measured with respect to base heart rates,
increase in pulse rates after a noxious stimulus, and levels of skin conductance.
The findings seem consistent in that boys defined as delinquent, psychopathic,
and refractory had lower base heart rates, showed a lesser increase in pulse
after the noxious stimulus, and manifested lower initial reactivity and longer
recovery times with respect to changes in skin conductance. The skin studies
appear to have been successful as well in differentiating psychopathic adults
from normals and hyperkinetic children from controls.
A second area of physiological research pertains to avoidance learning, the
capacity to avoid certain behaviors after punishment. In adults, it seems estab-
lished that psychopaths show less anxiety and decreased ability to learn follow-
ing punishment,17 and a similar finding has been made in refractory boys
between the ages of 11 and 16.
A third set of studies concerns the notion, possibly physiological in nature,
that psychopathic individuals are thrill-seekers because of a heightened need
for stimulation. The evidence gained from a number of studies indicates that
conduct-disordered boys score poorly on tasks requiring continuous attention,
engage more readily in boredom-relieving activities, and spend less time view-
ing slides when they could control the speed of presentation. To what degree
these findings reflect the biological substrate, rather than psychological endow-
ment or familial influence, is hard to say. But it is at least plausible that the
differences in physiological reactivity between behaviorally disordered and
normal individuals, noted earlier, might reflect abnormalities in the nervous
systems of aggressive delinquents.
HYPERACTIVITY AND CONDUCT DISORDER
Hyperactivity (or ADD) is currently defined as a disorder starting before

the age of three with primary features of (a) inattention to a degree inappropri-
ate to the child's age, and (b) impulsivity. Hyperactivity per se mayor may not be
a feature of the syndrome. Although this diagnosis is separate and distinct
from the diagnosis of Conduct Disorder, there are a considerable number of
cases in which the two diagnostic entitles overlap. 18 In fact, the nature of the
relationship between hyperactives and aggressive children causes some authors
to call into question the validity of the diagnostic category of hyperactivity
altogether, suggesting the view that hyperactivity is not a specific category but
"can be found as a symptom in a variety of psychiatric disorders".15
In addition to the overlap between hyperactivity and conduct disorder,
Rutter 9 has delineated three other findings regarding the association between
hyperactivity and delinquency: first, long-term follow-up of hyperactive chil-
dren indicates an increased risk of delinquency in later life; second, family
studies indicate a correlation among hyperactivity, alcoholism, delinquency,
and adult antisocial behavior; and third, certain features of the inattention
characteristic of hyperactive youth are reminiscent of the stimulus-seeking and
easy boredom detected in refractory teenagers and antisocial adults. Stewart l9
has found differences in personality factors between hyperactives with conduct
disorder and those without and finds the former group similar to aggressive
children without hyperactivity.
Though ADD is behaviorally defined in DSM-III, it is generally thought of
as reflecting some kind of developmental lag within the central nervous system.
The data allows us to conclude only that there is a high correlation between
hyperactivity and conduct disorder in children and that delinquency occurs
more frequently in those adolescents with histories of hyperactivity than in
those without. Beyond this we can only speculate that delinquent behavior may
sometimes result when the rate of development of the nervous system falls
behind that of the rest of the body.
This argument is appealing for two reasons. First, it fits nicely with the
irrefutable evidence that "crime is a young man's profession," and that crimi-
nals tend to "burn out" when they reach their late thirties. 20 The idea of a
maturational lag playing a role in the genesis of conduct disorder in children,
delinquency in adolescents, and criminality in adults makes sense in light of
these observations. But it is also appealing in that once again biological foot-
prints lead to the central nervous system as the causal agency, suggesting a
more unitary biological notion of delinquency causation.
LEARNING DISABILITY: RETARDATION
Learning problems and lower IQ scores are significantly associated with

juvenile delinquency and violent behavior,2! even in studies that have con-
trolled for race and social class. 22 .23 Other studies of children who were learn-
ing disabled (LD) but not necessarily of low IQ, such as Satterfield et al.'s
prospective study,24 indicate a higher incidence of serious offenses among the
LD group than the normals. In their study, a group of children with ADD and
learning disabilities was studied against a control group until the subjects ap-
proached 18. None of the students in either group had any serious delinquent
problems at the outset, but by the end of the study, a full 25% of the LD's as
against only 6% of the controls had been arrested for serious offenses "multi-
ple times."
An association between violent behavior and outright retardation has also
been noted, but it is particularly hard to generalize about such a diverse group
who may be retarded for so many different reasons, and who may become
violent more commonly in response to goading, or simply to escape fearful
situations. 25 The relevance of this data to a consideration of the biological
causes of delinquency is unclear. The correlation between LD and aggressive
behavior may have little to do with biology. For example, some students with
conduct disorders may do poorly on IQ tests or in school out of hostility or
indifference and may therefore only appear to be learning disabled or of low
IQ. Another possibility is that the learning problems are primary but lead to
disenchantment with school, a negative identity, and delinquency. In neither of
these hypothetical situations would there be any biological link between the
learning disability and the conduct disorder; and such situations could explain
the statistical correlations completely.
The only relevance of the retardation-LD-delinquency correlations from
the standpoint of biological causation would be if some form of brain dysfunc-
tion could be shown to be a common denominator in these conditions. At this
point it is not possible to draw such conclusions. More research should cast
further light not only on relationships between such concepts as IQ, delinquen-
cy, LD, and hyperactivity but also on the meanings of these relationships from
the point of view of cause.
NEUROLOGICAL FACTORS: STRUCTURAL AND FUNCTIONAL

ABNORMALITIES
As noted earlier, it is well known that altered behavior patterns can result
from structural distortions in the brain. Tumors, hydrocephalus, and subdural
hemorrhages are examples of conditions that can bring about gross and often
bizarre alterations in behavior patterns. Injuries that do damage to the frontal
and temporal lobes in particular may cause far-reaching changes in behavior.
In a paper by Morrison and Silverstein 26 recommending more widespread
use of neuropsychological testing, for example, a case is presented of a 17-year-
old boy who had assaulted a female coworker. The boy had a history of head
trauma but without loss of consciousness either time and with EEG's each time
showing no abnormalities. Though there were family problems, the behavior
was sufficiently out of character for him that the evaluating forensic psychia-
trists felt a neurological and neuropsychological evaluation was advisable. Ab-
normalities compatible with possible cerebral damage were found on a Luria-
Nebraska profile, and a skull X ray revealed intracranial calcifications. Further
evaluation with CT scan led to the surgical excision of an arachnoid cyst, and
postoperative follow-up revealed no further behavior difficulties.
This case illustrates a cardinal point to be made in this chapter: one should
never overlook the possibility that neurological disease may play a part in
delinquent behavior. Although the previous case is unusual in that a discrete
space-occupying lesion could be pinpointed and removed surgically without
damage to the healthy brain, resulting in a total cure, other options for treat-
ment have become available in recent years for other forms of neurological
illness. Although it is more likely that something neurological will surface when
delinquent behavior (a) represents a change that cannot be well explained
dynamically or as a response to something in the environment, (b) is accom-
panied by physical symptoms, such as nausea and vomiting, headache, weak-
ness, or diplopia, (c) is accompanied by disturbances in the sensorium or (d) is
associated with a history of head trauma, the psychiatrist should never feel
diffident about initiating a thorough neurological examination if his index of
suspicion is at all raised.
Epilepsy
A longstanding dispute in neuropsychiatry has centered around the issue
of whether violent behavior occurs in association with seizures and whether
epileptics are more likely to be violent. For all practical purposes we are talking
about psychomotor, or temporal lobe epilepsy, as opposed to petit mal (absence
states) or grand mal types. In their review of these issues, Pincus and Tucker4
note that serious problems of definition hamper much of the research in this
area. The issue of just what constitutes temporal lobe or psychomotor epilepsy
is obviously crucial to this discussion. If the diagnosis is to be based on both
signs and symptoms and EEG abnormalities, which signs and symptoms and
which EEG patterns are to be accepted as pathognomonic of the disease? To
quote Pincus and Tucker:
There is no doubt that spikes, spike and wave discharges, focal slowing with
phase reversal and paroxysmal activity during wakefulness are abnormal. But
there remains a question about theta rhythms intermixed with a dominant alpha
pattern, prolonged slowing after hyperventilation, or even 14 and 6 positive
spikes, all of which are often seen in normal adolescents. Do these have clinical
significance or are they merely maturational deviations from the norm that the
individual will outgrow?
Furthermore there is the question once again of the chicken and the egg.
Because many violent adults and adolescents come from violent homes where
they have often sustained trauma, including head trauma, from abusive par-
ents or siblings, are EEG abnormalities a result of conditions leading to delin-
quent behavior rather than a cause? The same problem occurs when we at-
tempt to think about the roles of alcohol and drug abuse in the genesis of
delinquency. Does delinquency lead to abuse of substances, which in turn leads
to brain damage, or does brain damage lead to a panoply of behaviors that
include drug and alcohol abuse?
Though there have been many reports linking violent behavior with actual
psychomotor seizures,3 better controlled studies, such as those by Rodin 27 and
Delgado-Escueta et al,28 reached opposite conclusions. In these studies, patients
with temporal lobe disease were photographed or videotaped during seizures
and their aftermaths. In Rodin's study of 57 patients, none of the subjects
demonstrated aggressive behavior related to seizures. In Delgado-Escueta's
study of 19 patients who sustained a total of 33 seizures, a total of seven
patients manifested seizure-related aggression, but these were all felt to be
automatisms, rather than in any way purposeful. Rodin also notes that ag-
gressive behavior could occur in his population if attempts were made to re-
strain patients during their seizures, but this type of violence could hardly be
considered to be caused by the seizure as such. In addition, Rodin reviewed
some 700 records of known temporal lobe epileptics and found only 5% with
histories of destructive behavior. In these cases, other factors, such as gender
and age, turned out to be better predictors of the behavior than EEG results.
To the degree that consensus exists today,29 it is that ictal violence is rare if
it occurs at all, and that postictal violence, also rare, is most likely a confused
response to attempts to control the seizure patient. Angry-irritable behavior
may occur in the interictal phase but it rarely results in actual physical injury to
another person.
Episodic Dyscontrol
When we look at the relationship between aggressive behavior on the one
hand and one or more signs of neurological abnormality (rather than the full
syndrome of temporal lobe epilepsy) on the other, a considerable amount of

evidence supporting a link between them exists.
Williams 30 found abnormal EEGs in 57% of over 1,000 prisoners who had
committed "crimes of aggression," as opposed to only 12% of those committing
a "solitary aggressive crime." Mark and Ervin 2 studied 400 violent adult pris-
oners and concluded that although less than 10% had "frank" temporal lobe
disease, fully one third had abnormalities in their EEGs and half had symptoms
"suggestive" of epileptic phenomena. Indeed, after more than 20 years of
research in this area, Monroe has come to think that many psychiatric disorders
that are episodic rather than continuous in presentation 31 may have what he
calls an "epileptoid" mechanism. In Monroe's view, it may be precisely because
some of these individuals do not have clinical seizures that "cerebral dys-
rhythmias" tend to build up with a concomitant increase in subjective tension
and irritability. A paroxysm of violent behavior, typically rather primitive in
nature, brief, self-limiting, and out of character for the individual, then occurs
as a behavioral concomitant to the discharge or venting of the accumulated
dysrhythmias, after which the process begins all over again.
Monroe has taken pains 32 to differentiate between such epileptoid types of
aggressive behavior and behavior that is a consequence of personality and
environmental factors, including family background. Ratner and Shapiro33
attempted to systematize this differential diagnosis of aggressive behavior still
further for forensic psychiatric use by specifying that three types of criteria
would have to be fulfilled in order for a diagnosis of "episodic dyscontrol,
epileptoid type" to be made: first, the act itself should have the characteristics
of a dyscontrol act in its suddenness, brevity, and primitively rageful nature,
followed by remorse, etc. Second, certain EEG abnormalities would have to be
present, either during routine sleep and waking records or on the "activated"
EEG performed by Monroe; and third, the individual would have to self-report
symptoms and signs (Monroe has designed a questionnaire) suggestive of
"soft" neurological phenomena.
Some support for the notion that episodic dyscontrol is a real neurological-
ly based syndrome comes from clinical research on the use of anticonvulsants
in such individuals and research laboratory work on animals, which has led to
the concept of kindling. The kindling phenomenon is observable in the limbic
systems of animals as a response to recurrent low-intensity electrical stimula-
tion delivered at intervals to the brain site. The response is a gradual lowering
of the animal's seizure threshold until an actual seizure takes place at a level of
stimulation that originally had no effect. As this takes place, rage, fearfulness,
and hyperactivity can usually be observed in the animals.
In a recent review of the relationship of epileptic phenomena to psychosis,
the authors 34 noted that "parallels can obviously be drawn between subcon-
vulsive limbic stimulation in animals producing behavioral and neurotransmit-
ter abnormalities and temporal lobe sub-ictal activity giving rise to brief psy-
chotic episodes in man." It is more plausible still that episodes of irritability and
aggressive behavior can exist as a consequence of such brain mechanisms.
The second avenue of support for such theory is clinical, in that Monroe,
for example, has reported improvement in his patients when treated by anti-
convulsants, principally Tegretol (carbamazepine). Others active in this field
have found Dilantin to be effective in controlling violence in patients diagnosed
as suffering "episodic dyscontrol."35 Although the work of still other investiga-
tors has resulted in opposite conclusions regarding the efficacy of Dilantin in
adults and adolescents with aggressive behavior, evidence is accumulating to
suggest that a subgroup at least of aggressive and violent youth and adults
suffers from neurological abnormalities of a subictal or epileptoid type that
playa role in their aggressive, violent, or destructive behaviors. One author
who has studied these seizure-like phenomena in adolescents extensively is
Dorothy Lewis, and some comments on her work seem appropriate at this
point.
The Work of Dorothy O. Lewis
Lewis and her associates have been largely responsible for applying devel-
opments in neuropsychiatry to the study of juvenile delinquency. Along the
way, she has produced several papers of relevance to the issue of how our
society treats its disturbed delinquents,36.37 and has pointed out that there is
little difference psychiatrically between samples of juveniles in hospitals and in
correctional institutions; the differences are those of class or race.
Others have already pointed out the larger than expected number of EEG
abnormalities to be found in irritable and violent children,38.4 7 but much of
what is quoted in the adolescent literature regarding the links between violence
and neurological disturbance has come from her work. Furthermore, she has
documented the links between aggressive behavior in adolescents and the de-
gree of physical and mental abuse that they have often sustained in their
families of origin or in public institutions where many grew up. In a sample of
children from a maximum security state training school in Connecticut, for
example,39 she was able to show convincingly that children who had sustained
or witnessed the most serious physical abuse in their homes were responsible
for the most serious violent behavior.
Lewis sees her work in the larger context of preventing the pendulum of
scientific inquiry into delinquency from swinging too far in the direction of
psychosocial causes. 40 Such views of delinquency as that it represents the ado-
lescent's acting out of the parents' unconscious antisocial desires, popularized
by Johnson and Szurek in the forties and fifties, coupled with the increasing
popularity of psychoanalysis as a cure-all during the fifties and early sixties,
drew attention away from an interest in the organic factors that might be
influencing the criminality of certain delinquents.
In her efforts to correct the swing of the pendulum, however, many feel
that she has overstated her case. This contention can be supported by the
comparison of the 1979 paper noted earlier, reporting on a study of 97 boys at
a state correctional school, and her 1982 paper,41 which draws additional and
somewhat more radical conclusions from the same data. For example, in 1979
she concluded that her sample demonstrated a "multiplicity of major and
minor neurological abnormalities." By 1982, however, she was stating that a
full 18.5% of these subjects suffer from psychomotor seizures. Of these, nearly
one third supposedly "had committed violent acts during a seizure," a figure
that seems high even to those who think that ictal violence may occur.
Many would take exception with her assumption that an "abnormal elec-
troencephalogram" is evidence in and of itself of a "major neurological abnor-
mality," or that "abnormal reflexes" and "abnormalities in coordination" are
necessarily signs of "minor neurological abnormalities" in adolescents. Others
feel that the diagnosis of psychomotor epilepsy should not be made without
either appropriately abnormal EEGs or other features of this syndrome, such
as automatisms.
Though Lewis attempts to take into account the element of possible "mal-
ingering" in her population, this reviewer feels that she underestimates moti-
vational factors. One has to look especially carefully at the nature of the violent
behavior, especially if it appears at all premeditated and/or goal directed.
Violence connected with epileptic or epileptoid discharge is marked by a primi-
tive, extensive, and inappropriate quality typically out of character with the
person's usual life pattern. When violent behavior does not fit this pattern, or
when hostility and aggressiveness seem characteristic of a subject's personality,
the clinician's index of suspicion must be very high for a nonneurological
explanation.
Addressing this issue, Walker42 suggested as additional criteria for at-
tributing a violent crime to an epileptic state that obvious motives not be pre-
sent, that the crime appears to be senseless, that the violence is unnecessarily
extensive, that no attempt is made to escape, and that there be no evidence of
premeditation.
Although this reviewer finds most of Lewis' conclusions regarding the
prevalence of psychomotor epilepsy and the incidence of ictal violence to be of
doubtful validity, her notion of a neurological vulnerability to delinquent be-
havior is one with which most workers in the field can agree. Similarly, her
calling attention to such causal chains as that which begins with physical abuse
of the child, leading to actual brain damage, leading in turn to violence toward
others and more brain trauma, has been a valuable addition to our more
psychological notions of causality.
Violent behavior is certainly the end result of a complex chain of causation
in which constitutional and environmental influences are much intertwined.
But as Rickler4 3 has pointed out in his comprehensive review, the entire area of
the relationship of innate to acquired etiologies of violent behavior remains
controversial and unclear.
What we are dealing with here is nothing less than the relationship of mind
to brain. As more is learned about this great dichotomy, more should become
clear about the relationship of seizure disorders and brain trauma to delin-
quent behavior.
NEUROTRANSMITTERS
Someday we may have a kind of unified field theory in which we can
understand many of the biochemical, physiological, and neurophysiological
correlates of violent behavior noted earlier in terms of brain biochemistry at
the level of neurotransmitters and receptors. Though that time is not here,
considerable research has been done regarding the relationship of central
neurotransmitters to behavior, in animals and humans. Investigators have be-
gun to study the role of neurotransmitters in many of the conditions we have
been discussing, which have themselves been correlated with violent behavior.
Mounting evidence suggests that such disparate phenomena as ADD, XYY
"supermales," the episodic dyscontrol syndrome, and PCP ingestion may
"cause" violent behavior by causing alterations in the levels of circulating
serotonin and other centrally acting neurotransmitters in the central nervous
system.
A good deal of the animal and clinical research in this area is summarized
and typified by the work of Brown, Goodwin, et al.l 0 ,44,45 at the National
Institute of Mental Health. To summarize these studies in a general way, it can
be said that increased aggressive behavior is associated with higher levels of
those centrally acting neurotransmitters that are predominantly excitatory,
such as the catecholamines norepinephrine (NE) and dopamine (DA) or
acetycholine (Ach), whereas decreased aggressive behavior is associated with
higher levels of centrally inhibitory neurotransmitters, primarily serotonin (5
HT) and GABA ('V-amino butyric acid). In fact, many conditions associated
with aggressive behavior have also been associated with relatively low levels of
cerebrospinal fluid serotonin or its metabolite, 5-hydroxyindole acetic acid (5-
HIAA), or with relatively high levels of CSF catecholamines and their metabo-
lites.
In their own clinical studies, Brown, Goodwin, and Bunney44 have found
significantly lower levels of CSF 5 HIAA in certain aggressive (and suicidal)
men. Lower levels of CSF 5 HIAA have also been found as a consequence of
LSD use and in certain men with an XYY genetic endowment. On the other
hand, individuals manifesting violent behavior have been found to demon-
strate enhanced levels of MHPG (3-methoxy-4hydroxyphenylglycol), a metab-
olite of the excitatory transmitter, NE. Ingestion of amphetamines, stress and
sleep deprivation, clinical conditions that may be associated with an increased
incidence of aggressive behavior, have also been found to trigger increased
activity at central NE and DA receptor sites.
Further evidence linking neurotransmitter levels with violent behavior
emerges from studies of drug and medication ingestion. Alcohol ingestion, a
well-known facilitator of aggressive behavior, is thought to decrease serotonin
availability in the CNS and to increase catecholamine activity. LSD also de-
creased available serotonin by competitively inhibiting it at the receptor site,
whereas PCP is thought to increase activity at NE and Ach receptor sites.
So far as medication is concerned, the well-known antiaggressive effects of
lithium appear to be mediated both by suppressing cholinergic and cate-
cholamine activity and enhancing serotonergic activity. The neuroleptics seem

to have an inhibitory effect on dopamine activity at the receptor site.
Epileptic and seizure-like electrical dysfunction, as in episodic dyscontrol
syndromes, may in some way be caused by a disequilibrium between inhibitory
and facilatory neurotransmitter effects. Serotonin and GABA are believed to
be especially important in this hypothesis. The amygdala, a part of the limbic
system where temporal lobe seizures can originate, is also thought to be impor-
tant in the regulation of serotonin metabolites.
Although current research still leaves much obscure, it has begun to pro-
vide a framework for understanding the mechanisms that relate many dispa-
rate clinical findings and syndromes to aggressive and violent behavior. Also, it
provides a basis for a rational understanding of the ways in which clinically
effective medications exert their effects on violent behavior, and it should
certainly speed up the search for better and more specific treatments.
TREATMENT
No clinical review would be complete without discussion of treatment strat-

egies. However, once again it must be emphasized that a comprehensive clinical
evaluation of the aggressive adolescent will invariably point out problems and
needs that far transcend a merely biological approach to the problem. Biolog-
ical treatment of the conduct disordered adolescent, when undertaken, must
be based not only on a clear assessment of the organic problem for which
treatment is proposed but also on an overall approach that deals with the
problems in the cultural, familial, and psychological spheres.
Most delinquent behavior is not treated with medication, because it is
typically not pinpointed as having biological or partially biological causes. Most
delinquents are not even exposed to a neuropsychiatric evaluation, and those
few who are may often get very cursory ones. Even in cases where psychiatrists
do get involved, there is a greater reluctance to utilize medication in the young
than in adults. Medication is often rejected by adolescents themselves for a
variety of reasons, and even when it is not, a compliance problem may emerge
in this population for other reasons.
With these thoughts in mind, a few words should be said about the medical
treatment of violent behavior. First, after a thorough evaluation, established
treatments should be offered for any specific conditions that are discovered.
Antipsychotics should be used for psychoses, whereas the stimulants, such as
Ritalin, may be used in children with ADD. In these syndromes and in others,
such as depression, appropriate treatment of the underlying medical condition
is also the treatment of choice for aggression and violent behavior associated
with these diseases.
In cases of epilepsy, appropriate anticonvulsant treatment is indicated.
Somewhat less conservative is the use of anticonvulsants in the treatment of
epileptoid disorders in which frank seizures may never have occurred, but
where the weight of clinical and EEG evidence and of history convinces the
clinician that some neurological dysfunction short of frank epilepsy exists. For
this purpose, although Dilantin has been found effective, carbamazepine
(Tegretol) is currently favored at regular therapeutic doses.
Lithium has been shown to have definite antiaggressive effects separate
and distinct from its value in manic-depressive illness. 46 It can be employed to
help control violence in a wide variety of different clinical conditions or in
combination with other medications.
The central effects of the benzodiazepines would cause one to predict that
if anything they might aggravate rather than relieve aggressive behavior. In
spite of this, they are often used with apparent success to help deal with ag-
gressive behavior; if so, it is because their effect on anxiety may on balance be
more significant than whatever excitatory effects they have on the central
neurotransmitters. They also seem to be clinically useful in dealing with indi-
viduals suffering from drug or alcohol intoxication.
SUMMARY
An attempt has been made to survey the broad field of biological factors in
the causation of violent and aggressive behavior, which is present in a high
proportion of delinquent acts. Many correlations between violent behavior and
biochemical, physiological, genetic, and neurological findings have been re-
viewed. What is new in recent years is the continuing elucidation of the role of
neurotransmission within the central nervous system. Alterations in the levels
of excitatory and inhibitory neurotransmitters may be the common biological
mechanism leading to aggressive behavior in a wide variety of clinical syn-
dromes where such behavior may typically be present. Some thoughts on treat-
ment, in the context of a biopsychosocial approach, are expressed.
REFERENCES
1. Himsie LE, Campbell Rj (eds): Psychiatric Dictionary, ed 4. New York, Oxford University
Press, 1970.
2. Mark V, Ervin F: Violence and the Brain. New York, Harper and Row, 1970.
3. McClearn GE: Biological bases of social behavior with specific reference to violent behav-
ior in Mulvihill Dj, Tumin MM, Curtis AC (eds): Crimes of Violence Washington, DC: US
Government Printing Office 1969, pp 979-1016.
4. Pincus j, Tucker G: Violence in children and adults-A neurological view. JAm Acad
Child Psychiatry 17:277-288, 1978.
5. Lewis DO (ed): Vulnerabilities to Delinquency. New York, Spectrum, 1981.
6. Hutchings B, Mednick SA: Registered criminality in adoptive and biological parents of
registered male adoptees, in Mednick SA, Schulsinger jT, Higgins B, Bell RA (eds):
Genetics, Environment and Psychopathology. Amsterdam, North Holland Publishing, 1980.
7. Crowe RR: An adoption study of antisocial personality. Arch Gen Psychiatry 31 :785-791,
1974.
8. Cadoret, Rj, Cain C: Sex differences in predictors of antisocial behavior in adoptees. Arch
Gen Psychiatry 37: 1171-1175, 1980.
9. Rutter M, Giller H: Juvenile Delinquency, Trends and Perspectives. New York, Guilford Press,
1984.
10. Brown GL, Goodwin FK: Aggression, adolescence, and psychobiology, in Keith CR (ed):
The Aggressive Adolescent: Clinical Perspectives. New York, The Free Press, 1984.
11. Ervin FS: The biology of individual violence: An overview in Mulvilhill Dj, Tumin MM,
Curtis AL (eds): Crimes of Violence. Washington, DC, US Government Printing Office
1969.
12. Virkkunan M, Penittinen H: Serum cholesterol in aggressive conduct disorder: A prelimi-
nary study: Bioi Psychiatry 19:435-439, 1984.
13. Ehrenkranz j, Buss E, Sheard MH: Plasma testosterone: Correlations with aggressive
behavior and social dominance in man. Psychosom Med 36:469-475, 1974.
14. Mattsson A, Schalling D, Olweus D, Low H, Svensson J: Plasma testosterone, aggressive
behavior, and personality dimension in young male delinquents.] Am Acad Child Psychiatry
19:4 76-490, 1980.
15. Cornwall TP, Ritchie VI, McCann ME, et al.: A neuropsychiatric perspective of aggressive
adolescents, in Keith CR (ed): The Aggressive Adolescent, Clinical Perspectives. New York,
The Free Press, 1984.
16. Dalton K: Menstruation & crime, Br Med] 3:1752-1973,1961.
17. Lykken D: A study of anxiety in the sociopathic personality.] Abnorm Soc PsychoI55:6-10,
1957.
18. Cantwell D: Hyperactivity and antisocial behavior revisited: A critical review of the liter-
ature, in Lewis DO (ed): Vulnerabilities to Delinquency. New York, Spectrum, 1981.
19. Stewart MA, Cummings C, Singer S: The overlap between hyperactive and un socialized
aggressive children, j of Child Psychol Psychiatry 22: 12-19, 1981.
20. Robins L: Deviant Children Grow Up. Baltimore, Williams & Wilkins, 1966.
21. Lane BA: The relationships of learning disabilities to juvenile delinquency: current sta-
tus. Journal of Learning Disabilities, 13:71-83, 1980.
22. Hirschie T: Causes of Delinquency. Berkeley, University of California Press, 1969.
23. Hirschie T, Hindelang Mj: Intelligence & delinquency: A revisionist review. Amer Sociol
Rev 42:571-587,1977.
24. Satterfield jH, Hoppe CM, Schell AM: A prospective study of delinquency in 110 adoles-
cent boys with attention deficit disorders and 88 normal adolescent boys. Am] Psychiatry
139:795-799, 1982.
25. Carr EG, Newson CF, Binkoff jA: Escape as a factor in the aggressive behavior of two
retarded children.] AppIBehavAnaI13:37-43, 1980.
26. Morrison HL, Silverstein ML: Relevance of modern neuropsychology in differential diag-
nosis in forensic psychiatry. Paper presented at the 13th Annual Meeting of the American
Academy of Psychiatry and the Law. New York, 1982.
27. Rodin E: Psychomotor epilepsy and aggressive behavior. Arch Gen Psychiatry 28:210-213,
1973.
28. Delgado-Escueta Aj, Mattson R, King L, et al.: The nature of aggression during epileptic
seizures. N Engl] Med 305:711-716,1981.
29. Blumer D: Epilepsy and violence. In Madden Dj, Lion jR (eds): Rage, Hate, Assault and
Other Forms of Violence. New York, Spectrum Books, 1976.
30. Williams D: Neural factors related to habitual aggression. Brain 92:503-508, 1969.
31. Monroe RR: Episodic psychosis misdiagnosed as schizophrenia or affective disorders.
Unpublished manuscript, 1980.
32. Monroe RR: Brain Dysfunction in Aggressive Criminals. Lexington, Mass, Lexington Books-
DC Heath, 1978.
33. Ratner RA, Shapiro D: The episodic dyscontrol syndrome and criminal responsibility.
Bull Am Acad Psychiatry Law 7:422-431, 1979.
34. McKenna Pj, Kane jM, Parrish K: Psychotic syndromes in epilepsy. Am] Psychiatry
142:895-904, 1985.
35. Leventhal BL: The neuropharmacology of violence and aggressive behavior in children
and adolescents, in Keith, C. (ed.): The Aggressive Adolescent, Clinical Perspectives. New
York, The Free Press, 1984.
36. Lewis DO, Balla D.: Delinquency and Psychopathology. New York, Grune & Stratton, 1976.
37. Lewis DO, Shanok SS: Medical Histories of Delinquent and Non-Delinquent Children.
Am] Psychiatry 134:1020-1025,1976.
38. Stevens JR: Roundtable discussion: Violent behavior and the electroencephalogram. Clin
Electroencephalogr 3:180-213,1972.
39. Lewis DO, Shanok SS, Pincus JH, Glaser GH: Violent juvenile delinquents: Psychiatric,
neurological psychological & abuse factors.] Am Acad Child Psychiatry 18:307-319, 1979.
40. Lewis DO: Neuropsychiatric vulnerabilities and violent juvenile delinquency. Psychiatric
Clinics of North America 6:4707-714, 1983.
41. Lewis DO, Pincus JH, Shanok SS, Glaser GH: Psychomotor epilepsy and violence in a
group of incarcerated adolescent boys. Am] Psychiatry 139:882-887, 1982.
42. Walker AE: Murder or epilepsy.] Nerv Ment Dis 133:430-437, 1961.
43. Rickler K: Episodic dyscontrol, in Blumer D, Benson F (eds): Psychiatric Aspects of Neu-
rological Disease. New York, Brunner/Mazel, 1986, pp 49-73.
44. Brown GL, Goodwin FK, Bunney WEJr: Aggression and suicide: Their relationships to
neuropsychiatric diagnoses and serotonin metabolism, in Ho BT, et al. (eds): Serotonin in
Biological Psychiatry. New York, Raven Press, 1982.
45. Brown, GL, Ebert MH, Goyer PF,Jimerson DC, et al.: Aggression, suicide and serotonin:
Relationships to CSF amine metabolites. Am] Psychiatry 139:741-746, 1982.
46. Sheard N: Lithium in the treatment of aggression.] Nerv Ment Dis 160:108-118, 1975.
47. Suriwillo WW: The electroencephalogram and childhood aggression. Aggressive Behavior
6:9-18, 1980.
4
A Psychodynamic Approach to
Understanding Juvenile
Criminality
RICHARD C. MAROHN
INTRODUCTION
The psychodynamics of juvenile criminality endows an exciting study. It is an

inquiry that embraces the origins and history of psychoanalysis, its various
viewpoints and models, inpatient and outpatient intervention modalities, and
the nuances of doing psychotherapy. It touches too on compelling social and
philosophical issues, and resurrects important questions about etiology and
responsibility.
HISTORICAL PERSPECTIVE
In Freud'sl view of the perversions and character disorders, psychological

problems are externalized, an alloplastic solution, instead of being experienced
internally or resulting in symptoms, as in the psychoneuroses, an autoplastic
outcome. The delinquent likewise causes trouble for others and the environ-
ment, rather than experiencing painful affect or disabling symptoms, by trying
to change the environment or a relationship. In terms of drive psychology, the
delinquent or criminal discharges internal tension through behavior. This for-
mulation is similar to Freud's concept of acting out, when in treatment the
patient behaves outside the treatment relationship in order to prevent himself
from remembering the original trauma and experiencing the accompanying
RICHARD C. MAROHN· Department of Clinical Psychiatry, Northwestern University

Medical School, Chicago, Illinois 60611.
45
46 RICHARD C. MAROHN
pain in the transference. Furthermore, in a sense, the transference is a kind of

acting out because one behaves instead of remembers. Today, acting out has
developed looser connotations and refers to various kinds of impulsive behav-
ior, not the precise sense of doing instead or remembering. Acting out does
suggest, however, that someone seeks to rid himself of internal psychic distress
by externalizing it onto the outside world.
August Aichhorn 2 was influenced by Freud's teachings and applied them to
the "wayward youth" of Vienna. He conceptualized delinquency as the result of
an early childhood deprivation and sought the psychic imbalance responsible for
delinquent behavior, an economic perspective; searched for the unconscious
conflicts responsible for the symptomatic behavior, a topographic position;
visualized the delinquent's behavior as the interactions of ego and superego, a
structural interpretation; and focused on the youth's attempts to master external
reality through his behavior, an adaptive orientation. He believed that such
children have a weak ego and superego and are structurally deficient because
they are still too attached to their ambivalently cathected parents. Psychological
damage causes deviant behavior, and the goal of treatment is to remove the cause
rather than simply to eliminate the behavioral phenomena.
Aichhorn taught that the underlying causes of delinquency can be dis-
covered and understood only within a clinical transference relationship. De-
viant behavior is the expression of a wished-for gratification; his residential
treatment staff needed to understand this approach, and, if possible, nurture
the child and gratify him psychologically. Such gratification would then result
in a neurotic conflict between the wish to be gratified and a prohibition against
gratification, and the staff member or therapist would then become a trans-
ference figure for the delinquent, reenacting the wishes, conflicts, fears, and
prohibitions of early childhood. This constellation would then be understood,
and the symptomatic delinquent behavior would resolve.
Aichhorn 3 discovered that a therapeutic relationship with a certain kind of
delinquent could be established only with great difficulty. The ')uvenile im-
postor"4 does not experience the therapist as a separate person, but rather as
an idealized part of himself, the ego ideal, attributing to the therapist certain
qualities that the adolescent believed he had or wanted to achieve. Aichhorn
insisted that one could work with this type of delinquent only by promptly
establishing a narcissistic transference bond. He and Willie Hoffer 5 urged the
therapist to encourage actively such a transference, usually the idealization of a
charismatic therapist, which they both believed was a defense against the deep-
er, more painful problem of unattended primitive grandiosity; their purpose
was to intrude into the ego ideal, unmask it, and demonstrate its inferiority by
proving the therapist's own superiority. Trainees of 25 years ago were taught
to impress the delinquent with how poorly he had functioned as a criminal and
how much smarter the psychiatrist was.
Franz Alexander6 observed that certain criminals act out of a sense of
neurotic guilt, which plagues them because of their forbidden aggressive or
sexual wishes, desires, or fantasies, and they attempt to provoke the external
world to punish them and set their consciences at ease. A well-known example
A PSYCHODYNAMIC APPROACH 47
is the person who confesses to crimes he has not committed. The psycho-
therapist tries to uncover the psychological "crime" for which the patient feels
guilty and to resolve the neurotic conflict.
Kate Friedlander 7 tried to convert behavioral disorders into psycho-
neurotics by blocking their avenues for impulse discharge, which would cause
the necessary psychic pain to work therapeutically. Whereas Aichhorn recom-
mended creating conflict by gratifying infantile wishes, Friedlander tried to
reverse the process by reinternalizing externalized internal conflict and by
converting motor behavior to affect, thought, and fantasy. Anna Freud 8 also
conceptualized delinquency as a failure of the socialization process, because the
child had failed to internalize the controls of his parents and other authority
figures; he had failed to "identify with the aggressor." Anna Freud taught that
the child normally identifies with the aggressor-parent (and later with the
aggressor-therapist as well) and this provides the psychotherapist with the
leverage he needs to modify the child's values and behavior. Many hospital and
residential treatment programs for treating behavioral disorders are based on
these pioneeering concepts of setting limits on behavior, both to create internal
distress and to teach socialization and controls.9
Johnson and Szurek 10 described delinquent children who responded to and
gratified the unconsciously transmitted, deviant, but disowned, urges and wishes
of their seemingly upright parents. The delinquent would then gratify the
parents vicariously. These motives are often uncovered in family therapy ses-
sions. Brian Bird II also observed that although such delinquents are able to
respond to the parental unconscious, they have no psychological capacity to cope
with their own unconscious wishes and urges and are driven and impulsive.
Glover'sl2,13 classification of juvenile delinquents into the structural and
the functional provides an interesting and useful way of approaching the etiol-
ogy of impulse disorders. When a behavioral pattern is an entrenched part of
the character structure, even though seemingly impulsive, like a person who
steals or sets fires repeatedly to defend against psychic distress, the delinquency
is structural. When behavior results from a discharge of overwhelming inner
tension in an almost random manner, including certain violent outbursts, the
delinquency is functional. Functional problems result from temporary periods
of developmental imbalance and stress, like adolescence, and are not likely to
persist as behavioral patterns.
Violent behavior does not necessarily express rage or destructiveness.
Often, adolescents and adults are violent because they are transiently frag-
mented or disorganized, frequently by the intense psychic stimulation of strong
longings for affection and intimacy. Such urges overwhelm them and create a
traumatic state. 14 Hospital and prison riots l5 may result in part from this
dynamic, when adolescents are stimulated by intense longings for affectionate
contact and disintegrate; their violent behavior can be understood then as
evidence of psychic chaos, and not necessarily the expression of fury or rage.
What is needed therapeutically is psychological structure and organization,
even distance, not frightening and disorganizing intimacy.
Baittle and Kobrin l6 studied a delinquent gang from psychoanalytic and
sociologic perspectives, and were able to correlate structural and functional

delinquents with social and community position and status. They found that
gang leaders were structural delinquents and evinced phallic narcissistic per-
sonality organization; their families stood not at the top of the social structure,
but just below the top and were upward striving. Most of the gang members
demonstrated functional delinquency, expressing through their membership
the various economic stresses of adolescent maturation. Schizoid and schizo-
phrenic adolescents stood at the periphery of the gang organization, and would
be swept up in a pseudo-affiliation, just as some adolescents are caught up in a
riot by contagion, 15 rather than in a expression of delinquent psychopathology.
Blosl7 has highlighted the tendency of the impulsive adolescent to act
instead of talk, and has pointed out that an adolescent may also communicate
symbolically an underlying wish or conflict, even though his behavior appears
meaningless or random. This underlying symbolism is often highly person-
alized and represents an interpersonal problem,18 such as may be seen in the
boy who steals a car and flees to another state in order to escape the narcissistic
injury or the fearful intimacy of a romantic involvement.
Fritz Redpg,20 emphasized the child's ego deficits, their developmental
origins, the functional impairment they produce in daily activities, and the
important external ego functions treatment staff and others provide. His and
similar work influenced much of the residential treatment of children and
adolescents in this country. However, correctional facilities for delinquent ado-
lescents no longer aspire to be therapeutic and rehabilitative in their mission.
The idea of structuring an environment to confront, uncover, and give mean-
ing to an adolescent's behavior is considered obsolete by many corrections
experts.
Winnicott 21 ,22 saw deviant behavior as the result of early and primitive
hunger for the mother who was once possessed, but later lost, and whom the
child hopes to recapture through active behavior. Although impulsive behavior
may seem purposeless, it is clearly a sign of hope, because the antagonist-
delinquent has not given up and is still searching, and the therapist may well
become the target of the search.
CURRENT PSYCHODYNAMIC PERSPECTIVE
Current Models
Psychoanalytic drive and conflict psychology has advanced our under-
standing of adolescent criminal behavior. These patients cannot use their fan-
tasies in life or in treatment to provide themselves substitute gratification,
because their fantasies awaken childhood feelings with shame, anger, and fear
of the others' reactions. They bring that fear into treatment and expect the
therapist to react with disgust; they are often right, because many therapists
find the fantasies that lie behind the impulsive behavior to be unacceptable and
evocative of difficult countertransference problems. Delinquents often hide
their shame over their fantasies with behavioral outbursts, creating a displace-
ment, and then are angry at those who might detect their fantasies and feel
disgust, contempt, and superiority toward them. This is a paranoid reaction,
but with a kernel of truth, because these reactors are enraged at such patients
and act against them. These patients are sensitive to contempt, and so their
tendency is to show how big, strong, and threatening they can be to achieve
equality. Of course, this breaks down, and the patient goes through the cycle of
retreating to fantasy, acting out, feeling shame, and being punished. The
punishment shifts away from the shame and repeats the childhood experience
in which they were first punished for "shameful deeds." One needs to look
closely at the precipitant of each incident of acting out to see how the old
pattern is reawakened by recent events, but this is difficult to accomplish, and
current models of treatment lay great emphasis on understanding and working
with countertransference reactions.
Often, adolescent delinquency arranges itself into well established delin-
quent behavioral patterns 23 that may foreshadow later adult impulsivity. The
closure of adolescence, if it proceeds satisfactorily, involves a calming of the
often prevalent turmoil, some ability to regulate the inner psychological world,
the development of a sense of self with continuity in time and space, a capacity
for intimacy, the integration of genital sexuality into the personality structure,
and the capacity to experience affect as part of oneself. Structurally impulsive
adults persist, with the ego distortion of the adult who acts out repressed,
conflictual sexuality in stealing, the primitive narcissism of the firesetter en-
raged at a seemingly unempathic world, or the rapist who is traumatically
overstimulated by intense affectionate longings.
Many delinquent adolescents lead risky lives and face violent death more
frequently than the average individual. 24 When they come to treatment, they
are usually difficult to work with: they are resistant and frustrating. They, and
we, do not understand their motives or their behavior. Because they are psy-
chologically deficient individuals, they are not attractive patients. When they
show up in the public sector, they are usually shunted out of the mental health
system (which can only attend to psychotic or suicidal patients) and into the
correctional system, where they are faced with no or uncertain diagnosis, little
or no psychotherapy, poorly monitored psychopharmacology if any, and an
attitude that behavior is consciously determined and under one's voluntary and
moral control. If psychotherapy is attempted, the therapist is often confronted
with a negativistic and hostile, sometimes violent, patient, and such is usually
equated with the absence of a treatment alliance or an untreatable patient. 25
Psychotherapists often prefer agreeable, compliant, and rapidly improving
patients.
The recent development of self psychology26-3! in psychoanalysis and
psychoanalytic psychotherapy offers renewed hope in working with the primi-
tively organized individual, such as the adolescent criminal. For example, act-
ing out behavior is not the result of some "inner" wish being expressed "out-
side" because the patient's experience is that he is at one with the world, which
is or should be under his omnipotent control as a part of himself. Rather,
acting out represents a state of psychic life where thought, word, and deed are
merged as one and inseparable, and the patient does not distinguish an inside
from an outside reality. These are the perspective of the healthier observer or
therapist, not of the inner experience of the impulse-ridden person. By persist-
ing in his attempts to empathize with the psychological world of the impulse-
disordered adolescent, the psychotherapist will ultimately help the primitive
selfobject transference unfold. Then, the reparative process can begin. 3 !
Contrary to the later recommendations of Aichhorn and Hoffer, it is not
necessary for the psychotherapist to encourage an idealization. Such efforts
may encourage the delinquent to further misdeeds if one tries to presents
oneself as an omniscient, omnipotent delinquent ego ideal. Primitively orga-
nized adolescent delinquents can often be best understood along the lines of
narcissistic pathology, and the properly trained psychotherapist uses his em-
pathic capacity to be sensitive to emerging narcissistic or selfobject trans-
ferences. Idealizing transferences do not need to be stimulated or fostered
because they will emerge and flourish given the suitable therapeutic ambience
and proper attention to self-selfobject issues.
HOSPITAL TREATMENT OF THE DELINQUENT
Patients experience their pathology in an autoplastic manner, as symp-

toms, or in an alloplastic way, as behavior. Developmentally, adolescents be-
have rather than experience symptoms, or affects, especially delinquents and
behaviorally disordered adolescents. Because adolescents generally show their
disturbances in their external behavior, rather than solely through traditional
psychiatric symptoms like psychosis and depression, psychiatrists and other
mental health professionals who ignore delinquent and behaviorally disor-
dered adolescents are missing, and failing, the vast bulk of disturbed teenagers.
The behavior of disturbed adolescents impinges on other patients, hospital
staff, and the environment and milieu-which must accommodate, change, or
push back. To push back is to try to reverse the externalization of the internal
psychological world to create an intrapsychic problem, the developmentally
earlier, original neurotic conflict. On the other hand, if the behavior represents
structural (ego-superego or self) deficits, the environment and others are
called on to perform the deficient functions. Here, pushing back means at-
tempting to understand the nature of the psychological deficit, to designate it,
and to supply it or to help the patient develop competence or compensatory
functions.
Fundamental to such interventions is a differential diagnostic assessment,
and this can usually be best accomplished by a multidisciplinary team's observa-
tions and by making inferences about the adolescent on the living unit of the
hospital or treatment center.
In the assessment and intervention processes, the milieu staff are never
passive receptacles or pliable objects. Ideally, they impinge, push back, or
respond actively to patient pathology, according to consensually agreed-on

diagnostic and therapeutic principles.
As part of an open system 32 and as part of a hierarchical system, the staff
also experience internal and external struggles in reaction to and in interaction
with patient psychopathology. These struggles, experiences, and interactions
may lead to staff symptoms and staff behavioral responses. For example, ab-
senteeism and an increase in sick days do vary with shifts in staff morale. Again,
supervisory and administrative staff push back and assert their own creative
initiatives against staff symptoms or behavior, based on conceptualized, taught,
and explainable principles: by helping them to understand the meaning of
their symptoms, feelings, and behavior; by helping them to control, limit, and
modulate when appropriate, or to change when possible, through supervision,
staff help, self-help, or personal psychotherapy. Such supervisory support and
attention are essential and basic ingredients of inpatient and residential work
with deviant and disturbed adolescents.
These symptoms and behaviors are the expressions of transferences, ex-
amples of acting out and resistance, manifestations of psychic deficits, or
efforts to heal the self by practicing "action thought"30 in both patients and
staff, as in any social system.
Leadership is very important to the clinical process, and successful clinical
administration can be described as charismatic and mirroring the worth of the
group or messianic and exemplifying the group's ideals. 33 Leadership is also
available and present, empathic and interested, confident and secure, ethical,
and clinically focused on a therapeutic approach. To lead is not to dictate but to
be part of an involved process with others, sensitive to others' wishes and ideas,
but capable of articulating one's own informed views. An idealized leader can
readily lose touch with the ideas and feelings of others, who may not speak
openly. Some followers rigidly adhere to treatment principles and practices
that need to be kept flexible and constantly refined and modified. New staff
members and trainees can provide the system with fresh ideas and viewpoints;
leadership must accept these contributions, incorporate them, and work with
them.
The treatment system is not isolated from outside influences; yet, the
leader must either protect the system from outside interference or properly
dose the amount of intrusion so that symptomatic patient or staff behavior is
not sustained, encouraged, or supported by others, such as lawyer-advocates or
family; so that the social system can heal itself and work on its own pathology,
an important self-regulating function; so that outside pathology, such as coun-
tertransference problems of lawyer-advocates or family pathology, do not
create behavior and deficits that cannot be regulated.
For example, a consulting psychiatrist loudly confronts a staff nurse in the
dayroom and asks her about her credentials in the presence of patients and
other staff. A lawyer tells his client, also in front of other patients, that his
rights and the rights of other patients are being violated and that the lawyer
will be working to resolve the issues. If clinical leadership cannot protect staff
and patients from such intrusions, the treatment alliance is readily disrupted.
Such a disruption occurred when an adolescent told his teacher that he did not
need to work with his therapist on his school behavior in order to be able to
return to the classroom, because "my lawyer will get me back into school."
Furthermore, he did not need to be seated in the classroom because his at-
torney would support him in his refusal. The predictable outcome was that he
did not attend psychotherapy sessions for several weeks because he now experi-
enced his attorney as the omnipotent transference figure, not the impotent
therapist, as increasingly, clinical matters became legal issues.
ASSERTIVENESS IN TREATMENT
Violence is a common problem in working with behaviorally disordered

adolescents. 34 Not only are they more likely to experience violent death 24 in
homicide, suicide, or trauma, but they also behave violently, and their violent
feelings and behaviors are common occurrences in psychotherapy and hospital
treatment. A treatment program that purports to experience no violence in
working with this kind of patient is either suppressing the violence or causing it
to be displaced, for example, onto the environment in destruction of property
and furniture.
Limit setting is an important aspect of the hospital treatment of the behav-
iorally disordered adolescent and the juvenile delinquent. How well a therapist
or staff member set limits has something to do with how well or how poorly
their own aggressive and assertive tendencies have been transformed and inte-
grated. Anna Freud 8 emphasized how the internal controls and taming of the
instincts that develop as a child matures and the superego develops can be
conceptualized as an identification with the aggressor, to the extent that the
parent, in frustrating the child's instinctual tendencies, is experienced as an
aggressor; in turn, that control and limit setting are internalized by the child
through identification with the aggressor. The importance of setting limits in
establishing internal psychological structure, controls, and coping mechanisms
was also emphasized in the work of Redl. 19,20 After the attempts to establish a
transference-gratifying treatment milieu were discarded, the value of behav-
iorallimits was recognized, in that the behavior of the delinquent adolescent be
confronted with controls, so that an internal neurotic conflict would be experi-
enced; this would then foster the development of transference, which could
then be analyzed and resolved.
Winnicott 21 ,22 also noted that juvenile delinquents need a period of prepa-
ration for psychotherapy in a training school before they are ready to engage in
a transference, and when he talked about the "antisocial tendency" of these
young people, he was referring to their inherent destructiveness and to their
continuous search for a firm object which can tolerate their testing destruc-
tiveness. It is this repetitive and constant seeking for contact with an object,
albeit at times destructive, which insures the prospect of a hopeful resolution
and favorable prognosis for working with delinquent adolescents. When the
secure and reliable object and environment are found, the delinquent has the
freedom to feel and to act.
It is important to provide an external structure in the hospital milieu that
can eventually be internalized as psychic structure by the adolescent. 9 This
general concept is applicable whether or not the adolescent is experiencing a
neurotic conflict that gets externalized and needs to be reinternalized, or
whether the adolescent is demonstrating a deficit of psychic functioning, in
which instance the ward staff perform important psychological functions that
the adolescent cannot provide himself and that eventually will become inter-
nalized functions. We know that many delinquent adolescents behave violently
because they are traumatically overstimulated, and for many of them this kind
of behavior demonstrates quite clearly the lack of internal psychic structure.
Many adolescents do not relate to objects in a libidinal or aggressive way as
traditionally described, but rather relate on the basis of primitive narcissistic
transferences, of either a mirroring or idealizing nature, and in many in-
stances, these primitive transferences can emerge only in a safe and secure
environment. Conceptualizing the hospital milieu must primarily emphasize
safety and security for patients and staff. Once this is provided, predictability,
dependability, and consistency can be provided, creating for the deficient and
disturbed adolescent's self the persistence in time and the continuity in space
that he lacks. Then, superimposed on these two fundamental principles can be
developed an individualized treatment plan, taking into account the unique
transferences and deficits of each adolescent.
A general goal of hospital or residential treatment of the behaviorally
disordered adolescent is to convert acting out behavior into some kind of
internalized experience. On the one hand, this can represent the blocking of
the symbolic discharge contained in true neurotic acting out in the same way
that, in a sense, transference is an acting out and an attempt not to remember
or reexperience something in the treatment, but rather to defend against that
experience and remembering. However, many adolescents do not exhibit be-
havioral problems as an expression of a defended-against neurotic conflict, but
behave delinquently because of psychological deficits, and a redefinition of
"acting out" is necessary. Many delinquents function at a regressed level and
are not capable of making distinctions between a psychological inner world and
an external world of reality; both merge and mix together, such that thought
and feeling are interchangeable with behavior, and the concepts of inside and
outside are concepts of the observer, rather than the adolescent's own experi-
ence.
When in treatment, however, we attempt to help the adolescent define an
inner psychological world and begin to understand the meaning of his behav-
ior, we do several things. We refuse to permit the kind of gratification that
comes through the symbolic expression of the internal wish, need, or conflict.
We make ourselves available as supportive and therapeutic selfobjects, trying to
provide a milieu in which all behavior can be understood. We also quite ob-
viously are attempting to convert motor behavior into verbal behavior, and as
such are trying to help the establishment of internal psychological structure.
The interpretation of the transference is not a gratification, then, but indeed a

frustration of the transference; and, at the same time, it represents an attempt
to provide something else, namely, insight.
Some therapists 35 •36 advocate more than simply an attempt to understand
the nature of the violent or destructive transference feelings and emphasize
how necessary it is to confront the destructive aggressions of many of these
patients. Kernberg 36 notes that it is impossible to think of a supportive psycho-
therapy with borderline patients because any failure to confront their inherent
destructiveness is a palliation that fails the needs of the borderline. They are
taught that the therapist is frightened of their destructiveness, are presented
with a false view of reality, and have another experience of failing to deal
effectively with a chaotic psychological world.
PSYCHOTHERAPY OF THE DELINQUENT
Hostility and destructiveness are part and parcel of the psychotherapeutic

work with many adolescents, and in many instances are not simply expressions
of resistance, but rather lie at the very core of their psychopathology. For
example, the negative transference 25 is frequently seen in working with behav-
iorally disordered adolescents and is not to be confused with the absence of the
therapeutic alliance. Defiance is as much an indication of a bond as is obe-
dience. In classical psychoanalytic theory, the positive transference was viewed
as an expression of the libidinal instinct, and the negative transference an
expression of the aggressive or destructive instinct. Because of the universality
of human ambivalence, both needed to be dealt with in treatment. It was
thought that many treatments failed because the negative transference was
never confronted and never dealt with. The negative transference could lead
to the destruction of the therapy, as it would spill over and interfere with the
establishment or maintenance of a therapeutic or working alliance, but, of
course, so can the positive or erotic transference. Both negative and positive
transference can become resistances.
The hospitalized juvenile delinquent frequently experiences a negative
transference. Sometimes negativism is not a true transference, but more of a
defense or a defense transference in an attempt to protect the adolescent from
the emergence of positive transference feelings. Oftentimes these are tendencies
to idealize the therapist or expressions of a search for an idealized parent. Part
and parcel of this tendency to idealize is also a tendency to de idealize or depreci-
ate. Such depreciation or deidealization may express a defense against the
emergence of intense primitive longings for a perfect parent. Other such ex-
pressions of hostility may, indeed, represent the disillusionment that the adoles-
cent has experienced time and time again-that the hoped-for parent has failed
to materialize-and he may indeed be reexperiencing with his new therapist the
combination of the two, the search for the wished-for parent and the expectation
that this therapist, like other parents in the past, will fail him. On the other hand,
he may also have noticed some defect in this therapist and immediately experi-
ence the disillusionment that the idealized parent has once again failed to
materialize. What is important in all of these instances is the realization that such
negativism and hostility in no way indicate that a therapeutic alliance is absent or
impossible. In fact, it is the very expression of this core pathology of the delin-
quent adolescent which indicates that an attachment does exist, an attachment
that needs to be understood and worked through in the same way that a positive
attachment needs to be worked through.
Anna Freud 37 had chronicled how the adolescent separates from the in-
fantile attachments to his or her parents. Sometimes this separation movement
is made through what she terms reversal, that is, the converting of positive
libidinal attachments to negative hostility. It is important to recognize, how-
ever, that there is also a narcissistic bonding with the parents that must be
modified,38 and much of the negativism and hostility that an adolescent shows
toward his parents is an expression of the need to change this narcissistic
bonding. For example, the adolescent who previously had turned to his parents
for mirroring and affirmation, can now no longer tolerate such mirroring and
affirmation and either turns away in disgust when his mother compliments the
adolescent, or insures that the parents will relate to him in a disgusted manner.
Similarly, deidealization and depreciation of the parents are an inherent part
of the breaking off of such narcissistic bonding. In many ways, of course,
Aichhorn 3 •4 led the way because he demonstrated for us the importance of
narcissistic bonding when he described the 'juvenile impostor."
STRUCTURALIZATION
Psychological structure is psychological function that endures over time.

Anna Freud 8 argued that the superego structure develops in part through an
identification with the aggressor. Earlier, Sigmund Freud 39 noted that the loss
of an object leads to an identification with the object: "when the shadow of the
object falls on the ego." This was later elaborated in the recognition that, in
child rearing, to frustrate the child and not gratify wishes would lead not to a
traumatic experience, but rather, if the frustration were tolerable, dosed prop-
erly, and could be managed by the child, the child would begin performing
functions for himself that he had heretofore expected from the parent.
Kohut 28 elaborated these concepts further in his idea of the transmuting inter-
nalization, in which he noted that the ideal climate for the building of psycho-
logical structure involves not the internalization of the person of the parent, or
for that matter, the person of the therapist, but rather certain functions, and
quite obviously depends on a potentiality and a readiness on the part of the
child or patient to change and to internalize.
ROLE OF THE PSYCHOTHERAPIST
In any treatment relationship, the therapist is experienced both as a real

object and as a transference object. In the treatment of adolescents, the thera-
pist is an important real-life person facilitating developmental change. At the
same time, the activity of the therapist can be viewed in a variety of ways. Some
theorists talk in terms of how the therapist's aggression in the face of trans-
ference demands and onslaughts needs to be channeled, sublimated, or tamed,
and express itself through interpretation. One can also think of this, however,
not as a taming or transformation of the aggressive drive, but rather as assert-
iveness, or initiative on the part of the therapist. In a sense, then, it is possible to
think of this kind of initiative or assertiveness as an expression of a narcissistic
transformation that occurs in the therapist. From one point of view, it repre-
sents a maturation and transformation of the idealized parental imago in the
sense that the therapist adheres now to the ideals of the treament model. From
another point of view, this initiative or assertiveness represents an expression
of a transformed, matured, and changed grandiose self. Now, the therapist's
self-esteem involves his activity with the patient; his self-assertiveness comes to
the fore; his therapeutic ambition moves him onward; his creativity shows itself
in the way in which he expresses himself, and in what he expresses; his thera-
peutic and interpretive activity can be viewed as a form of exhibitionism in
which he displays to the patient his inner self; it is a form of self-expression;
and finally, it is a manifestation of his self-security in the sense that he refuses
to be moved from his therapeutic aims.
To be firm in the face of transference demands, in the face of devaluation,
depreciation, or other onslaughts, may seem aggressive to some, and to in-
terpret or to refuse to gratify transference wishes and demands may also seem
cruel, but it can also be understood as the expression of a secure, confident,
and unmovable therapeutic agent.
As we have already noted, idealization and deidealization are important
aspects of psychotherapeutic work with delinquent adolescents. In fact, there is
good reason to believe that a capacity to idealize (or deidealize) is an important
assessment criterion for a positive prognosis. There are many charismatic fig-
ures who work with adolescents, capable of being idealized and capable of
establishing the important narcissistic bonding. At the other end of the spec-
trum, we see insecure, ambivalent, and frightened therapists who cannot en-
gage the adolescent in any kind of treatment relationship. The ideal road is the
middle ground, that of the confident and secure therapist who does not assault
his patients, but who shows initiative and assertiveness as he expresses his well
defined and securely held therapeutic aims.
CLINICAL EXAMPLES
Nancy is a I3-year-old who was hospitalized for 2 years, and who, prior to
admission, had had multiple group placements and psychiatric hospitalizations.
She was violent at home, at school, and at other treatment facilities, stole fre-
quently, truanted, and ran away. After admission, she would assault staff without
any apparent precipitant, and it was only after several months that the sources of
her rage became more clear. For awhile, there was considerable pressure to think
of her as having some kind of biological or hormonal imbalance, because it
seemed that her disruptive and assaultive behavior was cyclical and not related to
any apparent precipitant. However, the unit chief insisted that the staff hold to its
philosophy that all behavior has meaning and can be understood psychologically,
and that eventually, if the structure of the unit and of the daily program were
maintained, the meaning of Nancy's behavior would become clear. Eventually, the
sources of Nancy's rage were able to be brought into the psychotherapy rather
than discharged with other staff members. Before she could talk openly in thera-
py sessions about her violent wishes and murderous urges, which made her feel
like "Hitler" and which she somehow felt were out of proportion to what they
should be, she discussed them with ward staff, and tried to organize some of these
feelings and test out whether or not it would be appropriate to discuss these issues
in psychotherapy. The ward staff were being used supportively. Often, when
Nancy became enraged, she would feel numb, a way of ridding herself of all
intense affect, particularly rageful feelings. Eventually, she would rage at her
therapist in sessions. She would scream at her, and her speech would become
garbled; she told her therapist that she wanted not simply to hurt her, but to
strangle her. Staff recognized that Nancy used the ward staff and the therapist as
selfobjects to complete herself and to provide psychological functions that she was
not able to perform for herself. Conversely, she expected the therapist to use her
also for narcissistic gain, and when the therapist recognized an accomplishment of
Nancy's or seemed to be pleased that Nancy was making progress in psycho-
therapy, Nancy became enraged and felt that her gains had now been turned to
"shit." The therapist met her rage by interpreting to her that Nancy felt that the
therapist would not permit her to grow up, and that she needed to kill the
therapist in order to mature. Nancy regained her composure, and agreed that in
order to grow, one had to kill the other person, that there was no way to have a
relationship continue once one begins to grow, that people simply won't let one do
that. Because the staff and therapist adhered to their treatment philosophy, Nan-
cy's rage was confronted in the therapy, rather than split off or suppressed.
Laura is a l6-year-old who, after a hidden and denied pregnancy, delivered
an infant whom she murdered. Laura was never psychotic, but, instead, gives
evidence of a severe narcissistic disorder. She expressed in the murder her rage at
her mother, and replicated this rage on the treatment unit with her therapist. She
was hospitalized for over 2 years during the course of which she would rage at her
therapist for daring to come onto the unit to talk to anyone else other than herself.
Earlier in the treatment, the transference rage was split off and displaced onto the
ward staff, and resulted in the patient engaging in sexual escapades on the unit in
defiance in staff rules, and fostering and encouraging an assault on a staff mem-
ber. The therapist, by consistently confronting the meaning ofthe patient's behav-
ior, eventually brought the rage into the treatment relationship where an explora-
tion of the murder and her feelings about the murder could occur. Laura's
murderous rage resulted from the need to maintain narcissistic perfection and to
blot out and destroy anything that impaired her sense of grandiosity. Her baby
was a transference object and represented a devalued and disavowed aspect of
herself, which needed to be destroyed. She murdered an intruder, something that
upset her narcissistic homeostasis. Similarly, certain behavior by the therapist
would enrage her because she could not control her therapist, or her feelings for
her, and she would rage at her or act out with other patients in an effort to
reestablish grandiose control. It was because of the therapist's efforts to confront
continually Laura's manipulative, delinquent, and unknown behavior that Laura
was able finally to talk openly about her delinquent activity in the past and her
current delinquent activity on the unit and as a result begin to idealize the
therapist.
Karl is a 16-year-old who presents himself in an arrogant and haughty man-
ner. Despite the fact that he claims to have significant career plans that he knows
he will realize, his failing grades at a private high school point in another direc-
tion. He seems to be bright, but is not doing well academically, much to the
chagrin of his academically oriented and financially successful parents. There
have been a number of attempts to treat his depressions and his behavioral prob-
lems over the years, and all these attempts at psychotherapy failed. During one
diagnostic interview when Karl and his parents were talking about the previous
attempts to help him with his problems, he turned to the psychiatrist and talked
with sarcasm about the "fool" who had treated him before, and how playing with
puppets was really a waste of his parents' time and money. The therapist was
taken aback by his sudden assault, thought for a moment, and then pointed out to
Karl that he must have been terribly disappointed in the past in someone that he
had looked up to and was quite angry and disillusioned with whomever that was.
He was silent for a moment and then went on talking about other things. The next
day his mother called to say that Karl had talked at length with her that night
about how he indeed did feel disappointed in people at times and went on to talk
about how disappointed he was with his father. When she suggested that that was
something he could discuss in another session, he latched onto the idea willingly
and requested another appointment a few days later. Then, he talked about how
often his father was unavailable to him, but at the same time how difficult it was
for him to reach out to his father. When later in that session, the psychiatrist
reiterated that Karl could profit from psychotherapy, he rejected it immediately,
indicating that it was not necessary, that he could handle his problems himself, but
that more than likely, even if his parents insisted that he come in six times a week,
he would have to do so, or otherwise lost valued privileges. This was an indication
that he needed to be seen more frequently, that he would agree to therapy, but
would need to save face in the process. What happened here is that a fledgling
therapeutic alliance was established by acknowledging the patient'S disillusion-
ment at an idealized figure, which emerged only when the psychiatrist realized
that Karl's verbal assault and his characterization of therapists as fools who play
with puppets must represent a transference. By the psychiatrist's countering the
patient's assault with an equally firm interpretive stance, the patient was able to
engage, at least initially, in a therapeutic alliance and a further deepening of the
transference relationship. This relationship was threatened later when, as a result
of slow therapeutic work, Karl agreed that he needed to enroll in a special educa-
tion program at the public high school he was now attending. His counselor sent
the psychiatrist a letter requesting information that the school staff would use in
its diagnostic evaluation and treatment planning; a release of information had
been signed by Karl's father. The therapist discussed this request with the patient,
indicating that he would want Karl's signature too before sending a report, a
report that he could also review. He seemed surprised, and then gleefully refused
to agree to the release. Initially, this seemed a resistance, the same kind of obstruc-
tion others had complained about. After several sessions, it became clear that Karl
had become enraged with what he perceived as the therapist'S impotence in not
being able to send a report, with or without his approval. He experienced a
sudden and profound disillusionment and deidealization, which enraged and
paralyzed him, and disrupted the treatment alliance. He began missing sessions or
coming late, until this was recognized, interpreted, and worked through.
Frank is a IS-year-old seen in the office after he had been involved in fre-
quent runaways, serious school truancy, stealing money from his parents, taking
the family car without permission, using alcohol and drugs to excess, being ar-
rested for selling marijuana, driving a stolen car, driving without a license, and
assaulting his sister. Very quickly, he began to depreciate and devalue the impor-
tance of the therapist, insisting that he not only did not need help, but that even if
he did, this therapist could not help him. Nonetheless, he came regularly to
treatment sessions, and it became clear that Frank was struggling to separate from
intense narcissistic bonding to his parents, which was replicated in the treatment
relationship. He believed that the therapist needed Frank for his own sense of
well-being and presumed that the therapist would demand of Frank some positive
statements about the efficacy of the treatment. As a result, any comment about his
improvement would be met with the same disdain and disgust that he now heaped
on his mother whenever she praised him. Frank was struggling to separate psy-
chologically, and eventually did-from the therapist-having developed the ca-
pacity to take much greater responsibility for his behavior and his life. Frank's
negativism was the result of his need to modify his ties to his parents and, by
transference, devalue and depreciate the therapist. His bonding with his parents
was intensely narcissistic, and he could adjust these attachments only by negating
their very nature. His negativism represented a defense against, and an ex-
pression of, the idealization of the therapist, a transference from the parents. The
expectation of an exploitative narcissistic relationship with the therapist, as with
the parents, was worked through, and separation achieved in termination. At
those times when Frank would confront the therapist with the failure of therapy
and with the fact that he did not need any kind of treatment, the therapist would
insist firmly that as far as the therapist was concerned, Frank desperately needed
help, that he was unhappy, depressed, and angry, and would not improve without
therapy. The therapist acknowledged that there was no way to force him into
treatment, but noted that his stand was unequivocal, that there was nothing the
patient could say or do to convince the therapist that he did not need help. The
patient stopped arguing about the fact that he thought that his parents were
dragging him into treatment, and continued to come to sessions. He brought his
friends from his distant suburb to a park ner the therapist's office to show them
"the city" and assumed that the therapist had himself been in the park that day.
Several months later, when the psychiatrist said that the patient had progressed to
the point that he could choose to continue or discontinue treatment himself, the
patient continued for another 6 months. Here, the therapist's taking a strong and
unequivocal stand about the patient's pathology enabled the patient to continue to
participate in treatment. At termination, he denied that treatment had really
helped him, because, indeed, he never needed help because he had no problems.
He noted that if the therapist had lived next door, it would have been much easier
to drop in and talk, every now and then, because he found it especially useful to be
able to complain about his parents.
These clinical examples demonstrate that violence, aggression, hostility,

and assertiveness are part of the behavioral repertoire of the behaviorally
disordered and delinquent adolescent. Similarly, the therapist is confronted
with assaultive behavior verbally, and sometimes, physically. The therapist re-
sponds in kind by insisting aggressively, assertively, or with initiative, that there
are certain kinds of pathology that need to be investigated. Whether one views
this as a modification or transformation of the therapist's aggressive instinct, or
an expression of his narcissistic initiative, or of his creative psychotherapeutic

work, is open to discussion. Nonetheless, it is clear that the therapist must feel
comfortable enough to withstand such assaults, while at the same time moving
assertively against the patient's pathology and defensive structure, clearly label-
ing behavior as worthy of investigation, and clearly labeling some behavior as
symptomatic of underlying pathology. Such labeling fosters introspection.
Such assertiveness provides the destructive and structurally deficient adoles-
cent with a secure object, an external psychological structure, a selfobject to
complete the self.
The use of aggression, assertiveness, and initiative in the treatment of the
juvenile criminal is fundamental. Such requires a secure therapist who does not
rely on reaffirmation, or mirroring, or gratitude from his patient in order to
establish or maintain ambition, but paradoxically an assertion that frees, rather
than molds, the patient-frees him to assert himself.
STATUS OF PSYCHODYNAMICS FOR THE PRACTICING

PSYCHIATRIST
Juvenile delinquency continues to be a serious social problem in the

United States. Yet, its impact is not limited to social disability, because juvenile
criminality also reflects serious underlying family and individual psycho-
pathology. The formal statistics do not disclose the extent of such disability,
because much delinquency is undetected and unreported, but serious.
Teenagers from affluent families tend to be handled by the mental health
system, usually in the private sector, whereas other adolescents are seen in the
public mental health sector and the correctional system. Often, when a white
delinquent is brought before the juvenile justice system, one seeks for a psycho-
logical explanation; when a black delinquent is brought to the system, his
behavior is considered normative, and correctional interventions are em-
ployed. Explaining psychopathological behavior as gang-related typically oc-
curs, especially in the inner city. Delinquent adolescent girls are frequently
treated lightly in station adjustments until their behavior has escalated to a
serious degree; then, they enter some system.
These events derive from some common biases of our society and its
preoccupation with teenage unemployment, racism, poor schools, neigh-
borhoods, poverty, and social class as the etiologies of juvenile delinquency.
Surely, social ills need to be eradicated or ameliorated whenever and wherever
possible-for their own sake. However, these are correlates, not causes, of
juvenile criminality, and the important explanations must be sought in family
and individual psychology and psychopathology.
Time and time again, national task forces on delinquency 40 have no psy-
chiatrist or behavioral scientist members, and their reports contain few recom-
mendations to provide psychological and psychiatric assessment and treatment.
We are advised to improve housing and recreation, study family planning and
religious values, improve inner city life and job opportunities, and recruit and
more police. In fact, official correctional policies have abandoned rehabilita-

tion in favor of providing a fair and lawful environment.
We now know that many adolescents express their emotional disorders
through behavioral symptoms and identified criminality, and not necessarily in
diagnosable psychiatric illness. Yet, the incidence of significant emotional ill-
ness in a juvenile correctional population is high.41
There are difficulties within psychiatry as well. These are not attractive
patients, often confronting the psychiatrist with hostility and resistance. Their
behavior is difficult to understand, and so they are frequently dismissed as
beyond the reach of a psychologically based approach. Working in the public
mental health system or the state or federal correctional systems are not attrac-
tive financially or in terms of professional status. Although many hospital
programs fill their beds with such adolescent patients, these patients and their
families are often confronted with inadequate insurance coverage and a dis-
charge at the termination of that coverage with little provision for aftercare.
Health Maintenance Organizations, like many health insurance plans, do not
recognize these behavioral disorders as being in need of psychiatric interven-
tion. Often, the psychiatrist emphasizes diagnoses of organicity or psychosis to
justify reimbursable treatment. When coverage is available, it is usually limited
to short-term care, clearly failing to provide the long-term, at times tedious,
treatment that behaviorally disordered adolescents need. In many instances,
patients eligible for public mental health services can receive longer term treat-
ment, and so middle-class families are caught in an interesting bind, believing
that the services they would be provided are adequate. Yet, the public sector is
often so underfunded and overwhelmed that only psychotic and suicidal ado-
lescents can be treated; dangerous adolescents are often kept because there is
nowhere else to send them, not because of some felt responsibility to treat
them. Again, society, and particularly this increasingly legalistic society, looks at
the externals of behavior and not at the inner psychological world.
As a result, more and more adolescent delinquents move into adulthood
with unresolved and untreated psychopathology. They do not necessarily per-
sist in a life of crime, but endure impoverished, impulsive, and depressed lives.
The cost to our society is immense, and the personal disability is monumental.
CONCLUSION
Reviewing the psychodynamic approach to understanding juvenile crimi-

nality is a worthy pursuit, because it takes one through the history of psycho-
analysis and psychodynamic psychiatry.
Psychoanalysis was there from the beginning! From the pioneering work
of August Aichhorn to the current modifications introduced by his analysand,
Heinz Kohut, the efforts to understand and modify adolescent deviant behav-
ior have enlisted the interest of some of the most prestigious psychoanalytic
thinkers and clinicians.
Today, most well-trained psychiatrists know something about the treat-
ment of the impulsive adolescent: the idealizing transference, primitive nar-

cissism, superego lacunae, separation-individuation struggles, traumatic states,
limit setting, staff serving as regulating selfobjects, and countertransference
Issues.
Yet, much more needs to be accomplished, and many more delinquents
need to benefit from these understandings, especially those trapped in the
public sector.
REFERENCES
I. Freud S: Three essays on the theory of sexuality (1905), in Strachey J (ed): Standard
Edition, vol. 7. London, The Hogarth Press, 1958, pp 132-143.
2. Aichhorn A: Wayward Youth (1925). New York, Viking Press, 1935.
3. Aichhorn A: Delinquency and Child Guidance-Selected Papers. New York, International
Universities Press, 1964.
4. Marohn RC: The ')uvenile impostor": some thoughts on narcissism and the delinquent.
Adolesc Psychiatry 5:186-212, 1977.
5. Hoffer W: Deceiving the deceiver, in Eissler KR (ed): Searchlights on Delinquency. New
York, International Universities Press, 1949, pp 150-155.
6. Alexander F, Staub H: The Criminal, the judge and the Public: A Psychological Analysis (1931).
New York, Collier Books, 1956.
7. Friedlander K: The Psycho-Analytical Approach to juvenile Delinquency: Theory, Case Studies,
Treatment. New York, International Universities Press, 1960.
8. Freud A: Dissociality, delinquency, criminality, in Normality and Pathology in Childhood:
Assessment of Development. New York, International Universities Press, 1965.
9. Marohn RC, Daile-Molle D, McCarter E, Linn D:juvenile Delinquents: Psychodynamic Assess-
ment and Hospital Assessment. New York, Brunner/Mazel, 1980.
10. Johnson AM, Szurek SA: The genesis of antisocial acting out in children and adults.
Psychoanal Q 21 :323-343, 1952.
II. Bird B: A specific peculiarity of acting out.j Am Psychoanal Assoc 5:630-647, 1957.
12. Glover E: On the desirability of isolating a "functional" (psycho-somatic) group of delin-
quent disorders. Br j Delinquency I: 104-112, 1950.
13. Glover E: The Roots of Crime. Selected Papers on Psychoanalysis, vol 2. New York, Interna-
tional Universities Press, 1960.
14. Marohn RC: Trauma and the delinquent. Adolesc Psychiatry 3:354-361, 1974.
15. Marohn RC, Daile-Molle D, Offer D, Ostrov E: A hospital riot: Its determinants and
implications for treatment. Amj Psychiatry 130:631-636.
16. Baittle B, Kobrin S: On the relationship of a characterological type of delinquent to the
milieu. Psychiatry 27:6-16, 1964.
17. Bios P: The concept of acting out in relation to the adolescent process, in Rexford EN
(ed): A Developmental Approach to Problems of Acting Out. New York, International Univer-
sities Press, 1966, pp 118-136.
18. Bloch DA: The delinquent integration. Psychiatry 15:297-303, 1952.
19. Redl F, Wineman D: The Aggressive Child. Glencoe, Ill, Free Press, 1957.
20. Redl F: When We Deal with Children. New York, Free Press, 1966.
21. Winnicott DW: The antisocial tendency, in Collected Papers. New York, Basic Books, 1958.
22. Winnicott DW: Delinquency as a sign of hope. Adolesc Psychiatry 2:364-371, 1973.
23. Offer D, Marohn RC, Ostrov E: The Psychological World of the juvenile Delinquent. New
York, Basic Books, 1979.
24. Marohn RC, Locke EM, Rosenthal R, Curtiss G: Juvenile delinquents and violent death.
Adolesc Psychiatry 10: 147 -170, 1982.
25. Marohn RC: The negative transference in the treatment of juvenile delinquents. Annual
Psychoanalysis 9:21-42, 1981.
26. Kohut H: Forms and transformations of narcissism. JAm Psychoanal Assoc 14:243-272,
1966.
27. Kohut H: The psychoanalytic treatment of narcissistic personality disorders. Psychoanal
Study Child 23:86-113, 1968.
28. Kohut H: The Analysis of the Self. New York, International Universities Press, 1971.
29. Kohut H: Thoughts on narcissism and narcissistic rage. Psychoanal Study Child 27:360-
400, 1972.
30. Kohut H: The Restoration of the Self. New York, International Universities Press, 1977.
31. Kohut H: How Does Analysis Cure? Chicago, University of Chicago Press, 1984.
32. Marohn RC: The therapeutic milieu as an open system. Arch Cen Psychiatry 22:360-364,
1970.
33. Kohut H: Creativeness, charisma, group psychology: Reflections on the self-analysis of
Freud, in Ornstein P (ed): The Search for the Self, vol. 2. New York, International Univer-
sities Press, 1978, pp 793-843.
34. Marohn RC: Adolescent violence: Causes and treatment. J Am Acad Child Psychiatry
21:354-360,1982.
35. Giovachini PL: Psychoanalytic treatment of character disorders: Introduction, in Boyer
LB, Giovachini PL (eds): Psychoanalytic Treatment of Characterological and Schizophrenic Disor-
ders. New York, Science House, 1967, pp 208-234.
36. Kernberg 0: Borderline Conditions and Pathological Narcissism. New York, Jason Aronson,
1975.
37. Freud A; Adolescence. Psychoanal Study Child 13:255-278, 1958.
38. Marohn RC: Adolescent rebellion and the task of separation. Adolesc Psychiatry 8: 173-
183, 1980.
39. Freud S: Mourning and melancholia (J 917), in Strachey J (ed): Standard Edition, vol. 14.
London, The Hogarth Press, 1958, pp 243-258.
40. The President's Commission on Law Enforcement and Administration of Justice: Task
Force Report: Juvenile Delinquency and Youth Crime. Washington, DC, US Govt Printing
Office, 1967.
41. Rosenthal RH, Viale- Val G, Clay R, Moss-Zerwic P, Stapleton M, Curtiss G: Prevalence of
psychiatric disorders in incarcerated juvenile offenders. Unpublished manuscript, 1986.
5
Childhood Identification and
Prophylaxis of Antisocial
Personality Disorder
LEWIS BLOOMINGDALE AND
EILEEN BLOOMINGDALE
INTRODUCTION
Physiological and psychological characteristics show considerable similarity be-

tween children with Attention Deficit Disorder with Hyperactivity (ADDH)
and adults with Antisocial Personality Disorder (ASPD). Prospective studies of
ADDH children, with or without Conduct Disorder (CD), show a high outcome
of ASPD. Recently, other forms of treatment have been added to the tradi-
tional psychopharmacological agents used for ADDH. If medication and new
treatment modalities are administered for a period of 3 years, a recent con-
trolled study indicates that the mean number of arrests for felony offenses and
the mean number of institutionalizations are reduced at a p < 0.0001 level
(1.32 vs. 0.19 and 0.49 vs. 0.00, respectively).
PHYSIOLOGICAL SIMILARITIES BETWEEN ADDH AND ASPD
In 1978 James Satterfield was probably the first to show the physiological
similarity between ADDH children and ASPD adults. l These physiological
factors have recently been described by Mednick and Volavka. 2 In both ADDH
and sociopaths, the following biological factors are significant. There is low
LEWIS BLOOMINGDALE and EILEEN BLOOMINGDALE· New York Medical College,

Valhalla, New York 10583. Reprinted with permission from the Journal of Forensic Science,
33(l): 187-199, 1988. Copyright 1988 American Society for Testing and Materials.
65
66 LEWIS BLOOMINGDALE AND EILEEN BLOOMINGDALE
autonomic nervous system (ANS) and central nervous system (CNS) activity,
indicated by:
1. EEG slow waves are increased (alpha and theta). This has been con-
firmed for both sociopaths and ADDH children by power spectrum
analysis of the EEG.
2. Skin conductance is decreased, particularly phasic arousal (responsivi-
ty).
3. Spontaneous fluctuations of skin conductance before an aversive stim-
ulus are dampened.
4. The skin conductance response to strong stimuli is greatly reduced.
5. ANS and CNS activity are increased with the administration of amphet-
amines or derivatives in both conditions, including inhibitory action
potentials.
6. Catecholamine levels showed no increase in psychopathic men just pri-
or to trial, whereas normals showed highly elevated catecholamine lev-
els in the same situation. 2 (See item 5 in following section on psycholog-
ical similarities.)
7. Cortical-evoked potentials reflect low arousal and poor attention. So-
lanto 3 suggested that the effect of psychostimulants on ADDH children
is to activate dopamine autoreceptors (inhibitory) consistent with the
theory elsewhere proposed that there is a deficiency of catecholamine
transfer at the synaptic junction, leading to hypersensitivity of postsyn-
aptic receptors.
In summary, there are comparable biological abnormalities in ADDH and
ASPD that can explain a number of similar psychological characteristics of
these two groups of individuals. Adult studies of hypoarousal in criminals have
not systematically evaluated attention. A crucial study would be to examine
inattentive, fidgety sociopaths physiologically.
PSYCHOLOGICAL SIMILARITIES
Elliott 4 described a number of psychological characteristics of sociopathic

individuals that are also typical of ADDH children:
1. Lack of foresight
2. Lack of insight
3. Defective affect
4. Inability to learn from experience
5. Diminished sense of fear
6. Inadequate motivation
7. Poor judgment
8. Absence of depression and neurotic anxiety. (ADDH children may
show dysphoria and some depressed children may show symptoms of
hyperactivity that respond to antidepressant medication. Typical
ADDH patients are neither depressed nor anxious.)
CHILDHOOD IDENTIFICATION 67
9. Frequent lies and inability to distinguish fantasies from reality

10. Self-defeating pattern of behavior. (There is a high covariance of
ADD and aggression as shown by Shapiro and Garfinkel 5 and Trites
and Laprade6 .)
Mednick and Volavka 2 also pointed out that the search for excitement
(including violence) in sociopaths is a way of increasing ANS and CNS activity.
Hyperactive children show a similar disregard for prudence and caution and
their behavior is both reckless and feckless. Not mentioned in any specific
reference is the externalization of blame by ADDH and ASPD individuals.
ADDH children frequently provoke fights with peers, get poor grades, and
annoy their mothers. They usually say it is the fault of the other child, the
teacher, or the mother when confronted with the unacceptability of their be-
havior. Similarly, a sociopathic person who steals a car to get to his destination
will tend to say that he did nothing wrong, it was the fault of the automobile's
owner who left his keys in the car and, besides, he had to get to where he was
going.
NOSOLOGY
Table I describes the research diagnostic criteria (RDC) for hyperac-

tivity/attention disorder. 7 The RDC in Table I represent a consensus of a
group of experts in this disorder who met for that specific purpose in Gro-
ningen, The Netherlands, in 1985. Social disorders characterizing hyperac-
tivity/attention disorder were a matter of considerable discussion but declined
by the majority of experts for inclusion in the RDC. For the purpose of this
paper, the following unpublished criteria that emanated from the Symposium
are reproduced in Table II.
Table I. Hyperactivity/Attention Disorder
1. Activity disorder
A. Motor restlessness, e.g., excess running, jumping, climbing:
fidgeting, squirming when seated
B. Cannot remain seated when required
C. Talkative, intrusive, noisy, interfering
D. Rapidly shifts from one activity to another
2. Attention disorder
A. Easily distracted
B. Inability to organize, e.g., does not complete tasks, difficulty
developing strategies for complex tasks
C. Impulsivity, e.g., immediately answers questions rather than
listening and thinking; cannot remain within guidelines,
pursues immediate gratification; avidly seeks reward
D. Difficulty in shifting from one directed activity to another
Note. From Sergeant JA: RDC for hyperactivity/attention disorder, in

Bloomingdale LM, SergeantJA (eds.) Attention deficit disorder: Vol. 5. Oxford,
Pergamon Press, in press.
Table II. ADDU Social Symptoms
3. Social disorders
A. Does not respond to punishment
B. Insensitive to feelings and needs of others; oblivious to the
effect of own behavior, verbal and nonverbal, on others
C. Cannot wait for turn: jabs, punches, shoves and provokes
other children
D. Controlling of peers and adults (parents), cannot tolerate
direction, orders, authority
Research criteria require input from various sources as indicated in Figure

from Sergeant. 7
COURSE
The usual course of development from ADDH to ASPD is the chronologi-

cal development of the ADDH child to oppositional disorder (OD), then un-
socialized conduct disorder, delinquency and, after the age of 18, ASPD.
The criteria for OD from DSM-III-R8 appear in Table III. A simpler form
of the oppositional phase from an unpublished paper by C. Edelbrock and R.
Loeber appears in Table IV.9 Un socialized conduct disorder is reproduced
from DSM-III-R8 in Table V.
There is a considerable covariance between ADDH and conduct disorder.
This overlap was found by Trites 6 in his study of 14,000 school children as the
percentage of subfactors of the Connors Teachers Rating Scale (CTRS)
TEACHER
~~~ V~~~~c~~red
fj < Observer
Psychological
Testing L---V~~ interview Observer II
[j
PARENT
Figure 1. Cross-situational comparisons used to select ADDH subjects. From Sergeant JA:
RDC for Hyperactivity/attention disorder, in Bloomingdale LM, SergeantJA (eds): Attention
Deficit Disorder: Vol. 5. Oxford, Pergamon Press, in press.
Table III. Oppositional Disorder
1. Often swears and uses obscene language

2. Blames others for his mistakes; stretches re-
ality to justify misbehavior
3. Dominates and is mean to other children
and pets (without physical cruelty)
4. Deliberately annoys others and overreacts
when annoyed by others
5. Often argues with adults; defies or refuses
adult requests or rules
Note. Modified by author from American Psychiatric

Association: Draft DSM-III-R in Development. Wash-
ington, DC, October 5, 1985.
Table IV. Simplified Form

of Oppositional Disorder
Argues
Bragging
Demands attention
Disobeys at home
(Oppositional) Temper tantrums
Stubborn
Teases
Loud
Note. Modified from Edelbrock C, Loeber, R: Un-

published material.
Table V. Unsocialized Conduct Disorder>
I. Fighting; hitting; assaultive; destructive

2. Untrustworthy; dishonest; cheats; lies
3. Actively disliked by peers
4. Not considered present until age 7 or diag-
nosed after age 17
aProposed by John Werry. Modified by author from

personal communication, 1985.
(Figure 2). It will be noted that 5.7% of all school children had ADD and 75%
of the ADD and CD combined group were afflicted by ADD (some of whom
will develop CD if not already present).
Shapiro and Garfinkel 5 studied 315 school children and found a very
similar percentage of hyperactivity/attention in these 315 children, namely,
5.3% and 60% of the combined cohort. QuaylO studied conduct disorder and
Tries: > 14,000 school children in Ottawa

Percentages on subfactors of Conners TRS
7.6%
Total ADD = 5.7% (75% of ADD + CD)
Shapiro and Garfinkel: 315 school children in Minnesota
8.9%
Total ADD = 5.3% (60% of ADD + CD)
Figure 2. Venn Diagrams of ADD·CD. Adapted from Trites RL, Laprade K: Evidence for an
independent syndrome of hyperactivity. ] Child Psychol Psychiatry 24:573-586, 1983. Adapted
from Shapiro SK, Garfinkel BD: The occurrence of behavior disorders in children: The
interdependence of attention deficit disorder and conduct disorder. ] Am Acad Child Psychiatry
25:809-819, 1986.
found that the weighted average correlation between conduct disorder and
attention problems was .54 (Table VI).
The dynamics of development of OD and CD from ADDH children is well
demonstrated in Figure 3. 11 Barkley has developed a powerful series of inter-
views with parents and ADDH children to interrupt the cycle indicated in his
diagram. We have used his method and found it to be highly effective but
requiring considerable reinforcement over a period of time, particularly if the
child attends a school where the teachers are uninterested in working with a
therapist.
Table VI. Intercorrelations among the Subscales of the RBPC

Conduct Disorder
Attention
Samples problems N (type tested)
I 0.56 505 (Random)

2 0.51 136 (Gifted)
3 0.49 34 (Problem children)
4 0.51 151 (Inpatient rated by staff)
5 0 ..'>5 100 (Inpatient rated by parents)
6 0.45 50 (Outpatients with tutors)
Weighted average: .54
Note. Quay H: Aggression, conduct disorder, and attention problems, in Bloom-

ingdale LM (ed). Attention Deficit Disorder: Identification, Course and Rationale. New
York, Spectrum, 1985, p. 37.
>7
yes
no
~ ,.
1
>?
~( "q";..,,",~)----~~·O
( aggression)
Figure 3. Vicious cycle of parent-child interaction in ADD ~ OD, CD, ASPD. From Barkley
RA: A Manual for Training Parents of Behavior Problem Children. New York, Guilford Press,
1981, p 3.
Table VII. Antisocial Personality Disorder
A. Current age at least 18

B. Evidence of conduct disorder before age 18 as indicated by
following symptoms before 15:
1. Truancy; expulsion; several suspensions
2. Lies consistently; steals; vandalizes
3. Repeatedly initiates fights
4. Voluntary sexual inercourse; smokes; drinks; other illicit
drugs before usual for general subculture
C. Irresponsible and antisocial behavior:
1. Irregular work or school attendance
2. Walks off jobs; voluntary unemployment
3. Unlawful behavior (whether arrested or not): destroying
property, harassing others, stealing, illegal occupation, as-
sault & battery, rape
4. Impulsive; does not plan ahead; wanders around country
aimlessly; reckless (driving while intoxicated, recurrent
speeding)
5. Promiscuous; poor parent (inadequate child nutrition, med-
ical care, etc.)
6. Lack of remorse (feels justified in having hurt, mistreated,
or stolen from another)
Note. Modified by author from American Psychiatric Association, Diagnostic

and Statistical Manual of Mental Disorders, ed 3. Washington, DC, 1980.
PROSPECTIVE STUDIES
It will be noted from Table VII that the first DSM-III criterion for anti-
social personality disorder is "evidence of conduct disorder before 18."13 The
percentage of children with CD who develop APSD is not known, It appears
from prospective studies l4 - 17 that ADDH children, psychopharmacologically
treated, showed 18% to 45% ASPD on follow-up. Many may have developed it
subsequently. The ASPD adults all exhibited CD because of the criteria prom-
ulgated in DSM-III and DSM-Ill-R. How many of them had ADDH is not
known, but Quay's statistics in Table VI would indicate that over 50% did have
ADD.
Interesting data were found by Lee Robins 18 in a multicenter study as
indicated in Tables VIII and IX. Table X and Table XI are data from Satter-
field l that are relevant to the questions raised.
Weiss and Hechtman l7 found in their sample of ADDH children, followed
for 15 years, that 1% or 2% of controls and 14% to 23% of hyperactives met
modified SADS or DSM-III criteria for antisocial personality disorder (p
< .01). They point out that this was significantly less than Loney found in her
sample, where 45% of the hyperactives and 18% of their brothers met modi-
fied SADS criteria for antisocial personalities. 16 They found that "most impor-
Table VIII. Risk of Children with Three

or More Conduct Problems Developing
Antisocial Personality (St. Louis only)
Percentage with
antisocial personality
Age group Men Women
18-29 40 24
30-49 48 26
50+ 22 22
Note. From Robins LN: Epidemiology of antisocial
personality, in Michels Ret al (eds). Psychiatry, vol. 3,
Philadelphia, J.B. Lippincott Co., 1986, p 12.
tantly the severity of antisocial behavior was significantly greater with the hy-
peractive group" (see Table XII). Satterfield et al. 19 found a significant dif-
ference between ADD children and their brothers, as shown in Table XIII.
They showed a more highly significant difference between ADD and normal
children in other studies. They also found that offender rates depended, at a
very high statistical level, on the types of family (broken or intact). These data
are shown in Tables XIV and XV.
Table IX. The Age at Initiation

of Conduct Problems before Age 15
(ECA Data)
Mean age at
initiation before 15
Problems in order
of occurrence Men Women
School discipline 9.0 9.8

Underachievement 9.3 10.2
Fighting 9.4 10.0
Lying 9.9 9.6
Stealing 10.0 9.7
Truant 11.0 12.0
Vandalism 11.2 10.7
Drunk 11.2 11.8
Runaway 11.6 12.3
Sex 11.7 13.0
Expelled 11.8 12.1
Arrest 12.4 12.6
Drugs 12.7 13.1
r = .87; z = 3.01.
Note. From Robins LN: Epidemiology of antisocial
personality, in Michels R et al (eds). Psychiatry, Vol. 3,
Philadelphia, J .B. Lippincott Co., 1986, p 11.
Table X. Symptoms of Hyperactive Children and Children in Adulthood

Diagnosed as Psychopaths
Hyperactive
Those showing children showing
symptom as children symptom
later diagnosed Adult psychopaths
Childhood symptoms psychopathic who had symptom Young Teenage
significantly related to personality a in childhood a HACb HAC'
adult psychopathy a (%) (%) (%) (%)
Pathological lying 39 26 43 83
Lack of guilt 38 32
Sexual perversion 37 13
Impulsive 35 38 59 84
Truant 34 66
Runaway 33 65 18
Physical aggression 32 44 59 13
Premarital intercourse 31 28
Theft 31 83 27 66
Incorrigible 30 80 57 83
Stays out late 30 54
Bad associates 30 56
Reckless 29 35 49 22
Slovenly 34 32
Enuresis 29 32 43 13
aData from Robins (1966); © 1966 the Williams & Wilkins Co., Baltimore.
bData from Stewart et al. (1966).
'Data from Mendelson et al. (1971); © 1971 The Williams & Wilkins Co., Baltimore.
Note. From Satterfield JH The hyperactive child syndrome: A precursor of adult psychopathy?, in Hare RD
and Schalling D: Psychopathic Behavior: Approaches to Research. New York, John Wiley, 1978, p 330.
Table XI. Prevalence of Childhood

Behavior and Symptoms
of Hyperactive Children a
Symptoms %
Contact with police 59.0

Taken to police station 18.0
Before juvenile court 19.0
Involved with police three or more times 17.0
Failed one or more grades 58.0
Attending regular school 65.0
Special school or class 27.0
School drop-out 2.4
State psychiatric hospital 2.4
aData form Mendelson et al. (1971); © 1971 The Williams

& Wilkins Co., Baltimore.
Note. From Satterfield JH: The hyperactive child syn-
drome: A precursor of adult psychopathy?, in Hare RD,
Schalling D: Psychopathic Behavior: Approaches to Research.
New York,John Wiley, 1978, p 331.
Table XII. Antisocial Diagnosis (Depending on Instrument, Criteria, and Source)
Controls Hyperactives
(n = 41) (n = 61) Significance
Chronic antisocial behavior since age 14 p < .01

18 (subjects' reports)
Modified SADS omitting close rela- 11 p < .05
tionship
Modified SADS plus other source in- 14 p < .01
formation
DSM-III 14 P < .01
Court record (last 3 years)
Criminal 0 3
Highway offenses under criminal 0 7 P < .07
code (e.g., speeding)
Court record since IS-year follow-up
Criminal 0 7
Highway 0 4
Note. From Weiss G, Hechtman LT: Hyperactive Children Grown Up. New York, The Guilford Press, 1986, p
10!.
Satterfield et al. 14,19 have shown the effect of multimodal treatment on the
outcome of their cohorts of hyperactive children, indicating very highly signifi-
cant differences (p < 0.0001) between patients, both in the number of arrests
for felony offenses and the mean number of institutionalizations between their
control group of ADD subjects treated with medication alone and those who
underwent multimodal treatment for 3 years. Significant at the .01 level was
the percentage of subjects treated with medication alone (control group) and
those who had multimodal treatment for 3 years in the number of repeated
arrests for felony offenses (cf. Table XVI).
Table XIII. Comparison of 35 ADD Youths and Their Brothers

on Serious Offender and Institutionalization Rates
Offender rate
One or more Multiple Institutionalization

Group N Mean agee offense offense rate
ADD 35 17.6 49%a 31%a 34%b

Brothers 35 18.0 11% 6% 0%
ap < .0 I Fisher's Exact Test.

'p < .001 Fisher's Exact Test.
eMean age in years at follow-up.
Note. From Satterfield JH, Satterfield B, Schell AM, Hoppe eM: Psychosocial effects on delinquency rates
in ADD youths and control subjects-An eight-year prospective study, in Bloomingdale LM (ed): Attention
Deficit Disorder: Vol. 3, London, Pergamon Press, 1988.
Table XIV.
Offender rate

Group N Mean age offense offense rate
Broken families:
ADD 63 17.3 48%a 27%a 30%b
Normal 17 16.9 18% 0% 0%
Intact families:
ADD 46 17.2 41%c 28%c 17 b
Normal 59 16.8 5% 0% 0%
ap < .05.
bp < .001.
cp < .0001.
Note. From Satterfield J H, Satterfield B, Schell AM, Hoppe CM: Psychosocial effects on delinquency rates
DefICit Disorder: vol. 3., London, Pergamon Press, 1988.
Table XV.
Offender rate
Mean One or more Multiple Institutionalization

Family type N age offense offense rate
Normal
Two biological parents 59 16.8 5% 0% 0%
One biological parent II 17.1 9% 0% 0%
Step-parent & one bio- 5 16.4 40%b 0% 0%
logical parent
Step-parent (l or 2) only 18.0 0% 0% 0%
ADD
Two biological parents 46 17.1 31% 18% 17%
One biological parent 36 17.1 50% 31% 28%
Step-parent & one bio- 22 16.9 55% 35% 41%a
logical parent
Step-parent (l or 2) 5 16.0 0% 0% 0%
only
ap < .07.
bp < .05.
Note. From Satterfield JH, Satterfield B, Schell AM, Hoppe CM: Psychosocial effects on delinquency rates
Deficit Disorder: Vol. 3. Oxford, Pergamon Press, 1988.
Table XVI.
Offender rate

Group N Mean age offenses offenses rate
ADD 110 17.3 a 45%b 28%b

Normal 76 16.9 8% 0%
ap < .05.
bp < .0001.
Note. From Satterfield JH, Satterfield B, Schell AM, Hoppe eM: Psychosocial effects on delinquency rates
Deficit Disorder: Vol. 3. Oxford, Pergamon Press, 1988.
RETROSPECTIVE STUDIES
Tupin, Maher, and Smith 20 found that 18 of 25 habitual violent offenders

had had childhood ADDH.
A study by Bach-y-Rita, Lion, Climent, and Ervin 21 found that the difficul-
ties of many of a group of 130 violent patients are probably the result of what
in children was termed miminal brain damage. This concept is supported by
the finding of Hertzig,22 who noted in adolescent males minimal brain damage
leads to antisocial behavior and assaults.
A study by Goldman, Lindner, Dinitz, and Allen 23 suggested that the
characteristic antisocial behavior of the simple sociopath is paralleled by a
characteristic physiologic behavior. The exaggerated response of the heart rate
to epinephrine seen here, coupled with the observations of others on the exag-
gerated pupil response, pain threshold,24,25 and digital skin resistance, mimics
a sympathetic de nervation hypersensitivity. If this de nervation supersensitivity
is general throughout the organism, the net effect would be to reduce and
otherwise distort incoming stimuli, to cause the sociopath to make faulty and
impulsive responses to emotion-laden stimuli, and to develop a response pat-
tern that is not only different but also inappropriate to the stimuli presented. 26
Tong 27 had previously studied stress reactivity in relation to psychopathic
behavior. His major research finding, which included heart rates GSR, VRP,
and other variables, after rating his cohort of 180 psychopathic patients with
the Lykken 28 scale was that "subjects who demonstrated social instability were
found to be of low stress reactivity."
FAMILY STUDIES
Morrison and Stewart29 found from interviews with parents of 59 hyper-

active and 41 control children a high prevalence of sociopathy, hysteria, and
alcoholism in parents of the hyperactive children. They found that one third of
the parents of the hyperactive children had some psychiatric diagnosis com-
pared to one sixth of the control childrens' parents (p < 0.025). The specific
differences between subject and control groups were in the prevalence of
alcoholism, sociopathy, and hysteria. When the prevalences of these three con-
ditions were combined, the two groups differed at the p < 0.01 level.
Cantwe1l 30 performed a systematic psychiatric examination of the parents
of 50 hyperactive children and 50 matched control children. Increased preva-
lence rates for alcoholism, sociopathy, and hysteria were found in the parents
of the hyperactive children.
Cadoret et al. 31 interviewed the adoptive parents of two grou ps of children
adopted at birth. One group, the experimental, was born of psychiatrically
disturbed biological parents (n = 59). The second, control group, had psychi-
atrically normal parents (n = 54), male experimental adoptees had an excess of
antisocial behaviors when contrasted with male control subjects.
Stewart et al. 32 pointed out that his study with Morrison 29 and Cantwell's3o
both used normal subjects and that his collaborators studied a group of 126
clinical and hospitalized children, of whom 25 were unsocialized aggressive, 33
unsocialized aggressive and hyperactive, 16 probable unsocialized aggressive
and hyperactive, 20 hyperactive, and 32 with other diagnoses, such as phobic
neurosis, depression, enuresis and encopresis or undiagnosed. One hundred
eighteen of the boys' natural mothers and 60 of the natural fathers were
interviewed. The results of this study, with the caveat that a much higher
number would be needed for exclusive validation, was that antisocial person-
ality and alcoholism were commoner in natural fathers of aggressive, antisocial
boys than in fathers of the remaining boys. However, the presence of these
disorders did not distinguish fathers of hyperactive boys from fathers of those
who were not hyperactive. Cantwe1l 33 has stated that 40% to 50% of CD/OD
children go on to ASPD and that almost all ASPD showed childhood CD.
DISCUSSION
The syndrome* of Attention Deficit Disorder, previously known as Mini-

mal Brain Dysfunction or Hyperactive Reaction of Childhood, has remained a
fascinating and controversial field for study. The introduction of DSM-III and
structured interviews have helped to discriminate these children from their
peers. Research diagnostic criteria have been formulated and DSM-III-R8 both
show considerable refinement on the criteria for defining this group of chil-
dren. As rating scales have indicated, there is a continuum in children and a
cut-off point, usually determined statistically, that is useful in differentiating
ADD children from normals. If these children are identified and given medica-
tion alone, the percentage of ASPD outcome mayor may not be reduced.
Recently, however, varied behavior modifications and parent training have
*Depending on the definition of "syndrome," ADDH is either a syndrome or not.

Table XVII. Comparison of Delinquency Outcome between the DTO Group

and the Three MMT Subgroups of Hyperactive Youths a
MMT
Group characteristics
of measurements DTO AC LT CT
Number of subjects 81 50 24 26
Mean number of arrests for 1.32 (2.22) 0.54 b (1.20) 0.92 (1.59) 0.19 d (0.49)
a felony offense
Mean number of 0.49 (1.01) 0.16 b (0.77) 0.35 (1.11) O.OOd (0.00)
institutionalizations
Percent of subjects arrested
for a felony offense
One or more 43% 38% 15.0%'
Two or more 28% 21% 3.8%'
Percent of subjects institu- 22% 17% 0.0%'
tionalized
aStandard deviations are in parentheses. Statistical comparisons are between the DTO (drug treatment
only) and the three MMT (multimodal treatment) groups (AC = all cases, LT = treated for less than 2
years, CT = treated for 2-3 years).
bp < 0.05.
'P < 0.01.
dp < 0.0001.
Note. From Satterfield JH, Satterfield BT, Schell AM: Therapeutic interventions to prevent delinquency in
hyperactive boys, JAm Acad Child and Adolesc Psychiatry 26:56-64, 1987.
proved to be effective over the short-run. These treatments, with or without

medication, given over a period of less than one year have shown a significant
relapse rate. However, Satterfield's statistics 14 (cf. Table XVII) showed that 3
years of psychopharmacological treatment of these children and their parents
combined with individualized programs of behavior modification, educational
therapy, parental and family therapy, teacher training, or whatever other in-
terventions are indicated, show highly significant and lasting improvement in
outcome statistics.
It is not clear how many of Satterfield's cohort had CD and his data have
not been replicated. However, Gittelman's study 15 deliberately chose a cohort
of ADD children without CD. These children were treated with medication
alone and showed a highly significant outcome difference in ASPD over con-
trols (see Table XVII).
CONCLUSIONS
In conclusion, hyperactive children and ASPD adults show similar physio-

logical and psychological signs and symptoms. All prospective studies of
ADDH children found that significant numbers of the cohort developed
ASPD. Within the last 5 years there has been a recognition that medication
alone is insufficient for treating ADDH children and psychological modalities
of treatment have been shown to be effective (although with a high rate of

relapse). To avoid this contingency, it appears from data of Satterfield et al. 14
that 3 years of continuous treatment with medication and other modalities
individually designed to meet the needs of subjects shows a highly significant
decrease in statistics pertaining to ASPD (Table XVII). In their 1987 paper,
Satterfield et al. 14 indicated that the cost of current institutionalization in Cal-
ifornia is $30,000 per year per patient, whereas the cost of multimodal therapy
is $3,000 per year per patient. Noninstitutionalized ASPD individuals may well
cost society considerably more than this ten-fold estimate. Any preventive mea-
sures will greatly benefit individual patients and their putative victims. It is
recommended that multimodal treatment of ADDH children be studied in a
multicenter design to see if Satterfield et al.'s14 data are replicated. If so, a
national (or international) program for the decreased prevalence of ASPD by
treatment, such as that described by Satterfield et al. 14 of ADDH children,
should be mounted.
REFERENCES
1. Satterfield JH: The hyperactive child syndrome: A precursor of adult psychopathy?, in

Hare RD, Schalling D: (eds): Psychopathic Behat';or: Approaches to Research, Wiley, London,
1978, pp 329-346.
2. Mednick SA, Volavka J: Biology and crime, in Morris N, Tonry M: (eds): Crime and
Justice: An Annual Review of Research, vol 2, University of Chicago Press, Chicago, 1981, pp
85-158.
3. Solanto MV: Behavioral effects of low-dose methylphenidate in childhood attention dis-
order: Implications for a mechanism of stimulant drug action,} Am Acad Child Psychiatry,
25:96-101, 1986.
4. Elliot FA: Neurological aspects of antisocial behavior, in Reid WH: (ed): The Psychopath,
Brunner/Mazel, New York, 1978, pp 146-189.
5. Shapiro SK, Garfinkel BD: The occurrence of behavior disorders in children: The inter-
dependence of attention deficit disorder and conduct disorder,} Am Acad Child Psychiatry,
25:809-819, 1986.
6. Trites RL, Laprade K: Evidence for an independent syndrome of hyperactivity,} Child
Psychol Psychiatry, 24:573-586, 1983.
7. Sergeant JA: RDC for hyperactivity/attention disorder, in Bloomingdale LM, Sergeant
JA (eds): Attention Deficit Disorder, Vol. 5, Pergamon Press, Oxford, in press.
8. American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, ed 3,
revised. Work Group to Revise DSM-III, DSM-III-R in Development, Washington, DC,
October 5, 1985.
9. Edelbrock C, Loeber R: unpublished manuscript.
10. Quay HC: Aggression, conduct disorder, and attention problems, in Bloomingdale LM
(ed): Attention deficit disorder: Identification, course and rationale. Spectrum, New York, 1985,
pp 33-47.
11. Barkley RA: A Manual for Training Parents of Behavior Problem Children, Guilford Press,
New York, 1981.
12. Hartacolis P: The syndrome of minimal brain dysfunction in young adult patients. Bull
Menninger Clinic 32: 105-106, 1968.
13. American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders
(Third Edition), Washington, DC, Author, 1980.
14. Satterfield JH, Satterfield BT, Schell AM: Therapeutic Interventions to prevent delin-
quency in hyperactive boys.] Am Acad Child Adolesc Psychiatry, 26:56-64, 1987.
15. Gittelman R, Mannuzza S, Shenker R, Bonagura, N: Hyperactive boys almost grown up,
Arch Gen Psychiatry, 42:937-947, 1985.
16. Loney J, Whaley-Klahn MA, Kosier T, Conboy J: Hyperactive boys and their brothers at
21: Predictors of aggressive and antisocial outcomes, in Van Dusen KT, Mednick SA
(eds): Prospective Studies of Crime and Delinquency, Boston, Kluwer-Nijhoff Publishing,
1983, pp 181-207.
17. Weiss G, Hechtman LT: Hyperactive Children Grown Up, New York, Guilford Press, 1986.
18. Robins LN: Epidemiology of antisocial personality, in Michels Ret al. (eds): Psychiatry, vol
3, Philadelphia, J.B. Lippincott Co., 1986, pp 1-14.
19. SatterfieldJH, Satterfield B, Schell AM, Hoppe CM: Psychosocial effects on delinquency
rates in ADD youths and control subjects: An eight-year prospective study, in Bloom-
ingdale LM: (ed): Attention Deficit Disorder Vol. 3. Oxford, Pergamon Press, 1988.
20. Tupin JP, Maher D, Smith D: Two types of violent offenders with psychosocial descrip-
tors. Diseases of the Nervous System, 34:356-363, 1973.
21. Bach-y-Rita G, Lion JR, Climent CE, Ervin FD: Episodic dyscontrol: A study of 130
violent patients. Am] Psychiatry 128:1473-1478, 1971.
22. Hertzig ME, Brich, HG: Neurologic organization in psychiatrically disturbed adolescents.
Arch Gen Psychiatry, 19:528-537, 1968.
23. Goldman H, Lindner LA, Dinitz S, Allen HE: The simple sociopath: Physiologic and
sociologic characteristics. Bioi Psychiatry, 3:77-83, 1971.
24. Hare RD: Detection threshold for electric shock in psychopaths.] Abnorm Psycho I, 73:268,
1968.
25. Schoenherr J: Avoidance of noxious stimulation in psychopathic personality. Doctoral
dissertation, Univ. California, Los Angeles, Univ. Microfilms, Ann Arbor, Michigan (No.
64-8334).
26. Lindner LA, Goldman H, Dinitz S, Allen HE: Antisocial personality type with cardiac
lability. Arch Gen Psychiatry, 23:260, 1970.
27. Tong JE: Stress reactivity in relation to delinquent and psychopathic behavior.] Ment
Science, 105:935-956, 1959.
28. Lykken DTA: Study of anxiety in the sociopathic personality,] Abnorm Soc Psychol, 55:6-
10, 1957.
29. Morrison JR, Stewart MA: A family study of the hyperactive child syndrome. Bioi Psychia-
try, 3: 189-195, 1971.
30. Cantwell DP: Psychiatric illness in the families of hyperactive children. Arch Gen Psychiatry,
27:414-417,1972.
31. Cadoret RJ, Cunningham L, Loftus R, Edwards J: Studies of adoptees from psychi-
atrically disturbed biologic parents - II: Temperament, hyperactive, antisocial, and devel-
opmental variables.] Pediatr, 87:301-306,1975.
32. Stewart MA, DeBlois CS, Cummings C: Psychiatric disorder in the parents of hyperactive
boys and those with conduct disorder.] Child Psychol Psychiatry, 21 :283-292, 1980.
33. Cantwell DP: The Arbour Hospital: Eleventh Annual Psychiatric Conference. April 22,
1987, Newton, Mass.
SUGGESTED READINGS
Arieti S: Psychopathic personality, Compr Psychiatry, 4:301-302.

Cleckley H: The Mask of Sanity, St. Louis, Mosley, 1964.
Garfinkel BD, Klee SH: Behavioral and personality characteristics of adolescents with a histo-
ry of childhood ADD, in Bloomingdale LM (ed): Attention deficit disorder: Identification,

course and rationale, New York, Spectrum, 1985, pp 17-31.
Hare RD, Cox DN: Psychophysiological research on psychopathy, in Reid WH (ed): The
psychopath, New York, Brunner/Maze!, 1978, pp 209-219.
Hechtman L, Weiss G: Controlled prospective fifteen-year follow-up of hyperactives as adults:
Non-medical drug and alcohol use and antisocial behavior, in Bloomingdale LM: (ed):
Attention deficit disorder: Vol. 3, Pergamon Press, Oxford, 1988.
Loeb J, Mednick SA: A prospective study of predictors of criminality: Electrodermal response
patterns, in Mednick SA, Christensen KO (eds): Biosocial Bases of Criminal Behavior, New
York, Gardner Press, 1977, p 285.
Loney J, LanghorneJE, Paternite CE, Whaley-Klahn MA, Blair-Broeker CT, Hacker M: The
Iowa habit: Hyperkinetic/aggressive boys in treatment, in Sells SB, Crandall R et al. (eds):
Human functioning in longitudinal perspective, Baltimore, Williams and Wilkins, 1980, pp
119-143.
Siddle DAT: Electrodermal activity and psychopathy, in Mednick SA, Christensen KO (eds):
Biosocial Bases of Criminal Behavior, New York, Gardner Press, 1977, p 199.
II
Sexual Issues
6
Psychiatric Aspects of Incest
Involving Juveniles
SHELDON TRAVIN
This chapter will focus on the psychiatric aspects of an extremely broad, in-
triguing, and ultimately enigmatic subject: incest. Even the contradictory ety-
mological origins of the word incest reflect its essential mystery. Incest is
believed to derive both from the Latin castus meaning "pure, chaste," and from
incestus meaning "impure, immodest, lewd." Yet another linguistic interpreta-
tion traces the word back to the latin word cestus, used both to described girdle
(of Venus), and to mean capable of arousing love. l
The term incest continues to pose particular challenges to attempts to
define it. Incest has been referred to as "intrafamily sexual abuse," and a recent
National Center on Child Abuse and Neglect publication uses this definition. 2
But the definition of incest is problematic, partly because of its frequent merg-
ing with such terms as child sexual abuse, child molestation, and child sexual
misuse. This lack of precision in definition is further compounded because the
forms of sexual activities and differences in ages and degrees of consanguinity
between the participants in the incestuous relationship are frequently not spec-
ified. 3 Brant and Tisza4 have used the term sexual misuse to describe a range of
cases in which children have been exposed to sexual stimulation inappropriate
to the "child's age, level of psychosexual development, and role in the family."
But what is deemed inappropriate may vary with the family, ethnic, and so-
ciocultural context. Although Summit and Kryso,5 who have described a con-
tinuum often categories of parent-child sexuality, emphasize that the "misuse
of sexuality between parents and children can have detrimental consequences";
they admit that "there is a vague border line between loving sensuality and
SHELDON TRA VIN • Department of Psychiatry, Bronx-Lebanon Hospital Center, Bronx,

New York 10456; Department of Psychiatry, Albert Einstein College of Medicine, Bronx, New
York 10461.
85
86 SHELDON TRA VIN
abusive sexuality." The National Center on Child Abuse defines child sexual
abuse as "contacts or interactions between a child and an adult when the child is
being used for the sexual stimulation of that adult or another person."2 Al-
though recognizing that incest and child sexual abuse may overlap, Finkelhor6
distinguishes incest, which he defines as sexual relations between two family
members whose marriage would be forbidden, from child sexual abuse, which
he defines as sex between an adult and a child. For the most part, this chapter
will concentrate on incestuous relationships, and particularly on the variety
most frequently reported to child protective services, that between father or
father surrogates and daughters. This focus should not blind us, however, to
the possibility that sibling incest may be the most widespread form and that
reports to appropriate social agencies are increasing on it. 7 In addition, father-
son incest is believed to be greatly underreported,8 and other varieties of incest
(such as mother-son,9 mother-daughter,IO multiple incest,ll and incest be-
tween a variety of other family members l2 ) have also been reported in the
literature.
Despite the increase of research by a variety of professionals, many areas
of dispute on the subject of incest still exist. Among the more important ques-
tions is whether the incestuous father is primarily motivated to have sex with
his child as an aspect of his sexual interest in children in general, or whether
the sexual abuse is a result of certain dynamic or interactive factors. 13 Al-
though the revised third edition of the Diagnostic and Statistical Manual of Mental
Disorders (DSM-III-R)14 currently includes incest among the Paraphiliacs in the
category of "302.20 Pedophilia, specify if limited to incest," and therefore
considers incest to be a subtype of pedophilia, the basic sexual motivation in
incest cases remains unclear. Another disputed issue concerns the extent of the
harm and psychiatric sequelae experienced by juveniles in an incestuous rela-
tionship with adults. 13 These two areas, the sexual motivation of the victimizer
and the consequences of the juvenile's sexual victimization will be discussed in
some detail. Finally, the incest taboo as reflected in mythology, religion, histo-
ry, anthropology, biology, and culture exerts a web of complex and constrain-
ing influences. These constraints will be briefly reviewed, along with some
relevant epidemiological information.
THE INCEST TABOO
The incest taboo has been referred to as the "universal taboo" or "ultimate
taboo" and has evoked feelings of intense dread expressed as the "horror of
incest," a horror that has been described in myriad ways and explained by
various theories. Incestuous relationships were attributed to the gods in Greek
and Roman mythologies; they occur in the Bible, as in the famous story of the
sexual union between the daughters of Lot and their father, and they occurred
among various peoples, such as the royal family in ancient Egypt and the
Zoroastrian Persians, who at one time advocated next-of-kin marriages; in the
middle ages, and in the modern world. IS Freud, in Totem and Taboo, 16 pointed
PSYCHIATRIC ASPECTS OF INCEST 87
out that the Polynesian word taboo connotes a concept that was once understood
by many ancient races, but because the term is no longer current, it is now
difficult to translate. Moreover, the severe restrictions invoked by taboos are not
based on religious or moral grounds, but are fundamentally of unknown origin.
Nevertheless, based on Darwin's primal horde hypothesis, Freud attempted to
explain incest by speculating that the incest taboo originated in the remorse and
guilt experienced by the primeval brothers who had killed and devoured their
violent tyrannical father. Westermarck 17 gave another psychological explana-
tion for the incest taboo; he argued that it arose from the natural aversion people
felt to having sex with persons with whom they had been raised close together as
children. The biological position on the origin of the incest taboo is that un-
checked inbreeding would produce defective offspring. ls . 19 A major an-
thropological view on the subject is that incestuous behavior would be extremely
disruptive and cause chaos in family relationships. As Malinowski 2o put it, "No
society could exist under such conditions." White 21 believed that the incest
taboo, by compelling outside-the-family marriages, increased human group
cooperation, and thus the chances of species survival. Levi-Strauss 22 suggested
that the taboo guaranteed an exchange of women, and thus served as a kind of
fundamental model for an exchange of everything else in society. In a cross-
cultural study of250 societies, Murdock 23 found that the incest taboo appeared
in some form in everyone of them. Murdock concluded that the best approach to
understanding the origins of the taboo was to consider the interaction of multi-
ple psychological, social, and cultural factors. But despite the strength of the
incest taboo, incestuous behavior remains a widespread phenomenon.
EPIDEMIOLOGICAL CONSIDERATIONS
Although it will probably never be possible to obtain really accurate statis-

tics on the occurrence of incest, the emerging epidemiological studies have
been truly startling. The major reasons for inaccurate statistics are extensive
underreporting (incest usually remains hidden in the family and surfaces only
during a family crisis) and the connected fact that data on incest generally has
been obtained from convicted offenders or other skewed populations. Based
on criminal statistics, the average number of most offenders in this country
from 1910 to 1930 was estimated to have been between 1.1 and 1.9 per million
persons. 24 Interestingly, this figure is consistent with the number of criminal
arrests for incest in Bronx County, which has a population of approximately
one million people, in the years 1981, 1982, and 1983, during which there were
only two arrests per year for incest. 25 In 1948, Kinsey et al. 26 wrote in a survey
of male sexual behavior that "heterosexual incest occurs more frequently in the
thinking of clinicians and social workers than it does in actual performance.
But 5 years later, Kinsey et al. 27 published data on a survey of white American
females that showed that 24% (1075) out of 4,441 subjects had as preadoles-
cents been approached sexually, either verbally or by actual physical contact, by
adults. In 1956, Landis 2S found that of 1,800 college students, 30% of the men
88 SHELDON TRA VIN
and 35% of the women had been sexually approached as children by adults;
about a third of the offenders were known to the child. In 1971, Woodbury
and Schwartz 29 estimated that about 10% of all Americans have had some kind
of incestuous experience. More recently, in a survey of 796 students, 530
females and 266 males, Finkelhor6 found 28% of the females and 23% of the
males reported having had an intra familial sexual experience, and that 19.2%
of the females and 8.6% of the males had been sexually abused as children.
About 43% of the sexually abused females were victimized by family members,
compared to only 17% of the males. Five girls had sex with their fathers and
two with stepfathers, which amounts to over 1% of the sample. Russell,3o in a
sample of 930 interviews with adult women in San Francisco, has brought to
our attention that 17%-one of six women-who had stepfathers had been
sexually abused by them, in contrast to 2% who were sexually abused by their
natural fathers. Moreover, in 47% of the cases involving stepfathers the sexual
abuse was at the very serious level, meaning sexual intercourse, fellatio, etc.,
compared to only 2% by the biological fathers. On the other hand, Phelan,31
who studied the data on 56 incestuous stepfather families, and 46 incestuous
biologic father families, was also able to compare biologic fathers with step-
fathers. Phelan found that biologic fathers had sex more frequently with more
than one daughter, engaged more often in full intercourse, and began the
sexual activities more often when their daughters were adolescents, than did
stepfathers. These differing findings do nothing to decrease the net impact of
these statistics; to the contrary they lend an increasing sense of urgency to
efforts to understand the motivations for and mechanisms of incestuous
behavior.
THE RELATIONSHIP BETWEEN INCEST AND PEDOPHILIA
As was mentioned above, DSM-III-R14 includes incest in the diagnostic

category of pedophilia, and defines pedophilia in the following way:
Over a period of at least six months, recurrent intense sexual urges and sexually
arousing fantasies involving sexual activity with a prepubescent child or children
(generally age 13 or younger). The person has acted on these urges, or is mark-
edly distressed by them. The person is at least 16 years old and at least 5 years
older than the child.
DSM-III-R14 also differentiates between an exclusive type of pedophiliac, peo-

ple sexually attracted only to children, and a nonexclusive type who are some-
times attracted to adults. DSM-III-R cautions that isolated sexual acts with
children who merely serve as substitutes for the unavailable preferred adult do
not necessarily warrant a diagnosis of pedophilia. There is no provision in
DSM-III-R for any diagnosis to be made for intra family sex that occurs over a
period of less than 6 months.
Significantly, DSM-III-R does not consider incest offenders to be a sepa-
rate group of child sexual abusers. Although Finkelhor32 admits that most
researchers would acknowledge that there are at least some differences be-
tween incest offenders and child molester offenders, there are enough sim-
ilarities between the two groupings, as the DSM-III-R classification suggests, to
validate a "unified theory" approach to the incest-pedophilia dispute, just as
there are enough dissimilarities to validate a separate-theory approach. Among
the separate-theory writers, De Young33 has drawn a clear distinction between
incestuous offenders and pedophilic offenders. Another example of the dis-
crete grouping of incest offenders is Oliver's 1967 study34 on the general
characteristics of nine incest cases out of a total of 202 sexual offenders who
had been paroled in one Western state. Oliver found that most of the nine
incest offenders were neither severely mentally ill nor medically sexual psycho-
pathic. And in 1965, Gebhard et al. 35 published the results of their study of 147
father-daughter incest cases out of a total of 1,356 white male sex-offenders
who were incarcerated at the time of the interviews. These researchers drew up
typologies of incest offenders. They found the 56 men who committed incest
with daughters below 12 years of age "rather ineffectual, nonaggTessive, de-
pendant" men; 66 men who perpetrated incest with adolescent daughters be-
tween 12 and 16 years of age as men to whom sex was not of great importance,
and who were "relatively unresponsive to psychological stimuli and not given to
fantasy" but to whom drinking was an important precipitant; and they de-
scribed 25 men who had incestuous relationships with adult daughters as "con-
servative, moralistic, restrained, religiously devout, traditional, and unedu-
cated." Gebhard et al. 35 briefly reported on a fourth type of 18 incest offenders
who had sexually abused females other than their own daughters, but they did
not provide any extensive analysis of this grouping. Among the first who began
to write about pedophilia being a possible factor in incest was Marcuse,36 who is
cited by Meiselman37 in her 1978 book in incest. Meiselman37 herself, however,
argued that "clinical studies of incestuous fathers have rarely found them to be
pedophiles, either behaviorally or in their fantasy," and concluded that "one is
left with the impression that the pedophile is a destructive type of incest of-
fender but that pedophilia is very seldom a factor in the occurrence of father-
daughter incest." On the other hand, without specifying the exact numbers,
Weinberg 24 described three major types of aggressive incest participants: the
endogamic type who is withdrawn into his family; the pedophilic type who
obtains his sexual gratification from young females but not with adult women;
and the indiscriminately promiscuous type who lacks any kind of constraints.
Langevin et al.,38 in a study to determine whether incestuous fathers were
pedophilic, aggressive, and/or alcoholic, concluded that in each of these cate-
gories the answer was a qualified yes. These researchers stress the hetero-
geneity of incest offenders and advocate a careful assessment of each in-
cestuous offender, including phallometric studies.
Working within the "unified theory" model, Finkelhor32 clearly saw no
advantage in creating different reference points for incest and nonincest cate-
gories; he strongly advocates constructing a single framework or multifaceted
model to account for the complex nature of child molesters, including in-
cestuous ones. Finkelhor32 stressed four preconditions that must exist in order
90 SHELDON TRAVIN
for incest to actually happen. Precondition 1 is "Motivation to Sexually Abuse"

comprising (a) emotional congruence, in satisfying emotional needs; (b) sexual
arousal, in that the child becomes sexually attractive to that person; and (c)
blockage in the availability of other sources of sexual gratification. Precondi-
tion 2 consists of "Overcoming Internal Inhibitions." This precondition means
that the prepertrator is able to overcome all family and social taboos. Precondi-
tion 3 "Overcoming External Inhibitors," refers above all to the most impor-
tant kind of restraining external force, the supervisor of the child, that is, the
mother. Finally, Precondition 4 consists of "Overcoming the Resistance of the
Child."
SEXUAL ATTRACTIVENESS OF CHILDREN

TO INCESTUOUS FATHERS
The question of whether incestuous fathers are sexually attracted to chil-

dren in general or particularly to their own family members still generates
discussion. This question is particularly intransigent because widespread data
on what so-called normal people find sexually attractive is lacking. A variety of
hypotheses purporting to explain the etiology of sexual preferences have been
proposed, incorporating such factors as constitutional, especially hormonal,
behavioral approaches, and psychoanalytic formulations. However, judgment
on these hypotheses cannot be made for a number of reasons, including con-
tradictory results or failure to replicate studies in the biological research, biases
of sample populations or insufficient numbers and control groups in the be-
havioral approach, and the general criticisms inherent in psychoanalytic
speculations.
BIOLOGICAL CONSIDERATIONS
The possibility of a biological basis of eroticism in the forma-

tion/development of gender or sexual identify was suggested by an earlier view
of an innate femaleness of the fetus, and the effects of androgen on mammalian
sexual organ differentiation. 39 However, Meyer39 emphasized that there are "as
yet, no clear links between biology-other than genital and reproductive dif-
ferences-and eroticism, or gender or sexual identity formation." Similarly,
Gadpaille 40 concluded that there is insufficient data to consider "any aspect of
sexual identity in humans as solely biological in origin," and sufficient data to
consider that "postnatal psychosocial influences probably playa greater role in
the development of most or all components of human sexual identity."
BEHAVIORAL APPROACHES
The behavioral perspective of the etiology of deviant sexual preference

combines classical learning theory with a more recent emphasis on the reinforc-
ing role of masturbation and fantasy in maintaining erotic stimulation. Classical

learning theory suggests that the deviant sexual act becomes paired with a
pleasurable sensation, and then becomes eroticized in a habitual manner.
McGuire et al. 41 believe that sexual deviant behavior develops more gradually;
they hypothesize that the initial deviant sexual experience merely supplies a
fantasy, which is based on distortions and selections of cues from the memory
of this experience. Because this precipitating incident is usually the first real
sexual experience, the stimulus value of this incident for a masturbatory fan-
tasy is strong and it becomes increasingly stronger with the continued frequent
pairing of masturbation with this deviant fantasy. Concomitantly, other sexual
stimuli are extinguished because of lack of reinforcement.
Increasingly, behaviorists have turned to penile tumescent studies to assess
the sexual arousal patterns of sex offenders,42 because erection response to
erotic stimuli is considered to be the most accurate physiological measurement
of male sexual arousal. 43 Freund 44 ,45 was able to record more erection re-
sponses in pedophiles as changes in the penile volume to children compared
with normal heterosexual and homosexual men. In another study, however,
Freund 46 demonstrated that even non deviant adult males responded to the
female child aged 6 years and older, with the crucial stimulus configuration
being the pubic region and buttocks. Although he did not conclude that all
adult males are erotically sensitive to young females, he did suggest that the
number of such males must be substantial. Quinsey et al. 47 also found that
penile circumference measurements differentiated 20 child molesters from
normal controls, In a later study, Quinsey et al. 48 found that incestuous mo-
lesters of daughter or stepdaughter victims showed more age appropriate sex-
ual preferences when compared with child molesters of unrelated child victims.
This finding supported Quinsey's49 hopothesis that "incestuous child molesters
are a special case of situational offenders whose offenses are related to family
dynamics and opportunism rather than inappropriate sexual preferences," On
the other hand, when Abel et al. 50 compared the erection measurements of six
heterosexual incest offenders with those of ten heterosexual pedophiles to a set
of seven 2-minute audiotape cues of various sexual acts, the results led them to
conclude that "the so-called cases of heterosexual incest are not different in
their sexual preferences from heterosexual pedophiles, since both groups are
highly aroused by young children other than female relatives." This sexual
preference to young girls may therefore be the primary motivation for having
sex with the child, and the dysfunctional state in many incest families may
actually be the result rather than the cause of incestuous behavior.
It becomes obvious from the previous reports that what is needed in penile
tumescent research are large N-size studies of normative, pedophile, and incest
responses to standardized pedophile cues, which would enable us statistically to
compare data of arousal patterns from these three populations. Although the
problem of sexual response faking can cast doubt on the validity of erection
measurement studies,51,52 this author agrees with Laws and Holmes,53 who
concluded that, despite the problem of response faking, the use of penile
erection measurements nevertheless remains the single best index of sexual
arousal
92 SHELDON TRA VIN
PSYCHOANALYTIC FORMULATIONS
Protter and Travin 54 traced the development of the general psychoanalytic

perspective of perversions as essentially corresponding to the changing trends in
psychoanalytic thinking, as a progression of concerns focusing respectively on
id-drive, ego-defensive, object-relational, and self-identity issues. The early
drive theorists were influenced, of course, by Freud's seminal Three Essays on the
Theory of Sexuality. 55 Freud viewed a perversion as essentially an instinctive (or
referred to later as an Id phenomenon) sexual element, carried over from
infancy without having undergone any transformation into adult genital activity.
Freud postulated castration anxiety as the oedipal-related dynamic causing this
disruption in normal sexual development. Later writers 56 ,57,58 basically main-
tained the Freudian model but increasingly emphasized the role perverse symp-
toms played in functions of defense, such as general neurotic formation,56 the
compensating for flaws in the development of a sense of reality, 57 and a re-
gressive adaptation against castration fears. 58 More recently, object relational
theorists, such as Masud Khan,59 have stressed the effect of a real maladaptive
environment in the early development of the infant child rather than placing a
sole emphasis on instinctual (drive-related) derivations of the unconscious dy-
namics leading to perverse activity. Kohut,60,61 from his self-psychological
framework, discusses perverse activity with regard to the basic concept of the
development of a coherent sense of self. He argues that the breakdown of the
needed empathic and mirroring maternal object (self-object) in early infant-
child development can result in the "disintegration product" of perverse behav-
ior, which serves as an eroticized reparative activity that shores up a weakened,
fragmented, and insecure self. The work of Robert Stoller62 ,63,64 depicts the
primary motivation of the perversion as the expression of hostility, meaning the
urge to harm an object rather than merely being forceful as in aggression. As
Stoller sees it, "hostility in perversion takes form in a fantasy of revenge hidden
in the actions that wake up the perversion and serves to convert childhood
trauma to adult triumph. 64
Howells65 has drawn our attention to some psychoanalytic considerations
specific to pedophilia. He cites Storr's66 interest in the specific psychological
problems of the pedophile, in particular the "sense of inferiority and related
need for dominance" that prevent the pedophile from establishing normal
adult relationships, and render children more attractive because they are affec-
tionate, easily dominated, and represent less of a threat. Howells65 also dis-
cussed Bell and Hall's67 in-depth case study of a pedophilic patient's sexual
interest in children as "an expression of the client's personal child-like level of
functioning," as well as Fraser's68 explanation of pedophilia as "the process of
narcissistic inversion," Kraemer's69 similar belief that pedophilic interest can be
traced back to narcissism, though narcissism is seen as a product of the nar-
cissistic relationship between the child and mother, Gordon's7o assertion that
"in many deviants ... there is an eternal longing for an idealized childhood
and youth," and Lambert's71 emphasis on "hostile themes in pedophilic
fantasy."
Groth 72 asserted that although there are indeed similarities in the dynam-
ics of pedophilia and parent-child incest, there is also an important difference,
for pedophilia "we are primarily dealing with the dynamics of an individual,
whereas in every case of parental incest there is some form of family dysfunc-
tion." Groth 72 recommended therefore that, in cases of parent-child incest,
the interrelationships among members of the family and the structure of the
family network be examined.
FAMILY DYNAMICS IN FATHER-DAUGHTER INCEST
Because the father-daughter incestuous relationship usually occurs in the

family context, it is only natural that family dynamics be presumed to be of
great importance as either etiolgic or contributory factors in such relationships.
Therefore, the following review of the literature on the subject attempts to
compile personality profiles of incest participants and to describe interactions
that create a dysfunctional family state and lead to acting out in incestuous
liaisons. As we have noted, most of the reported studies are of skewed popula-
tions of detected cases of offenders, victims of incest in treatment, or of the
results of questionnaires in select surveys of incest victims many years later. It is
virtually impossible to obtain information on random samples of the vast ma-
jority of undetected cases.
The protagonists in the incest drama have been described in various and
even contradictory ways. After psychologically testing five of them, Weiner 73
characterized the incestuous father as having no psychotic features, of high
intelligence with good intellectual defenses, but exhibiting paranoid trends and
having problems in identity. In a study of the Minnesota Multiphasic Personality
Inventory (MMPI) of 12 incestuous fathers, Cavallin 74 found indications of weak
object relation, weak psychosexual identity, unconscious homosexual strivings,
and projection as a major defense. Similarly, Meiselman 37 found, in 10 out of 13
fathers of her psychotherapy sample who were actually seen by a therapist, a
common tendency to use projection as a defense. The dominant, even tyrannical
nature of the father in the family has been pointed out by Weinberg,24 Cormier
et at.,75 and Meiselman 37 among others. Alcohol abuse in incestuous fathers is
probably somewhere in the range between 20% and 50%.37 Rada 76 found that
nearly 50% of child molesters drank at the time of the offense. Incestuous child
molesters have been found to be more socially introverted than nonincestuous
child molesters, whereas the latter reveal a more immature level of psycho-sexual
function in MMPI testing. 77 Julian and Mohr 78 have been able to analyze the
data base ofthe National Study on Child Neglect and Abuse Reports in order to
compare 106 cases of father-daughter incest with physically abusive fathers and
families, and to construct a profile of the incest offender. Among their many
interesting findings are the following: there were present in incest families
considerable discord (65.7%), alcohol dependence (32.4%), mental health prob-
lems (31.1 %) and spouse abuse (25.5%). The profile of the incest offender that
emerged in this study was that of a man gainfully employed, financially support-
94 SHELDON TRA VIN
ing his family, without any previous court record (80%), who had at least some
high school education (73%). Significantly, they also found recidivism to be rare
after the incestuous act was reported to the authorities and the father received
psychiatric treatment.
The importance of the nonparticipating member, usually the mother, in
the interpersonal triangle leading to incest in the family has been underscored
by Machotka et al. 79 These authors emphasize the nonparticipant's crucial role
in fostering the incestuous relationship, in particular the way her denial of the
pathological relationship helps perpetrate it. Meiselman 37 pointed out that the
mother has been repeatedly described in three ways: passive, dependent, and
masochistic. Browning and Boatman II found that mothers in incest families
are frequently depressed, which could account for their passivity, their sexual
withdrawal from their husbands, and their inability to extend any emotional
assistance to their daughters. Herman and Hirschman Bo described the ways in
which the mothers frequently become powerless through battering, physical
disability, chronic mental illness, or repeated childbearing, and are thus unable
to function effectively in the family and protect their daughters.
De Young33 aptly characterized the role of the child as "often shrouded in
misinformation, naive interpretation, and even myth, much of it propagated by
researchers." In general, it is the oldest daughter who experiences puberty first
who is likely to be victimized by the father. The theme of a "special" daughter
being chosen by the father is based more on his perception of her being in
some way defective, which adds to her vulnerability, rather than on her attrac-
tiveness. 37 The notion of seduction by the daughter has taken a complete
turnabout; this will be discussed in the section of victim traumatization.
The family dynamics considered to be conducive to incestuous behavior,
though certainly distinctive in tile individual family, usually contain elements
of certain recognizable themes. One central dynamic found by Kaufman et al. BI
in a study of 11 incestuous families was a fear of desertion, to which all the
family members reacted, culminating in the incestuous acting out. A common
pattern was the desertion of the maternal grandmother by the maternal grand-
father, after which the maternal grandmother selected one daughter who re-
sembled the maternal grandfather in order to displace hostile feelings on to
her. This process repeated itself in the next generation when this daughter
married a man similar to her own father, a man who would also periodically
desert her in some way. The mother would then single out one of her own
daughters to whom she would relinquish responsibilities and thus effectively
create a role reversal. This young daughter developed into a facsimile of the
grandmother, enabling the mother to displace the original hostility felt for her
mother on to this young daughter. All the family members seemed to be in
need of a mother figure and on an unconscious level the incestuous sexual
activity somehow allayed the anxiety in each of them about desertion. In an-
other important dynamic postulated by Lustig et al.,B2 incest is a tension-reduc-
ing defense employed in a dysfunctional family to preserve the integrity of the
family unit. These authors enumerated five conditions necessary for father-
daughter incest to occur: (a) the daughter assumes the mother's role; (b) the
relative discontinuation of sexual activity between the parents; (c) the un-
willingness of the father to seek sex outside the family; (d) the shared fear of
abandonment and family disintegration; (e) the conscious or unconscious con-
sent given by the mother. Cavallin 74 also emphasized that incest is an ex-
pression of severe intrafamilial conflicts, and the fear that if the father left it
would lead to a total family breakdown. Researchers have found incest trans-
mitted over three generations through the father in one study,83 and in an-
other study84 either through the father or the mother. Lukianowicz 12 pro-
posed an interesting hypothesis regarding paternal incest that implicates social
and cultural factors and condoning mothers in certain subcultures, rather than
attributing incest to real sexual deviation on the part of fathers. Alexander85
presented a systems theory conceptualization of incest, in which incest is viewed
within the framework of a closed family structure "characterized by decreased
interaction with the environment, by minimal elaboration of functions and
roles, and by an emphasis on homeostasis to the detriment of morphogenesis."
Consequently, Alexander recommended a therapeutic approach that con-
fronts this underlying family structure in order to eliminate the symptomatic
expression of incest.
PSYCHIATRIC EFFECTS OF INCESTUOUS VICTIMIZATION
The extent of the psychiatric consequences of paternal incest on the victim

remains a matter of considerable uncertainty. There have even been pen-
dulous shifts in how the child was viewed, from playing an active and willing
role to being a reluctant victim in the sexual liaison. The difficulties of obtain-
ing an accurate picture of incestuous victimization are substantial: most of the
available information has been based on inferences from a relatively small
number of psychoanlytic cases, observations made on small select groups with-
out adequate control studies, and self-report surveys of particular populations;
moreover, some symptoms appear in a delayed reaction only years later, and
thus it is difficult to establish a clear connection between the child's incestuous
experience and the psychopathology of the adult victim later in life. In-
creasingly, though, there is consensus on two points: that the child is always the
victim in a paternal incestuous relationship, and that there are a variety of
symptom manifestations, including immediate and delayed or chronic ones.
The literature on the subject of childhood sexual experience in the genesis
of psychopathology has always been somewhat variable. In general, earlier
writers tended to minimize the traumatic effects of incestuous relationships on
the child. Although Freud 86 originally conceived of infantile sexual trauma as
etiologic for adult hysteria, he later concluded that his psychoanalytic patients'
reports of their early sexual experiences were only memories of childhood
fantasies. Abraham,87 another early psychoanalyst, believed that the child un-
consciously desired the incestuous sexual activity and either initiated it or went
along with it, felt guilty later on and so did not report it, but suffered no mental
disease. The often cited article written by Bender and Blau 88 in 1937, pertain-
96 SHELDON TRAVIN
ing to 16 successive preadolescent admissions to the Children's Ward of Bell-

evue Psychiatric Hospital in New York City following sexual activities with
adults, revealed the children to be charming and lacking guilt, fear, or anxiety;
actually, only four cases of incest were included in this study. In a 1952 follow-
up report on these 16 cases, Bender and Grugett89 concluded that the early
sexual activity did not necessarily lead to maladaptive adjustments in adult-
hood. Yurukoglu and Kemph90 described two cases of parent-child incest and
concluded that neither child suffered any serious or permanent psychological
damage. The reason for this, according to these authors, was that the 13Y2-
year-old son involved with his mother and the 17-year-old daughter involved
with her father already had adequately developed ego functioning and de-
fenses. Henderson,91 in a chapter of a 1975 prominent psychiatric text, wrote
that "the daughters collude in the incestuous liaison and play an active and
even initiating role in establishing the pattern." In regard to possible adverse
effects, Henderson also wrote that:
Incestuous relationships do not always seem to have a traumatic effect. ...
Moreover, the act offers an opportunity to test in reality an infantile fantasy
whose consequences are found to be gratifying and pleasurable.
More recently, writers have been emphasizing the proximate and long-
standing harmful psychological effects experienced by incest victims. The pre-
vailing viewpoint has also dramatically changed to regard the father as the
aggressor and the one solely responsible for the sexual activity because of his
position of dominance over the victim. 92 He is in a position to take advantage
of the child's need for affection or to use his parental authority to pressure the
child into having sex with him. In no case is the child considered competent to
give informed consent about the sexual activity.93 But child sexual abuse can
only be identified if the professional is aware of the variety of presenting
symptoms, some of which may actually mask the underlying problem. Despite
increased awareness, some physicians may still miss obvious signs of the condi-
tion in the child essentially because of countertransferential difficulties in being
able to deal with the possibility that the child was molested by a parent and in
asking questions about child sexuality.94 What is needed for proper diagnosis,
once an index of suspicion for the condition exists for the physician, is for the
physician to make a detailed evaluation, including a commitment to advocate
for the child. 95
Although it is often difficult to establish a direct linkage between child
sexual abuse and adverse psychiatric effects, certain patterns in the develop-
ment of immediate and enduring symptoms and characterological problems
have been increasingly reported. Lewis and Sarrell96 specified some of the
factors surrounding seduction, incest, and rape in childhood that contribute to
subsequent psychological outcomes. These factors include the form and fre-
quency of the sexual assault, the offending person's relationship to the victim,
the age of the child and the phase of ego development (both of which have a
bearing on the child's capacity to deal with the increased anxiety), and the
closeness of the sexual experience to the prevailing fantasies. Lewis and Sarrell
write that most of the manifestations of acute anxiety following the sexual
assault are "phase-specific." For example, such symptoms as thumbsucking,

nosepicking, and nailbiting, as well as other neurotic ones such as eneuresis,
encopresis, and speech problems are found in early childhood; transient symp-
toms such as fears, nightmares, and occasionally eating disorders, as well as
more persistent signs of emotional disturbance such as school difficulties, are
found in middle childhood; and depression, acting-out behavior, and delin-
quency are found in adolescence, which is considered the most vulnerable
phase. But if the child engages in acting out behavior closely resembling the
intensified fantasy induced by the sexual assault, this manifestation of anxiety
is "trauma-specific" as well as "phase-specific."
Gomes-Schwartz et al. 97 studied the behavioral problems of 112 preschool,
school-age, and adolescent children who had been sexually abused, 62% of
them by family members. These researchers found that severe psychological
difficulties were found more frequently in the 7- to 13-year-old group. Surpris-
ingly, relatively few preschool children and adolescents exhibited severe psy-
chopathology, a finding these researchers explained by suggesting that young
children do not comprehend the sexual nature of the experience, whereas
adolescents may be able cognitively to process the sexual event. On the other
hand, Adams-Tucker,98 who studied the proximate effects of 28 sexually
abused children who had been victimized by 36 molesters, half of whom were
fathers or father surrogates, found the most severe emotional disturbances
were in children who had been molested by their fathers, when the abuse
began at an early age and continued for a long time, and in teenagers even if
molested only one time. After studying the charts of 22 identified incest victims
treated in a children's clinic in Oregon, Krener99 found that, although the
behavioral disturbances may have subsided, the persistance of significant
symptoms that tended to recur and interfere with "concurrent and future
relationships resemble the symptoms of Post-Traumatic Stress Disorder."
Again, though, the relationship between incest and its effects remains diffi-
cult to establish precisely, as can be seen in the work of Emslie and Rosenfeld, 100
who completed a study of 65 children who had been psychiatrically hospitalized,
a significant percentage of whom had a history of incest, and who concluded that
"social and psychological pathology serious enough to warrant hospitalization is
not a simple effect of incest itself but is a consequence of severe family disor-
ganization and the resulting ego impairment." In studying the effects of incest
on 60 adolescent female victims, O'Brien 101 found profound disturbances in the
resolution of the developmental tasks of separation from the family and estab-
lishment of peer relationships, a positive sense of self, and heterosexual rela-
tionships and the development of reality testing, body image, sense of mastery,
and basic trust. And hysterical seizures have been reported to be a sequel to incest
in some adolescent girls. 102.103 Molnar and Cameron lO4 were so impressed by
the consistency of the clinical picture seen in midadolescent female victims
associated with the disclosure of incest, and in adult females victimized from 6
months to 10 years before beginning treatment, as to suggest the existence of an
"incest syndrome." The first group was characterized by depressive-suicidal or
runaway reactions and the second "delayed-presentation" group suffered from
sexual problems, believed to stem from the previous untreated incest. In an
98 SHELDON TRAVIN
attempt to create a framework in which to conceptualize the traumatic impact of

child sexual abuse, Finkelhor and Browne 105 proposed using a model based on
four traumagenic dynamics-traumatic sexualization, betrayal, stigmatization,
and powerlessness. These four trauma genic dynamics can be used systematically
to assess victimized children as to the likelihood of their developing psychological
problems.
There has been increasing recognition that the persistent or the delayed-
onset psychiatric effects of childhood incest can have a tremendous impact in the
later lives of victims. Katan 106 wrote detailed case studies of two of her psycho-
analytic patients, which typified four others, all of whom had been sexually
abused as children. One women in her thirties, who had been sexually molested
as a small child by her father and also one time by a stranger, suffered from
constant agitation, anxieties, and depression. Katan wrote that all six of these
patients had many pathological symptoms and tendencies, with a "marked
tendency to repeat the traumatic incidents in various ways throughout life."
These women appeared to fantasize about acquiring a penis and to identify with
men to "escape the unbelievably low self-esteem." RosenfeldI0 7 called attention
to the surprisingly high number of female outpatients-6 out of a sample of 18
patients whom he evaluated or treated in a year-who when questioned, ac-
knowledged having a history of incest. Although it was difficult to ascertain the
effects of the incestuous relationships on their present lives, there were among
them a high number of marital problems, sexual dissatisfaction, and hysterical
characterological features. In a study of 83 victims of rape and incest, Becker et
ai.lOS found that 56% had sexual dysfunctions, of which 71 % of them stated that
the sexual assault had brought on the dysfunction. At the March 1987 meeting of
the American Orthospychiatric Association, Williams and Fulher I09 reported on
the results of their survey of 40 women and three men chosen randomly from a
clinical population who were adult victims of child sexual abuse. At least 91 % of
the abusers were known to their victims; of this 91 %, 30% were fathers and 7%
were stepfathers. These researchers found that at least two thirds of the victims
suffered from a posttraumatic disorder, depression, or generalized anxiety
disorder, and one half of them could be considered to have a borderline syn-
drome and sexual dysfunction disorders. After reviewing the burgeoning liter-
ature, Gelinas 110 divided the underlying persistent negative effects of incest into
three categories: (a) chronic traumatic neurosis, (b) continuing relational im-
balances, and (c) increased intergenerational risk of incest. Gelinas stressed that
most of these underlying negative effects are not readily recognizable; instead,
the former victims come to treatment with "disguised presentations." The most
common reason incest victims request treatment is for "an a-typical depression
which has strong overtones of poor self-esteem, guilt and needy depressiveness."
TREATMENT IMPLICATIONS
The complexities of intrafamilial sexual relations suggest certain treat-

ment considerations. First of all, the notion of focusing on either the victim or
the victimizer is outdated. Ill In the incestuous family, all members have vary-
ing degrees of disordered functioning, psychopathology, or adverse psychiatric

effects that require therapeutic intervention. But the incestuous behavior can
not be viewed as merely a symptom in a dysfunctional family that can be
treated in a traditional family therapy model; 112 the "criminal and addictive
nature of the abusive behavior" must be recognized and taken into account.
The immediate crisis intervention work "requires an active, directive, even
coercive approach."1l2 Reporting the incest to appropriate state agencies is
mandatory and having the father removed from the home, at least initially, is
necessary to ensure the safety of the child. Giarretto 1l3 reported successful
treatment of many incestuous white middle-class families who were involved
with the Child Abuse Treatment Program (CSA TP) of the Juvenile Probation
Department in Santa Clara County, California. Giarretto insisted that:
The authority of the criminal justice system and the court process the offender
must undergo seem absolutely necessary in order to satisfy what may be termed
an expiatory factor in the treatment of the offender and his family.
Giarretto also found that because disclosure to civil authorities further

exacerbates an already fragmented family, the father, mother, and daughter
initially should be treated separately before eventual family therapy can be
effective. In the crisis period, Herman l12 underscored the need for the child to
receive intense supportive measures, such as assurance that her story is be-
lieved, praise for her courage in exposing the secret, and reassurance that she
is not hurting but is actually helping the family. The mother should be helped
to accept her daughter's allegations and to withstand the temptation to side
with her husband. The father has to understand that the secret is broken, the
relationship is over, and that he must stop denying it.
The subsequent treatment of the child, according to Berg and Ruelas, I 14
must be based on a comprehensive approach. They established a paradigm that
begins with a multidimensionsal assessment and is followed by a multimodal
treatment program in which a multidisciplinary team participates. Berg and
Ruelas I 14 argued that the type of treatment intervention offered must depend
on the results of the child's developmental assessment. Sgroi et al. 115 delineated
the common therapy issues related to treating sexually abused children. Those
considered more specific to victims of incest include problems in trusting
adults, diminished role boundaries, pseudomaturity, and self-mastery.
The general dearth of treatment reports on incest 1l6 is perhaps most
extreme in the case of the nonparticipating mother in such families. Zuelzer
and Reposa 117 identified some of the areas that need to be considered in
treatment of the mothers as "personality dynamics and her role within the
context of parent-child, nuclear, and extended family interactions." Such basic
issues as separation-individuation, identification, and fear of intimacy are also
considered crucial issues in treating the nonparticipating mother.
As our views of the incestuous father change, so too do our approaches to
his treatment. Still, group and family therapy seem to be the most common
form of treatment. Reporting on the treatment outcome of 600 white middle-
class families, 75% of which were the father-daughter type, Giarretto l18
claimed that no recidivism had been reported in the 6 years of the program's
100 SHELDON TRA VIN
existence. (The children were returned home within the first month.) How-
ever, it is important to note that Giaretto's data is based exclusively on self-
report, and that many behavior therapists believe that only by direct psycho-
physiological assessments, that is, erection responses to erotic stimuli, can the
offender's sexual arousal, and thus his likelihood to act out in a sexually deviant
fashion, be determined. Failure to perform such erection measurements could
result in inaccurate diagnoses, a possibility that gains emphasis from Abel et
al. 'S119 report that more than half of the offenders' population studied showed
erection responses to multiple paraphiliac disorders. Significantly, in 60.2% of
the cases, patients who had initially denied any deviant interests acknowledged
having many of these paraphiliac interests when confronted with their psycho-
physiologic responses. This suggests that additional diagnoses should be incor-
porated into the cognitive-behavioral paradigm as described by Travin et al. 120
A major criticism of this cognitive-behavioral approach, which relies on psycho-
physiologic assessments, has to do with the lack of scientific proof, as yet, of the
absolute correlation between the individual's physiologic response and para-
philiac disorder. 121 In addition, as Freund l22 has emphasized, although Abel
and Blanchard l23 noted phallometric test results correlating with behavior
outside the laboratory before treatment, there is still some question about
correlations of test results and actual deviant behavior after treatment. Thus,
there is a great need for follow-up studies on patients who have completed
cognitive-behavioral treatment. Recently, Protter and Travin 54 integrated a
focused psychodynamic treatment approach into the basic cognitive-behavioral
paradigm.
CONCLUSION
As this discussion makes clear, parent-child incest remains a phenomenon

surrounded by more questions than answers. Only more and different kinds of
research (both in terms of the methodology and in terms of the populations
studies) can provide answers to some of the pressing questions that remain to
be answered. The question of sexual attractiveness, of the danger posed to
other children outside the family by the incest offender; the question of the
most appropriate and successful treatment of victims, offenders, and nonpar-
ticipating family members; and finally the question of prevention l24 can only
be resolved through an active search for answers. Nonetheless, some answers
have begun to emerge. It seems clear that most incest offenders act only within
their own family, and that the familial context is an essential if not a contribut-
ing factor in incest. And it is abundantly clear that the children who are victims
of incest suffer not only immediate side effects but also severe, long-term
consequences. One particularly distressing long-term effect is that some un-
known number of children who were sexually abused will grow up to become
themselves sexual offenders. 125 This fact, made even more urgent by the
shockingly high estimates of the occurrence of incest in our society cited in this
discussion, argue that mental health professionals must explore these issues.
Previously the domain of myth, religion, cultural anthropology, and history,

incest is now clearly a major psychiatric concern, in which professionals must
become increasingly involved for the sake of their patients and society at large.
REFERENCES
1. Maisch H; Incest. London, Andre Deutsch Limited, 1973.

2. U.S. Department of Health and Human Services, National Center on Child Abuse and
Neglect: Child Sexual Abuse: Incest, Assault, and Sexual Exploitation. Washington, DC,
DHHS Publication No. (OHDS) 81-30166, issued 1979, revised April 1981.
3. Saragin E: Incest: Problems of definition and frequency.]ournal of Sex Research 13: 126-
135, 1977.
4. Brant, RST, Tisza VB: The sexually misused child. Am] Orthopsychiatry 47:80-90,1977.
5. Summit R, Kryso J: Sexual abuse of children: A clinical spectrum. Am] Orthospychiatry
48:237-251, 1978.
6. Finkelhor D: Sexually Victimized Children. New York, Free Press, 1979.
7. Smith H, Israel E: Sibling incest: A study of the dynamics of 25 cases. Child Abuse and
Neglect II:101-108, 1987.
8. Dixon KN, Arnold E, Calestro K: Father-son incest: Underreported psychiatric prob-
lem? Am] Psychiatry 135:835-838, 1978.
9. Wahl CW: The psychodynamics of consummated maternal incest. Arch Gen Psychiatry
3:188-193,1960.
10. Lidz RW, Lidz T: Homosexual tendencies in mothers of schizophrenic women.] Nero
Ment Dis 149:229-235, 1969.
II. Browning DH, Boatman B: Incest: Children at risk. Am] Psychiatry 134:69-72, 1977,
12. Lukianowicz N: Incest: I: paternal incest II: other types of incest. Br ] Psychiatry
120:301-313, 1972.
13. Eisenberg N, Owens RG, Dewey ME: Attitudes of health professionals to child sexual
abuse and incest. Child Abuse and Neglect II: 109-II6, 1987.
14. American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, ed
3, revised. Washington, DC, Author, 1987.
15. Masters REL: Patterns of Incest. New York, The Julian Press, Inc., 1963.
16. Freud S; Totem and Taboo (1913-1914), in Strackey J (ed): Standard Edition, Vol 13.
London, The Hogarth Press, 1955.
17. Westermarck E: The History of Human Marriage, ed 5. London, Macmillan & Co, 1921.
18. Lindzey G: Some remarks concerning incest, the incest taboo, and psychoanalytic theo-
ry. Am PsychoI22:1051-1059, 1967.
19. Adams MS, NeelJV: Children of incest. Pediatrics 40:55-62,1967.
20. Malinowski B: Sex and Repression in Savage Society. London, Routledge and Kegan
Paul, 1927.
21. White LA: The definition and prohibition of incest, American Anthropologist 50:416-435,
1948.
22. Levi-Strauss C: The Elementary Structure of Kinship. Boston, Beacon Press, 1969.
23. Murdock GP: Social Structure. New York, Macmillan Co, 1949.
24. Weinberg SK: Incest Behavior. New York, Citadel Press, New York, 1955.
25. Travin S, Bluestone H, Coleman E, Cullen K, Melella J: Pedophilia: An update on
theory and practice. Psychitr Q 57:89-103, 1985.
26. Kinsey AC, Pomeroy WB, Martin CE: Sexual Behavior in the Human Male. Philadelphia,
W. B. Saunders Company, 1948.
27. Kinsey AC, Pomeroy WB, Martin CE, et al: Sexual Behavior in the Human Female.
Philadelphia, W. B. Saunders Company, 1953.
102 SHELDON TRAVIN
28. Landis JT: Experiences of 500 children with adult sexual deviation. Psychiatr Q 30:91-
109, 1956.
29. Woodbury J, Schwartz E: The Silent Sin. New York, New American Library, 1971.
30. Russell DEH: The prevalence and seriousness of incestuous abuse: Stepfathers vs. bio-
logical fathers. Child Abuse and Neglect 8:15-22, 1984.
31. Phelan P: The process of incest: biologic father and stepfather families. Child Abuse and
Neglect 10:531-539, 1986.
32. Finkelhor D: Child Sexual Abuse: New Theory and Research. New York, The Free Press,
1984.
33. DeYoung M; The Sexual Victimization of Children. Jefferson, NC, McFarland & Com-
pany, 1982.
34. Oliver BJ: Sexual Deviation in American Society. New Haven, Conn, College and University
Press, 1967.
35. Gebhard PH, Gagnon JG, Pomeroy WB, et al: Sex Offenders: An Analysis of Types.
New York, Harper & Row, 1965.
36. Marcuse M; Incest. Am] Urology Sexology 16:273-281, 1923.
37. Meiselman KC: Incest: A Psychological Study of Causes and Effects with Treatment
Recommendations. San Francisco, Cal., Jossey-Bass, 1978.
38. Langevin R, Handy L, Russon AE, et al: Are incestuous fathers pedophiliac, aggressive,
and alcoholic? in Langevin R (ed): Erotic Preference, Gender Identity and Aggression in Men:
New Research Studies. Hillsdale, New Jersey, Lawrence Erlbaum Associates, 1985.
39. Meyer JK: Paraphilias, in Kaplan HI, Sadock BJ (eds): Comprehensive Textbook of Psychia-
try/IV, vol 1, ed 4. Baltimore, Williams and Wilkins, 1985.
40. Gadpaille WJ: Biological factors in the development of human sexual identity, in Meyer
JK (ed): Symposium on Sexuality, The Psychiatric Clinics of North America, vol 3, April 1980.
41. McGuire RJ, Carlisle JM, Young BG: Sexual deviations as conditioned behavior: A
hypothesis. Behav Res Ther 2:185-190, 1965.
42. Earls CM, Marshall WL: The current state of technology in the laboratory assessment of
sexual arousal patterns, in Greer JG, Stuart IR (eds): The Sexual Aggressor. Current Per-
spectives on Treatment. New York, Van Nostrand Reinhold Company, 1983.
43. Zuckerman M: Psysiological measures of sexual arousal in the human. Psychol Bull
75:297-329,1971.
44. Freund K: Diagnosing heterosexual pedophilia by means of a test for sexual interest.
Behav Res Ther 3:229-234, 1965.
45. Freund K: Diagnosing homo- or heterosexuality and erotic age-preference by means of
a psychophysiological test. Behav Res Ther 5:205-228, 1967.
46. Freund K, McKnight CK, Langevin R, Cibiri S: The female child as a surrogate object.
Arch Sex Behav 2:119-133, 1972.
47. Quinsey VL, Steinman CM, Bergerson SG, Holmes TF: Penile circumference, skin
conductance, and ranking responses of child molesters and "normals" to sexual and
nonsexual visual stimuli. Behavior Thepray 6:213-219, 1975.
48. Quinsey VL, Chaplin TC, Carrigan WF: Sexual preferences among incestuous and
non incestuous child molesters. Behavior Therapy 10:562-565, 1979.
49. Quinsey VL: The assessment and treatment of child molesters: A review. Can Psychol Rev
18:204-220, 1977.
50. Abel GG, Becker JV, Murphy WD, et al: Identifying dangerous child molesters, in Stuart
RB (ed): Violent Behavior: Social Learning Approaches to Prediction, Management and Treat-
ment. New York, Brunner/Mazel, 1981.
51. Henson DE, Rubin HB: Voluntary control of eroticism. J Appl Behav Anal 4:37-44,
1971.
52. Farkas GM: Comments on Levin et al. and Rosen and Kopel: Internal and external
validity issues.] Consult Clin PsychoI46:1515-1516, 1978.
53. Laws DR, Holman ML: Sexual response faking by pedophilies, in Abel GG (ed): Treat-
ment of Sexual Aggressives, Criminal Justice and Behavior 1978.
54. Protter B, Travin S: Sexual fantasies in the treatment of paraphiliac disorders: A bi-
modal approach. Psychiatr Q 54(4):279-297, Winter 1987.
55. Freud S: Three essays on the theory of sexuality, in Strachey J (ed): Standard Edition, vol
7. London, Hogarth Press, 1905, pp 125-243.
56. Sachs H: Zur Genese der Perversionen. Internationale Zeitschrift fur Psychoanalyse 9: 172-
182, 1923.
57. Glover E: The relation of perversion formation to the development of reality sense. Int]
Psychoanaly 14:486-504, 1933.
58. Bak R: Aggression and perversion, in Lorand S, Balint M (eds): Perversions: Psycho-
dynamics and Therapy. London, Random House, 1956.
59. Khan MMR: Alienation in Perversions. New York, International Universities Press, 1979.
60. Kohut H: The Analysis of the Self. New York, International Universities Press, 1971.
61. Kohut H: The Restoration of the Self. New York, International Universities Press, 1977.
62. Stoller RJ: Perversion. New York, Pantheon, 1975.
63. Stoller RJ: Sexual Excitement. New York, Pantheon, 1979.
64. Stoller Rj: Observing the Erotic Imagination. New Haven, Yale University Press, 1985.
65. Howells K: Adult sexual interest in children: Considerations relevant to theories of
aetiology, in Cook M, Howells K (Eds): Adult Sexual Interest in Children. New York,
Academic Press, 1981.
66. Storr A: Sexual Deviation. Hammondsworth, Penguin, 1964.
67. Bell AP, Hall CS: The personality of a child molester, in Weinberg MS (ed): Sex Research:
Studies from the Kinsey Institute. Oxford, Oxford University Press, 1976.
68. Fraser M: The Death of Narcissus. London, Secker and Warburg, 1976.
69. Kraemer W: The Forbidden Love: The Normal and Abnormal Love of Children. London,
Sheldon Press, 1976.
70. Gordon R: Paedophilia: Normal and abnormal, in Kraemer W (ed): The Forbidden Love:
The Normal and Abnormal Love of Children. London, Sheldon Press, 1976.
71. Lambert K: The scope and dimensions of paedophilias, in Kraemer W (ed): The Forbid-
den Love: The Normal and Abnormal Love of Children. London, Sheldon Press, 1976.
72. Groth AN: Patterns of sexual assault against children and adolescents, in Burgess A W,
Groth AN, Holmstrom LL, Sgroi SM (eds): Sexual Assault of children and Adolescents.
Lexington, Mass., Lexington Books, 1978.
73. Weiner IB: Father-daughter incest: A clinical report. Psychiatr Q 36:607-632, 1962.
74. Cavallin H: Incestuous father: A clinical report. Am] Psychiatry 122:1132-1138,
1966.
75. Cormier BM, Kennedy M, SangowiczJ: Psychodynamics of father-daughter incest. Can
] Psychiatry 7:203-217, 1962.
76. Rada RT: Alcoholism and the child molester. Ann NY Acad Sci 273:492-496, 1976.
77. PantonJH: MMPI profile configurations associated with incestuous and non-incestuous
child molesting. Psychol Rep 45:335-338, 1979.
78. Julian V, Mohr C: Father-daughter incest: Profile of the offender. Victimology: An
International Journal 4:348-360, 1979.
79. Machotka P, Pittman FS, Flomenhaft K: Incest as a family affair. Fam Process 6:98-116,
1966.
80. Herman J, Hirschman L: Families at risk for father-daughter incest. Am] Psychiatry
138:967-970, 1981.
81. Kaufman I, Peck AL, Tagiuri CK: The family constellation and overt incestuous rela-
tions between father and daughter. Am] Orthopsychiatry 24:266-279, 1954.
82. Lustig N, Dresser, JW, Spellman SW, Murray TB: Incest: A family group survival
pattern. Arch Gen Psychiatry 14:31-40, 1966.
104 SHELDON TRAVIN
83. Raphling DL, Carpenter BL, Davis A: Incest: A genealogical study. Arch Cen Psychiatry
16:505-511, 1967.
84. Cooper I, Cormier BM: Inter-generational transmission of incest. Can] Psychiatry
27:231-235, 1982.
85. Alexander PC: A systems theory conceptualization of incest. Fam Process 24:79-88,
1985.
86. Freud S: The aetiology of hysteria, In The Complete Works of Sigmund Freud London,
Hogarth Press, 1955.
87. Abraham K: The experiencing of sexual traumas as a form of sexual activity, in Selected
Papers of Karl Abraham. London, Hogarth Press, 1927.
88. Bender L, Blau A: The reaction of children to sexual relations with adults. Am J
Orthospychiatry 7:500-518, 1937.
89. Bender L, Grugett F AE: A follow-up report on children who had atypical sexual experi-
ences. Am] Orthopsychiatry 22:825-837, 1952.
90. Yorukoglu A, KemphJP: Children not generally damaged by incest with a parent.] Am
Acad Child Psychiatry 5: 111-124, 1966.
91. Henderson JD: Incest, in Freedman AM, Kaplan HI, Sadock BJ (ed): Comprehensive
Textbook of Psychiatry, vol 2, ed 2. Baltimore, Williams & Wilkins, 1975.
92. Burgess A W, Holmstrom LL: Sexual trauma of children and adolescents: Pressure, sex,
and secrecy. Nursing Clinics of North America 10:551-563, 1975.
93. Abel GG, Becker JV, Cunningham-Rathner J: Complications, consent, and congnitions
in sex between children and adults. Int] Law Psychiatry 7:89-103, 1984.
94. Rosenfeld AA: The clinical management of incest and sexual abuse of children. ]AMA
242:1761-1764, 1979.
95. Dejong AR: The medical evaluation of sexual abuse in children. Hosp Community Psychia-
try 36:509-512,1985.
96. Lewis M, Sarrel PM: Some psychological aspects of seduction, incest, and rape.] Am
Acad Child Psychiatry 8:606-619, 1969.
97. Gomes-Schwartz B, Horowitz JM, Sauzier M: Severity of emotional distress among
sexually abused preschool, school-age, and adolescent children. Hosp Community Psychia-
try 36:503-508, 1985.
98. Adams-Tucker C: Proximate effects of sexual abuse in childhood: A report on 28
children. Am] Psychiatry 139:1252-1256, 1982.
99. Krener P: Clinical experience after incest: Secondary prevention:] Am Acad Child Psychi-
atry 24:231-234, 1985.
100. Emslie GJ, Rosenfeld A: Incest reported by children and adolescents hospitalized for
severe psychiatric problems. Am] Psychiatry 140:708-711, 1983.
101. O'Brien JD: The effects of incest on female adolescent development.] Am Acad Psycho-
anal 15:83-92, 1987.
102. Goodwin J, Simms M, Bergman R: Hysterical seizures: A sequel to incest. Am J Ortho-
psychiatry 49:698-703, 1979.
103. Gross M: Incestuous rape: A cause for hysterical seizures in four adolescent girls. Am J
Orthopsychiatry 49: 704-708, 1979.
104. Molnar G, Cameron P: Incest syndromes: Observations in a general hospital psychiatric
unit. Can] Psychiatry 20:373-377,1975.
105. Finkelhor D, Browne A: The traumatic impact of child sexual abuse: A conceptualiza-
tion. Am J Orthopsychiatry 55:530-541, 1985.
106. Katan A: Children who were raped. Psychoanal Study Child 28:208-224, 1973.
107. Rosenfeld AA: Incidence of a history of incest among 18 female psychiatric patients. Am
] Psychiatry 136:791-795, 1979.
108. Becker JV, Skinner LJ, Abel GG, Tracey EC: Incidence and types of sexual dysfunctions
in rape and incest victims.] Sex Marital Ther 10:185-192, 1984.
109. Researchers identify psychiatric problems of adults abused sexually as children. Psychi-
atric News 22:23, April 1987.
110. Gelinas DJ: The persisting negative effects of incest. Psychiatry 46:312-332,1983.
111. Serrano AC, Gunzburger DW: An historical perspective of incest, in Barnard CP (ed):
Families, Incest and Therapy. Int] Fam Ther 5:70-80, 1983.
112. HermanJ: Recognition and treatment of incestuous families, in Barnard CP (ed): Fami-
lies, Incest, and Therapy. Int] Fam Ther 5:81-91, 1983.
113. Giarretto H: The treatment of father-daughter incest: A psycho-social approach. Child
Today 5:2-35, 1976.
114. Clinicians present comprehensive approach to treatment of sexually abused children.
Psychiatric News 22:46-49, May 1987.
115. Sgroi SM: Handbook of Clinical Intervention in Child Sexual Abuse. Lexington, Mass.,
Lexington Books, 1982.
116. Rist K: Incest: Theoretical and clinical views. Am] Orthopsychiatry 49:680-691, 1979.
117. Zuelzer MB, Reposa RE: Mothers in incestuous families, in Barnard CP (ed): Families,
Incest, and Therapy.lnt] Fam Ther 5:98-109, 1983.
118. Giarretto H, Giarretto A, Sgroi SM: Coordinated community treatment of incest, in
Burgess AW, Grath AN, Holmstrom LL, Sgroi SM (eds): Sexual Assault of Children and
Adolescents. Lexington, Mass., Lexington Books, 1978.
119. Abel GG, RouleauJL, Cunningham-Rathner J: Sexually aggressive behavior, in Curran
WJ, McGarry AL, Shah SA (eds): Forensic Psychiatry and Psychology. Perspectives and Stan-
daTiis for Interdisciplinary Practice. Philadelphia, F. A. Davis Company, 1986.
120. Travin S, Bluestone H, Coleman E, Cullen K, MelellaJ: Pedophile types and treatment
perspectives.] Forensic Sci 31:614-620,1986.
121. Travin S, Cullen K. MelellaJT: The use and abuse of erection measurements: A forensic
perspective. Bull Am Acad Psychiatry and Law (in press).
122. Freund K: Assessment of pedophilia, in Cook M, Howell K (ed): Adult Sexual Interest in
Children. New York, London, Academic Press, 1981.
123. Abel GG, Blanchard EG: The measurement and generation of sexual arousal in sexual
deviates, in Hersen H, Eisler RM, Miller PM (eds): Progress in Behavior Modification, vol 2.
New York, London, Academic Press, 1976.
124. Cohn AH: Preventing adults from becoming sexual molesters. Child Abuse and Neglect
10:559-562, 1986.
125. Freeman-Longo RE: The impact of sexual victimization of males. Child Abuse and Neglect
10:411-414, 1986.
7
Intrafamilial Child Sexual
Abuse and Forensic
Psychiatrists
ALAN J. TUCKMAN
The evaluation of a child sexual abuse (CSA) case brings with it many conflict-
ing problems, caused by the roles the forensic psychiatrist assumes in the
judicial system and by the highly complex material being dealt with. As psychia-
trists and presumed humanitarians, we want to aid and protect these helpless,
victimized children, at times, speaking for them because they often cannot
speak or fight for themselves. Yet, we know all too well the fallibility of psychia-
try in applying its expertise to certain legal issues. Psychiatry has a long history
of jumping into an issue (or being pulled in by the courts), only to find itself
over its head, embarrassed that it promised more than it could deliver. 1 Exam-
ples included the offer to rehabilitate offenders, to predict dangerousness of
the mentally and criminally ill, to use hypnosis in "refreshing" lost memories,
in order to identify material that can be used in criminal prosecution,2 and to
predict which murderers would murder again and should be put to death. 3
Although in all of these examples, as with CSA, psychiatry may have much
to offer, it is essential to view critically the specific role we play in the judicial
process. In CSA, psychiatrists have been drawn in as validators of children's
unsworn statements, in many jurisdictions testifying for the children and cor-
ALAN J. TUCKMAN • Forensic Psychiatry Clinic, Rockland County, New York 10956;
Department of Psychiatry, New York University School of Medicine, New York, New York
10003.
107
108 ALAN J. TUCKMAN
roborating, or validating, that they have been sexually abused. They may even
identify or confirm the identify of the abuser. 4 One wonders what Jonas
Robitscher would have said about this practice, which, again, bestows on psy-
chiatrists extraordinary power, often without much foundation. Psychiatrists
are asked to act as police detectives or lie detector machines, rather than as
mental health professionals: What follows is an attempt at providing both sides
of some of the issues. If a sense of ambivalence comes through, it derives from
the current lack of clarity in this area.
EVOLUTION OF THE DISORDER
There certainly is an appropriate role for the forensic psychiatrist in the

evaluation of sexually abused children, and in testifying about the dynamics of
the victim's symptoms and their families' problems, without extending the
testimony into fact finding. Over the last 25 years, combinations of symptoms
have been identified as being indicative of specific traumatic emotional experi-
ences and have been adopted into the psychiatric nomenclature.
In 1962, Kempe defined the battered child syndrome,5 allowing children
who have been physically abused to be identified by health professionals. In
1974, Burgess and Holmstrom contributed to the literature the description of
the rape trauma syndrome6 and sexual trauma of children and adolescents.7
Then, in 1975, Sgroi published Sexual Molestation of Children. 8 These defined
further the symptom complex, which could be utilized to identify that a woman
or a child has been sexually abused. This, then, came to be used as confirma-
tion of an allegation of abuse.
In 1980, the DSM-III was published, adding the new category of "Post-
Traumatic Stress Disorder,"9 which would codify and formalize symptoms
resulting from an overwhelming trauma, including rape or child sexual abuse.
It would seem that by the 1980's, everyone in the health professions would
be sensitized to these disorders and would have educated all other caregivers,
such as the judiciary, in identifying the symptoms that result from sexual
abuse. Yet, there still appears to be an enormous degree of denial in identifying
abuse of children. As Sgroi stated:
Recognition of sexual molestation in a child is entirely dependent on the adult's
inherent willingness to entertain the possibility that the condition may exist. As a
matter of fact, the more advanced the training of the observer, the less likely (or
willing) are some to suspect molestation. 1O
Dramatic Statistics
To emphasize and underline the extraordinary degree of denial practiced
by adults, one might only peruse the statistics of this subject. It is estimated that
25% of girls and 20% of boys have had sexual contact with an adult by the time
they reach 18 years old. Approximately 10% of girls are estimated to have been
INTRAFAMILIAL CHILD SEXUAL ABUSE 109
actually sexually victimized by an adult during childhood. One third of all

offenders are family members and 20% are fathers. Of non family perpetra-
tors, 75% are known to the child. The average age of initiation of sexual abuse
is 7 years old, with 25% being initiated before they are 5 years old. Physical
corroborating evidence is only found in one third of victims, leaving two thirds
exposed to allegations of lying or confabulation. Yet, it is estimated that only
2% of children actually lie about unfounded sexual abuse and fewer children
invent, imagine, or exaggerate it. ll
Because children do tend, inadvertently, to distort their recollections of
events, commensurate with their ages and capacity to maintain a consistent
mental picture, it has also been shown that the most accurate account of the
abuse will occur in the first interview. 12 With repeated retelling to police,
investigators, social services caseworkers, attorneys, judges, and, of course,
parents, (all of whom, unwittingly, add to, and distort, the original story), the
child will adopt bits of information, offered by these questioners, contaminat-
ing the account and possibly appearing less credible. This may result in a
charge of fabricating the abuse when the story unfolds in court, because it will
contain discrepancies when compared to the original story. In addition, there is
the ever-present danger that some of these questioners will increase the child's
confusion and guilt through their inappropriate comment or suggestions.
Statutory and Case-Law Basis
All jurisdictions have codified the statutory requirements of child sexual

abuse and many have defined the necessary evidence required to convict an
alleged abuser of this offense. In New York, for example, the Family Court
Act, Section 1046 (a) VI), Article 10 and Penal Law 130.16 require for cor-
roboration of abuse, "any evidence, other than the child's out-of-Court state-
ments, tending to prove the child was abused and the Respondent was the
perpetrator." Corroboration may include admissions of a parent, sworn testi-
mony of other adults or children, medical evidence, presence of sexually trans-
mitted disease and validation of a child's statements by a qualified expert. 13 In
addition, through case law, "out-of-Court statements" by the child, made to a
health professional, may be admitted into evidence if the expert can validate
the child's statements by confirming the existence of what has come to be
known as "the intra familial child sexual abuse syndrome."14 As a matter of
fact, the New York Family Court Act even allows the expert validator to testify
to the child's unsworn, out-of-Court statements, without the child testifying at
all. 15 These statements of the child need not be positive and direct; the expert's
conclusion may be derived from circumstantial evidence l6 (e.g., child abuse
symptoms), or the expert may testify to the validity of the child's statements,
thus identifying or confirming that the child's allegations are credible.
A recent New York case, though, cautions that the expert's function
should not be to substitute an estimation of credibility for the trier of fact, or to
be a criminal investigator, but simply to give scientific guidelines to follow. The
expert opinion should compare the complainant's behavior and mental charac-
110 ALAN J. TUCKMAN
teristics with those of others subjected to similar trauma, be reliably based on

experience, and offer, in some detail, the factual basis for it. 17 Following this,
the expert should see the child (and the family) as close as possible to the time
of disclosure, and videotape all interviews. In some jurisdictions the videotape
can be admitted into evidence at trial and may even be allowed in lieu of the
child's testimony.
There are those experts who do not believe that the parents (including the
alleged abuser) should be evaluated, because this allows the expert to testify to
whether the parents fit the alleged syndrome of an abuser-prone family. This is
a highly controversial issue at present, with one writer claiming that "investigat-
ing the parents to determine culpability in CSA cases is clinically unhelpful,
ethically unsound and intellectually absurd,"18 while other investigators have
been working on a profile of characteristics of abuser-prone families. 19
Generally, the following characteristics appear to occur with some fre-
quency in the parents of children who have been sexually abused (by one of the
parents): the mother is sexually and emotionally unavailable to her husband.
She is passive, dependent, possibly rejecting, and emotionally angry toward the
child. She has been ostracized by the family (father and children) and has
significant conflicts about her maternal role, frequently relegating it to one of
the children, often the abused child, who is, interestingly, herself protective of
her mother. The father is usually dominant, involved and very needy, exclud-
ing the mother from the family and attempting to become the nurturant par-
ent. He is often rigid, moralistic, patriarchal and has had no extramarital
affairs, other perversions, or antisocial acts. His own sexual functioning may be
adequate or inadequate and it appears irrelevant to the sexual abuse. He may
be on disability, physically ill, or unemployed. Both parents usually have few
extrafamilial involvements and few adult relationships. They are socially iso-
lated, with few outside interests.
Because there is significant controversy surrounding the validity of these
characteristics (or the frequency with which they occur in confirmed abuser
families) it would seem that the appropriate role of the expert would be to
evaluate all members of the family, and to testify to the findings, but to caution
the court about any conclusions reached. As in all expert testimony (including
that of the evaluation of the abused child) the expert must be cautious to
present the data without answering the ultimate question and without usurping
the role of the trier of fact.
The Evaluation of the Child Victim

In evaluating the child victim alone or as part of the family constellation,
there are significant informed consent issues that are rarely dealt with.2o No
one can or does really explain to the child, prior to the divulging of the abuse
or of the child's descriptions of each of the parents' relationships with her, that
the information gathered will likely have dire consequences for the family. The
father may be jailed, the mother may reject the child (and siblings), the child
will likely be removed from the home if the mother is too ambivalent about her
allegiance to the child, if she and the father choose not to believe the child, or if
she is felt to be too weak to protect the child from further abuse, (all of which
are frequently found). It is generally believed that the abuse is severely disrup-
tive to the family structure and has already caused serious damage. It is also
accepted that an attempt at repairing these wounds through exposure and
termination of the abuse is critical. Yet, one must recognize that the process of
exposure and prosecution of the abuser, are often as traumatizing to the child
as the abuse itself. Many victims, long after the abuse and exposure have
occurred, remember all too well their anger at the agencies, professionals, and
courts, while continuing to feel affection and guilt for the father-abuser (at
least in those cases where the abuse occurred without serious threats of harm to
the child).
Development of the Syndrome

In those cases of CSA in which the abuse was infrequent, limited to fon-
dling, without threat, and with a degree of tenderness, the child is usually left
with few overt symptoms of the abuse. Therefore, the development of various
symptoms and disruptions in emotional and social functioning seem depen-
dent on the manner in which the abuse was carried out. In many cases the child
proceeds through a series of stages, which Summit has classified as the "child
sexual abuse accommodation syndrome."21 In this morality play, the child, in
her attempted cover-up, is often labeled the villain.
Summit, in a major contribution to the field, has identified five progressive
stages of this syndrome:
1. Secrecy. In this first phase, at the time of the first contacts by abuser-
parent, the child experiences a terrifying reality. The sexual act occurs only
when the child is alone with the abuser-parent and she must never share it with
anyone else. The child is entirely dependent on the abuser-parent for whatever
explanation and reality are assigned to the experience. The ideas of danger
and a fearful outcome, if divulged, are universal. The secrecy and fear makes
the act bad and dangerous, and the child is severely demoralized by the secret.
The child lives in constant fear that the secret will come out, terrible things will
befall her family and herself, and she will be blamed. This fear isolates the child
from intimate relations with others.
2. Helplessness. The child is small and actually incapable of resisting
(due to the dynamics of the victim-perpetrator, child-parent, relationship)
and thus submits, ashamed and intimated by her helplessness, fear, and in-
ability to communicate her feelings to other adults (who do not want to hear
her pleas).
3. Entrapment and Accommodation. The process goes on, with the
child being unable to blame the parent (whom she still needs for nurturing)
and thus blaming herself, deciding she is bad. She attempts to be good by
earning love and acceptance from the abuser-parent, a serious ego-splitting
process. The child continues to live in mortal fear of her power to destroy her
112 ALAN J. TUCKMAN
family. This fear may be converted to rage at others, manifesting itself as

acting-out behavior, rebellion, sexual attacks or seductions of other children,
depression, and self-mutilation.
4. Delayed, Conflicted, and Unconvincing Disclosure. Most cases are
never disclosed, and if they are, the disclosure occurs during an evaluation or
investigation of a related event in the child's life, such as an antisocial act,
truancy, suicide attempt, or other family problem; the disclosure often occurs
years later, in adolescence, as the child tries to pull away from the father, or the
resulting misbehavior brings the child into contact with a therapist or other
community professional, to whom the abuse is divulged. But because the child
is already manifesting behavioral and emotional problems, her credibility is
undermined and she is accused of "contriving the story" to cover her own
misconduct, when in actuality the misconduct is the cover or outward man-
ifestation of the underlying conflicted sexual abuse. Everyone in the family is
drawn into turmoil; the mother is paralyzed by her indecision over whom to
believe, her husband, who she is very dependent on, or her daughter, who she
is supposed to protect from harm. Believing one means rejecting the other-
often an impossible decision for many of these mothers. The father must
continue his denial, believing that to do otherwise will bring down the wrath of
the judicial system and alienate him from his entire family. All relationships
suffer, and the family is torn apart.
5. Retraction. Under the onslaught of being called a liar by her father,
rejected by her mother, and often alienated from her siblings who are angry
with her for "breaking up the family," the child-victim decides that all of her
fears have come true and her only choice seems to be to again save the family
by making a retraction of the charges. Although she will be called a liar and a
fake, she can at least have her family together and no longer have to live with
her terrible guilt. Of course, this results in emotional withdrawal, social isola-
tion and a continuation of her prior problems.
If strong support is forthcoming from mother, siblings, and agency per-
sonnel, her conflict is lessened, but not altogether gone, as long as her father
makes no admission, or if he is prosecuted and jailed. Her guilt and her grief
for the lost relationship, then, are added to her other problems.
Obviously, the only solution that will produce a reasonably healthy out-
come is an admission by the father and, through therapy, a rapprochement in
the family, redefining roles and relationships. Sadly enough, this is not the
usual outcome.
The Symptomatology of CSA

As a result of the previously defined child sexual abuse accommodation
syndrome and the conflicts arising from it, all areas of the child's functioning
may be affected. In those situations in which the child has been threatened, and
lives in fear of exposure and destruction of the family, the symptoms are more
pervasive. Where the abuse was sporadic and without threat, no overt symp-
toms may occur at all. Therefore, caution must be exercised in requiring the
presence of CSA symptoms in order to conclude that abuse has occurred, or to
validate the child's allegations.
Although Post-Traumatic Stress Disorder (DSM-III) has been utilized as
the formal diagnosis in these cases, it usually does not accurately reflect the
clinical picture. Psychic numbing, flashbacks, and amnesia (found in PTSD) are
usually absent in CSA.
In addition, the required number of these symptoms is still unclear and is
consistent with but certainly not pathognomonic of child sexual abuse, because
the symptoms may occur with other stressors (such as an acrimonious marital
separation); in the presence of an accusation of abuse by the child, however,
there is heightened certainty that the abuse has occurred.
• Shame, guilt, and an inner sense of "badness"
• Social withdrawal, disrupted school functioning, and distractedness
• Emotional lability and generalized anxiety
• Regression, with separation fears and clinging (in younger children);
depression, suicidal ideation, or acts and running away (in older chil-
dren), nightmares and phobias
• Frightened, avoidant, mistrustful attitude toward males; hostility toward
both parents
• Physical complaints, including headaches, abdominal pain, genital irrita-
tion, enuresis, encopresis, fatigue
• Excessive interest in, and unusual (age inappropriate) knowledge of,
sexual matters. Frequent masturbation and indiscriminate seductive be-
havior, putting the child at risk for repeat abuse by others, due to the child's
confusion of affectionate with sexual feelings
• Increased sexual themes in drawings and doll play and the ability to act
out the sexual abuse in these media, when words may not be available to
describe the abusive acts
False versus True Positives

It has already been stated that children rarely fabricate or confabulate
CSA. But, in some cases, false allegations of abuse may actually occur, often in
the midst of an acrimonious marital separation and custody dispute, in which a
simple accusation of CSA against the father is enough for many courts to
suspend visitation for many months, disrupting the parent-child relationship
and dealing a fatal blow to the father's ever having adequate, unsupervised
visitation, much less custody.
Some of these allegations have even been purposefully contrived by parent
and/ or attorney as a means of killing off the father's chances for custody. More
unfortunate are those cases in which the allegations occur inadvertently or
unwittingly, as a result of the animosity, regression, and distorted allegiances of
the parents and the children in the midst of a marital separation.
The typical scenario is that of a child coming home from a weekend visit
with her father, and as a result of the stress of the transition and regression, is
114 ALAN J. TUCKMAN
noted by her mother to be "touching herself," possibly a form of masturbatory

activity. The mother, angry, abandoned, regressed herself, develops the idea
that her child may have been "sexually abused." She asks the child, "Did daddy
touch you there?" which, of course, he did, while bathing her. The child,
picking up mother's suggestion, says that he did (innocently), and the mother is
off and running with a CSA allegation, unaware that she and the child have
unwittingly fabricated this event. Once other investigators are involved, the
child's story may become even more contaminated, and elaborate.
Because of the enormous danger of missing an actual abuse or of charging
a parent when no abuse has ever occurred, much work is now being done 22 to
attempt to distinguish true from false allegations. The data is coming in, but is
currently difficult to assess. Is there more abuse? Is it being overreported? Are
there more episodes of false accusations, especially in divorcing parents? Are
mothers turning to this to disengage themselves from their spouses and to
isolate the fathers from their children, now that charges of adultery are no
longer very valuable to effect this end?
Thus it becomes crucial for the forensic psychiatrist to be able to under-
stand the differences in symptomatology presented by the child in whom CSA
has actually occurred, from one in which it has been purposely or inadvertently
fabricated. Yet, there remains the caution as stated previously, that it would
appear to be beyond the role of the psychiatrist to attempt to determine that
CSA has occurred. It will need to be left to each practitioner (and court) to
decide how far to go in these evaluations.
Table I, from the extensive work by Arthur Green,23 attempts to define
the differences in characteristics of true from false CSA allegations.
The Child in the Courtroom

Most allegations of CSA are disposed of, short of trial. Some are dropped
for lack of evidence, others are settled, informally, with an agreement made for
counseling or termination of the relationship with the child (and with the rest
of the family). But a small number do get to trial, in which the alleged abuser
consistently denies the charges and the county attorney (family court) or dis-
trict attorney (criminal court) proceeds to litigate the issue. The child's testi-
mony often becomes crucial to the prosecution of the case. Yet, one must
remember that these children have already been severely traumatized by the
abuse, by the disruption of the family preceding and following the divulging of
the abuse, and probably as significantly, by the handling of the child by "well-
meaning" hordes of investigators, attorneys, caseworkers, and others, "need-
ing" to gather information for the successful prosecution of the abuser. The
anger of the victims is not, as it would be assumed, at the abuser (with whom
many have already had a reconciliation), but at all of the agencies whom she
perceives to have mistreated her, frequently in a fashion far worse than the
actual sexual abuse.
Cohen, in an outstanding plea for greater understanding of this particular
aspect of the problem, has recommended that in all cases of alleged CSA, an
Table I. Distinguishing between True and False CSA Allegations
Characteristic True CSA allegation False CSA allegation
Disclosure Delayed, conflicted, often Easy and apparently spon-

with retractions taneous, wlo guilt and
fear
Expressed feelings Painful and depressive Absent
with disclosure
Discussion of abuse Child reticent to discuss Discusses, when prompted
with mother and others by mother; checks with
mother, visually
Confronting of father Rarely will confront father Can confront father, espe-
with allegation, even with cially with mother pres-
mother present ent
Attitude in father's Fearful with father-con- Discrepancy between child's
presence and inter- gruent with ideation-re- angry accusations and ap-
est in visitation luctance to be with him parent comfort in his
presence (especially when
mother absent) but may
be very angry
Mother's mental state Often depressed-little pa- Prominent paranoid and
thology other than self- hysterical psychopathol-
reproach and guilt ogy
Signs of CSA syn- Usually present Absent
drome
Attitude with male Frightened, cautious, very Comfortable-may be se-
examiners seductive or reticent ductive-less stress evi-
dent
Knowledge of sexual Excessive and graphic (may Age appropriate-usually
matters be distorted but detailed) without intense affect or
and may be very preoc- information, often one
cupied. May attempt to dimensional without
seduce other children. depth to description
Inner sense Much badness-inner Normal or conflicted
shame, pain
Consistency of story External-Same over time External-Same or shifts
Internal-Much detail and Internal-Flat, little detail,
logical superficial
Reaction to challenge May withdraw and become May become angry or give
and questions of depressed it up
lying
Reaction to removal Marked improvement in Little change or may deteri-
from alleged abuser functioning orate
Note. Adapted from Green A: True and false accusations of sexual abuse in child custody disputes. JAm
Acad Child Psychiatry 25:449-456, 1986.
116 ALAN J. TUCKMAN
advocate should immediately be assigned, who would act as an intermediary

between the child and all agencies and other investigators, having the authority
to refuse to allow the child to be mishandled by these "well-meaning" people.
She also recommends (as do many others) that at the earliest possible phase of
the investigation (preferably, immediately upon first disclosure of the abuse)
the child be evaluated by a trained child abuse specialist and the entire inter-
view be videotaped. Thereafter, rather than subjecting the child to repeated
humiliating, intrusive, and often contaminating interviews, the videotape can
be viewed, possibly even at trial, in lieu of the child's actual testimony.24 If we
are truly to consider the child's best interests, then we must do much more to
protect these already damaged victims and not perpetuate the victimization.
At times, however, it does become necessary to have the child testify
against the alleged abuser in court. In these situations, again with the best
interests of the child being most important, modifications and protections of
the child's testimony can be ensured. Suggestions that have been offered in-
clude the following: 2s - 27
• Prepare the child before trial with discussions, visits to the courtroom,
and a lot of support.
• Remind the child, repeatedly, that he or she is believed, but that some
questions may appear to be directed at shaking that belief.
• Have all parties agree that the child can tell the story in a narrative, in his
or her own words, rather than in the traditional courtroom question and
short answer method.
• Limit the child's testimony to short periods with ample breaks for rest
and more support.
• If necessary, have a child specialist available to interpret and explain to
the court, the child's age appropriate language, thus avoiding misunder-
standings and misinterpretations of the child's statements.
• Allow a young child to sit in the lap of a trusted friend or caregiver to
lend a greater sense of safety and security to the child.
• Attempt to avoid having the child testify in front of the accused, to
prevent subtle intimidation and guilt. The use of two-way television
cameras and monitors can be arranged as a means of allowing the child
to avoid the confusion, turmoil, and fear engendered by a busy court-
room, while assuring the constitutional rights of the accused to face his
accuser and (in some fashion) to be able to cross-examine the child.
The decision about whether the child should testify at all should be made
solely on the basis of whether it would be beneficial to the child and not whether it
meets the needs of the prosecutor or system. It is extraordinarily difficult to
assess the risk-benefit ratio of having a child testify against her own parent or
other previously loved family member. Generally, it would seem appropriate.
But, working in the field, one comes to know all too well that many of these
children will be reunited with the abuser, with, and many times, without the
cooperation of the agencies involved in the exposing and prosecuting of the
abuse. CSA is a destructive process for the child's (and the family's) develop-
ment. Yet, it is not clear whether prosecution is the most appropriate method
of resolution. What is clear is that abusers come in various sizes and shapes,
having inflicted varying degrees of harm on the child. The method of resolu-
tion of the problem must be suited to the particular family.
Disposition and Outcome

Factors to be considered in making a recommendation regarding prosecu-
tion, therapy, or other disposition, include: (a) the extent of the abuse: fon-
dling versus actual intercourse, fellatio, etc. (b) presence or absence of threats
and fear, during or after the acts; (c) the length of time the abuse had con-
tinued; (d) the age of the child; (e) the mental status of the abuser: whether
other pathology also exists; the degree of the obsession with the child; prior or
concurrent history of mistreatment of children. (f) the mental status of the
mother; her capacity to protect the child (and other children) from future
abuse; her own perspective on her allegiance (to the abuser or to the child) and
her willingness to see her role in the events of the disrupted family, and the
abuse (without shifting the blame to her). (g) the willingness of the abuser to
enter therapy, confront the abuse (in some way) and make peace with the child.
A hard and fast rule that all abusers must openly admit to and apologize to
the child for the abuse appears too rigid. It may mean that an abuser-parent,
with a reasonable relationship with spouse and children, not severe psycho-
pathology and abuse limited to fondling, would be permanently barred from
seeing his children again, if he could not bring himself openly to admit to the
abuse. The relationships and psychodynamics that lead to the abuse, are much
too varied and complex to allow for a simple and single solution.
Many other questions have yet to be investigated in this complex process,
relating to treatment of the CSA family. Some treatment centers require an
admission from the abuser in order to treat him, others treat the abuser sepa-
rate from the child-victim and other family members. Clearly, the most appro-
priate and systems-theory-sensitive approach is to have one program (and
possibly, one therapist) treat all of the family members, because with all but the
most seriously disturbed families (or offenders), reconciliation of the family
would appear to be the optimum goal of treatment. Retribution may be appro-
priate for other types of crimes, but in CSA, when the offender is also the
child's parent or other family member, more sophisticated methods of re-
habilitation and healing must be considered.
As with other disorders, CSA is a complex problem. Today it heads the list
of subjects for investigation and intervention. Lest we be too zealous in our
involvement, let us remember that part of the Hippocratic Oath that states,
"First, do no harm," and second, remain psychiatrists and not lawyers.
REFERENCES
1. Robitscher J: The Powers of Psychiatry. Boston, Houghton Mifflin Co, 1980.

2. Rock v Arkansas, 288 Ark. 566 (1986).
3. Barefoot v Estelle, 463 U. S. 880 (1983).
118 ALAN J. TUCKMAN
4. Social Servs. v Bertha C. - N.Y. - 130 Mise. 2d 1043 (1986).

5. Kempe C, et al: The Battered Child Syndrome.]AMA 181:17-24, 1962.
6. Burgess A, Holmstrom L: Rape Trauma Syndrome. Am] Psychiatry 131:981-986, 1974.
7. Burgess A, Holmstrom L: Sexual trauma of children & adolescents: Pressure, sex &
secrecy. Nursing Clinics of North America 10:551-563, 1975.
8. Sgroi S: Sexual molestation of children: The last frontier in child abuse. Child Today 4:44,
1975.
9. American Psychiatric Association, Diagnostic Statistical Manual of Mental Disorders, ed 3.,
Washington DC, Author, 1980, pp 236-239.
10. Sgroi S: Sexual molestation of children: The last frontier in child abuse. Child Today 4: 18-
21, 1975.
11. Mann E: The assessment of credibility of sexually abused children in criminal court cases.
12. Mann E: The assessment of credibility of sexually abused children in criminal court cases.
6:9-15, 1985.
13. Matter of Tara H, 129 Misc 2d 508 N.Y. (1985).
14. Matter of Michael G, 129 Misc 2d 186 N.Y. (1985).
15. N.Y. Family Court Act Para. 1046 (a) (vi).
16. People v Dow 34 AD 2d 224, 229 (1970).
17. Hawaii v Kim 64 Hawaii 598 P2d 1330 (1982).
18. Bursten, B. Detecting child abuse by studying the parents. Bull Am Acad Psychiatry Law
13:273-281,1985.
19. Milner JS, Wimberly RC: Prediction and explanation of child abuse. ] Clin Psychol
36:875-885, 1980.
20. Renshaw D: When you suspect child sex abuse: Take the child's sexual history. Medical
Aspects of Human Sexuality, June 1986, pp 19-24.
21. Summit R: The child sexual abuse accommodation syndrome. Child Abuse and Neglect
7:177-193,1983.
22. Schaeffer P: Child custody-visitation disputes spawn allegations of sex abuse. Clinical
Psychiatry News 14:3, December 1986.
23. Green A: True and false allegations of sexual abuse in child custody disputes.] Am Acad
Child Psychiatry 25:449-456, 1986.
24. Cohen R: The trust goes only so far. Editorial, N.Y. Newsday, December 16, 1986.
25. Nurcombe B: The child as witness: Competency and credibility.] Am Acad Child Psychiatry
25:473-480, 1986.
26. Bernstein B, Claman L: Modern technology and the child witness. Child Welfare, 65: 155-
163, March-April, 1986.
27. Claman L, et al: The adolescent as a witness in a case of incest: Assessment & outcome.]
Am Acad Child Psychiatry 25:457-461, 1986.
8
Special Considerations in the
Psychiatric Evaluation of
Sexual Offenders against
Minors
FRED S. BERLIN
INTRODUCTION
The first priest approached the bishop and asked, "Father, may I smoke while
praying?" to which the bishop responded, ''I'm sorry, my son, but that is not
permitted." The second priest, having overheard the conversation, thought for
awhile before going to the bishop a few weeks later to ask, "Father, may I pray
when smoking?" to which the bishop replied, "Of course, my son, of course."
The terms we use and the assumptions we make can influence significantly
how we relate to and deal with issues and people. This is especially true when it
comes to the question of how we deal with those people who become involved
sexually with children. Who among us would approach with sympathy the
"child molester," the "sexual pervert," or the "abuser of children"? On the
other hand, who among us would choose voluntarily if we had the choice,
which we do not, to live his life afflicted with a sexual orientation directed
toward children? Who among us would fail to empathize with the innocent
child prematurely introduced to sexual activity by an adult in a fashion des-
tined to warp that youngster's developing sexuality? At what point should that
child, so warped in his sexual development by virtue of his victimization (possi-
bly himself developing a sexual attraction toward children), be relabeled and
FRED S. BERLIN· Department of Psychiatry, Johns Hopkins University School of Medi-

cine, Baltimore, Maryland 21205.
119
120 FRED S. BERLIN
stigmatized as a victimizer? Often the victim and the victimizer are one and the
same.
Pedophilia is an Axis I psychiatric diagnosis, presumably suggestive of a
need for and a right to humane and professional psychiatric care. "Child
molester" and other similar terms are pejoratives whose connotations suggest a
rather different and certainly less compassionate approach. Before mental
health workers can begin providing care to adults who have become involved
sexually with children, they must first genuinely appreciate that there is profes-
sional legitimacy in doing so.
Some adults who become involved sexually with children suffer from ped-
ophilia. Pedophilia is one of the paraphilic disorders, perhaps as a group
among the most professionally ignored, least studied, and most undertreated
of the DSM-UI Axis I conditions'! Not all adults who become involved sexually
with children manifest a pedophilic disorder, however, and before one can
even begin considering treatment options, and perhaps also legal options, a
differential diagnosis must first be made.
DIFFERENTIAL DIAGNOSIS, NONPARAPHILIC SEX OFFENSES
A person is defined legally as a sex offender by virtue of behavior alone.

Thus, if an adult becomes involved sexually with a child, according to the law
such behavior constitutes a sex offense. Persons can engage in similar behav-
iors, however, for a variety of reasons. In evaluating such persons the psychia-
trist must first attempt to determine the mental or motivational state that led
the individual to act.
One of the major diagnostic distinctions that must be made is to try to
determine whether the offending behavior in question was engaged in by a
person manifesting a paraphilic or nonparaphilic sexual drive. Many sex of-
fenses are commited by persons manifesting perfectly conventional (non-
paraphilic) sexual orientations. The father, for example, who becomes in-
volved in an incestuous relationship with his 14-year-old stepdaughter, may fall
into such a category. Indeed, most men might have found the young lady in
question to be physically appealing. Thus, cases of nonparaphilic incest by
definition cannot be explained on the basis of an aberration of the sex drive
itself.
There are many circumstances besides an aberration of the sex drive
which can result in an adult becoming involved with a child in a sexual way.
Consider, for example, the plight of some persons who are mentally retarded.
If one has the mental age of an 8-year-old, how does one go about convincing
an adult to become involved in an intimate way? Most adults would have little
interest in such a relationship. For this reason some mentally retarded indi-
viduals may attempt to persuade, or in rare cases even to coerce children (who
may be of a similar mental age) into sexual activities. The offending behavior in
a case such as this can best be understood as a reflection of the individual's
PSYCHIATRIC EVALUATION OF SEXUAL OFFENDERS 121
limited intellectual and coping skills, rather than as a manifestation of pa-

thology fundamental to the sex drive itself.
Although rare, persons sometimes become involved sexually with children
in response to the delusions or hallucinations of an affective disorder or of
schizophrenia. Other reasons why persons with nonparaphilic sexual orienta-
tions could become involved sexually with children could easily be listed. The
crucial point in evaluating an adult who has become sexually involved with a
child is to appreciate the importance of making a differential diagnosis, partic-
ularly with reference to the issue of whether or not there is something funda-
mentally different about the individual's sexual drive, per se.
DIFFERENTIAL DIAGNOSIS, PARAPHILIC SEX OFFENSES
There is a belief endemic to our culture that all persons are created equal.
Although surely all persons should be afforded equality of opportunity and be
thought of as possessing equal moral worth, all persons are not equal in the
sense that equal means the same. One way in which persons differ from one
another is according to the gender of partner and age range of partner whom
they find to be erotically arousing. 2 •3 Each person is generally consciously
aware of the gender and age range that they find appealing, although they may
rarely pause to give the matter much thought. The average male, for example,
is attracted sexually to females, with the attraction limited to a rather broad age
range. The average male is not terribly tempted to engage in sexual activities
with a 6-year-old child, nor is he generally very tempted sexually by the elderly.
There are some individuals who are in no way whatsoever attracted sexu-
ally to adults, yet they recurrently experience temptations to become involved
with children in a sexual, and perhaps even romantic fashion. Some such
persons are attracted to children exclusively, whereas for others there is some
degree of attraction to adults as well. Clearly if a person experiences recurrent
intense erotic attractions toward children that fact may lead to problems.
When a person is erotically attracted toward children he or she is said to
have a pedophilic sexual disorder. The majority of such persons are male.
Pedophilia is a disorder, then, in which there is something fundamentally
different about the individual's sexual drive (or eroto-affectionate pair-bond-
ing drive) per se. The plight of the individual whose sexual attractions are
directed exclusively toward children is perhaps readily appreciated. Who
among us would want to volunteer to experience life on a daily basis from such
a perspective? The problems faced by the individual with a nonexclusive ped-
ophilic disorder (i.e., the person who is attracted sexually to children, but to
adults as well) can also be cumbersome. The sexual drive is a biologically based
appetite and appetites have contained within them various tastes. The fact that
an individual may be attracted sexually to adults does not necessarily mean that
intense temptations to become involved with children are absent.
In some cases the sexual attraction experienced by an individual for chil-
122 FRED S. BERLIN
dren is unwanted, causing conflict with that individual's personal moral beliefs
and values. In such an instance those sexual desires are said to be egodystonic.
When no such internal conflict is present those desires are said to be egosyn-
tonic. Because sexual activity is ordinarily pleasurable, there is often some
degree of ambivalence about having to stop such behavior permanently.
Pedophilia is an Axis I diagnosis. Persons manifesting a pedophilic erotic
orientation mayor may not have an Axis II personality disorder diagnosis as
well. The egosyntonic pedophile who believes that he is not harming children
by his actions is not necessarily lacking in conscience or generally antisocial in
his makeup. Rather, he may have a genuine affection for children and believe
he is doing no harm. He cannot be expected to show guilt and remorse if he
does not believe, perhaps because his sexual attraction toward children seems
so natural to him, that his actions were wrong. Such a person may show guilt
and remorse in therapy if he begins to appreciate that his actions did cause
suffering.
In evaluating adults who have become involved sexually with children, one
must not necessarily assume the presence of an Axis II personality disorder.
Many adults who become involved in such a fashion do so in response to an
aberrant sexual drive rather than because of a generally antisocial attitude or
because of malicious disregard for the well-being of others. In fact, as Money
points out in his book, Love Sickness, one of the tragedies of the pedophile is not
ordinarily that he dislikes children but rather that he likes them, or perhaps
even loves them, too much and in the wrong way.4 Appreciating that this is so
can be important in counseling the "offender" and the victim as well.
The process of differential diagnosis itself as always depends on a good
clinical history and mental status examination. Obtaining additional informa-
tion, such as the individual's prior criminal record and a clear description of
any current criminal allegations, is also crucial. Psychological testing of intel-
ligence level, reports from persons who know the evaluee, and prior psychiatric
records regarding possible past episodes of mental illness should also be ob-
tained. In some instances evaluations are best performed on an inpatient basis.
Diagnosis in adolescents can at times prove particularly difficult because clear
behavioral patterns, especially in the sexual sphere, may not yet have emerged.
ETIOLOGY
One can treat a fever with aspirin but this does not mean that the fever was
caused by aspirin deficiency. Effective treatment does not necessarily depend
on a complete understanding of etiology or cause. Nevertheless, attempting to
understand etiology can be important. When it comes to understanding the
etiology of sex-offending behavior, once again differential diagnosis becomes
crucial. Understanding the causes of antisocial personality, mental retardation,
or schizophrenia as related to a sexual offense against a child can be a very
different issue from appreciating the causes of an aberrant sexual drive such as
pedophilia.
Many years ago alcoholism was thought of as purely a moral issue. Alco-
holics were bad people. Today we have the Betty Ford Clinic and similar
facilities recognizing that fundamentally decent people may require psycholog-
ical and medical help in order to learn how not to succumb to cravings for
alcohol. Alcoholism does pose moral questions but also raises legitimate ques-
tions of medical and scientific merit. Perhaps today most persons still assume
that sexual activity between an adult and child is purely a moral issue. Surely
any person drawn sexually toward a child, particularly if he or she succumbs to
such temptations, must be irresponsible, evil, or bad. We know that he is bad
because otherwise he would not have acted in such a fashion. Why do we think
he acted in such a fashion, because he is bad? In this sense the term bad is
simply a label masquerading as an explanation. Good people are attracted
sexually toward adults of the opposing gender, bad people are attracted sexu-
ally toward adults of the same gender or toward children.
It is a legitimate scientific question to ask why any of us experience particu-
lar sorts of sexual desires and attractions. Why are most of us attracted sexually
to adults of the opposite gender? Why do some persons experience no such
attractions? Why are some person's erotic attractions directed exclusively to-
ward children?
The first answer, and perhaps the one of most relevance from a forensic
and moral point of view, relates to the issues of what is not the cause of the
sexual desires that an individual experiences. The erotic desires that indi-
viduals experience are not the result of a voluntary decision. The adult male
with a nonparaphilic erotic orientation did not decide because he was a good
youngster, to grow up experiencing sexual attractions toward women. Rather,
he discovered himself to be such a person. Similarly, the man who is attracted
toward young boys sexually did not decide because he was a bad youngster to
experience such desires. In our society who among us would decide to be that
way if one were free to make such a choice?
If pedophilia is not the result of a voluntary decision, then what factors do
contribute to the development of this erotic orientation, and how do we deter-
mine scientifically whether or not a given factor increases the probability of
developing a disorder such as pedophilia?
If one were to look at all persons who smoke, most do not get lung cancer.
However, when investigators look at groups of people who do have lung can-
cer, the overwhelming majority are smokers. When such data has been ana-
lyzed statistically it has been possible to conclude that smoking increases the
risk of developing lung cancer. The fact that some persons seem to be immune
to the effects of cigarette smoking on the lungs does not change this conclusion.
Conversely, lung cancer is still just that even if the person with it has never
smoked.
If one looks at a group of persons who were sexually involved with adults
during childhood, in growing up most do not develop a pedophilic sexual
orientation. One the other hand, when investigators such as Nicholas Groth
have looked at groups of men, all of whom do manifest a pedophilic sexual
orientation, they have reported that the overwhelming majority of such men
124 FRED S. BERLIN
were sexually active with adults during childhood. 5 ,6 When such data have
been analyzed statistically it has been possible to conclude that sexual involve-
ments with an adult during childhood increase the risk of developing a ped-
ophilic orientation. The fact that some youngsters seem immune to being
affected in this fashion by such sexual activity does not invalidate that conclu-
sion. Conversely, pedophilia is still just that, even if the adult manifesting such
an orientation was not sexually active during childhood. There is now data
suggesting that an oversuppression of the normal curiosity about sex during
childhood (e.g., an overly punitive attitude toward self-exploration and mas-
turbation) may also increase the risk of developing a pedophilic drive. 7
None of us are interested in having sex as the result of having read a book
that informed us that such an interest is logical or rational. Rather, the sexual
drive is biologically based. Therefore it is reasonable to wonder whether some
persons may experience aberrant sexual desires mentally because of factors
which affect their biological makeup physically. With this possibility in mind
researchers have compared men manifesting pedophilic and non pedophilic
erotic orientations on a variety of biological parameters. Unfortunately much
of the research addressing this issue has looked at nondiagnostic entities such
as "incest offenders," "child molesters," or "sexual aggressors" and therefore is
not of much value. 8 However, when comparisons have been made based on
similarities or dissimilarities in mental state (e.g., having a pedophilic or non-
pedophilic sexual orientation) rather than looking for similarities or dis-
similarities in behavior (e.g., having or not having had sex with a child) signifi-
cant findings have been reported. 9 ,10 It appears that persons are at increased
risk of developing a pedophilic disorder if they manifest brain damage during
childhood or certain forms of hormonal or chromosomal pathology.
Etiologically, sexual orientation is somewhat like language. The ability to
speak and to think is biologically determined, whereas which language one
speaks is a function of the environment. Once a person has learned to think in
English, regardless of the degree of contribution made by biology and environ-
ment, this issue becomes a fact of mental life that cannot be erased. Similarly,
once an adult is attracted sexually to other adults, or conversely to children,
these too, regardless of the role played by biology and environment, are facts of
mental life not easily altered.
TREATMENT
The treatment of adults who have become sexually involved with children
depends on first having made a proper differential diagnosis. If the behavior
in question is a manifestation of nonparaphilic conditions, such as mental
retardation, affective disorder, antisocial traits, schizophrenia, or drug intox-
ication, treatment must address these issues. The discussion of treatment here
will be limited to those instances of sexual interactions between adults and
children that are the manifestation of a pedophilic erotic drive.
Four types of therapy have been proposed to treat pedophilia. They are (a)
insight-oriented psychotherapy, (b) behavior therapy, (c) surgery, and (d) med-
ication plus group counseling. The theories on which insight-oriented psycho-
therapy are based presume that if all goes well during early psychological
maturation, by adulthood persons will develop an erotic, and perhaps even
romantic attraction, toward other adults of the opposite gender. Conversely
these theories propose that in some instances the maturation process is some-
how impeded, resulting in a paraphilic disorder such as pedophilia. Therapy
involves helping the individual gain insight regarding what went wrong. Such
theories seem to have a special appeal in our technologically based society.
Metaphorically, therapy involves figuring out how things got broken and fixing
them.
Some problems cannot be resolved by introspection alone. It seems un-
likely that an adult male manifesting conventional heterosexual interests could
figure out why it is he is erotically and romantically attracted to women. Even if
he could, doing so would not change that fact. Similarly, the person erotically
drawn toward children may not be able to figure why that should be so. Even if
he could figure it out, doing so might not help. There is little empirical evi-
dence suggesting that insight-oriented psychotherapy is an effective method of
treatment for the individual manifesting a pedophilic erotic drive. This is
certainly true if the priority in treatment, as it must be, is behavioral change
rather than simply a better understanding of the problem with such change
emerging in time.
Behavior therapists, as opposed to insight oriented psychotherapists, tend
in treatment to focus not so much on how the person developed a pedophilic
erotic orientation, although they usually assume that it was learned. The pri-
mary goal of behavior therapy is to help the person alter his aberrant erotic
arousal pattern, which is directed toward children, and the behavior associated
with it. Clearly this can be a formidible task. Expecting the man attracted
exclusively toward boys to lose that attraction and develop an interest in women
is analagous to expecting the man attracted exclusively toward women to lose
that attraction and at the same time develop an erotic interest in boys.
Behavior therapists, such as Able and Becker, have made a number of
important contributions to the field. I I Through use of the penile plethys-
mograph, a device that can measure varying degrees of erections in males, they
have been able to document physiologically that some men are indeed sexually
aroused by children, in some cases exclusively. Following a variety of behavior
therapy techniques, such as covert sensitization or masturbatory satiation, they
have been able to demonstrate in laboratory settings that some men previously
aroused sexually in looking at nude photographs of children are no longer so
aroused. They have also been able in some instances in the laboratory to show
erotic arousal in men with pedophilic orientations, following behavioral therapy
treatment, while looking at pictures of nude adults.
There are a number of important limitations to behavior therapy, particu-
larly with respect to use of the penile plethysomograph. There are no good
demographic data indicating how many men who become erotically aroused
when looking at photographs of nude children never act in response to such
126 FRED S. BERLIN
arousal. Thus the plethysmograph has not been shown to be an instrument that
can reliably distinguish prior to, or even subsequent to treatment, which indi-
viduals who are erotically aroused by children will actually become sexually
involved with a child. Clinically, however, if an adult male denies any erotic
attraction toward children but gets an erection when looking at nude pho-
tographs of them, confronting him with that discrepancy can be useful.
Behavior therapists must not presume that changes in erotic arousal pat-
terns, following treatment, of men looking at pictures of nude children in a
laboratory setting necessarily predict long-term behavioral change in the com-
munity. Certainly human beings are capable of responding one way in a labora-
tory setting and yet in a very different way in a real life setting. Theorists refer
to this phenomenon as discrimination learning or discrimination performance.
The challenge for behavior therapists will be to gather reliable, long-term
measures of behavioral change in the community and then to see whether or
not such changes were accurately predicted by changes in erotic arousal pat-
terns observed in the laboratory. High-quality, large-scale studies of this sort
have yet to be reported.
BIOLOGICAL METHODS FOR TREATING PEDOPHILIA:

SURGERY AND MEDICATION PLUS GROUP COUNSELING
As of yet there is no known biological method for altering sexual orienta-

tion. It may be possible, however, at least in some instances, to lower the
intensity of sexual drive as a means of making it easier to resist succumbing to
unacceptable erotic urges. This can be accomplished by lowering the hormone
testosterone, which is produced by the male testes.
Testosterone, a powerful hormone, "masculinizes" the male brain prior to
birth, resulting in subsequent suppression of the monthly peak in leutinizing
hormone characteristic of the adult female brain. Prior to birth, testosterone
also causes tissue that would otherwise have become the female clitoris to
enlarge, forming the male penis, and tissue that would otherwise have become
the female labia to modify, forming the male scrotal sac. At puberty testoster-
one production peaks in males causing the voice to deepen, muscle bulk to
thicken, facial, axial, and pubic hair growth and a marked increase in sexual
drive and interest.
Lowering testosterone seems to influence sexual motivation rather than
just the ability to perform sexually. In animals, for example, removing the
penis while leaving the testes intact interferes with the male animal's ability to
perform sexually, but he still appears motivated and tries to do so. Conversely,
removal of the testes (castration) while leaving the penis intact, in most in-
stances seems to decrease the animal's desire and interest in sexual activity even
though he still maintains the anatomical structures that would allow him to
perform. 12
Studies conducted in humans also suggest that lowering testosterone af-
fects sexual drive and not just the ability to perform. In Denmark, over 900
males whose testes had been removed were studied over follow-up periods
extending in some cases for as long as 30 years. 13 Over 4000 follow-up exam-
inations and interveiws were done. The recidivism rates among that group of
men, all of whom had previously committed some form of sexual offense, was
less than 3%. When interviewed, many of these men reported an ability to
perform sexually, but they simply did not feel so driven to do so. Although
lowering testosterone by means of removal of the testes did not guarantee that
an individual would not commit a sexual offense, in a number of cases this
procedure seemed to help vulnerable persons refrain from again doing so,
often without causing impotence. An approved use for depo-testosterone is to
increase sexual libido in males whose erotic drive is low because of inadequate
testosterone production.
It is not necessary to perform surgery in order to lower testosterone pro-
duction. Two medications, medroxyprogesterone acetate (Depo-Provera) and
cyproterone acetate (Androcar) can do so, a fact that can easily be documented
in any given individual by means of a simple blood test. Cyproterone acetate,
which is used widely in Canada and Europe in conjunction with the treatment
of paraphilic disorders, has not been approved for human use in the United
States by the Food and Drug Administration.
There seems to be widespread misunderstanding among the public about
the use of psychotropic medications, which have sometimes been referred to as
"mind-altering" drugs. Psychotropic medications are used medically to restore
function (as with antipsychotics), to diminish suffering (as with antidepres-
sants), or to increase the ability to exercise necessary self-control (as with
antiandrogens).
Although all medications produce side effects, those associated with the
use of medroxyprogesterone acetate (MP A) probably pose no greater risk than
do the side effects of other more commonly employed psychotropic medica-
tions, and perhaps more is known about its biological mechanism of action.
The customary starting dosage in treating pedophilia and other paraphilic
disorders is 500 mgs. intramuscularly once per week of the 100 mg per cc
concentration. This dosage should be divided and administered into two sepa-
rate injection sites. MPA should not be used if it seems unnecessary. Converse-
ly, the psychiatrist should not deny the person with a pedophilic sexual orienta-
tion, who recurrently feels driven and tempted to act, the opportunity to try
this form of medical treatment to see whether or not he finds it helpful.
MPA is certainly not curative. For this reason it is ordinarily used in con-
junction with group counseling. Such counseling can provide emotional sup-
port by affording the opportunity to meet others who also find children to be
erotically appealing. It also affords an opportunity to confront self-deceiving
rationalizations. In counseling sessions an attempt is made to identify triggers
and situations that increase the individual's vulnerability and to develop strat-
egies for more successfully resisting unacceptable sexual temptations. Support
groups to assist concerned family members may also be useful, and in cases of
pedophilic incest family counseling and monitoring should be implemented.
The patient needs to understand that he has a life-long vulnerability requiring
continual self-vigilance.
128 FRED S. BERLIN
Homosexual pedophilia (N = 158)

r------------------------------,r---------------------------~ 1000/0
Relapse - Likely recidivism No relapse

18.98% 57.0% (N = 17) 81.02%
(N = 30) (N = 128)
--- Not likely recidivism

43.0% (N = 13)
I I I
Cruising or nonsexual Inappropriate sexual Unknown
31.42% 2.85% 62.84% 2.85%
(N = 10) (N = 19) (N = 1)
I
I I
Expose, solicit; Penetration or unknown
nongenital fondle;
genital fondle 14.0% 20.0%
66.0% (N = 13) (N= 6)
Figure 1. Clinical relapse and recidivism (criminal arrest) data on 158 men with a diagnosis of
homosexual pedophilia treated at Johns Hopkins Sexual Disorders Clinic. Median time at risk
for relapse was approximately 3 years.
When it comes to the issue of treatment, documentation of efficacy is

crucial. Pedophilia, particularly homosexual pedophilia, has traditionally been
considered a disorder very difficult to treat. Figure 1 shows that of 158 homo-
sexual pedophiles treated at The Sexual Disorders Clinic at The Johns Hop-
kins Hospital over the past several years, over 80% were relapse-free. The
median time at risk of relapse for these individuals was approximately 3 years.
Clinically, relapse included behaviors that did not result in arrest and convic-
tion (recidivism). It also included behaviors such as cruising to seek out an
unacceptable sexual partner (such as an adolescent), which did not actually lead
to sexual contact.
Figure 2 summarizes data on 113 homosexual pedophiles in treatment for
at least one year or more. Of note is the fact that clinical relapse rates were low
both for those treated with group counseling plus MPA, and for those treated
with group counseling alone. These two groups differed in that those given
MPA were individuals who reported more of a compulsive component associ-
Homosexual pedophiles in treatment 1 year or more (N = 113)

100°1c
I °
I I
Never on MPA Ever on MPA (e)
N= 38 N = 75
I I
I I I
Relapsed No relapse Relapsed (A) No relapse
N = 8 (22%) N = 30 (78%) N = 19 (25%) N = 56 (75%)
I
I I I
After stopped Starting dose Lower dose
taking (N = 8) (8) (N = 10) (N = 1)
Figure 2. Relapse data on 113 men with a diagnosis of homosexual pedophilia treated at
Johns Hopkins Sexual Disorders Clinic for one year or more either with or without medroxy-
progesterone acetate (MPA). Those administered MPA had reported more compulsive sexual
behavior prior to treatment. Recidivism data (arrests) are not shown. A/C = % of homosexual
pedophiles who have taken medroxyprogesterone acetate (MPA) who relapsed (25%). B/C =
% of homosexual pedophiles who have taken MPA who relapsed on starting dose (500 mg
im/week) (13%).
ated with their pedophilic orientation. Thus, the point here was not to do a
study regarding the efficacy of MP A. Rather the point in presenting these data
here is to document the fact that when afforded access to treatment the over-
whelming majority of these individuals appear to have done well.
THE INSANITY DEFENSE AND OTHER MEDICO-LEGAL AND

MORAL ISSUES
It is comforting to believe that any goal can be achieved simply through the
application of hard work and will power. What is the scientific evidence that
this is so insofar as behaviors related to biologically based drives are concerned?
Wirth and Folstein reported an investigation pertaining to this issue in looking
at a group of patients who required periodic renal dialysis treatments because
of non functioning kidneys. 14 Dialysis causes thirst but patients are directed not
to consume too much fluid between treatment sessions because doing so can
endanger their health. Most of these patients failed in their efforts to restrict
fluid intake, and the investigators reported that the best predictor of the de-
gree to which they failed was the degree of thirst engendered within a given
individual by the dialysis procedure. The more thirst an individual ex peri-
130 FRED S. BERLIN
enced the more difficulty he had in restricting fluid intake, even at the risk of
compromising his own health.
Hunger is another biologically based drive. Although some individuals
clearly do not experience problems related to overeating, many find it ex-
tremely difficult if not, in some cases, impossible to maintain consistent dietary
control. McHugh and others have conducted research that suggests that bio-
logical factors may quite precisely regulate daily caloric intake, which may
explain why some persons experience such difficulty in trying to reduce caloric
consumption. 15 Metaphorically, such persons may indeed be fighting nature.
Like thirst and hunger, the sexual drive is biologically based. Although
some persons seem to experience little difficulty exercising proper self-control
over their sexual behaviors, for others this may not be so easy.16
In some states where there is a volitional and a cognitive component to the
insanity defense, an individual who experiences considerable difficulty exercis-
ing self-control as a consequence of a psychiatric disorder might not be consid-
ered criminally responsible. This matter can be a difficult one for a judge or a
jury to resolve because some persons who could control themselves better may
not make a maximal effort to do so. Others may try their best but fail. This
issue can become even more complicated by virtue of the fact that in the face of
intense desire a person may begin to rationalize, compromising an objective
appreciation of the need to try to resist succumbing to temptation.
In Maryland on more than one occasion either ajudge or ajury has found
a defendant in a sexual offense case involving children not to be criminally
responsible, in part on the basis of that defendant manifesting a paraphilic
disorder. Some have argued that because persons with paraphilic disorders
rarely commit sex offenses in the presence of a police officer, this is prima facia
evidence that they are capable of exercising necessary self-control. In persons
manifesting a paraphilic disorder the presence of a police officer at the time of
a potential sexual offense might engender fear sufficient to deter improper
sexual behavior at that moment, but that fact does not adequately address the
issue of whether or not the individual in question is capable of proper self-
control in the absence of such external constraints.
In analyzing any given behavior one can look at the behavior itself, the
consequences of that behavior, and the mental state of the individual who
engaged in it. It is mental state alone that determines criminal responsibility, a
fact not often appreciated by the public, which tends to assume that knowing
the behavior and the consequences is what really matters. Hence, if Hinkley
shot President Reagan he must be guilty.
If two persons have an argument during which one shoots and kills the
other, the behavior and consequences are obvious. However, ifthe person who
did the shooting was 3 years old, or had the mental age of a 3-year-old, it is
mental state alone that becomes crucial with respect to the issue of criminal
responsibility.
Persons have sex with children because to do so feels good. This is a
statement about mental state, and it is undoubtedly true, especially for the
person with a pedophilic sexual orientation. It is precisely because it does feel
so good that an individual may experience difficulty in not succumbing to such
temptations. Urinating when the bladder is distended also feels good, but to
argue that the person doing so is just having fun is to miss the point. In not
doing so that individual continues to feel increasingly more discomforted, a
fact that may ultimately drive him to behave in a way that will diminish his
distress. A chronically un satiated sexual drive, of necessity frustrated because it
is directed toward children, can for some become similarly discomforting. Re-
gardless of whether or not a person with a paraphilic disorder is considered to
be so driven in his actions as not to be held criminally responsible, clinically
there can be little doubt that such individuals can experience considerable
difficulty in controlling their behavior, and that they may need professional
help.
If persons do not decide voluntarily to be sexually attracted toward chil-
dren, and if it can be difficult for a person who experiences such attractions to
control his behavior, how are these observations, if correct, addressed by the
criminal justice system? Does that system distinguish the pedophile from the
crook, other than through the adversarial process of the insanity defense, and
should it? At the present time in general it does not in a supportive fashion
(e.g., by mandating the availability of treatment). Perhaps it should.
There are some ways in which the law does treat persons differently in a
detrimental fashion if they have become involved sexually with children. In
some states, for example, adults who have become involved sexually with chil-
dren cannot seek psychiatric help without being reported for purposes of
possible criminal prosecution. In the author'sjudgment, such laws can inadver-
tently deter interested persons from appropriately seeking out needed medical
care, and may also violate 5th Amendment rights by virtue of the fact that the
state is compelling the individual to self-incriminate in order to obtain needed
treatment. The author does believe, however, that appropriate notification
should be made in the case of patients attending therapy as a condition of
parole or probation, should they become noncompliant in their responsibility
to avail themselves of such care.
Psychiatry and the law both have an interest in trying to understand
human behavior and in some instances in trying to modify it. The law under-
stands behavior through the application of moral concepts such as good and
evil, and certainly the concepts of moral accountability and responsibility have
validity and need to be preserved. The method used by the law to try to modify
human behavior is punishment. In Maryland 2300 inmates, having been
punished, were released from prison by the Department of Correction in 1980.
By 1983, 3 years later, approximately 40% had been reincarcerated, having
committed another felony and those figures did not even include out of state
arrests, parole violations, or jailable misdemeanors.17
Psychiatry attempts to understand human behavior as the expression of
particular mental and motivational states and tries to understand those states
by looking at the influences exerted by the environment, maturation, and
biology. As knowledge continues to emerge, particularly as advances occur in
the neurosciences, there will be an increasing need to integrate moral concepts
with scientific discoveries and observations. Stating that it is wrong for adults to
engage in sexual activities with children because of the potential for harm is a
132 FRED S. BERLIN
moral judgment. Feeling distressed and concerned about the potential for such
harm to cause lasting damage to children is an understandable human reac-
tion. Transcending those feelings by showing compassion, understanding, and
empathy for those afflicted with sexual orientations directed toward children
requires scientific knowledge regarding the nature of such conditions, and the
moral conviction that helping and caring for others, even for those who pose
some degree of risk to the community, is a proper virtue.
In discussing the matter of the pedophile and the child, the first priest
asked the bishop whether it was important to help the victimizer to which the
bishop responded, "I'm sorry my son, that must not be a priority." The second
priest in discussing the matter of the pedophile and the child asked whether or
not it was important to help both victims, to which the bishop responded, "Of
course my son, of course."
REFERENCES
I. Task Force on Nomenclature and Statistics of the American Psychiatric Association:

Diagnostic and Statistical Manual of Mental Disorders, ed. 2 1978, Ll-L33.
2. Berlin FS, Meinecke CF: Treatment of sex offenders with antiandrogenic medication:
Conceptualization, review of treatment modalities and preliminary findings. Am] of
Psychiatry 1981; 138:601-607.
3. Berlin FS, Krout E: Pedophilia: Diagnostic concepts, treatment and ethical considera-
tions. Am] Forensic Psychiatry 1986; 7(1):13-30.
4. Money J: Love and Love Sickness: The Science of Sex, Gender Difference, and Pair-Bonding.
Baltimore, Johns Hopkins University Press, 1980.
5. Groth AN: Men Who Rape, Plenum Press, New York, 1979.
6. Groth AN: Sexual trauma in the life histories of rapists and child molesters. Victimology:
An International]ournalI979; 4(1):10-16.
7. Money J, Gaskin RJ: Sex reassignment. Int] Psychiatry 1971; 9:249-282.
8. Berlin FS: Issues in the exploration of biological factors contributing to the etiology of the
"sex offender" plus some ethical considerations, in Proceedings of the New York Academy of
Sciences Conference on Human Sexual Aggression, 1988.
9. Goy R, McEwen BS: Sexual Differentiation of the Brain. Cambridge, Mass, MIT Press, 1977.
10. Berlin FS: Sex offenders: A biomedical perspective and status report on biomedical
treatment, in Greer JG, Stuart IR (eds): The Sexual Aggressor: Current Perspectives on Treat-
ment. New York, Van Nostrand Reinhold, 1983, pp 83-123.
II. Abel GG, Becker JV, Cunningham-Rathner J, et al.: The treatment of child molesters: A
manual, unpublished manuscript, Columbia University, 1984.
12. Freund K: Therapeutic sex drive reduction. Acta Psychiatrica Scandinavica 1980; 62 (suppl
287): 1-39.
13. Sturup GK: Castration: The total treatment, in Resnik HPL, Wolfgang ME (eds): Sexual
Behaviors: Social, Clinical and Legal Aspects. Boston, Little Brown, 1972,361-382.
14. WirthJB, Folstein MS: Thirst and weight gain during maintenance hemodialysis. Psycho-
somatics 1982; 3:1125-1134.
15. McHugh PR, Moran TH: Accuracy of the regulation of caloric ingestion in the Rhesus
monkey. Am] Physioll978; 23:R29-R34.
16. Carnes P: Sexual Addiction, Minneapolis, Minn, Compcare Publications, 1983.
17. Recidivism data made available by Maryland Department of Parole and Probation, 1984.
9
Diagnosis and Treatment of
Juvenile Sex Offenders
JUDITH V. BECKER AND RICHARD J. KA VOUSSI
The exact incidence of sexual crimes committed by adolescents is not known.

However available data (victim reports and arrest statistics) indicate that ap-
proximately 20% of all rapes and 30% of all child molestation cases are perpe-
trated by adolescent offenders 1,2
Ageton 3 conducted a survey of male adolescents 13 to 19 years old. In her
sample of 863 adolescent males, the rate of sexual assault per 100,000 adoles-
cents ranged from 5,000 to 16,000. The highest rate was for 17-year-olds.
These statistics indicate that the prevalence of sexual violence in our society by
adolescents is widespread.
Our society has become particularly sensitive to sexual victimization of
children and adults perpetrated by adult offenders. Until recently very little
attention has been paid to the adolescent offender. There are several reasons
for the lack of attention to the adolescent offender:
1. Frequently, adolescent sexual offenses are written off as sexual experi-
mentation. Family members, treatment agents, and the criminal justice system
have difficulty in labeling inappropriate sexual behavior on the part of an
adolescent as a sexually deviant act or as a sexual crime.
2. Adolescents will deny and minimize their deviant sexual acts. This be-
havior may be motivated by shame, guilt, or fear of the consequences they will
sustain if they are forthcoming in discussing their aberrant behavior. Of ado-
lescent sexual offenders evaluated at the Sexual Behavior Clinic (an outpatient
evaluation and treatment center for adolescent sex offenders aged 13 to 18),
JUDITH V. BECKER· New York State Psychiatric Institute and Department of Psychiatry,
College of Physicians and Surgeons, Columbia University, New York, New York
10032. RICHARD J. KAVOUSSI • Mount Sinai School of Medicine, New York, New
York 10029.
133
134 JUDITH V. BECKER AND RICHARD J. KAVOUSSI
only 26.9% admitted to the total extent of the reported sexual crime, 31.3%
denied completely having committed a crime, and 41.8% admitted in part to
the offense. 4
3. Parents will also deny or minimize their son's deviant sexual behavior.
Frequently, the denial and minimization is motivated by the parents' concern
that their son will be taken from the family. In other cases, parents may have
something to hide (for example, sexual or physical abuse within the family) and
do not want their families being scrutinized by the criminal justice system.
Knopp5 discussed differences in evaluating an adolescent sexual offender
and a non-sexually offending adolescent within the mental health system. She
reported that the mental health professionals tended to underestimate the risks
involved in evaluating adolescent sexual offenders, or were pressured by de-
fense attorneys, the offender, or the offender's family to show the offender in a
more favorable psychological state so that serious consequences would not
occur to the offender.
Adolescent sex offenders differ from adult sex offenders in several ways.
First, adolescents do not report the frequency and intensity of deviant sexual
fantasies that adult sex offenders do. Second, compared to adult offenders, the
adolescents have fewer distorted beliefs regarding their deviant behavior.
ETIOLOGY
There has been little success in defining specific etiologic factors that lead
to the development of deviant sexual behavior in adolescents. Studies of pre-
dictors of male delinquency have suggested that inadequate parental supervi-
sion and discipline, parental criminalty, poor academic performance, stealing,
lying, and trauncy are risk factors in the development of delinquent behavior
in general. 6 In adult sex offenders, poor social skills, poor assertive skills, lack
of sexual knowledge, and inappropriate beliefs about sexual behavior have
been postulated to contribute to sexually deviant behavior.7 Although school
and behavior problems, social isolation, poor academic achievement, and a
history of physical or sexual abuse are common in the histories of adolescent
sex offenders,8 it is not clear to what extent these factors determine their
deviant sexual behavior.
Early studies of male juvenile sex offenders suggested that the behavior
was usually experimental in nature and that the problem was usually self-
limiting. 9 However, recent studies have suggested that this is not the case and
that these boys often have serious psychopathology. 10 Other studies have indi-
cated that a high percentage of these boys have prior nondeviant sexual ex peri-
ences,4,8 suggesting that their inappropriate sexual behavior is not a part of
normal adolescence.
Some researchers have suggested that juvenile sex offenders and male
juvenile offenders share many characteristics. Lewis lO compared adolescent
males incarcerated for violent nonsexual acts. She found that both groups had
a high prevalence of psychiatric symptoms-depression, auditory hallucina-
tions, paranoia, and thought disorder and that all of the sexual as saulters had a
DIAGNOSIS AND TREATMENT 135
prior history of violent nonsexual behavior. Both the sexual assaulters and the
violent nonsexual assaulters had a much higher incidence of being sexually or
physically abused or of having witnessed extreme violence than did a group of
less violent, nonsexual offenders. However, it is important to note that these
studies were done with incarcerated juvenile offenders. A large percentage of
boys who engage in sexually inappropriate behavior are not confined or are
confined only for brief periods and are referred for outpatient evaluation. In a
sample of 67 male adolescents referred to an outpatient clinic because of de-
viant sexual behavior, only 10.5% had been arrested for prior sexual crimes
and only 18.4% had a history of prior nonsexual crimes. 4 In addition, approx-
imately one third of these boys had no evidence of conduct disorder. I I
Thus, it is clear that not all juvenile sex offenders are alike, and there are
many reasons why an adolescent would engage in sexually deviant behavior.
Future studies of etiology and prediction will need to focus on different sub-
groups of these boys.
DESCRIPTIONS
As noted earlier, juvenile sex offenders are a heterogenous group and

there appear to be many different antecedents to their behavior:
I. The adolescent sex offender may have a true paraphilia, that is, "recur-
rent intense sexual urges and sexually arousing fantasies" involving young
children (pedophilia), rubbing or touching a nonconsenting person (frott-
eurism), exposing his genitals to a stranger (exhibitionism), or watching an
unsuspecting person undress (voyeurism).12 For example, A., a 16-year-old
boy, presented for evaluation after having been found fondling an 8-year-old
boy. During an interview, he reported that he had been fondled himself by an
older man when he was 8 years old. He revealed that since that time he has had
recurrent sexual fantasies involving young boys and had masturbated to these
fantasies as he had gotten older. He reported having fantasies of boys or girls
his own age or older. He had no history of nonsexual delinquent acts. He was
of normal intelligence, and had no evidence of psychosis or other psychiatric
disturbance.
2. An adolescent may engage in deviant sexual behavior as part of an
overall pattern of antisocial behavior or conduct disorder. For example, B., a
IS-year-old boy, was referred for evaluation for raping an adult woman. At the
interview, he revealed that on the night of the offense, he and three other boys
his age decided to rob a woman whose car had broken down. He reported that
after robbing her money, they decided to rape her. He denied previous or
current fantasies of rape and had a history of non deviant sexual experiences.
He had a history of other delinquent acts and showed little remorse for his
sexual crime. He was of normal intelligence, and had no evidence of psychosis
or other psychiatric disturbance.
3. An adolescent who is mentally retarded may engage in inappropriate
sexual behavior because of his impaired cognitive capabilities. For example, C.,
a 14-year-old boy who was mildly mentally retarded, was referred for evalua-
tion after having been involved with an 8-year-old girl who lived near his home.
He reported that he had been playing with her in the park and had tried to put
his penis into her because he had seen his parents doing the same to each other.
He had no history of delinquent behavior, and no evidence of psychosis or
other psychiatric disorder.
4. Adolescents who have impaired impulse control because of psychiatric
disorders may commit a sexual offense. For example, D., a 15-year-old boy, was
evaluated after having exposed himself to a group of girls in school. His school
records and family gave a history of recurrent impulsive behavior since he was
a young child. The boy had been diagnosed as having attention deficit disorder
and had been treated with methylphenidate when he was younger but he had
been off medicine for several years. He denied any deviant fantasies and had
no history of delinquent acts. Other disorders, such as psychosis or substance
abuse, could also contribute to inappropriate sexual behavior.
5. Adolescents who are socially isolated because of social anxiety or poor
social skills may have sexual contact with young children because they have
little contact with their peers. For example, E., a 14-year-old boy, was evaluated
after having fondled a 7-year-old girls. At the initial interview, he reported
having no friends his own age. He revealed that he only played with young
children in the neighborhood because he did not feel comfortable with boys
and girls his own age. He reported that he had been having sexual fantasies of
adult women and had acted on these with the young girl. He had no history of
delinquent behavior and no evidence of impaired intelligence or psychiatric
disorder.
The previous groups are not all inclusive and there are other factors that
are involved in adolescent sex offenses (e.g., unresolved homosexual feelings,
poor anger control). There are also other classification schemes postulated for
these boys. Saunders13 divided juvenile sex offenders into three groups: those
involved with nonphysical contact (e.g., exhibitionism, voyeurism, obscene
phone callers, etc.); those who sexually assaulted victims their own age; and
those who sexually molested a child. However, we must be cautious in classify-
ing adolescent sex offenders in anyone category based on target or type of
behavior. With adult offenders, we know that the individuals who commit one
type of sex offense often have fantasies or have engaged in behaviors of an-
other type. For example, AbeF found that 50% of their sample of 321 adult sex
offenders had multiple sexual deviations.
Whatever scheme is used, future studies must look at differences in these
groups with regard to etiology, prediction of recividism, and response to treat-
ment interventions.
ASSESSMENT
The evaluation of adolescents who have engaged in sexually inappropriate

behavior is often a difficult task. They usually present for evaluation having
been either mandated by the courts to do so or under pressure from their
families. They often deny or minimize their sexual offense. For example, the
boy may blame his behavior on alcohol. He may accuse the victim of lying or
blame the victim for initiating the sexual contact. If other boys were involved,
he may report that he was only a bystander at the offense.
Of immediate concern in the evaluation of the adolescent sexual offender
is the difficult judgment as to whether the offender should be placed away
from the community (such as in a secure juvenile detention center or a psychi-
atric hospital) or should receive community-based evaluation and treatment.
This judgment must be based on a careful evaluation by the clinician of the
adolescent's current and past level of impulse control and aggressivity. For
example, sexual offenses that involve a high degree of aggressivity or violence
toward the victim should be evaluated in secure settings. A history of nonsexual
aggressive acts or a prior history of violence also should alert the clinician to
recommend evaluation in a residential setting. If there is evidence of a psychi-
atric disorder, such as psychosis or attention deficit disorder, psychiatric hospi-
talization is usually indicated. Smith and Monastersky14 examined selected
reoffense predictor variables but found few that were reliably associated with
reoffense status (e.g., understanding the exploitative nature of the sexual of-
fense, ability to identify personal strengths, and having the belief that all sexual
behavior was to be avoided). Unfortunately, as with other clinical predictions
(such as of dangerousness or suicidality), they found that global judgments of
risk were not reliable in identifying sexual reoffenders.
The issue of confidentiality when assessing juvenile sex offenders must be
addressed. With adult sex offender parolees, Kaplan 15 demonstrated that the
offenders do not reveal the extent of their deviant act even when they are
promised confidentiality in a secure setting. Abel, Mittleman, and Becker4
reported that 49% of the adult sex offenders they evaluated failed to disclose
the full nature of their inappropriate sexual behavior. Approximately 30% of
adolescent sex offenders referred to an outpatient evaluation program totally
deny their offense (Becker, 1986). Thus, the clinician must use all available
information in assessing the adolescent offender-court records, victim state-
ments, prior psychiatric records, and psychological testing. Interviews with the
offender's family are also imperative; however, there may be a great deal of
denial on the part of the family. For example, a I3-year-old boy was evaluated
for having forced a 7-year-old girl to perform oral sex with him. His father felt
that too much had been made of the incident and that "the girl was very
sexual ... she seduced him." Based on the previously cited issues, the assess-
ment of the adolescent sex offender should include:
1. A careful clinical evaluation of the offender's sexual behavior and fan-
tasies, both consensual and deviant. The exact nature of the sexual offense and
the details of the adolescent's behavior and thoughts during the offense need
to be explored. Prior sexual experiences should be discussed. The clinician
should inquire about fantasies used during masturbation. Each boy should be
specifically asked about being sexually or physically abused. Finally, the inter-
view should include an exploration of the adolescent's sexual orientation and
fears of homosexual feelings.
138 JUDITH V. BECKER AND RICHARDJ. KAVOUSSI
2. A detailed psychiatric evaluation. The offender should be assessed for

intelligence and cognitive ability. The clinician must be alert for signs of psychi-
atric disorders such as psychosis, depression, and attention deficit disorder.
Each boy should be asked about alcohol and substance use during the offense
as well as at other times.
3. An assessment of the offender's family. It is important to assess any
factors in the family that might have led to the sexual offense. Has the boy
witnessed extreme violence or sexual abuse in the family? Are there absent or
inadequate male role models for the boy? Is there open discussion of sexual
behavior in the family? Finally, is the family aware of the exact nature of the
sexual offense?
4. Assessment of nonsexual aspects of the offender's life. The clinician
should evaluate the boy's sexual knowledge, peer relations, social skills, assert-
ive skills, empathy, and ability to deal with anger. Sexual offenders often have
faulty beliefs about sexual behavior (e.g., "she wanted to be raped because she
was wearing a short skirt" or "You can't hurt a little boy just by playing with his
penis"). These must be assessed and recorded for use during treatment.
5. Other sources of information. The offender's school performance and
behavior should be assessed. Prior psychiatric evaluations or psychological test-
ing should be reviewed. In view of their frequent denial, court records, police
reports, and victim statements can all give valuable information in the assess-
ment of the adolescent sex offender.
It is clear that many sex offenders do not give a reliable report of their
deviant arousal and behavior. 7 In adult sex offenders, measurements of penile
erection have been used to assess sexual arousal in response to audio and visual
stimili in the laboratory. A transducer (either a thin metal ring or a mercury-in-
rubber strain gauge) is placed around the individual's penis and the degree of
erection is recorded while he is exposed to various sexual stimili (audio-tapes,
slides, videotapes) depicting appropriate and deviant sexual scenes. This infor-
mation is then recorded on a polygraph or computer and the degree of arousal
to deviant sexual scenes is compared to arousal to consensual sexual scenes. In
adults, this testing has been shown to discriminate heterosexual arousal from
fetishism, transvetism, exhibitionism, and pedophilia. 16 The role of this testing
in adolescent sex offenders is not clear at present. We studied erectile response
to audiotaped verbal descriptions of sexual scenes in a sample of 31 outpatient
adolescents who had been sexually involved with young boys. Those with high-
er numbers of victims were found to have higher arousal to sexual scenes
involving young boys. This suggests that this testing is of most value in boys
who have a pattern of repeated deviant behavior and of less value in boys who
are presenting with their initial sexual offense. However, future research is
needed to validate this testing in this population.
TREATMENT
Various treatment modalities have been advocated for use with adult sex
offenders. Biologic treatments have focused on blocking or decreasing levels of
circulating andorgens, thus decreasing sexual arousal. Although surgical cas-

tration has been used in Europe with incarcerated adult offenders, the lack of
demonstrated efficacy and the serious legal and ethical questions raised by this
procedure do not warrant its use at this time.
Antiandrogenic medications have been widely used throughout the world
to treat adult sex offenders.17 The most widely studied of these are the pro-
gestin derivatives medroxyprogesterone acetate and cyproterone acetate (the
latter is not available in the United States). These medications act by blocking
testosterone synthesis (cyproterone acetate also blocks androgen receptors),
leading to a decrease in circulating levels of testosterone and a concimitant
decrease in sexual arousal. Although these medications have a role in the
treatment of adult sex offenders, they are not indicated in the treatment of
adolescent offenders due to the potential damage these medications may have
on an adolescent boy's developing hypothalmic-pituitary axis. In addition,
these medications have significant long-term side effects: weight gain, in-
creased blood pressure, impaired glucose tolerance, and gall bladder disease. 18
Antipsychotic medications such as chlorpromazine, thioridazine, and de-
pot fluphenazine decanoate have also been used to treat deviant sexual behav-
ior. Unfortunately, there have been no controlled studies of their effectiveness.
These medications may be most useful in offenders with psychosis, borderline
or schizotypal personalities, or mental retardation. Medications such as lithium,
proprandol, carbomazepine, and donazepam, which have been used to treat
nonsexual aggressive behavior, may have a role in the treatment of sexually
aggressive behavior in adolescents.
A variety of behavior therapies have also been used to treat adult sex
offenders. Covert sensitization is a technique in which the offender pairs his
inappropriate sexual thoughts with aversive, anxiety-provoking scenes under
the guidance of a therapist. Satiation is a technique in which the offender uses
his deviant fantasies in a repetitive manner to the point of satiating himself with
the deviant stimili, making the fantasies and behavior boring. The use of these
techniques in adolescent offenders is discussed later.
Other treatments, such as family therapy for incest offenders I9 and psy-
chodynamic psychotherapy, have also been used with adult and adolescent
offenders. Knopp20 compred juvenile and adult programs and found: (a) a
larger percentage of adult programs are located in prison (70% versus 33%),
(b) more juvenile than adult programs are community based, and (c) family
therapy is widely used with juvenile offenders compared to adults.
Lacking in the literature are controlled outcome studies to evaluate the
effectiveness of treatment programs for adult and adolescent sexual offenders.
The ideal treatment program will combine various modalities with emphasis on
certain areas of treatment based upon the needs of the offender. The following
is an example of a community-based, multicomponent treatment program for
adolescent sexual offenders.
Cognitive Behavioral Treatment Model

The Sexual Behavior Clinic at the New York State Psychiatric Institute
provides outpatient treatment to adolescents between the ages of 13 to 18 who
have committed sexual crimes. The majority of adolescents seen at the clinic
are referred by the criminal justice system. The treatment program is a modifi-
cation of a program for adult offenders.21 Preliminary data on the effective-
ness of the program with an adolescent population is described elsewhere. 22
In working with adolescent offenders, it is critical to gain parental support.
The parents are instrumental in seeing that their sons attend therapy sessions
and comply with therapeutic recommendations. As noted earlier, parents
sometimes deny that their son has a problem, or attempt to minimize the
severity of the problem. Thus, a first step in treating the adolescent is to insure
that the parents know the nature of the sexual crime, and encourage their son
to receive treatment. The adolescent may refuse to inform his parents of the
exact nature of the crime he committed. In that case, the therapist should
assess his concerns about disclosing his crime to his parents. Frequently, the
adolescent is fearful that he will be asked to leave the home or experience other
forms of punishment. The therapist should explain to the parent that the
adolescent has certain concerns about disclosing important information to the
parent in an attempt to secure from the parent an agreement that the adoles-
cent's concerns will not be realized.
If the adolescent continues to refuse to disclose his behavior to his par-
ent(s), the victim's report of the crime should be read to the parent. If the
parent attempts to discredit the victim's statement, the therapist should inform
the parent that although it is understandable that the parent would have diffi-
culty believing their child has a sexual problem, denial and minimization are
not helpful to their son.
The first component of the treatment program utilizes satiation, the be-
havioral technique first described by Marshall,23 discussed earlier. Satiation
teaches the offender how to use deviant thoughts in a repetitive manner to the
point of satiating himself to the very stimili that he may have used to become
aroused. The therapist provides the adolescent with a phrase to satiate (based
on the offender's fantasies or behavior). While repeating the deviant phrase,
the adolescent is required to look at a slide depicting a deviant target. Each
adolescent is required to complete eight, 30-minute sessions of verbal satiation.
One session is done per week. The adolescent is seated in a sound attenuated
room. He then places a mercury-in-rubber strain guage on his penis to monitor
his arousal during the treatment session. The therapist is seated in an adjacent
room. The rooms are connected by an intercom. A nondeviant slide (e.g.,
picture of an adolescent) is projected onto a screen, which is located six feet
from the adolescent.
The therapist instructs the adolescent to look at the slide and imagine
himself being with the person on the slide. After a 2-minute period, the slide is
terminated and the adolescent's erection is allowed to return to baseline (this
takes anywhere from one to three minutes).
A deviant slide that consists of one of the following categories, (a) rape of a
peer, (b) nude prepubescent female, (c) nude prepubescent male, is then pro-
jected. The adolescent is then instructed to repeat a deviant phrase over and
over for 20 minutes. The phrases are highly sexually suggestive but not
obscene. For example, "I am getting into bed with this child (or girl)." The
therapist listens to the session in its entirety to insure compliance. At the com-
pletion of the eight satiation sessions, the adolescent is given feedback on his
erectile responses.
The remainder of treatment is provided in group format. Groups should
be run by male and female cotherapists and limited to eight adolescents. Dur-
ing an orientation session, the goals of the group are stated: teaching the
offender not to engage in further deviant sexual behavior and learning how to
relate to peers in an appropriate manner. Cognitive restructuring is the first
component of group treatment and consists of a 75-minute group session held
weekly. The adolescent is confronted with his rationalizations about why it was
alright for him to engage in deviant sexual behavior. Most adolescent sex
offenders know that the deviant behavior that they have engaged in is a vio-
lation of the laws and ethics of our society; however, each one has in essence
given himself permission to override societal prohibitions. These permission-
giving statements, if left unconfronted, will keep the adolescent at risk for
committing sexual crimes. Such cognitive distortions are confronted by the
method of role playing. Each adolescent is assigned a role to play. One will play
the part of the victim, another the victim's family member, a third an offender's
family member, a fourth a judge, etc. The adolescents are then required to
challenge the inappropriate beliefs presented by the therapists. Those adoles-
cents in the group who have experienced sexual victimization themselves as
children are asked to share what the experience was like for them.
Covert sensitization constitutes the next component of treatment. Covert
sensitization, as noted earlier, is a therapeutic technique used to disrupt the
behaviors that are antecedent to the offender's coming into contact with his
victim. Each adolescent is asked to identify the precursors (risk factors) toward
committing a sexual crime. He is then asked to list the consequences to himself
and the victim for having engaged in the deviant behavior. The adolescent
then verbalizes on audio tapes the various feelings or behaviors that led him to
commit the sexual crime. He then associates the negative consequences (aver-
sive images) with the precursor. The adolescents are required to complete eight
I5-minute covert sensitization tapes over a 4-week period.
The next treatment component consists of social skills training. Through
discussion and role playing the adolescent learns the requisite skills to relate in
a functional manner to peers. Adolescents often find themselves in social situa-
tions in which they have difficulty knowing how to respond. Each boy indicates
on an index card specific social situations that he would find difficult to deal
with: "I meet a girl in a pizza parlor, how do I know if she likes me?"; "I am out
on a date with a girl, how do I know if she wants to have sex with me?" The
therapist then collects the cards, presents the situation and assists the adoles-
cents in finding solutions to those situations.
Many adolescent sex offenders use physical or verbal aggression as a means
of problem solving. Consequently, the next component of therapy focuses on
anger control. Adolescents are taught means of problem solving through role
playing. This treatment component consists of four 75-minute sessions.
142 JUDITH V. BECKER AND RICHARDJ. KAVOUSSI
The following represent examples of the types of situations that an of-

fender may have difficulty with: "I am out with my girlfriend, a guy picks a
fight with me; I do not want to fight, but I am afraid what my girlfriend might
think if I don't."; "My teacher blamed me in front of the class for something I
did not do. I know who did it, but I would look bad if I told, and the boy who
did it won't speak up."
The next component of therapy consists of four sessions (75 minutes each)
related to sex education. Session 1 focuses on sexual myths and also pubertal
development. Session 2 is a brief course in anatomy and physiology. In Session
3, responsible sexual practices are discussed including birth control and sexu-
ally transmitted diseases. Session 4 is on sexual communication.
The last component of treatment consists of two 75-minute sessions
focused on relapse prevention, in which the offender is taught to identify and
cope with situations that might serve to threaten his control. At the end of this
portion of treatment, the adolescents are reevaluated and those who are in
need of further treatment (e.g., family therapy, individual therapy, medica-
tion) are given appropriate referrals.
Preliminary data indicates that this treatment program is effective as mea-
sured by self-report, penile plethysmography, and recividism rate. However,
controlled outcome studies need to be designed to investigate which compo-
nents of therapy are effective given the specific characteristics of an adolescent
offender.
CONCLUSION
The evaluation and treatment of adolescent sexual offenders are at early

stages of development. Future research should focus on factors predisposing
adolescents to commit sexual crimes and in some cases to develop paraphilias.
Long-term follow-up studies are needed to determine those factors which are
predictive of recividism and those which lead to maintainance of treatment
gams.
REFERENCES
1. Brown Fj, Flanagan Tj, McLead M: Sourcebook of Crimirw,l justice Statistics. U.S. Depart-
ment of justice, Washington, DC, 1984.
2. Deisher RW, Wenet GA, Paperny DM et al: Adolescent sexual offense behavior: The role
of the physician. journal of Adolescent Health Care, 279-286, 1982.
3. Ageton S: Sexual Assault among Adolescents. Lexington, Mass, Lexington Books, 1983.
4. Becker jV, Rathner jC, Kaplan MS: Adolescent sexual offenders: Demographics, crimi-
nal and sexual histories, and recommendations for reducing future offenses. journal of
Interpersonal Violence 1:431-445, 1987.
5. Knopp F: Recent developments in the treatment of adolescent sex offenders, in Otey EM,
Ryan GD: Adolescent Sex Offenders: Issues in Research and Treatment. Department of Health
and Human Services Publication, NO (ADM), 85-1396, 1985.
6. Loeber R, Dishion T: Early predictors of male delinquency: A review. Psychol Bull 94:68-
99, 1983.
7. Abel GG, Mittleman MS, Becker JV: Sexual offenders: Results of assessment and recom-
mendations for treatment, in Ben-Aron H, Hucker S, Webster C (eds): Clinical Crimi-
nology. Toronto, M & M Graphics, 1985. pp 191-205.
8. Febrenbach PA, Smith W, Monastersky C, Deisher, RW: Adolescent sexual offenders:
Offender and offense characteristics. Am J Orthopsychiatry 56:225-233, 1986.
9. Atcheson JD, Williams DC: A study of juvenile sex offenders. Am J Psychiatry III :366-
370, 1954.
10. Lewis DO, Shanok SS, Pincus JH: Juvenile male sexual assaulters: Psychiatric, neu-
rological, psychoeducational, and abuse factors, in Lewis, DO (ed): Vulnerabilities to Delin-
quency. New York, Spectrum Publications, 1981, pp 89-105.
11. Kavoussi RJ, Becker JV, Kaplan MS: Psychiatric diagnoses in juvenile sex offenders.
Presented at American Psychiatric Association Annual Meeting, May 1987.
12. American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, ed 3,
revised. Washington, DC, Author, 1987.
13. Saunders E, Awad GA, White G: Male adolescent sexual offenders: The offender and the
offense. Can J Psychiatry 31 :542-549, 1986.
14. Smith WR, Monastersky C: Assessing juvenile sexual offenders' risk for reoffending.
Criminal Justice and Behavior 13: 115-140, 1986.
15. Kaplan M: The impact of parolee'S perceptions of confidentiality on the reporting of
their urges to interact sexually with children. Doctoral Dissertation, New York University,
1985.
16. Earls CE: Some issues in the assessment of sexual deviance. IntJ Law Psychiatry 6:431-
441, 1983.
17. Berlin FS, Meinecke C: Treatment of sex offenders with antiandrogenic medication:
Conceptualization, review of treatment modalities, and preliminary findings. Am J Psychi-
atry 138: 601-607, 1981.
18. Meyer WJ et al: Physical, metabolic, and hormonal effects on man of long term therapy
with medroxyprogesterone acetate. Fertil Steril43: 102-109, 1985.
19. Giarretto H, Giarretto A, Sgroi S: Coordinated community treatment of incest. In Bur-
gess A, Groth A, Holmstrom L, Sgroi S (eds): Sexual Assault of Children and Adolescents.
Lexington, Mass, Lexington Books, 1978.
20. Knopp F: Report on Nationwide Survey ofJuvenile and Adult Sex Offender Treatment Programs
and Providers. New York, Safer Society Press, 1986.
21. Abel GG, Becker JV, Rathner JC, Rouleau J, Kaplan M, Reich J: The Treatment of Child
Molesters: A Manual. Unpublished manuscript, 1984.
22. Becker JV, Kaplan M, Kavoussi ~: Measuring the effectiveness of treatment for the
aggressive adolescent sexual offender. Ann NY Acad Sci 528: 236-247, 1988.
23. Marshall WL: The modification of sexual fantasies: A combined treatment approach to
the reduction of deviant sexual behavior. Behav Res Ther 11 :557 -564, 1979.
10
The United States Age-of-
Consent Laws Governing the
Sexual Conduct of Minors
A Rationale for National Uniformity; an Overview of the
Present Law; a Proposal for Reform
JUDIANNE DENSEN-GERBER AND JOHN R. DUGAN, JR.
In 1974, the primary author in conjunction with Jean Benward, the then
Director of Research for Odyssey House, Inc. of New York, prepared and
presented a paper at the annual February meeting of The American Academy
of Forensic Sciences entitled "Incest, a Dynamic Factor in the Production of
Antisocial and Drug Taking Behaviors of Females." On a specific day in 1973,
that study had surveyed 100 females being treated by the Odyssey system who
had been previously residents of 26 jurisdictions. Over 38% had experienced
some type of sexual trauma during childhood: most of it severe in nature,
repetitive, lasting over several years, and involving a known person, often a
custodial guardian, parent, or equivalent. These females discussing their child-
hood, almost to a person, reported feelings of lessened self-worth and esteem,
a sense of helplessness and shame, social isolation, condoning or unavailable
female role models, a lack of a sense of the ability to control or design their own
destinies, and a myriad of like traits, which most of us in forensic psychiatry
associate with the antisocial, drug-taking female. Only too often, such a female
is a premature parent, frequently abusive and neglectful, who passes on to her
child pre morbid characteristics that we anticipate will yield juvenile delinquen-
cy, crime, drug taking, and other antisocial behaviors. Sadly, it is currently
these females who are bearing AIDS-infected babies.
Prior to our paper, Ms. Benward had found only one other in the psychi-
JUDIANNE DENSEN-GERBER • Odyssey Institute Corporation of Connecticut, 817 Fair-

field Avenue, Bridgeport, Connecticut 06604. JOHN R. DUGAN,JR.• Research Foun-
dation of the City University of New York, 79 Fifth Avenue, New York, New York 10003.
145
146 JUDIANNE DENSEN·GERBER AND JOHN R. DUGAN, JR.
atric literature, a study from northern Ireland which showed a concordance of

4% between early childhood sexual trauma and schizophrenia in hospitalized
female patients.
Similar surveys were undertaken in subsequent years by other noted re-
searchers such as Finklehor, Kempe, Gill, Strauss, et al. Their findings had
incidence studies of between 38% and 50%. These studies were conducted in a
variety of populations: in- and outpatients; incarcerated persons; those in drug
treatment programs; juvenile placement settings; and in the general popula-
tion. In 1975, Odyssey itself repeated the work with another group of females
reporting out a 44% incidence, but in addition, Odyssey separately surveyed a
group of males that revealed an incidence of 25%. Odyssey's population was all
dysfunctional in the workplace; had on the average at least 5 years of intra-
venous drug taking (primarily opiates); had been arrested and incarcerated;
and were now in a residential drug treatment program. To be included, the
patients themselves had to describe the sexual activity as coerced and
traumatic.
In a like setting in 1980, Odyssey Australia duplicated the study in Mel-
bourne, Victoria. The female incidence was 86% with that in males equalling
50%. It is not our conclusion that there is more child sexual abuse in Australia,
but rather that there had to be greater trauma to an individual in that nation
(as at that time drugs were less available than in the States) for a person to seek
drugs to deaden the pain caused by traumatic memories. Many persons report-
ing in the United States and in Australia told of violations by more than one
perpetrator and over half reported being involved in sex for sale activities
starting at 11 and 12 years of age. Indeed, one girl from Idaho experienced
sexuality working in a brothel beside her mother before she (the patient) was 6.
The average age of the initial onset within the family was before 10 years of
age, peaking at around 6 to 8 (for girls and 8 to 10 for boys). Many of the more
severe brutal activities, particularly instrumentation, lead the child to develop
disassociative defense mechanisms; consequently, multiple personality disorder
was diagnosed frequently in our patient population. These findings are well
supported by those of David Finkelhor (1982) in his excellent study of juniors
in five New England colleges in which the incidence was 19.6% for females and
8.9% for males. Again, Finkelhor's figures can only be considered to be the
most conservative estimate, as he had screened in: (a) for persons who were
able to function on higher levels than the general population, that is,juniors in
college; (b) for persons who self-selected and were willing to participate in the
study; and (c) for persons who described the sexual activity forced upon them
as children as still unresolved and traumatic.
In addition, in the ensuing years since our 1974 initial paper, the media,
the academic world, and the general population have come to a clear awareness
of the rampant nature not only of child sexual abuse, child pornography, and
prostitution, but also that it affects all levels of the socioeconomic population. It
is now generally accepted that such early activity will mar and harm every child
involved to some extent, but does in a great preponderance of cases leave
psychic scars and injuries that lead to feelings of being different, cynicism,
hostility, and generalized antisocial behaviors. Therefore, the authors accept as
AGE-OF-CONSENT LAWS 147
a given that the majority of the readers believe, as we do, that it is in the best
interests of our children and our society to protect to the greatest extent possi-
ble such activities from occurring through massive education programs in-
creasing public awareness, early detection and treatment interventions, and
legislative reform to provide strict sanctions when adults transgress against
minors, especially when such children are in the perpetrating adult's custody.
Indeed, a clear mandate was given to all Americans by Mr. Justice Byron
White writing in New York v Ferber (458 U.S. 747, 102 S. Ct. 3348 [1982]), a
child pornography case, that First Amendment guarantees did not extend to
protect child pornographers, as children were "a sacred trust" and, therefore,
the adult society is in the position of a fiduciary toward these minors and must
act to protect them accordingly. The authors of this chapter concur completely
and never cease to be amazed when confronted by officers and members of
societies such as the North American Man/Boy Love Association (NAMBLA)
who appear in various media presentations to articulate their position that the
earlier a child is sexualized by adults, the healthier his/her future sexual life
will be. There is nothing in the scientific or psychoanalytic literature that in any
way supports such a conclusion. At this late date, this debate seems pointless,
after we have had almost 15 years of awareness of the high incidence of child-
hood sexual trauma and the later psychiatric disturbance in adult survivors. It
was obvious to us that one prong of the attack to protect our children and to
enable them to grow up healthy and enter the American mainstream is to
lessen the number of childhood sexual victims.
As noted before, one of the ways to do so is through legislation against and
appropriate sanction for sexual activities involving children and adults. There-
fore, in 1981, the Law and Medicine Division of Odyssey Institute, a charitable
corporation whose purpose is to develop and recommend policies in the best
interests of children, began a review of the existing legislation involving sexual
activities with the children in the 50 states, the District of Columbia, and Puerto
Rico. Odyssey has a well-respected reputation in the field of protective legisla-
tion involving children. In 1973-1974, Congressman Peter Peyser (R/New
York) introduced legislation, subsequently passed, which created the National
Center on Child Abuse and Neglect (NCCAN) at Odyssey's initiation and upon
the presentation to Congress of the full range and extent of physical child
abuse. In 1977, Congressman Dale Kildee (D/Michigan) did the same with the
Protection of Children Against Sexual Exploitation Act of 1977 (P.L. 85-225),
after Odyssey's campaign to make the general public aware of such noxious
materials. Odyssey subsequently consulted with 38 legislatures on state protec-
tive statutes. Institute staff members throughout the United States, Australia,
and New Zealand have lectured and written extensively not only on the prob-
lems of child pornography, early sexualization, and trauma, but also on child
prostitution, the runaway, the throwaway child problem whose numbers are
conservatively estimated by government sources to be well over one million
children, etc. Odyssey assisted not only the Parliament of the United Kingdom
to strengthen its laws but also that of The Netherlands, a country known for its
leniency and tolerance. Antipornography legislation, albeit with minor sanc-
tions, at least now exists in the latter European nation.
148 JUDIANNE DENSEN-GERBER AND JOHN R. DUGAN, JR.
However, Odyssey's role was not only in "the underground dark world of
antisocial behavior"; we spoke out against the inappropriate use of children
and their betrayal in both senses of the word in commercial television, general
advertising, and Hollywood films such as Pretty Baby and Blue Lagoon. In 1981,
the Sunday New York Times Magazine section had an article asking the question:
"Is Childhood Necessary?" implying, as many had already begun to, that child-
hood and in particular childhood innocence are products of the Industrial
Revolution and in reality are not necessary components for healthy develop-
ment into well-functioning adults. Indeed, the "adultomorphication" of Amer-
ica's children has come into full force as their ability to influence parental
buying habits (consumerism) was appreciated by marketeers. The New York
Times did not reach a conclusion, but Dr. Samuel Janus (1983) in his book,
Death of Innocence, had formed a definite position that children are not being
left alone, free from adult sexual aggression and exploitation and that as a
result, great harm is presently occurring to them which in turn will be passed
on to the next generation, with each subsequent group showing greater and
greater dysfunction. It is with this latter viewpoint that the present authors
agree, and that our combined experience with patients and clients confirms.
Odyssey also has had the unique experience of writing for the Federal
Government (NCCAN) the pamphlet, Drug-Related Child Abuse and Child-Abuse
Related Drug Taking (1976). In undertaking this task, it was essential to define
parenting. Parenting, in order to rear a healthy child, must embody three
essential elements. First, a minimum amount of love and security is necessary!
No one objects to a maximum amount, but without a minimum provided from
birth to age 5 (Freud pointed to this fact in his early work in the 1900s), the
child is unable to make subject-to-subject relationships but only subject-to-
object or object-to-object ones and, therefore, at best falls within the personality
disorders, such as the antisocial or borderline types as defined in DSM-III.
Diagnoses of borderline personality types have risen dramatically in almost all
treatment centers throughout the country. This was easily predictable in the
sixties-the flower children's lack of structure and value clarification could be
anticipated to produce in their children empty, vague, unattached, borderline
pathology. One must love and care for one's child first, not simply the whole
world equally without mutual responsibility and expectation. Demands on self
and others are necessary developmental elements to maturity.
The second essential factor in parenting is the ability to negotiate the
system on behalf of the child. Not only has the system become more complex
but fewer and fewer services are now being provided with literally thousands of
children homeless, with more than a quarter living below the poverty level and
with half in single-parent homes. Single parenthood, by its very definition,
implies an impediment to negotiating the system. There is double the work
with usually half the resources.
The third essential element is that parents be appropriate role models for
their children. In reality, childhood is an apprenticeship for living. The exam-
ples that adults set for children are the patterns that children accept as normal
behavior; if they later learn that they have been abused, exploited, or betrayed,
the results are more than likely to be moderate to severe psychopathology.

In light of these factors and experience, Odyssey decided that the various
state laws governing sexual activities with children by adults should be analyzed
as to consistency from state to state. It makes no sense to the authors that
children should be better protected in one state than another but rather that
there should be a national standard of conduct with similar enforcement stan-
dards. Children, particularly runaways, cross state lines; it can only result in
confusion to children and in an appearance of hypocrisy that Connecticut, for
example, should have one of the strictest standards of behavior in the United
States, but its contiguous state, New York, be one of the most lenient.
Connecticut protects children to the fullest extent possible until age 18,
whereas New York permits valid consent to certain sexual conduct by children
as young as age 11. Indeed, New York and Arkansas have the youngest ages of
consent. This is particularly harmful, as 75% of America's children live within
seven states, New York being one of them. The others are Texas, California,
Pennsylvania, Ohio, Illinois, and Massachusetts. Therefore, if model legislation
were in place in these seven jurisdictions, three quarters of our nation's chil-
dren would be safeguarded.
What we have witnessed as a nation when drinking-age laws were not in
conformity is many times magnified in the area of sexual mores. Where chil-
dren are concerned, there should be an articulation of a national standard of
protection and morality. This has become even more important in view of the
epidemic of AIDS. Many perpetrators are in AIDS high-risk groups. If AIDS
becomes a m~or adolescent disease because of the lack of consequential think-
ing and maturity in this age group (i.e., teenage pregnancy, lack of use of
condom, or practice of safe sex), the spread will be more rapid than in adults
and the death toll will strike even younger persons. Already, it is common for
underage teen mothers to have AIDS babies. Children and adolescents must be
afforded the same protections and sexual standards regardless of the state they
live in or travel to and there must be the same sanctions imposed throughout
the country on the commercialization of youngsters.
Second, in view of the changing concepts toward males and females, and
because both sexes can be equally victimized and traumatized, it has been
decided to insure that boys and girls are similarly protected. There was and is
no rationale for protecting our daughters more than our sons; nor one body
part more than another, other than the traditional incorrect view that sex is
something that a male does to a female. Indeed, we became quite confused as
we realized that some states placed higher penalties if the offense violated the
mouth and/or the anus than the vagina; but in others, vaginal penetration
incurred the most wrath and punitive vengeance. Medical evidence correlates
the degree of damage with other factors, such as the longer time the violation
lasts the worse the residual trauma or the closer the relationship between the
child and the perpetrator (particularly if the perpetrator is in an authority
position). Damage is magnified if a body part (any body part-the inner ter-
ritory or self) is penetrated, and if violence or other active coercion and/or
threat are used. Threats can be direct (to the child) or to a loved one (such as
the mother or another sibling) or to the integrity of the family as a whole.

Sadly, the latter often comes to pass in intrafamilial rape (incest) when law
enforcement authorities step in to protect the child by either removing the
victim or the perpetrator from the home. Fortunately, it is in this area as well as
in the evidentiary one that the past 5 years have seen the most innovation and
attention.
Last, the reviewers looked at the states' codes as to time the legislation was
enacted, the medical and legal knowledge gained since passage, and the
changes that have occurred in society as a whole. With this in mind, we re-
viewed the statutes with the idea of modernizing them and creating a model
code to protect all America's children uniformly. The next section will discuss
the present state of the laws throughout the country. A following section will
provide an introduction to the proposed model code on age of consent, where-
as the model code itself is presented as an appendix to the chapter.
Before beginning the review of the present state of the legislation through-
out the country, a summary of general psychiatric principles that influenced
our thinking and that should be kept in mind when evaluating the present
efficacy of the law is in order.
First, the marked differences between the states create confusion, increase
skepticism, and cause cynical reaction formation, particularly in the adolescent
who is prone to such and in potential perpetrators who have a need to justify
and rationalize their behavior. Inconsistency encourages pathology!
Second, with the lessening of the differentiation in responsibility and con-
sequential thinking between male and female sexuality, plus the realization that
either or both sexes can be perpetrators or victims, underage persons (boys or
girls) should be equally protected. These laws should not pander to homo-
phobic concerns, nor should they ignore the reality that intrafamilial rape
(incest) has the highest occurrence incidence. The greater the abuse of authori-
ty, the closer the relationship, the higher the magnitude of fear and coercion,
the longer the length of time over which the activities take place, the more
there is likelihood of long-term psychic damage to the victim. Stranger molesta-
tion allows for support for the victim by the family; father-child rape often is
hidden or the consequences that befall the family are seen by the family to be
the fault of the victim rather than the perpetrator.
Third, the severity of residual psychopathology is more related to whether
or not there is penetration of one's body (inner integrity/space) than which
space is violated (anus, mouth, vagina). Human beings need to have control
over both their inner and outer territorial regions. Violations (i.e., invasion or
entry without permission) of these areas result in rage that can either be turned
outward-homicidal equivalents (mass murderers and repetitive sexual offen-
ders often were violated as children) or inward-suicidal equivalents such as
prostitution, drug addiction, passivity, and victim mentality. Especially damag-
ing is instrumentation of the child and/or genital mutilation.
Fourth, legislation, either independently or in the model code, should
provide for immediate psychiatric or other therapeutic interventions, allowing
the victim to recover the costs and punitive damage where appropriate and
whenever possible, first from the perpetrator, but if not, then from state social
services and/or the victims compensation board.
Fifth, in most states, the statute of limitations in civil actions is tolled until
the plaintiffs majority is reached and then immediately begins to be operative.
However, because many victims disassociate, we believe, it should not run until
the time the victim realizes not only what happened, but what the traumatic
consequences are. The International Society for Multiple Personality and Dis-
associative States has recommended that every victim of significant sexual trau-
ma be evaluated for multiple personality and/or other disassociative phe-
nomena. The earlier the intervention, the more humane, effective, and in the
long run, less costly it is, as the pathology is not allowed to become as en-
trenched. In her own practice, the primary author has seen dysfunctional
patients who have suppressed, repressed, or disassociated from long-term sex-
ual abuse for more than 30 years. This concept of the date of discovery as
regards the statute of limitations is already precedent in our legal thinking, as
for example, the sponge in the abdomen in surgical cases. Therefore, it would
be more in line with our compensation system to have the statute of limitations
run from the time of discovery and knowledge rather than from the time of
occurrence.
Sixth, it should be recognized that although minors should not be able to
consent to activities with adults, noncoercive activities between peers is best
handled by an appropriate social and educational program rather than by legal
or punitive sanctions. However, the authors wish to make it very clear that
coercion and exploitation is inherent in the very existence of minor-adult
sexuality. Children and adolescents need and deserve not exploitive, but caring
love for its own sake, not for the secondary gain of adult sexual needs. We
recognize that children are sensual and sexual, but such mutually exploratory
learning experiences, to be healthy, must be between peers-persons of equal
power. Healthy sexuality is a relationship of equals who are interdependent,
with a minimum amount of power dynamics. Inherent in the adult-child rela-
tionship, as the employer-employee one, is the power differential and the
desire of the inferior to please the superior authority; nowhere is this more
clearly shown than in sexual instances between parent and child, teacher and
pupil, or clergy and parishioner. Elements of hero worship and dependency, as
well as punishment and fear, often also playa role in the giving of consent. For
instance, there are many cases of incest in which the threat is to harm the
mother or other siblings, or to withhold food. Compliance is clearly tied to
survival in such instances. Furthermore, below a certain age, children are what
we call in psychojargon, "polymorphous perverse"; young persons lack the
ability to judge right from wrong, have been taught to please adult figures, and
strive for acceptance. Such conditions create situations ripe for exploitation
and abuse. Society must protect, particularly through legislation. We must
respond to the direction of Mr. Justice Byron White that children are to be
considered a "sacred trust" and parents, custodians, and ultimately society are
the fiduciaries of such a trust. With this as our inspiration and focus, we shall
now proceed.
SURVEY OF STATE AGE-OF-CONSENT STATUTES
The balance of this section is devoted to listing the age of consent statutes
which are currently in force in the 50 states, the District of Columbia, and
Puerto Rico. Certain conventions have been adopted in the preparation of the
list that deserve explanation.
Age of Victim. This is the age below which the victim must be in order for
there to be an offense under the statute. If there is an age spread in this
column, the victim must be at least the lower age and less than the higher age.
For example, the notation "13-16" means that persons of ages 13, 14, and 15
are included. Some states require that a victim be of previous "chaste" char-
acter, or use similar language; such restrictions are indicated by the word
"chaste." Mississippi has a unique statute pertaining to the children of
"cohabitants. "
Age of Actor. The age of actor is the minimum capable age for the
offense. Other terms are used in this column: "Guardian" in its most general
sense refers to anyone with legal authority over the victim; Virginia has a
statute covering those who provide services for the state and commit offenses
in providing those services.
Gender. "Specific" indicates that the statute in question is specific to
victims of one sex. This limitation can arise from the crime itself, which may
speak a male perpetrator and a female victim, or from the definitions section of
the statute, which sometimes specifically limits sexual intercourse to its com-
mon law definition of sexual relations between a man and a woman. "Neutral"
indicates that the statute treats both sexes equally.
Acts Included. "Intercourse" as used here means vaginal intercourse
between a man and a woman. "Oral or anal sex" means contact between the
mouth and sex organs, between penis and anus, and, in a few states, mouth and
anus. "Sexual penetration" generally refers to instrumentation, that is, the
insertion of a foreign object into the victim's genitals. Some states define it to
include sexual intercourse as well. "Touching of intimate parts" includes any
physical contact for lustful purposes with the genitals or buttocks, and may also
include, depending on the state, any of the following: contact with the inside of
the thigh, the groin area, the breasts of a female, or the clothing covering these
parts of the body. Other acts included by statute are explained in the chart.
This column also makes note of particular defenses that may arise in some
states by virtue of a victim's "character."
Citation. "Citation" refers to the statutory compilations for the states as
set forth in A Uniform System of Citation.
Minimum and Maximum. These columns list the minimum and max-
imum penalties for the particular class of offense. As is noted, several states
have increased penalties where serious injury accompanies some offenses. As a
general rule, changes in penalties are not listed unless they are specifically
referred to in the statute itself, as opposed to the broader changes that can
apply under the criminal codes of the state.
Age-of-Consent Statutes
State Victim Actor Gender Acts included Citation Minimum Maximum Citation
Alabama 12 16 Neutral Intercourse 13A-6-61 10 years Life 13A-5-6

$20,000
12 16 Neutral Touching of intimate 13A-6-66 1 yr and 10 years 13A-5-6
parts 1 day $5,000
12 16 Specific Oral or anal sex 13A-6-63 10 years Life 13A-5-6
$20,000
12-16 16 Neutral Oral or anal sex 13A-6-64 1 yr and 10 years 13A-5-6
1 day $5,000
12-16 16 and 2 years Specific Intercourse 13A-6-62 1 yr and 10 years 13A-5-6
older 1 day $5,000
12-16 19 Neutral Touching of intimate 13A-6-67 1 year 13A-5-7
parts $2,000 13A-5-12
....U1 16 Neutral Enticing "with 13A-6-69 5 years 13A-6-69
t.lQ lascivious intent" to $5,000
engage in above
acts
Alaska 13 16 Neutral Intercourse, oral or 11.41.434 30 years 12.55.125
anal sex, sexual
penetration
13 16 Neutral Sexual contact 11.41.436 10 years 12.55.125
$50,000 12.55.035
13 Under 16 and Neutral Intercourse, oral or 11.41.440 1 year 12.55.135
3 years anal sex, sexual $5,000 12.55.035
older penetration or con-
tact
13-16 16 and 3 years Neutral Intercourse, oral or 11.41.436 10 years 12.55.125
older anal sex, sexual $50,000 12.55.035
penetration
(continued)
13-16 16 and 3 years Neutral Sexual contact 11.41.438 5 years 12.55.125

older $50,000 12.55.035
18 18 and guard- Neutral Intercourse, oral or 11.41.434 30 years 12.55.125
Ian anal sex, sexual
penetration
18 18 and guard- Neutral Sexual contact 11.41.436 10 years 12.55.125
Ian $50,000 12.55.035
Arizona 15 Neutral Intercourse, oral or 13-1405 15 years 20 years 13-604.1
anal sex, sexual $150,000
penetration, mas-
turbatory contact
15 Neutral Molestation by touch- 13-1410 12 years 17 years 13-604.1
.... ing of genitals, or $150,000
I;,n
~
causing victim to do
same
15 Specific Touching of female 13-1404 5 years 10 years 13-604.1
breast $150,000
15-18 Neutral Intercourse, oral or 13-1405 9 months I'h years 13-70 I
penetration, mas-
turbatory contact
Arkansas 14 18 Neutral Intercourse, oral or 41-1804 5 years 20 years 41-1101
anal sex, sexual $15,000 41-901
penetration
14 18 Neutral Soliciting to engage in 41-1810 I year 41-1101
any of the enumer- $1,000 41-901
ated acts
14 18 Neutral Touching of intimate 41-1808 10 years 41-1101
parts $10,000 41-901
14 2 years older Neutral Intercourse, oral or 41-1803 10 years Life 41-1101
anal sex, sexual $15,000 41-90 I
penetration
16 Neutral Intercourse, oral or 41-1807 90 days 41-1101
anal sex, sexual $500 41-901
penetration
16 20 Neutral Intercourse, oral or 41-1806 I year 41-1101
anal sex, sexual $1,000 41-901
penetration
California 14 Neutral "Any lewd or 288 3 years 8 years 288
lascivious act"
14 10 years older Neutral Anal sex 286 3 years 8 years 286
14 10 years older Neutral Oral sex 288a 3 years 8 years 288a
16 21 Neutral Anal sex 286 5 years 286
16 21 Neutral Oral sex 288a 5 years 288a
18 Neutral Anal sex 286 I year 286
18 Neutral Oral sex 288a 1 year 288a
18 Specific Intercourse, oral or 261.5 I year 264
anal sex
.... 18 and Specific Enticing victim into 266 I year 266
(Jl
(Jl "chaste" prostitution of "ill- $2,000
icit carnal connec-
tion with any man"
Colorado 15 4 years older Neutral Intercourse, oral or 18-3-403 2 years 8 years 18-1-105
anal sex, any va- $2,000 $500,000
ginal or anal pen-
etration
15 4 years older Neutral Touching of intimate 18-3-405 16-11-309
and Guard- parts
Ian
15 4 years older Neutral Touching of intimate 18-3-405 2 years 8 years 18-1-105
parts $2,000 $500,000
18 Guardian Neutral Intercourse, oral or 18-3-403 2 years 8 years 18-1-105
anal sex, any va- $2,000 $500,000
ginal or anal pen-
etration
(continued)
18 Guardian Neutral Touching of intimate 18-3-404 6 months 24 months 18-1-106

parts $500 $5,000
Connecticut 15 Neutral Touching of intimate 53a-73a 1 year 53a-36
parts $1,000 53a-42
16 Neutral Intercourse, oral or 53a-71 I year 10 years 53a-35a
anal sex
16 $5,000 53a-41
18 Guardian Neutral Intercourse, oral or 53a-71 I year 10 years 53a-35a
anal sex $5,000 53a-41
18 Guardian Neutral Touching of intimate 53a-73a I year 53a-36
parts $1,000 53a-42
Delaware 16 Neutral Intercourse, oral or Title II 3 years 30 years Title 11
....
~
anal sex Sec. 773 Any fine Any fine Sec. 4205
c:n 16 Neutral Sexual contact Title 11 7 years Title II
Sec. 768 Any fine Sec. 4205
16 Neutral Sexual penetration Title 11 10 years Title II
Sec. 770 Any fine Sec. 4205
District of Co- 16 Specific Intercourse 22-2801 Life 22-2801
lumbia
16-21 Specific "Seduce and carnally 22-3001 3 years 22-3001
know" $200
Florida 12 18 Neutral Intercourse, oral or 794.011 Death 775-082
anal sex, sexual
penetration
12 Under 18 Neutral Intercourse, oral or 794.011 Life 775-082
anal sex, sexual
penetration
12-18 Guardian Neutral Intercourse, oral or 794.041 30 years 775.082
anal sex, sexual $10,000 775.083
penetration
12-18 Guardian Neutral Solicitation to engage 794.041 5 years 775.082
in sexual activity $5,000 775.083
18 and Neutral Intercourse 794.05 15 years 775.082
"chaste" $10,000 775.083
Georgia 14 Neutral Immoral or indecent 16-6-4 1 year 20 years 16-6-4
act in presence of
victim
14 Neutral Soliciting or enticing 16-6-5 I year 20 years 16-6-5
for molestation or
"indecent acts"
14 Specific Intercourse 16-6-3 I year 20 years 16-6-3
Hawaii 14 Neutral Intercourse 707-731 10 years 706-640
$10,000 706-660
14 Neutral Intercourse with reck- 707-730 20 years 706-640
less infliction of se- $10,000 706-659
rious injury
14 Neutral Oral or anal sex 707-734 10 years 706-640
....
U1
$10,000 706-660
..;J 14 Neutral Oral or anal sex with 707-733 20 years 706-640
reckless infliction of $10,000 706-659
serious injury
14 Neutral Touching of intimate 707-736 5 years 706-640
parts $5,000 706-660
14-16 4 years older Neutral Touching of intimate 707-737 1 year 706-640
parts $1,000 706-663
Idaho 16 Neutral "Any lewd or 18-1508 Life 18-6607
lascivious act"
18 Specific Intercourse 18-6101 I year Life 18-6104
Illinois 13 17 Neutral Intercourse, oral or Title 38 6 years 30 years Title 38
anal sex, sexual Sec. 12-14 $10,000 Sec. 1005-8-1
penetration
13 17 Neutral Solicitation for inter- Title 38 1 year 3 years 1005-8-1
course, oral or anal Sec. 11-6 $10,000 1005-9-1
sex, sexual penetra-
tion
(continued)
13 17 Neutral Solicitation for touch- Title 38 I year 1005-8-3

ing of intimate Sec. 11-6 $1,000 1005-9-1
parts
13 17 Neutral Touching of intimate Title 38 3 years 10 years 1005-8-1
parts Sec. 12-16 $10,000 1005-9-1
13-16 17 Neutral Intercourse, oral or Title 38 I year 1005-8-3
anal sex, sexual 12-15 $1,000 1005-9-1
penetration, touch-
ing of intimate
parts
18 Family mem- Neutral Intercourse, oral or Title 38 4 years 15 years Title 38
ber anal sex, sexual Sec. 12-13 $10,000 Sec. 1005-8-1
penetration
...
~ 18 Family mem- Neutral Touching of intimate Title 38 3 years 10 years 1005-8-1
00 ber parts Sec. 12-16 $10,000 1005-9-1
9 Under 17 Neutral Intercourse, oral or Title 38 6 years 30 years 1005-8-1
anal sex, sexual Sec. 12-14 $10,000 1005-9-1
penetration
9 Under 17 Neutral Touching of intimate Title 38 3 years 10 years 1005-8-1
parts Sec. 12-16 $10,000 1005-9-1
9-16 Under 17 Neutral Intercourse, oral or Title 38 I year 1005-8-3
anal sex, sexual 12-15 $1,000 1005-9-1
penetration, touch-
ing of intimate
parts
Indiana 12 Neutral Intercourse, "deviate 35-42-4-3 6 years 20 years 35-50-2-5
sexual conduct" $10,000
12 Neutral Touching of intimate 35-42-4-3 2 years 8 years 35-50-2-6
parts $10,000
12-16 16 Neutral Intercourse, "deviate 35-42-4-3 2 years 8 years 35-50-2-6
sexual conduct" $10,000
12-16 16 Neutral Touching of intimate 35-42-4-3 I year 4 years 35-50-2-7
parts $10,000
Iowa 12 Neutal Any sexual act 709.3 25 years 902.9
14 Neutral Any sexual act 709.4 10 years 902.9
$5,000
14-16 6 years older Neutral Any sexual act 709.4 10 years 902.9
$5,000
14-16 Relative or Neutral Any sexual act 709.4 10 years 902.9
Guardian $5,000
Kansas 12 Neutral Enticing to engage in 21-3511 I year 5 years 21-4501
unlawful sexual act $10,000 21-4503
16 Neutral Enticing to engage in 21-3510 I year 21-4502
unlawful sexual act $2,500 21-4503
16 Neutral Enticing to enter a 21-3509 2 years 10 years 1983
room, vehicle, etc. $10,000
for unlawful sexual
.... act
CJ1 Neutral Intercourse, touching 21-3503 3 years 20 years 21-4501
Ie 16
of intimate parts $15,000 21-4503
16 Neutral Oral or anal sex 21-3506 5 years Life 1983
$15,000
16 Guardian Neutral Intercourse, touching 21-3504 5 years Life 21-4501
of intimate parts $15,000 21-4503
Kentucky 12 Neutral Intercourse 510.040 10 years 20 years 532.060
$10,000 534.030
12 Neutral Intercourse with se- 510.040 20 years Life 532.060
rious injury $10,000 534.030
12 Neutral Oral or anal sex 510.070 10 years 20 years 532.060
$10,000 534.030
12 Neutral Oral or anal sex with 510.070 20 years Life 532.060
serious injury $10,000 534.030
12 Neutral Touching of intimate 510.110 I year 5 years 532.060
parts $10,000 534.030
(continued)
14 Neutral Touching of intimate 510.120 1 year 532.090

parts $500 534.040
14 18 Neutral Intercourse 510.050 10 years 20 years 532.060
$10,000 534.030
14 18 Neutral Oral or anal sex 510.080 5 years 10 years 532.060
$10,000 534.030
14-16 5 years older Neutral Touching of intimate 510.130 90 days 532.090
parts $250 534.040
16 21 Neutral Intercourse 510.060 1 year 5 years 532.060
$10,000 534.030
16 21 Neutral Oral or anal sex 510.090 1 year 5 years 532.060
.... $10,000 534.030
C'l Louisiana 12 Neutral Oral sex 14.43.4 20 years 14.43.4
Q
12 Neutral Vaginal or anal inter- 14.42 Life at hard 14.41
course labor
12-17 17 and 2 years Neutral Intercourse, oral or 14.80 10 years 14.80
older anal sex
15 3 years older Neutral Oral sex 14.43.3 15 years 14.43.3
15 3 years older Neutral Touching of intimate 14.43.1 10 years 14.43.1
parts
17 2 years older Neutral "Any lewd or 14.81 5 years 14.81
lascivious act" on or $5,000
in front of victim
Maine 12 Specific Intercourse 17-A.252 20 years 17-A.1252
14 Neutral Intercourse, oral or 17-A.253 20 years 17-A.1252
anal sex, sexual
penetration
14 3 years older Neutral Touching of intimate 17-A.255 5 years 17-A.1252
parts $2,500 17-A.1301
14-16 19 and 5 years Neutral Intercourse, oral or 17-A.254 <I year 17-A.1252
older anal sex, sexual $1,000 17-A.1301
penetration
18 and Teacher Neutral Intercourse, oral or 17-A.253 5 years 17-A.1252
student anal sex, sexual
penetration
Maryland 14 4 years older Neutral Oral or anal sex, sex- Art. 27 20 years Art. 27
ual penetration Sec. 464A Sec. 464A
14 4 years older Neutral Touching of intimate Art. 27 10 years Art. 27
parts Sec. 464B Sec. 464B
14 4 years older Specific Intercourse Art. 27 20 years Art. 27
Sec. 463 Sec. 463
14-15 4 years older Neutral Oral or anal sex, sex- Art. 27 I year Art. 27
ual penetration Sec. 464C $1,000 Sec. 464C
Massachusetts 16 Neutral "Any unnatural or C.272 $100 5 years C.272
.... lascivious act" Sec. 35A $1,000 Sec. 35A
Q) 16 Neutral Intercourse, "un- C.265 Any term
.... C.265
natural" inter- Sec. 23 of years Sec. 23
course, and abuse
Michigan 13 Neutral Intercourse, oral or 750.520b Life 750.520b
anal sex, sexual
penetration
13 Neutral Touching of intimate 750.520c 15 years 750.520c
parts
13-16 Neutral Intercourse, oral or 750.520d 15 years 750.520d
anal sex, sexual
penetration
13-16 Relative or Neutral Intercourse, oral or 750.520b Life 750.520b
guardian anal sex, sexual
penetration
13-16 Relative or Neutral Touching of intimate 750.520c 15 years 750.520c
guardian parts
(continued)
Minnesota 13 Neutral Touching of intimate 609.345 5 years 609.345

parts $10,000
13 36 months Neutral Intercourse, oral or 609.342 20 years 609.342
older anal sex, sexual $35,000
penetration
13 36 months Neutral Intercourse, oral or 609.344 10 years 609.344
older or less anal sex, sexual $20,000
penetration
13 36 months Neutral Touching of intimate 609.343 15 years 609.343
older parts $30,000
13-16 24 to 48 Neutral Intercourse, oral or 609.344 5 years 609.344
... months anal sex, sexual
C'l older penetration
~
13-16 48 months Neutral Intercourse, oral or 609.342 20 years 609.342
older and anal sex, sexual $35,000
guardian penetration
13-16 48 months Neutral Touching of intimate 609.343 15 years 609.343
older and parts $30,000
guardian
older parts $10,000
13-16 Guardian Neutral Touching of intimate 609.345 5 years 609.345
parts $10,000
13-16 More than 48 Neutral Intercourse, oral or 609.344 10 years 609.344
months anal sex, sexual $20,000
older penetration
16-18 48 months Neutral Intercourse, oral or 609.344 10 years 609.344
older and anal sex, sexual $20,000
guardian penetration
guardian
Mississippi 14 Neutral Intercourse, oral or 97-3-95 30 years 97-3-95
anal sex, sexual
penetration
14 13-18 Neutral "Carnally and un- 97-3-65 Any term 97-3-65
lawfully knowning"
14 18 Neutral "Carnally and un- 97-3-65 Death 97-3-65
lawfully knowing"
14 18 Neutral Touching "for lustful 97-5-23 1 year 10 years 97-5-23
purpose" $10 $1,000
14-18, Neutral "Carnal knowledge" 97-3-67 6 months 5 years 97-3-67
"chaste," $500
single
.... 14-18, Older than Neutral "Carnal knowledge" 97-5-41 10 years 97-5-41
Q)
!.IO single, victim
step-
child
14-18, Older than Neutral "Carnal knowledge" 97-5-41 10 years 97-5-41
single, victim
adoptee
14-18, Older than Neutral "Carnal knowledge" 97-5-41 10 years 97-5-41
part- victim
ner's
child
18 and Older than Neutral "Seduce and have il- 97-5-21 10 years 97-5-21
"chaste" victim licit connection"
Missouri 12 Neutral Touching of intimate 566.100 5 years 558.011
parts $5,000 560.011
12 Neutral Touching of intimate 566.100 7 years 558.011
parts, with serious $5,000 560.011
injury
( continued)
12-14 Neutral Touching of intimate 566.110 1 year 558.011

parts $1,000 560.016
12-14 Neutral Touching of intimate 566.110 5 years 558.011
parts, with serious $5,000 560.011
injury
14 Neutral Oral or anal sex, 566.060 5 years 15 years 558.011
touching genitals
14 Neutral Oral or anal sex, 566.060 10 years Life 558.011
touching genitals,
with serious injury
14 Specific Intercourse 566.030 5 years 15 years 558.011
14 Specific Intercourse with se- 566.030 10 years 30 years 566.030
rious injury
0)
'""'
~ 14-16 Neutral Oral or anal sex, 566.070 7 years 558.011
touching genitals $5,000 560.011
14-16 Neutral Oral or anal sex, 566.070 5 years 15 years 558.011
touching genitals,
with serious injury
14-16 Specific Intercourse 566.040 7 years 558.011
$5,000 560.011
14-16 Specific Intercourse with se- 566.040 5 years 15 years 558.011
rious injury
14-16 Under 17 Specific Intercourse 566.090 1 year 558.011
$1,000 560.016
17 Neutral Oral or anal sex, 566.090 1 year 558.011
touching genials $1,000 560.016
Exactly 16 17 Neutral Oral or anal sex, 566.080 5 years 558.011
years touching genitals $5,000 560.011
Exactly 16 17 Neutral Oral or anal sex, 566.080 7 years 558.011
years touching genitals, $5,000 560.011
with serious injury
Exactly 16 17 Specific Intercourse 566.050 5 years 558.011
years $5,000 560.011
Exactly 16 17 Specific Intercourse with se- 566.050 7 years 558.011
years rious injury $5,000 560.011
Montana 16 Neutral "Deviate sexual rela- 45-5-505 20 years 45-5-505
tions" $50,000
16 Neutral Sexual contact 45-5-502 6 mths. 45-5-502
$500
16 Opposite Intercourse 45-5-503 2 years 20 years 45-5-503
$50,000
16 3 years older Neutral Sexual contact 45-5-502 20 years 45-5-502
$50,000
16 3 years older Opposite Intercourse 45-5-503 2 years 40 years 45-5-503
$50,000
Nebraska 14 19 Neutral Sexual contact 28-320.01 5 years 28-105
$10,000
16 19 Neutral Intercourse, oral or 28-319 I year 50 years 28-105
....
C7I anal sex, sexual
CJ1 penetration
Nevada 14 Neutral Intercourse, oral or 200.366 10 years Life 200.366
anal sex, sexual
penetration
16 18 Neutral Intercourse, oral or 200.368 I year 10 years 200.368
anal sex $10,000
New Hampshire 13 Neutral Intercourse, oral or 632-A:2 15 years 651:2
penetration
13 Neutral Sexual contact 632-A:3 7 years 651.2
$2,000
13 Neutral Touching of intimate 632-A:4 I year 651:2
parts $1,000
13-16 Neutral Intercourse, oral or 632-A:3 7 years 651:2
penetration
( continued)
13-16 Relative or Neutral Intercourse, oral or 632-A:2 15 years 651:2

guardian anal sex, sexual $2,000
penetration
13-16 Relative or Neutral Touching of intimate 632-A:4 1 year 651 :2
guardian parts $1,000
New Jersey 13 Neutral Intercourse, oral or 2c: 14-2 10 years 20 years 2c:43-3
anal sex, sexual $100,000 2c:43-6
penetration
13 4 years older Neutral Touching of intimate 2c: 14-2 5 years 10 years 2c:43-3
parts $100,000 2c:43-6
13-16 4 years older Neutral Intercourse, oral or 2c: 14-2 5 years 10 years 2c:43-3
....
Q'l
penetration
Q'l 13-16 Guardian Neutral Intercourse, oral or 2c: 14-2 10 years 20 years 2c:43-3
penetration
13-16 Guardian Neutral Touching of intimate 2c: 14-3 3 years 5 years 2c:43-3
parts $7,500 2c:43-6
16-18 Guardian Neutral Intercourse, oral or 2c: 14-2 5 years 10 years 2c:43-3
penetration
New Mexico 13 Neutral Indecent exposure 30-9-14 <1 year 31-19-1
$1,000
13 Neutral Intercourse, oral or 30-9-11 24 years 31-18-15
anal sex, sexual $15,000 31-18-15.1
penetration
13 Neutral Touching of intimate 30-9-13 2 years 31-18-15
parts $5,000 31-18-15.1
13-16 Guardian Neutral Intercourse, oral or 30-9-11 12 years 31-18-15
anal sex, sexual $10,000 31-18-15.1
penetration
13-18 Guardian Neutral Touching of intimate 30-9-13 2 years 31-18-15
parts $5,000 31-18-15.1
New York 11 Neutral Insertion of object Penal Law 25 years Penal Law
into anus or vagina Sec. 130.70 Sec. 70.00
11 Neutral Touching of intimate Penal Law 7 years Penal Law
parts Sec. 130.65 Sec. 70.00
11 Specific Intercourse Penal Law 25 years Penal Law
Sec. 130.35 Sec. 70.00
11 Specific Oral or anal sex Penal Law 25 years Penal Law
Sec. 130.50 Sec. 70.00
14 Neutral Touching of intimate Penal Law 1 year Sec. 80.05
parts Sec. 130.60 $1,000 Sec. 70.15
14 18 Specific Intercourse Penal Law 7 years Penal Law
Sec. 130.30 Sec. 70.00
14 18 Specific Oral or anal sex Penal Law 7 years Penal Law
Sec. 130.45 Sec. 70.00
~ 15-17 5 years older Neutral Touching of intimate Penal Law 3 months Sec. 80.05
~
...;r parts Sec. 130.55 $500 Sec. 70.15
17 21 Specific Intercourse Penal Law 4 years Penal Law
Sec. 130.25 Sec. 70.00
17 21 Specifc Oral or anal sex Penal Law 4 years Penal Law
Sec. 130.40 Sec. 70.00
North Carolina 13 Over 12 and 4 Neutral Oral or anal sex, sex- 14-27.4 Life 14-1.1
years older ual penetration
13 Over 12 and 4 Specific Intercourse 14.27,2 Life 14-1.1
years older
16 16 and 5 years Neutral "Indecent liberties, 14-202.1 10 years 14-1.1
older lewd or lascivious
acts"
18 Guardian Neutral Intercourse, oral or 14-27.7 15 years 14-1.1
anal sex, sexual
penetration
(continued)
North Dakota 15 Neutral Intercourse, oral or 12.1-20-03 10 years 12.1-32-01

penetration
15 Neutral Intercourse, oral or 12.1-20-03 20 years 12.1-32-01
penetration, with
serious injury
15 Neutral Touching of intimate 12.1-20-03 10 years 12.1-32-01
parts $10,000
15-18 Neutral Intercourse, oral or 12.1-20-05 1 year 12.1-32-01
penetration, or so-
l-'
al
licitation to engage
00 in same
15-18 18 or guard- Neutral Touching of intimate 12.1-20-07 1 year 12.1-32-01
Ian parts $1,000
Ohio 13 Neutral Intercourse, oral or 2907.02 5 years 25 years 2929.11
anal sex $10,000
13 Neutral Solicitation to engage 2907.07 60 days 2929.21
in sexual activity $500
13 Neutral Touching of intimate 2907.05 2 years 10 years 2929.11
parts $5,000
13-16 18 Neutral Intercourse, oral or 2907.04 2 years 10 years 2929.11
anal sex $5,000
13-16 18 and up to Neutral Intercourse, oral or 2907.04 6 months 2929.21
4 years anal sex $1,000
older
13-16 18 and 4 years Neutral Solicitation to engage 2907.07 60 days 2929.21
older in sexual activity $500
13-16 18 and 4 years Neutral Touching of intimate 2907.06 60 days 2929.21
older parts $500
Oklahoma 16 Specific Intercourse Title 21 15 years Death Title 21
Sec. 1111 Sec. 1115
16 3 years older Neutral Touching of intimate Title 21 I year 20 years Title 21
parts, enticing to Sec. 1123 Sec. 1123
engage in sexual
acts
18 Neutral Causing "to engage in Title 21 I year 25 years Title 21
prostitution" Sec. 1088 $5,000 $25,000 Sec. 1088
18 Neutral Offering for "any ... Title 21 I year 10 years Title 21
lewd or indecent Sec. 1087 Sec. 1087
act
Oregon 12 Neutral Oral or anal sex 163.405 20 years 161.605
en
""' $100,000 161.625
CC 12 Neutral Touching of intimate 163.425 5 years 161.605
parts $100,000 161.625
12 Specific Intercourse 163.375 20 years 161.605
$100,000 161.625
14 Neutral Sexual penetration 163.408 10 years 161.605
$100,000 161.625
14 Neutral Touching of intimate 163.415 I year 161.615
parts $2,500 161.635
14 3 years older Neutral Oral or anal sex 163.395 10 years 161.605
$100,000 161.625
14 3 years older Specific Intercourse 163.365 10 years 161.605
$100,000 161.625
14-18 4 years older Neutral Touching of intimate 163.415 I year 161.615
parts $2,500 161.635
16 3 years older Neutral Oral or anal sex 163.385 5 years 161.605
$100,000 161.625
( continued)
16 3 years older Specific Intercourse 163.355 5 years 161.605

$100,000 161.625
16 Relative Neutral Oral or anal sex 163.405 20 years 161.605
$100,000 161.625
16 Relative Specific Intercourse 163.375 20 years 161.605
$100,000 161.625
18 18 Neutral Intercourse, oral or 163.435 1 year 161.615
anal sex $1,000 161.635
18 and Neutral Intercourse, oral or 163.445 30 days 161.615
single anal sex $500 161.635
Pennsylvania 14 18 Neutral Intercourse Title 18 10 years Sec. 1101
... Sec. 3122 $25,000 Sec. 1103
~ 16 Neutral Oral or anal sex Title 18 20 years Sec. 1101
= Sec. 3123 $25,000 Sec. 1103
Puerto Rico 14 Neutral "Any indecent or Title 33 4 years 8 years Title 33
lewd act" Sec. 4067 Sec. 4067
14 Specific Intercourse Title 33 10 years 25 years Title 33
Sec. 4061 Sec. 4061
18, single Specific Seduction by promise Title 33 2 years 5 years Title 33
and of marriage Sec. 4063 $5,000 Sec. 4063
"moral"
Rhode Island 13 Neutral Intercourse, oral or 11-37-8.1 20 years Life 11-37-8.2
anal sex, seuxal
penetration
13 Neutral Touching of intimate 11-37-8.3 6 years 30 years 11-37-8.4
parts
13-16 18 Neutral Intercourse, oral or 11-37-6 5 years 11-37-7
anal sex
South Carolina 11 Neutral Intercourse, oral or 16-3-655 30 years 16-3-652
anal sex, sexual
penetration
11-14 Neutral Intercourse, oral or 16-3-655 20 years 16-3-653
anal sex, sexual
penetration
14-16 Guardian Neutral Intercourse, oral or 16-3-655 10 years 16-3-654
anal sex, sexual
penetration
South Dakota 10 Neutral Intercourse, oral or 22-22-1 25 years 22-6-1
penetration
11-16 Neutral Intercourse, oral or 22-22-1 5 years 22-6-1
penetration
16 14 and up to Neutral Touching of intimate 22-22-7 1 year 22-6-2
I>""
3 years parts $1,000
~ older
I>""
16 14 and 3 years Neutral Touching of intimate 22-22-7 10 years 22-6-1
older parts $10,000
Tennessee 13 Neutral Intercourse, oral or 39-3703 20 years Life 39-3703
anal sex, sexual
penetration
13 Neutral Touching of intimate 39-3704 5 years 35 years 39-3704
parts
13-18 2 years older Neutral Intercourse, oral or 39-3711 5 years 39-3711
anal sex, sexual
penetration. (De-
fense that victim is
over 14 and "a
bawd, lewd, or kept
person.")
( continued)
Texas 14 Neutral Intercourse, oral or Title 5 5 years Life Title 5

anal sex, sexual Sec. 22.021 Sec. 12.32
penetration
17 2 years older Neutral Intercourse, oral or Title 5 2 years 20 years Title 5
anal sex, sexual Sec. 22.011 Sec. 12.32
penetration
Utah 14 Neutral Intercourse 76-5-402.1 5 years Life 76-5-402.1
$10,000
14 Neutral Oral or anal sex 76-5-403.1 5 years Life 76-5-403.1
$10,000
14 Neutral Sexual penetration 76-5-402.3 5 years Life 76-5-402.3
$10,000
14 Neutral Touching of intimate 76-5-404.1 1 year 15 years 76-3-203
I-'
"-l parts, taking "in- $10,000 76-3-301
N decent liberties"
16 Neutral Intercourse 76-5-401 1 year 76-3-204
$1,000 76-3-301
16 3 years older Neutral Intercourse 76-5-401 5 years 76-3-203
$5,000 76-3-301
Vermont 16 Neutral Intercourse, oral or Title 13 20 years Title 13
anal sex, sexual Sec. 3252 $10,000 Sec. 3252
penetration
16 Neutral Intercourse, oral or Title 13 25 years Title 13
anal sex, sexual Sec. 3252 $15,000 Sec. 3253
penetration, with
serious injury
Virginia 13 Neutral Intercourse 18.2-61 5 years Life 18.2-61
13 Neutral Oral or anal sex 18.2-67.1 5 years Life 18.2-67.1
13 Neutral Sexual penetration 18.2-67.2 5 years Life 18.2-67.2
13-15 Neutral Intercourse 18.2-63 2 years 10 years 18.2-10
13-15 Under 18 and Neutral "Carnally know" 18.2-63 $100 18.2-11
up to 3
years older
13-15 Under 18 and Neutral "Carnally know" 18.2-63 5 years 18.2-10
3 years
older
14 18 Neutral Enticing to engage in 18.2-370 5 years 18.2-10
sexual acts, or to
enter any premises
to do same
14 18 Neutral Indecent exposure 18.2-370 5 years 18.2-10
15-18 State services Neutral "Carnally know" 18.2-64.1 5 years 18.2-10
provider
15-18 Up to 3 years Neutral "Carnally know" 18.2-64.1 $100 18.2-11
older and
provider
18 18 and guard- Neutral Enticing to engage in 18.2-370.1 5 years 18.2-10
~
Ian sexual acts, sexual
-.J abuse
~
18 18 and guard- Neutral Indecent exposure 18.2-370.1 5 years 18.2-10
ian
Washington II 13 Neutral Intercourse, oral or 9A.44.070 Life 9A.20.021
penetration
ll-14 16 Neutral Intercourse, oral or 9A.44.080 10 years 9A.20.021
penetration
14 Neutral Touching of intimate 9A.44.100 10 years 9A.20.021
parts $20,000
14-16 18 Neutral Intercourse, oral or 9A.44.090 5 years 9A.20.021
penetration
16 48 months Neutral Touching of intimate 9A.44.100 10 years 9A.20.021
guardian
( continued)
West Virginia 11 14 Neutral Intercourse, oral or 61-8B-3 5 years 25 years 61-8B-3

penetration
11 14 Neutral Touching of intimate 61-8B-7 1 year 5 years 61-8B-7
parts $10,000
16 16 and 4 years Neutral Intercourse, oral or 61-8B-5 1 year 5 years 61-8B-5
older anal sex, sexual $10,000
penetration
16 16 and 4 years Neutral Touching of intimate 61-8B-9 90 days 61-8B-9
older parts $500
Wisconsin 13 Neutral Intercourse, oral or 940.225 20 years 939.50
anal sex, sexual
penetration, touch-
~
ing of intimate
~
" parts
13-18 Neutral Intercourse, oral or 940.225 10 years 939.50
penetration, touch-
ing of intimate
parts
Wyoming 12 18 Neutral Touching of intimate 6-2-304 5 years 6-2-306
parts
12 4 years older Neutral Intercourse, oral or 6-2-303 20 years 6-2-306
or guardian anal sex, sexual
penetration
12 4 years older Neutral Touching of intimate 6-2-305 1 year 6-2-306
or guardian parts
16 4 years older Neutral Intercourse, oral or 6-2-304 5 years 6-2-306
anal sex, sexual
penetration
INTRODUCTION TO THE UNIFORM SEXUAL ABUSE OF

MINORS ACT
The foregoing sections have clearly demonstrated the need for the devel-
opment and adoption of a uniform age-of-consent statute. In designing a
model statute, a number of different considerations had to be kept in mind. As
has been discussed earlier, there are currently some statutes that fail to desig-
nate offenses that apply regardless of the sex of the victim. Consequently the
model statute has been developed with the intention of defining offenses solely
in terms of the age of the victim and that of the perpetrator, that is, the statute
is gender neutral. The statute also recognizes that a certain amount of sexual
experimentation is inevitable among peers. Without wishing to become em-
broiled in any controversy over the morality of such behavior, we find that to
whatever extent society may wish to discourage such activity, penal codes are
not suitable vehicles for doing so. The age differentials that are used in the
statute have been selected so that sexually precocious peers need not fear
prosecution for their conduct. *
The model statute creates three offenses: (a) intercourse with minors (Sec-
tion 4 of the act); (b) sexual contact with minors (Section 5); (c) indecent
exposure to minors (Section 6).
All operative definitions for the purpose of the statute are set forth at
Section 3 of the act. A section-by-section summary of the offenses follows.
SECTION 4: INTERCOURSE WITH MINORS
Table I presents the age groups and punishments created by this section of
the act. It should be noted that "intercourse" is defined to include vaginal, oral,
or anal contacts. Penetration is not necessary to establish intercourse within the
term's meaning in the act. The age distinctions that have been drawn stem
from a number of considerations. Subsection (a) is intended to protect persons
who have not yet reached puberty from sexual exploitation by their elders. An
age differential of only 2 years is established because at these tender years such
a difference represents a significant difference in physical and mental matu-
rity. Age differentials in succeeding subsections are presented with the inten-
*The authors have recently become aware of another attempt to draft a model statute to cover
such matters. Shouvlin, Preventing the SexWLI Exploitation of Children: A Model Act, 17 Wake
Forest L.R. 535 (1981). A comparison of the authors' model, which was developed indepen-
dently, with Shouvlin's proposed act reveals that Shouvlin's proposal is much more en-
cyclopedic in dealing with a wide variety of subjects, for example, child sexual abuse, child
pornography, and child prostitution. The authors feel that a more refined approach is
needed concentrating on the specific subject of sexual abuse. In the past few years the states
have made enormous strides in dealing statutorily with the subject of child pornography as a
specific issue. Shouvlin's proposal ignores the problem of peer sexual activity, which is clearly
a subject of some consequence.
Table I. Intercourse with Minors a
Age of victim Perpetrator's age Imprisonment b
Any age < 12 Victim's age +2 Up to 10 years

12 :s age < 14 Victim's age +3 Up to 6 years
14 :s age < 16 Victim's age +5 Up to 6 years
Any age < 19 Up to 10 years, where
perpetrator is re-
lated to, or has
custody of, victim
a"Intercourse" is defined in the Act as "any sexual act involving contact

between the penis and the vulva, between the penis and the anus, between
the mouth or tongue and the penis, between the mouth or tongue and the
vulva, or any anal or vaginal penetration by a part of the body or an object."
bAll penalties may be increased by up to 2 years at the court's discretion when
penetration occurs. An additional 2-year penalty will be added where the
perpetrator engages in intercourse with a minor knowing that he or she is
infected with a contagious venereal disease.
tion of recognizing that sexual activity among peers should not be treated as
criminal behavior. It is believed that the gradually increasing age gaps reflect a
relatively accurate picture of normal teenage sexual activity, that is nonex-
ploitative activity.
Subpart three of subsection (b) imposes criminal liability on an individual
under circumstances that are totally independent of the age differential be-
tween victim and perpetrator. It provides significantly greater penalties for a
perpetrator who has legal authority over his or her victim. It recognizes the
difficulty of teenagers in such situations making independent decisions about
the propriety of such relationships, as opposed to normal peer sexual activity.
Because this area is one with a particularly great potential for abuse, and one in
which the harm to the victim can be of extraordinary magnitude, the age of
majority has been chosen for the age of consent.
The section also contains two other provisions worthy of note. Subsection
(d) adds 2 years to any penalty where the perpetrator engages in intercourse
knowing that he or she is infected with a contagious venereal disease. Such
conduct constitutes a particularly aggravating circumstance in the sexual ex-
ploitation of children, and dearly warrants a longer sentence.* Finally, subsec-
tion (e) would create a misdemeanor offense for anyone who knowingly fails to
report to criminal justice authorities the commission of an offense under the
section.
*The problem of acquired immunodeficiency syndrome (AIDS) is particularly troublesome.

It is worth noting that in at least two states, New York and Maine, local prosecutors have
brought attempted murder charges against individuals who know that they are infected with
the virus yet have engaged in conduct likely to result in the transmission of the virus.
SECTION 5: SEXUAL CONTACT WITH MINORS
This section proposes to deal with a variety of physical contact short of

intercourse that is initiated for the purposes of sexual gratification at the ex-
pense of a minor. Table II presents the age groups and punishments created
by this section. The age groups parallel those contained in Section 4 of the act.
The additional penalties that Section 4 makes available in instances of inter-
course would not apply to the commission of an offense under this section
because sexual contact as defined in the act does not involve penetration and
there is no possibility of the transmission of a contagious venereal disease. As
the crime of sexual contact with minors is less severe than that of sexual inter-
course with minors, no offense for failure to report episodes of sexual contact
with minors has been created.
Table II. Sexual Contact with Minors a
Age of victim Perpetrator's age Imprisonment
Any age < 12 Victim's age + 2 Up to 6 years

12 :s age < 14 Victim's age + 3 Up to 3 years
14 :s age < 16 Victim's age + 5 Up to 3 years
Any age < 19 Up to 5 years, where
perpetrator is re-
lated to, or has
custody of, victim
a"Sexual contact with minors" is defined in the Act as "touching the intimate
parts of another person, or causing another person to touch one's intimate
parts or those of a third party, for the purpose of sexual arousal or gratifi-
cation,"
SECTION 6: INDECENT EXPOSURE TO MINORS
This section is offered so that the act will in fact cover all forms of sexual
exploitation of children on the interpersonal level, as opposed to statutes de-
signed to protect children from sexual exploitation in connection with the
production of commercial products, such as films, videotapes, and magazines.
Such commercial exploitation has been very capably addressed by Congress in
federal legislation. (See, e.g., the Protection of Children against Sexual Exploi-
tation Act of 1977, P.L. 95-225.) State legislatures have also been responsive in
recent years, which have seen an immense increase in the number of states that
have chosen to enact statutes specifically designed to proscribe such commer-
cial activity.
APPENDIX: UNIFORM SEXUAL ABUSE OF MINORS ACT
§ 1. Short title
This act shall be known as the Uniform Sexual Abuse of Minors Act.
§2. Gender
For the purposes of this Act, words of the masculine gender include the femi-
nine and neuter; and, when the sense so indicates, words of the neuter gender may
refer to any gender.
§3. Definitions
For the purposes of this Act, the following definitions apply:
1. "Intercourse" means any sexual act involving contact between the penis and
the vulva, between the penis and the anus, between the mouth or tongue
and the penis, between the mouth or tongue and the vulva, or any anal or
vaginal penetration by a part of the body or an object.
2. "Intimate parts" means the genitals, groin, buttocks, inner thighs, or (in the
case of a female) breasts of a human being, or the clothing covering those
parts of the body.
3. "Sexual contact" means touching the intimate parts of another person, or
causing another person to touch one's intimate parts or those of a third
party, for the purpose of sexual arousal or gratification.
4. "Minor" means a person of the age of eighteen, or under.
5. "Contagious venereal diseases" shall include all those considered as such by
the American Academy of Dermatology. Any person who tests sero-positive
for acquired immunodeficiency syndrome (AIDS) shall be considered to be
infected with a contagious venereal disease within the meaning of this
definition.
§4. Intercourse with minors

a. No person shall engage in intercourse with another person who is at least 2
years younger than he is, such other person being less than 12 years old. An offense
under this subsection is punishable by imprisonment for up to 10 years.
b. No person shall:
1. Engage in intercourse with another person who is at least 3 years young-
er than he is, such other person being at least 12 years old but less than
14 years old; or
2. Engage in intercourse with another person who is at least 5 years young-
er than he is, such other person being at least 14 years old but less than
16 years old; or
3. Engage in intercourse with a minor over whom he has authority by virtue
of familial relation of action of the state.
An offense under this subsection is punishable by imprisonment for up to 6
years, except that an offense under part (3) of this subsection is punishable by
imprisonment for up to 10 years.
c. Where the offense of intercourse involves actual penetration of the anus or

vulva by the penis or an object, the penalties specified in subsection (b) supra may be
increased by up to 2 years, at the discretion of the court.
d. The penalties specified in subsection (b) supra shall be increased by 2 years
for any person who commits such offense with knowledge that he is infected with a
contagious venereal disease.
e. Any person 19 years of age or over who, knowing of the commission of an
offense under this section of the Act, fails to report such incident to the appropriate
authorities, shall himself be guilty of an offense, the punishment for which will not
exceed imprisonment for one year, or a fine of up to $1,000, or both.
§5. Sexual contact with minors
a. No person shall engage in sexual contact with another person who is at least
2 years younger than he is, such other person being less than 12 years old. An
offense under this subsection is punishable by imprisonment of up to 6 years.
b. No person shall:
1. Engage in sexual contact with another person who is at least 3 years
younger than he is, such other person being at least 12 years old but less
than 14 years old; or
2. Engage in sexual contact with another person who is at least 5 years
younger than he is, such other person being at least 14 years old but less
than 16 years old; or
3. Engage in sexual contact with a minor over whom he has authority by
virtue of familial relation or action of the state.
An offense under this subsection is punishable by imprisonment for up to 3
years, except that an offense under part (3) of this subsection is punishable by
imprisonment for up to 5 years.
§6. Indecent exposure to minors
No person shall indecently expose himself, or perform an indecent or lewd act,
in front of another person who is less than 14 years old. Any offense under this
section shall be punishable by imprisonment for up to one year, or a fine of up to
$1,000, or both.
§7. Defenses
It is a defense to any prosecution under this Act that:
1. The parties involved were or reasonably believed themselves to be lawfully
married at the time; or
2. The act involved was performed for a valid medical or health-related
purpose.
§S. Limitations of prosecutions

In cases where the victim was under the age of IS when the alleged violation of
this Act occurred, the statute of limitations shall not begin to run until the later of
the date on which the victim reaches the age of IS, or the date on which the victim
discovers or obtains knowledge that a violation of this Act has been committed.
180 JUDIANNE DENSEN·GERBER AND JOHN R. DUGAN, JR.
§9. Fines
The court may, in its discretion, levy such fines upon persons convicted of
violations under this Act as to the court may seem just and proper, given the nature
and circumstances of the offense. Such fines may, in the court's discretion, be used
to defray the costs of any psychiatric, psychological, or other medical treatment
which the victim may need to undergo as a result of the crime. In the alternative,
fines may be deposited in a fund to compensate other victims of such offenses.
ACKNOWLEDGMENT
We would like to thank John A. Banker for his assistance with this paper.
He was responsible for collecting the data which can be found in the lengthy
table within this chapter.
III
Clinical Considerations
11
Assessment of Juvenile
Psychopathology for Legal
Purposes
RICHARD ROSNER
The assessment of juvenile psychopathology for legal purposes differs from

such assessment for clinical purposes in that the ends of law differ from the
ends of medicine. Whereas medical ends are therapeutic, legal ends are not.
This fundamental distinction affects the entire process of consultation regard-
ing the mental condition of juveniles.
Although the child and adolescent may reasonably expect that a psychia-
trist seen in a medical relationship will have the interests of the juvenile as a
central ethical commitment, such an expectation is ill-founded in a forensic
psychiatric consultation. The examining psychiatrist may owe his principal
ethical loyalty to the court, to one of the attorneys in a case involving the
youngster, to one of the parents of the child or teenager, to a social service
agency or private institution, to the probation department, to the parole board,
to any of a wide range of persons and organizations that do not have the well-
being of juveniles as their concern in a legal proceeding. To make this point
more clearly: the function of a court is to receive cases over which it has
jurisdiction, to resolve disputes, and to make dispositions of cases. This societal
function takes precedence over other concerns for the court. Thus, the court
may be appropriately interested in sending a youngster to a juvenile or adult
detention facility, in separating a child from one or both of its parents, in
placing restrictions on the juvenile's freedom of action. Although such judicial
roles are appropriate to the courts' social function, they may not be perceived
RICHARD ROSNER· Forensic Psychiatry Clinic of the New York Criminal and Supreme
Courts, New York, New York 10013; Department of Psychiatry, New York University School
of Medicine, New York, New York 10016.
183
184 RICHARD ROSNER
by the juvenile (and may, in fact, not be) consistent with the mental health,
growth, and development of that juvenile. The same non therapeutic goals may
be prominant in the concerns of all of the other parties who may have sought a
forensic psychiatric consultation about the child or adolescent. The psychiatrist
who functions in a forensic capacity must understand that the data he obtains
will be used for nontherapeutic purposes. It is even more important that the
child or adolescent understand this point. Failure to clarify this matter is un-
ethical and may lead to having the results of the examination excluded from
legal consideration.
The ethical forensic psychiatrist is obliged to make known to the juvenile:
who has retained the psychiatrist, who will be given access to the examination
results, and that the usual protections accorded to patients by their therapists
will not apply in a psychiatric examination for legal purposes. One expectable
result is that the juvenile will be more cautious and less trustful in the courst of
the interviews with the forensic psychiatrist than might be usual in a therapeu-
tic relationship. Correspondingly, the examining psychiatrist is well advised to
be more skeptical about what he is told in a forensic interview than in a clinical
interview. The always difficult task of assessing psychopathology in children
and adolescents is made even more so by the special circumstances inherent to
forensic examinations.
The majority of psychiatric practitioners are not trained in child and ado-
lescent psychiatry as a specialty. There is some controversy as to whether or not
it is appropriate to have juveniles subjected to mental evaluations by persons
who lack special training relevant to that age group. On the one hand, it is
argued that the amount of credibility accorded to testimony by general psychia-
trists should be less than that accorded to child and adolescent specialists. On
the other hand, it is argued that it is unrealistic to restrict testimony on juvenile
issues to the small number of specialists in the field; the court would be denied
access to needed information in those parts of the country where child and
adolescent experts are in short supply or unavailable. Perhaps the most honest
position is for the general psychiatrist to clarify for the court the extent and
limits of his experience with juvenile assessments, so that factor can be taken
into consideration by the court in reviewing his testimony. The converse argu-
ment has also been made, that is, that only experts in forensic psychiatry should
testify, that child and adolescent psychiatrists are insufficiently knowledgeable
about legal matters to be relied on by the courts. The ideal expert witness,
trained in forensic psychiatry and in juvenile mental health, is extremely hard
to find.
Given the likelihood that a general psychiatrist will have to examine a
juvenile, simply because there are not enough child and adolescent specialists
to do the work, it is important to provide some guidance to the generalist as to
how to approach the task. Basic to any evaluation of juvenile mental health is
the developmental perspective, that is, the understanding that children and
adolescents are in a normal process of change over time, that the criteria
against which they are to be measured depend on the particular phase of
normal development through which they are passing. What one finds in in-
ASSESSMENT FOR LEGAL PURPOSES 185
fants is different from what one finds in toddlers, which is distinct from early
childhood, middle childhood, late childhood, preadolescence, early adoles-
cence, middle adolescence, and late adolescence. Each of these normal devel-
opmental stages is marked by its own constellation of bio-psycho-social charac-
teristics. Although most general psychiatrists lack experience with the diagnosis
and treatment of disturbed juveniles, they have some experience in dealing
with normal children and adolescents, if only in the course of their daily lives.
Thus, although the general psychiatrist may not be able to say exactly what is
wrong with an individual juvenile, or exactly how that youngster should be
treated, it is not unreasonable to believe that the general psychiatrist can detect
that someone is unusual and that some treatment is warranted. Although read-
ing of textbooks in child and adolescent psychiatry is useful, there is no sub-
stitute for the general psychiatrist having had interpersonal contact with a wide
range of children and teenagers, so as to have an experiential baseline to
compare with any given juvenile being examined. Although some might argue
that the general psychiatrist is no better able to detect a disturbedjuvenile than
the average citizen is able to do, at least the general psychiatrist is no worse
equipped for the task.
The psychiatrist is, in fact, better equipped than the average citizen. The
average person is not trained to consider the functional capacities, the signs
and symptoms of disturbance, that may indicate the presence of a mental
disorder. A psychiatrist can be expected to inquire as to the juvenile's relations
with his family, his peers, his performance at school, his use of leisure time, his
physical health, and (if appropriate) his sexual development, his job history, his
religious commitment, his manifestation of psychiatric symptoms. The psychia-
trist is trained not simply to recognize that something about the specific juve-
nile is unusual in comparison to others of the same age, but to specify what that
unusual factor appears to be. Further, with the advent of the third edition of
the American Psychiatric Association's Diagnostic and Statistical Manual of Mental
Disorders and the new revised third edition, the psychiatrist has been given the
objective and operational criteria to make a diagnosis of the child or adolescent.
Thus, although the specialist in juvenile psychiatry may be better trained and
more experienced in the diagnosis and treatment of children and adolescents,
it is not unrealistic to ask the general psychiatrist to detect the presence of
psychopathology in youngsters.
It may often be sufficient to address three imprecise, but important, ques-
tions: Is this youngster disturbed? How disturbed is this youngster? What is the
prognosis for this youngster? A specific diagnostic estimate may not be re-
quired for the legal issue under consideration; a "rough and rapid" assessment
may be required. For example, the court may want to know if a given juvenile
should be psychiatrically hospitalized for his immediate protection or for the
protection of the community; what is sought is as rapid an evaluation as is
possible, rather than the most thorough that is possible (the complete evalua-
tion can be done later, perhaps in a psychiatric inpatient unit of a hospital).
The provision of such a rapid assessment can be understood as an integra-
tion of the developmental approach with the functional assessment. First,
186 RICHARD ROSNER
globally, is this juvenile different from the majority of juveniles of his age?
Second, in what particular ways is the juvenile different from his age mates?
These two questions correspond, in rough fashion, to the court's concern as to
whether the child is disturbed and as to the severity of the disturbance. The
examining psychiatrist should review the available court records, including
materials developed by the probation department and data submitted by all
parties to the legal proceedings, should interview the youngster and should
interview at least one adult who knows the youngster, such as a parent, a
guardian, a teacher, a social worker.
More than one source of information about the child or adolescent is
needed, both because the juvenile may be realistically reluctant to be honest (it
may not be in his interest to be honest) and because the juvenile may lack
perspective and insight into his own problems. Even in therapeutic (as opposed
to forensic) practice, it is rare for a juvenile to seek help for himself. He is
usually referred by some adult authority, a parent or a teacher, who is able to
state the indications of disturbance more forthrightly than the juvenile. Thus,
the report of the arresting police officer, the files of the prosecutor, the report
from the school, the report from the social service agency, the statement of the
parent or the foster-parent are essential supplements to the interview with the
juvenile. Although it should not be assumed that the reports from the adult
authorities are completely trustworthy, they should be given careful considera-
tion. Often, such reports will provide the basis for the interview with the
juvenile, who might otherwise not even mention the materials contained in the
statements from the adults. A child who has nothing to say about his problems
may become surprizingly vocal when presented with what adult authorities
have said about him.
How does one talk with a child? With difficulty, depending on one's expe-
rience in attempting to communicate with youngsters. In general, especially for
forensic purposes where time is often an issue, it is useful to structure the
interview, rather than to offer a nondirective, open-ended approach. The
juvenile should be told who the examiner is, why the examination has been
requested, the fact that it is not for therapeutic purposes, and the limits of the
confidentiality (if any) surrounding the examination. The doctor should make
an effort to modify his vocabulary and style of expression to accord with the
juvenile's age. Simpler words and shorter, uncomplicated sentences are appro-
priate with younger children. Essentially customary vocabulary and expression
are reasonable to use with older children and adolescents. The juvenile should
be encouraged to ask for a clarification if he does not understand what is said
by the examiner. Often a question that is misunderstood can be made com-
prehensible by rephrasing in simpler, more direct language. The examiner
should feel equally free to ask the juvenile to explain words and ideas with
which the physician is unfamiliar. It is not helpful to talk down to a teenager,
nor to use slang or colloquial expressions that are not part of one's ordinary
language in order to attempt to create a sense of relatedness with the young-
ster; such behaviors are likely to appear insincere and condescending. Most
children and adolescents are aware of the gap that exists between them and
adults in language and usage; tact, patience, and an honest attempt to commu-
nicate constitute the best approach to such verbal problems.
It should be obvious that the same skepticism regarding adults verbal
productions also apply to children and adolescents. It is not merely a matter of
lying and deliberate distortion of the facts. Rather, it is that the meaning and
significance of what is said may not be apparent. Youngsters may say one thing
and mean another, just as adults do. Similarly, youngsters may not know why
they think, feel, and act as they do, just as adults are often ignorant of the roots
of their thoughts, affects, and behaviors. It is important to consider how some-
thing is said, in what context it is said, with what emotional tone it is said, with
what facial expression and physical gestures it is said, as well as the formal
content of the verbal statements. This is no different with children and adoles-
cents than it is with adults. Although the juvenile's verbalizations mean some-
thing, exactly what that something may be can be difficult to determine, as with
adults. The examining psychiatrist may wish to be forthright with the court
regarding doubts that he has about the gap between what a juvenile has said
and what the juvenile may mean; inferences and interpretations should be
labeled as such, so that the trier of fact can distinguish between hard data and
opinion.
What should the doctor ask? The answer depends on the specific legal
issue under consideration. If the issue is a custody determination between two
competing parents, a large portion of the interview with the juvenile should be
directed to the history and present nature and quality of the juvenile's rela-
tionship with each parent. If the issue is competence to stand trial, the bulk of
the examination may be directed to the juvenile's understanding of the charges
against him, the court proceedings, and his capacity to assist his lawyer. How-
ever, if the issues are those which we noted earlier, summed up in the question
"Is this juvenile disturbed and how disturbed is this juvenile?" the discussion
should systematically address the quality of functioning of the child or adoles-
cent. Questions should include a review of family relations, peer relations,
school performance, leisure time, physical health, sexual function (if appropri-
ate), employment, religious involvement, and psychiatric symptoms. With re-
gard to each of these items, the examiner should attempt to assess the juvenile's
status as being good, adequate, or impaired. The more the number of impair-
ments, the more severe the pathology. The longer the impairments have been
in evidence, the graver the prognosis. For many legal purposes, related to
immediate disposition of the juvenile, for example to home, to detention, or to
a mental hospital, such a rapid assessment of severity of psychopathology and
likelihood of rapid response to psychiatric treatment are essential.
As this chapter is meant to encourage general psychiatrists and forensic
psychiatrists who have not graduated from specialty residency programs in
child and adolescent psychiatry to up-grade their knowledge and skills, so as to
make themselves more competent and more credible as expert witnesses in
cases related to juveniles, a brief digression regarding how to pursue relevant
study is in order. It is recognized that some specialists in child and adolescent
psychiatry will question whether it is ever appropriate for a nonspecialist to
188 RICHARD ROSNER
provide allegedly expert testimony about juveniles in court. It is this author's

experience that the majority of medical practitioners, including specialists in
child and adolescent psychiatry, have difficulty keeping up-to-date with pro-
gress in medical science. Despite having once completed a residency in child
and adolescent psychiatry, supposedly trained specialists may have fallen be-
hind current knowledge. A general psychiatrist or forensic psychiatrist who is
possessed of the latest relevant information may be a better expert witness than
a specialist whose data is dated and whose skills are outmoded. In this science,
as in all others, knowledge fixed at one point in time is soon obsolete, in-
complete, and faulty. The general and forensic psychiatrist is encouraged to
learn the relevant information and specific techniques to fill the gap in his
prior formal training.
It is, of course, impossible to substitute reading this or any other single
chapter for the full range of didactic and clinical experiences provided in a
formally accredited residency training program in child and adolescent psychi-
atry. However, as it is unrealistic to expect that a substantial proportion of
general psychiatric practitioners will abandon their private practices to return
for 2 years of additional residency training, it is prudent to provide some
guidance to those general psychiatrists who will be called on to provide expert
testimony in cases that focus on children and adolescents. Fortunately, oppor-
tunities for self-education are excellent, both in number and quality.
A plethora of books are available dealing with the special psychiatric back-
ground knowledge required for work with juveniles. The list of Suggested
Readings at the close of this chapter indicates some of those which this author
has found useful in teaching medical students, residents, and general psychia-
trists attending postgraduate medical education courses; the relatively self-
explanatory titles may guide the inquiring reader to those texts which are most
relevant to his immediate needs and interests. In general, it is best to start with
some introductory overview of normal development in childhood and adoles-
cence. Thereafter, a review of the main forms of juvenile psychopathology
would be appropriate. Because of the importance of the work of Freud and his
followers and that of Piaget and his students, the forensic psychiatrist who
hopes to testify about facts will have to be alert to sift out the documentable
data from theoretical speculations; separating the wheat from the chaff is not
always an easy task. A major step forward in this regard has been the develop-
ment of the atheoretical third edition, and subsequent revised third edition, of
the American Psychiatric Association's Diagnostic and Statistical Manual, DSM-
III and DSM-III-R.
Also available, as a supplement to independant readings, are postgraduate
continuing medical education courses. These may be provided by reputable
national professional organizations at their annual scientific and educational
conventions. The American Academy of Child and Adolescent Psychiatry gen-
erally meets in October yearly. The Society for Adolescent Psychiatry holds its
convention each May. Some of these courses are practical workshops that teach
specific techniques, so that the general psychiatrist can have an experience
approximating that provided in some specialized residency programs, howbeit
briefly. The American Academy of Psychiatry and the Law, through its com-
mittee on child and adolescent psychiatry, periodically may offer subspecialty
presentations on forensic juvenile psychiatry at its annual conventions in Oc-
tober. Relevant courses may often be provided by large general mental health
organizations, such as the American Psychiatric Association and the American
Orthopsychiatric Association at their annual meetings. Detailed statements of
the exact courses offered by any of these national associations may be obtained
in advance of their conventions by writing to their central offices to be placed
on the mailing list for future programs.
Supervision in hands-on case experience may be obtained in a variety of
manners. One can hire an experienced child and adolescent psychiatrist to
provide hourly private case supervision, in much the same manner that such
private fee-for-service supervision is available in learning psychotherapy, psy-
choanalysis, or forensic psychiatry. One can take a part-time job with a pro-
gram providing services to children and youths, obtaining on-the-job training;
such opportunities may exist in Family Court mental health clinics or in Child
Guidance Centers. Many hospital facilities for psychiatric care and treatment of
juveniles are staffed by general psychiatrists under the supervision of child and
adolescent psychiatric specialists; part-time employment may be available in
such settings. Finally, in some instances, half-time residency programs in child
and adolescent psychiatry are available in some locations.
Although one can never have too many credentials as an expert witness,
courts are often more interested in the fact that a psychiatrist has had practical
experience, has kept abreast of relevant literature, and has obtained pertinent
training through continuing medical education than in the technical fine point
of whether he has graduated from a residency in child and adolescent psychia-
try at some time in the past. The general psychiatrist who has dilligently en-
gaged in systematic independant study, and who is prepared to document that
fact, can expect to be regarded as a credible witness by most courts.
Assessment of juvenile psychopathology is founded on several factors that
are unique to juveniles. These include the fact that children and teenagers are
often unable to be reliable historians, the fact that they are in a series of
processes of changes in their physical and psychological development so the
way that they appear at the present moment may not correlate well will how
they have been in the relatively recent past and how they will be in the relatively
near future, and the fact that their motivation to participate in a psychiatric
evaluation may be minimal notwithstanding its importance to their own well-
being. As a result, several alterations in the procedures used in the evaluation
of adults are indicated in the assessment of juveniles.
To cope with the reliability of personal history issue, it is valuable, and
some would say essential, to utilize more than one source of information. In
addition to interviewing the juvenile, data should be obtained from at least one
of the juvenile's parents. Information should be sought from the school that
the child or adolescent is supposed to be attending. If there are other persons
who may reasonably be presumed to have data about the juvenile's behaviors
away from parents and school, it is worth the effort to contact them for that
190 RICHARD ROSNER
information; such persons may include the athletic coach of a team the juvenile
has participated in regularly, the leader of the scout group in which the juve-
nile is enrolled, the religious counsellor who supervises the child or adolescent's
activities in church, synagogue, or religious education, the same-sex best friend
and the opposite-sex best friend of the juvenile, the aunts and grandparents
who provide supervision when the parents are unavailable, and anyone else
who is likely to have pertinent data. This is not to suggest that all these persons
must be interviewed in every case, but to indicate the range of persons who
should be considered in determining with whom to seek interviews to supple-
ment the information obtained from the child or adolescent.
There are a variety of reasons for the unreliability of children and adoles-
cents as personal historians. Part of the difficulty is the juvenile's lack of psy-
chological maturation, with a concommitant inability to make abstract gener-
alizations from specifically concrete phenomena; an inability to see the forest
because of the trees.
One of the many methods for eliciting data from a teenager who does not
want to speak, or who persistently denies that there is anything to discuss, is to
interview that adolescent in the company of the person complaining about him
or her. A juvenile who denies misbehavior when interviewed alone may be
unable to resist the urge to challenge his or her parent's accusations in a joint
interview, as in cases for the assessment of whether or not the juvenile is a
Person-In-Need-of-Supervision (PINS). If that is not feasible, as in delinquency
cases or criminal offense cases, reading the legal complaint form to the teen-
ager may prompt both a denial and a statement of the adolescent's side of the
story. However, in some instances, there is no way to engage the juvenile into a
relevant discussion and one must have recourse to the data from outside
sources, as noted earlier.
The data that one seeks should be broad:
• How is the juvenile relating with his parents?
• How is the juvenile relating with his siblings?
• How is the juvenile relating with peers at school?
• How is the juvenile relating with adults at school?
• How does thejuvenile behave in structured settings, such as a classroom?
• How does the juvenile behave in relatively unstructured settings, such as
a free-play period in school?
• How does the juvenile fill his discretionary time?
• How does the juvenile function at chores?
• How does the juvenile function in religious activities?
• How does the juvenile manage aggressive impulses?
• How does the juvenile manage sexual impulses?
• How is the juvenile's physical health?
• How does the juvenile manifest any psychiatric symptoms?
What is sought is a range of functional assessments. One seeks a specific rating
for each of a variety of functional capacities and manifestations of impair-
ments. Another factor is the juvenile's difficulty in attempting objective self-
observation, the capacity, as it were, to step outside of oneself and view one's
behavior from a neutral vantage. For teenagers, this factor is combined with
powerful affective forces, so that the adolescent's views often become convic-
tions. Adolescents tend to be present-tense oriented, with a dismissal of the past
as bygone and irrelevant. (The teenager who attempted suicide last week be-
cause her boyfriend left her may not mention the event today because she has
fallen in love with a new boy, or insist that it does not matter any more because
she feels quite differently at present.) These matters are apart from the issue of
conscious and deliberate attempts to manipulate the data.
The deliberate attempts to conceal and to alter information are often the
result of the internal emotional conflicts that are hallmarks of adolescent psy-
chological development. Teenagers notoriously struggle with conflicting needs
for dependence versus independence, passivity versus assertiveness, so that an
interview is superimposed upon affective turmoil. Younger children are often
concerned to preserve the relationships with their parents and fear to reveal
facts that they experience as disloyal or that might disrupt familiar parent-
child attachments, for example, facts about sexual abuse. Juveniles are, of
course, able to have many of the same reasons that adults have for deliberately
distorting data, such the desire to obtain their own ends, and are able to
demonstrate evasiveness, passive-resistant noncooperation, and outright lying.
As in all forensic psychiatric evaluations, the interviewer must not naively
succumb to the belief that he is being told the truth. A juvenile should be
considered as able to be distorting the truth whenever his or her lips are
moving. The same level of suspicion regarding self-serving testimony that one
has with adults is appropriate with juveniles. The only protection that one can
have against naive over-credulity is a high index of suspicion as to the reliability
of what one is told in a forensic examination. All data should be scrutinized for
consistency, coherence, likelihood, self-serving motivation, and should be re-
garded as provisional, being in need of confirmation from other sources before
being believed.
It may be sufficient to have a simple evaluation of each function previously
enumerated as being impaired, adequate, or superior. What is sought is an
assessment of the strengths and weaknesses of the juvenile in question. For
example, a child elected as president of his school class might be regarded as
having superior abilities in peer relationships, whereas another child who was
consistently picked on by his classmates might be regarded as having impaired
peer relationships. Although numerical ratings may give such assessments an
aura of scientific precision, all that is usually at issue is whether or not there is a
functional problem.
Thus, one could chart a functional assessment of a juvenile, as follows:
.-
Free
Parents Sibs Peers Teachers Grades Play Time Work Anger Sex
192 RICHARD ROSNER
Each functional area can be scored: (+) = superior function, (ok) = adequate
function, (-) = impaired function. The resulting pattern can be then evalu-
ated: the more impairments, the more severe the pathology. The actual
number of items charted could be extended to include the presence or absence
of physical health problems and overt symptoms of psychological illness. The
value of the chart is as an aid to the memory of the examiner and for potential
graphic display in the court as a visual aid to the judge and the jury. In general,
a child or adolescent who has across-the-board impairments will be recognized
as ill by laypersons. The more areas of adequate functioning that exist, the less
severe the illness. In many cases, the court is less interested in the formal
diagnostic nomenclature that is applied to a juvenile than it is in how func-
tionally impaired the juvenile is in the activities of daily living.
Because of the fact that juveniles are in a process of change, both phys-
ically and psychologically, it is important to integrate this functional current
assessment with a developmental perspective. For each of these tasks of every-
day living, there is a prior relevant developmental history. One may wish to
think of the unfolding of a pattern of functioning over the course of time,
organizing the juvenile's life into developmental periods: neonatal, infancy,
toddler, early childhood, middle childhood, late childhood, preadolescence,
early adolescence, middle adolescence, late adolescence, and preadulthood.
These terms need not refer to the same period of time with each juvenile, for
example, in our culture, girls begin puberty at a younger age than boys, so that
it is the developmental phase that is of issue rather than the chronological age.
Thus, one could integrate the functional assessment chart with the devel-
opmental course, to create a gridwork such as Figure 1. The gridwork provides
a structure to guide the psychiatrist's collection of relevant clinical information.
There may be circumstances under which all of the current and past data
indicated on the gridwork may not be needed, but the form alerts the examiner
to the scope of a reasonable assessment of the severity of juvenile psychopathol-
ogy.
In general, the longer a particular functional impairment has been pre-
sent, that is, the more developmental phases in which the juvenile has a history
of specific impaired functioning, the more likely it is to persist in the future;
things that have been so are likely to remain so. Thus, the gridwork can pro-
vide a prognostic estimate in addition to an estimate of severity of psycho-
pathology. The longer a maladaptive pattern of functioning has been estab-
lished, the more likely that therapeutic intervention will have to be intense and
prolonged to effectuate a constructive change. This is merely a restatement of
the fact that acute problems are usually more amenable to treatment than are
chronic problems.
CASE A
Tom, a 16-year-old white single male was referred for evaluation in aid of
sentence, having been charged with a felony level theft that was plea-bargained
down to a misdemeanor. He was likely to be granted probation and the issue was
whether or not he should be required to have psychiatric treatment as one of the
conditions of probation. On direct examination, Tom denied the offense, claim-
Free
Parents Sibs Peers Teachers Grades Play Time Work Etc.
Neonatal
Infant
II
Toddler
Early
childhood
Middle
childhood
Late
childhood
Preteen
Early teen
Mid teen
Late teen
Preadult
'-
Figure 1. Functional assessment gridwork of juvenile developmental periods.
ing that he only entered a plea because his lawyer told him to do so to escape the
risk of a felony trial and possible conviction. He denied any prior psychiatric
problems. Mental status revealed a thin white male of average height, dressed in
T -shirt, blue-jeans and sneakers, with a mild acne problem, whose speech was of
conversational rate and volume, who presented his thoughts in a logical, relevant
and coherent manner, whose mood was self-described as "okay" and whose appar-
ent emotional tone was neither anxious nor depressed, who was oriented to
time/ place/ person , was able to perform serial seven subtractions from one hun-
dred, knew the names of the presidents from Reagan back to Kennedy, was able to
give adequately generalized interpretations of proverbs and whose response on
routine questions regarding social judgments was adequate.
An interview with Tom's mother provided useful information. Tom had a
long history of prior contact with the family court for theft, having been given
warnings and finally brief probation in that separate juvenile jurisdiction system,
dating back to his preteen period, His relationship with his parents had been
poor: as long as his mother could recall he was a liar and he had been repeatedly
found to be stealing money from household funds. He had been truant from
school intermittently since his earliest teen years. On several occasions his teachers
had reported him for initiating fights with other students. In response to parental
efforts to discipline him, Tom had run away from home half a dozen times or
194 RICHARD ROSNER
more. Neighbors had complained that Tom had intimidated their own children
into giving him money. The parents had tried to use family court to frighten Tom
into better behavior, but had been discouraged by the fact that threats and proba-
tion had little effect on him.
Using the gridwork as a structure, the author advised criminal court that
Tom's impaired functioning with parents, peers, teachers, and self-control
were suggestive of at least moderate psychopathology and that the history of
problems dating back from his mid teens to preteens made the likelihood of
spontaneous remission remote. The specific diagnosis, conduct disorder, was
less meaningful to the court than the enumeration of the problems in social
adaptation.
CASE B
Sandy, a 14-year-old white single female, was referred for examination in
relation to a civil suit by her parents against the owners of their apartment house.
They alleged that Sandy had suffered psychological damage as a result of being
raped in the basement of the apartment house; the rapist presumedly had entered
through a broken-locked door; the landlords might be held liable for failure to
provide adequate security to the building.
Sandy was fidgety and made minimal eye-contact during the initial interview.
She was polite, deferential, and laconic. Her speech was soft, but of such terseness
that its rate was not easily estimated. She reported feeling "ashamed" and "unhap-
py," her apparent emotional tone was both anxious and sad. Her thoughts were
logical, relevant, and coherent. Her sensorium was intact in routine testing.
An interview with Sandy'S parochial school teacher and with the priest in her
parish supplemented interviews with Sandy and her parents. Because of the fi-
nancial interest that the parents had in the resolution of the legal case, it was
believed essential to obtain data from non family witnesses to Sandy'S behavior.
The data indicated that Sandy had been a good student throughout her academic
career, but that there had been a marked deterioriation in her grades since the
alleged rape. Further, Sandy had been active in extracurricular activities, having a
long-standing participation in the church's charity drives, as well as a commitment
to group singing; since the alleged rape, she had dropped out of those social
activities. As these changes in Sandy'S behavior dated to after the rape, yet before
the initiation of the law suit, it was thought likely that they represented genuine
reactions to the stressful event. As there was a prior history of good adaptation, it
was thought likely that treatment would be helpful to Sandy, especially if it were
provided rapidly and if the law suit was resolved. This information was conveyed
to the landlords' insurance company, which had requested the independent psy-
chiatric evaluation, and was regarded as valuable in the decision to offer a cash
settlement.
CASE C
Billy, a 17-year-old single black male, was referred for an evaluation of com-
petence to stand trial, having been accused of disorderly conduct and assaulting a
police officer while resisting arrest. Billy's lawyer provided a long list of the psychi-
atric prior history, primarily with special school services for the developmentally
disabled. On interview, Billy was difficult to communicate with and seemed to
have essentially no understanding of the charges against him, of basic court pro-
cesses, nor was he regarded as able to cooperate effectively with his attorney (who
was present at the interview). The issue was less whether or not Billy was compe-
tent to stand trial (he was thought to be incompetent) and more whether or not he
could ever be restored to competence.
Records from the special school services indicated a long history of impaired
relationships with peers, inadequate intellectual functioning, strained rapport
with parents and siblings, impoverishment of utilization of free time and repeated
intelligence test data that placed Billy's IQ at between 50 and 65 over the course of
years. The court, the district attorney, and the complaining police officer were
advised of the findings. Billy was diverted from the criminal justice system into
more intensive care for the developmentally disabled.
These abreviated case reports, modified to conseal the identity of the real
juveniles, are meant to illustrate two principles: the need to obtain information
about the juvenile at issue from sources other than the juvenile himself and the
value of a developmental perspective for the assessment of psychopathology in
children and adolescents.
Although the thrust of this chapter has been to encourage general and
forensic psychiatrists to obtain the background information and technical skills
that were not included in their basic residency training, to learn on their own
about child and adolescent psychiatry, perhaps the most important item to be
learned is the limit of any program of systematic self-education. The self-
taught practitioner should be aware of instances in which he is not equipped to
do a competent juvenile psychiatric evaluation. In a simpler world, one in
which either a doctor was trained as a juvenile psychiatrist or he was not, either
he was competent to evaluate juveniles or he was not, this type of issue might
not exist. In the real world, in which issues of professional competence are
gray, rather than black or white, it is incumbent upon the general and forensic
psychiatrist to determine on a case-by-case basis whether or not his skills are
adequate. In some cases, it may be necessary to refer an attorney to a better
qualified child or adolescent psychiatrist. In some cases, it may be necessary to
work in close collaboration with either a pediatrician or a child and adolescent
psychiatrist. In some cases, psychodiagnostic assessment by an experienced
child and adolescent psychologist may be needed. Close cooperation may be
particularly appropriate in instances in which the legal background of the
forensic psychiatrist is required as well as the specific knowledge and skills of
the juvenile psychiatrist. The Delphic maxim, "Know thyself," meant "Know
your own limitations." That adage is as appropriate today as it was 2,500 years
ago.
SUGGESTED READINGS
Child Psychiatry
Barker P: Basic Child Psychiatry. New York, Science House, 1971.
Beitchman J: Child Psychiatry, Psychiatric Clinics of North America, vol 8, Philadelphia, W. B.
Saunders, 1985.
196 RICHARD ROSNER
Chess S, Hassibi M: Principles and Practice of Child Psychiatry, ed 2. New York, Plenum Press,
1986.
Erikson E: Childhood and Society, ed 2. New York, W. W. Norton, 1963.
Fraiberg S: The Magic Years, New York, Charles Scribners, 1959.
Freud A: Normality and Pathology in Childhood, New York, International University Press, 1965.
Gardner R: Therapeutic Communication with Children, New York, Science House, 1971.
Group for the Advancement of Psychiatry: Divorce, Child Custody and the Family. New York,
Mental Health Materials Center, 1980.
Group for the Advancement of Psychiatry: The Process of Child Therapy. New York, Brun-
ner/Mazel, 1982.
Group for the Advancement of Psychiatry: Psychiatric Consultation in Mental Retardation. New
York, Mental Health Materials Center, 1979.
Harrison S, McDermottJ: Childhood Psychopathology, New York, International University Press,
1972.
Josephson M, Porter R: Clinician's Handbook of Childhood Psychopathology, New York, Jason
Aronson, 1979.
Kessler J: Psychopathology of Childhood. Englewood Cliffs, NJ, Prentice Hall, 1966.
Mussen P: The Psychological Development of the Child, Englewood Cliffs, NJ, Prentice Hall, 1963.
Noshpitz J: Basic Handbook of Child Psychiatry. New York, Basic Books, 1979.
Piaget J, Inhelder B: The Psychology of the Child, New York, Basic Books, 1969.
Rosner R: Family Law, Domestic Relations and Forensic Psychiatry, in Critical Issues in Ameri-
can Psychiatry and the Law, Springfield, Ill, Charles C Thomas, 1982.
Simmons, J: Psychiatric Examination of Children, Philadelphia, Lea and Febiger, 1987.
Spitz, R: The First Year of Life: A Psychoanalytic Study. New York, International University Press,
1965.
Stone L, Church J: Childhood and Adolescence, ed 2. New York, Random House, 1968.
Adolescent Psychiatry
Aichhorn A: Wayward Youth. New York, Viking, 1963.
Bios P: On Adolescence: A Psychanalytic Interpretation. New York, Free Press, 1962.
BIos P: The Young Adolescent. New York, Free Press, 1970.
Caplan G, Lebovici S: Adolescence: Psychosocial Perspectives. New York, Basic Books, 1969.
Dusek J: Adolescent Development and Behavior, Englewood Cliffs, NJ, Prentice Hall, 1987.
Eissler K: Searchlights on Delinquency. New York, International University Press, 1949.
Erikson E: Identity, Youth and Crisis, New York, W. W. Norton, 1968.
Feinstein S et al.: Adolescent Psychiatry, New York, Basic Books, vols 1-3, 1971-1974.
Feinstein, S et al.: Adolescent Psychiatry, New York,Jason Aronson, vols 4,5,1975-1977.
Feinstein, S et al.: Adolescent Psychiatry, Chicago, University of Chicago Press, vols 6-10 and
12-14, 1978-1982 and 1985-1987.
Group for the Advancement of Psychiatry: Crises of Adolescence: Teenage Pregnancy, New York,
Brunner/Mazel, 1986.
Group for the Advancement of Psychiatry: Friends and Lovers in the College Years, New York,
Mental Health Materials Center, 1983.
Group for the Advancement of Psychiatry: Normal Adolescence, New York, Charles Scribners,
1968.
Group for the Advancement of Psychiatry: Power and Authority in Adolescence, New York,
Author, 1978.
Heacock D: A Psychdynamic Approach to Adolescent Psychiatry, New York, Marcel Dekker, 1980.
Holmes D: The Adolescent in Psychotherapy, Boston, Little, Brown & Co., 1964.
Josselyn I: Adolescence, New York, Harper and Row, 1971.
Josselyn I: The Adolescent and His World, New York, Family Service Association of America,
1952.
Meeks J: The Fragile Alliance, Baltimore, Williams & Wilkins, 1971.

Miller, D: Adolescence: Psychology, Psychopathology and Psychotherapy, New York, Jason Aronson,
1974.
Offer D: The Psychological World of the Teen-ager, New York, Basic Books, 1969.
Rosner R: Adolescent Psychiatry and the Law, Critical Issues in American Psychiatry and the Law,
vol 2. New York, Plenum Press, 1985.
Rutter M, Hersov L: Child and Adolescent Psychiatry: Modem Approaches, ed 2. Boston, Blackwell
Scientific Publications, 1985.
Sugar M et al.: Adolescent Psychiatry, vol II, Chicago, University of Chicago Press, 1983.
12
Emotional, Cognitive, and
Moral Developmental
Considerations in Interviews of
Adolescents for Forensic
Purposes
ROBERT WEINSTOCK
The forensic psychiatrist involved with the courts and legal system can be
involved in many capacities. He or she is more likely to be involved in a
treatment or treatment-related capacity in work with adolescents than in work
with adults. Except for the most severe offenses in which the adolescent may be
tried as an adult, some interest in treatment still is evident for adolescents
involved with the criminal justice system, despite the general trend to become
more punitive and non treatment oriented.
The entire juvenile justice system originally was developed to divert the
youthful offender from adult courts and prisons in order to prevent the devel-
opment of criminal careers. The differences, however, often have been more
illusory than real. Even status offenses such as truancy, run-aways, etc. in
reality often have resulted in treatment of the adolescent like a criminal with
out legal protection or rights and without addressing the underlying precipi-
tants or problems.
Forensic psychiatrists can become involved with the need to interview an
adolescent either as part of a standard forensic evaluation in regard to a legal
issue relevant to a crime, to help the court in making a disposition, or in a
ROBERT WEINSTOCK· Department of Psychiatry, University of California-Los Angeles,

Los Angeles, California 90024; Department of Medicine, University of California-Irvine,
Irvine, California 92717.
199
200 ROBERT WEINSTOCK
treatment capacity. Interviewing adolescents, even under the best of circum-

stances, can present a challenge. An unmotivated adolescent who is coming for
an evaluation because of a court referral can be a special challenge. Few psychi-
atrists have special training in working with adolescents. Adult psychiatrists
frequently have no training or experience working with them. Child psychia-
trists often have little training or experience with adolescents.
Because the forensic psychiatrist often must gather a great deal of infor-
mation in a short time, rapport must be established quickly. As opposed to
work with adults, a psychiatrist must be more of a real person in work with
adolescents, much like what is required to establish rapport with severely dis-
turbed adults. It is essential to be real and to interact and not allow prolonged
silences. Adolescents usually interpret silence as disinterest, which increases
their anxiety. Any discussion, no matter how trivial, is preferable to silence. If
necessary, the psychiatrist should carryon the conversation, periodically invit-
ing and encouraging the youngster's participation. Even negative feedback, if
not overly critical and given in an atmosphere of honest interest and concern,
can be better than silence. At least it helps persuade the adolescent that the
psychiatrist is honest.
It is important, however, not to allow the interview to become an inter-
rogation. The adolescent should be given an opportunity to describe in his own
words what is going on. It is the best way to obtain meaningful information. It
is helpful to make empathic comments that show that the psychiatrist knows
that the evaluation itself must be difficult and anxiety provoking and that the
psychiatrist is aware that the adolescent may feel angry if he or she has been
compelled to have the interview. If possible, open-ended questions are most
useful, that is, questions which do not lend themselves to "yes" or "no" answers
but which allow adolescents to talk about themselves. Some knowledge of the
background and psychodynamics of adolescents can be helpful in understand-
ing what conflicts they are experiencing and how the problems developed.
Adolescent turmoil was previously considered to be a normal part of ado-
lescence. More recent studies by Offer l have shown that most healthy adoles-
cents do not go through significant turmoil. However, those adolescents who
become involved with the legal system frequently are in great turmoil. Adoles-
cence is a time of rapid change with the resurgence of sexual feelings and
attempts at independence and conflicts resulting from such efforts. According
to psychoanalytic theory, adolescence is a time in which sexuality reappears
after the latency years. There is a second chance to work out problems about
self-identity not resolved in earlier years. Adolescence is also a time of in-
creased sensitivity. Deaths and divorces can have the greatest impact during
this period, just as during the years immediately prior to the child's latency
years.
Because of the frequent turmoil in adolescence, temporary psycho-
pathology can be seen that does not have the same long-term significance or
prognosis as it may have with adults. It is often difficult to distinguish such
temporary turmoil from severe pathology, such as schizophrenia or major
affective disorders, which can also make their appearance during these years.
In particular, antisocial personality should not be used as a diagnosis for ado-
DEVELOPMENTAL CONSIDERATIONS 201
lescents. DSM-III-R appreciates this fact by using the diagnosis of conduct

disorder for children and adolescents and reserving antisocial personality for
adults. Some forensic psychiatrists with little experience with adolescents do
still use antisocial personality inappropriately.
A study several years ag0 2 suggested a tendency to use antisocial person-
ality as a diagnosis inappropriately in situations where the psychiatrist disliked
the patient without any evidence of the required diagnostic criteria. If the
person had been injail, this tendency was especially increased. Adolescents can
stir up strong reactions-both negative and positive-in evaluations. It is es-
pecially important not to react to an angry, uncooperative adolescent by using a
label of antisocial personality inappropriately, as a manifestation of anger or
negative countertransference.
As discussed earlier, rapport is a true challenge in evaluating adolescents.
If the psychiatrist is involved in a forensic evaluation as opposed to a therapeu-
tic situation, it is essential to establish rapport quickly if the examination may be
of potential benefit to the adolescent. The adolescent's frequent mistrust of
adults may not allow him to be self-revealing to a forensic psychiatrist who is
trying to obtain helpful information. If the evaluation of the adolescent is for
the side which is against the adolescent, rapport without clear-cut and continu-
ing warnings about the purpose of the examination would be dishonest and
unethical on the part of the evaluator.
However, the adolescent may mistrust all adults, even the forensic psychia-
trist hired by his or her attorney, as well as the attorney representing him. This
factor should be considered in an evaluation of the adolescent's competency to
stand trial. A very frightened, mistrustful, and even angry adolescent may be
incapable of assisting his attorney in his defense. Rapport is an essential prereq-
uisite before any meaningful information can be solicited. Rapport can often
be achieved and anxiety reduced by discussing subjects of interest to the adoles-
cent, such as sports or movies. For adolescents interested in sports, discussion
about it can yield valuable information about peer relations and aggressions.
Even which sports an adolescent likes to play can be significant. Team sports
are different from individual sports. Aggressive and competitive violent sports
have different implications than less competitive and nonviolent individual
sports. Informal language and an informal situation, such as not sitting behind
a desk and using current language, can be useful if it feels natural. However, it
would seem false and phony to wear the latest fad or use heavy slang.
With adolescents, there is probably a greater danger of the adolescent
hiding pathology because he is afraid of psychiatrists and afraid of being
thought crazy than there is of sophisticated malingering. Feigning sanity in
order to conceal feared psychopathology was a problem described earlier by
Diamond. 3 Most adolescents would not be capable of malingering mental ill-
ness in a manner which could not be detected by an evaluating psychiatrist.
Sometimes an adolescent charged with a crime may do a poor job of malinger-
ing insanity in a feeble attempt to be excused for a crime. This readily detected
malingering, however, may sometimes obscure truly mitigating, underlying
severe pathology that even the adolescent is afraid to acknowledge.
Because of these many risks, it is impossible in my opinion to make any
meaningful forensic evaluation of an adolescent in a brief interview. It is prob-

ably necessary to have at least several interviews in order to establish rapport
that will enable the adolescent to reveal adolescent "secrets." Such revelations
will enable the evaluator to understand truly why the adolescent tends to be-
have the way he or she does. Unfortunately, the fees for examinations of
adolescents paid by courts frequently are inadequate to encourage an adequate
examination by the evaluator. In addition, evaluators of adolescents frequently
have little experience with adolescents or relevant training.
The most essential thing in working with adolescents is to be honest and to
be oneself. It is important not to playa role. Adolescents do much testing to see
whether adults can be trusted. Adolescents in trouble with the law are es-
pecially mistrustful. It is important to be warm, yet consistent and firm. It is
also necessary to be flexible and not rigid. It is important to understand adoles-
cent rebellion without overidentifying with it. Adolescents frequently rebel
against their parents' values. In my experience in a college setting, adolescents
currently rebel by frequently becoming more conservative, materialistic, self-
interested, and more pro law and order than their parents. This contrasts with
the sixties and seventies when adolescents usually rebelled by becoming more
liberal or radical than their parents and exhibited greater concerns about
society.
In treatment of adolescents, it is impossible to treat the adolescent without
some attempt to include the family if there is an involved family. Although
parents may not be the ogres psychiatrists previously thought, it is crucial not to
ignore family pathology. Problems may sometimes be causal or develop as part
of an interaction between the adolescent and the family, and the problems
should not be totally relegated to either one to the exclusion of the other.
Parents can make problems, not because they are ogres, but because of their
own pathology, and they may use an adolescent for their own unconscious
needs. In extreme cases, either violent or sexual child abuse by parents can
cause severe problems. Such cases seem more frequent than had been recog-
nized previously.
It is essential to work with an involved family in order to prevent their
sabotaging and undermining treatment just at the point that an adolescent is
making progress toward healthy separation-individuation, a development
which may threaten some parents. Frequently, however, with adolescents in
trouble with the law, families are uninvolved or have given up on their chil-
dren. Alternately, parents may be inconsistent and withdraw when the adoles-
cent needs them most. Undoubtedly, the adolescent can be very provocative.
However, it is important not to shift the blame totally from the family to the
adolescent, a frequent current trend. In my experience, the problems and
blame are shared by the adolescent and family. Family therapy can be essential
in ameliorating problems.
In treatment of the adolescent, it is essential not to focus totally on under-
standing how the problems developed, placing the blame entirely on the par-
ents. Too much emphasis on insight as opposed to change can result in the use
of therapy as a resistance or an excuse for not changing, yet all the time
appearing to work on the problem. Such impasses can lead to prolonged

therapies with minimal results. Instead, the treatment should focus on under-
standing how the problem developed, but should insist that the responsibility
for making changes rests now with the adolescent. The adolescent is no longer
a child, and the world is not the family. It is, therefore, not necessary for the
adolescent to continue maladaptive behavior patterns that may have been ap-
propriate as a child within the family, but not in the current world of the
adolescent.
In evaluating adolescents, it is important to distinguish current crises caus-
ing a change in behavior from more chronic conduct disorder problems. It is
always important to inquire, "Why now?" An adolescent who had been strug-
gling reasonably well with adolescence can develop problems and get into
trouble in response to external traumatic events. There can be desperate at-
tempts to hold the parents or family together in response to family conflict.
There can be a panic-like anxiety over guilt regarding imagined responsibility
for parental conflict. In some families the adolescent may feel that his problems
or his getting into trouble can provide a nexus around which the family can
rally together.
Other adolescents have trouble with the emotional developmental tasks
and stresses, which are an inherent part of adolescence. The additional stresses
of adolescence can highlight and activate points of relative weakness in the
personality structure. The upheaval of adolescence can bring into open view
unresolved maturational problems which a careful history can show to have
been present in a nontroublesome manner during earlier stages. On the hope-
ful side, adolescence can provide a second opportunity to work out these
problems.
In our present era of therapeutic pessimism and nihilistic readiness to
resort to cost cutting and punitive measures, it is critical not to misdiagnose
temporary adolescent turmoil as pre-antisocial personality behavior. Placing
such an adolescent in antitherapeutic juvenile halls or even adult prisons could
make such predictions come true by placing the adolescent in a brutal situation
that fosters bitterness and anger at society.
In working with an adolescent, it is also important not to engage constantly
in struggles where it is as important for the psychiatrist as it is for the adoles-
cent each to prove he or she is right. It is usually better to avoid the struggle
and even to point out to the adolescent that he or she can succeed in sabotaging
your attempts at treatment and can defeat you, but that in so doing he or she
would become the greatest loser, insofar as you will not be able to help the
adolescent or give an opinion to his or her attorney or the court, as the case
may be.
The timing of interpretations is especially important with an adolescent.
Adolescents can often be very adept at provoking anger. Even a correct in-
terpretation, when given in an angry context, will be seen as hostile and not
helpful and will fall on deaf ears even if true. For example, an adolescent may
have problems with narcissism and feel entitled, that the world owes him things
and that he need do nothing in return. If said, however, when the psychiatrist
is angry at the adolescent, it will perhaps correctly be perceived by the young-

ster as a hostile blow. However, if stated at a time when the psychiatrist is not
angry, but means to be helpful and to show how the adolescent does not
achieve his own goals in life by a manner that alienates others, then the in-
terpretation is much more likely to have impact and be heard. If the psychia-
trist is angry, it should be expressed directly and not disguised as an interpreta-
tion. Honest expressions are much more likely to lead to trust even if the
expression is one of anger.
It is also important to remember that except for the most verbal adoles-
cents, most feel that they cannot adequately convey their feelings by words.
Nonverbal signs can often be the best clues to the adolescent's true feelings.
Physical signs, such as shifting position, moving arms, tapping feet, moving
head and legs, often can be the best indication of what the adolescent is feeling.
COGNITIVE AND MORAL DEVELOPMENT
Another developmental concern is in the development of cognitive and

moral capabilities. The discussion in this section is about the development of
cognitive and moral capabilities as studied by Piaget and Kohlberg, and not
what has been termed "cognitive therapy." It is salient to consider that some
problems in adolescents may result from their not yet reaching mature levels of
cognitive or moral development. Such issues are frequently neglected in eval-
uations of adolescents who may be struggling to give an expression of maturity
and independence.
Forensic psychiatrists generally are relatively unfamiliar with the issues
and stages of cognitive and moral development as developed by Piaget and
Kohlberg. Psychiatrists generally are acquainted with the tests of "concrete"
thinking developed by Vygotsky and used to distinguish schizophrenia and
organic brain syndromes. Such tests are an integral part of the usual mental
status exam.
However, some of the difficulties in communicating with adolescents can be
a result of cognitive developmental difficulties. Many adolescents, as well as
many adults, have not yet reached the highest stage-the formal stage of think-
ing as described by Piaget, the stage of abstract thought. The majority of adoles-
cents also have not reached the highest stage in Kohlberg's analysis of moral
development. Many adolescents are partially at the formal stage of thinking in so
far as they do well on some of Piaget's tests but not others. Such problems in
thinking can be demonstrated by the inability of some adolescents to explore
alternatives to a suggested course of action.
At the beginning of adolescence many youngsters begin to make the
change into the formal stage of thinking as described by Piaget. Early adoles-
cents generally are fascinated by their new abstract thoughts and can spend
significant time playing with thinking and thinking about thinking. As a result
of their fascination with thinking, much adolescent thought is impractical.
Adolescents often almost believe they can alter the world by thinking about it.
Unlike the later adolescent, young adolescents and latency age children
tend to be oriented toward the present. They base their thinking on experience
and are unable to understand how present actions can help or harm them at a
later time. They cannot project their thoughts into the future. Impulsive ado-
lescents, and even many impulsive adults, never do seem to change in this
regard. Their thinking never does seem to enter the formal stage. One of the
problems is that they cannot consider alternative possibilities.
Changes in thinking in adolescents generally seem to parallel some of the
physical changes of adolescence. At the onset of puberty physical changes are
rapid. The lack of control over themselves physically also seems to pervade
their thinking. About a year after the onset of puberty, there can begin to
develop a more stable body image. Concurrent with the greater sense of con-
trol of their bodies, the adolescents can begin to think more about other people
and less about themselves. Adolescents begin to enter the formal stage of
thought. They can develop abstract ideas and hypotheses and develop future
plans. They can better understand the consequences of their actions. It is
important to remember, however, that such development of cognitive abilities
can be inconsistent, and adolescents may not always function at the formal
level, particularly when under stress. Not even all adults function at the formal
level. With the return to a cognitive test of insanity, as demonstrated by a
return in many jurisdictions to a McNaghten test for insanity, it is important to
consider that adolescents may not always know fully the nature or quality of
their actions or appreciate fully the wrongfulness of their actions. Their in-
ability to function at the formal stage may lead to their not always being able to
consider alternative possibilities or foresee the consequences of their actions. It
is important to take such factors into consideration, especially when an adoles-
cent is being tried as an adult. Moreover, an adolescent probably has not
reached the higher stages of moral development, as described by Kohlberg.
The "mental defect" in such cases may be the lack of cognitive and/or moral
maturational development in the adolescent, even if no serious emotional psy-
chopathology is present.
According to Piaget, cognitive development occurs in age-specific stages.
Each stage builds on the past ones and is dependent on them insofar as it
cannot occur without the development of the earlier stages. However, the
development is not constant and linear. An adolescent can reach the formal
stage in some areas of his thinking, yet not be there in other areas.
F1avel4 provides an excellent review of the development of the genetic
epistemological stages of Piaget, which will be summarized in the following
description of Pia get's stages. The first stage is the sensorimotor stage that
ordinarily occurs from age 0 to 2. This stage will not be discussed because it has
little relevance for adolescents, who will at least have passed through this ear-
liest stage.
The next stage is the preoperational stage of age 2 to 7, or the egocentric
stage. This stage will be discussed briefly because it is important in order to
understand later stages and such thinking can sometimes manifest itself in
adolescents during times of stress. One of the characteristics of this stage is
egocentrism or the inability to take the view of another person. The child
cannot see an object from one position and envision what it would look from
another position. He or she cannot adopt to the needs of a listener but can
perceive the situation only from his or her own perspective.
Another characteristic of this egocentric preoperational phase is centra-
tion, or the tendency to focus attention on a striking feature, thereby neglect-
ing all other aspects. The child focuses impressionistically on a momentary
condition, and cannot integrate his or her perceptions. Such thinking also is
found in paranoid adult patients, who focus on one aspect of a situation and
lose the total perspective. The assimilatory network of a child's cognitive orga-
nization ruptures in the process of accommodating to new situations. The
conceptual network becomes overloaded, leading to an unstable, discontinuous
cognitive life. There is a lack of equilibrium between assimilation and ac-
comodation. Those representations that do exist are close to overt actions.
Things are what they appear in egocentric immediate perception to the child at
this phase. Insubstantial phenomena, such as names, thought, moral obliga-
tion, or dreams, are treated as quasi-tangible entities.
Preoperational thinking is irreversible. The child is unable by means of
successive decenterings to compose the changes which result from a transfor-
mation into an organized system. He or she cannot see how each change could
be annulled by its inverse (that which would compensate for it). Preoperational
thinking is imagistic and intuitional, in contrast to being schematic or abstract.
The reasoning is called transducive, which means the child proceeds from
particular to particular, centering on one salient element of an event. The
reasoning is neither inductive or deductive. Associative connections are made
by juxtaposition, rather than by a true causal relationship. Association by jux-
taposition is similar to the thinking of some schizophrenic patients. Preopera-
tional thinking also is syncretic, with a correlation of diverse things in a disor-
ganized manner. Cause and effect requirements are very lax. The child is
unable to form any real concept of probability or chance.
During the transition phase to concrete operations, a thawing out of pre-
viously rigid thinking structures occurs. Thinking becomes more flexible, de-
centered, and reversible. In the transition phase from preoperational to con-
crete operational thought, the child, after centering on a single facet, begins to
decenter and take other aspects into account. The child begins to learn how to
figure out what caused something, how to undo it, and how to compensate for
it by some other means.
The next stage, the stage of concrete operations, occurs ordinarily from
age 7 to 11. The child at this stage has developed a coherent and integrated
cognitive system with which the child organizes and manipulates the world
around him or her. The child has a solid, yet flexible, cognitive bedrock with
which he or she can structure the present in terms of the past without a
tendency to stumble into contradiction and perplexity. The concrete opera-
tional child can assimilate much new information, and achieve a functioning
equilibrium with assimilation and a finely tuned accommodatory mechanism.
The concrete operational child can consider interpersonal values, as well
as interpersonal interactions. With the growth of moral values, norms of moral

conduct, and a notion of moral obligation enter the thought of the child in
parallel with a notion of logical necessity and logical norms. Immanuel Kant's
moral imperativeS (basically the golden rule) begins to seem a priori (intuitively
obvious), at least in principle, even if not necessarily in everyday moral behav-
ior. Reciprocal interaction develops among peers. The child, by frustrating
interchanges with peers, comes to cognitive grips with perspectives and view-
points that differ from his or her own.
A physical example of the conceptual problems of a child at the preopera-
tional stage may help in understanding what capacities are lacking at this stage
and the nature of the development of concrete operational thinking. For exam-
ple, if a liquid from one vess,el is poured into another differently shaped vessel,
the preoperational child is unduly impressed by either the height or the width
and decides that one or the other of the vessels contains more liquid. In con-
trast, the concrete operational child can pay attention to transformations as
well as states. He or she can see a transformation as associated with another
possible transformation that would annul it, such as pouring the liquid from
the second vessel back into the first one. The child can also see the original
transformation as one example of possible other transformations, such as
pouring the liquid into vessels of varying shapes. The child can also imagine an
indefinite set of inverse compensations. For example, he or she would realize
that in each new vessel, for each decrease in height of the liquid there would be
an exact compensatory increase in width. Each specific reality is seen as not the
only one, but as the "is" of "could be" totality. Concrete operational children
can extend their thought from the actual to the potential to a certain degree, so
long as it is directly based on experience. For example, in a parking lot with
cars, children at this stage can see spaces and know that they are spaces with a
potential for a car.
There are important limitations on concrete operations, however, as op-
posed to formal operations. Early adolescents generally are not yet at the
formal stage, and some adults do not ever even reach it. It is important to be
aware of these conceptual limitations in adolescents, because adolescents fre-
quently may have difficulty considering possible alternative actions that could
be obvious to an adult who has reached the formal stage of development.
These difficulties will be especially manifest when the youngster is under stress.
In the concrete operational phase the structuring and organizing activity is
directed toward concrete things and events in the immediate present and not
the full potential. Organization of the immediate present occurs but there is
little extrapolation to what is not there. Concrete operational thinking as op-
posed to formal operational thinking does not at the outset delineate all possi-
ble eventualities and try to discover which of these possibilities do occur in the
present data. In formal operational thinking the real becomes a special case of
the possible and not the other way around. The concrete operational thinker
has no total system, even though he or she has some primitive concepts of
negation and reciprocity as in the previous vessel problem. However, the con-
cepts are inadequate for multivariate problems. He or she cannot use the "all
other things being equal" method and control and vary factors as needed to test
cause and effect.
In the formal stage, the person has the potential for considering the hypo-
thetical and imagining all that might be there, thereby better insuring finding
all of what in fact is there. In the formal stage, all the possible variables and
configurations can be isolated. It is possible to consider things like: A might be
necessary and sufficient for X, or B might be, or that both might be needed. A
formal stage adolescent can analyze multivariate problems, such as how much a
rod will bend. He can consider the effects and interactions of variables, such as
the material it is made of, the amount of weight attached to the end, the rod's
length, thickness, and cross-sectional form.
The stage of formal operations commonly is reached sometime during
adolescence. It can be reached at varying times and can be reached inconsis-
tently. Adolescents can sometimes demonstrate it. At other times they can still
think according to the stage of concrete operations. Some adolescents never
reach the forml stage at all. Many adolescents and even many adults only
partially attain the stage of formal operations. They can consider all the actual
relations of one thing to another at the same time. However, they cannot
consider all the possibilities and do not form abstract hypotheses.
The formal stage adolescent can consider all the possibilities. The concrete
stage adolescent or a younger child cannot consider possibilities too removed
from experience and cannot see many steps into the future. The concrete stage
adolescent cannot understand complex interactions and things not being what
they seem in any complex way. The concrete stage adolescent is incapable of
considering that there is more than one way to achieve one's goals. Many
impulsive adolescents demonstrate concrete operational as opposed to formal
operational thinking, and at times even demonstrate thinking common to the
preoperational phase. Formal stage adolescents, unlike children at earlier
stages, can consider the future and the hypothetical. Their conceptual world is
filled with theories of the self and life and plans for the future for themselves
and society. Future possibilities, such as occupation and marriage, can be con-
sidered as well as the more concrete family and friends.
Initially, adolescents in the formal stage can be so captivated by the ability
to consider all possibilities that they become fascinated with thought itself and
become idealistic, with a disregard for obstacles, as if thought were omnipotent
and could modify the world. There are periods of egocentrism when the for-
mal stage adolescent enters a new and untried field of cognitive action. How-
ever, by successive states of disequilibrium they soon develop a new equilibrium
and reach a new plane of cognitive functioning. Stress or the development of
severe psychopathology seems capable of returning the adolescent to earlier
and even preoperational levels of thought.
It is important in treating adolescents and in evaluating them for forensic
purposes to appreciate that their cognitive development may be limited as well
as their emotional development. These issues need to be better understood,
especially because we are returning to more cognitive as opposed to emotional
or volitional tests in areas such as the insanity defense. Psychiatrists generally
are most knowledgeable and adept with emotional issues, but the criminal
justice system is returning to tests that emphasize solely the cognitive. The only
exception is if an expansion of the meaning of the words know and appreciate is
made along with supporting epistemological arguments, in order to include the
emotional as well as the cognitive.
Piaget6 ,7 has written on the development of morality in children and has
described two stages-the morality of constraint and the more equilibrated
morality of cooperation, the higher stage. Robert Coles 8 has also described the
development of morality in children, utilizing narratives and meaningful de-
scriptive case studies of the ways in which children struggle with problems of
moral choice. Kohlberg has expanded on Pia get and described basically three
levels of moral development, each of which he divided into two stages.
Kohlberg has been criticized by moral relativists or subjectivists who dis-
pute the universal necessity of his stages across other cultures. However, his
stages probably do fit most people's intuitive concepts of morality, at least in
Western culture. As such, they are important for forensic psychiatrists insofar
as they describe developmental stages of morality in o~r culture, even if they
are not universal. Kohlberg, however, believed his stages are universal and has
studied them in many other cultures. He believed his stages are analogous to
Piaget's stages. People must reach one stage in order to reach a later one. They
cannot operate at a later stage until they master the earlier ones. Once they
reach a stage, they consistently are able to perform at that level. In addition,
not all people do reach the later stages, much like with experimental studies of
Piaget's stages.
Kohlberg focused on the establishment of cooperative relationships with
an emphasis on the concept of justice in his scheme. Successive stages build
upon and elaborate previous stages. Advanced stages introduce more complex-
ity in order to achieve a better and more balanced reciprocity of benefits and
obligations. A greater understanding of social structures and society is neces-
sary for the higher stages. Kohlberg's evidence for the progressive nature of
the stages was that each is more differentiated and integrated than the previous
one; each employs cognitive operations that are more reversible and equili-
brated than the previous ones; and each stage has a more encompassing per-
spective on society.
In brief, Kohlberg's earliest stage of morality involves obeying external
rules with some rudimentary concepts of egalitarianism and reciprocity. The
mid stage involves trying to be thought good by others and doing things to help
the current social order survive. The highest stage, according to Kohlberg,
considers the possible. It considers social contract theory and principles of
forming a better society, as well as consideration of conscience and universal
principles. Kohlberg, much like Piaget, conducted extensive series of inter-
views with children and adolescents, interviewing them on 3-year cycles.
Kohlberg employed a case study method that allows the interviewer the
flexibility to ask whatever questions he or she considers relevant. He consid-
ered moral problems, such as the dilemma of Heinz in testing for levels of
moral thinking. According to this dilemma, a woman is near death from can-
cer, and there is one drug the doctors thought might save her. The druggist in
town had recently discovered it. It was expensive to produce, but the druggist
charged ten times what it cost to make it. He paid $200 for the materials and
charged $2000 for a small dose. The sick woman's husband tried to borrow
money from everyone he knew, but he could only raise $1000. He told the
druggist his wife was dying and asked him to sell it cheaper or let him pay later.
The druggist refused, saying he discovered the drug and wished to make
money from it. Heinz got desperate and broke into the man's store to steal the
drug for his wife. Kohlberg then analyzed not only the opinion each person
would have about the morality of Heniz's action but more importantly, the
reasoning that led to such an opinion.
Level 1,10 according to Kohlberg, is the preconventional, wherein moral
values reside in external quasi-physical happenings, bad acts, or in quasi-phys-
ical needs, rather than in persons and standards. Stage 1 is the egocentric point
of view and involves an obedience and punishment orientation, egocentric
deference to superior power or prestige, or a trouble-avoiding set. There is a
notion of objective responsibility and an orientation to concepts of obedience
and punishment. It does not consider the interests of others or recognize that
they may differ from the actor. Young children operate at this stage. If an act is
punished, it is wrong. Stage 2 involves a naively egoistic orientation. It is a
concrete individualistic perspective. The right action is that instrumentally sat-
isfying one's own and occasionally other's needs. There is awareness that value
is relative to each person's needs and perspectives. There is a naive egalitarian-
ism and an orientation to exchange and reciprocity. Everyone has his own
interest to pursue and these conflict, so right is relative.
Level 2 is the conventional. Moral values reside in performing good or
right roles, in maintaining the conventional order, and in meeting others'
expectations. Stage 3 involves an orientation to approval and to pleasing and
helping others. There is the perspective of the individual in relationship with
other individuals. There is conformity to stereotypic images of the majority or
natural role behavior. There is judgment by intentions. The individual consid-
ers a concrete golden rule ("Do unto others as you would have them do unto
you") of putting oneself in others' shoes, but does not consider a generalized
perspective. Some beginning capacity to handle formal logical operations is
probably necessary to solve problems at this stage.
Stage 4 is an orientation to doing one's duty and to showing respect for
authority and maintaining the given social order for its own sake. There is
regard for the earned expectations of others. There is differentiation of a
societal point of view from interpersonal agreement or motives. The person
takes the point of view of the system that defines roles and rules. The value of
the individual is considered in terms of his place in the system. People who are
superpatriots might be operating at this stage.
Level 3 is the postconventional. Moral values are derived from principles
that can be applied universally. Morality considers possibilities that go behond
the current system or mores. Moral value resides in conformity by the self to
shared or sharable standards, rights, and duties. Most postconventional solu-
tions to the problem of Heinz would conclude that it was right for Heinz to
steal the drug. Stage 5 is a prior-to-society perspective. It involves a contractual
legalistic orientation. There is a recognition of an arbitrary element in rules or
expectations for the sake of agreement. Duty is defined in terms of contract,
general avoidance of violation of the will or rights of others, or of following the
majority will and promoting majority welfare. The person consides moral and
legal points of view. He or she recognizes that these sometimes conflict and
finds it difficult to integrate them.
Stage 6 shows an orientation to conscience or principles, not only to or-
dained social rules, but to principles of choice appealing to logical univerality
and consistency. Conscience is a directing agent together with mutual respect
and trust. There is consideration of a generalized golden rule or categorical
imperative 5 ("So act as you would after considering how everyone should act if
they were in the situation"). There is the perspective of a moral point of view
from which social arragements derive and universal principles of reciprocal
role taking. It recognizes that persons are ends in themselves and must be
treated as such. Differing issues, of course, are raised, depending on the nature
of the problem. Even children can distinguish between stealing and violating a
rule such as crossing a street when there is a red light. Also, moral reasoning is
not the same as moral behavior. Good reasoning does not necessarily translate
into good actions. There are affective and volitional as well as cognitive ele-
ments that accompany moral behavior.
Piaget presented a view of moral motivation as well as of cognition. As
children come to understand the purpose, function, and nature of cooperative
arrangements, they come to have mutual respect for their coparticipants and
develop a sense of solidarity with them. As a child comes to appreciate his stake
in supporting social arrangements, his ego boundaries are extended to include
others in a social system of mutual respect. Each individual values the other
and realizes the value of cooperating to create a social order of much value.
According to Piaget and Kohlberg, the development of logical forms of think-
ing make possible new structures of meaning with both logical and affective
aspects.
Kohlberg 11 himself initially tried to educate problem adolescents and pris-
oners regarding morality by discussing Heinz-and-the-drug type dilemmas. It
was a weak impetus for personality transformation and moral development.
The past and present prison social experience of these people, who came from
disrupted families and predatory neighborhoods, tended to disconfirm any
concept of cooperation imagined in hypothetical moral dilemmas and discus-
sions. Moral discussion alternatively can help with youth from privileged and
benign social backgrounds but not with the ordinary prisoner. Kohlberg then
expanded his interventions with prisoners to include the establishment of just
communities within the prison itself.
Piaget also had emphasized peer interaction as crucial for development.
He believed that the morality of cooperation is more equilibrated than the
morality of constraint. He believed morality to be the equilibrium of indi-
viduals in society, with individuals each reciprocating with other individuals
according to rules that balance the benefits and burdens of cooperation. A

social system is equilibrated if its rules balance the benefits and burdens among
participants in a fair way, adjudicates conflicts between individuals without
destroying the social system, and attracts support from participants who appre-
ciate the fairness of the system.
Piaget's morality centers on the concept of justice, which prescribes how
reciprocity among individuals should be balanced. For Piaget, the earlier stage
of morality is the morality of constraint (heteronomous). The later stage is the
stage of cooperation (autonomous). Piaget described only two stages. Stage
structures work behind the scenes in organizing moral judgments. The subject
may be unable to describe them much because of being unable to describe the
cognitive stages of development.
The younger child, according to Piaget, has a sense of objective responsi-
bility with a focus on the obvious, concrete aspects of rule conformity. Older
children have a sense of subjective responsibility and understand enough about
the nature and function of rules that ameliorating circumstances, including the
actor's intentions, can be taken into account. According to Piaget, both the
child who has reverential views of rules and the child who flagrantly disregards
them are both egocentric and operating according to the early stage of morali-
ty. However, recent research has raised questions by showing that subjects can
be inconsistent even on the same dimension. 12 The criminal law itself also can
regress to the earlier concepts of objective responsibility insofar as strict liability
laws still exist.
Society's laws and values, according to Kohlberg, should be ones that any
impartial reasonable person could accept. It is therefore based on principles.
The central concept of Kohlberg's stages are: Stage 1, the morality of obe-
dience: "Do what you are told!" Stage 2, the morality of instrumental egoism
and simple exchange: "Let's make a deal!" Stage 3, the morality of interper-
sonal concordance: "Be considerate, nice, and kind, and you'll get along with
people!" Stage 4, the morality of law and duty to the social order. "Everyone in
society is obligated and protected by the law." Stage 5, the morality of social
consensus: "You are obligated by whatever arrangements are agreed to by due
process." Stage 6, the morality of nonarbitrary social cooperation. This stage is
"how impartial people would organize. Cooperation is moral."
Like Piaget, Kohlberg's central concept isjustice. Kohlberg's stories used in
clinical tests of children are open-ended, covering many features and topics, as
opposed to those of Piaget, which focus on only one dimension. However,
Kohlberg's data can be difficult to score. Kohlberg, like Piaget, did not regard
didactic instruction by adults as important in moral development. He believed
that children must attend to the reasons for social arrangements and to their
purposes and functions. Like Piaget, he believed that each successive stage
employs new cognitive operations and is more reversible and equilibrated. The
new operation creates a new and more integrative or equilibrated form of
justice.
According to Kohlberg 13 reversibility of moral judgment is what is ulti-
mately meant by the criterion of the fairness of a moral decision and is a
justification for his stage concept. A moral judgment is reversible in the sense
of a decision in which all interested parties could agree insofar as they can
consider their own claims impartially, as the just decider would. A highest stage
solution would be reversible. In the previous Heinz and druggist dilemma, the
wife could put herself in the druggist's position and maintain her claim. The
druggist could not put himself in the wife's position and maintain his claim. A
just decision is reached by "ideal role-taking." Even the druggist would have to
admit that if his life were at stake, he would favor preserving life over property
rights. A "moral musical chairs" would lead to no change in solution at the
highest stage.
Justifications for Kohlberg's stage concept of moral development are that
the later stages are more differentiated, systematic, and integrated. Higher
stages have a progressively more encompassing perspective on society. At Stage
6, the person must disentangle nonrelevant considerations in valuing human
life. The higher stages are more adequate to solve more moral problems than
are the lower stages. In general, experimental studies have found that subjects
can understand moral problems below their modal level but only one stage
above their modal level.
Kohlberg has analyzed responses to moral problems in terms of his six
stages, including the area of capital punishment. 14 A correlation of 0.76 was
found between moral judgment stage and opposition to capital punishment. In
Kohlberg's later scoring system, Stage 5 is a rarity even among adults and Stage
6 often is not present at all. I5 In Kohlberg's earliest scoring system 40% of age
16 boys scored at Stages 5 and 6. As can be seen, the scoring system employed
can strongly influence the stage obtained.
DIT research (Defining Issues Test)16 has tried to simplify scoring of
Kohlberg's stages by focusing on differing levels of cooperation. It also creates
a more objective test, in contrast to Kohlberg's clinical interview method. Stage
1 provides a structure for human interaction with great inequality between
parties and little reciprocity. The system is determined by accident of birth or
who is more powerful. Stage 2 makes progress toward a more balanced reci-
procity through recognizing each person's special point of view through the
device of simple exchange and favors. Stage 3 is a more enduring system of
cooperation through relationships of mutual caring and affection and commit-
ment to the other's welfare. However, it is arbitrarily limited to friendships that
have been established. Stage 4 establishes a societywide system of cooperation
through formal social systems governed by law. It can, however, allow gross
inequalities and arbitrary distribution of benefits if the social order is set up to
give advantage to some over others, such as in a slave society. Stage 5 attempts
to eliminate arbitrary rules by giving procedures to make rules that reflect the
will of the people, giving each person an equal voice. It has not completely
insured, however, that the outcomes of duly enacted laws produce a nonarbi-
tary balancing of peoples' interests, such as the early acceptance of slavery in
America. It guarantees procedural justice but not necessarily substantive jus-
tice. Stage 6 maintains that even if a majority want a law or social policy, it does
not necessarily make it moral. The defining feature is an appeal to ideal princi-
pies of justice. Many modern philosophies would be scored at Stage 6. As can

be seen, the DIT scoring system is very similar to Kohlberg's.
Good moral reasoning, however, does not necessarily translate into good
deeds. To quote Rest, "moral judgment is one player in a large cast of players,
and even if it is a star, it is not the whole show." 15 The ideas a person verbalizes
in a hypothetical situation are not necessarily operative in real situations in
actual decision making. However, moral reasoning and moral actions are statis-
tically related. 17 There also are affective components as well as competing
motivations regarding which a choice must be made. An individual may be
persuaded by competing motivations to choose an action other than the most
moral one. There also are other times when prosocial1 8 acts may be performed
in which the individual places the welfare of others above his or her own. The
person does not perform any kind of cost-benefit analysis but places the wel-
fare of others above his or her own, and does a deed that involves self-sacrifice.
In addition to knowing the best moral action, people also need the means
of implementing an action and the courage and will to carry it out. Empathy
with the other person can be a motivation, but it can sometimes even prevent a
moral action, such as when empathy is so strong it becomes difficult to produce
temporary pain in another individual, even if it is for his or her own good.
Even mood fluctuations can affect moral decision making. People have been
found to be more generous after a success or after thinking about happy
experiences. 19
Rest l5 proposed a four-part framework to attempt an integrated picture
of morality and to represent the diverse kinds of cognitive processes. Compo-
nent 1 involves interpreting the situation in terms of how the welfare of people
is affected by possible actions of the person. Component 2 involves figuring out
what the morally ideal course of action would be. Component 3 involves select-
ing among valued outcomes to choose and intend to do the moral course of
action. Component 4 involves executing and implementing what one intends to
do.
There also have been many theories about the origin of moral motivation.
These include its being rooted in human nature; its being rooted in conscience,
superego, or fear of God; its being an internalization of parental prohibitions;
its being motivated by subtle reinforcements; its being a manifestation of social
intelligence and education; and its being derived from a sense of awe and
subjugation to something greater than oneself, such as in identification with a
cause or a crusade.
Alternative central concepts could have been made central to a moral
scheme instead of the concept of justice chosen by Kohlberg and Piaget. Exam-
ples include love of humanity, survival of the human race, an intuitive sense of
moral duty, or the welfare of the most people. However, the concepts of justice
and fairness do seem central to morality, at least as conceptualized in Western
democratic societies.
Criticisms have also been made of Kohlberg's stage concept. For example,
the acquisition of cognitive structures has been found to be gradual rather than
abrupt. Individuals also fluctuate in their uses of differing stage structures,
even on the same task. 15 Variation in testing procedures and scoring criteria
can also produce significant differences in stage scores. Moreover, the type of
task and the type of response can determine the organization of thinking. As
summarized by Rest,15 although controversies exist over the ways to define
developmental features, the assessment methods, research strategy and even
the stage concept itself, there is fairly strong evidence to support the claim that
over time people change in the direction of making moral judgments on the
basis of a better understanding of social relationships and arrangements.
There is also fairly strong evidence that such shifts in moral judgment reflect
new cognitive capacities. Other factors besides moral development do influ-
ence scores on Kohlberg's tests, such as ability to extract information from a
story, ability to draw inferences about motives and intentions, holding bits of
information in mind and combining them, and selectively attending to differ-
ent cues. Nevertheless, Piaget's and Kohlberg's studies of moral development
do address concepts of morality that make intuitive sense, at least in Western
culture.
Rawls' theory of moral motivation 20 synthesizes several concepts of moral
motivation by including the concept that cognitive understanding by itself is
not enough. He believes moral motivation develops as a child experiences love
and fidelity and the benefits of living in just and caring communities. As the
child begins to experience the benefits of "good" behavior, the child begins to
appreciate the benefits of social arrangements governed by principles of justice
and to appreciate the abstract ideals of just cooperation. The good community
experiences come first and provide the motivation to understand them.
Kohlberg himself came to appreciate the failure of moral education for pris-
oners who did not have any experience in the past of good loving parents, a
benevolent and fair community, or even a just community within the prison
itself. These prisoners lacked confirmation that cooperation is preferable or
even workable. Good experiences are necessary. Education alone is not
enough.
There has been much research on the role of education in helping people
achieve the next stage. The results have been inconsistent. Kohlberg was in-
volved in a study that involved developing a 'Just community" in a women's
prison with democratic self-government through community decisions as well
as small-group moral discussions. The program produced an upward change
in moral reasoning, as well as later changes in life-style and behavior. 21 .22 For
Kohlberg, the opportunity for discussion and understanding of reasoning is
important in moral upbringing that encourages development of later stages.
Peer interaction that involves reasoning is essential in interventions that enable
people to achieve a higher level of moral reasoning. In addition, a good emo-
tional experience is crucial to provide the motivation for understanding and
acting at a higher moral developmental level.
Research has shown that Kohlberg's stage 5 judgment is more predictive of
moral action than is any lower stage. 23 This finding shows a connection be-
tween moral stage structures and moral action. Moral development beyond
Stage 5 appears to be characterized by metaphysical and existential reflection
and theorizing. Stage 6 is not necessarily more related to moral action but
seems more related to the creation of moral systems. However, Kohlberg justi-
fied the higher status of Stage 6 by its greater reversibility.
As can be seen, adolescents develop along all the dimensions that have
been presented. Forensic psychiatrists should be aware of these emotional,
cognitive, and moral developmental issues in their evaluation and treatment of
adolescents. Some of the problems and difficulties of an adolescent can be
perceived as problems in adolescent development and should not be consid-
ered from the perspective of a highly developed adult. At times of stress,
emotional, cognitive, and moral capabilities in adolescents may regress to ear-
lier stages even in a youngster who has functioned at times at a higher stage.
A meaningful forensic evaluation of an adolescent should make some
attempt to attend to all these developmental factors. A thorough analysis of all
these facets may be necessary in order adequately to explain an adolescent's
behavior in a forensic psychiatric evaluation. Whether such factors lead to a
possible insanity or diminished capacity defense should depend on the specifics
of the deficit, and the situation. Even if believed to be insufficient, the relevant
factors should be presented to the court in order to help in their understanding
of the adolescent's actions and in order to enable the court or jury to come to its
own decision.
These factors also, of course, are essential in the treatment of adolescents
in order fully to understand the youngster's problems and in order not to make
interpretations or make interventions that are beyond the adolescent's develop-
mental capabilities. As can be seen, most adolescents will not have reached the
highest levels on at least one, if not all, the developmental dimensions that have
been presented.
REFERENCES
l. Offer D, Offer JB: From Teenage to Young Manhood: A Psychological Study. New York, Basic
Books, 1975.
2. Weinstock R, Nair M: Antisocial personality-diagnosis or moral judgment? j For Sci
29:557-565, 1984.
3. Diamond B: The simulation ofsanity.j Soc Therapy 2:1-3,1956.
4. Flavell JH: The Developmental Psychology ofjean Piaget. Princeton, NJ, Van Nostrand, 1963.
5. Kant I: Critique of Pure Reason. New York, St. Martin's Press, 1929.
6. Piaget J: The Moral judgment of the Child. New York, Free Press, 1965.
7. Piaget J: The general problem of the psycho-biological development of the child, in
Tanner JM, Inhelder B (eds): Discussions on Child Development vol 4. New York, Interna-
tional Universities Press, 1960.
8. Coles R: The Moral Life of Children. Boston, Houghton Mifflin Company, 1986.
9. Kohlberg L, State and sequence: The cognitive approach to socialization, in Goslin D (ed):
Handbook of Socialization Theory and Research. Chicago, Rand McNally, 1969.
10. Sprinthall N, Collins WA: Adolescent Psychology, A Developmental View. Reading, Mass,
Addison Wesley, 1984, p 179.
11. Kohlberg L, Kauffman K, Scharf P, et al.: The Just Community Approach to Corrections.
Cambridge, Mass, Moral Education Research Foundation, 1974.
12. Lickona T: Research on Piaget's theory of moral development, in Lickona T (ed): Moral
Development and Behavior: Theory, Research, and Social Issues. New York, Holt, Rinehart and
Winston, 1976.
13. Kohlberg L: The Claim to moral adequacy of a highest stage of moral judgment. J Philos
40:630-646, 1973.
14. Kohlberg L: Elfenbein D: The development of moral judgments concerning capital
punishments. AmJ Orthopsychiatry 45:614-640, 1975.
15. Rest JR: Morality, in Mussen P (ed): Handbook of Child Psychology vol 3. New York, John
Wiley and Sons, 1983, pp 556-629.
16. Rest JR: Revised Manual for the Defining Issues Test. Minneapolis, Minnesota Moral Re-
search Projects, 1979.
17. Blasi A: Bridging moral cognition and moral action: A critical review of the literature.
Psychol Bull 88:593-637, 1980.
18. Eisenberg-Berg N: The relation of political attitudes to constraint-oriented and pro social
moral reasoning. Dev Psychol 12:552-553, 1976.
19. Staub E: Positive Social Behavior and Morality, vol 2 Social and Personal Influences. New York,
Academic Press, 1978.
20. Rawls J: A Theory of Justice. Cambridge, Mass, Harvard University Press, 1971.
21. Kohlberg L: Moral stages and moralization, the cognitive developmental approach, in
Lickona T (ed): Development and Behavior, Theory, Research, and Social Issues. New York,
Holt, Rinehart and Winston, 1976, pp 31-53.
22. Hickey J, Scharf P: Toward a Just Correctional System. San Francisco, Jossey-Bass, 1980.
23. Kohlberg L, Levine C, Hewer A: Synopsis and detailed reply to critics, in Kohlberg L: The
Psychology of Moral Development, The Nature and Validity of Moral Stages, vol 2, Essays on Moral
Development. San Francisco, Harper and Row Publishers, 1984, p 375.
13
Adolescent Psychological
Development
Normal and Abnormal
EVERETT DULIT
The focus of this chapter will be to try to develop some useful answers to the
following questions: What does the forensic psychiatrist need to know about
normal adolescent psychological development and about adolescent psychiatry
and psychopathology to be able effectively to make an informed assessment of
psychopathology in the adolescent who is brought to his or her attention in the
court, hospital, or detention center setting; and to make an informed treatment
recommendation for the adolescent in trouble seen in those same settings?
SOME THOUGHTS ABOUT PSYCHOPATHOLOGY IN

ADOLESCENCE
One major question, recurrent for anyone working with the adolescent in
trouble, is: To what degree do the difficulties seen here with this youngster
justify and require a diagnosis of mental illness or to what degree can the
observed phenomena be adequately covered instead simply by a lesser diag-
nosis of "adolescent overdoing" or of "adolescent bad judgment" (i.e., by a
clinical judgment that no mental illness underlies the behavior in question,
even though that behavior may be socially unwelcome or even seriously prob-
lematic)? That question remains a persistently vexing one, even for the experi-
enced adolescent psychiatrist at work. Fortunately, for a substantial fraction of
EVERETT DULIT • Department of Psychiatry, Montefiore Medical Center, Bronx, New

York 10467; Department of Psychiatry, Albert Einstein School of Medicine, Bronx, New York
10461.
219
220 EVERETT DULIT
the cases brought to the attention of the adolescent psychiatrist, the decision
(i.e., mental illness or none) can be made with a satisfactory degree of confi-
dence and reliability. But, in my opinion, for another not insignificant propor-
tion of cases brought to our attention (maybe 10% to 25%, as a very rough
estimate), a confident reliable assignment is not really possible, given our cur-
rent state of knowledge, even in experienced hands.
The root cause for this unsatisfactory state of affairs can be found in some
features of the timetable for the emergence of psychopathology in adolescence
and some features of normal development in adolescence. Together, these two
features of development in adolescence add up to make it quite plausible that
the decision "mental illness versus none?" might well remain as uncertain of
resolution as it is for a substantial minority of cases seen in an adolescent
psychiatry practice, forensic work included, despite the best of evaluations by
the most experienced of people. First, consider that the typical age of onset for
two of the more serious and more well defined mental illnesses in DSM-IU,
namely schizophrenia and manic-depressive disorder, does not come until late
adolescence or early adulthood. As a consequence, during middle adolescence,
and even by late adolescence, even in those cases where either of those disor-
ders will be present in clear and well-defined form some few years later (i.e., by
young adulthood), when first encountered in the second decade those disor-
ders are commonly seen in ill-defined, atypical, and ambiguous forms, pa-
thology still in a state of becoming, still fluid and not yet crystallized, and
difficult to distinguish from some of the more pronounced and even flamboy-
ant forms of ordinary excesses (i.e., non-mental-illness varieties) of adoles-
cence. Second, "something there is" about some varieties of non-mentally-ill
behavior in the second decade that can take on an intensity, a flamboyance, and
a dramatic (even exhibitionistic) quality that is simply not seen (or hardly seen)
in the same way to the same degree before or after the second decade. As a
consequence, for a substantial minority (i.e., about 10% to 25%) of adolescents
brought for assessment showing unsettled or acting out or withdrawn or vol-
atile behavior, that behavior could equally plausibly derive from: (a) the very
early stages of an incipient emerging severe mental illness (schizophrenia or
manic-depressive disorder), which will not take on its classical forms for yet a
few years more, or (b) it could represent the "stably unstable" youngster (i.e.,
persistently and/or recurrently emotionally volatile) who will eventually be
judged to require a diagnosis of borderline condition (remaining borderline
through the teens and into the 20s and 30s), or (c) it could represent merely
normal and/or neurotic difficulties, expressing themselves in a particularly
florid form because they are refracted through those features of the organism
in the second decade that can tend through those years to intensify the emo-
tional and/or the rebellious and/or the antisocial aspects of normal and/or
neurotic behavior, but which behavior will give way by the early and middle
twenties to more settled and structured forms of normal and/or neurotic be-
havior, much more clearly well within the wide range of normal. The in-
terested reader is referred to the work of WeIner, of the Washington St. Louis
group, which has been so active and interested in work on diagnostic refine-
ADOLESCENT PSYCHOLOGICAL DEVELOPMENT 221
ment and diagnostic stability (i.e., diagnoses that go beyond the merely descrip-
tive, but which get at features of psychopathology that can be expected to
endure).l WeIner demonstrated that for a sizable group of adolescent patients
who showed features of psychopathology that would have justified a diagnosis
of borderline condition (if they had been adults), that by the time they did
become adults (years later, in follow-up studies) this group of patients became
fairly evenly divided into three groups: (a) psychotic adults (i.e., the early
borderline features were incipient psychosis), or (b) borderline adults (i.e., they
remained stably borderline), or (c) neurotic adults (i.e., adolescence had tended
to make the neurotic picture look worse and more borderliney when first seen
in adolescence). He judged there to be no reliable grounds, from the clinical
data he had available to him, upon which to base a decision in the patient's
adolescence as to which one among the three possible later tracks the patient's
clinical course would move onto by later young adulthood. WeIner even
favored a generous use in such cases of the response: "diagnosis deferred," or
the use of the label "Undiagnosed Illness," an approach I rather like for its
straightforwardness and honesty. The interested reader is also referred to an
article by Kernberg in which he explores a cluster of reasons that tend to
confound the reliable differentiation in adolescence between the diagnosis of
borderline condition versus the diagnosis of neurosis. 2
Another, somewhat different approach to the task of diagnostic assess-
ment in adolescence can be illustrated by the following. Let us begin with a
youngster who comes to our attention for some form of rule-breaking behav-
ior, for example burglary, public drunkenness, or the selling and use of illegal
drugs. One can make the diagnosis of conduct disorder based on a sufficient
clustering of behaviors of that sort. Note that the term diagnosis here is a use of
the term that operates quite close to the observables, quite close to the observ-
able surface of behavior, quite close to the descriptive level. Note that one could
also, however, aspire to cut through or cut past that descriptive level to some
deeper diagnostic terms, closer to cause, closer to etiology. Such deeper or
more fundamental diagnoses are usually seen as lying behind or beneath the
more surface (observable, descriptive) diagnoses. Note that the etymology of
the word diagnosis means "knowing through," and that the tradition in medi-
cine is to look through or past those descriptive levels close to the symptom and
to try to see (or find) meaningful entities behind or beneath the symptom level,
those deeper levels conceptualized as more fundamental, with the more sur-
face levels closer to description, closer to symptom. For example, behind fever
one can diagnose infectious disease, or cancer, or yet other illnesses. And if the
deeper diagnosis is infectious disease, even within that large overarching um-
brella category one can aspire to pinpoint the particular causative organism,
and even its precise pattern of antibiotic vulnerabilities. In like manner, behind
the surface phenomenon of antisocial or delinquent behavior (seen as symptom
or as surface diagnosis, close to description) one can aspire to identify the
structure or category or name of the pattern of the psychiatric disorder (a
deeper diagnosis) that underlies and generates the behavior in any particular
case. One version that seems useful to this author for the range of possibilities
222 EVERETT DULIT
that might underlie antisocial behavior in adolescence or conduct disorder in

adolescence would be provided by the following listing:
1. Normal: No psychiatric diagnosis appropriate. Sometimes with tem-
peramental leaning toward high activity level and consequent action
orientation. The antisocial behavior is often part of a group process,
into which the youngster got caught up. Usually a relatively isolated
event from which one sees youngster afterwards in genuine strong
recoil ("I don't know what got into me. That is not 'me' or 'my way' ").
2. Neurotic: Psychodynamically intelligible, understandable in the context
of centrally important motivational trends in the person's life. For ex-
ample, trying to "prove something" to the self and others (like indepen-
dence, not being controlled by others) some version of manhood or
womanhood, to be a "somebody" instead of an average "nobody," as a
defense against depression by creating some action that will offset and
temporarily lift one out of depression, etc. Material supportive of your
interpretation should be relatively readily available from interview, and
relatively capable of being brought within the awareness of the adoles-
cent as a truth (sometimes hotly defended against) about the self.
3. Structured Character Disorder: Also psychodynamically intelligible, but
differs from previous category in that this is relatively late stage of a
process that was still alive and accessible in previous category but by
now relatively fixed and frozen and relatively more inaccessible. Now
more at the core of who the person is or has become rather than (as in
previous category) being something the person has. Now has a more
central and all-encompassing place in the personality, touching or col-
oring much or even most of the person's behavior, instead of just some
of it. By now more something that the discerning outside observer can
see as a dominant theme (similar themes to those listed in #2) but tends
now to be more outside of awareness of adolescent him/herself, more
taken for granted, more the way they are, which is relatively unnoticed
because it is so central and so taken for granted, like a hat or ring one
loses awareness of because it is always there.
4. Borderline Condition: Could certainly be grouped with previous category,
and is so treated in DSM-III, which identifies borderline condition as
one of the personality disorders. But my own preference is to separate
it off as a category in its own right, and to favor a view of borderline
condition (initially introduced by Donald Klein, and a conceptualization
I tend to find persuasive and useful) as a broad overarching category
containing within itself a wide range of essentially biologically based
disorders of affect regulation, those disorders leading either to the
emotionally unstable subtype (i.e., given to emotional storms and out-
bursts) or to the schizotypal subtype (emotionality at very low ebb,
washed out). Most of the affect regulation disorders in this umbrella
category are not yet well delineated or named in our time. They seem
instead likely to become increasingly delineated and named over subse-
quent years and decades, analagous to the progressive discovery and

identification of discrete infectious diseases within the broad overarch-
ing umbrella concept of infectious disease, the broad category having
been recognized relatively early with identification and delineation of
the contained subentities following only gradually over decades, and
even centuries. Some of these subcategories are however already identi-
fied in our time, such as borderline to schizophrenia (genetic loading
for schizophrenia but disorder not fully developed), and to manic-
depressive disorder, and also for some of the special categories that
Klein has been trying to delineate, for example, panic disorder, or
emotionally unstable character disorder, or hysteroid dysphoria etc.
5. Clear CNS Disorder, including:
A. Attention Deficit Disorder, especially with hyperactivity. This disorder
in childhood quite commonly becoming conduct disorder in adoles-
cence, with high activity level, with school failure, drug use and
abuse, major turmoil within family, and drift to association with
marginal peer group of similarly conduct-disordered others.
B. Seizure-Related Disorders. With abnormal EEG. Formerly called "ex-
plosive personality disorder." Not always associated with frank sei-
zures, but conceptualized as near-neighbor, with abnormal EEG
being reflection of only marginal control of underlying discharge
potentials in CNS, reflected here more in uncontrolled outbursts of
energy and action rather than in uncontrolled large muscle contrac-
tions.
C. Organic Mental Syndrome. Broad general category intended to cover
wide range of actual brain damage and brain dysfunctional states,
eg permanent aftermath of serious head injury in childhood from
chronic child abuse or congenital intrauterine CNS damage second-
ary to fetal alcohol syndrome or to other drug use/abuse during
pregnancy etc., all leading to impairment of control mechanisms.
D. Psychosis. Schizophrenia. Not a frequent finding, but needs to be in-
cluded for completeness (and not rare either).
E. Affective Disorder. Particularly bipolar, with manic tendancies ap-
pearing as energy out of control, but also unipolar with action ori-
entation of second decade being pressed into service as antidepres-
sant.
F. Intellectual Limitation. Relative incapacity to understand the rules,
particularly those subtle social expectations that are never fully ar-
ticulated but are quite adequately picked up by wide range of nor-
mal individuals (e.g., how to conduct oneself when approached and
questioned by police or security guards, i.e., "respectfully" or else
you're likely to be in for some trouble, as can so easily happen to the
intellectually limited).
The foregoing is intended to illustrate an approach to diagnosis, quite
relevant for work with the behaviorally disturbed patient at any age and in any
224 EVERETT DULIT
context, but here applied to work with adolescents seen in the context of
courtroom, prison, or detention center. At the surface of the behavior are
those part behaviors (e.g., rule breaking, theft, truancy, intoxication, driving
without a license, etc.) that can justify a first level or surface level diagnosis like
conduct disorder, which is fairly close to the descriptive level (identifying a
cluster quite close to the observables). And then behind that level one reaches,
if possible, for some sort of second level or more fundamental diagnosis, one
aspiring to "know through" the descriptive surface, at least reaching toward
more fundamental structures (more causative, more etiological) that are con-
ceptualized as generating the surface behaviors. One possible example would
be some form of conduct disorder (drug abuse? truancy?) as the diagnosis
closer to the surface, closer to the observables, closer to description, and that
surface disorder being generated by some form of affect disorder (unipolar?
bipolar?) as the more fundamental diagnosis, conceptualized as beneath or
behind the conduct disorder.
To move just a bit further away from the courtroom or detention center
scene and a bit further into adolescent psychiatry proper, let us take a moment
to play out the same approach in the area of the study of adolescent depression.
Depression is a phenomenon less likely to be identified as the chief complaint
for adolescents brought to the attention of the forensic psychiatrist, but it is so
very commonly present and behind those acting-out behaviors that serve as a
defense against depression that it is quite commonly seen by the forensic psy-
chiatrist, even if the young person is brought in primarily for acting-out
behavior.
The observables, close to the surface, that make for a diagnosis of depres-
sion are in adolescence mostly quite close to those used in adulthood: a drop in
basic mood state from "OK" to "down" or "blue" or "sad," a decrease or
complete absence of a sense of pleasure in living, a decrease in the sense of
meaningfulness about one's everyday activities and relations, a decrease in the
sense of having a satisfactory relation to one's own inner self, including a drop
in self-esteem, self-respect, and interest in one's own interests and in one's own
best interests, a decrease in energy and vitality, a slowdown in mental functions
and bodily functions, some sleep disturbances, and sometimes thoughts of
suicide.
Some relative qualifications need to be introduced to make that listing yet
more relevant to the assessment of depression in the second decade: in both
childhood and adolescence there is generally somewhat less (than in adulthood)
of the overall slowdown, the profound loss of motor function, facial ex-
pressiveness, and bodily vitality, so common as a part of depression in adulthood,
particularly in later adulthood. (Though for a modest subset of adolescents their
symptomatology is really quite close to the adult model, particularly where there
is an underlying family history of clear and well developed unipolar depressive
disorder linking two or three generations in the same family.) Also in adoles-
cence one does not usually see the vegetative signs (early morning awakening,
loss of appetite, tendency to constipation) and instead sees more of "energies
gone awry" into the form of irritability, touchiness, agitation, general malaise
and simply "not thriving." That can be made to seem plausible by simply remind-
ing on self that the first and second decades tend to be characterized normally by
a surfeit of "youthful energy," which probably partially masks and overrides the
depletion features of depression in the first two decades, and leads more to
symptomatology in the direction of energies gone awry, like irritability and
agitation.
Here, just as for conduct disorder, one can aspire to look through the
surface picture of depression to a range of underlying deeper diagnoses.
There follows a version of that listing that this author finds useful:
1. Depressions of Everyday Life. Included here just for the sake of com-
pleteness. By definition, not a psychiatric disorder. A normal human
reaction propensity. The "machinery" operating normally. Com-
monplace, and important to distinguish it from psychiatric disorders.
But no sharp line of demarcation from the next category which begins
to be psychopathology.
2. Reactive Depression. The "machinery" also operating normally. The per-
son here reacting to an event that the individual concerned experiences
and defines as depressing. (It may require an act of empathy on the
part of the observer, to feel his/her way into the life of the other person,
to experience why the event hits the person as so depressing.) Dis-
tinguished from the preceding category only by duration, intensity, and
the fact that these reactions begin to interfere significantly with life.
Usually they are transient and self-limited. But one can see more chron-
ic reactions to chronically depressing situations (e.g., living daily in a
pathological family structure).
3. Neurotic Depression. Psychodynamically intelligible (like the preceding
category) but this is an enduring or chronic state that comes about from
a prohibition to the self of pleasures, such as sensual, or sexual, or
aggressive pleasures, commonly arising out of prohibitions in and from
the family, internalized by the child become adolescent.
4. Devitalized* Deprived. Children-become-adolescents who grow up in or-
dinary, good-enough families (let alone optimal families), have the ben-
efit of "10 1 daily inputs" to the child from the parent that provide
* I use the word devitalized instead of the word depressed here to make a point: for this category
and for the following category these are patients who have never been nondepressed, never
been in an "OK mood" as baseline state for their experience in living. The word depression
tends to imply an OK state followed by a drop down below that state, as when one speaks of a
depression in a surface. The use of the word implies that there has been a prior OK state,
from which there is a depression, and to which the youngster might be "restored" if one can
only "eliminate the causes" of the depression. But for youngsters in these two categories the
situation is more like a lifelong nutritional deficiency syndrome, more like rickets, in which
there has never been as background level a normal mood state. These are youngsters who
live and have always lived in a "down" state and to make sure that is highlighted I prefer the
term devitalized here. Functionally, however, these youngsters certainly are in a clinically
depressed state.
226 EVERETT DULIT
pleasure for the child, that essentially "teach" the child about pleasure-
in-living by creating the experience, labeling it, and by highlighting for
the child that it is an important experience and that it can be an expec-
tation in life for the child. Some children grow up in families (or in
institutions) with a marked absence of this experience. These are fami-
lies that are a kind of "psychological desert," within which the experi-
ence of pleasure does not appear or happen for the child. These are
families mostly made that way because of mental illness (notably de-
pression, also schizophrenia) in a parent, or these are families bur-
dened, wrecked and/or drained by poverty. Therapy here is clearly not
something done well on two sessions per week, nor a matter primarily
handled by interpretation. Therapy instead is a matter of trying to
develop some late blooming version for the child-become-adolescent of
what should more properly have transpired much earlier in that adoles-
cent's life. The time scale for therapy here is years (2 to 5) and not
months. Sometimes this is work particularly well done in group home
settings, where the children are essentially put into surrogate family
situations with parent-substitutes who can parent in a more normally
nurturant fashion.
5. Devitalized Damaged. Here we begin to get into categories where the
heart of the matter is something wrong with the machinery, contrary to
the previous categories where the heart of the matter was in life experi-
ences and/or interpretations of life experiences. A prototypical patient
here would be the borderline patient, after the model previously out-
lined (affect regulation failures of the emotionally unstable or schiz-
otypal variety) or the ADDH patients (who commonly go through life
having the greatest of difficulty drawing pleasure from the experiences
of daily living, such as companionship, or meaningful games, or learn-
ing and use of the mind).
6. Unipolar Depression.
7. Bipolar Depression.
8. Schizophrenia-Related Depression. All three of the foregoing diagnoses are
commonly strengthened by a family history of that disorder. For all
three the most typical age of onset is later in life than adolescence
(young or middle adulthood for unipolar, young adulthood for bipolar,
late adolescence and young adulthood for schizophrenia) but all can be
emergent in the second decade (and sometimes even the first decade).
For the last category the primary diagnosis would be schizophrenia. But
that commonly includes real depressive symptomatology, likely even to
be in the forefront of the clinical picture during relative remissions of
the more classical schizophrenic signs and symptoms. Some of that is
undoubtedly "biological spillover" of the core pathophysiology into pa-
thology "in the machinery" of affect regulation. But some of it also is
undoubtedly depression through the different pathway of chronic de-
pressive reaction by the person to awareness by that person of the
deleterious effects on their life of the major mental illness, schizo-
ADOLESCENT PSYCHOLOGICAL DEVEWPMENT 227
phrenia. That pathway is similar to depression regularly seen with

other serious medical illnesses that can markedly impair the quality of
an adolescent life, like sickle cell disease or diabetes in adolescence.
Of special import for those in the field who work with the adolescent in
acting out (acting up) sorts of trouble would be recognition of the connection
between depression and conduct disordered forms of behavior that comes
about through the defensive use of action and activity against an inner sense of
emerging depression, emptiness, depletion. Particularly in adolescence, with its
age-specific tilt toward high energy level and high activity level, the most
favored defense against a private inner sense of decline in pleasure in living is a
conscious, deliberate attempt to create from outside the self a strong sense of
"something happening, man." Through that link the clinical picture is a recur-
rent one in adolescence of depression at the core, conduct disorder at the
surface.
How about treatment recommendations by category? There follows a brief
summary of highlights:
1. Depression of Everyday Life. Not even properly identified as psycho-
pathology. Does not call for treatment. Just included for the sake of
completeness. Takes care of itself. By definition, transient and not
seriously interfering with a life.
2. Reactive Depression. One can get away with leaving reactive depression
untreated,just as previous category, because it is transient. But a better
approach, in my opinion, would be to give serious consideration here to
a course of brief therapy (about six sessions, plus or minus four).
Though someone gets over a reactive depression in general even with-
out help, there is real virtue in trying to use brief therapy: (a) To help
the person, especially in adolescence, a stage in the life cycle during
which identify formation is a current key issue, to get a better sense of
the meaning of "what happened," the better to integrate the experience
into the life and sense of self, rather than to have it left in the mind as
something that happened that one does not want to and cannot really
think about without pain and/or shame. (b) To try to use the brief
therapy to better understand the vulnerability that set up or made
possible the depressive reaction, perhaps thereby to be able to reduce
vulnerability to future recurrences. For example, if the depressive reac-
tion was to the ending of a relationship, some time spent on working
through ideas and feelings about relationships and the endings of rela-
tionships can certainly help to soften and decisively to alter later reac-
tions to otherwise similar endings as are likely to happen in any real life.
3. Neurotic Depression. This is the ground on which psychodynamically
informed psychotherapy makes the most sense. The key and central
issues here have to do with meanings,judgments, and valuations, some
of them within awareness, some on the edge of or altogether outside
awareness. Psychological work on those issues can make all the dif-
ference, can lead on to different and better reworkings of those central
228 EVERETf DULIT
issues, can help with the transformation of the same material (sexual
and aggressive impulses and feelings) from forbidden and root of de-
pression to accepted and source of real pleasures.
4. Devitalized Deprived. Work with children-become-adolescents who have
had a decade or more of growing up in families that are psychological
deserts is not work done in two sessions per week, nor is it primarily
interpretive work. The heart of the matter here is to provide for the
child-become-adolescent some late-blooming version of what should
normally have been an ongoing experience of nurturance and pleasure
in the first decade of life. Probably one of the best ways of trying to
reverse what has been done (or, perhaps more accurately, not done)
here is the possibility of placement in a good group home, within which
the child can have the experience over some years of a kind of child-
rearing (or of adolescent rearing) experience that he/she missed out on
earlier. Key nurturing relationships here are with counselors, cook, and
often with other kids in the home (as "good brother" and "good sister"),
which can be very meaningful. The time scale here is 3, 4, 5 years,
during which time period a frightened, hopeless, depressed youngster
of 11, 12, 13 can often (it does not happen all the time, but it does
happen, and it is always worth trying for) slowly and gradually blossom
out into a much more self-assured and self-confident young man or
woman of 16, 17, 18, 19.
5. Devitalized Damaged. Treatment here is the least satisfactory of all the
subgroups. If you accept the notion that this is a cluster of biologically
based disorders of affect regulation, and given that our understanding of
the biopathology in this area of affect regulation disorders is only very
partial (the subcategories not even being delineated or named in most
instances) it is not surprising that we are without effective medications
for most of the patients in this category. (By contrast, the subcategories
that follow have established psychopharmacological approaches that are
far more effectively worked out.) And it is not surprising that exclusively
psychological approaches would fail to be getting at the heart of the
matter here. An analogy that works for me in this subcategory is to point
out that talking treatment here is comparable to rehabilitation work done
with patients who have sustained an irreversible physical injury, like a
stroke or a loss of a limb. The goal of the treatment there is to help the
patient to make the best use of those capacities that they have left that are
unimpaired, and even to find ways to stretch what is unimpaired into
filling in where possible for work that would ordinarily be done by parts
of the machinery in fact impaired and unable to function. That is worth-
while therapeutic work, and it is difficult. But at best it is mostly palliative,
and rarely can it be decisively curative.
6-8. For these three categories there are established psychopharmacolog-
ical approaches that deserve a trial, in addition to supportive psycho-
therapeutic work. For unipolar depression the mainstay would be anti-
depressant medication, like the tricyclic antidepressants. For bipolar
depression, the mainstay would be Lithium. For schizophrenia-related

depression, the mainstay would be the least sedating among the anti-
psychotic agents, for example, Stelazine.
INTERVIEW TECHNIQUE
Under this heading I should like to highlight a theme that relates not only
directly to the subject of an optimal interview approach for the adult inter-
viewer talking with the adolescent interviewee or patient or client, but this is a
theme with very broad applicability for the understanding and interpretation
of some central trends in the behavior and attitudes of adolescents. The theme
is that adolescents are in an interesting, relatively unique (in the life cycle)
position as regards power relative to the adult interviewer, and that that fact
colors and effects much of what is likely to transpire in the interaction. Adoles-
cents, compared to children, have considerable power. I refer there to mus-
cular power, sexual power, financial power, force of personality, all adding up
to some inner sense on the part of the adolescent, while engaged in interaction
with the adult, of being the bearer of some considerable, substantial, only
recently emergent personal force and power. However there is also awareness
by the adolescent of two factors pulling in a different direction: (a) in general
the adult has more power (to influence and control the adolescent, certainly to
influence and control his or her surroundings and environment). (b) The
adolescent is not yet accustomed to having power, and as part of that, not yet
able to be smooth and polished in the uses of power. In those respects the
adolescent is in a position rather like that of a small newly emergent nation
(often quite touchy about real or imagined slights, requiring clear messages
about "recognition") and in some ways like that of labor in labor-management
negotiations (labor having much less power to control management directly
than management has to control labor directly, but labor having considerable
power to disrupt, which confers a kind of power over the other, which forces
the other to have to pay attention, and to have to accommodate, to some
degree). In dealing with the adolescent, the adult is in the position of an
established power center dealing with a newly emergent power center, newly
emergent in the midst of the family, newly emergent out of childhood pliability
into adolescent relative-independence and control over areas of his/her own
life (e.g., drug use, sexuality, choice of companions, activities outside the home,
etc.) that it is truly difficult for adults even to be continuously well informed
about, let alone to control.
All of the foregoing effects the optimal tone and stance an interviewing
adult should bring to any official or unofficial interview with an adolescent.
The adult is dealing with someone who is not so weak or pliable as the child, not
yet as secure and comfortable in his or her emergent personal authority as an
adult is likely to be. What is called for on the part of the adult interviewer is
some artful blend of relaxation, easygoing self-respect, easygoing personal
authority, and respect for the standing (and power, and "sovereign" indepen-
230 EVERETT DULIT
dence) of the adolescent. People who do that well avoid the twin pitfalls of
either authoritarian stiffness and patronizing, intimidating, or condescending
attitudes on the one hand, or artificial false imitation of would-be youthful
stance and language on the other hand. Instead they find their way to their
own individual version of the style and stance arrived at by the best of high
school teachers and youth workers, respectful toward young people without
being intimidated or intimidating, relaxed and friendly without pandering or
fawning or pretending to be an adolescent in manner. Two things that help
much are humor and honesty. Humor provides a good vehicle in which serious
matters can be handled with a light touch. The best of youth workers com-
monly have, as a prominent feature of their natural everyday style, an under-
current of good humored "rapping," banter, or "kidding around" that tends to
convey relaxation, basic friendliness of intention, reassurance, and (very
important) to provide a flexible vehicle in which to communicate quite complex
matters in a way that does not feel "heavy, man." As for honesty, a much valued
teacher of mine on adolescent themes once identified adolescents as "hypocrisy
detectors." It is a nice turn of phrase that points to an important truth. Chil-
dren are much easier to fool and adults are much more courteous and willing
to play the game of certain socially accepted, conventional falsehoods we cus-
tomarily exchange (of the "so nice to have met you" variety). Adolescents are
past the first and not yet comfortably (for better and for worse) much into the
second. They tend to react badly to stiff, formal, official adult talk, especially
when they have reason (often good reason) to think that behind it lurks inten-
tions about which they think they would do well to be wary. Adults who regu-
larly comfortably work well with young people tend, without strain to them-
selves, to be able to stay quite close to the truth as they go along, and usually in a
way that makes it apparent to the listener that the truth is being spoken, and yet
to do it in a way that does not appear to be trying too hard to do that very thing.
It is a kind of art form: natural candor, relaxed lively honesty. It is a style worth
trying to acquire if you are going to be working with adolescents more than a
little.
SOME THOUGHTS ABOUT TREATMENT OF

PSYCHOPATHOLOGY IN ADOLESCENCE
Treatment Specificity
In the preceding section on assessment and diagnosis, I emphasized treat-
ment specificity. For example, where I had a spectrum of diagnostic pos-
sibilities lying behind the surface symptom of either depression or conduct
disorder, I indicated that the optimal treatment approach clearly depended on
underlying diagnosis. Where the depression was primarily reactive, one consid-
ered brief therapy or even the possibility that no treatment was necessary.
Where the issue was neurotic interference with the capacity for experiencing
pleasure, the optimal approach would be some form of psychodynamically
oriented talking treatment. Where the roots of the depression were primarily
in affective disorder (biologically rooted depression, the machinery not work-
ing properly) one's thoughts ought to be turning to a trial of the appropriate
antidepressant medications.
The foregoing remains valid, but there is an important and interesting
counter-truth pulling in an opposite direction that seems important to set down
here as a necessary qualifier to the (generally sought after and welcome) notion
of specificity, which is only a partial truth (like most truths in our field). Often a
correct identification of the root cause underlying the symptom picture leaves
one, despite correct identification, without any effective specific treatment. For
example, I would submit that that is indeed the case for those patients who fall
into the broad category one identifies as borderline condition (much literature
on the treatment of the borderline condition notwithstanding). For the ADD
patient, medications may not be as effective in adolescence at reducing the
acting out behavior (which can derive from the core feature of hyperactivity) as
those same medications can be at reducing the core symptom of hyperactivity
when it is first seen in earlier childhood. For the chronically psychotic patient,
one may (appropriately) be wary of a chronic course of medications on grounds
of concern about tardive dyskinesia. For the chronically depressed patient with
real biological disease, with family history and genetic loading, there may be an
unwillingness by the family or patient to use medications at all or regularly, and
there may be a less-than-satisfactory response to medications that are properly
and regularly used. As a consequence, sometimes optimal treatment cannot be
specifically tied to diagnosis. Instead, one may be then in a position where all
patients with the same final-common-pathway symptom have to get essentially
the same kind of treatment, treatment more specifically tied to symptom than
to underlying diagnosis. The situation that then prevails is that the treatment
approach is the same for the same symptom picture regardless of underlying
diagnosis. And then commonly it is the treatment result (or outcome) that
varies markedly depending on what was the underlying diagnosis. For exam-
ple, when the surface symptom picture is severe conduct disorder, and when
neither outpatient nor hospital treatment proves helpful, the youngster is
sometimes then sent away to one of the very hard-hitting programs for the
treatment of the incorrigibly criminal adolescent (e.g., Elan in Maine, Vision
Quest in the West) where all youngsters (regardless of diagnosis, to which it is
almost their policy to pay no attention) get essentially the same hard-hitting,
limit-setting treatment and resocialization through powerful group pressures
(as in the similar self-help programs for drug abusers like Odyssey, or for
alcoholics, like AA). And then what one often sees there is that the outcome
varies with the underlying diagnosis, the less ill, less damaged, less intrinsically
impaired youngsters getting more out of the treatment and able to make far
more progress toward ordinary self-restraint, as a learned experience, out of
committment to and involvement in the powerful group process that is at the
core of what makes those programs work. And the more impaired youngster
comes away with less net gain. And that outcome is probably the best that can
be accomplished through strictly psychological means at this point in history, at
232 EVERETT DULIT
a time when we lack more effective treatment for the underlying biological
damage (for example, for the broad category we call borderline condition as I
conceptualize it, for ADDH in adolescence and adulthood, or for medication-
resistant forms of psychosis or affect disorder). Again, for me a pertinent and
useful comparison, just as a way of thinking about the overall structure of the
situation, is to compare psychotherapy done with people who have persistent
relatively un treatable biological damage underlying their pathological (anti-
social or depressed, for example) behavior, is with rehabilitation work done
with poststroke patients, where one does not expect to alter the core damage
and its direct consequences, but does try to help the patient to make the best
use of what he or she has left that is undamaged. That is worthwhile and even
wonderful work. But it accepts that some changes for the better will not hap-
pen and are not within the realm of realistic expectation.
On the Combination of "Muscle" with "Heart and Head" in

Psychological Work with Conduct Disordered Adolescents
The following is a combination of some quite straightforward perspectives
deriving from fairly well-established facts in adolescent psychiatry combined
with, as will be obvious, an unabashedly advocate stance attempting to use this
chapter (in part and, I think, legitimately) as an opportunity to transmit a
message, from the author as adolescent psychiatrist to the readers as forensic
psychiatrists likely to be working with conduct-disordered adolescents in trou-
ble. There are some things I should like to urge you to do (if you can, and if
you end up agreeing with me). In any case, there follow some things I would
like to leave you thinking about. My goal is to alert you to an angle on our work-
in-common with conduct-disordered adolescents where I think you are in a
uniquely favorable position to make an essential contribution to the effective-
ness of attempts at treatment of that adolescent in trouble with the law. A
critical component of effective therapy with the conduct disordered adolescent
is limit setting. For useful psychotherapeutic work even to begin, one has to
block acting out as a way out-a way out for the adolescent from having to deal
with states of inner tension that arise from the conflict within between impulse
to action versus inner awareness of expectations by others (parents, school,
community, etc.) for more restrained behavior by the adolescent. For the con-
duct disordered adolescent, acting out represents an all-purpose, always-at-the-
ready safety valve and defense against the buildup of inner tension, including
potentially productive inner tension. Recourse to action when inner tension
builds up has the dual effect of releasing that inner tension and commonly also
setting into motion a chain of reactions. Physical violence or verbal explosions
(of the f.y. variety) almost always set into motion a quite dramatic chain of
events (of reaction and counter-reaction) that almost invariably have the effect
of upstaging and replacing as focus of attention whatever it was that was going
on that preceded the acting out. As a consequence those who would deal with
the conduct disordered adolescent about Issue A (e.g. some envious feelings,
some unresolved interpersonal tensions) all of a sudden find that instead they
are having to deal with new Issue B (the fight, the injuries, the counter-attack
that needs to be restrained) and Issue A never gets dealt with (or even recalled),
especially once the action moves on to Issue C and Issue D ("What was it that
got all this started anyway?" "Beats me. I can't remember anymore."). But if
acting out is decisively stopped, as it can be, by staff in a hospital or residential
treatment program for acting-out adolescents, you have right there at that
moment at least the beginnings of a potentially productive situation in which
the initial buildup of feelings is caught and frozen in time for a moment, not
relieved or dispelled by acting-out behavior and its aftermath, but instead right
then is dealt with, optimally in dialogue and in relation with staff. From such a
point of departure, useful work and real learning can begin, especially includ-
ing learning to think instead of to act. (Thinking is what you do while you count
to ten. If you never stop to count to ten, but act immediately on impulse, you do
not get much practice in reflecting, musing, or thinking.) The adolescent can
learn instead to tolerate the buildup of inner tension. The adolescent can learn
instead real self-observation, about one's own feelings, and real observation of
the complex feelings and motivations of others, all of that encouraged, model-
ed, and taught in an intensive inpatient or residential treatment program.
To actively stop acting-out behavior in that way takes muscle, literally and
figuratively. In a hospital or a residential treatment center that is achieved by
having as staff some large strong men who can grab and handle any kid in the
joint. It is important that there be enough of them, and that they be big enough
so that not only is it possible, but so that it is immediately obvious to the would-
be troublemaker that it is possible, which almost invariably eliminates the need
for any actual physical struggle to have to take place. It is easier for a tough kid
to give in without losing face when the odds against him or her are obviously
overwhelming. To cool the situation commonly the adolescent is placed at that
point into some kind of a secure "quiet room," sometimes with staff also in (for
interactions) and then out (for further cooling off.) With a combination of real
muscle to put a sharp immediate stop to escape from inner tension via acting
out, and with some time afterwards and a place in which to settle down and do
some thinking, and with lots of encouragement and modeling from staff (in
group meetings, where the youngster sees staff dealing intensely and effective-
ly and responsibly with strong real feelings all the time), one stands a very good
chance of starting something new, especially if there is a germ of readiness for
it and latent capacity for attachment, by the adolescent, to some one (or more)
key person(s) on staff. One stands a chance of starting a relation between the
kid and someone (a counselor, a therapist) the kid cares about enough to
restrain himself or herself at least a little bit and at least sometimes for the sake
of preserving that relationship. And that is a critically important beginning.
And one stands the chance of starting a pattern of thinking before acting. (At
first it usually begins at the same time as the acting, and then later shifts to
"before" and "instead of.") And with thinking can come the beginnings of
responsible behavior, or at least of the dialogue that leads on to responsible
behavior.
And how does that relate to you and your work? Where do you come in to
234 EVERETT DULIT
all this? Answer: One key source of muscle (figuratively speaking, but very
much to the point) is the courts and the police. Kids are scared of the courts, and
the police, and jail. (There are exceptions, but the rule is way over in the
aforestated direction.) Court orders for treatment in a secure treatment center
(hospital, residence, detention center with Rx capability) backed by police
power can be the essential first step in an effective treatment for the conduct-
disordered youngster, already with some criminal track record. Without that
muscle, treatment usually does not even begin, despite the best of intentions
and efforts from the most well-meaning, kindly, thoughtful, caring therapists.
And to get that kind of court order takes a working together of court, police,
forensic professionals, and treating professionals in the treatment centers that
do this work. And within that structure, the forensic psychiatrist is critically
placed to bring the diverse parties involved together into a cooperative working
relationship. It takes leadership, and it takes leadership on the scene. You are
on the scene and you can take the leadership role. Certainly sometimes exactly
that happens. But we need much more of it. And sometimes unfortunately
there is a well-intended opposite trend, within the legal system and on the part
of various watchdog agencies, centered on checks and balances against overuse
and abuse of restrictive treatment capacities by treatment staff and centers.
Clearly that concern is legitimate and clearly well intended at core. Abuses are
possible, and in some programs actual. But to do this work and to do it effec-
tively takes real muscle, real force, real clash, real restriction, real limit setting,
really active blocking of acting out by acting-out adolescents, just to begin the
work.
Clearly what is needed is some capacity for assessing and for distinguishing
between too much restriction versus just right restriction, between restrictions
that are improper interferences with freedom to which the citizen is entitled
versus restrictions that are proper because they are essential components of an
effective treatment program for pathological individuals. At bottom, it is a
technical question, an assessment of optimal treatment strategy. And that can
and should be made by people who become expert in this area (whether they
come at it first from the legal side or the therapy side). Working in a system
with built-in checks and balances, in a well-designed system of review and
consultation, they should be able to generate the treatment decisions that find
the optimal middle road between too much and too little restriction. It is one
man's opinion (mine) that the pendulum has swung too far toward restraint of
muscle and worry about the use of muscle, and that we need to find our way in
the field to responsible ways to be able to generate sufficient muscle in treat-
ment programs for the conduct-disordered youngster to be able to do the work
well and to have an impact. And among all the diverse professionals and
participants directly involved in this enterprise of working with the conduct-
disordered adolescent, the ones who seem to me most favorably positioned in
the system to playa key role as coordinators, leaders, and catalysts of a cooper-
ative venture among us all (courts, police, forensic psychiatrists, treatment
staff) tackling this problem are you-the forensic psychiatrists.
CONCLUSION AND SUMMARY
In summary, the basic tasks for the forensic psychiatrist working with
adolescent clients or offenders or patients in the court-related setting is:
1. To make a special effort to try to sort out those cases where some
significant degree of psychiatric illness is a significant underlying con-
tributing factor to the overall clinical picture (taking for granted that
there will be other significant underlying contributing factors as well,
including (a) special situational circumstances, and (b) social class fac-
tors, and (c) special family circumstances, as three regularly relevant
major factors), recognizing that this effort to lift out psychiatric disor-
der as contributing factor is especially important where that psychiatric
disorder is relatively specifically treatable, such as for example the more
classic forms of affective disorder, or even ADDH, and other conditions
as well.
2. To accept that in a substantial minority of cases seen in adolescence a
distinction cannot be made with confidence between the presence of
underlying mental illness versus merely a bad case of adolescence (i.e.,
flamboyance, excessiveness, unconventionality, rule breaking, re-
belliousness that is at the upper end of the wide range of normal), and
that only time will tell. But not to let that truth dissuade or distract one
from the serious and important effort to make that distinction in the
larger proportion (indeed the majority) of cases where that distinction
can be made with quite adequate reliability.
3. To have good and easy access to a wide range of different treatment
approaches/services/programs to which one can effectively refer (or
commit, against their will) youngsters for appropriate (and even specif-
ic) treatment. That means developing, through a career, an increasing-
ly clear and sophisticated set of ideas that permit differentiating out
significantly separate clinical pictures (separate and different as regards
cause, probable prognosis, and optimal treatment approach) from an
initially undifferentiated group of "kids in trouble." And that also
means, again throughout career, particularly in a single locale, develop-
ing a network of connections with key people in key programs to whom
one can turn for real (and essential) assistance in doublechecking the
appropriateness of and facilitating the placement of a kid into a low cost
outpatient program, a less restrictive or more restrictive hospital inpa-
tient program, a special treatment program for suicidal or eating disor-
dered or depressed patients, a special hard-hitting residential treat-
ment program for the hard-core, conduct-disordered youngster, etc.
4. To find one's way, particularly important for the behavioral sci-
enist/helping professional who works in the court-related setting to a
middle ground that feels right and that works well for you on the issue
of more versus less restrictiveness in treatment imposed on psychi-
236 EVERETr DULIT
atrically disturbed adolescents, particularly the conduct-disordered ad-

olescents, even more particularly on the more hard-core conduct-disor-
dered adolescents. It is this author's opinion/judgment that some
considerable degree of imposed restrictiveness and muscle is an abso-
lutely essential, (obligatory) ingredient for the would-be-effective treat-
ment program for the conduct-disordered (particularly hard-core con-
duct-disordered) adolescent patient. The forensic psychiatrist is placed
at a key position in the system for being the spokesperson for the
inclusion and the maintenance of that component in would-be-effective
treatment programs in your venue. That implies the need for becoming
acquainted with and sophisticated about the multiple interlocking con-
siderations that come together around this issue, developing a position
and then becoming an effective spokesperson and even "shaker and
maker" for it.
REFERENCES
1. Fards K, Hudgens RW, Weiner A: Undiagnosed psychiatric illness in adolescents. Arch Gen
Psychiatry 35:279-282, 1978.
2. Kernberg OF: The diagnosis of borderline conditions in adolescence. Adolesc Psychiatry
6:298-319, 1978.
14
Substance Abuse among

Juveniles
HEIDI M. PETERSEN AND ROBERT B. MILLMAN
INTRODUCTION
The use of psychoactive substances to alter mood, perception, and behavior has
become an integral part of the coming of age in Western society. Whereas the
majority of adolescents have experimented with drugs, drug use patterns vary
widely in response to a multiplicity of societal, psychological, and biological
factors. Many adolescents experiment with particular drugs for a period of
time and then cease drug use. Others use drugs periodically or regularly in a
controlled manner and mayor may not suffer adverse consequences of this
behavior. Still others develop compulsive and dangerous drug use patterns and
often experience subsequent physical and psychosocial deterioration. l Cur-
rently, drug abuse may well be considered the primary cause, direct or indirect,
of preventable premature death among adolescents in the United States.
This chapter will address the epidemiology of adolescent drug abuse, the
determinants of behaviors, general patterns of abuse, the various treatment
and preventative methods currently employed, and the psychoactive effects of
specific drugs and alcohol. Although the legal implications are only briefly
discussed, the authors recognize that these implications are diverse and com-
plex. Although the literature consistently shows a statistical relationship be-
tween delinquent behavior of adolescents and their alcohol and drug abuse, it
is not entirely because illicit drug use violates criminal statutes, and alcohol use
among adolescents violates local and state welfare codes. Adolescent substance
HEIDI M. PETERSEN· New York Academy of Medicine, 2 East 103rd Street, New York,
New York 10029. ROBERT B. MILLMAN· Departments of Psychiatry and Public Health,
New York Hospital-Cornell Medical Center, New York, New York 10021.
237
238 HEIDI M. PETERSEN AND ROBERT B. MILLMAN
abuse is indicative of a general deviance syndrome that involves a broad range

of norm-violating and illegal behaviors. Adolescents adjudicated by the juve-
nile court and committed to programs to treat their delinquent behavior are at
high risk for drug and alcohol use and abuse. 2 In New York City alone, 8% of
all adolescents sent to detention centers were adjudicated on charges concern-
ing the sale and/or possession of drugs and/or drug paraphenalia. 3 The per-
centage of youths sent to such sites who also abuse drugs, however, is actually
much larger. One large study4 found that over 50% of the adjudicated adoles-
cents sent to residential delinquency treatment programs had a "noteworthy
drug or alcohol problem." Moreover, the long-term significance of this popula-
tion's drug and alcohol related behavior is indicated by longitudinal research
that reveals that antisocial youths who are incarcerated are at risk for adult
alcoholism and drug abuse. 2
DEFINITION OF TERMS-ABUSE, TOLERANCE, AND

DEPENDENCE
There is no absolute boundary distinguishing the appropriate use of drugs

from misuse or abuse. Abuse is a relative term, the definition of which is depen-
dent on the existing social medical or legal sanctions of convention. What might
be considered an acceptable level of use at one time or in a particular so-
ciocultural setting could, at another time or in a different environment, be
identified as abusive drug taking and indicative of aberrant behavior. Abuse is
used primarily to imply that some harm, to the individual and/or to society,
occurs incident to this pattern of use. 5
Tolerance is characterized by a lower-than-normal quantitative response to
a drug resulting from previous exposure to that drug. That is, the original dose
that evoked specific pharmacologic effects no longer evokes the same intensity
of effects upon subsequent exposure, or a larger dose than that which was
administered initially is needed to replicate the original effects. Cross tolerance
refers to the ability of one drug to induce tolerance to another. Cross tolerance
may develop with drugs from a similar class or between classes. 5 .6 Several
mechanisms of tolerance have been proposed. The most widely accepted and
studied include dispositional, functional, and behavioral tolerance. Dispositional
tolerance is induced when the rate of elimination of a drug increases with
continued use. Thus, upon repeated exposure to the same dose, the action of
the drug will diminish. Dispositional tolerance is not selective and all actions of
a given drug are affected. Functional tolerance develops through a variety of
possible mechanisms at the drug's site of action. Functional tolerance implies
that, upon repeated use, additional drug is needed to attain the pharmacologic
effect initially produced. Unlike dispositional tolerance, functional tolerance is
selective and tolerance to some actions of the drug may be more apparent than
to other actions. Behavioral tolerance develops as a result of adaptation in
anticipation of the known effects of a drug. Thus, upon repeated administra-
SUBSTANCE ABUSE AMONG JUVENILES 239
tion the expectation of desired effects may serve actually to inhibit their onset. 5
Dependence is characterized by an adaptative physical, psychologic, and
biochemical state induced by multiple exposures to a drug. Drug use continues
in order to avoid an abstinence or withdrawal syndrome and abstinence from
specific drugs induces specific withdrawal symptoms. Compulsive drug seeking
behavior usually accompanies dependence. 5 ,6 Tolerance and dependence
often occur together. Both states involve the attempt to regain physiologic
equilibrium following the initial disruption produced by the drug. Tolerance
usually precedes dependence and is produced by an initial set of homeostatic
mechanisms; upon continued drug use dependence results. If the drug of
dependence were withdrawn the new equilibrium established through mecha-
nisms of tolerance and dependence would be disrupted and an abstinence
withdrawal syndrome would ensue. 5
In recent years, it has become recognized that substance abuse disorders
may exist independent of other psychiatric conditions. Accordingly, the revised
third edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM
III-R)1 permits the independent diagnosis of substance use and dependence
apart form other psychiatric disorders. Nine separate classes of substances are
included under the heading of substance use disorders: alcohol, barbiturates,
or similarly acting sedatives or hynotics, amphetamines or similarly acting sym-
pathomimetics, opiods, cannabis, cocaine, phenycyclidine (PCP) or similarly
acting arylcyclohexylamines, hallucinogens and tobacco. Individuals meeting
three or more of the following criteria would receive a diagnosis of depen-
dence:
1. The repeated effort to cut down or control substance abuse
2. The frequent intoxication or impairment by substance use when one
is expected to fulfill social or occupational obligations (for example,
absence from work because of being hung over or high, going to work
high, driving when drunk)
3. The need for increased amounts of the substance in order to achieve
intoxication of the desired effect, or experiencing diminished effect
with continued use of the same amount of the substance (tolerance)
4. The experience of a substance-specific syndrome following cessation
or reduction of intake of the substance (withdrawal)
5. The frequent preoccupation with seeking or taking the substance
6. The relinquishing of some important social, occupational, or recrea-
tional activity in order to seek or take the substance
7. The frequent use of psychoactive substance to relieve or avoid with-
drawal symptoms (for example, taking a drink or diazepam to relieve
morning shakes)
8. The frequent use of the substance in larger dose or over a longer
period than is intended
9. The continuation of substance use despite a physical or mental disor-
der, or despite a significant social problem that the individual knows is
exacerbated by the use of the substance
10. The presence of a mental or physical disorder or condition that is

usually a complication of prolonged substance use (for example, cir-
rhosis, Korsakoffs Syndrome, or perforated nasal septum. 6
EPIDEMIOLOGY
During the mid to late 1960s a marked increase in drug use throughout
the country became apparent, particularly among adolescents and young
adults. A general upward trend of drug use continued throughout the 1970s.
Since 1979, when national prevalence rates peaked, there has been a general
decline in the use of most drugs. Despite this overall decline, the prevalence of
drug use remains quite high and the use of certain drugs even has increased as,
for example, the use of the freebase form of cocaine ("crack") in urban areas.
According to the High School Senior Survey, a steady decrease in illicit
drug use has been apparent from 1980 through 1984. This trend halted in
1985, however, when the proportions of seniors using any illicit drug in their
lifetime, the past year, and the past month remained virtually unchanged from
the preceding year. A similar halt in the decline of drug use was observed
among the nations college students. 8
In 1985, 61 % of high-school seniors reported having used one or more
illicit drugs in their lifetime. Of the students surveyed, 54% reported having
used marijuana at some point in their lives, 41 % reported use within the past
year and 26% reported use within the past month. With the exception of
alcohol or cocaine, marijuana remains the most frequently used and abused
drug among adolescents, though its rate has declined significantly since 1979.
Similarly, prevalence rates for the illicit use of tranquilizers, barbiturates,
amphetamines, and methaqualone have decreased. Inhalent use among high-
school seniors has altered little since 1980. 8
Although drug use in general has decreased since the late 1970s, the use of
certain drugs has actually increased. As noted, cocaine use increased steadily
from 1983 through 1985. In 1983, 4.9% of all high-school seniors had used
cocaine within 30 days prior to being interviewed; in 1985 it rose to 6.7%. More
recent data indicate that the increase in cocaine use appears to have peaked.
These data are preliminary, however, and are based on falling cocaine sales
rather than on an observed decreased in use. 9 The number of students using
PCP also increased from 1984 to 1985, although this number remains signifi-
cantly lower than that reported in 1979.
Males continue to be somewhat more likely than females to use illicit
drugs. However, the gap between males and females has narrowed consider-
ably since the mid-sixties, when alcohol and drugs were used to a far greater
extent by males. The ratio of male/female prevalence rates for cocaine use, for
example, which was large during the mid-seventies, diminished significantly by
1980. Similarly, only slightly more males use marijuana periodically. A far
greater proportion of males, however, use marijuana on a daily basis; (6.9% of
highschool senior males vs. 2.8% of female seniors).
Trends regarding daily drug use patterns are of particular concern be-
cause regular use may indicate dependence on the drug(s) taken. The percent-
age of high-school seniors smoking pot on a daily basis was significantly less in
1985 than in 1975. Daily use of barbiturates and stimulants has also declined.
Conversely, and congruent with the upward trend of periodic cocaine and PCP
use, daily use of these drugs has increased as well. Although the percentage of
daily users remains quite small-daily use of PCP was .03%, daily use of co-
caine was 0.4%, these percentages actually represent a large number of stu-
dents-9,000 daily users of PCP and 12,000 daily users of cocaine. 8
The reasons for the recent overall decline in drug use are uncertain, but
may be attributed, in part, to changing cultural styles, a general tendency
toward more conventional behaviors, and changed attitudes among adoles-
cents toward drugs. Attitudes and beliefs concerning drugs and the perceived
harmfulness of drugs were quite different in 1985 than they were in 1975,
when the majority of adolescents ascribed little risk to experimental or periodic
use of illicit drugs. From 1975 through 1978, the perception of harmfulness
associated with all levels of marijuana use declined. In 1979, this trend reversed
and preceded a concomitant decline in overall use of the drug. From 1979
through 1984 a steady increase was noted in the number of students who
believed that regular use of illicit drugs is harmful. In 1985, the percentage of
students reporting such attitudes remained the same as in 1984. Thus, the
perceived risk of harm associated with drug use appears to parallel the actual
trends of drug use. 8
Although the preceding data reflect general trends in drug use patterns
among adolescents, these statistics must be interpreted cautiously. Accurate
assessment of the incidence and prevalence of drug use is difficult given a
number of important measurement problems. First, prevalence data on adoles-
cent drug use are obtained primarily through self-reports; individuals are
asked to indicate their use or abuse habits by questionnaire and less often by
interview. In light of the illicit nature of these practices it is likely that the actual
prevalence of drug use is underreported. Second, the majority of data cited in
this review were obtained from a government report concerning a 10-year
national survey on drug use patterns among high-school seniors; approx-
imately 125 to 140 public and private schools throughout the country were
selected to participate. Thus, a significant proportion of adolescents who
dropped out of school were not included. High-school dropouts typically rep-
resent adolescents of a lower socioeconomic status, and with less achievement
initiativelO-characteristics that predispose toward substance abuse behavior.
Were this population included, it is probable that higher prevalence rates for
use of all drugs among older adolescents would have been reflected from 1975
through 1985. In fact, recent studies suggest that whereas in the 1960s and
early 1790s, the college educated were more likely to smoke marijuana than
people who had never graduated from high school, in 1985, a national house-
hold survey conducted by the University of Kentucky found that the better
educated young people were, the less likely they were to be using marijuana.
For example, in 1985 approximately 3% of the nation's college graduates used
cocaine compared to 10% of those who had not completed high school. Data
from the University of Michigan high-school-senior survey also suggest that the
greatest reduction in drugs other than marijuana occurred among students
whose parents had the most education. 8 Thus, although use is decreasing
among the well-educated middle-class, use remains rampant among the urban
poor and the minorities.
A third and significant problem with many data reflecting drug use pat-
terns is that because drug use patterns among the young frequently change in
relatively short periods of time, the survey data obtained in 1985 may be
outdated at the present time.
DETERMINANTS OF ABUSE
Multiple determinants of drug abuse among adolescents have been re-

viewed in the literature; in broad terms, these include sociological and psycho-
biological factors. Although strong associations between individual determi-
nants and drug abuse patterns have been shown, they should not be regarded
as cause and effect relationships. It should also be recognized that these deter-
minants have been correlated with drug use of any type or severity. None of
these characteristics has been determined to be singularly predictive of the
development of drug dependence or of which people will use which drugs.
Moreover, it is not useful to depend on any single theory of drug use etiology,
to view all adolescents as experiencing the same psychobiological developmen-
tal processes, or to view drug taking as a static process. The complex interplay
of all possible determinants must be thoroughly characterized for each patient
in order to provide treatment that is specific to and focused on each patient's
needs.
Sociological Factors
An array of societal factors plays a significant role in promoting adolescent
substance abuse. Family relationships, peer pressure, socioeconomic status, and
the media are strong influences on the initiation and continuation of drug use.
Alcohol is generally the initial psychoactive substance used and is often first
introduced in the home. Frequently, this introduction is associated with special
events or celebrations. Among many adolescents who abuse alcohol and drugs,
the home is often a critical factor in promoting substance abuse, either directly
or indirectly. Parents or siblings frequently use or abuse drugs themselves,
indicating this behavior to be acceptable. Il - 17 Such behavior acts as a strong
influence on the child and he or she may initiate use by perceiving this behavior
as acceptable. Parental attitudes or perceived parental attitudes may also influ-
ence the adolescent's decision to begin smoking, drinking, or taking drugs; 18
family instability, parent rejection, under- or overdomination by families, and
divorce have been found to be associated with adolescent substance abuse as
wel1.14, 17, 19,20
Peer influences playa major role in the initiation, development, and main-
tenance of substance abuse. 21 As children progress through adolescence,
friends and peers who use drugs become more important role models than
parents, and most adolescents feel a strong need to identify with a group and
conform to group norms. Again, as with aspects of family influence, peer
influence may derive from perceived supportive attitudes of peers or from the
perception that the use of a given substance is normative. Adolescents who
progress to abusive drug taking patterns typically overestimate the prevalence
of use among their contemporaries. Frequently, the adolescents' degree of
involvement with a particular substance is related to their estimate of the pro-
portion of peers using that substance. 1
As noted previously, socioeconomic status is a powerful determinant asso-
ciated with substance abuse. Generally, adolescents of lower socioeconomic
status initiate use at younger ages, and more frequently become compulsive
drug abusers than their more affluent counterparts. 12 ,14,17,22 A number of
factors interact to influence this trend-unhappiness with homelife and the
surrounding environment, lack of appropriate role models (drug dealers and
pimps), and a dearth of realistic, rewarding alternatives. A general disillusion-
ment with the possibility of obtaining power, wealth, or pleasure through hard
work in conventional pursuits renders drug taking a predictable, attractive
option.
The media have also had a profound effect on substance abuse patterns.
Drug use has been romanticized and frequently appears as an exciting, reward-
ing behavior in the print media, on TV, and in the movies. The recent national
trend against drug use seems to have spawned a more cautious attitude toward
the use of drugs among some, but may have had the reverse effect among
others. Graphic presentations on the horrors of drug use, as depicted by young
girls selling their bodies for a "hit" of the pipe, violent crimes committed to
maintain supplies during a run, and "medical" experts suggesting that one
inhalation leads to long-term addiction, although professed deterrents, may
serve actually to augment the problem. 23 Young people are apt to deny poten-
tial adverse consequences and may even feel that if it is that bad, it must be
good and should therefore be tried. Some former drug abusers have indicated
that these programs or articles only act to increase their craving for the drugs.
Psychological Factors
Considerable debate continues, despite an abundance of data concerning
the psychological determinants of adolescent drug and alcohol abuse, as to
whether specific personality patterns induce drug abuse or dependence and
also whether particular patterns of abuse are associated with certain personality
types. 24 ,25 Youthful drug abusers typically believe their lives are controlled by
outside forces of which they are not in control ("external locus of control").
They generally have a lowered sense of self-esteem, 19,26 more frequent feel-
ings of dysphoria, are more rebellious,27 more untrustworthy, more explosive,
and less ambitious than the general population of adolescents who do not abuse
drugs. Among some adolescents, the drugs are taken as a form of self-medica-
tion in an attempt to reduce painful feelings of shame, rage, and loneliness. 28
Similarly, drugs may be used to control specific drives that are misunderstood
and considered unacceptable, including sexual needs and primitive sadistic and
aggressive influences.!
Although these characteristics are associated with drug abuse and depen-
dence, they do not occur among users exclusively. Much of the data has been
formulated retrospectively. Personality traits and disorders were assessed and
determined after the subjects initiated heavy drug use. The personality disor-
ders or psychopathology noted may be, in fact, a result of pharmacology of the
drugs or the patterns of abuse in a society that stigmatizes such behavior. 25 The
continued abuse of opiates, for example, may induce chronic depressive states
through profound and perhaps irreversible alteration of neurochemical fac-
tors. Protracted abstinence symptoms occuring after drug use cessation may
mimic psychopathology states as well. This is a particularly provocative pos-
sibility in light of the work currently being done on endogenous morphine-like
substances, the discovery of high-affinity binding sites for benzodiazepines in
the brain,29 and the evidence suggesting that chronic cocaine use may lead to
depletion of particular neurotransmitters, such as dopamine, and induce sub-
sequent chronic depressive or anhedonic states. 5
In a recent study of substance abusers with coexisting psychiatric disor-
ders, the relationship between drug use and the attendant psychopathology
was deemed at best unclear, and the clinical implications of these relationships
were determined uncertain. It has been hypothesized that among drug depen-
dent people, "the emotional and defensive states of the user become inter-
twined with the chemical effects of the drug," affecting each other so that the
problems "evolve co-extensively".3o
Adolescent drug abusers differ significantly from each other with regard
to personality patterns and psychopathology; some are normal whereas others
are seriously disabled. It is imperative that the meaning of the drug use pattern
and the accompanying psychobiological characteristics be determined for each
patient individually. Intermittant or infrequent use of drugs may not be associ-
ated with psychopathologic disorders, whereas compulsive use often is.5 Most
observers agree, however, that the more aberrant an individual's abuse pattern
for a specific social or cultural milieu, the greater the likelihood of coexisting
psychopathology ("dual diagnosis").!
Choice of drugs and abuse patterns are also strongly associated with psy-
chiatric symptomatology. Borderline or psychotic adolescents may take opiates,
depressents, or alcohol in order to control severe symptomatology.28,3! Studies
reveal opiates to have significant antipsychotic properties. Use of cocaine and
amphetamines may demonstrate an attempt to self-medicate hyperactive syn-
dromes, attention deficit disorders, and depressive disorders. 5 Some adoles-
cents who use sympathomimetic agents report that the drugs actually induce
better sleep, more normal eating habits, and enhanced concentration and pro-
ductivity. Alcohol or depressants may be taken to control panic attacks or to
permit the expression of long-supressed anger. Frequently, severely disturbed
patients will choose to use opiates or depressants and refrain from taking
marijuana, hallucinogens, or stimulants, because these weaken their connec-
tion to reality and intensify states of paranoia, psychosis, or anxiety. Paradox-
ically, some reports indicate that some patients continue to use these drugs,
despite feelings of paranoia and anxiety, in order to protect themselves from
their own thoughts and emotions (an attempt to distance themselves from who
they are). Such behavior also might be an attempt to rationalize underlying
psychopathology, (e.g., "I am not crazy, I am a pot head").24
As mentioned, abuse patterns are frequently indicative of specific person-
ality types and may be of diagnostic significance. Borderline or psychotic ado-
lescents typically use a variety of drugs in a disorganized manner and experi-
ence frequent adverse reactions or overdoses. Some of these youngsters have
little else with which to identify and proudly deem themselves "garbage heads."
In Erikson's terms they seek "negative identity" for their feelings of worth or
self-definition. 32
PATTERNS OF ABUSE
Alcohol or tobacco are generally the first psychoactive substances used by

young people. Alcohol is often first introduced to an adolescent or even pre-
adolescent by a family member. lo Drug use generally begins in early adoles-
cence; however, many youngsters who progress to abusive drug taking patterns
initiate drug use by the age of 13 or earlier. The average age of initiation, in
fact, appears to be moving down. s
Marijuana is generally the first illicit drug used. Adolescents typically
smoke their first ')oint" with a close friend or group of peers. Initially, the
intention may be to share an exciting, frightening, and pleasurable experience.
Such behaviors may serve as a focus for group interaction and identity. Follow-
ing experimentation with marijuana, some adolescents will initiate use of other
drugs. These often include, depressents, stimulants, and hallucinogens. Opi-
ates are frequently the last substances used. In certain sociocultural environ-
ments, however, experimentation with opiates may begin early in adoles-
cence. 33 .34 The progression from one drug to another is complex, variable, and
nonlinear. In more recent years, for example, cocaine use, particularly among
the affluent young, has been initiated without prior use of many other drugs.
Patterns of use and abuse among adolescents are extremely variable and
highly dependent on sociocultural and psychobiological influences. Some indi-
viduals experiment with marijuana once and never try this or any other drug
again. Others will continue cannabis use and explore additional drugs as well.
Use patterns may be periodic-drugs are taken only on special occasions; or
they may be regular, but controlled-a pattern that does not appear to inter-
fere with normal daily activity. Depending on the drugs consumed, physiologi-
cal and or behaviorally induced withdrawal symptoms and craving may super-
vene, resulting in a compulsive abuse syndrome. This type of progression from
mild or experimental use to dependence often depends on premorbid psycho-
pathology in the youngster. 5 As noted, drug taking patterns that are disor-
ganized and dangerously multiple are characteristic of severely disturbed
adolescents.
It is often difficult though important to attempt to distinguish individuals
who abuse drugs in a manner that disrupts daily living and induces adverse
sequelae, from those who use drugs recreationally. Many individuals who take
drugs periodically, or, in some cases, regularly, are well adjusted to society and
lead productive, active lives. Such individuals may be aware of the risk drug use
presents but, nevertheless, prefer the pleasurable effect of the drug(s) to a life
with less risk involved.
Controversy persists concerning whether or not the use of particular drugs
(i.e., marijuana) leads to experimentation with other drugs. A "stepping stone"
hypothesis has been proposed that suggests a specific progression does exist. 35
Although difficult to validate and frequently denounced as retrospective falsi-
fication, this theory deserves analysis. In a study of young men residing in
Manhatten, 37% of marijuana users had experimented with psychedelics,
whereas no nonusers of marijuana had used psychedelics. Similarly, whereas
34% to 36% of marijuana users had used prescription stimulants, sedatives, or
opiates, only 1% to 5% of nonusers had used these drugs. Studies also reveal
that the frequency of cannabis use is associated with the use of stronger drugs.
In one nationwide study, it has been shown that of young men who had used
marijuana 1000 times or more, 73% used cocaine and 33% used heroine; of
those men who had never used marijuana, less than 1% proceeded to experi-
ment with heroin or cocaine. 36 Although these studies do not prove a causal
relationship, they lend significant merit to the proposed theory. It should be
understood, however, that the psychological and social predisposition of indi-
vidual adolescents have a far greater influence on drug taking patterns than
whether or not marijuana was ever tried.
PREVENTION AND TREATMENT
Prevention programs and early treatment measures are essential and must
be accessible before established patterns of abuse have developed and before
adverse sequelae of these behaviors become manifest. Unfortunately, many of
the programs implemented throughout the past 15 to 20 years have proved
relatively ineffective. High-power educational campaigns, supported by the
community and often implemented in schools, often emphasize the dangers
associated with any drug use and have induced results counter to the programs'
intended purpose. These programs have been designed primarily to frighten
adolescents from experimenting with or pursuing drugs. Frequently, however,
in reaction to such scare tactics, rebellious or mistrustful adolescents are
prompted to continue experimenting with drugs. Even the more naive adoles-
cent may become curious and begin to experiment. Accurate information pre-
sented intelligently and realistically is often perceived as such by adolescents
and this approach is more likely to educate adolescents and successfully warn
them against initiating use or continuing potentially harmful patterns. At-

tempts should be made to emphasize the pleasurable and rewarding aspects of
life without these drugs. 37 ,38 Alternative activities, which stimulate an adoles-
cent's curiosity and interest instead of those geared to constrain and stifle life-
styles, should be offered by communities and schools.
A new generation of prevention programs that presents substance abuse as
a socially acquired, normative, purposive, and functional behavior have been
introduced recently. These approaches stress increased awareness of the social
and psychological factors that encourage use and emphasize enhanced coping
skills. Students are taught specific techniques for resisting social pressures to
initiate or continue drug use. 39 Although the effectiveness of these programs
has not been documented as yet, this alternative approach appears promising.
The treatment of substance abuse problems requires a knowledge of the
specific drugs used and abused and an understanding of the psychosocial
characteristics of the youngster, his or her abuse patterns, and the phar-
macologic effects of the substances abuse. Obtaining such information requires
careful history taking, which includes a drug history, physical examination, and
psychiatric assessment. When the accuracy of self-report information may be
questioned, an observed urine sample may be obtained for toxicological analy-
sis. Lab results should be viewed only as a confirmation of clinical impressions.
Many patients and some therapists believe that underlying psycho-
pathology is the cause for substance abusing behavior and they are convinced
this behavior will stop once the primary disorder is treated. Tactful persuasion
and education are essential to help patients recognize and appreciate the im-
pact of their drug use. Identifying the problem and helping the patient to
accept the proposed intervention may require some degree of confrontation in
a family, work, or school setting. 24
Treatment of substance abuse involves initial and long-term stages. During
the initial stage efforts must be made accurately to assess the problem. The
therapist should attempt to help the patient terminate the drug use patterns
and attain a drug-free state. Often, intoxication, adverse sequelae, or with-
drawal signs must be attended to. If necessary, detoxification from the various
drugs should be effected. During this stage, consideration should be given to
the type of long-term treatment that best suits the patient's needs. A variety of
treatment options are available and the therapist should carefully assess possi-
ble coexisting psychopathologic disorders and the nature of his or her abuse
patterns in order to select the most appropriate mode of follow-up treatment.
Comprehensive treatment programs, offering a broad range of services, in-
cluding group and individual supports and recreational options, appear the
most effective and efficient means of treating adolescents. A wide variety of
long-term programs geared toward this population have been developed, in-
cluding school- and community-based programs as well as inpatient psychiatric
hospital rehabilitation programs and therapeutic communities. Some of these
programs are run by recovering chemically dependent people who themselves
completed treatment successfully. These programs not only provide some es-
sential services to the adolescent but also provide positive role models with
whom patients can identify. Unfortunately, many of these programs include

too few professional members trained to attend to the complex nature of
substance abuse and its often associated psychopathologic disorders.l
A model of treatment for adolescent substance abusers that provides a
wide range of treatment options includes a coordinated inpatient and outpa-
tient therapeutic community structure. This program rotates adolescents
through a series of stages. The nature and severity of an individual's problem
determines at what stage he or she enters the program. The adolescent might,
for example, enter as an inpatient, eventually move to an intensive day care
center, and finally to a more limited, less concentrated outpatient setting.
Thus, the initial stages of treatment include more intensive treatment, which
decreases as the need for services and support decreases and as the patient
becomes better adjusted and develops stronger ties to society.l
A variety of intervention programs have been developed to provide treat-
ment after young people have been arrested, indicted, or convicted for crimi-
nal activity. The rationale behind the development of such programs is that if
treatment and rehabilitation can be provided early in the criminal careers of
young men and women, the efficacy of rehabilitative efforts can be improved.
There are a variety of pretrial diversion programs and programs that place
young people in substance abuse treatment programs after conviction as well as
before and after sentencing. These programs have met with markedly variable
success depending on the characteristics of the programs and the people work-
ing in them.
A recent study undertaken by the University of Kansas examined the
effects of a specific type of delinquency program on adolescent drug and
alcohol use and abuse. This study found that group home programs (small
residential settings in which a group of four to ten adolescents live with and
receive structure and guidance from program staff) have met with variable
success with regard to modifying drug and alcohol abusing behavior. Some
change in behavior was found among adolescents while residing in these
homes, however lasting improvements outside this setting did not occur. The
study concluded that, in light of their findings and the fact that residentially
placed juvenile offenders appear to be at risk for drug and alcohol misuse,
there is a need for structured drug and alcohol prevention and treatment com-
ponents in delinquency programs, as well as a need for research and develop-
ment concerning behavior change strategies for such programs that would have
greater long-term effects on drug and alcohol use and abuse. 2
PSYCHOACTIVE EFFECTS AND ADVERSE SEQUELAE

ASSOCIATED WITH COMMON DRUGS OF ABUSE
Cannabis (Marijuana)
Psychoactive effects of Cannabis are highly variable and dependent on
dose, mode of administration, social environment in which the drug is taken,
and the personality of the user. Effects commonly reported include enhanced
perception of visual, auditory, tactile, and gustatory stimuli; drowsiness, hi-
larious hyperactivity, altered time perception, impairment of short-term mem-
ory; moodiness, exhibited by a sense of relaxed well-being or occasional feel-
ings of anxiety, depression, and paranoia; and impairment of motor perfor-
mance and reaction time.
Adverse sequelae associated with cannabis use are predominantly psychol-
ogic in nature. These sequelae are similar to those seen with psychedelic drugs,
but are observed less frequently. Acute panic reactions, depersonalization,
transient paranoid ideation, and depression are the most commonly noted
complications. Most of these effects, however, subside within several hours
after initiating use. Prolonged psychotic reactions have been precipitated by
cannabis, although such effects are usually observed among individuals with
preexisting psychopathologic disorder. "Flashback" phenomena have been
noted as well, but such an experience is rare.
An amotivational syndrome has been described among habitual marijuana
users. The predominant symptom involves apathy with work and/or school.
Depression is frequently exhibited among chronic users as well. Although con-
troversy exists with regard to the true nature of this syndrome, it seems likely
that, among predisposed individuals, lack of ambition and an inability to set
goals is characteristic of chronic marijuana use.
Central Nervous System Depressants

The drugs in this class most frequently abused by adolescents include the
benzodiazepines, particularly diazepam, chlordiazepoxide, aprazolam, xanax,
and triazolam; the short-acting barbiturates, particularly pentobarbital,
seconal; and other hypnotics, particularly Methaquaalone. Amitriptiline, an
antidepressant, is also abused for its sedative properties.
Central nervous system (CNS) depressants act to depress nerve tissue, as
well as skeletal, smooth, and cardiac muscle, although at low doses the CNS is
affected primarily. Tolerance develops rapidly to all depressants, although the
range is narrow. The lethal dose with barbiturates is not much greater than
that in non tolerant individuals. Sudden discontinuation of habitual use of any
depressant induces withdrawal phenomena. Mild withdrawal symptoms are
characterized by anxiety, insomnia, restlessness, and tremor. A more severe
syndrome might include seizures, occuring within the first several days,
marked agitation, and a delirium characterized by disorientation to time and
place, global confusion, and auditory or viseral hallucinations. Delirium can
also be associated with hyperthermia and tachycardia and can lead ultimately to
exhaustion and cardiac collapse.
When depressants are abused the typical effects desired are similar to
those associated with intoxication from alcohol (i.e., a "high" characterized by a
feeling of hilarity, disinhibition, followed by tranquility, sleepiness, slurred
speech and incoordination). Low doses may decrease sexual anxiety and are
reported to enhance performance and pleasure. Higher doses lead to a dimin-
ished ability to perform sexually. Violent or aggressive behavior may also result
from abuse of these drugs.
The psychoactive effects of alcohol, also classified as a general depressant, are
similar to those of other depressants and tranquilizers. In individuals who are
nontolerant social drinkers, the level of intoxication is dependent on the amount of
alcohol injested and roughly correlates with blood alcohol levels. Small intestine
aborption and gastric emptying influence alcohol absorption; on an empty stom-
ach, low levels will produce a blood alcohol level of 100mg/100mi. Such consump-
tion is associated with a state of mild to moderate sedation and inebriation; Under
such conditions, anxiety is reduced and individuals may perform better in social
situations.
Overt signs of intoxication occur at blood alcohol levels between 100 and
200 mg. per 100 ml. At such levels visual motor coordination, integration and
evaluation of sensory information, sustained attention of stimuli, judgment,
and sexual performance are impaired. Blood alcohol levels above 200 mg. per
100 ml. are associated with severe intoxication and marked sedation.
Drinking large amounts of alcohol over a period of time leads the indi-
vidual to become tolerant. Chronic alcohol abusers may appear sober and are
able to function effectively, even at high blood levels. The range of alcohol
tolerance, however, is narrow. Blood levels that reach 450 mg. per 100 ml. are
usually associated with severe somnolence or coma for the non tolerant and
tolerant individuals. Cross tolerance occurs between alcohol and most depres-
sants, though not between alcohol and opiates. The combination of alcohol
with other depressants or with opiates has additive effects and the conse-
quences of combining these substances are often lethal.
Acute intoxication often precipitates an acute withdrawal syndrome (hang-
over) marked by anxiety, depression, feelings of guilt, headache, nausea,
vomiting, diarrhea, agitation, and tremulousness. Persistent drinking of large
amounts of alcohol increases the severity and intensity of this acute withdrawal
syndrome. Auditory or visual hallucinations (alcohol hallucinations) are often
experienced and in several cases, grand mal seizures may occur up to 14 hours
after drinking has stopped. Adolescent alcoholics generally have not been
drinking for long enough periods to develop delirium tremens, though this
syndrome does occur. This syndrome is characterized by global confusion,
disorientation, delusions and hallucinations, severe agitation, and autonomic
hyperactivity.
There has been accumulating evidence indicating that subsequent to the
acute withdrawal syndrome, a protracted withdrawal syndrome may persist,
marked by tremulousness, anxiety, depression, and insomnia, lasting as long as
6 months after cessation of drinking. This syndrome remains poorly charac-
terized though it is thought to act as a physiologic and psychologic reinforce-
ment for resuming alcohol consumption.
In young people, the acute intoxicating effects of alcohol are more fre-
quently causes of disability and death than are the sequelea of chronic use.
These include accidents, violent behavior, and suicide.
Central Nervous System Stimulants
Cocaine, amphetamines (amphetamine, dextroamphetamine, and meth-

amphetamine), and amphetamine homologs (ritalin, preludin, and tepanil) are
frequently abused by adolescents and are commonreferred to as "ups" or
"speed." With the increased stringency of regulations regarding amphetamines
and related drugs, these drugs have become available primarily from illicit
laboratories and use has declined significantly. In contrast, the use of cocaine
has increased markedly in recent years.
When taken at low doses stimulants produce increased alertness, increased
physical and cognitive functioning, and decreased appetite and fatigue. Al-
though some tolerance to all stimulants can develop, it develops differentially
to the various actions of the various drugs. For example, tolerance to most
actions of the amphetamines is profound whereas tolerance to cocaine's eu-
phoric and appetite suppressant effects is quite modest. Behavioral tolerance
does seem to occur with cocaine in that individuals perceive diminished eupho-
riant properties and adverse effects with continued usage. A phenomenon
called sensitization or reverse tolerance may occur with cocaine in that seizures
and often adverse effects may occur with continued use at doses that would not
produce these effects upon initial use. Some cross tolerance between various
amphetamines as well as between amphetamines and cocaine also occurs.5
After cessation of cocaine use, in distinction to opiates or alcohol, craving is
decreased and a withdrawal syndrome marked by exhaustion, depression, som-
nolence, and increased appetite has been described.
The use of high doses of cocaine produces anxiety, restlessness, hyper-
alertness, and paranoia. A paranoid psychosis occurs at high doses, though the
threshold for this adverse reaction seems to vary according to pre morbid psy-
chopathology. Many abusers of both amphetamines and cocaine excoriate their
skin and develop ulcers and infections-the so called "cocaine bugs."5 Such
behavior may be a function of tactile hallucinations or a form of primitive,
stereotyped behavior. Such psychotic reactions are often indistinguishable
from acute paranoid schizophrenia.
Although a life-threatening withdrawal syndrome does not occur upon
cessation of prolonged cocaine use, cocaine is one of the most powerfully
reinforcing drugs known. That is, use of the drug produces a strong craving to
repeat the experience. The intensity of the craving depends, in large part, on
the dose taken and the mode of administration. The higher the dose and the
more rapid the onset of effects, the more profound the desire to repeat the
experience. The smoking of free base or "crack," an alkaline form of cocaine
hydrochloride, or the intravenous injection of cocaine, cause the drug to be
absorbed rapidly into the blood stream and thereby induce particularly intense
physiologic and psychoactive effects. Crack, in particular, has been associated
with violent behavior, especially among adolescents. Recently, reports of
groups of youths from Los Angeles and Miami smoking and selling crack while
heavily armed, and committing crimes, including murder, with a terrifyingly
casual attitude, have been described in the popular press. It is likely that the
sense of invulnerability, and lack of fear associated with adolescence, coupled
with the aggressiveness and paranoia induced by crack, is responsible for this
unprecedented violence and disregard for the law.
Opiates-Narcotic Analgesics
All opiates, both the illicitly and licitly obtained, are subject to abuse.
Heroin, an illicit short-acting opiate, is the most commonly abused drug of this
class. Other commonly abused opiates include, morphine, codeine, and de-
laudad. Synthetic opioids subject to misuse, include demerol, fentanyl, per-
codan, and methadone.
Tolerance develops rapidly but differentially to the various effects of opi-
ates. Profound tolerance occurs to the euphoriant, sedative, anorectic effects,
though little develops to the constipating effects of the drug. Behavioral toler-
ance also occurs through what appears to be a classical conditioning paradigm.
The drug is expected, a conditioned response results opposing the drug's
action, and tolerance is induced. 5
Dependence with repeated use of opiates is remarkably profound. Initially
there may be little discomfort, aside from the mild depression, but a strong
desire to reproduce the pleasurable, euphoric effects of the drug often occurs.
Upon continued use, more profound physical dependence is induced, charac-
terized by a stereotypical set of withdrawal symptoms, including drug craving,
anxiety, restlessness, depression, runny eyes and nose, irritability, yawning,
perspiration, dilated pupils, sneezing, coughing, nausea, vomiting, diarrhea,
abdominal cramps and "bone" pains. Severe medical consequences, such as
convulsions and shock, are rare. Following withdrawal, a protracted abstinence
syndrome typically ensues. For the first several weeks, symptoms may include
profound depression or anxiety, increased pupillary size, and elevation of
blood pressure, body temperature, and respiratory rate. For another several
months, body temperature, pulse rate, and respiratory rate may be below
normal. 5 Insomnia, dysphoria, anxiety, and craving for opiates may also persist
and may be a powerful reinforcement to resume drug taking.
Adverse sequelae resulting from opiate use are related generally to the
administration of uncertain quantities of the drug and the mode of use. Ap-
proximately 75% of opiate-related deaths result from accute heroin reactions,
characterized by cyanosis, pulmonary edema, respiratory depression, and
coma. 40 Intravenous use of the drug under unsterile conditions is associated
with various bacterial infections, cellulitis and endocarditis and viral infections
including Hepatits B. More recently, transmission of the HIV (AIDS) virus
through the use of unsterile needles has presented a serious health risk to IV
drug abusers and to their non-drug-using consorts.
Crimes related to opiate use typically involve the attempt to get money for
sufficient drugs to allay abstinence symptoms. Many addicts engage in daily
criminal activity, including prostitution, burglary, and muggings in order to
maintain their habits. In distinction to cocaine, an individual under the influ-
ence of heroin or another opiate may feel satiated or content and usually is not
aggressive or violent. In the throes of the withdrawal syndrome, however,
addicts may engage in crimes against people and/or property.
Hallucinogens
The hallucinogens abused most frequently include lysergic acid diethyl-
amide (LSD), psilocybin, mescaline, and the substituted amphetamines, such as
2,5 dimethoxy-4-methyl-amphetamine (DOM, "STP"). The anesthetic agent,
Phenycyclidine ("PCP"), also has been abused for its psychedelic effects. These
drugs produce profound alterations in perception, thought, feelings, and
behavior.
In terms of psychoactive effect, LSD is 1000 times more potent than
psilocybin and 4000 times more potent than mescaline. Central sympathomi-
metic stimulation is effected within 20 minutes following ingestion and is char-
acterized by mydriasis, hyperthermia, tachychardia, hypertension, piloerec-
tion, increased alertness and facility of reflexes. Nausea and vomiting may
occur occasionally as well. Within 2 hours after ingestion, the psychoactive
effects of hallucinogens are fully manifest. They may vary markedly depend-
ing on the dose, setting, personality, and expectations of the user. Upon drug
intoxication, thoughts may assume extraordinary importance and clarity. Ob-
jects may seem to waver or melt and distortions of the body are often per-
ceived. Illusions and synesthesias, the overflow of one sensory modality into
another, are also common. l
Tolerance to hallucinogens develops rapidly. Within 3 to 4 days, daily
doses of these drugs become ineffective. Cross tolerance also occurs between
most hallucinogens, indicating some common mechanism of action.
The most common adverse reaction to psychedelic use is the acute panic
reaction ("bad trip"). The syndrome is variable and feelings of insanity, sensa-
tions of breathlessness, and fear of bodily harm may be experienced. Usually,
as the drug effect dissipates, these symptoms also abate. It is rare that pro-
longed psychotic episodes occur, which are characterized by paranoid ideation,
grandiosity, bizarre delusions and hallucinations, and affectual disturbances.
These psychotic episodes may be clinically indistinguishable from the func-
tional psychoses, but generally are more responsive to treatment and abate
more quickly.
Some aspects of a previous trip may recur even when the adolescent is no
longer intoxicated by the drug (flashback). Usually these episodes are not
severe, although marked psychotic behavior has been reported. Panic attacks
and psychotic reactions occur more frequently among emotionally disturbed
adolescents who take high doses of a hallucinogen. It is not yet clear whether
hallucinogens can induce prolonged psychotic reactions in reasonably healthy
individuals.
Doses of LSD related psychedelic drugs are rarely associated with phys-
iologic toxicity and no toxic deaths have been reported. The acute toxic effects
of PCP resemble those of LSD, although violent and psychotic reactions are
reported to occur more frequently. Unlike with LSD, PCP is associated with
severe physiologic toxicity and deaths have been reported.!
Criminal activity related to hallucinogen use is quite rare. In the throes of
an anxiety reaction or psychotic episode, as a result of markedly impaired
judgment or delusions, violent acts may occur. PCP is reported to be associated
with psychotic reactions and violent episodes.
CONCLUSION
In young people, delinquency and substance abuse should be considered

part of a pattern of unconventional behaviors that might also include impaired
family and social relationships, impaired school performance, teenage preg-
nancy, and other antisocial behaviors. It is often less productive to attempt to
define what came first, or what factors were etiologic than to characterize the
areas in which the youngster is developing problems. The family, the school,
and certainly the criminal justice system must become more sensitive and more
responsive to the needs of these troubled young people, as early as possible.
Physicians and other health personnel may also represent early contacts for
identifying adolescents at risk. Much remains to be learned and done.
Because such a significant portion of young people who do get into trouble
with the legal authorities have drug problems or are likely to develop them, the
legal system represents a critical environment to develop imaginative, humane,
and effective interventions. This is no easy task, to be sure, because effective
treatment must be sufficiently comprehensive to address the various problem
areas. The drug problem cannot be dealt with unless the psychological and
social aspects of a youngster's life are considered as well. Rather than simply
attempting to tell them what to do, we must develop resources and methods to
help them to decide what they may do with honor and the hope of reward. At
the same time, more knowledge and more effective interventions may effect
remarkable change in the lives of these disabled young people.
REFERENCES
1. Millman RB, Botvin Gj: Substance use, abuse and dependence, in Levine MD, Carey WB,
Crocker AC, Gross RT (eds): Developmental Behavioral Pediatrics. Philadelphia, Saunders
Co, 1983, pp 683-708.
2. Braukmann Cj, Bedlington MM, Belden BD, Braukman PD, Hustedjj, Ramp KK, Wolf
MM: Effects of community-based group-home treatment programs on male juvenile
offenders' use and abuse of drugs and alcohol. Am] Drug Alcohol Abuse 11 :249-278, 1985.
3. Personal communication with the Honorable Ellen Schaller, Commissioner of juvenile
justice, New York City Department of juvenile justice.
4. Murray CA, Cox LA: Beyond Probation. Beverly Hills, Cal, Sage, 1979.
5. Hollister LE: Drug Tolerance, Dependence and Abuse in Current Concepts. Kalamazoo, Mich,
The Upjohn Co, 1985.
6. Millman RB: General principles of diagnosis and treatment, in Frances Aj, Hales RE
(eds.): Psychiatry Update, Annual Review, vol 5. American Psychiatric Press, Washington
DC, 1986, pp 122-136.
7. Rounsaville BJ: Interim eveluation of DSM-IU: Substance use disorders in DSM-UI (R)
in Development Work Group to Revise DSM-UI. Washington DC, American Psychiatric
Association, 1985.
8. Johnston LD, O'Malley PM, Bachman JG: Drug Use Among Highschool Students and Other
Young Adults: National Trends Through 1985. U.S. Department of Health and Human
Services, National Institute on Drug Abuse, 1986, and the University of Michigan In-
stitute for Social Research, 1986, pp 1-237.
9. Wall Street Journal: Coming down: Signs indicate that america's cocaine habit is easing.
July 20, 1987.
10. Select Committee on Narcotics Abuse and Control: Drugs and Dropouts-A Report.
SCNAC-99-2-2, 1986, pp 1-39.
11. Bewley B, Bland J: Academic performance and social factors related to cigarette smoking
by school children. Br] Preventive Social Medicine 31: 18-24, 1977.
12. Borland BK, RudolphJP: Relative effects of low socioeconomic status, parental smoking
and poor scholastic performance on smoking among highschool students. Soc Sci Med
9:27-30, 1975.
13. Demone HW: The nonuse and abuse of alcohol by the male adolescent, in Chafetz M
(ed): Proceedings of the Second Annual Alcoholism Conference. DHEW publication (HSM)
73-9083, Washington DC, US Government Printing Office, 1973.
14. Gergen MK, Gergen KJ, Morse SM: Correlates of marijuana use among college students.
] Appl Soc Psychol 2: 1-16, 1972.
15. Kandel D: Adolescent marijuana use: Role of parents and peers. Science, 181: 1076-1081,
1973.
16. Wechsler H, Thurn D: Alcohol and drug use among teenagers. A questionnaire study, in
Chafetz M (ed): Proceedings of the Second Annual Alcoholism Conference, DHEW Pub. No.
(HSM) 73-1083. Washington DC, US Government Printing Office, 1973.
17. Williams AF: Personality and other characteristics associated with cigarette smoking
among young teenagers.] Health Soc Behav 14:374-380, 1973.
18. Hunt WA, Barnett LW, Branch LG: Relapse rates in addiction programs.] Clin Psychol
27 :455-456, 1971.
19. Braucht C, Brakarsh D, Follingstad D, Berry K: Deviant drug use in adolescence: A
review of psychosocial correlates. Psychol Bull 79:92-106, 1973.
20. Seldin NE: The family of the addict: A review of the literature. 1nt] Addict 7:97-107,
1972.
21. Freeland JB, Campbell RS: The social context of first marijuana use. 1nt] Addict 8:317-
324, 1973.
22. US Public Health Service: Teenage Smoking: National Patterns of Cigarette Smoking, Ages 12
through 18, in 1972 and 1974. US Dept. Health. HEW, no. (NIH) 76-931. Washington, DC,
US Government Printing Office, 1976.
23. Millman RB: Taking issue: Cocaine use and the media. Hosp Community Psychiatry
38(5):449, 1987.
24. Millman RB, Khuri ET: Adolescence and substance abuse, in LowinsonJH, Ruiz P (eds):
Substance Abuse: Clinical Problems and Perspectives. Baltimore, The Williams and Williams
Co, 1981, pp 739-751.
25. Zinberg NE: Addiction and ego function, in Eissler, RS, Freud A, Kris M, Jolnit AJ (eds):
The Psychoanalytic Study of the Child. New Haven, Conn, Yale University Press, 1975.
26. Williams AF: Personality and other characteristics associated with cigarette smoking
among young teenagers.] Health Soc Behnv 14:374-380, 1973.
27. Jarvik ME et al.: Research on Smoking Behavior. National Institute on Drug Abuse Research
Monograph 17, DHEW pub. no. (ADM) 78-581. Washington DC, US Government Print-
ing Office, p 383, 1977.
28. Khantzian EJ, Mack JE, Schatzberg AF: Heroin use as an attempt to cope: Clinical
observations. Am] Psychiatry 131:160-164, 1974.
29. Meyer RE, Mirin SM: The Heroin Stimulus-Implications for a Theory of Addicition. New
York, Plenum Press, 1979.
30. Talbott JA: Chronic Mentally III Young Adults (18-40) with Substance Abuse Problems: A Review
of Relevant Literature and Creation of a Research Agenda. Submitted to Alcohol, Drug Abuse
and Mental Health Administration. US Department of Health and Human Services and
Department of Health and Mental Hygiene, 1986.
31. Vereby K, VolavkaJ, Colvet D: Endorphines in Psychiatry: An overview and/or hypoth-
esis. Arch Gen Psychiatry 35:877-888, 1978.
32. Erikson EH: Childhood and Society, ed 2. New York, W. W. Norton, 1963.
33. Kandel D, Single, E, Kessler RC: The epidemiology of drug use among New York State
highschool students: Distribution, trends, and change in rates of use. Am] Public Health
66:43, 1976.
34. Hamburg BA, Braemer HC, Jahynken WA: Hierarchy of drug use in adolescence: Be-
havioral and attitudinal correlates of substantial drug use. Am] Psychiatry 132: 1155-1167,
1975.
35. Goode E: Marijuana use and the progression to dangerous drugs, in Miller LL (ed):
Effects on Human Behavior, New York, Academy Press, INC. 1974, pp 303-338.
36. Millman RB: Treatment of marijuana abuse, in Kleber H (ed): Treatment of Substance Abuse
Disorders. American Psychiatric Press, in press.
37. Jacobson R, Zimberg NE: Social basis of drug abuse prevention. Washington DC, Drug
Abuse Council, 1978.
38. Millman RB: Drug abuse in adolescence: Current issues, in Senay E, Shorty V, Alksne H
(eds): Developments in the Field of Drug Abuse: Proceedings of the 1st National Drug Abuse
Conference, 1974; New York, National Asociation for the Prevention of Addiction to
Narcotics, 1975.
39. Botvin GJ, Eng A: the efficacy of a multicomponent approach to the prevention of
cigarette smoking. Prev Med 11: 199-211, 1982.
40. Cherubin CD: A review of the medical complications of narcotic addiction. 1nt] Addict
3:167,1968.
15
Issues in the Forensic
Assessment of the Black
Adolescent
RICHARD A. ELLISON
INTRODUCTION
There is no reason to believe that the general principles of medical and psychi-
atric diagnosis and treatment cannot be uniformly applied to all people, re-
gardless of their race. This is equally true in the area of adolescent psychiatry
and the law. However, there are a number important reasons for the serious
student of forensic psychiatry to pause to consider separately the Afro-Ameri-
can. The social, political, economic, and legal disenfranchisement of blacks has
continued unabated for decades since the official end of slavery. 1.2.3 Indeed,
racism can even be found in the traditions of the practice of American psychia-
try.3.4 It is obvious that a group with such a unique history and common
experience would be likely to have differences in their behavior and psychol-
ogy that would warrant special attention.
There is, however, another compelling reason why particular considera-
tion should be given to the black population: Black people are affected by
almost every major health problem in the United States today more adversely
than any other group.5.6 Nowhere is this frightening fact more pronounced
than in the areas where the forensic psychiatrist who evaluates and treats
juveniles is likely to have a primary concern: crime and delinquency. Much of
the discussion in this chapter will be focused in this area. The problems of the
black juvenile in America today are unique, and profoundly difficult. By look-
RICHARD A. ELLISON· William S. Hall Psychiatric Institute. 1800 Colonial Drive, Colum-
bia. South Carolina 29202.
257
258 RICHARD A. ELLISON
ing at some important demographic variables, and considering specific clinical

issues, with case examples where appropriate, this chapter will offer the clini-
cian a brief glimpse into "the soul of his turmoil."7
DESCRIPTIVE DEMOGRAPHICS OF THE BLACK JUVENILE
Psychiatrists with a knowledge of life in the black community and with

experience in the evaluation of the black juvenile can not help but assume, as
do Comer and Hill, "that much of the etiology of mental illness and mental
anguish is rooted in social conditions rather than in individual defects."2 It is
for this reason that, in order more clearly to understand this group, some
familiarity with the social characteristics of this population is essential. Even the
most cursory review of a few of the economic, health, and legal system statistics
as they relate to young blacks will enlighten one to the profound problems with
which this group is faced.
Social Indicators
Table I highlights some selected economic variables. It can be clearly seen
from this data that most blacks continue to find themselves at an economic
disadvantage when compared with whites. The unemployment rates for black
teenagers continue to be staggering. Comer and Hill contend that:
Programs such as Aid for Families of Dependent Children (AFDC), food stamps,
subsidized housing, Medicaid, and a variety of income substitute programs
maintain only the status quo or promote more Black family deterioration. The
AFDC program, for example provides cash assistance primarily to single parent
families and to two parent families in which the principle breadwinner is unem-
ployed. It is often harmful to the mental health of children in two ways. First, the
amount of support cannot provide even a minimum quality of life. Second,
eligibility requirements often promote out of wedlock pregnancy and force men
out of the household, leaving women and children under the stress of inade-
quate income, social, and psychological support. 2
The birth rate for black teenagers and women is higher for every age
group from age 10 to 24, ranging from almost twice the white birth rate for 18-
to 19-year-olds to nearly seven times the rate for 10- to 14-year-olds. 5 The birth
rate for unmarried girls age 15 to 19 in 1985 was almost 4.5 times greater for
blacks than for whites. 8 Black women are having children at a younger age, on
the average, and at times in life when they are less equipped, financially or
emotionally, to care for them. The problems for these young mothers, "chil-
dren having children," and for their growing offspring, are enormous. These
youngsters are likely to be unmarried, academic underachievers, and to be
condemned to a life of poverty. They suffer increased rates of complications
during pregnancy, and tend to have increased family and interpersonal diffi-
culties. Their children commonly suffer from the effects of poverty, poor
nutrition, and poor parenting skills. 9 They are less likely to complete high
ASSESSMENT OF THE BLACK ADOLESCENT 259
Table I. Selected Economic Facts
Percentage of selected groups who were living below

1985 poverty levels (defined as income for a family
of four of less than $10,989)
Of all whites 11.4

Of all blacks 31. 3
Of all black children 43.1
Of all black female head of household 50.5
Percentage of unemployment as of June, 1987
Total U.S. population 6.1

Of all whites 5.2
Of all blacks 12.7
Of all whites, age 16-19 15.9
Of all blacks, age 16-19 33.3
Median incomes, 1985
Lower fifth of all whites $14,528

Lower fifth of all blacks $6,750
Top 5% of all whites $80,000
Top 5% of all blacks $54,030
Note. Adapted from Hoffman MS (ed): The World Almanac

and Book of Facts-J988. New York, Pharos Books, 1987.
schoo1. 9 ,!O This fact undoubtedly contributes to the problem of the excessive
rate of high-school dropouts among blacks. It has been estimated 10 that 20% of
black youths in the 18-21 age group are without a high school diploma.
These facts, taken together, represent one of the most serious social prob-
lems facing America today: a growing black underclass that is young, poor,
excessively fertile, and undereducated, a group locked in a system of public
support policies that only foster and maintain the status quo.
Crime Statistics
It is by now virtually common knowledge that blacks, especially black

juveniles, are vastly overrepresented when one looks at crime in America.
Gibbs l l estimated that in 1979, 15% of all black adolescents in the 15 to 19 age
group were arrested. In 1985, 36.9% of the youths in juvenile facilities in
America were black. 12 This problem has persisted for some time. Table II
further illustrates this. It can be seen that the majority of arrests of persons
under the age of 18 for violent crimes in 1986 were black. These statistics, even
for property crimes and other categories where blacks are not the majority of
those arrested, are even more shocking when one considers that blacks are
estimated to make up only 12.3% of the total United States population, and
Table II. Arrests of Persons under Age 18

for Selected Crimes, 1986
Percentage distribution
by race
Whites Blacks Others
Murder/manslaughter 49 48 3
Forcible rape 46 53
Robbery 33 66 I
Aggravated assault 56 42 2
All property crimes 72 26 2
All violent crimes 47 52
Note. From US Department of Justice, Federal Bureau of Investiga-
tion: Uniform Crime Reports. Washington DC, US Government Print-
ing Office, 1987.
only about 14% of the adolescent age group,5 Black youths are accused of
committing crimes at an alarmingly excessive rate, and are clearly overrepre-
sented as offenders in the criminal justice system.
A fact that is perhaps not as commonly appreciated, but one that is crucial
to the psychiatrist evaluating the black juvenile, is that young black people are
themselves more likely to be the victims of crime. The leading case in point is
homicide. Although the national homicide rates have generally been declining
since 1980,14 the magnitude of the problem for young blacks has remained
quite grave. It was recently estimated that "Black males have a 1 in 21 lifetime
chance of becoming a homicide victim. The chance for White males is 1 in
131."6
The mortality rate for black males between the ages of 15 and 24 in 1985
from "Homicide and Legal Intervention" was nearly six times that of white
males in the same age group, and nearly 17 times greater than the rate of white
females. 5 Of the 10- to 14-year-old murder victims in the United States in 1986,
33.7% were black. Of the 15- to 19-year-old murder victims in 1986, 48.9%
were black. 13
Table III illustrates that the victimization rate in almost every crime cate-
gory is higher for young blacks than it is for young whites.
It is extremely common clinically, when evaluating a black juvenile for a
forensic purpose, to obtain a history of victimization from the patient. In a
survey of a community mental health center in a black community in Chicago,
Bell et al. 15 discovered that a large percentage of their adolescent patients
either had been sexually and/or physically assaulted, or knew of a person close
to them who had. Clearly, it is important for the clinician to search for this
history in order to enhance his understanding of his patient'S personal life
experience.
A comprehensive explanation of these selected demographic variables is
far beyond the scope of this chapter. They are presented here as a point of
Table III. Estimated Rate per 1,000

Population 12 and over of Victimization
from Selected Violent Crimes, 1985
Whites Blacks
Total rate 29.1 38.2

Rape 0.6 1.8
Robbery 4.2 10.9
Assault 24.2 25.9
Larceny with contact 2.3 4.8
Note. From US Department of Justice, Bureau of Jus-

tice Statistics: Sourcebook of Criminal Justice Statistics-
1986. Washington DC, US Government Printing Of-
fice, 1987.
reference in an understanding of the black juvenile that is necessary in per-

forming a psychiatric examination for legal purposes. They will perhaps come
into better focus as we move to consider other, more clinical issues. However,
the findings of Comer and Hill may provide some insight into the problems
which we have highlighted: "When a disproportionate number of families
within a group are traumatized by social policy shortcomings, a disproportion-
ate number of children will present with learning, antisocial, social, and/or
behavioral problems."2
ASPECTS OF THE PSYCHOLOGY OF THE BLACK YOUTH
As is clear from the preceding, blacks are overrepresented in indicators of

problems and failure in American society. They are also underrepresented
among the professions that attempt to cope with these problems, particularly in
medicine and psychiatry.8,16 This fact may in part explain why there is scant
psychiatric literature relating to the evaluation and treatment of black adoles-
cents, particularly delinquents. In fact, among the major theories of the etiolo-
gy of juvenile delinquency, none specifically address the peculiar situation of
the Afro-American. 17 Wilkinson and Spurlock point out that "accurate de-
scriptions of the developmental progression of the dynamic forces that origi-
nate in both poverty and racism and result in emotional illness have yet to be
articulated. "3 With an awareness of this problem in mind, we will briefly sketch
below some of the more salient issues, which, in the view of this author, are
important to the psychiatrist involved in the evaluation of the black juvenile for
legal purposes.
General Considerations
Perhaps the best way to begin this discussion is to alert the clinician to what
many consider is an inherent element of the psychology of many blacks in
America today. Cultural paranoia was a term first coined by Grier and Cobbs. IS
It refers to the notion that blacks tend to have a natural paranoia when it
comes to their relationships to whites and white-dominated institutions. This
results from a common, cultural experience of racism in almost every aspect of
their daily lives. This is reflected in several commonly reported clinicial prob-
lems. For example, blacks frequently express reluctance in one way or another
to be evaluated or treated (lateness, missed appointments, etc.).3·19.20 Blacks
sometimes can be minimally revealing of themselves in evaluative and thera-
peutic situations. 3 •21 Blacks may feel, sometimes with justification, that whites
will perceive them in a negative or discriminatory light, and/or not understand
them. 20 This will obviously affect the clinical presentation.
To look at the problem in another light, it can be seen that the societal
reasons for black juveniles to maintain a sense of paranoia can be quite real, as
the following case example will illustrate.
CASE 1
A 20-year-old black male with at least a 3-year history of schizophrenia was pre-
sented to a professor at a teaching conference at a university affiliated medical
center. The young man spent most of his time complaining that the local police
were harassing him. He claimed that he was frequently stopped and even
searched for no apparent reason, and believed that the police had a conspiracy
against him because he was black. In the subsequent discussion of this case, the
professor (who was white) explained at great length that this patient's fear of the
police was indicative of the paranoid delusional thinking typically seen in schizo-
phrenia. To illustrate his point, the professor asked the students if they believed
that they were harassed by the police. The two black students who were present
were the only ones to report that they had been stopped several times in the area.
One student had even been falsely arrested while coming from a visit with his wife,
who was a patient in the hospital. Both indicated their belief that their problems
with the police were because they were black.
This case illustrates the point that it is normal for blacks to be overly cautious
and suspicious in certain situations. One's black skin multiplies the chances of
being stopped and/or accused, particularly in cases where unusual appearance
and behavior, perhaps because of mental illness, are also present. It is not
necessarily a sign of pathology for a young black to be reluctant to talk or
cooperate, or to complain about their treatment at the hands of whites.
Black youngsters in the criminal justice system are often significantly edu-
cationally handicapped. They are ill equipped to fend for themselves in a
system that they frequently perceive as being inherently against them. They are
likely to be poorly represented by an overburdened public defender system.
Many welfare families cannot afford even a seemingly modest bail. It is com-
mon to encounter cases where the youngster was encouraged to plead guilty to
a charge, even though innocent, in order to get out of jail quicker on a plea
bargain arrangement. Thus, some may have an undeserved prior criminal
record, which only serves to enhance them as targets for future police arrest. In
most areas, the poor and black neighborhoods are more heavily patrolled by
the police, thus increasing a black youth's chances of arrest for activities that
might go undetected elsewhere. In discussing this particular group of Black
adolescents, Baker states:
The mental health problems affecting many Afro-American adolescents and
young adults are a direct result of the accumulated consequences of poverty,
being at the lowest end of the socioeconomic scale. . . this Black youngster is
alienated from society, drops out of school, which perpetuates a sense of failure,
and turns to "what's happening in the street" as the only source of life's good
things. The problems with substance abuse, sexual activity, and sometimes overt
criminal acts results in a delinquent label. The youngster then enters the correc-
tional system rather than a mental health facility.22
Many black youths claim that they were encouraged and/or trapped into a
criminal activity by others, sometimes the police. The following case is reveal-
ing of this latter problem:
CASE 2
Peter was an IS-year-old black male who was brought to the hospital emergency
room by the police. They claimed that after his arrest for snatching a gold chain
on a subway train, he became wildly belligerent and uncontrollable. In fact, in the
emergency room, he was described as "grossly psychotic." He was highly agitated,
restless, spitting, cursing, and swinging at anyone who came near him. No co-
herent conversation was possible, and he required physical and chemical re-
straints. Forty-eight hours later, he was calm enough to be interviewed. No signs
of a thought disorder were evident. He claimed that he had previously done 2
years in a youth camp for robbery and was on probation. He stated that he was on
his way to work, and that a man next to him repeatedly suggested that they both
snatch the valuable gold chains of a man who was apparently intoxicated and
asleep across from them. Peter claimed that he finally gave into this temptation,
and was immediately arrested by both men, who turned out to be undercover
police officers. "I guess I just couldn't handle it," Peter claimed, as he realized
what had happened to him, and thought of the likelihood of another lengthy
period of incarceration.
The previous case may also serve to remind the forensic clinician that the
incarcerated juvenile is under a tremendous amount of stress. Incarceration is
likely to be the single most stressful experience in the young person's life. 23
Physical injuries 24 and suicidal behavior25 are very common among this popu-
lation. This fact should not be taken lightly, but carefully considered, particu-
larly when evaluating the mental status of the black juvenile. Incarceration can,
for some, become the final straw in what the youngster perceives to be an
already unduly stressful life experience.
The Question of Diminished Endowment

The natural paranoia of blacks, together with differences in language and
appearance, may combine to make the black juvenile present themselves in
ways that appear to be abnormal. This frequently leads to black youths being
labeled as retarded or of borderline intellectual functioning based on a clinical

evaluation, as the following cases will illustrate.
CASE 3
A 19-year-old black male was evaluated in a correctional center where he was
being held for burglary. When initially seen, he was described as being sloppily
dressed, avoiding eye contact. His speech was minimally spontaneous and at times
unintelligible. He appeared unable, at times, to understand most questions put to
him. He was given a diagnosis which included "rule out mental retardation." He
was subsequently evaluated by a black examiner who was able to gain this patient's
confidence. He began to make good eye contact, and spoke volubly, with a thick
southern accent, about his career as a burglar. He described in detail how he
carefully planned and executed many break-ins, including being knowledgeable
about the particular neighborhoods, and being prepared with the tools that may
be necessary for each job.
CASE 4
A 16-year-old black female was referred for a prepleading examination. Accused
of the murder of a 60-year-old man, her attorney and the judge were unable to
communicate with her. Her attorney reported that the girl seemed "confused" by
most of his questions, could provide no information, and he wondered if she
might be "retarded." The young girl presented with her clothing and hair un-
kempt, and sat mutely in her chair and avoided eye contact. With some persistence
on the part ofthe examiner, which included efforts to demonstrate empathy with
the young girl, she gradually began to reveal herself. She was the oldest of 6
children. Her mother, who was unmarried, supported the family with welfare.
She claimed to be an average student, and denied any prior criminal activities. She
claimed that the murder occurred in the course of an attempted rape. Devastated
by her experiences, she felt isolated and alone, that no one would ever understand
her. She wished she were dead. Corrections officials were warned that she was
possibly suicidally depressed.
The previous cases are examples of black patients who at first are labeled
as retarded, when, in fact, they clearly are not. This is a grave error in the
forensic psychiatric evaluations of black juveniles, and is more likely to be made
when the examiner encounters some difficulty in understanding his patient.
It is a long established fact that blacks, on average, score lower than whites
on standardized intelligence tests.26.27.28 The general finding that is frequently
reported in the clinical literature is that those who are officially designated as
delinquents tend to score lower on IQ tests than do nondelinquents. 26 There
are those who suggest that these facts, taken together, may in part explain why
blacks are overrepresented in delinquency.26.27 Wilson and Herrnstein claim
that:
If lowered measured intelligence is associated with crime independently of so-
cioeconomic status, and if Blacks, on the average, have lower such scores, then
these facts may help explain some of the Black-White differences in crime
rates. 27
A full discussion of the intelligence-race-heredity-delinquency issue is be-

yond the scope of this chapter. But there are several important issues that the
clinician who is involved in the evaluation of black juveniles should bear in
mind. To begin with, the debate about IQ tests and what they mean, what they
measure, has raged on in the literature for very many years. 28 At one point, the
Black Psychologists of America were advocating legislation to prohibit the use
of IQ tests, believing them to be a means of racial discrimination. 29 There are
many who believe, as does Flynn, that "between-group score differences on IQ
tests may not be equivalent to intelligence differences."3o
The psychiatrist is traditionally taught that human intelligence is a com-
plex combination of abstract thinking and mechanical and social abilities. It is
often unclear as to how the clinical assessment of these qualities correlates with
an individual's performance on standardized tests of intelligence. Fear and
cultural paranoia, which are exacerbated by cultural differences between the
examiner and the patient, as well as stress and mental illness, can all interfere in
the accurate assessment of intelligence. 28 There is ample evidence that racial
differences on standardized academic achievement tests can be narrowed as
available educational opportunities become similar in the two groups.28.3! In
the assessment of the Blackjuvenile for legal purposes, extra care is warranted.
The clinician must be aware of the tendency to presume mental inferiority on
the part of the patient when such may not in fact be the case.
Diagnostic Considerations
It is important for the clinician to bear in mind that larger societal and
racial factors may in fact determine whether the black juvenile is to be found in
the court system or in the hospital. The few studies that have addressed the
issue have found that the most important factors that distinguish between the
delinquent adolescent in these two settings are racial and social, and not psy-
chological: the incarcerated delinquent is more likely to be black, whereas the
hospitalized one is more likely to be white, with the psychological and behav-
ioral problems comparable between the two groups.32.33 One major study
found that even among serious adolescent offenders, whites are significantly
more likely to have received prior mental health care than are blacks. 34 Lewis et
ai. emphatically state:
Our clinical and epidemiological findings indicate clearly that many seriously
psychiatrically disturbed, aggressive Black adolescents are being channeled to
correctional facilities while their equally aggressive White counterparts are di-
rected toward psychiatric treatment facilities. As a result of this practice, correc-
tional facilities in the United States are being asked to function as the mental
hospitals of the lower socioeconomic class Black population. 33
There may be considerable reluctance on the part of white dominated

health care facilities to deal with black juveniles, especially in the case of the
violent black youth. There is some evidence in the literature suggestive of this.
For example, Mahorn, Offer, et ai., in discussing "psychodynamic types" of
juvenile delinquents, give an example of "the impulsive delinquent" who is

"not ... particularly likeable on first meeting." Their example which they pro-
vide of this type of delinquent just happens to be a black male adolescent who
is, they imply, untreatable. 35
All of these findings should alert the forensic clinician to be much more
cautious in assessing the black juvenile encountered in the public sector. He
may not have previously received the psychiatric attention that his condition
deserves.
With regard to more specific diagnostic issues concerning the black juve-
nile, one finds little guidance from traditional psychiatric sources. Williams
notes that:
The earliest American epidemiologic studies of psychiatric illness distorted the

rate of mental illness among Afro-Americans. One hundred and forty-five years
later, there is still no comprehensive, unbiased study of mental illness in the
Afro-American population. 36
Nevertheless, there are a few areas worthy of attention. The interpretation

of psychological tests, including intelligence tests, must be made with extra
care. Knowledge of common findings in blacks is clearly required. For exam-
ple, MMPI results can be seriously misleading unless the fact that blacks (pa-
tients and nonpatients) tend to score higher on Schizophrenia and Hypomania
scales is considered. 28 ,37
Self-esteem and a sense of control over one's environment are, as one
might expect, necessary for a child's normal development. 19 The lack of such a
sense of mastery has been correlated with the development of delinquency. 38 It
is common to discover blackjuveniles who are angry and bitter. At a young age,
with a lifelong experience of poverty, they have lost any vision of a positive
future for themselves, a future full of the material success of the American
dream. Studies have shown36 that black males tend to score lower on ratings of
self-efficacy, and it is very common to encounter hopelessness and lack of
enthusiasm about the future among black adolescents. Such a finding should
be considered a typical reaction to the socialization process, and not inherently
a sign of depression or other pathology.2o
There is no evidence to suggest that serious mental illness, depression or
thought disorder, are any more prevalent among whites than among blacks,
once socioeconomic status is controlled for.36 On the other hand, there is
strong evidence to suggest that where mental illness and a history of childhood
injury and illness does exist in black juvenile delinquents, it may have been
overlooked and or untreated. 39 ,4o
It is therefore incumbent upon the forensic clinician to provide as thor-
ough an evaluation as possible. He or she should carefully search for some of
the more common findings in this population: a history of a disruptive home
environment (e.g., marked impoverishment, lack of basic necessities or ade-
quate space, frequent change of residence, homelessness, etc.); a poorly func-
tioning family unit (e.g., family violence, drug abuse, or the absence of a father,
wage earner, or effective disciplinarian, etc.); criminal victimization; childhood
injury (particularly head and facial injuries, which may possibly be related to
aggressive, violent behavior41 ); abuse and neglect; personal and family history
of mental illness. It is often the case that for the black juvenile, the forensic
evaluation will be the most comprehensive medical examination that the
youngster has ever had. The value of such an examination can obviously ex-
tend beyond the legal establishment that requested it.
Black youths, particularly aggressive adolescent males, are frequently di-
agnosed as having an "undersocialized" conduct disorder. It has been demon-
strated that youths given the diagnosis of conduct disorder, undersocialized-
aggressive type, are more likely as adults to have criminal convictions or incar-
cerations than the socialized type. 42 In one major study, Kashani et al. reported
that those diagnosed as nonaggressive were predominantly white, whereas
those diagnosed as undersocialized-aggressive were predominantly black. The
authors complained that they were unable to "explain why this is the case."43
The forensic clinician would be wise to use caution when applying the
official diagnosis of a conduct disorder, particularly undersocialized type, to a
black adolescent. The connotations and implications of this diagnosis are ob-
vious. We have already pointed out that black youths are overrepresented
when it comes to violent crime. It must be remembered that the diagnosis of
conduct disorder, both in its history as a diagnostic entity and in its clinical
application, is rooted in activities that are officially (legally, societally) labeled as
delinquent. The meaning of this diagnosis from the point of view of medical
treatment and prognosis remains obscure. 44 It may also prove difficult to
accurately assess a black youth's level of socialization. This should be quite
apparent when one considers the factors that we have already discussed, partic-
ularly the difficulties one may encounter in communicating with and under-
standing the background of such a youngster. It is important to remember that
the socialization experience for blacks may not conform to what the tradi-
tionally trained clinician might expect. In discussing research conducted with
black, violent delinquents, Fagan et al. report that:
Social and economic conditions in inner cities amplify the social processes which
contribute to delinquency ... increased opportunities for illegal activities and
the attenuation of bonds with schools are likely results of these processes ...
neighborhoods are limited in their material resources with the result that social
institutions and cohesions among residents are weakened, and the "natural"
social controls of family, school, and neighborhood exert less influence than in
middle-class or high-income areas. 45
Reliance entirely on official records in applying such a negative label as under-

socialized should certainly be avoided.
CONCLUSION
We began this chapter with an overview of the dismal social-demographic

statistics of black youths in America today. No one doubts that they are quite
literally a generation that is in crisis. It is important to realize that there are few
tasks in forensic psychiatry potentially more challenging than the evaluation of

these youngsters. An attempt has been made to describe some common, impor-
tant issues, but the review has not been exhaustive. The most important mes-
sage that one should come away with is that, when faced with a young black, a
unique set of external factors and conditions are brought into play. It is crucial
that the forensic clinician take extra care. It may well be left to him or her to
provide the only thoughtful, informed, thorough, and fair examination that
the youngster will ever receive. We must be mindful of our duty to educate the
patient, his caretakers, and society in general about the health and psychiatric
difficulties to which the black juvenile is exposed.
ACKNOWLEDGMENT
Special thanks is extended to Richard Dudley, for his thoughtful guidance

in the preparation of this chapter.
REFERENCES
I. Bennett L: Before the Mayflower. Chicago, Johnson Publishing Co, 1964.

2. Comer JP, Hill H: Social Policy and the Mental Health of Black Children.] Am Acad Child
Psychiatry 24:175-181,1985.
3. Wilkinson CB, SpurlockJ: The mental health of Black Americans: Psychiatric diagnosis
and treatment, in Wilkinson CB (ed): Ethnic Psychiatry. New York, Plenum Press, 1986, pp
14-60.
4. Sillen TS: Racism and Psychiatry. New York, Brunner/Maze!, 1972.
5. US Department of Health and Human Services, Public Health Service, Center for Health
Statistics: Vital Statistics of the US, 1985, vol 2. Washington DC, US Government Printing
Office, 1988.
6. US Department of Health and Human Services: Report of the Secretary's Task Force on
Black & Minority Health, vol 1, Executive Summary. Washington, DC, US Government
Printing Office, 1985.
7. Johnson RL: Black adolescents: Issues critical to their survival.] Natl Med Assoc 77:447-
448, 1985.
8. Hoffman MS (ed): The World Almanac and Book of Facts-1988. New York, Pharos Books,
1987.
9. Spivak H, Weitzman M: Social barriers faced by adolescent parents and their children.
]AMA 258:1500-1504,1987.
10. Hardy J, Welcher D, Stanley J, et al.: Long-range outcome of adolescent pregnancy. Clin
Obstet GynecoI21:1215-1221, 1978.
II. GibbsJT: Black adolescents and youth: An endangered species. Am] Orthospychiatry 54:6-
21, 1984.
12. US Department of Justice, Bureau of Justice Statistics: Sourcebook of Criminal Justice Statis-
tics-1986. Washington, DC, US Government Printing Office, 1987.
13. US Department of Justice, Federal Bureau of Investigation: Uniform Crime Reports, Crime
in the United States-1986, Washington, DC, US Government Printing Office, 1987.
14. Homicide: A Current Overview. Stat Bull Metropol Life 1nsur Co 68:13-21,1987.
15. Bell CC, Taylor-Crawford K,Jenkins EJ, et al.: Need for victimization screening in a Black
population. J Nat! Med Assoc 80:40-48, 1988.
16. Bell M, Ellison R: Issues in the psychiatric-legal evaluation of the Black elderly, in Rosner
R, Scwartz H (eds): Critical Issues in American Psychiatry and the Law, vol 3. New York,
Plenum Press, 1987, pp 327-333.
17. Shoemaker D]: Theories of Delinquency: An Examination of Delinquent Behavior. New York,
Oxford University Press, 1984.
18. Grier WH, Cobbs PM: Black Rage. New York, Bantam Books, 1968.
19. Simmons JE: Psychiatric Examination of Children. Philadelphia, Lea and Febinger, 1987.
20. Levy DR: White doctors and Black patients: Influence on race on the doctor-patient
relationship. Pediatrics 75:639-643, 1985.
21. Ridley CR: Clinical treatment of the nondisclosing Black client. Am Psychol39: 1234-1244,
1984.
22. Baker FM: The Afro-American life cycle: Success, failure, and mental health.] Natl Med
Assoc 79:625-633, 1987.
23. Holmes T: Life situations, emotions, and disease:] Acad Psychosom Med 19:747, 1978.
24. Woolf A, Funk SG: Epidemiology of trauma in a population of incarcerated youth.
Pediatrics 75:463-468, 1985.
25. Alessi NE, McManus M, Brickman A, et al.: Suicidal behavior among serious juvenile
offenders. Am] Psychiatry 141 :286-287, 1984.
26. Hirschi T, Hindelang M]: Intelligence and Delinquency: A Revisionist Review. Am Sociol
Rev 42:571-587, 1977.
27. Wilson JQ, Herrnstein RJ: Crime and Human Nature. New York, Simon and Schuster,
1985.
28. Williams CI: Issues Surrounding Psychological Testing of Minority Patients. Hosp Commu-
nity Psychiatry 38:184-189, 1987.
29. Jackson GD: Comment on the report of the ad hoc committee on educational uses of tests
with disadvantaged students. Am Psychol 30:88-93, 1975.
30. Flynn JR: Massive IQ gains in 14 nations: What IQ tests really measure. Psychol Bull
101:171-191, 1987.
31. Jones LV: White-Black achievement differences-The narrowing gap. Am Psychol
39:1207-1213,1984.
32. Westendorp F, Brink KL, Roberson MK, et al.: Variables which differentiate placement of
adolescents into juvenile justice or mental health systems. Adolescence 21 :23-37, 1986.
33. Lewis DO, Shanok SS, Cohen RJ, et al.: Race bias in the diagnosis and disposition of
violent adolescents. Am] Psychiatry 137:1211-1216, 1980.
34. Cornell DG, Benedek EP, Benedek DM: Characteristics of adolescents charged with
homicide: Review of 72 cases. Behavioral Sciences & the Law 5: 11-23, 1987.
35. Mahorn RC, Offer D, Ostrov E, et al.: Four psychodynamic types of hospitalized juvenile
delinquents. Adolescence 14:446-483, 1979.
36. Williams DH: The epidemiology of mental illness in Afro-Americans. Hosp Community
Psychiatry 37:42-49, 1986.
37. Adebimpe VR, GigandetJ, Harris E: MMPI diagnosis of Black psychiatric patients. Am]
Psychiatry 136:85-87, 1979.
38. Hoffman VJ: The relationship of psychology to delinquency: A comprehensive ap-
proach. Adolescence 19:55-61, 1984.
39. Lewis DO, Balla DA, Shanok SS: Some evidence of race bias in the diagnosis and treat-
ment of the juvenile offender. Am] Orthopsychiatry 49:53-61, 1979.
40. Lewis DO, Feldman M, Barrengos A: Race, health and delinquency. ] Am Acad Child
Psychiatry 24: 161-167, 1985.
41. Bell CC: Coma and the etiology of violence. Part I,J Natl Med Assoc 78: 1167-1176, 1986.
Part 2,] Nat Med Assoc 79:79-85, 1987.
42. Henn FA, Bardwell R, Jenkins RL: Juvenile delinquents revisited. Arch Gen Psychiatry
37:1160-1163,1980.
43. Kashani JH, Horwitz MA, Daniel AE: Diagnostic classification of 120 delinquent boys.
Bull Am Acad Psychiatry Law 14:51-60, 1982.
44. Lewis DO: Adolescent psychiatry, in Kaplan HI, Sadock BJ, (eds): Comprehensive text-
book of psychiatry, vol 4, Baltimore, Williams and Wilkins, 1985.
45. Fagan J, Piper E, Moore M: Violent delinquents and urban youths. Criminology 24:439-
471, 1986.
16
A Reintroduction to Pediatric
Medicine for Forensic
Psychiatrists
SARLA INAMDAR
Worldwide, the health of children is influenced by many factors, such as nutri-

tional deficiencies, the prevalence of infectious diseases, and the cultural, eco-
nomic, educational, and sociopolitical environment. Pediatrics, as a specialty,
has expanded its scope in this century, particularly in the last 50 years. l The
United States has been successful in decreasing the infant morality rate (IMR)
from 20011 000 live births in the late 19th century to 75/1000 in 1925 and
10.911000 in 1984. This decline in IMR can be attributed to the control of
infectious diseases, nutritional support, well-child care, and effective manage-
ment of metabolic disturbances in children. Also important have been the
discovery of antibiotics and effective antibacterial agents, sophisticated tech-
nological advances and expertise in the management of newborns and pre-
mature infants, exponential increase in the body of knowledge in pediatric
subspecialties to care effectively for children with chronic illnesses, genetic
disorders, and congenital malformations.
More recently, the 1979 Task Force on Pediatric Education 2 emphasized
the need for curriculum development and implementation of vital issues that
were neglected from most programs designed for medical students and pedi-
atric houseofficers. These issues were listed as the "New Morbidity" and in-
cluded health maintenance and preventive pediatrics, psychosocial and behav-
ioral pediatrics, the handicapped child and the needs of adolescents and young
adults.
SARLA INAMDAR • Department of Pediatrics, New York Medical College, Valhalla, New
York 10595.
271
272 SARLA INAMDAR
Table I. Birth in America: A Fact Sheet (Figures for 1984)
Nonwhite
Births White Black Total Total
Total 2,923,502 592,745 745,639 3,669,141

Mothers 19 and younger 324,912 140,1l2 154,735 479,647
Mothers younger than 15 3,959 5,720 6,006 9,965
Percentage of all births to 11.1 23.6 20.S 13.1
teenagers
Percentage of all low- 5.6 12.4 11.1 6.7
weight births
Percentage of all low- 15.3 26.0 24.4 IS.4
weight births to mothers
19 and younger
Prenatal care
Percentage of babies born
to women who began
prenatal care in first tri-
mester
Total 79.6 62.2 64.1 76.5
Mothers 19 and younger 56.7 47.0 47.3 53.7
Percentage of babies born
to women who began
prenatal care in third
trimester
Total 4.7 9.6 9.3 5.6
Mothers 19 and younger 10.9 14.0 14.1 11.9
Infant mortality (Infant deaths per 1,000 live births)
Total 9.4 IS.4 16.1 IO.S
Neonatal 6.2 I1.S 10.2 7.0
Postneonatal deaths 3.3 6.5 5.S 3.S
Source. National Center for Health Statistics, as calculated by children's Defense Fund.
The problems facing present and future pediatricians can be outlined as

follows.
Health care services in many parts of the country are fragmented and
poorly coordinated. Children in inner city neighborhoods from poor so-
cioeconomic backgrounds and minority groups are particularly vulnerable (see
Table I).
Child abuse is now assumed to be the greatest single cause of death in
infants between 6 and 12 months of age. This may reflect the more accurate
recognition and reporting of child abuse cases. Deaths caused by accidents and
by violence occupy the premier position in all age groups between 1 and 24
years of age. Suicide and homicide are second only to accidents as a cause of
death in the age group 15 to 24 years.
In 1982, one out of five households with minor children was headed by a
A REINTRODUCTION TO PEDIATRIC MEDICINE 273
single mother. Many such one parent families have incomes below the poverty
level.
In 1986, 55% of children less than 6 years old had mothers in the work
force as compared to 19% in 1960. Thus 9 million preschoolers spend their day
in the hands of someone other than their mother. Millions of older children
participate in programs providing after school supervision.
Approximately 20% of the total live births, that is, 600,000 infants are
born to adolescent mothers each year. In 1978, 32% of these births were out of
wedlock in the 15- to 19-year-old age group and 87% out of wedlock at the 15-
year-old level. Many studies have indicated that infants of teenage mothers
have a higher incidence of preterm births, low birth weights, stillbirths, and
neonatal deaths. 3 •4 •5
Advances in perinatal medicine have led to 95% or greater chance of
survival for infants born between 1501-2500 grams, but those weighing less
have a significantly higher mortality. Infants who are low birth weight and are
discharged from the nursery have a higher mortality rate than term infants
during the first 2 years of life. They have a higher incidence of failure to thrive,
sudden infant death syndrome, child abuse, and inadequate mother-infant
bonding. 5 The increased medical needs of this group of children further stress
the financial and emotional resources of the family. These babies often require
ongoing medical care for bronchopulmonary dysplasia, congenital anomalies,
central nervous system injuries, hypoxic-ischaemic encephalopathy and devel-
opmental handicaps.
Increased environmental risks to the pediatric population, such as intra-
uterine exposure to nicotine, narcotic agents, alcohol, cocaine, and to infectious
agents such as Human Immunodeficiency Virus (HIV).
Legal and bioethical issues have increased the pediatricians responsibilities
as children form the core of the juvenile justice system, divorce proceedings,
laws governing rights of children, consent for treatment, termination of paren-
tal rights, child abuse and neglect. The practicing pediatrician finds that he or
she is being called upon by courts, attorneys, social agencies, and families to
consult and give advice in legal matters regarding children.
The concerns just outlined have initiated some changes in the delivery of
health care services for women and children. There is an obvious and compel-
ling need to continue and expand our programs for maternal and infant nutri-
tion (WIC programs) and to develop ideal settings for care of infants of work-
ing mothers.
Education of medical students, pediatric residents, family practitioners,
and nurse practitioners has increasingly incorporated the shift in health deliv-
ery from inpatient to outpatient settings. Training programs in pediatrics and
Medicine that prepare physicians for primary care have received considerable
support from the Robert Wood Johnson Foundation and from the United
States Department of Health and Human Services.
Primary Care mandates a continuity of patient-physician relationship and
provides health care that is comprehensive, easily accessible, available, and
longitudinal. Ideally such care begins in the prenatal period with a knowledge
274 SARLA INAMDAR
of the resources available to the mother for basic support of the infant's needs,
her socioeconomic status, the support systems available within the family, ex-
tended family, and friends. The primary care provider must assure her con-
tinuity of care and access to all needed services and ongoing health education
aimed at fostering health-promoting life-styles and an enhanced awareness of
the environmental risks to the child's life.
CLINICAL ASSESSMENT
Clinical assessment of infants and children requires experience, patience,
time, and the use of age-appropriate examination techniques. This evaluation
is best accomplished by individuals with special training in the field of pedi-
atrics and/or the pediatric subspecialties, family practitioners, and pediatric
nurse practitioners.
The purpose of the clinical evaluation is twofold: (a) to determine the
nature of illness, and (b) to maintain health. Though forensic psychiatrists are
unlikely to deal with the diagnostic and therapeutic decision-making process in
diseases of children, their m~jor role will be to assess objectively the overall
health of the child and the family they represent. This entails a critical review
of the data base in the pediatric history that will offer an insight into the child's
state of health and development. It is important to identify the source of the
history, because infants and young children are unable to communicate their
problems effectively. If necessary, the facts may have to be elicited from several
sources, for example, parents, grandparents, babysitter, siblings, friends,
neighbors, school personnel, social service agencies, referring institutions.
Chief complaints list the reason for the visit or referral to the pediatrician,
emergency room or clinic. Whether this visit was an emergency visit or for a
general checkup for well-baby care, school or camp physical, or follow-up for a
clinical problem should be recorded. Present illness outlines details relevant to
the chief complaints. It is important to take care to the point of being obses-
sional in documenting these facts accurately and in chronological order. Past
history in children entails review of all available data with reference to the
following. Prenatal history records maternal age, complications, and illnesses
during pregnancy. Birth history includes the type of delivery, Apgar Scores,
birth weight, and neonatal complications with particular emphasis on preterm
births and their associated complications, such as respiratory distress syn-
drome, intracranial hemorrhage, and asphyxia. The birth review should also
include the number of days the infant spends in nursery. Previous illnesses
should be noted, including any hospitalizations and surgical interventions. De-
velopmental milestones achieved should be noted as well as any behavioral prob-
lems noted in the past. Assessment of school performance should come under
this heading. Physical growth is evaluated by a review of the record of growth
measurements available from previous visits. Immunizations and other screening
procedures conducted during well-child visits should also be reviewed. Family
history lists all medical conditions in blood relatives, with an emphasis on those
that may have a bearing on the health of the child. Social history explores socio-
economic status, stability of family environment, single parent versus nuclear
family versus extended family, and support systems that are available.
It is useful to pause after completion of the interview and summarize the
available facts and ask two vital questions before proceeding with the examina-
tion:
1. Has the child received ongoing medical supervision in any setting?
2. Who is the primary care provider?
The physical examination in children entails more than a hurried assess-
ment to determine the presence or absence of an underlying disease. An expe-
rienced clinician may be able to discern very quickly if the child appears
healthy, well nourished, and responds in an age-appropriate manner.
The examination will emphasize:
• Anthropometric measurements (height, weight, head circumference)
and their distribution on growth charts
• Developmental assessment, especially in the infant and preschool child
• Assessment of speech and language development
• Thorough evaluation of all systems of the body for presence or absence
of abnormalities.
The assessment following the completion of the previous tasks results in
the formulation of a problem list that should cover the following items:
• Adequacy of well-child care, that is, nutrition, immunizations
• Growth and developmental status
• Behavioral and psychosocial problems
• Presence of chronic underlying disease states
• Family background and socioeconomic problems
With a careful and thorough assessment, a plan for appropriate diagnostic
workup, therapeutic intervention, patient and/or parent education and follow-
up is recommended at the end of the evaluation.
Pediatricians must recognize the need for help from various disciplines
whenever they formulate a strategy for diagnosis, treatment, and follow-up.
The concept of the interdisciplinary-team approach in the management of
children deserves special mention, because this group has expanded signifi-
cantly to provide comprehensive care to children. The team usually includes
two or more of the following personnel:
• Primary care pediatrician, family practitioner, pediatric nurse practi~
tioner
• Nursing staff, clinical nurse specialists
• Social workers
• Child psychiatrists
276 SARLA INAMDAR
• Child neurology and developmental specialists

• Pediatric subspecialists, including pediatricians with expertise in adoles-
cent medicine, child abuse, and sexual abuse
• Rehabilitation services
• City and state, for example Special Services to Children
• School personnel
NORMAL GROWTH AND DEVELOPMENT
All disease states and adverse environmental conditions influence growth

and development of the infant and child. Growth refers to an increase in body
size and its parts, whereas development is a process of maturation and differ-
entiation of various cells and their functions. The two processes occur simul-
taneously in a parallel and orderly fashion. Each child has an individual growth
pattern and the timing of adolescent growth spurt. This pattern of growth is
dependent to a large extent on the child's ethnic background, the size of his
family members, adequate nutrition, and the absence of adverse physical and
psychosocial conditions. Charting the progress of growth in a longitudinal
manner is an objective method of ascertaining the child's health. This section
will provide an overview of the normal pattern of growth, the factors essential
for growth, and the major causes of growth failure. Readers interested in
obtaining a comprehensive review of the characteristics of growth and develop-
ment in children should refer to the texts by Lowrey6 and Illingworth. 7
The human growth curve is characterized by rapid growth during the
early intrauterine period, which peaks at 4 months of gestation. During this
phase cellular differentiation occurs and major organ systems are developed.
Fetal growth is predominantly accomplished by further maturation and devel-
opment with an increase in the size of the baby. The term newborn infant in
the United States is usually 3.2 kg. and 50 cm. long with a head circumference
of 34 cms. The size of the baby at birth is determined by maternal size and
nutrition in the absence of adverse environmental influences. Intrauterine
growth may be limited by many factors that lead to birth of low birth weight
babies. The incidence of hospital births less than 2500 grams varies between
6% to 16% in the United States. (The frequency among blacks in the United
States is twice that in whites.)
Assessment of fetal growth and its relation to gestational age has been
prepared by Lubchenco et at. 8 •9 Causes of intrauterine growth retardation can
be listed as follows:
• Maternal nutrition, low socioeconomic level, lack of prenatal care
• Age of mother « 16 years or > 35 years)
• Multiple births
• Hypertension and preeclampsia
• Maternal diabetes, heart disease, renal disease
• Maternal use of alcohol, nicotine, narcotic agents
• Intrauterine viral infections such as toxoplasmosis, cytomegalovirus,

HIV, rubella
• Drugs during pregnancy such as dilantin, propylthiouracil, anticoagu-
lants; radioactive iodine, (131 I) irradiation.
• Genetic birth defects and chromosomal disorders
After birth there is a marked deceleration in the velocity of growth in the
first year of life, followed by a slow and steady pace of growth during the
preschool and early school years.
A healthy newborn will grow an average of 200 to 250 gm. a week and
easily doubles his birth weight by 5 months of age and triples it by one year.
The length increases from 50 cms. to 75 cms. during this period, and the head
size, which is 34 to 35 cm at birth increases to 44 cm by 6 months and to 47 cms
by one year.
During the second year of life there is a slow rate of growth with an
average gain of 2.5 kg and about 12 cm. The head circumference increases by 2
cm. and has reached approximately 80% of its adult size. The child's loss of
appetite and reduction in the velocity of growth at this time is often a source of
frustration to parents who have witnessed a dramatic growth rate up to this
point. Parental concerns and conflicts may initiate eating disorders and growth
disturbances in the toddler.
The preschool years constitute a period of steady gains of 2.0 kg and 6 to 8
cms per year followed by a steady growth phase during the early school years.
The preadolescent growth spurt, occuring by about the age of 10 years in girls
and about 12 years in boys, is followed by a period of rapid growth and sexual
maturation during adolescence. The exact timing of these events varies be-
tween the sexes and also between individuals within the same sex. Growth
ceases with fusion of the epiphysical growth plates.
Adequacy of growth can be assessed by a review of the nutritional status
and anthropometric measurements of the infant and child at each visit. The
records maintained must be accurate and accessible at each visit to survey
growth in a longitudinal manner.
The most useful measurements are:
• Head circumference, length, and weight. Data are plotted on standard
reference charts available, such as the National Center for Health Statis-
tics (NCHS) growth charts.
• Nutritional assessment by measuring skinfold thickness, calf circum-
ference, plotting weight by stature on growth charts.
• Maturation index or bone age obtained by radiological studies is useful in
determining variations in growth as well as in assessing the potential for
future growth particularly in the older child and adolescent. A delayed
bone age is commonly seen in endocrine disorders such as hypo-
pituitarism and hypothyroidism. The bone age is also delayed in constitu-
tional delay, intrauterine growth retardation, psychosocial dwarfism. It is
normal in genetic or familial short stature.
• Body proportions can be measured by determining the sitting height or
278 SARLA INAMDAR
the ratio of upper segment (vertix to symphis pubis) to lower segment

(symphysis pubis to heel) of the body. The sitting height represents 70%
ofthe body length in the newborn, 57% at 3 years and 52% at the time of
menarche in girls and about 15 years in boys. Persistence of infantile
body proportions is seen in hypothyroidism and achondroplasia.
The interplay of several factors in a coordinated manner allow growth to
proceed in an orderly sequence. The essential ingredients for human growth
are:
• Nutrition
• Nurturing environment
• Normal skeletal structure
• Neuroendocrine regulation
The hormonal regulation of growth can be outlined briefly as follows:
• Growth hormone, insulin, and thyroxine have a major role in promoting
growth. Corticosteroids have a negative influence.
• Parathyroid hormone, calcium and phosphorus metabolism, and Vi-
tamin D and its metabolites are the major determinants of skeletal
growth and ossification.
• Gonadal and adrenal steroids work synergistically with the previously
listed factors for achievement of adolescent growth spurt and skeletal
maturation.
Causes of Growth Failure
Many factors may retard growth and the duration and timing of these
negative influences may limit the individual's growth potential permanently.
Worldwide, the single most important cause of growth retardation is malnutri-
tion. In the United States the pediatrician must carefully evaluate the child's
growth and developmental status and investigate the underlying cause of
growth failure.
An extensive review of different classifications outlining the etiology of
growth problems in children is beyond the scope of this chapter. However, it is
important to provide a brief discussion of the common causes of growth delay
encountered in a pediatric practice.
• Genetic, familial short stature
• Constitutional delay in growth
• Failure to thrive
• Emotional deprivation
• Chronic systemic diseases
• Intrauterine growth retardation
• Skeletal diseases
• Endocrine disorders
Genetic or familial short stature refers to an apparently normal child who is
below the third percentile in height but has a normal growth velocity and
Table II. Etiology of Failure to Thrive
Organic Environmental
Perinatal asphyxia Inadequate nutrition

Intracranial hemorrhage Emotional deprivation
Cerebral palsy Poor socioeconomic status
Intestinal malabsorption Drug abuse or addiction
Cystic fibrosis Emotional instability
Congenital heart disease Psychiatric problems
Renal diseases Family stresses
Obstructive uropathy Single parent
Tubular disorders Marital discord
Congenital malformations Immaturity at handling
Intrauterine growth retardation parenting tasks
skeletal maturation. His family members are usually short and attest to his
limited growth potential. Constitutional delay in growth is characterized by a
normal growth velocity along the lower growth percentiles. The bone age is
consistent with the height age but the bone age is delayed. These children,
usually males with a family history of similar growth pattern, will achieve their
adolescent growth spurt later than their peers but will eventually achieve the
adult height that is commensurate with the child's genetic potential. Failure to
thrive is a term used for infants and children, particularly below the age of 2
years, who fail to gain weight or may lose weight. The patient may be brought
to the pediatrician with a paucity of symptoms and signs that prompts the
physician to embark on an in-depth investigation for an underlying disease.
Often the baby is seen in the emergency room for the first time after infant's
discharge from the nursery in a critical condition with severe marasmus and/or
dehydration.
All infants with failure to thrive need a careful clinical assessment and
investigations to search for an organic illness, particularly in the gastroin-
testinal and genito-urinary tract (Table II). Initial laboratory investigations
include a stool fat and reducing substances, urinalysis, urine culture, urinary
amino acid screen and blood urea nitrogen and creatinine, serum electrolytes,
and a sweat test. All cases of failure to thrive must be reviewed by the social
worker who will interview the mother and the family to obtain vital information
regarding environmental status, mother's attitudes toward her infant, her con-
cerns, her experience, and her ability to be a parent.
When the diagnostic workup fails to elucidate the etiology of failure to
thrive, an assessment of the infant's general condition during hospitalization
may provide further clues with respect to his or her nutritional intake and
feeding pattern as well as maternal involvement with the care of the infant.
Infants with emotional deprivation may actually gain weight and become more
responsive to hospital staff.
Preventive measures that may help in decreasing this problem are:
• Prenatal care and counseling
• Parent education programs
280 SARLA INAMDAR
• Development of support systems

• Provision of adequate nutrition
• Primary care health maintenance visits
• Supervision at home by visiting nurse services
Chronic illnesses have a detrimental influence on growth because their
effects are usually prolonged and may extend into the period of adolescent
growth spurt. The pediatric subspecialists and primary care pediatricians need
to work closely to treat the underlying diseases as effectively as possible and use
growth limiting drugs such as steroids in a judicious manner.
Intrauterine g;rowth retardation places the infant at increased risk for prob-
lems associated with physical growth and development of the central nervous
system. There are fairly distinct patterns of growth followed by low birth
weight infants. Premature babies, appropriate for gestational age, will exhibit
"catch-up" growth followed by a rate that is similar to term infants. The lower
the birth weight and the shorter the gestational age, the lower the percentiles
followed in subsequent growth. The height, weight, and head size of children
who were born small for gestational age remain significantly below those who
were born prematurely but appropriate for gestational age. 6
A gestational age of less than 28 weeks and a birth weight less than 1200
grams each carry 70% risk of moderate-to-severe handicap. 10 A gestational age
of between 28-31 weeks or a birth weight between 1200-1500 grams has a risk
of about 50% of either neurologic or intellectual problems. An increased inci-
dence of behavioral problems in children of low birth weight babies has been
studied, including a higher incidence of battered child syndrome. lO
Psychosocial dwarfism or emotional deprivation dwarfism is an important
cause of growth retardation in the preschool and school-aged child. These
children have a growth pattern that is shared by children who have isolated
growth hormone deficiency.ll They have low levels of somatomedins and an
inadequate growth hormone response to provocative stimuli. The basis of the
growth failure is a disturbance in the mother-child or family-child interaction
that may be difficult to identify and correct. Emotionally deprived children
manifest an increased incidence of behavioral problems and learning difficul-
ties.
Assessment of Neurological and Psychological Development
Development in children is a dynamic and continuous process and de-

pends on the maturation and myelination of the nervous system. Each child
follows a sequence of cephalocaudal development at a certain rate. The critical
assessment of these developmental milestones is necessary to detect problems
early, to seek appropriate consultations, make recommendations for interven-
tion and to answer parental questions, offer anticipatory guidance and allay
their concerns and anxieties.
The developmental assessment should not be used to make predictions for
a child's intelligence. It essentially determines a child's progress, detects neu-
rological deficits and handicaps, and may signal the onset of a serious illness.
The routine administration of developmental tests assists pediatricians in
their task to:
• assure parents if their children are normal
• follow progress of infants that are products of high risk pregnancies
• study effects of treatments for perinatal complications
• study effects of child abuse, head trauma, central nervous system
infections
• counsel prospective parents with regard to adoption
Methodology for completing a neurobehavioral and developmental assess-
ment consists of the utilization of age-appropriate tasks that have been devel-
oped by personnel who assess children in various settings. To obtain a thor-
ough review of these procedures the following references are provided:
• Assessment of maturity at birth: Dubowitz et al.,12 Lubchenco et al.,13
Gruenwald et al. 14
• Behavioral assessment of infants: Brazelton I5
• Assessment of infant's neurological status: Prechtl I6
• Gesell and Amatruda's developmental diagnosisI 7
• The Revised Denver Development Screening Test I8
• Bayley Scales of Infant Deveiopment I9
Assessment of motor, adaptive, language, and personal-social behavior can
be accomplished by using a questionnaire for parents who will check off tasks
that the infant can perform. Examination includes observation of infant's re-
sponse to the examiner and his parents during the exam, observation of in-
fant's activity and muscle tone and posture in supine and prone positions, when
he is pulled from supine to sitting position, and his ability to sit alone, bear
weight on legs, pull to standing position, and walk alone. His reaction to mov-
ing objects, to objects held within sight and grasp, and his response to sounds
are elicited carefully.
After the first year of life, the infant's ability to play with blocks, use a
crayon or pencil, imitate or copy a circle, cross, square, his ability to walk, run,
hop, skip, and jump, self-feeding skills, playing, dressing/undressing, toilet
training, and acquisition of language skills are ascertained.
Children who attend school can be evaluated by obtaining pertinent infor-
mation from school teachers and other school personnel regarding their social
skills, academic performance, motivation and attitudes toward school and
homework, relationship to adults and peers, behaviors at home and in the
classroom. Psychological testing is requested when a more thorough evaluation
is indicated.
The orderly sequence of behavioral development is dependent on the
infant's genetic potential, environmental, and sociocultural influences. In the
infant with an intact central nervous system, with normal vision and hearing
and the absence of a debilitating chronic illness, one can anticipate develop-
mental progress.
282 SARLA INAMDAR
Central nervous system disease or injury and adverse environmental fac-

tors can hamper and/or permanently retard growth. The effects of severe
malnutrition, child abuse and neglect, prolonged hospitalization, institu-
tionalization, and understimulation may significantly alter the child's behav-
ioral responses.
CHILDREN AS VICTIMS
Violent deaths in infancy, along with sudden infant death syndrome, kill
more infants between 1 and 12 months of age than any other cause. 20 .2!
Children who survive the first year are more likely to succumb to tragic events,
in that accidents, homicide, and suicide form a leading cause of death between
1 and 24 years of age. Preventive pediatrics' current focus on these problems
has been overdue. We have to look beyond those shots in the arm and the
childproof bottle caps to develop strategies for reduction in morbidity and
mortality from accidents.
Child Abuse
Child abuse and neglect is a nationwide problem that exists in all segments
of society and socioeconomic groups. The problem has received national atten-
tion since C. H. Kempe described the nonaccidental nature of injuries sus-
tained by the battered child 22 and Caffey23 described the radiological features
of this problem. Since then, most states have laws requiring responsible adults
(teachers, nurses, physicians, social workers, neighbors) to report cases of sus-
pected child abuse and neglect. For purposes of the law an abused child is a
child less than 18 years of age whose parents or other legal guardians have
inflicted physical injury or sexual abuse on him or her or have allowed such
injuries and abuses to be inflicted upon him or her by others or have directly or
indirectly created a substantial risk to his physical safety. A maltreated child is
defined by law as a child less than 18 years of age whose parents have failed to
provide him or her with adequate food, clothing, education, shelter, or medical
care even though they are financially able or have been offered help to do so.24
Beyond these definitions are aspects of abuse that are difficult to define clearly
and encompass a range of adult behaviors that result in emotional scars. Even
well-intentioned parental concerns may represent child abuse, as in cases of
"Munchausen syndrome by proxy."25
Approximately 0.5 to 1 million children in the United States are assumed
to be either sexually molested, or severely abused. The real incidence of child
abuse is difficult to determine. About 2000 children are killed each year, either
murdered by their parents or caretakers. One third of the children abused are
under the age of 1 year, one third are between 1 and 6 years of age, and the
remainder are more than 6 years of age. Premature babies have a threefold
greater risk of abuse.
To detect cases of child abuse and neglect requires a high index of suspi-
cion. In the majority of cases the abuser is a related caretaker (90%), a male
friend of the mother (5%), an unrelated babysitter (4%), and rarely a sibling
1%). The incidence is greater in families already burdened with tremendous
stress, marital discord, and unemployment. Parents who are inadequately pre-
pared for child rearing tasks and/or lack knowledge of normal infant behavior
may react adversely to their child's excessive crying or other behaviors.
Table III. Historical Facts and Clinical Features of Child Abuse and Neglect
History Discrepancy between history and child's clinical findings

Lack of ongoing medical supervision; episodic care, emergency
room visits at odd hours
Inappropriate parental concern or attitudes: being quiet, pas-
sive, hostile, angry, ignorant of child's problem
Delay in seeking medical help
Repeated hospitalizations or visits to the doctor for medical con-
ditions that present a diagnostic and/or therapeutic challenge
to the medical personnel, an undue involvement of parent in
nursing and hospital tasks should alert physicians to explore
the possibility of "Munchausen syndrome by proxy"; in this
condition, children are subjected to unnecessary hospitaliza-
tions or office visits, often with invasive diagnostic and thera-
peutic interventions
Examination findings Evidence of neglect
Failure to thrive, lack of immunizations, poor hygiene, skin rash
Multiple injuries in various stages of healing, such as bruises,
welts, lacerations, burns, and scars, particularly over the but-
tock and back; marks of belts, whips, cord or rope; bruises on
neck.
Evidence of intracranial injury, bulging fontanelle, altered ac-
tivity and sensorium, focal or generalized seizures, retinal
hemorrhages; these may occur without any external evidence
of trauma specially in the young shaken-baby syndrome 26
Burns secondary to contact with cigarettes, heating grate, grid,
immersion of body parts in hot water resulting in burns with
characteristic distribution and demarcation
Abdominal injuries with rupture of liver, spleen, tears of small
bowel, intramural hematomas
Genital injuries, venereal diseases; all suspected cases of sexual
abuse need evaluation by trained personnel who can perform
an examination according to the state laws established for as-
sessment of such victims. Use of appropriate techniques and
dolls may lessen further trauma to such children
Diagnostic tests Blood tests for detection of anemia and bleeding disorders
Radiographs of long bones for documentation of fractures, espe-
cially in a child less than 5 years of age; metaphyseal fractures,
spiral fractures, rib fractures, fractures in different stages of
healing
CT scan of the brain for evidence of intracerebral, intraven-
tricular, subdural, and subarachnoid hemorrhages
Bloody cerebrospinal fluid (CSF)
284 SARLA INAMDAR
There is no single diagnostic criterion for child abuse and neglect. Certain
historical facts and clinical features (summarized in Table III) lead one to
embark on further investigations.
Management involves medical intervention with neurological, neurosurgi-
cal, surgical, and orthopedic consultations as dictated by the nature of the
child's injuries. The protocol for legal review of such cases involves the pedi-
atrician following this outline:
• Careful documentation of historical facts

• Thorough and precise documentation of all positive physical findings
• Radiographs, CT scans, and appropriate laboratory investigations as
seem necessary in each case
• Photographs of all external injuries, burns, skeletal deformities
• Documentation of report to Special Services to Children that investigates
all cases of abuse and neglect. Clear account of reason for referral
• Protection of child from further harm
• Planning of final disposition and long-range planning for care of the
child
The mere fact that children are often the victims of multiple abuse be-
hooves us to provide them with effective supervision and follow-up, both in the
hospital as well as after discharge.
Sudden Infant Death Syndrome (SIDS)

An infant dies in his sleep without premonition, his death is sudden and
unexpected. Autopsy fails to reveal the cause of death. Such deaths are listed as
sudden infant death syndrome. More lives are claimed from SIDS in the age
group of 1 to 6 months than any other cause.
The average incidence of SIDS in the United States ranges from 1.6 to 2.3
per 1000 live births with the highest incidence among blacks (2.9) and Ameri-
can Indians (5.9). It usually strikes infants between 2 to 3 months of age and is
uncommon before the age of 2 weeks or after 6 months. 27 Boys are more
affected than girls. Infants usually die in their sleep, most of the deaths being
reported during the winter months.
SIDS has eluded most researchers. The etiology of these deaths remains a
mystery. However, certain genetic, environmental, and social factors associated
with increased risk of SIDS have been identified:
• Premature births, low birth weight infants

• Poor socioeconomic status, overcrowding
• Maternal use of nicotine, narcotic agents
• Sibling of infant with SIDS
• Previous episode of near-miss SIDS
Pathologists have attempted to search for clues that may explain the termi-
nal event, that is, cardiorespiratory failure in infants with SIDS. There is no
definite histopathologic feature that is found in all babies with SIDS. Increase
in muscularity of the pulmonary circulation in victims of SIDS has been in-

terpreted as indirect evidence of hypoxia. 28 No direct evidence of hypoxia has
been clearly found. These sudden unexpected deaths defy medical interven-
tion. Families of such infants need emotional and psychologic support and
efforts must be directed at long-term follow-up. The possibility of abuse,
though rare in most instances, should be investigated.
Investigators in various parts of the country are currently exploring the
pathogenesis of SIDS in the hope of preventing such deaths. 29 "Apnea cen-
ters," usually under the direction of pediatric cardiologists and pediatric pul-
monologists study groups of infants identified to be at increased risk for SIDS.
Investigations include:
• Blood chemistries
• Pneumogram with pulse oximetry
• 12- to 24-hour ECG monitoring
• pH study of lower esophagus for gastro-esophageal reflux
• Head ultrasound and EEG
To date, no explanation has been forthcoming to elucidate the nature of
the cardiorespiratory or central nervous system events leading to SIDS.
Home monitoring of the cardiorespiratory system was introduced to
monitor the infant's ventilation and/or heart rate and thereby prevent he oc-
currence of SIDS. There is no consensus as to whether SIDS can be prevented
by such an approach and there are concerns about the possible adverse effects
of monitoring on the infant and the parents. Monitoring has been recom-
mended for siblings of infants with SIDS, infants who have had an episode of
near miss SIDS, and infants with significant apneic episodes. Members of the
household receive instructions to use the monitor and are taught how to render
cardiopulmonary resuscitation.
Accidents and Poisonings

Accidents and poisonings are a major cause of morbidity and mortality in
the United States, responsible for more deaths in children of 1 to 14 years of
age than any other cause of death. Accidents, along with homicide and suicide,
occupy the top three places among the leading causes of death in adolescents
and young adults 15 to 24 years of age. For each accidental death there are
many children that are injured, often with serious consequences, such as phys-
ical disability and mental retardation.
Accidents by definition refer to events that are sudden, unexpected, and
thereby unpreventable. There has been a recent shift in this view to delineate
the conditions that promote such accidental injuries and death and thereby
seek effective measures to control and prevent them. 31 The efforts of various
agencies such as the American Academy of Pediatrics,32 the Division of Mater-
nal and Child Health of the United States Department of Health and Human
Services,33 the Consumer Product Safety Commission (CPSC) along with the
1970 Poison Prevention Packaging Act have been directed to decrease the
incidence and reduce the injury from accidents.
286 SARLA INAMDAR
Practicing primary care pediatricians have began to focus on anticipatory

guidance toward injury prevention and injury reduction during their counsel-
ing sessions with parents and children. Most accidents occur on the road or at
home and the school. Children need ongoing educational programs at home
and at school to safeguard their health and learn how to deal with danger in an
effective manner.
When accidental injuries occur, particularly in a young child, the pediatri-
cian and/or pediatric surgeon must explore all events that led to such event and
the possibility of child abuse or neglect should not be ignored in spite of the
reported accidental nature of the injury. The risk of accidents in unsupervised
settings are obviously greater than in a well-supervised environment provided
by a responsible, organized caretaker.
The Syndrome of Hospitalism

The syndrome of hospitalism as described by Spitz 34 is marked by social
unresponsiveness and apparent retardation. This condition was described in
children subjected to prolonged institutionalization. Advances in pediatric care
have significantly reduced the need for prolonged hospitalization and the aver-
age length of stay in pediatric acute care hospitals has decreased to 4 or 5 days.
Children with chronic illnesses are being managed in outpatient settings with
emphasis on care at home with involvement of the family members. Excellent
support systems have been developed for management of children in intensive
care units, burn units, hemodialysis and outpatient transfusion and chemother-
apy units. Extended visiting privileges for parents and family members, room-
ing-in facilities for parents, hospital child-life programs have helped to alleviate
some of the consequences of chronic illness in children.
Pronounced and prolonged separation from parents is an inevitable fate
for many children requiring intensive care in neonatal high risk units. The
effects of psychosocial deprivation are reversible if infant-parent bonding is
established early,35 because a woman is most ready for assuming the respon-
sibilities as a mother soon after the birth of her baby.36
Children abandoned or abused by their caretakers and infants of drug
addicted mothers are often the wards of inpatient pediatric services whenever
alternate arrangements for care of these children are not readily available and
the number of foster parents are limited. Effective long-range plans for such
babies must be instituted with a sense of urgency to provide a caring and
responsible adult and to maintain a constancy in the infant-caretaker relation-
ship.
REFERENCES
I. Behrman RE, Vaughan VC (eds): Nelson Textbook of Pediatrics. Philadelphia, W. B. Saun-

ders Co., 1987.
2. The Task Force on Pediatric Education: The Future of Pediatric Education. Evanston, Ill,
1979.
3. Naeye RL: Teenaged and preteenaged pregnancies: Consequences of the fetal-maternal

competition for nutrients. Pediatrics 67: 146-150, 1981.
4. Lawrence RA, Merrit A: Infants of adolescent mothers: Prenatal, neonatal and infancy
outcome: Semin Perinatal, January 1981, pp 19-32.
5. Naeye RL, Tafari N (eds): Risk Factors in Pregnancy and Diseases of the Fetus and Newborn.
Baltimore, Williams & Wilkins Co., 1983.
6. Lowrey GH: Growth and Development of Children. Chicago, Year Book Medical Publishers,
1986.
7. Illingworth RS: The Normal Child. New York, Churchill Livingstone, 1987.
8. Lubchenco LO, Hansman C, Dressler M, et al.: Intrauterine growth as estimated from
liveborn birth weight data at 24 to 42 weeks gestation. Pediatrics 32:793-800, 1963.
9. Lubchenco LO, Hansman C, Boyd E: Intrauterine growth in length and head circum-
ference as estimated from live births as gestational ages from 26 to 42 weeks. Pediatrics
37:403-408, 1966.
10. Villar J, Smeriglio V, Martorell R, et al.: Heterogenous growth and mental development
of intrauterine growth-retarded infants during the first three years of life. Pediatrics
74:783-791,1984.
II. Money J: The syndrome of abuse (psychosocial) or reversible hyposomototropism. Am]
Dis Child 131:508-513,1977.
12. Dubowitz LM, Dubowitz V and Goldberg C: Clinical assessment of gestational age in the
newborn infant.] Pediatr 77:1-10,1970.
13. Lubchenco LO: Assessment of gestational age and development at birth. Pediatr Clin
North Am. 17:125-145, 1970.
14. Gruenwald P: Growth in the human fetus. I Normal growth and its variations. Am] Obstet
Gynecol, 94:1112-1119,1966.
15. Brazelton TB (ed): A Neonatal Assessment Scale. Clinics in Developmental Medicine, vol
50. London, Heinemann, 1973.
16. Prechtl HFR: The Neurological Examination of the Full-term Newborn Infant. Clinics in
Developmental Medicine, vol 63, London, Heinemann, 1977.
17. Knobloch H, Stevens F, Malone AF: Manual of Developmental Diagnosis. The Administration
and Interpretation of the Revised Gesell and Amatruda Developmental and Neurological Examina-
tion. New York, Harper and Row, 1980.
18. Frankenberg WK, Goldstein A, Camp BW: The Revised Denver Development Screening
Test:] Pediatr 79:988-995, 1971.
19. Bayley N: Bayley Scales of Infant Development Manual. New York, The Psychological Corpo-
ration, 1969.
20. Heins M: The "battered child syndrome."]AMA 251:3295-3300,1984.
21. Rosenberg N, Bottenfield G: Fractures in infants. A sign of child abuse. Ann Emerg Med
11:178-201,1982.
22. Kempe CH, Silverman FN, Steele BF, et at.: The battered child syndrome.]AMA 181: 17-
24, 1962.
23. Caffey J: Multiple fractures in the long bones of infants suffering from chronic subdural
hematoma. A]R 56: 163-173, 1946.
24. New York State Child Protective Services: Mandated Reporter Manual. Fall, 1984.
25. Meadow R: Munchausen Syndrome by Proxy-the Hinterland of child abuse. The Lancet,
13:343-345, August 1977.
26. Ludwig S: Shakenbaby syndrome. A review of 20 cases. Ann Emerg Med 13:104-107,
1984.
27. Valdes-Dapena MA: Sudden infant death syndrome: A review of the medical literature
1974-1979. Pediatrics 66:597-614, 1980.
28. Williams A, Vawter A, Reid L: Increased muscularity of the pulmonary circulation in
victims of sudden infant death. Pediatrics 63: 18-23, 1979.
29. Haddad GG, Leistner HL, Lai TL, Mellins RB: Ventilation and ventilatory pattern during
sleep in aborted sudden infant death syndrome. Pediatr Res 15:879-883, 1981.
288 SARLA INAMDAR
30. Alpert]], Guyer B (eds): Injuries and Injury Prevention. Pediatr Clin North Am 32: I, 1985.
31. Haddon WH: Advances in the epidemiology of injuries as a basis for public health policy.
Public Health Report 95:411-421, 1982.
32. TIPP - The Injury Prevention Program, American Academy of Pediatrics, Illinois.
33. Bassin G, Bloomberg C, et al.: Developing childhood injury prevention programs. An
administrative guide for state maternal and child health (Title V) program. Washington
DC, Department of Health and Human Services, Division of Maternal and Child Health,
1982.
34. Spitz RA: Hospitalism: An inquiry into the genesis of psychiatric conditions in early
childhood, in Eissler RS, et al. (ed): The Psychoanalytic study of the child, vol 1. New York,
International University Press, 1945, pp 53-74.
35. Rutter M: Maternal deprivation considered.] Psychosom Res 16:241-250, 1972.
36. Fanaroff A, Kennel], Klaus M: Follow-up oflow birth weight infants. Predictive values of
maternal visiting patterns. Pediatrics 49:287-290, 1972.
17
Issues of Adolescent Medicine
PROMISE AHLSTROM AND S. KENNETH SCHONBERG
Adolescence, from the Latin "adolescer"-to grow up, is defined as the period
of life between the onset of puberty and maturity, the state or process of
growing up from childhood to adulthood. This process is best understood as a
combination of complementary and interlocking developmental phenomena.
Although the complexity of these events defies easy categorization, simplicifa-
tion is required for the sake of understanding this journey from childhood to
adult status. For the purpose of this discussion the processes of adolescence will
be divided into five categories of development: physiologic, psychologic, psy-
chosexual, cognitive, and social. Often as a result of accomplishing these tasks,
and at times because of a failure adequately to negotiate these tasks, the adoles-
cent becomes subject to health risks that are particular to the age and of import
to all who address the needs of youth.
Physiologic Growth and Development

The onset of physiologic puberty is characterized by the development of
secondary sexual characteristics and followed by the further change of these
characteristics as well as statural growth and reproductive maturation. The first
markings of puberty are usually breast budding in girls and testicular enlarge-
ment in boys. The sequence of events that follows these first signs is less
variable than is the age at which they first begin. Girls enter puberty an average
2 years earlier than boys. The mean age at which breast budding occurs is 10.5
years (range 8-15 years). Subsequent development would include enlargement
of the breasts to an adult configuration, the appearance of pubic and axillary
hair, and an accelerated increase in height. Full development is usually com-
PROMISE AHLSTROM and S. KENNETH SCHONBERG· Division of Adolescent Medi-

cine, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York
10456.
289
290 PROMISE AHLSTROM AND S. KENNETH SCHONBERG
pleted during the next 4 years (range 12-18). In boys, enlargement of the
testes and the development of pubic hair, the first signs of puberty, usually
begin at about age 12 (range 10-14 years). As in girls, there will be a period of
rapid increases in height. Other components of puberty will include the devel-
opment of facial as well as pubic and axillary hair, and an increase in muscle
mass. These processes are usually completed over the ensuing 4 to 5 years
(range 14-18 years).
Tanner staging, also known as Sexual Maturity Rating (SMR),1 is a classifi-
cation system that provides clinicians with a method of quantifying and record-
ing these changes. Tanner Stage 1 is defined as the prepubertal state, Tanner
Stage 5 as the fully mature adult state in each sex. Therefore Tanner Stages 2,
3, 4 represent intermediate stages of pubertal development. This system uti-
lizes breast and pubic hair development in the female and the external genitalia
including scrotum, testes, penis, and pubic hair in the male. This system allows
for charting individual development, and gives more accurate information
regarding developmental stage than is conveyed by chronologic age alone.
Tanner staging refers only to physical development; it does not predict psycho-
logical development.
The onset of menstruation in girls is the most dramatic sign of pubertal
development and is often the easiest to pinpoint. The average of menarche is
culturally and racially variable. In the United States the average age is 12.7
years with differences observed among several racial and ethnic groups. The
mean age for blacks is 12.6 years and whites 12.8 years. The mean age for
Hispanics has not been well studied. The age of onset of puberty does not
correlate with the speed of passage to completion, that is, early maturing
females do not mature in less time than their late-maturing counterparts.
Adolescence is also remarkable for the physical growth and changes that
accompany sexual development. The adolescent growth spurt occurs in all
children and is the only time during extrauterine life that growth velocity
increases. During peak velocity, growth averages 10 cm/year in boys and only
slightly less, 8 cm/year, in girls. What causes the striking differences in the sizes
of adult men and women results from the disparity of the onset, duration, and
intensity of the adolescent growth spurt. Prior to puberty girls and boys differ
by only 2% in height; after puberty that difference averages 8%. This dif-
ference in average eventual height is secondary to a more prolonged period of
accelerated growth in males. After the growth spurt, growth drops off
dramatically.
Growth of the muscular system occurs after peak height velocity has been
attained. Subcutaneous body fat decreases during the time of the growth spurt,
but increases as the rate of growth decelerates. This is particularly true in the
female, accounting for the greater percentage of body weight attributed to
subcutaneous body fat in adult women.
Just as there are differences in the age at menarche in various ethnic and
racial groups, there has been a significant historical shift in the age of men-
arche over the past 100 years in industrialized countries. From 1880 to 1960
there has been a decline in the age at menarche from 15.1 years to 12.7 years, a
decline of approximately 0.3 years per decade. The cause of this trend is
ISSUES OF ADOLESCENT MEDICINE 291
multifactional; better nutrition and improved therapy for illnesses are thought
to be largely responsible.
Full reproductive function is attained in the female at the time of men-
arche, although for the first 2 years menses are frequently accompanied by
anovulatory cycles. Approximately 55% of cycles in the first year are not ac-
companied by ovulation, owing to immaturity of the regulatory endocrine
system. 2
In males, the first ejaculation most commonly occurs within 2 to 3 years of
the onset of puberty although erection in the male is intermittently present
since infancy. Sperm are first identified in the ejaculate at about the same time.
Hence full reproductive function is attained at approximately age 13.
Psychologic Development
Adolescence is the period of life during which we develop a concept of self
as an independent, unique individual, separate from the image of the family,
possessed of one's own strengths and weaknesses. Until the teen years the child
is viewed by others and is viewed by himself or herself as a part of a family
constellation. Attaining adult status requires a psychological separation from
the family, that is, the development of a self-identity. Bright or dull, handsome
or unattractive, good or bad, successful or a failure, are all perceptions of self,
developed, in the main, during adolescence. With the development of this self-
perception or self-identity is the opportunity for confidence or defeatism, ela-
tion or depression, and with these moods the potential for behavioral disrup-
tion.
Psychosexual Development
Adolescence is that time during which we develop our patterns of adult
sexual behavior. Coincident with physiologic changes in appearance and the
maturation of secondary sexual characteristics is the evolution of adult sexu-
ality. The child emerges from isosexual groups, that is, boys playing with boys
and girls playing with girls, into heterosexual groups, then dating, hand hold-
ing, necking, petting, and sexual intercourse. Before graduation from high
school over half the adolescents in the United States will have had a first sexual
intercourse experience. This rapid emergence of adult sexuality is accom-
panied by obvious health consequences, including pregnancy and venereal
disease.
Cognitive Development
Children think in concrete terms with the ability to master names and
dates and facts, but are unable to abstract. Issues of future time, shades of gray,
and the complexities of life are beyond the capabilities of the child. Algebra
and geometry can not be taught in the first grade. During adolescence there is
the development of the ability to think in abstract terms. Much more than a
simple process learned in school or home, this emerging ability has the qualities
of physiologic maturation of the power to think. As adolescents attain this
capability they are able to assume greater responsibility and conversely we hold
them increasingly responsible for their actions.
Social Development
There are countless tasks and rites of passage which separate the child
from the adult. The ability to vote, to drink, to drive a car, to marry, to consent,
to earn a living are all among that long list of skills which must be mastered
during that rapid journey from childhood to adulthood. The individual enters
adolescence dependent upon family and must emerge less than a decade later
with the ability to start a new family. Many of these tasks, in particular learning
to drive and learning to drink, are characterized by particular risk to young
people and hence are of great concern to all who care for youth.
ADOLESCENT MORTALITY AND MORBIDITY
Adolescents are the only segment of our population that has experienced
an increase in the rate of death over the past 30 years. Infants, adults, and the
elderly have all decidedly profited from advances in health care. However, a
50% rise in death from social causes among teenagers aduring the past 3
decades has negated the impact of medical advances. Accidents (25,000/year),
homicide (5,500/year), and suicide (5,000/year) are the three leading causes of
death among the nearly 40 million adolescents and young adults between the
ages of 15 and 24 in the United States. This social mortality clearly relates to
the process of adolescence with risk-taking behavior, drug abuse, social disrup-
tion, and psychological volatility all being contributing factors. Other develop-
mental tasks of adolescence, and, in particular, emerging sexuality, contribute
to morbidity during the teen years. An understanding of the process of adoles-
cence serves as background for addressing health issues within this at-risk
population.
Among those health problems encountered with greatest frequency
among adolescents are those that relate to sexuality, including pregnancy and
sexually transmitted diseases (STDs); the consequences of drug abuse; acciden-
tal death; and suicidal behavior.
CONSEQUENCES OF EMERGING SEXUALITY
Sexually Transmitted Diseases

Sexual activity frequently begins at an early age. National surveys demon-
strate that by age 19 approximately 50% of girls and 70% of boys are sexually
active. 3 Within urban environments approximately 60% of white females and
80% of black females have had sexual intercourse by age 19. Lower mean ages
are found in high-risk groups including runaways, residents of group homes,

and juvenile detention centers. A consequence of early sexual activity is a high
incidence of sexually transmitted diseases including chlamydia, gonorrhea,
syphilis, condyloma or venereal warts, and herpes. 4 Recently the risk of
Human Immunodeficiency Virus (HIV) infection and the development of the
Acquired Immume Deficiency Syndrome (AIDS) has become an additional
consequence of early sexuality.
It is known that chlamydia trachomatis is the cause of more episodes of
sexually transmitted diseases than gonorrhea or any other organism. Chlamyd-
ia is responsible for illness in men, women, and infants born to infected moth-
ers. In the infant conjunctivitis and pneumonia may occur. In men, the orga-
nism is isolated in approximately 50% of cases of nonspecific urethritis and
epididymitis. In the female the organism may cause infections of the uterine
cervix and lead to pelvic inflammatory disease. Both the male and female may
experience no symptoms of the disease, contributing to underdiagnosis and
further spread.
Syphilis was on the decline until 1985, yet is now experiencing a dramatic
increase in the United States. Earlier in the 1980s syphilis was seen in greatest
frequency among homosexual men and prostitutes. In 1985 a rapid rise in
reported cases was encountered which was in the main within the heterosexual
population.
Sexually active teenagers (15-19 years) and young adults (20-24 years)
are the two groups at greatest risk for acquiring gonorrhea. Approximately
one quarter of all reported cases of gonorrhea are in persons 15 to 19 years.
There are over one million reported cases in adolescents annually.
Although these 3 STDs, chlamydia, syphilis, and gonorrhea, are easily
treated, their presentations vary from asymptomatic to grossly visible, hence
conscientious screening must precede accurate diagnosis and treatment. A
recent study of admissions to a juvenile detention center showed a prevalence
rate for gonorrhea of 5% (3% for boys and 18% for girls). The overall rate for
syphilis was 1% (.63% for boys and 2.5% for girls).5
Human papillomavirus (HPV), and genital herpes simplex both cause cut-
aneous viral infections. The prevalence of these viruses is known to be rapidly
increasing. HPV, which causes genital warts in both sexes, and cervical changes
in the female, is found in approximately 10% of the adolescent population. A
recent study in a largely minority, inner-city population of sexually active ado-
lescent females revealed a 30% prevalence of the virus.
AIDS poses new problems for adolescents. The syndrome first identified
in 1981 in homosexual men has now been identified in over 70,000 adults in
the United States. The incidence of infection with this virus among adolescents
has yet to be determined. Adolescents at high risk for AIDS would include (a)
the intravenous drug abuser (IVDA), (b) homosexual or bisexual males, (c)
recipients of transfusions of blood or blood products, and (d) sexual partners
of members of a high-risk group.
Adolescents, as a group, have not yet been identified as being at high risk
for HIV infection. Yet adolescents are in the process of developing sexual
behaviors, contraceptive practice, and drug use patterns that may expose them
to, or alternately, protect them from the human immunodeficiency virus. Ado-
lescents in the inner cities, predominantly black and Hispanic youth, are at
increased risk because of the increased prevalence of the virus among these
populations in major metropolitan centers. Blood testing of new military re-
cruits reveals a national HIV infection rate of 1.611000. Within areas of New
York City there is a tenfold increase to 16/1000 or 1.6%.6
Urban adolescents would appear to be at particularly high risk for acquir-
ing and spreading the HIV virus. Urban teenagers often have an early age at
first sexual intercourse, multiple sexual partners, low if any use of barrier
contraception, and high rates of other venereal diseases. In New York approx-
imately 50% of IVDA are HIV positive and it is thought that some of these
young adults contracted the virus during their teenage years, because intra-
venous drug abuse often begins during adolescence. However, as of 1987 only
a few hundred adolescents had been diagnosed as having AIDS. Many of these
adolescents had acquired their infection through the transfusion of blood
products. In addition, approximately 200 adolescents were found to be positive
for the virus, but not yet suffering from the disease, via mandatory screening
for the military service. Studies currently in progress are aimed at discovering
the prevalence of the virus in several adolescent high-risk populations. Until
such studies have been completed, adolescents must be seen as an important
group requiring age-appropriate risk-prevention education. 7
Pregnancy
One woman among 10 (10%) aged 15-19 will become pregnant each year.
By the time a young girl who is sexually active has reached age 19 she has a one
in four (25%) chance of having experienced a pregnancy. Of the one million
pregnancies per year in teens approximately one half result in live births, about
40% in elective abortions, and 10% in miscarriages.
The birthrate for adolescent girls is actually decreasing-from a high of 91
per 1000 in 1960 to 69.7 per 1000 in 1970 to 53.4 in 1979. Because ofthe large
baby boom cohort coming to adolescence in the 1970s, paradoxically the abso-
lute numbers of births to adolescents increased. Teenage pregnancy rates
among blacks are nearly twice as high as those in whites in the 15- to 19-year-
old group (163.2/1000 vs. 83.411000 in 1981). However, it is the dramatic
increase in pregnancy among white teenagers that is responsible for the in-
crease in the birth rates; the pregnancy rate among black adolescents has
decreased slightly over recent decades. Perhaps more indicative of changes in
sexual behavior is the increase in out-of-wedlock births. In 1981 80% of preg-
nancies to teenagers were conceived out of wedlock. Approximately half were
terminated by abortion and one out of eight resulted in marriage before birth.
Of all live births to teens, approximately 75% were born to single, unmarried
adolescents. Most pregnancies, about three quarters among 15- to 19-year-old
women, are unintentional. The high rates of sexual activity among teenagers in
combination with low use of effective contraception contribute to this high rate
of pregnancy.B.9
Contraception
Teenagers routinely wait on the average of 12 months after becoming
sexually active before seeking contraceptive services. Only half of teenagers use
contraception at the time of first intercourse. Of these about 20% use condoms,
10% withdrawal, and one sixth an oral contraceptive pill. Hence only about one
third of teens use an effective method of contraception at first intercourse. 10
Nationwide studies tracking adolescent behavior during the 1970s re-
ported that 34% of sexually active women always used contraception, 39% used
it sometimes, and 27% reported never using it. This failure to employ effective
means of contraception is attributed in large part to the lack of knowledge
concerning sexual reproduction as well as cognitive-developmental immaturity
in adolescents. The reasons most often given by teens for not using contracep-
tion include: thinking they could not get pregnant; not expecting to have
sexual intercourse; feeling that planning for sex by contemplating contracep-
tion made the experience less appealing; feeling that contraception interferes
with pleasure; and that contraception is bad for one's health.
The multitude of factors contributing to unintended adolescent pregnan-
cy and childbearing, especially the low use of contraceptives, require further
research and planning of programs aimed at all teenagers for the discussion of
sexuality and distribution of effective contraception.
Homosexuality
In the 1940s Kinsey reported that 10% of adult men were homosexuals. I I
In the 1970s Sorenson reported that 11 % of boys and 6% of girls between the
ages of 13 and 19 had had at least one homosexual experience. 12 It is estimated
that up to 10% of the adolescent population may be homosexual.
A recent study of adolescent male homosexuals shows the acquisition of a
homosexual identity to be a prolonged process. 13 •14 It may begin with the
recognition of homosexual feelings and attraction during late childhood and
early adolescence, but is defined by the persistence of these feelings and their
validation through sexual experimentation. Male homosexuals are known to be
at increased risk for the classic sexually transmitted diseases as well as viral
hepatitis, gay bowel syndrome, and AIDS. In contrast, lesbians are not at
increased rate for STDs nor AIDS. Psychosocial dysfunction is common in
male and female homosexuals, often stemming from conflicts about sexual
identity. Physicians and other professionals working with adolescents need to
be aware of the medical and psychosocial implications of sexual orientation.
Drug Use and Abuse

Although the experimentation with mind-altering substances has existed
throughout recorded history, current concern is now focused on the breadth of
such use in the adolescent population. For certain substances, namely alcohol,
tobacco, and marijuana, experience by the adolescent is now the norm. Current
surveys indicate that 93% of high-school seniors have had some experience
with alcohol, 71 % have smoked cigarettes, and over 50% have used mari-
juana. I5 These prevalence rates support the concept that drug experimenta-
tion among adolescents in the United States is nearly universal. Such use is not
confined to "difficult or problem youth," in fact it has become a part of normal
psychosocial development. These patterns of prevalence tend to cut across
class, gender, ethnic, and geographic lines. When asked about "current use"
(within the past 30 days) 71 % of high-school seniors have used alcohol, 29%
have used cigarettes, and 32% report use of marijuana. Such data suggest that
a significant percentage of youth use drugs casually and perhaps routinely.
However, such behavior, which may be normative, is not necessarily healthy.
Large numbers of youth develop problems with drug abuse and have concomi-
tant difficulties with other problem behaviors, including precocious sexual ac-
tivity, delinquency, violence, truancy, and educational failure.
During the past quarter century there has been a decline in the number of
adolescents abusing opiates (heroin and methadone) and barbituates, but a
corresponding increase in the use of marijuana. Currently, major concern is
being focused on the consequences of the intoxicants, alcohol and marijuana,
as the frequent use of these drugs by a large number of teenagers emerges as a
major contributor to adolescent morbidity and mortality. As noted previously,
accidents are the leading cause of death in the adolescent age group. Of the
25,000 annual accidental deaths among adolescents, 15,000 are a result of
automotive collisions, and in nearly half of those collisions intoxication is a
causative factor. I6 Homicide, the second leading cause of death, also relates to
drug use, with some 30% of homicide victims being intoxicated at the time of
their deaths. By these criteria alone, alcohol and marijuana emerge as the
leading contributors to mortality within the adolescent population.
Concurrent with the national antismoking campaign there has been a slow
decline in cigarette use among adolescents, although 12% of high-school sen-
iors report smoking at least one half a pack daily. Currently more adolescent
girls than boys are smokers, representing a reversal of data among the sexes
that has occurred in recent years. A new area of concern has been the increase
in the use of smokeless tobacco (snuff and chewing tobacco). National surveys
show a prevalence of use in boys aged 12 to 17 to be from 10% in the Northeast
to 27% in the South. I7 Such use has been associated with the development of
oral cancers.
Suicide
Suicide among adolescents has increased since the 1950s and is now the
third leading cause of death among young adults, following accidents and
homicide. IS Adolescent suicide accounts for roughly 5,000 deaths annually. In
addition, some deaths coded as accidents are no doubt the result of a self-
destructive attempt.
Completed suicides occur three to four times as often in males than
females; the reverse is true for suicide attempts, which are far more common
among girls. Females more commonly use ingestion of pills as the means of
suicide, whereas boys are more likely to use more lethal means, such as hanging
and firearms.
It is estimated that for every completed suicide in adolescents there are
between 50 to 200 attempts. Many suicide attempts in teenagers may reflect a
cry for help or a wish to call attention to or escape from an intolerable situation,
more than a true desire to die. Approximately 50% of adolescents who attempt
suicide have seen a physician in the month prior to their attempt. Often these
young people seek medical attention for psychosomatic complaints and under
such circumstances physicians need have a high index of suspicion and evalu-
ate for the risk of suicide by assessing psychosocial factors including depres-
sion, school failure, family dysfunction or conflict, personal loss, drug abuse,
and a family history of violence or suicide.
Ideally, a young person evidencing suicidal ideation would be detected
prior to an attempt allowing aggressive intervention to be initiated to amelio-
rate causative factors and prevent a self-destructive act. At a minimum those
young people who are brought to attention after an attempt will require special
attention to prevent a subsequent death. Most often a brief hospitalization on
either a medical or a psychiatric service is indicated for both crisis intervention
and to evaluate for purposes of determining the most appropriate disposition
for the adolescent or the family.
ISSUES OF CONFIDENTIALITY AND CONSENT
Adolescents exist within a behavioral and legal middleground possessed of

some, but not all, of the behavioral skills and legal protection of the adult. A
full exploration of the legal concerns regarding medical care for adolescents is
a chapter unto itself, however some mention need be made regarding issues of
confidentiality, consent, and the right to care.
Obtaining a meaningful and truthful medical history from an adolescent
regarding such sensitive topics as sexuality and substance abuse requires some
assurance that information volunteered will be held in confidence. Obtaining
such a history in the presence of a parent would not yield reliable information
and the knowledge that all information would be subsequently relayed to a
parent would result in a similar loss of relevant and valuable data. Yet as-
surances of confidentially need be tempered by the limits of any such promises.
Certainly any information from an adolescent that would indicate imminent
danger to self or others will need be relayed to a responsible third party. The
difficulty is in defining imminent danger. If defined too broadly to include any
potential harm or any behavior of which the parent may disapprove then the
relationship and trust of the patient (and other adolescents) will be sacrificed
and with it the opportunity for therapeutic intervention. If defined too nar-
rowly the clinician risks potential parental chagrin, litigation, and above all a
lost opportunity for therapeutic assistance from informed and well-intentioned
family. In all cases it is best to reach an understanding regarding confidentiality
and its limits during the initial medical encounter with the adolescent and the
family.
Regulations regarding the right of an adolescent to consent to his or her

own care differ among the states. As societal attitudes about young people have
changed, so too have the laws that regulate their conduct. A review of three
major movements provides a background for a discussion of basic guidelines of
the laws governing young people.
In early colonial America, parental sovereignty held that parents had abso-
lute authority over their children. Children had no constitutional or protective
rights of their own, except the right to support. In return for their obligation to
support, parents were entitled to their children's absolute obedience.
In the 19th and early 20th centuries, social reformers sought to protect
children from economic exploitation. Laws governing child labor and com-
pulsory education were enacted to limit parental control regarding the daily
lives of children.
In the 1960s the United States Supreme Court expanded the rights of
children to sex-related health care. Among the important issues that concern
health care delivery to minors are who gives consent (when does the minor
have the right to consent to medical treatment), what is informed consent
(risks, benefits and options to treatment), and what treatments may represent a
special circumstance (including contraception, abortion, sterilization, sexually
transmitted disease, psychiatric care, drug abuse, emergency care, etc.). Con-
sent-now expanded to "informed consent"-requires that the person must
understand the medical condition, the treatment and its risks, benefits, possible
outcomes, and reasonable alternatives. The general requirement of parental
consent for health care of minors rests on three assumptions: (a) parents were
assumed to have the right to all decision making regarding minors, (b) minors
were judged to lack the developmental maturity required to give their own
consent and (c) because parents must assume financial responsibility for their
minor children, they are allowed to determine what medical care is given.
Parental right to consent is not required when the minor has been emanci-
pated. A minor becomes emancipated when he or she is a parent, is married, is
pregnant, or is living away from home and is self-supporting. Parental rights
are also curtailed in specific areas of health care, including emergency health
care, some psychiatric treatments, abortion, contraception, the diagnosis and
treatment of sexually transmitted diseases, drug use treatment and blood dona-
tion. Although there has been extensive discussion of ethical questions con-
cerning consent and minors, unfortunately no national, standard approach is
in existence. The guidelines in any given locale can be found with the help of
city and state departments of health, state attorneys general, local bar associa-
tions, medical societies, and independent organizations such as Planned Par-
enthood, The Children's Defense Fund, ACLU, etc. 19
Health Care within the Juvenile Justice System

Although exact numbers are unavailable, between 250,000 and 500,000
teenagers pass through our correctional system each year. These adolescents
are at particularly high risk for health problems secondary to multiple factors.
Often they have experienced medical neglect over the years that preceded
their incarceration. The life-style of delinquency or criminality that results in
incarceration carries with it the consequences of drug abuse, early and promis-
cuous sexuality, and trauma. Their need for quality comprehensive medical
care exceeds that of the general adolescent population.
A variety of systems of care have evolved in the effort to provide medical
services for adolescents within jails, lock-ups, and detention centers. 20 Re-
gardless of the nuances of a particular system, certain components are essential
to all programs. They would include a need for rapid screening for infectious
illness to prevent contagion within the prison population; a complete medical
history, physical examination, and laboratory assessment to detect either acute
conditions or chronic illnesses that may never have been addressed; easy access
to "sick-call" for acute problems that might arise during incarceration; provi-
sion for ongoing care for chronic conditions while detained, including access to
specialists as needed; and a system for follow-up care subsequent to release
from detention.
Within a delinquent population certain medical conditions will be encoun-
tered with great frequency. Sexually transmitted diseases are commonplace.
The consequences of drug abuse, including addiction and infection, are quite
frequent. Poor dental hygiene is near universal. Learning disabilities and de-
pression are also quite frequent and suicidal ideation, suicidal behavior, and
frank psychosis are far from rare. Tuberculosis, which is in general uncommon
among adolescents, will be encountered among this high-risk population. The
ability to evaluate and treat these conditions needs be inherent to any system of
medical care in a detention facility. Standards and guidelines for such care
have been propagated by a number of national organizations. 21 ,22,23
The clear need to provide health care services within the detention system
must be met despite the unique difficulties faced by physicians working in these
circumstances. 24 Prisons are not an attractive locale for a medical practice. Staff
burn out is common in dealing with a continuum of health problems that are
difficult to resolve under any circumstances but certainly are among a transient
population of delinquent youth who mayor may not be appreciative of the care
being offered. Issues of confidentiality, a problem inherent to all adolescent
care, are of particular poignancy where medical records may be subject to
review by detention personnel, parole officers, and the courts. Court ordered
examinations, at times without any medical validity, are an abrasion to the
physician who must concur or face the consequences of defiance. The end
result of these compounded difficulties is the paradox that those adolescents
most in need of quality medical care most often have the greatest difficulty in
achieving access to such services.
ROUTINE HEALTH CARE FOR THE ADOLESCENT
Adolescence is a time for transferring the responsibilities of a parent to the

emerging adult in many ways-health care certainly is one such area where the
individual teenager may be given increasing responsibility as maturity and

independence progress. In fact, making the adolescent increasingly responsi-
ble for his or her own health is an essential step on the road to adulthood. In
early adolescence the prepubertal or early pubertal child may be most comfort-
able if accompanied by the parent during the medical and psychosocial history.
Questions pertaining to background information may be addressed to the
parent, whereas more current or recent events may best be reported by the
adolescent. Even at a young age the teen must be offered time alone to discuss
matters that they may consider private: sexuality, peer relationships, drug
experimentation, feelings of stress or depression, and family conflict. Time
spent alone with the teen, even if quite brief, will let the individual know they
are the patient and that their ideas, thoughts, and experience are of primary
importance to the practitioner. Even if such private sessions with the young
patient are unproductive they prepare the developing adolescent and the fami-
ly for subsequent visits when privacy and confidentiality may be essential. As
adolescence progresses more and more time should be devoted to the adoles-
cent independent of the parent.
History taking is best carried out while the adolescent is fully clothed. The
adolescent can then be asked to undress in private and appropriate gowns or
drapes offered as necessary. It is appropriate to let the patient redress and
summarize medication or other medical plans with the adolescent again fully
clothed. Parents may again be asked to join, especially if the teen so requests, or
if the early developmental stage of the patient necessitates parental involve-
ment. Seeing the patient alone and respecting the modesty of adolescents will
be important steps toward establishing an open and trusting relationship.
Interviewing the Adolescent

The routine assessment of the adolescent should focus on the areas of
disease and dysfunction now known as the "new morbidity."
The successful interview is based upon a comfortable and mutually re-
spectful relationship between the practitioner and the adolescent. Skillfully
formulated questions with particular attention to the developmental stage of
the adolescent will provide useful information to the practitioner. Essential to
the interview is a physical setting that provides privacy and is arranged in such
a way that physician, patient, and/or parents are seated at the same level, at a
distance comfortable for conversation.
The beginning of an interview can serve several purposes. First, of course,
it is used to greet and introduce oneself with a brief description of one's role or
function. Second, a few minutes of informal talk directed at the adolescent
interests will be helpful in establishing the practitioner's concern for the adoles-
cent. It will also allow the practitioner to assess the developmental stage of the
adolescent and gear the rest of the interview to an age-appropriate level. As
noted previously, an initial statement regarding confidentiality is of impor-
tance but with the stipulation that if there is a question of a life-threatening
illness or suicidal ideation, confidentiality might need to be breached.
In the performance of a medical interview, flexibility on the part of the

practitioner is necessary. Open-ended rather than yes or no questions will allow
most adolescents to respond and offer more than one word replies. In a less
articulate or hostile patient, simple questions necessitating simple answers may
be all that is possible.
Psychosocial History
Beyond the review of systems that would be a routine part of every medical
interview there are areas of particular concern when assessing adolescents.
Among these areas would be the appraisal of the broad spheres of academic,
vocational, social, recreational, and sexual activities.
Educational-Vocational Plans
Recent schooling should be assessed, with an eye for a history of the need
to repeat grades, school failure, and truancy. If the adolescent is not currently
in school, one should inquire if are there plans for return, or if the adolescent is
in need of information on how to do so. Future educational plans and voca-
tional goals and current employment may also be assessed.
Family
It is important to learn with whom the youth lives. Do they have contact
with both parents and from whom do they receive social and financial support?
In general, how are things going for them at home? Do they get along with
parents and siblings? If they are no longer at home, what precipitated the
change? Did they run away? Are they "homeless"? How have things gone since
they have been on their own?
Friends
There is a need to assess the social sphere of the adolescent. A way to begin
is to ask what they do on a Friday night. Who do they see? How old are their
friends? What do they like to do? If the adolescent has dated, are they currently
in a relationship, or has one recently ended?
Sexual Activity
It is necessary to ask about sexual activity with all adolescents. It is often
easier for teens to acknowledge past activity, hence asking if they have ever had
sexual intercourse in the past is a good place to start. If the answer is affirma-
tive, then further questioning can bring it up to the present. If no, then it is
appropriate to ask if they are contemplating sexual activity and ask if they have
any questions about it. Asking a teenager about sexual activity is at times
uncomfortable for both patient and practitioner. Each physician needs to de-
velop a line of questioning which is personally most comfortable. Such ques-

tioning as part of a dating history or a menstrual history is often least stressful.
Although during an initial interview an adolescent may not spontaneously
reveal sexual abuse or incest, the practitioner can open the door by asking if
they have ever been "touched" by someone against their will or in a way they
did not like. Mentioning this possibility in a concerned fashion may allow for
later disclosure.
All adolescents contemplating sexual intercourse should be asked about
contraceptive use. Possible initial questions are: What kind of contraception do
you use? or more concretely: What do you and your partner do so you (she)
won't get pregnant and have a baby? It is always important to ascertain past
pregnancies for females and for men, if they have fathered a child.
If a person acknowledges sexual activity, one may follow with, "Have you
had sex with guys, girls, or both?" If a history of homosexual experience is
uncovered one may go on with such questions as, "Do you think of yourself as
gay, bisexual, or homosexual? Do you have a partner? Who have you talked to
about your sexual preferences? What do your parents think?" As with other
areas, the youth may not be able to discuss these issues on a first meeting but
their mention may allow for discussion at a later time.
Drug Use
Because drug use is widespread, questions about its use can be worded in
such a way that the practitioner assumes there is use and is trying to uncover its
scope in the adolescent. Rather than: "Do you ever drink alcohol?", a better
question might be: "On a regular Friday night how many drinks (beers) do you
and your friends usually have?" Or, "At a party, do friends drink alcohol or
smoke marijuana? How much?" Leading up to, "What do you do at parties?"
The response of the practitioner to revelations about drug use will in large
part determine the validity of the adolescent's subsequent answers. If the teen
senses disapproval or disgust, little will be revealed. This is especially true when
asking about other less socially acceptable drug use including cocaine, crack,
and intravenous drug use.
An assessment is needed of the disruption experienced by the adolescent
either as a consequence or corollary of drug use. Has intoxication ever placed
the adolescent at risk? Have there been instances of injury or violence with
drug use? Also, has the adolescent ever been arrested? Is there any evidence of
delinquent behavior?
Suicide, Depression
Given the complexity of the tasks of adolescence, adjustment reactions and
depression are commonly encountered. An effort should be made to detect
vegetative signs of depression, such as fatigue, difficulty sleeping, loss of libido,
decreased appetite, weight loss, constipation, as well as the more common
adolescent problems of acting out behavior including delinquency, drug abuse,
truancy, school failure, and sexual promiscuity. Direct questioning about self-
destructive thoughts should ensue.
PHYSICAL EXAM
Although most aspects of the physical examination would not be specific to

adolescents certain areas deserve special mention. 25
Vision and Hearing

Screening for myopia should be done every 1 to 2 years using a Snellen eye
chart. If vision screening is less than 20/30 in either eye, the patient should be
referred for further examination by an ophthalmologist. It is not uncommon
for vision problems to first manifest during adolescence.
Audiometry may reveal a defect of sensorineural or conduction etiology. It
is best done one or two times during the adolescent period.
Dental
Caries, gingivitis, and malocclusion are the common dental problems of
adolescents. Encouragement for and education of proper oral hygiene, and
referral for yearly dental checkups are necessary in the adolescent years. Den-
tal problems are probably the most common health issue for teenagers.
Genital Exam
Female. A pelvic examination should be performed in all sexually active
females and in any girl with unexplained vaginal bleeding or lower abdominal
pain. Such an examination includes inspection of the external genitalia with
assessment of Tanner stage, and seeking evidence of infection or abnormality.
A speculum exam, and a bimanual vaginal-abdominal or recto-abdominal ex-
amination may reveal abnormalities or infections of the vagina, cervix, uterus,
and adnexa. The high incidence of STDs and pregnancy among adolescents
mandates attention to this portion of the examination.
Male. Examination of the male genitalia includes Tanner staging and
inspection for any penile or testicular abnormalities or infections. Testicular
self-examination should be taught to all males.
Breast. In girls, breasts should be examined as part of the determination
of Tanner staging of pubertal development and in search of any masses which
may exist. Although nearly all breast masses in adolescents are benign fibro-
adenomas, all masses that persist beyond two or three menstural cycles should
be referred to a surgeon for further evaluation via biopsy or excision. The
breast examination also represents an opportunity to instruct the adolescent in
the techniques of self-examination.
In boys, breasts should be screened for gynecomastia. This condition is

common in adolescent boys, usually in Tanner Stages 2 or 3 and rarely lasts
more than 2 years. It may be unilateral or bilateral, tender or non tender.
Treatment may be hormonal or surgical and referral to an experienced spe-
cialist is needed if gymecomostia persists.
Rectal Examination
A rectal examination is not indicated for routine screening in adolescents
but inspection of the perineal area may reveal anal warts, skin tags, or other
problems.
Laboratory Screening
As at other ages certain laboratory assessments should be a routine part of
health maintenance and others only performed as might be clinically indicated
(see Table I). As noted previously, vision testing and audiometry should be
routinely performed every 1 to 2 years. A hemoglobin or hematocrit determin-
ation and a urinalysis should be performed on an annual basis.
A tuberculin skin test should be performed at 1- to 2-year intervals. All
females without adequate documentation of prior rubella immunization
should have serologic testing. Those with negative standard serologic findings
Table I. Laboratory Assessment
Laboratory screening
Vision testing
Audiometry
Rubella screen in females
Hemoglobin or hematocrit
Urinalysis
Tuberculosis skin test
Sickle cell screen
Sexually active adolescent
Gonorrhea culture
Chlamydia culture or microtrak
Syphilis-VDRL
HIV as indicated
Females-Pap smear, wet prep
BHCG, Nickerson as indicated.
Homosexual males
Same as for sexually active adolescent plus:
HIV
Hepatitis B surface antigen and antibody
Drug-abusing adolescent
LFT's
Hepatitis B
HlV
can receive the rubella vaccine. Vaccine should be withheld from females who
are or might be pregnant. The sickle cell screen should be done in all black and
Hispanic individuals unaware of their status.
In the sexually active adolescent, chlamydia, gonorrhea, and syphilis
screening is necessary to rule out asymptomatic infection. A Papanicolaou
smear is recommended for all sexually active girls annually. HIV screening
should be done in patients with history of behaviors placing them at high risk
for infection.
Homosexual males require the same screening tests as all sexually active
teens as well as hepatitis B surface antigen and antibody and HIV screening
tests. The drug abusing adolescent patient likewise would benefit from liver
function tests, hepatitis B, and HIV screening tests.
CONCLUSION
I t can be seen that the care of adolescents requires an understanding of the

interlocking categories of development. The adolescent must negotiate the
many tasks of adolescence, including physiologic, psychologic, psychosexual,
cognitive, and social development. It is hoped that this chapter will serve as an
introduction to the range of developmental processes occurring during adoles-
cence, the health risks particular to the age, and a general approach to the
medical care of this population.
REFERENCES
1. Tanner JM. Growth at Adolescence. London, Blackwell Scientific Publications, 1982.

2. Sanfilippo JS. Yussman MA: Gynecologic problems of adolescence, in Labery JP, San-
filippo JS (eds): Pediatric and Adolescent Obstetrics and Gynecology. New York, Springer-
Verlag, 1985, pp 61-84.
3. Zelnick M, Kantner JF: Sexual activity, contraceptive use and pregnancy among metro-
politan-area teenagers: 1971-1979. Fam Plann Perspect 12:230-238, 1980.
4. Bell T, Hein K: The adolescent and sexually transmitted disease, in Holmes K et al. (eds):
Sexually Transmitted Diseases. New York, McGraw-Hill, 1984, pp 73-84.
5. Alexander-Rodriquez T, Vermund SH: Gonorrhea and Syphilis in Incarcerated Urban
Adolescents. Pediatrics 80:561-567, 1987.
6. US Dept of Health and Human Services: Human T-Lymphotropic Virus Type
III/Lymphadenopathy-Associated Virus Antibody Prevalence in US Military Recruit Applicants.
Atlanta, Centers for Disease Control, 1986.
7. Hein K: AIDS in Adolescents: A Rationale for Concern. New York State Journal of Medicine
87:290-295, 1987.
8. Baldwin W: Trends in adolescent contraception, pregnancy and childbearing, in
McAnarney ER (ed): Premature Adolescent Pregnancy and Parenthood. New York, Grune and
Stratton, 1983, pp 1-19.
9. Hayes C (ed): Risking the Future. New York, National Academy Press, 1987.
10. Zelnick M, Kantner JF: Sexual activity, contraceptive use and pregnancy among metro-
politan-area teenagers: 1971-1979. Fam Plann Perspect 12:230-238, 1980.
I I. Kinsey AC, Pomeroy WB, Martin CE: Sexual Behavior in the Human Male. Philadelphia, W.
B. Saunders, 1948.
12. Sorenson RC: Adolescent Sexuality in Contemporary America. New York, World Publishing,
1973.
13. Remafedi G. Male homosexuality: The adolescent's perspective. Pediatrics 79:326-330,
1987.
14. Remafedi G: Adolescent homosexuality: Psychosocial and medical implications. Pediatrics
79:331-337, 1987.
15. National Institute on Drug Abuse: National Survey on Drug Abuse: Main Firuiings 1979.
Rockville, MD, US Dept. of Health and Human Services, 1980.
16. Rivara FP: Motor Vehicle Injuries in Adolescents. Pediatr Ann 17:107-113, 1988.
17. Center for Disease Control: Smokeless tobacco use in the united states-Behavioral risk
factor surveillance system, 1986. MMWR 36:337-340, 1986.
18. Blum R: Contemporary threats to adolescent health in the United States. JAMA
257:3390-3395, 1987.
19. Morrissey JM, Thrope JC: Rights arui Responsibilities of Young People in New York: A Legal
Guide for Service Providers. New York, Center for Public Advocacy Research, 1986.
20. Schonberg SK: Health care of the adolescent in the correctional system, in Wallace HM,
Gold EM, Oglesby AC (eds): Maternal arui Child Health Practices. New York, John Wiley
and Sons, 1982.
21. American Academy of Pediatrics, Committee on Youth: Health standards for juvenile
court residential facilities. Pediatrics 52:452-457, 1973.
22. Bell TA, Farrow JA, Stamm WE, et al.: Sexually transmitted diseases in females in a
juvenile detention center. Sex Transm Dis 12:140-144, 1985.
23. Woolf A, Funk SG: Epidemiology of trauma in a population of incarcerated youth.
Pediatrics 75:463-468, 1985.
24. Hein K, Cohen MI, Litt IF, et al.: Juvenile detention: Another boundary issue for physi-
cians. Pediatrics 66:239-245, 1980.
25. Marks A, Fisher M: Health assessment and screening during adolescence. Pediatrics 80,
Supplement: 135-157, 1987.
SUGGESTED READINGS
Adelson J (ed): The Handbook of Adolescent Psychiatry. New York, John Wiley and Sons, 1980.
Emans SJH, Goldstein DP: Pediatric and Adolescent Gynecology. Boston: Little, Brown and Co,
1982.
Hoekelman RA, Blatman S, Friedman SB (eds) et al.: Primary Pediatric Care. St. Louis, C.V.
Mosby Company, 1987.
Neinstein LS: Adolescent Health Care. Baltimore, Urban and Schwarzenberg, 1984.
18
An Introduction to Child and
Adolescent Neurology for
Forensic Psychiatrists
HART DE COUDRES PETERSON
Psychiatrists approaching adolescents or children with possible brain disease

(encephalopathy) will find it useful first to attempt to classify the general
nature of the neurologic pathology. All patients can be so classified and the
time course of the illness will facilitate close focus on certain diagnostic catego-
ries and elimination of others. It must be emphasized that this classification
requires a generally accurate history. The categories of neurologic disease can
be listed as follows:
1. Congenital-chromosomal-genetic
2. Traumatic
3. Toxic-metabolic
4. Inflammatory
5. Vascular
6. Neoplastic
7. Degenerative
When one is considering which of the seven categories of neurologic dis-
ease is possibly appropriate it is also useful to divide patients into those with
completed brain disease (static encephalopathy) and those with active progress-
ing brain disease (progressive encephalopathy).
With static encephalopathy we are dealing with consequences of a disease.
Although the nature of the insult may be of great forensic importance it is generally
HART DE COUDRES PETERSON' Departments of Pediatrics and Neurology, New York

Hospital, New York, New York 10021; Departments of Pediatrics and Neurology, Cornell
University Medical College, New York, New York 10021.
307
308 HART DE COUDRES PETERSON
not fundamental to medical management. In progressive encephalopathy one

hopes to attack the fundamental pathologic process in order to benefit the patient.
A classic neurologic diagnostic error is to confuse these two categories; for exam-
ple, to fail to recognize a slowly progressive neurodegenerative disease and instead
label it as cerebral palsy or mental retardation.
Congenital and chromosomal encephalopathies are generally identified at
or shortly after birth. They may also be identified by their association with
other obviously prenatally acquired anomalies. Certain neurologic symptoms,
such as mental retardation, cannot be identified until after infancy so that a
chromosomal disorder such as the fragile X syndrome, which causes mild to
moderate mental retardation in males, would not ordinarily be picked up in
early childhood. The vast majority of congenital and chromosomal abnor-
malities are static encephalopathies and many have well-defined patterns of
inheritance and consequent genetic implications.
Genetic disorders have defined inheritance patterns. They may be present
at birth, for example, Werdnig Hoffman disease, or they may present later, for
example, Huntington's disease. Some are static and some, such as the two
previous examples, are progressive. Many of the genetic disorders can be
equally well classified under the toxic-metabolic or degenerative categories.
Traumatic encephalopathies are identified by history and are generally
maximum at onset with variable improvement. Traumatic encephalopathies
are almost invariably static but multiple undocumented trauma as in child
abuse might present a progressive picture. Occasionally a complication of head
trauma may be converted into a progressive condition, such as the develop-
ment of subdural hematoma or hydrocephalus. Hypoxic-ischemic encepha-
lopathy is a common perinatal injury and produces a static encephalopathy the
nevertheless may show marked change as the nervous system matures and
becomes increasingly able to reflect an adult pattern of nervous system dys-
function. For example cerebral palsy syndromes are almost never diagnoseable
in the first 6 months and may show considerable change in the first 2 years.
Toxic-metabolic encephalopathies can be subdivided into exogenous in-
sults, for example lead poisoning or hyponatremia, and endogenous insults,
for example phenylketonuria, hypothyroidism, uremia. Most toxic-metabolic
encephalopathies are progressive until the fundamental error is corrected. Age
may be a factor in the reversibility of a toxic-metabolic encephalopathy, for
example both phenylketonuria and hypothyroidism are capable of causing
irreversible brain injury in the immature brain but the same stress is entirely
reversible once the brain is mature.
Inflammatory disease of the brain virtually always presents as an acutely or
subacutely evolving progressive encephalopathy, usually with signs of systemic
infection. Inflammatory brain disease can be subdivided into diffuse processes
affecting the entire brain and perhaps spinal cord as in meningitis or encepha-
litis, and focal processes as in brain abscess or subdural empyema. Early diag-
nosis of bacterial meningitis and Herpes Simplex Encephalitis is crucial because
early antibiotic or antiviral treatment greatly improves prognosis. The same
cannot be said for other central nervous system (CNS) viral infections including
CHILD AND ADOLESCENT NEUROLOGY 309
those causing the encephalopathy of AIDS. Brain abscess often presents as a

mass lesion with little or no evidence of infection. Brain abscess should be
suspected in the presence of focal neurologic signs in an individual with
cyanotic congenital heart disease, purulent sinusitis, or other remote bacterial
infection. Brain abscess was a difficult diagnosis prior to the revolution in brain
imaging techniques of the last decade but the diagnosis is readily made on CTT
scan.
Brain tumors are not uncommon in children and adolescents. Most of
these are primary rather than metastatic and most present with neurologic
symptoms evolving over a period of weeks. Under the age of 10 the majority of
tumors arise in the posterior fossa so that ataxia and cranial nerve signs are
commonly seen early. In teenagers the adult pattern of hemispheric neoplasm
is more often seen. Headache is an uncommon presenting complaint in brain
tumor. It is commonly present when inquired for and described as dull, not
very severe, and maximum in the early morning. The recent onset of hemi-
paresis, ataxia, or strabismus should suggest brain tumor. Seizures are rela-
tively uncommon in preteens with brain tumor but because of their more
frequent hemispheric location in adolescents are relatively common. Until suc-
cessfully treated, brain tumors are progressive encephalopathies.
Vascular brain disease generally presents with a sudden, usually focal
deficit maximal at outset. Generally one is left with a static encephalopathy.
The etiology of the vascular insult must be sought because many vascular
insults represent underlying active or progressive diseases such as systemic
lupus, sickle cell disease or ruptured saccular aneurysm.
The final category, degenerative encephalopathies, are by definition pro-
gressive. It includes numerous conditions that are fairly well understood and
could equally well be categorized as metabolic, for example, Tay Sachs disease,
metachromatic leukodystrophy and others whose fundamental mechanisms
are less well understood, such as multiple sclerosis, Leigh's disease, and
Friedreich's ataxia. The majority of these are un treatable but many have well
worked out genetics and important implications for parents and siblings.
FORENSIC ISSUES
Forensic issues in the neurologic patient are most likely to arise when there
is impaired mental function. The remainder of this discussion will address
patients with chronically impaired ability to understand the environment nor-
mally (cognitive impairment) and patients with intermittent impairment III
contact with the environment (impaired consciousness, confusion).
Mental Retardation
Mental retardation occurs in approximately 3% of the population and is
considerably more common in males possibly because of the previously noted
fragile X syndrome. Conventionally mental retardation is classified by the se-

verity of the cognitive deficit as expressed by IQ score. Mild mental retardation
represents IQ 50-70, moderate mental retardation IQ 35-49, severe mental
retardation IQ 20-34, and profound mental retardation IQ less than 20. This
system of classification is substantially inferior to one that describes functional
status such as communication ability, self-care ability, and degree of supervi-
sion the individual requires. Children in the mild range of mental retardation
are regarded as educable and potentially are candidates for considerable inde-
pendence in society. It may be possible for these individuals to learn to read,
handle money, and travel independently. Children in the moderate range of
mental retardation are not candidates for complete societal independence but
can learn work and self-care skills that enhance their self-esteem and greatly
reduce the extent of external supervision required. Children in the severe and
profound range of mental retardation will require assistance in most activities
of daily living. Prior to the antibiotic era mentally retarded children had sub-
stantially shortened lives. Currently, however, shortened life expectancy can be
anticipated only in those children with severe feeding problems, recurrent
respiratory difficulty, and those children whose level of function renders them
bedridden.
Very few causes of mental retardation are medically treatable. Treatable
causes would include phenylketonuria and some of the related aminoacidurias
and aminoacidemias, hypothyroidism, and hydrocephalus, regardless of its
cause. The remainder of the cases represent static encephalopathies of many
etiologies. The etiology of mental retardation maybe a focus of medicolegal
action but is primarily important for prognosis and genetic counseling.
Frequently, knowing the etiology is useful in prognosis and management.
For example infants with trisomy 13 and trisomy 18 can be expected to have
substantially shortened lives, whereas individuals with cerebral gigantism
(Soto's syndrome) or mosaicism for trisomy 21 will probably function in the
educable range of mental retardation.
Etiologic diagnosis may also reveal a known increased risk for similar
mental retardation in future pregnancies. Women who have had a child with
Down syndrome are at increased risk for repetition even in the absence of
translocation. The same is true for spina bifid a and associated hydrocephalus
as well as anencephaly.
Children who are mentally retarded commonly have other neurologic
problems including epilepsy, cerebral palsy, attention deficits, and symptoms
of pervasive developmental disorder. Management of mental retardation is
primarily through counseling of parents and appropriate psychoeducational
placement. This should begin as soon as mental retardation is suspected. Infant
stimulation and early intervention programs are of enormous value for par-
ents, although it is unclear that they improve the long-term cognitive prognosis
for the infant. These programs are based on rational principles and are superi-
or to the changing variety of nontraditional and cult therapies that will be
offered to desperate parents.
Cerebral Palsy
The term cerebral palsy describes a static encephalopathy effecting the
motor system and developing prenatally, perinatally, or in early childhood.
The majority of cases are of prenatal (congenital) origin or related to pre-
mature or traumatic birth. Any severe encephalopathic insult can cause cere-
bral palsy. As in mental retardation the etiology is generally not important in its
management.
Cerebral palsy is most often classified by the predominant motor impair-
ment. In approximately 70% of cases this is spastic and in 20% of cases motor
impairment is athetoid or dystonic. Ataxic and hypotonic varieties make up the
remainder. Mental retardation is present in at least 50% of cases and is es-
pecially common when there is microcephaly, severe spastic weakness of all
four extremities, and severe hypotonia. Mental retardation is commonly mild
or absent when spasticity is limited to the lower extremities or is unilateral. The
term hemiplegia is used traditionally, although the term hemiparesis implies that
the paralysis is not total. Spastic quadriplegia describes a child with significant
spastic weakness of all four extremities. Spastic diplegia describes a child with
substantially less spasticity in the upper extremities than the legs. Spastic para-
plegia implies virtual sparing of upper extremity (hand) function.
In any cerebral palsy clinic there will from time to time appear children
thought to be suffering from static encephalopathy who in fact have unrecog-
nized progressive diseases. This should be suspected when a child shows unex-
plained deterioration in neurologic function. A high index of suspicion should
occur when there is no historical etiology and especially in individuals classified
as ataxic.
The primary goal of therapy in cerebral palsy is to prevent the develop-
ment of deformity, such as contracture or hip dislocation. A secondary goal is
to suppress abnormal reflex patterns and by so doing facilitate the develop-
ment of more normal motor control. Primary treatment modalities utilize phys-
ical therapy, occupational therapy, and speech therapy. Although these various
therapies are widely believed to be valuable there is little objective data to
support this belief.
Assistive devices such as various types of braces and wheel chairs are often
of great importance in improving the level of independence of the cerebral
palsied child. For spastic patients orthopedic surgical procedures are fre-
quently helpful. These include lengthening of shortened achilles tendons and
various procedures to prevent or correct hip dislocation. Correction of hip
dislocation should be pursued even in very low functioning individuals in order
to avoid painful hips 10 to 20 years later.
Attention Deficit Disorder

Attention deficit disorder (ADD) is well known to child psychiatrists and
criteria for its diagnosis are outlined in DSM-IIII. Such children, usually boys,
commonly have neurologic soft signs. Soft signs are abnormalities reflecting
lags in neurologic development that viewed in isolation mean nothing but when
clustered lend support to the notion that neurologic development is delayed.
Examples would include the 6-year-old boy who can not hop on either foot, a
skill mastered by the fifth birthday in 85% of boys, or the 7-year-old who, in
spite of efforts to teach him, cannot differentiate left from right. These stand
in marked contrast to hard signs such as a Babinski response or consistent
reflex asymmetry. Soft signs tend to disappear during adolescence and the
neurologic examination of teenagers thought by history to have suffered from
ADD is commonly disappointing. Although delays in fine motor and gross
motor coordination are common in ADD children they are not necessary for
the diagnosis.
Children with ADD commonly have learning disabilities, such as dyslexia,
which can be suspected by history but only established by an educational or
psychological test battery. The early recognition and effective treatment of
learning problems in ADD may be the most important element in overall
therapy.
The treatment of attentional deficits with stimulant drugs such as meth-
ylphenidate, pemoline, or amphetamine is occasionally a useful adjunct in
management. Stimulants should never be used as the primary approach. Once
the situation in which attentional problems are identified (usually the class
room) a brief trial of therapy can be carried out with the observer reporting the
effect after a week or two of treatment. Stimulants should not be continued
unless a benefit can be appreciated and generally not in other settings, such as
weekends or holidays. In general the response to stimulants ceases during the
teenage years.
ADD is infrequently a result of discrete neurological injury. The majority
of cases are probably familial and a positive family history of early school
problems, clumsiness, and attentional deficits tends to support the diagnosis.
Diagnostic imprecision makes prognostication especially difficult. Early studies
of outcome, which surely reflected the most severe cases, suggested that a poor
educational and social outcome could be expected in many cases. The fact that
the diagnosis can be suspected in retrospect in parents and sibs of ADD chil-
dren and that many of the parents are highly successful argues that a bleak
prognosis may be inappropriate with appropriate intervention.
Episodic Dyscontrol Syndrome

Episodic dyscontrol syndrome refers to sudden explosive outbursts or rage or
aggression occurring in response to minimal provocation 2 . The episodes can-
not be regarded as ictal because consciousness is maintained and there is gener-
ally memory for the event. The rage although excessive in degree is otherwise
indistinguishable from "ordinary" rage and the aggression is not confused,
disoriented aggression. It is simply quantitatively inappropriate. That there
may be a neural basis in part is suggested by the excessive representation of
patients with neurological disturbances, such as complex partial seizures (psy-

chomotor seizures), attention deficit disorder, and head injury. The majority of
sufferers are male and generally the violence is intrafamilial.
Although the pathophysiology and even precise diagnostic criteria are
unclear pharmacotherapy is sometimes beneficial. Carbamazepine and pheny-
toin have been reported to be beneficial, as have propranolol and imipramine.
Epilepsy
Forensic issues commonly revolve around episodes of altered conscious-
ness or perception, impaired memory, or impaired motor control. Epilepsy in
its various forms is the commonest neurologic cause of periodic recurrent
neurologic dysfunction. Indeed the term epilepsy incorporates in itself a predic-
tion of future episodes of neurologic dysfunction (seizures) and prevention of
recurrent seizures is the primary goal of treatment. Epilepsy is not a disease but
a condition, commonly but by no means always a consequence of static enceph-
alopathy. An investigation of primary etiology is always in order.
The epilepsies can be classified as follows 3 :
I. Generalized epilepsies (seizures without local onset)
A. Primary generalized epilepsies
(etiology unknown)
B. Secondary generalized epilepsies
(etiology known or suspected)
II. Partial epilepsies (seizures with local onset)
(etiology known or suspected)
Generalized epilepsies include tonic-clonic seizures, absence (petit mal)
seizures, myoclonic seizures, and atonic seizures. Truly idiopathic epilepsies as
in classic petit mal are considered primary whereas seizures generalizing from
an anatomic or electroencephalographic focus are considered secondary.
Partial seizures can be subdivided into simple partial seizures and complex
partial seizures on the basis of whether there is alteration of consciousness.
Simple partial seizures are associated with maintained consciousness and com-
plex partial seizures with altered consciousness or confusion. It is extremely
common for a simple partial seizure to progress to a complex partial seizure or
generalized seizure. An aura is a simple partial seizure recognized by the pa-
tient as the beginning of complex partial or generalized seizure. Partial seizures
can be motor, sensory, autonomic, or psychic. Partial seizures that are psychic
are of special interest to the psychiatrist because they must be differentiated
from psychiatric phenomena.
Psychic symptoms of partial seizures are generally unpleasant, stereo-
typed, and recognized as distortions by the patient. Common manifestations
include deja vu (inappropriate sense of familiarity), jamais vu (inappropriate
sense of unfamiliarity), depersonalization, and distortion of perception, includ-
ing temporal sense and formed hallucinations. It would be inappropriate to
make a diagnosis of epilepsy on the basis of these symptoms alone without

other evidence whether in the form of progression to a more objectifiable
manifestation of a seizure or through electrographic correlation.
Complex partial seizures (psychomotor seizures) are associated with confu-
sion or altered consciousness. They may take the form or a blank stare not
easily clinically differentiated from an absence seizure. Automatisms may occur
such as fumbling, wandering, disrobing, or mumbling but their relationship to
the environment invariably demonstrates impaired awareness of the environ-
ment. Amnesia is usual.
Violent behavior during an complex partial seizure is extremely rare. A
recent study of 5400 recorded seizures in patients with possible violent behav-
ior revealed only 3 with actual or threatened violence against persons 4 • What
kind of violence might be seen during a partial complex seizure? Generally it
would be the kind of violence of a confused person. During a seizure such a
person might strike out at attempts to restrain him. It is conceivable that a
person holding a knife might cut someone interfering with him during a sei-
zure. It is not conceivable that he would go and find a knife and commit an
aggressive act as a manifestation of a seizure.
Differentiating psychogenic from true epileptic seizures is occasionally
quite difficult. This is especially true when psychogenic seizures develop in a
patient with epilepsy. In patients who are free of epilepsy the electroen-
cephalogram interictally and postictally is usually normal. Patients with epilep-
sy commonly have abnormal EEGs and almost always show abnormalities dur-
ing and immediately after a seizure. Psychogenic seizures are generally bizarre
in manifestation, occur in the presence of observers familiar to the patient,
un associated with postictal confusion or drowsiness, and virtually never associ-
ated with urinary incontinence or tongue biting. Patients with epilepsy are
difficult because they have been trained by repeated history taking and de-
scriptions of their seizures. Psychogenic seizures are more common in females.
Neurological Tests
Electroencephalography. Electroencephalography is the oldest objective
and noninvasive neurological test. The advent of modern imaging techniques
has reduced its importance in neurology but it remains the cornerstone of
diagnosis and management of epilepsy. As previously noted, the diagnosis of
seizures is based on a clinical description, but an epileptiform EEG provides
powerful confirmation. It must be remembered, howeer, that individuals with
markedly epileptiform records may have never suffered a seizure and indi-
viduals with well-established epilepsy, especially complex partial seizures, may
have repeatedly normal records.
The previous caveats not withstanding, most patients with epilepsy have
abnormal EEGs; frequently an epileptiform pattern. The nature and severity
of the pattern provides a crude measure of the severity of the seizure disorder,
especially in children. The EEG is probably required for the diagnosis of classic
petit mal epilepsy and is also required for the diagnosis of hypsarrhythmia and
Rolandic epilepsy. The EEG is widely used in the diagnosis of brain death. The
EEG is very helpful in differentiating primary generalized from secondarily
generalized epilepsy. The EEG is especially useful when patients can be fol-
lowed serially and in the evaluation of candidates for discontinuation of anti-
convulsant therapy. When evaluating seizure patients the initial EEG should
always be carried out both awake and asleep.
There are a wide variety of EEG techniques to localize a seizure focus.
Nasopharyngeal electrodes or sphenoidal needle electrodes permit an elec-
trode closer to the inferior surface of the temporal lobe. Newer techniques
such as brain EEG mapping offer more precise localization of EEG abnor-
malities but have not proved to be of great clinical utility. Depth electrodes are
only justified when epilepsy surgery is contemplated. Techniques are now
available to do extended EEG monitoring of ambulatory patients and to corre-
late electrical abnormalities with videotaped seizures. This is helpful in a small
group of patients in which there are persisting questions about seizure fre-
quency or even the very existence of ictal events. Documentation that a possible
seizure is accompanied by an electrical seizure discharge may justify a pro-
longed and extensive trial of anticonvulsants that might otherwise not have
been undertaken.
Evoked Response Testing. Somatosensory Evoked Response testing
(SEP), Brain Stem Auditory Evoked Response testing (BAER) and Visual
Evoked Response testing (VER) are all measures of the existence and speed of
transmission of specific impulses within the nervous system. They require little
cooperation and generate an objeCtive report. They may be especially useful in
possible malingering or conversion symptoms.
Contrast Techniques. Skull X rays are performed much less frequently
than in the past but remain the technique of choice in suspected skull pa-
thology. Skull X rays should always be carried out in suspected child abuse and
possible severe head trauma. Depressed skull fractures requiring surgical ele-
vation will usually be missed on CTT.
Computed Transaxial Tomography (CTT) or Computed Axial Tomogra-
phy (CAT) are the same. They provide a detailed view of brain anatomy at two
to three times the cost of a skull series and with comparable radiation exposure.
CTT is extremely sensitive to intracranial calcification as occurs in tuberous
sclerosis or Sturge Weber syndrome. Intravenous contrast enhancement great-
ly improves the quality of the study where there is possible break down of the
blood brain barrier, as in cerebral edema, adjacent to tumors, etc. Contrast
enhancement adds a risk to this essentially riskless procedure because of possi-
ble hypersensitivity to contrast material. CTT is rapid, can be carried out by a
technician, and is relatively easy to interpret.
Although it is a major advance in brain imaging, CTT has some limita-
tions. It is not highly sensitive to lesions in white matter. Because CTT depends
on differences in density of cranial and intracranial structures, enhancing le-
sions close to bone may not be well seen. These include lesions in the anterior
temporal lobe and hypophyseal region and adjacent to the calvarium, for ex-
ample, subdural hematoma. Isodense lesions in the pineal region may also be
missed.
Magnetic Resonance Imaging (MRI) and Nuclear Magnetic Resonance
Imaging (NMR) are identical procedures providing a detailed anatomic brain
study using magnetic pulses and sparing the patient a radiation dose. It pro-
vides an excellent study of brain white matter and is extremely valuable in the
diagnosis of multiple sclerosis. MRI is helpful in certain areas where CTT is
weak, especially in studying the temporal lobes and craniocervical junction.
MRI does not image calcium and therefore does not image bone.
MRI has certain limitations. It is slow, requiring 45 to 60 minutes. Ferrous
materials may not be present because of the powerful magnetic field. This
precludes study of most patients on respirators. The current design of the
scanners precludes close monitoring of patient status during the study. Cur-
rently MRI costs two to three times more than CTT.
Positron Emission Tomography (PET) is a new tool available at a few
highly specialized centers. It involves injection of radioactive isotopes that mea-
sure and map metabolic activity of various brain areas using techniques similar
to CTT. It is currently and probably will remain only a research tool.
Angiography was once a commonly performed procedure but the newer
safer techniques have greatly reduced the need for it. It is now used primarily
to study intravascular pathology, such as aneurysm or arteriovenous
malformation.
There are no current indications for pneumoencephalography.
REFERENCES
I. American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, ed 3.

Washington DC, Author, 1980.
2. Elliott FA: The episodic dyscontrol syndrome and aggression. Neurologic Clinics 2: 113-125,
1984.
3. Merlis JK: Proposal for an international classification of the epilepsies. Epilepsia II: 114-
119, 1970.
4. Delgado-Escueta AV, Mattson RH, King L et al.: The nature of aggression during epileptic
seizures. N EnglJ Med 305:711-716, 1981.
IV
Hospital Issues
19
The Psychiatrically
Hospitalized Adolescent as
Victim
Forensic Psychiatric Considerations
SUBHASH C. INAMDAR
The admission of an adolescent to a psychiatric unit is a traumatic process for

everyone. No one wishes to see a child at a tender age, suffering or even worse,
admitted to a hospital. It is obviously a painful trauma to the child and the
family but it is also a source of anxiety to mental health professionals-the
caregivers.
In most states laws exist that allow parents or guardians voluntarily to
admit their minor children for necessary psychiatric hospitalization. Critics of
these procedures remind the public that the admissions are voluntary on the
part of parent or guardians but not on the part of children, who are "volun-
teered for admission."l
In 1979 the Su preme Court of the United States reversed the findings of a
District Court in the case of Parham v J.L. andJ.R. The District Court had held
that a Georgia statute providing for voluntary admission of children, under the
age of 18, to State regional hospitals based merely on the application by a
parent or guardian was unconstitutional because it failed to protect the due
process rights of these children, and that due process included at least the right
to an adversary-type hearing before an impartial tribunal.
In a majority opinion delivered by Chief Justice Burger, Georgia's medical
fact-finding processes were found to be consistent with constitutional guaran-
tees. The court however recognized that "risk of error inherent in the parental
SUB HASH C. INAMDAR • Department of Psychiatry. New York University School of Med-
icine, New York, New York 10016.
319
320 SUBHASH C. INAMDAR
decision to have a child institutionalized for mental health care is sufficiently

great that some kind of inquiry be made by a 'neutral fact-finder' to determine"
the need for admission. The "neutral fact-finder" could be a staff physician as
long as he or she could evaluate independently the child's mental and emo-
tional condition and need for treatment. The evaluation "must carefully probe
the child's background using all available sources including, but not limited to,
parents, schools and other social agencies." The review had to include an
interview with the child and the decision maker had to have the authority to
refuse to admit any child who did not satisfy the medical standards for admis-
sion. Finally, the court required that the child's "continuing need for commit-
ment be reviewed periodically by a similar independent procedure" which
could also provide "a necessary check against the possible arbitrariness in the
initial admission decision."2
This landmark decision took into account a large body of controversial,
complex, and at times interrelated issues that are of interest to note and should
be of ongoing concern to psychiatrists. The court observed that as knowledge
about mentally ill children and public concern about these conditions in-
creased, states, with large federal support, had sought to ameliorate this
human tragedy. Ironically, as this assistance for mentally ill children and ado-
lescents expanded, these actions became subject to "increasing litigation and
heightened constitutional scrutiny." Courts were required to "resolve thorny
constitutional attacks on state programs and procedures with limited preceden-
tial guidance."
The court noted that hospitalization involved a "severe deprivation of a
child's liberty" which included "bodily restraint" and the possibility of "emo-
tional and psychic harm."
The Georgia District Court had held that the "inexactness of psychiatry"
coupled with the possibility that the sources of information used might not be
always reliable made the commitment decision arbitrary. Although the Su-
preme Court did not directly address the issue of the "inexactness of psychia-
try," it assumed that the admission process for children made few diagnostic
errors, an assumption that has not been supported by clinical experience or
research studies. The Court however did not accept "the notion that the short-
comings of specialists ... can ... be avoided by shifting the decision from a
trained specialist ... to an untrained judge."
Child psychiatric hospitals have often been accused of being "dumping
grounds." The Court observed that no specific evidence of "dumping" could
be found in the record. It also noted that the witness who had made the
statement about "dumping" was not referring to the parents who "dump" their
children but that some juvenile court judges and child welfare agencies mis-
used the hospitals!
Concern about parents "guilty of railroading their children into asylums" or
using the "voluntary commitment procedures in order to sanction behavior of
which they disapprove" was made short shrift of. It was considered unrealistic that
trained psychiatrists could be so easily deceived. The Court also challenged the
concept of labeling the child by flatly stating that hospitals do not label a child, they
merely provide the diagnosis and treatment that medical specialists conclude the
THE PSYCHIATRICALLY HOSPITALIZED ADOLESCENT 321
child requires. On the issue of stigmatizing a child by hospitalization, research data

was presented to suggest that what was truly stigmatizing was the symptomatology;
"untreated abnormal behavior ... arouses ... at least as much negative reaction as
treatment that becomes public knowledge."
The Georgia District Court had held that the child's constitutional rights
should not be subordinated to the parents' traditional responsibility for up-
bringing children because of the likelihood of parental abuse when a child was
committed. The Supreme Court, upholding a vast tradition of parental rights,
denounced the "statist notion that governmental power should supercede pa-
rental authority in all cases because some parents abuse and neglect their
children ... [moreover, this is] ... repugnant to American tradition." It fur-
ther observed that in this case not a single instance of bad faith by any parent
had even been demonstrated.
The Supreme Court thus addressed many of the complex and emotional
issues that surround the admission of a child under 18 to a psychiatric hospital.
This has not and will not quell the intensity of the debate. Legal scholars and
mental health professionals continue to be concerned about the commitment of
children and are still troubled by many of the issues touched on here.
Critics of this Supreme Court opinion note that the American Psychiatric
Association (AP A) brief would have provided precommitment hearings in a
much larger number of situations. The AP A brief recognized
that the interest of parents differed from those of legal guardians, that an
adolescent child was more competent to make a treatment choice, that an ac-
credited institution differed from a warehouse, and that a short-term hospi-
talization offered less risk of institutionalization than long-term treatment. It
urged post-commitment review in all cases. l
In fact the AP A brief exempted from due process hearing requirements only
those cases where an intact family wished to admit a preadolescent child to an
accredited institution for a short term.
The initial reactions ranged from viewing the decision as a devastating
defeat to pragmatic reassessment of where future directions lay. Some saw it as
"a hell of a way to celebrate the year of the child."3 whereas others saw it as a
"resounding victory for parental authority."4 Although it seemed unlikely that
the decision would be overturned, as some wished, the next round of battle
clearly had to shift to the state level.
Prior to and since the decision, states have in fact evolved procedures that
attempt to safeguard the rights of minors. An array of due process protections
have been provided. A recent review of psychiatric commitment practices for
children and adolescents concluded that
although approximately half of the states maintain the traditional pattern of
unilateral parental consent, others have provided judicial or administrative re-
view, selected some form of sharing authority between parents and children, or
placed greater authority with the child by lowering the age of consent. 5
North Carolina alone requires formal adversarial hearings for all admissions
and at specified intervals thereafter.
In New York State, for instance, an adolescent under 16 years of age can
be admitted on an emergency admission or a minor voluntary status (Sec. 9.13,

M.H. Law). A minor between 16 and 18 years of age can be admitted on his
own application. An emergency admission, an involuntary hospitalization
based on a "dangerousness" standard, has to be confirmed within 48 hours by
another physician and has to be changed within 15 days to a minor voluntary
status (by a parent or guardian signing) or a Two Physicians Certificate Admis-
sion. The physicians must be licensed to practice medicine in New York State.
At this time, if an adolescent does not wish to be in the hospital, he can request
the assistance of the Mental Hygiene Legal Service (a court agency indepen-
dent of the facility). He has a right to be represented by a lawyer and a right to
a court hearing at any time during his stay in the hospital. A request for release
from the hospital can be made by a minor under 18 years of age as well as the
parent or guardian. The hospital has to release him in 72 hours or request a
court order authorizing involuntary retention.
Clinicians continue to be seriously concerned and troubled by procedures
in those states that provide full-blown adversarial proceedings. Burlingame
and Amaya 5 , citing a limited body of literature6 . 7 •8 , attest to the
numerous damaging byproducts of contested hearings, including: psychiatric
decompensation of the child or adolescent; further deterioration of the already
troubled relationship between parent and child; damage to the relationship
between the patient and therapist as the latter testifies in opposition to the
patient's release; assaults on the adolescent's already shaky self-esteem due to the
disclosure of diagnosis and other results of personality appraisal; anxiety and
resistance in response to the premature revelation of personality dynamics or
unconscious content; the reinforcement of pathological defenses among delin-
quently oriented and narcissistic youths who seek to avoid responsibility for their
plight; and a myriad of undesirable effects on the milieux of child and adoles-
cent units.
They also raised the issue of judicial error and attorney malfeasance.
Judicial incursion, however, into the previous domain of parents and clini-
cians regarding the hospitalization of minors is infrequent in most states. It
may still be necessary in other areas. Adolescent patients have adequate safe-
guards in the commitment process but their physical and emotional well-being
may still be at risk. Substantive due process violations can continue; that is, the
substance of their rights may not be appropriately or adequately safeguarded.
Their right to appropriate diagnostic and treatment planning, in the least
restrictive setting, reasonably close to their families, coordinated and imple-
mented smoothly and efficiently between different settings, is in many in-
stances still inadequately met. This is and should be a source of concern.
Psychiatrically hospitalized adolescents often continue to be victimized by
circumstances totally beyond their control, and as minors they are often un-
aware of their rights. They are victimized by problems related to domicile
(where they come from) and problems related to placement (where they have
to go to). These problems are often inextricably intertwined. Problems related
to domicile include: (a) illegal alien adolescents; (b) out-of-state adolescents;
and (c) homeless adolescents (including abused, maltreated, and runaway ado-
lescents). Problems related to placement ("boarder status") include: (a) adoles-

cents awaiting parent/guardian or return to existing placement; (b) adolescents
awaiting agency determination or plan; and (c) the unavailability of long-term
care for medical and/or psychiatric treatment and for adolescents with dual
diagnosis or multiple handicaps.
The absence of data on the number of adolescents involved and the fre-
quency of such events necessitate the reliance on anecdotal accounts. The
following case histories, in the shape of vignettes, may convey the scope and
dimensions of a problem of massive proportion. The experiences recounted
are those of adolescents admitted mainly to a single psychiatric hospital in a
large Eastern city. (Their names and situations are disguised.) At any given
time in the hospital, there are sometimes several adolescents who face the issues
described.
Problems Related to Domicile

Undomiciled adolescents as described in the case vignettes to follow face
the problem of being totally alone. There is no family to give an adequate
developmental history, history of the present illness, or response to past treat-
ment. They have come from a lonely, painful past and have to face a lonely,
painful future. Hopelessness 9 will tinge whatever psychiatric problem they
have.
Illegal Alien Adolescents

Illegal aliens often have very limited legal rights. The adolescent described
here faced a variety of problems that posed special difficulties during her
treatment.
CASE 1
M. is a 16-year-old South American female who was admitted following a
suicide attempt. She was brought to the emergency room after a drug overdose.
The patient claimed that she had come from South America on a Visitor's Visa but
had refused to go home because she had been unhappy there. She had suicidal
ideation since age 11 and had long wanted to leave home. Her mother had a
drinking problem and was separated from her father, who was a gambler, and
both blamed her for their problems. While living with an aunt in New York she
had made her first suicidal attempt and had already been hospitalized once at
another hospital.
During the hospitalization, she met criteria for major depression with tem-
porallobe seizures but she refused to take medication. When discharge was being
considered, her aunt decided she did not want to live with M., nor did M. want to
return to live with her aunt.
The major problem was that as an illegal alien she was not entitled to public
funding to be placed in residential treatment. After a few months in the hospital
and faced with few alternatives, M. accepted a trial at home with her aunt, who
also agreed to the trial period.
After a brief period, however, she ran away to a shelter because she claimed
her aunt made her have sex with several men and she could no longer tolerate
this. After a week at the shelter she made a third suicidal attempt and was readmit-
ted to the hospital. Once again disposition planning became a problem. She had
no place to go. The hospital authorities insisted that Immigration authorities
should be notified and deportation hearings held. M. told the staff that she would
not return to South America voluntarily, that she would rather commit suicide.
Finally she requested discharge from the hospital. At a court hearing, M., now 17,
was granted permission to return to the shelter and stay at one of their (non-
public-funded) group homes. She had stayed a total of 10 months in the hospital.
Out-of-State Adolescents
CASE 2
N., a chunky 15-year-old adolescent and the ward of a neighboring state, was
admitted from a temporary shelter to a New York City hospital because of both
suicidal and assaultive behavior.
His saga was verified by several sources. His mother had abandoned him to
grandparents at 4 months of age, while his father was a drug addict in New York.
When he was 13, his grandfather died and he started skipping school, became
uncontrollable at home, and frequently assaulted his grandmother. He was placed
in a group home and his grandmother gave up custody to the state. He frequently
eloped from there and when several charges for disturbing the peace were
pressed against him, the group home discharged him to live with a counselor who
eventually became his foster father.
When N. found out that his grandmother had moved out of her apartment
without leaving a forwarding address, he became depressed, increasingly truant,
and increasingly violent. He stopped going to school to avoid embarrassment,
because he read only at the second or third grade level.
N. then ran away to Puerto Rico. He stayed there for about 10 months and
was arrested almost every month for petty crimes before he came to New York to
look for his father. When he found his father, N. realized that he had a severe
drug addiction with no time, desire, or space for him. N. then worked as an
adolescent male prostitute, living on the streets until he found a place in a tempo-
rary shelter for homeless youth.
In the hospital he was considered to have "bipolar affective disorder" which
did not respond well to treatment. He fluctuated between suicidal and assaultive
behavior, and between compliance and rebellion, which could at times be linked to
his mood changes. N. eloped on two separate occasions when he was being taken
to a clinic, but was brought back on each occasion from the shelter he had run to.
N. needed treatment in a closed, structured setting. If he had been in a state
hospital, in another state, he could have been relatively easily retransferred to the
state hospital, but this was to be far more difficult. He had to be first made a ward
of New York State through the Bureau of Child Welfare. During this period N.
requested a court hearing to be released from the hospital. The judge, after
hearing testimony, instead remanded him to a state hospital for children. The
state hospital however had no beds and placed him on a waiting list.
Almost 6 months after admission, N. was finally transferred for continued
treatment at a state hospital for children. He promptly eloped from there.
Homeless Adolescents
In major urban centers many runaway youngsters move from one tempo-
rary shelter to another until they end up living on the streets and are described
as homeless. The out-of-state adolescent just described could also be consid-
ered a homeless adolescent. Some adolescents are abandoned by their families
because of severe problems in the home. In turn some adolescents abandon
their families when life becomes too harsh.
The adolescent described in the following vignette could be considered
homeless because of the special circumstances that arose in his family.
CASE 3
P. was a IS-year-old male who was also brought to a psychiatric hospital from
a temporary shelter. He had threatened to commit suicide if the staff at the shelter
let his father forcibly take him home.
P. had run away from home many times after reporting physical abuse by his
father and stepmother. He claimed he had been scratched over his body, beaten
with sticks, locked in a room, forced to work long hours and beaten if he did not
bring home enough money. The parents denied that they had abused P. and in
turn they claimed that the shelter had allowed him "to run the streets." They
missed scheduled appointments to discuss plans for P. and demanded that he be
sent home.
P. had to be kept in the hospital, even though his psychiatric status did not
warrant hospitalization on a continued basis. The extent of his problems at home
were meanwhile assessed and discharge plans considered. He continued to threat-
en suicide if he was sent home. Plans, against his father's wishes, were therefore
made to send him to a residential treatment center. Multiple applications were
made to various treatment facilities. Some said he was already too old, some said
he was too disturbed, and some did not initially respond. Finally a place was found
for him in a residential setting in a neighboring county. His father reluctantly gave
permission for him to be placed. P. was ultimately placed in a residence almost 3
months after admission to an acute care hospital.
Problems Related to Placement (Boarder Status)
Adolescents with Multiple Handicaps. Adolescents who have multiple

handicaps pose special problems for psychiatric hospitals. Diagnostic issues
often lead to jurisdictional issues as to who should assume ultimate responsibil-
ity. While these issues are being resolved, adolescents can be victimized by
having to stay far longer in a hospital than necessary. The following case
histories illustrate the enormous difficulties faced in attempting to treat and
adequately plan for these adolescents.
CASE 4
D., a IS-year-old adolescent, was admitted to a psychiatric hospital for multi-
ple agressive acts. She had thrown her father across a room, attacked her mother
with a stick, and attempted to break down her parents' bedroom door with a knife.
She had a diagnosis of mental retardation (Down syndrome) and a seizure

disorder.
Her elderly Asian parents could no longer control her as she became bigger
and taller during adolescence. They had previously tended to deny her problems.
Culturally traditional and therefore unassimilated, they felt stigmatized by having
a mentally retarded child who also had seizures (that were not fully controlled by
medication).
Placement was considered mandatory because it would offer D. the stability,
structure, and training that she needed. D. was rejected by 11 residential facilities,
and there were no responses from 6 other programs to which she had been
referred by the Committee on the Handicapped. (Funding had just been ap-
proved by the New York State Education Department.)
It took 9 months in all to place her in a program. This program was almost 2
hours away from where her elderly parents lived. The enormous wait, however
precluded the possibility of considering anything closer and risking further delay.
CASE 5
V., a 12-year-old Hispanic male, was admitted to a psychiatric hospital with
the assistance of police. Prior to admission he had bit his mother, resulting in a
facial wound. He had also threatened his younger brother with a knife and
thrown his older sister to the floor by her hair.
As a child he had been given a diagnosis of schizophrenia, childhood type,
with autistic features. He had subsequently been followed for 3 years in a child
outpatient clinic. He was noted to be moderately mentally retarded and was treat-
ed with chlorpromazine to "control his behavior at home" until residential place-
ment could be found. At the time of admission he had been rejected from all New
York State residences because of his reported "unmanageable behavior." The
Committee on the Handicapped (C.O.H.) had begun referral to some out-of-state
facilities.
Upon admission he appeared restless, agitated, frightened and was physically
aggressive toward staff and peers. When chlorpromazine was increased there was
a gradual resolution of his agitation and aggressive behavior. An improvement in
his attention span, as well as in his ability to handle stress, was noted. There was
also improvement observed in his ability to tolerate ward activities as well as his
socialization with peers.
A few weeks after admission no management problems were noted on the
ward and his neuroleptic medication was reduced. Placement plans were now
considered for a structured setting that could offer him the special education and
training he needed.
His home had not been considered suitable because of the physically as-
saultive behavior between his parents, suspected child abuse, and the lack of
structure (he was found lost in the city on two separate occasions). The mother
had poor judgment and was suspected to have limited intelligence. During the
hospitalization, the mother came in and reported that she was going to be evicted
from her home within 10 days and requested the names and addresses of shelters
she could go to.
Ten months elapsed before V. was placed in a group home that had just
opened for adolescents with special problems. He was their first client.
CASE 6
c., a 13-year-old, was transferred to a city hospital on a court remand after
staying 15 months at a suburban county hospital.
C. had been abandoned at birth by his natural mother, a drug abuser. He had
run away at age 10 from his foster mother and was ultimately hospitalized because
of auditory hallucinations. He was then placed in a residential treatment center
where he stayed for 2 years. There he became increasingly impulsive, destructive,
and instigated fights. He reported isolated auditory hallucinations. Because of
"uncontrollable anger" he was hospitalized at a county hospital with a diagnosis of
schizophrenia, disorganized type (DSM-III 295.11). The county hospital saw no
evidence of a psychosis and considered him to be mentally retarded (FSIQ 42
[WISC-RJ and when retested, FSIQ 55). When the hospital completed its evalua-
tion and initial treatment, the residential treatment center refused to take him
back despite a written agreement to do so, presumably because they thought he
was not ready to return.
C. continued to be aggressive, impulsive, oppositional, and had to be trans-
ferred at one point to an adult unit. He "occasionally irUured other patients and
staff." He did not respond well to several trials of different medications to reduce
his aggressivity.
The county hospital then attempted to send him to a state hospital, which
refused to consider him because he was "mentally retarded." At the same time he
was referred to the Office of Mental Retardation and Developmental Disabilities
(OMRIDD). Because of a dispute between the Office of Mental Health (OM H)
and OMR/DD as to who had responsibility for placing C., the case was referred to
their Dispute Committee. It was determined that OMR/DD had responsibility but
they "did not have a facility in which they could place him!" Meanwhile the
Committee on the Handicapped (COH; Board of Education) for that district was
assigned the responsibility of placing C. in an appropriate residential setting.
They began working "albeit slowly" to find an out-of-state setting.
Three months later (13 months after hospitalization), the staff of the county
hospital posited in Family Court that "acute care hospitalization was not in C.'s
best interests" and argued that he be immediately transferred, because the hospi-
tal was an acute care facility that could not provide the kind of treatment the
patient required, and that he lived in (his legal address was in) the city. Their
"disposition recommendation embodied the belief that ... C .... belonged ... in
the least restrictive environment appropriate to his diagnosis and functioning.
Clearly that ... was ... not acute psychiatric care."
The county hospital argued that C. did not need acute care and it had felt that
because "no placement in a facility sought by COH seems likely in the near
future ... C .... as an interim disposition should 1) return, on court order to ...
the original residence; 2) be placed, on court order, in a specialized group home;
or 3) be placed, on court order, in specialized foster care."
The Family Court did not accept these recommendations and decided to
transfer him to a state hospital for children "forthwith," but the transfer was
rejected! Over the objections of the county hospital he was finally transferred to
an acute care psychiatric hospital in the city. This was 15 months after admission.
At the city hospital the patient was considered psychotic! He gave a history of
both auditory and visual hallucinations, his affect was considered to be constricted
and he had vague nondelusional paranoia. IQ testing moreover revealed a FSIQ
of 72 and projective test data was considered to be consistent with a "schizo-

phrenic psychosis, with pervasive developmental and organic deficits." Questions
about whether he had been cooperative in his earlier IQ testing were raised.
After another 6 months he was ultimately transferred to a State Hospital for
children, to receive continued treatment.
CASE 7
A 14-year-old Florida youth was recently 10 quarantined in a psychiatric hospi-
tal ward after state health officials said "the youth had been exposed to AIDS, was
sexually active and represented a danger to public health."
The youth, whose name was withheld because of his age, was said to have
been under state supervision since he was 6 because of various problems. He had
been depressed for about 4 months after he took a test that revealed he had been
exposed to AIDS. He had recently taken an overdose of pills, presumably to end
his life.
Florida health officials, noting that the youth had a history of psychiatric
problems, of running away and staying away from home two to three nights a
week, felt that he was a risk to public health. The judge, acting under a state law
providing for isolation of a person with a sexually transmissible disease, felt that
all other reasonable means had been exhausted and no less restrictive alternative
existed.
Advocates of rights of the victims of AIDS termed the decision outrageous.
Quarantine orders for victims of AIDS are rare. Female prostitutes with AIDS
have recently been restricted in California, Nevada, and Illinois.
Problems during Hospitalization

Adolescents also encounter problems related to their hospitalization:
Inappropriate Hospitalization. Unwarranted hospitalization can in
some instances be easily solved as soon as the problem is recognized. Appropri-
ate preadmission screening can in most instances prevent this. Given the scar-
city of beds, difficult adolescents are sometimes transferred in the middle of
the night by group homes or residential facilities under the guise of an emer-
gency. A working relationship and an ongoing review process between the two
institutions can prevent most instances of such abuse.
Diagnostic Problems. Until recently "myths alluding to the tumultuous
nature of adolescence and the benign effects of adolescent symptom forma-
tion ... continued ... to abound" despite convincing evidence, from many
centers, to the contrary.ll Prevailing attitudes in child psychiatry also failed to
stress a systematic clinical approach to diagnosis.1 2
Diagnosis of adolescent patients has been recognized as difficult.ll,13 De-
layed diagnosis, or more often misdiagnosis, of a patient'S problems results in
obvious undertreatment that ultimately exposes the troubled adolescent to
even greater risk during and after hospitalization.
Lewis 14 stressed the inadequacy of the "20- to 60-minute psychiatric inter-
view with delinquent children, particularly in the absence of other psychiatric,
medical and social information." She has stressed the contributions of medical,
neurological, and social problems as multiple determinants of psycho-
pathology.
A widely held viewpoint has been that childhood withdrawal and isolation
are the most common precursors of adult psychosis.1 5 A recent report, how-
ever, indicated that violent and suicidal behavior is a common behavioral man-
ifestation of psychosis in adolescents. 16 Moreover, the combination of the two
was especially characteristic of psychotic adolescents. Thus, violent adolescents
should not be dismissed as incorrigible sociopaths and their suicidal behavior
considered conscious manipulations. These behaviors, the most life-threaten-
ing behaviors encountered, should alert psychiatrists to consider the possibility
of a psychosis.
Treatment Problems. Diagnostic problems during adolescence and the
fluctuating psychopathology often contribute to inadequate or inappropriate
treatment. The use of antipsychotics and antidepressants should be considered
for adolescents where indicated despite the fact that "pediatric psychopharma-
cology is a long way behind adult psychopharmacology."17
Adolescents do have the right to refuse "major tranquilizers" or anti-
psychotic drugs in New York State but this refusal is likely to be infrequent if
there is a good physician-patient relationship and the adolescent's fears relat-
ed to medication are addressed. The use of ECT with adolescents is relatively
rare and remains an area of controversy, as with adults. In some states judicial
oversight may be necessary.4
Problems Related to Treatment Personnel. It is obvious that the quality
of the treatment an adolescent receives will be determined by the caregivers.
However, even a well-organized psychiatric hospital may have difficulty in
maintaining an ideal setting for troubled adolescents. Staff changes and/or
shortages often occur, at every level of professional and paraprofessional staff,
which will impact treatment plans.
Adolescent inpatient units require a larger number of well-qualified staff
than most adult units. The needs oftroubled adolescents are intense and imme-
diate. The incidence of assaultive behavior is often high. Group/gang behavior is
at its height during adolescence and scapegoating or victimization can easily
occur if the staff is not vigilant.
Juvenile rights advocates have argued for
constitutional and statutory rights of incarcerated children to minimum re-
strictions on mail and visiting privileges, humane living conditions, decent edu-
cational and vocational opportunities, and freedom from physical and sexual
abuse while in confinement. 4
These arguments were raised in class action suits brought to correct inhumane
conditions in children's training schools or detention centers. Though condi-
tions are presumably better in most psychiatric hospitals, even a small lapse in
vigilance by staff can result in a vulnerable adolescent being physically or
sexually abused, in the best of settings.
CONCLUSION
Hospitals are meant to be havens for the ill and a refuge from the stresses of
the outside world while the process of cure is fostered. For some psychiatrically ill
adolescents, as described here, hospitals are neither havens nor refuge but places
where they receive brief respite from their troubled existence.
Adolescents in hospitals, awaiting placement to less restrictive settings,
may well be the largest group of adolescents who are being deprived, at their
developmental level, of their rights to appropriate treatment with a concomi-
tant risk to their physical and emotional well-being.
Because of the paucity of data, the greatest need perhaps is a hospital-by-
hospital, state-by-state assessment and collection of information about the
number of adolescents at risk. If victimization can occur in the most visible of
public settings, the number of adolescents in private psychiatric facilities, resi-
dential treatment centers, and group homes who face similar problems may be
Immense.
At the individual level it is clearly evident that staff do make vigorous and
exhaustive efforts to help these troubled adolescents, but only when the scope
and immensity of the problem is measured at a state and national level can this
issue be contended with more fully. Vigorous legal efforts for each adolescent
may still have to be pursued as a procedural remedy to force an agency to take
action. Psychiatrists in hospital settings, however, should review treatment at all
levels of care in the journey of a troubled adolescent.
Arguments continue endlessly about what minimal standards of care are
and how fast or how soon the state should meet such standards. Judges have
been criticized, and supported, for getting into court matters that were pre-
sumably better left to legislators. Although
the legal rights of juveniles to decent residential care have been established in the
law books, there is wide disagreement about how far courts can mandate the
details of such care or whether they can insist state legislators pay for this care. 4
It is very clear that the adolescents described earlier did not get the decent
care they needed and deserved. They fell "between the cracks" of a scattered
system organized and funded privately or by city and state.
Judicial review on a mandatory basis to monitor the level of care received
by every adolescent in any setting is unlikely and would be an enormous bur-
den, but administrative or clinical review alone (as a condition of licensure), as
has been suggested,5 is not likely to be very successful. Because some of the
problems are related to a system of interlinked institutions only an interagency
system that can regularly review, monitor, recommend, and facilitate urgent
change is likely to succeed. This seems to be a critical need at the local and state
level. Judicial oversight of such an agency would be helpful if delays in imple-
menting recommendations because of funding or any other reason, are an
Issue.
Stone,I8 in a critical review of the juvenile court system, noted the failure
of collaboration between the legal and mental health systems and the failure of
psychiatric facilities to serve delinquent youth. He charged that "the court's

only function in many cases is to funnel children from unsuitable homes to
unsuitable placements" and that "the practice and paucity and poverty of dis-
positional options is seen to distort, corrupt and betray the whole system."
This is also true of those psychiatrically ill adolescents, who are betrayed as
they leave unsuitable homes and are unsuitably held in hospitals while they
await at times unsuitable placement.
REFERENCES
I. Benedek E: Psychiatry and juvenile law. Psychiatric Clinics of North America 6:695-705,
1983.
2. Parham v]L and]R. 47 LW 4740,1979.
3. American Psychological Association: Monitor 10(7), July 1979, p 2.
4. Wald PM: Introduction to the juvenile justice process: The rights of children and the rites
of passage, in Schetky DH, Benedek EP (eds): Child Psychiatry and the Law. New York,
Brunner/Mazel, 1980, pp 9-20.
5. Burlingame WV, Amaya M: Psychiatric commitment of children and adolescents: Issues,
current practices and clinical impact, in Schetky DH, Benedek EP (eds): Emerging Issues in
Child Psychiatry and the Law. New York, Brunner/Mazel, 1985, p 248.
6. Amaya M, Burlingame WV: Judicial review of psychiatric admissions.] Am Acad Child
Psychiatry 20:761-776, 1981.
7. Planavsky G, Ritchie V, Silverstein E: Intensive residential treatment for adolescents in
North Carolina and the present legal system: A review and proposed changes. N Carolina
] Mental Health 8:1-15,1978.
8. Silverstein E: Civil commitment of minors: Due and undue process. North Carolina Law
Review 58:1133-1159,1981.
9. Siomopoulos G, Inamdar SC: Developmental aspects of hopelessness. Adolescence 14:233-
239, 1979.
10. McFadden RD: Florida judge orders hospital quarantine for youth in AIDS case. New
York Times, June 12,1987.
11. Weiner IB, DelGuadio AC: Psychopathology in adolescence: An epidemiological study.
Arch GenPsychiatry 33:187-193,1976.
12. Wing W, Oftedal G, Weinberg W: Depressive illness in childhood presenting as severe
headache. Am] Dis Child 120:122-124,1970.
13. Masterson JF: The Psychiatric Dilemma of Adolescence. Boston, Little, Brown and Co., 1967.
14. Lewis DO: Diagnostic evaluation of the delinquent child: Psychiatric, psychological, neu-
rological and educational components, in Schetky DH, Benedek EP (eds): Child Psychiatry
and the Law. New York, Brunner/Mazel, 1980, pp 139-155.
15. Offord NR, Cross LA: Behavioral antecedents of adult schizophrenia. Arch Gen Psychiatry
21:267-283, 1969.
16. Inamdar SC, Lewis DO, Siomopoulos G et al.: Violent and suicidal behavior in psychotic
adolescents. Am] Psychiatry 139:932-935, 1982.
17. Werry JS: An overview of pediatric psychopharmacology.] Am Acad Child Psychiatry 21 :3-
9, 1982.
18. Stone A: Mental Health and the Law: A System in Transition. New York, Jason Aronson,
1976.
20
Special Considerations in the
Inhospital Treatment of
Dangerously Violent Juveniles
GLORIA FARETRA AND GARY J. GRAD
INTRODUCTION
In this chapter we will discuss the psychiatric inpatient treatment of a group of

adolescents, 13 years of age and older, who have been convicted of committing
violent crimes and who are thereafter found to require psychiatric hospitaliza-
tion. We have derived treatment concepts and techniques from our experience
working within a state psychiatric hospital unit specifically delineated to treat
juveniles who between their 13th and 16th birthdays committed crimes for
which they were held accountable as adults in the criminal justice system.The
New York State Juvenile Offender Law l describes 18 severe crimes for which
conviction leads to sentencing as an adult. These include such offenses as
homicide, rape, sodomy, kidnapping, assault, manslaughter, arson, and armed
robbery. Those juveniles who might require psychiatric hospitalization during
their incarceration cannot legally be inpatients with civil populations. There-
fore, this unit was established by the State Office of Mental Health and has
statewide responsibility.
The unit was established in 1983 and houses up to 10 males at anyone
particular time. The youths treated derive from a high-risk population. They
are largely of lower socioeconomic and minority status, few have intact families,
and most have histories of multiple drug abuse. Their incarceration in the
Division for Youth (DFY) becomes a considerable stress to these already highly
GLORIA FARETRA and GARY J. GRAD· Queens Children's Psychiatric Center, Belle-
rose, New York 11426.
333
334 GLORIA FARETRA AND GARY J. GRAD
vulnerable individuals. Demographically, our population resembles other stud-

ied populations of antisocial adolescents, including those with severe psychi-
atric problems. 2 ,3,4 The population of the unit derives from youths referred
from the Division for Youth correctional secure facilities who, while incarce-
rated, evidenced suicidal ideation or gestures, serious depressive manifesta-
tions, various psychotic features including visual and/or auditory hallucina-
tions, and bizarre behavior. In some instances unmanageably aggressive
behavior was considered to be related to an underlying psychiatric disorder
and screening by the unit was requested.
PATIENT CHARACTERISTICS
We assessed a variety of demographic characteristics of our first 30 pa-

tients. All were male and all but one were black or Hispanic; they ranged in age
from 14 to 17 on admission and most were living in the New York City area
prior to sentencing. Eight were sentenced for murder, three for rape, and the
rest were serving time for armed robbery and assault. Few were living in intact
families prior to their arrest and only 5 of the 30 had both natural parents in
the home after they were six. About half of our patients had family histories of
psychiatric illness and/or antisocial activity. Most of the patients had previous
psychiatric treatment, residential care and/or psychiatric hospitalization. FUF-
thermore, most of them had histories rife with reports of school failure for a
wide variety of reasons, including school refusal, learning disabilities, and re-
tardation. Again, characteristics such as these have been recognized in similar
studied populations. 3 - 6
From a diagnostic perspective, approximately a third of the group were
diagnosed as schizophrenic and almost 50% suffered from personality disor-
ders. In most of those with personality disorders and schizophrenia, evidence
of paranoia was quite clear. As noted, many had been multisubstance abusers.
There is considerable variation in the literature on diagnostic groupings of
similar populations, probably dependent on such issues as whether they were
in psychiatric or legal settings, pre- or postsentencing, etc. 3 ,4,7,8 These studies
heavily note the paranoia, depression, and personality disorders in this popula-
tion. Furthermore, disturbances of personality are noted by several authors 7 ,9
as related to severity of delinquency and as foci of therapeutic attempts. Es-
pecially noted among personality characteristics of the patients with personality
problems are their borderline characteristics,7 narcissism, grandiosity, and
need to feel in contro1. 9 About a quarter of the boys were at least mildly
retarded and only a few reached a full-scale IQ level of 100; a tenth had an
abnormal electroencephalogram (EEG) and/or seizure disorder. Interestingly,
hard signs of neurological disorder were extremely uncommon and few of the
youths prior to admission were being treated for chronic medical problems.
EEG and neurological abnormalities have been reported prevalently in some
similar populations previously studied and have been related to the violence
evidenced by these patients by some authors. 2 ,3,5,10 Other authors have not
DANGEROUSLY VIOLENT JUVENILES 335
seen prevalent neurological or EEG disturbances and/or do not relate these to

the violence of this population. I I Our population is similar to the latter in
terms of neurological characteristics. Projective testing revealed that patients
were often guarded, denied aggression, had sexual identity conflicts, and anti-
social ideation; paranoid trends were noted throughout. Patients tended to
deny responsibility for their actions, and as has been noted by others, often
misperceived human beings as nothing but objects. 12 In sum, the youths on this
unit had committed violent crimes, were hospitalized for severe psychiatric
disorders, very frequently had difficulties with learning, and came from fami-
lies with little structure or support.
UNIT STRUCTURE
In determining the unit structure, our original notions were to attempt to

replicate a kind of therapeutic community with patient participation in pro-
gram aspects and decision making, such as orientation of new patients to unit
admission and discharge procedures, levels of care, assumption of individual
responsibility, and community meetings. 13 However, it rapidly became clear
that because of characteristics such as their sociopathy, distrustfulness, para-
noia, tendencies rapidly to become aggressive, and other severe personality
disturbances, they were not able to partake in shared unit responsibilities. Even
after resolution of more acute and/or psychotic psychopathology, personality
style and usual responses to milieu with which they were familiar dictated self-
involved, grandiose, antisocial, controlling responses, often uncaring of
others. 9.12,14,15
Dynamics of violence on the unit related to several major sources. One was
aggression, which came about as an immediate response to frustration in a
youngster with few coping skills and poor impulse control and within whom
patterns of retaliation and aggression existed. This was usually short-lived and
directed at a frustrating person or object. It has been possible clearly to identify
antecedents to such aggression so that conflict resolution could occur, often
without violence. 9 ,12 Another kind of aggression presented by these youths
might be characterized as that of the acting out of an intense emotional conflict,
similar to other psychiatric patients. We were confronted by behavior related to
psychotic symptomatology, including command hallucinations and delusional
behavior, ongoing paranoia, and homosexual fear. Finally, the most difficult
type of aggression to deal with on the unit was that which might be termed
predatory and often included dehumanization of the potential targets of the
violence. 9 ,12 Although the youth on this unit often evidenced aspects of all of
these types of aggression, the last form was the most problematic to manage as
this potential type of aggression, if actualizable, would undermine everyone's
safety, security, capacity to trust one another, and potential for humane psychi-
atric treatment.
Program structure was developed to deal with the different kinds of ag-
gression present as well as the other clinical characteristics of the population. In
evolving the milieu, we attempted to take into consideration both the model
therapeutic community already noted, which might allow for the patient to
reorganize gradually and then take some part in their ongoing care prior to
discharge, and their personality characteristics and potential for violence that
would undermine community organization. The literature in the area of resi-
dential care of this type of patient varies between programs that see the vio-
lence of these patients as resultant from underlying neuropsychiatric distur-
bances 2 •5 and/or conflict requiring therapeutic resolution 14 to that suggesting
that the milieu must focus on the patients becoming aware of results of their
behavior in order to effect change. 16 Our approaches varied between these
extremes.
In addition to individual patterns of aggression that served to undermine
unit structure, group dynamics played a role in disorganizing the milieu. These
youths tended to organize antisocial activities in order to attempt to control the
unit themselves, which might well lead to a "pecking order" whereby larger
and stronger youths could take advantage of staff and/or other weaker or
smaller members of our population. Although a unit allowing this to occur
might seem stable and without violence, it would be based on constant fear of
retaliation among patients and even staff. Modification of behavior by staff was
rapidly seen as being accomplished not necessarily only by individual, group,
or other kinds of therapy, but by manipulation of the ward milieu itself. One
example of this form of behavior exemplifying individual and group predatory
aggression occurred when several of the youths, led by the then largest and
strongest boy in our population, began to taunt and verbally threaten a new
admission. He had given some of his lunch to a youngster, who, because of his
particular crime, the fact that he had had homosexual liaisons prior to incar-
ceration, his poor social abilities, and deprecatory stance, had low status on the
unit. The new patient was made fun of for involving himself with the low-status
patient and remarks were made as to his homosexuality, of which there was no
other evidence other than his interacting with the youth who had a history of
active homosexuality. It may be that the group needed to defend itself against
this potential for homosexuality, adding impetus to their desire to keep these
two youths from relating. Within an hour several punches were traded between
the new patient and the patient group leader. Tensions were lessened with
therapy aide and professional staff intervention leading to discussion of the
situation, assertion that the youths should relate to staff rather than fight out
differences among themselves, and clarification that having friends on the unit
was a matter of individual choice rather than group dictate.
It was necessary to structure the life of the patients on a 24-hour basis with
clear, consistent guidelines, constant close supervision, intolerance of rule
transgression, clear definition of conditions for attainment of privileges, and
loss of such.l 4 - 16 We defined types of interaction among the youth to the
extent that exchange of objects other than food is not allowed so that victimiza-
tion and manipulation in the population is lessened. Special security pro-
cedures are always maintained on the unit. For example, doors are not left
half-open, half-shut, blocking visibility, but are either open completely or lock-
ed. We attempted to remain constantly aware of changes in patient affective

states and even physical symptoms, as well as behavior, so that counseling can
take place either by professional staff or therapy aides if the patients' emotional
state seemed to be leading to regression or some form of aggression. Patient
awareness of their emotional states demanded that they become aware of feel-
ings that, because they have been long denied, except in action, are very pain-
ful for these adolescents to bear. 9 Efforts are made, as noted in the example, to
reduce group formation when directed toward antisocial goals. Therapy aide
staff have available a range of time-out procedures, from quiet room with staff
counseling to locked seclusion prescribed by the psychiatrist. Even visiting is
accompanied by therapy aide staff because contraband has been passed to our
patients by relatives. External controls were devised to help prevent youths
from rapidly exercising their response to lack of structure, which was often
antisocial and/or aggressive. It was hoped that this would also act as a model for
development of internal controls and fairness to others.
The unit does not function with a behavioral program of rewards for
positive behavior with such indicators as tokens or accumulation of points, but
instead each of the youths is evaluated personally on a weekly basis by members
of the staff, including treatment assistants, teachers, and professionals. Ob-
viously, we are also attempting to modify the demand for immediate gratifica-
tion and litigious bargaining about each activity of the day, as well as making
clear to our patients their behavior and associating responses to it. The patient
participates directly in this process with staff in order to evaluate his overall
behavior in relation to the unit's guidelines as well as his interaction with other
patients and staff during the course of the week. Recognition for positive
behavior then occurs, whereby the youth might receive some form of special
privilege or gift, for example, special grooming articles, not generally available
on the unit. It was important to develop this procedure as it became clear that
other systems of rewards and punishments were easily able to be manipulated
by the youth, whereas a forum for discussion of their behavior fostered their
capacity to interact verbally and to consider their activities realistically, the basis
upon which some well-recognized programs function. 16
The backbone of the program, shared also by other programs of its type,17
is the presence of two to four specially selected and trained treatment assistants
present in the unit at all times. During working hours of the professional staff,
there is also capacity for direct contact and support of treatment assistant staff
by professional staff, whose offices are on the unit. The treatment assistants not
only watch the patients but interact with them to their daily activities, from
helping them read letters to taking part in complex games and sports. They
also oversee unit rules and regulations and mete out necessary restrictions for
rule transgressions. These might entail early bed, loss of smoking privileges,
etc. Unit rules, regulations, and structure become the primary way by which
the unit provides safety and security, enabling psychiatric treatment to occur.
We are aware that these youths have not had adequate experiences of structure
and safety in their environments in their lives and may have experienced abuse
as well. 3
Indications of incipient severely aggressive behavior, often resultant from

what we call predatory activity, tend to be met by team discussion, followed by
behavioral responses to the individual, which we feel will rapidly terminate the
behavior before it escalates and/or becomes dangerous. Aggression related to
intrapsychic conflict or other evidence of psychiatric disturbance such as hallu-
cinations or delusions is most often met by more usual psychiatric techniques
such as therapy, discussion, medication, and/or use of seclusion room, depend-
ing on the level of emotion present and/or violence having occurred. In all
instances throughout the day and even in light of any kind of grossly disturbing
behavior on the part of the patients, youth are encouraged to discuss their
feelings, ideas, and behaviors directly with the ongoing therapy aide staff on
the unit before emotion is translated into aggression. Every effort is made to
avoid the youths seeing all decisions as made by professional staff or the team
leader alone. This helps avoid staff manipulation and division. The team lead-
er acts as the communicator of joint staff decisions concerning a youth, in that
the team leader maintains a distance from the actual psychotherapy of the
patient and from the daily issues, such as supervision, restriction, program.
This also helps heighten the effectiveness of this communication as being
special.
At times when aggressive activities have appeared to be verging on becom-
ing rampant on the unit, the whole staff, as a team, discusses the problem. In
addition to previously noted responses, staff might meet with all of the youth in
an effort to stem any potential unitwide aggression. Again the object is to
maintain a consistent atmosphere of safety and security for all staff and pa-
tients on the unit so that appropriate behavioral and psychiatric treatment can
occur. Breaks in staff appropriateness, consistency, and/or cohesion rapidly
have led to patient aggression, whether against other patients or staff. Another
result of inconsistency is that these youths then begin directing anger with
threats of violence to particular individuals perceived as independently acting
with hostility. They tend to focus anger, appropriate to the situation or not, at
individuals, whereas staff group actions tend to inhibit this form of violence.
For example, on one of the shifts when the patients were not supposed to have
smoking privileges, one of the therapy aides rewarded all of the youth on the
unit with smoking privileges after losing a game to one of them. Another
youth, on smoking restriction, then decided to attempt to get a cigarette and
did do so from another patient. The staff member who had abrogated the unit
rules then took smoking privileges away from all of our patients. The patient
group, within hours, attempted to physically attack the youngster whose ac-
tions led to the loss of the inappropriate smoking activity. Tension was finally
relieved on the unit several days later when the treatment team reviewed the
situation with all of the patients involved and acted with a mild restriction for
all of the patients in light of the fighting that they had all taken part in. Issues
with the therapy aide staff on duty at the time of the abrogation of the unit
rules and the fight were left to the treatment team leader and not discussed
with our clients. No attempt is made to overjustify staff actions, 14 because it is
important therapeutically that these patients not constantly become locked in
litigious processes that tend to foster their lack of responsibility for their ac-
tions, but begin to respect variability in settings that are, on the whole, fair. In
all instances these youths, whose self-concepts and capacity to understand their
own emotions are so limited, are encouraged to attempt to discuss and under-
stand their behavior, ideas, and feelings with staff rather than acting on them
individually or as a group.
Therapeutic, educational, and recreational programs had to be developed
with recognition not only of the youths' developmental needs but their severe
limitations and personal pathology as well. From an educational perspective, as
we noted, they suffered from combinations of learning disabilities, low normal
IQ at best, and poor past school attendance. For example, youths ranged in
academic performance ability from pre-first grade reading to high-school level.
They are sensitive to their inabilities and unwilling to disclose their weaknesses
to their also sociopathic peers. Educational programming tended to break the
youth into small, more cohesive groups and even allowed for individual re-
mediation and tutoring. Recreationally these youths presented a challenge for
staff because of neurological deficits such as poor coordination, inability to
relate positively with others in the group, less practice than youth not involved
with sociopathic activities, and grandiosity about their capacities. Recreational
programming demanded direct staff involvement in activities from group
sports to one-on-one games in order to maintain interest and participation and
allow those with few skills more recreational activities.
PSYCHIATRIC TREATMENT
Group therapeutic approaches attempting to develop an interaction with

the youth in order to determine unit structure and rules and regulations failed
because of sociopathic behavior. Even group approaches that were purely
therapeutic or educational in purpose were often sociopathically undermined.
For example, when we attempted to have an educational program having to do
with health issues or sex, it became clear that if a youth were to ask a question,
others would make fun of him as being stupid simply to have to ask something.
In a sense, the youths had very omnipotent views of themselves and allowed no
challenge to their omnipotent view, especially in group settings. The amount of
emotion engendered by group discussion would also often become so great
that problem solving, especially with our type of patient,9 could not become
fruitful. We were able to have very structured group activities with therapy
aides or professional staff which dealt with here-and-now issues often some-
what removed from the patient's own control or influence, such as family not
visiting.
Within the context of a safe, secure, well-structured setting, programming
appropriate to these patients' psychiatric and developmental needs as well as
special characteristics such as sociopathy, 14 becomes possible. It should be
noted that admission to the unit was often seen in one of several ways by
patients-as an embarrassment to be removed from their peers or as a place
more easily manipulated because of their previous experiences with mental

health professionals. As noted, usual admission difficulties included acute psy-
chotic symptomatology, depression, suicidal behavior, unmanageable pro-
longed aggression, and constant fights with staff and peers where severe psy-
chiatric problems are assumed to underlie the behavior. Though our patients
often stated a wish to be discharged back to places from which they came, overt
anxiety, behavioral symptomatology, and sociopathy often increased when dis-
charge was contemplated. We attempted to make clear to our patients that
antisocial activity could not be used to bring about early discharge or stop
appropriate discharge from occurring. Delineation of antisocial behavior from
the youths' more acute psychiatric symptoms is an ongoing difficulty for the
staff with many of the patients. The unit also functions very differently from
the Division for Youth (DFY) in that whereas punitive responses are mini-
mized, direct observation, contact, and stimulation of youth to observe and
note behavior and feelings is fostered. For many of our patients this is very
different from other settings of which they may have been part.
Much like other psychiatric hospital settings, we attempt individual psy-
chotherapy with psychotropic medication as needed, recognizing the degree to
which our patients are suffering symptomatically. It is well recognized that
individual psychodynamic psychotherapy with patients of this type has had
limited usefulness. We modify individual treatment and medication utilization
in some of the following ways.
Individual therapy with the patients on our unit tends to be initially very
supportive while the youngster evidences more acute and severe psychiatric
disturbance. More didactic approaches, cognitively oriented, often become util-
ized thereafter. There is a need for these youngsters to learn responsibility,
control, and empathy, and for them to be confronted with their own distortions
that they use to blame and disown responsibility for actions, and that ultimately
in many cases also leads to manifestation of acute psychiatric disorder, such as
depression or psychosis. 14 Unit behavior is readily used in the therapy sessions
to demonstrate aspects of difficulty and/or pathology. Individual therapy as
well tends to be strategic in nature, whereby particular aspects of the indi-
vidual's behavior are brought into the therapy session at the time when the
problem is evolving. Thus the patient can observe, experience, and think
through the problems as they occur, rather than shunting them to the side until
the behavioral manifestations of their symptoms and personalities and its ef-
fects on the unit make the problem a behavioral issue, clouding the psychologi-
cal problems. The therapist and patient can also relate to previous experiences
and ideas that would not otherwise become part of the treatment unless ex-
emplified by current difficulties.
Countertransference issues are very important for all of the staff, from
therapy aides to the therapists. 18 Clearly these youths had engaged in a variety
of heinous acts and evidenced severe psychopathology so as to make the staff
feel angry, rather helpless, and basically incapable of reversing underlying
psychopathology and sociopathy. Furthermore, the youths tended to try to
manipulate the staff and/or therapists when they are on the unit and these
manipulations range from lying to assault with even the possibility of injury.
There is considerable discussion among staff both informally and at team
meetings about negative feelings engendered by the youths and/or their care.
Free ventilation of these feelings among staff at all levels leads to clarity about
reactions to the youth and understanding of the therapists' tasks, and helps
alleviate negative feelings. This approach is very supportive to therapy aide
staff who must daily interact with the patients. The cognitive nature of the
therapy and the fact that more expressive therapy most often comes about
after the youths feel safe and secure on the unit and are not acting in an as
aggressive a fashion helped diminish some of the countertransference prob-
lems for staff.
Finally, many of our patients are very unwilling to take any kind of medi-
cation for their psychiatric disturbances. In light of their psychopathology it is
clear that psychotropic medication must come into play in their treatment. The
general approach was to be very consistent, supportive, and didactic in order to
help the youths see how the symptoms in question are detrimental to them-
selves, understand why medication might be useful, and allow them slowly to
accept the use of medication without loss of self-esteem. In some instances,
medication used on an emergency basis could later be shown to the patient to
be of ongoing usefulness. Collaboration with medication treatment could then
come about.
It was also important to educate the youths to the fact that many of them
suffer from forms of disturbance that would be aided by medication taken long
term even after return to correctional facilities or to their homes. 19 In such
instances, youths are under considerable pressure from their peers and even
staff on the unit and at the DFY not to take any kind of help from the doctors
and not to take any kind of drug or medication that might affect their thinking
or behavior.
Our patients often complain of nonspecific physical symptoms, such as
headaches or stomachaches. We attempted to help them delineate whether
their complaints might relate to some emotional upset or be actually a sign of a
physical illness. We attempted as well to discuss emotionally related pain at the
time that it occurs, so that it does not lead to inappropriate use of pain medica-
tion or patient withdrawal from programming. Allowing physical pain to be
used for medication gain or to avoid programming leads to contagion of sim-
ilar behavior on the unit. As we are in a hospital setting, physical pain related to
medical problems can also be easily attended to by seeking rapid medical care,
giving the youth direct evidence of staff caring for them. Our experience to
date is that even those with chronic problems such as asthma have not experi-
enced frequent exacerbations of their symptoms.
SUMMARY
In the years that we have been in operation, we have seen some of the
clearly most violent adolescent psychiatric patients in our state. Though our
goal has always been the lessening of more acute psychiatric symptomatology,
we have found that lessening of such symptomatology has to go hand in hand
with dealing with the antisocial and characterologically disturbed aspects of the
youths themselves. It was most important to present the youths with an orga-
nized setting within which their behavior might be observed, considered, modi-
fied, and improved, and in which staff awareness of their distress and more
acute psychiatric problems could be shared in an affectively meaningful fash-
ion in order to enhance their cooperation with treatment.
The focus we have learned and must maintain is one where a safe, secure
environment promotes and provides for clear, consistent psychiatric care with
the possibility that these individuals, who largely tend to blame others and deny
responsibility for their acts,5,9,20 would begin to be responsible for some of
their actions and even some of the care of their psychiatric difficulties.
REFERENCES
1. Juvenile Justice Reform Act, NYS Laws of 1976, Chapter 880.

2. Lewis DO, Balla DA: Delinquency and Psychopathology. New York, Grune and Stratton,
1976.
3. Lewis DO, Shanok SS, Pincus JH, et al.: Violent juvenile delinquents-Psychiatric, neu-
rological, psychological, and abuse factors.]. Am Acad Child Psychiatry 18:307-319, 1979.
4. Hollander HE, Turner FD: Characteristics of incarcerated delinquents: Relationship
between development disorders, environmental and family factors, and patterns of of-
fense and recidivism.] Am Acad Child Psychiatry 24:221-226, 1985.
5. Lewis DO (ed): Vulnerabilities to Delinquency. SP Medical and Scientific Books, Jamaica NY,
1981.
6. Brickman AS, McManus M, Grapentine WL, et al.: Neuropsychological assessment of
seriously delinquent adolescents.] Am Acad Child Psychiatry 23:453-457, 1984.
7. McManus M, Alessi NE, Grapentine WL, et al.: Psychiatric Disturbance in Serious Delin-
quents. J Am Acad Child Psychiatry 23:602-615, 1984.
8. KashaniJH, Henrichs TF, ReidJC, et al.: Depression in diagnostic subtypes of delinquent
boys. Adolescence 17 :943-949, 1982.
9. Marohn RC: Adolescent violence: Causes and treatment.] Am Acad Child Psychiatry
21:354-360, 1982.
10. McManus M, Brickman A, Alessi NE, et al.: Neurological dysfunction in serious delin-
quents.] Am Acad Child Psychiatry 24:481-486, 1985.
II. Hsu LKG, Wisner K, Richey ET, et al.: Is juvenile delinquency related to an abnormal
EEG? A study of EEG abnormalities in juvenile delinquents and adolescent psychiatric
inpatients.] Am Acad Child Psychiatry. 24:310-315, 1985.
12. Armstrong B: Conference report: Handling the violent patient in the hospital. Hosp
Community Psychiatry 29:463-467, 1978.
13. Gutheil TG: The therapeutic milieu: Changing themes and theories. Hosp Community
Psychiatry 36:1279-1285, 1985.
14. Reid WH: The antisocial personality: A review. Hosp Community Psychiatry 36:831-837,
1985.
15. Burke EL, Amini F: A significant aspect of acting out, and its management on an adoles-
cent ward: ''Jailification''. Adolescence 16:33-37, 1981.
16. Yochelson S, Samenow SK: The Criminal Personality, vols I & 2. New York, Aronson,
1976-1977.
17. Rogers R, Ciula B, CavanaughjLjr.: Aggressive and socially disruptive behavior among
maximum security psychiatric patients. Psychol Rep 46:291-294, 1980.
18. Maier Gj, Stava Lj, Morrow BR, et al.: A model for understanding and managing cycles
of aggression among psychiatric inpatients. Hosp Community Psychiatry 38:520-524, 1987.
19. Marder SR, Swan E, Winslade Wj, et al.: A study of medication refusal by involuntary
psychiatric patients. Hosp Community Psychiatry 35:724-726, 1984.
20. Cormier BM, Markus B: A longitudinal study of adolescent murderers. Bull Am Acad
Psychiatry Law 8:240-260, 1980.
21
Psychiatric Restraint of
Children and Adolescents:
Clinical and Legal Aspects
DONALD S. GAIR
Serious discussion of any form of restraint of psychiatric patients leads to

civilization's perennial dilemma of how to regard and manage the mentally ill:
when and how and whether at all it may be justified to interfere with their
freedom because of mental illness. The inescapable disputes about restraint
apply to all ages and the special factors pertaining to children* will therefore
have to be addressed in the context of the overriding issues. t Because in the
absense of universal agreement any discourse on the subject is largely a person-
al statement of the individual author's views and experiences, some of the
ground gone over elsewhere in this book will be repeated in this chapter.
*Although the field of child psychiatry is in the process of changing its name to child and
adolescent psychiatry, for simplicity I will hereafter use "children" to include adolescents
and, unless otherwise specified, I am primarily writing about children below the legal age of
decision to give or withhold permission for psychiatric hospitalization and related medical
procedures.
tA 1987 survey of laws and regulations governing seclusion and restraint in the United States'
revealed that in 28 (84%) of the 34 states responding the same regulations applied to chil·
dren and adults. Only 6 (21 %) of those 28 states mentioned children in the restraint regula·
tions'. Six of the 34 states responding (17%) do have separate policies and procedures specific
for children,
DONALD S. GAIR • Gaebler Children's Center, Massachusetts Department of Mental

Health, Waltham, Massachusetts 02254; Department of Child Psychiatry and Child Develop-
ment, Boston University School of Medicine, Boston, Massachusetts 02118,
345
346 DONALD S. GAIR
INTRODUCTION
Individual freedom and its protection is the ethical bedrock of the Western
democracies. Justifications for any interference with freedom has therefore
engendered repeated passionate and painstaking debate in legislative,judicial,
and philosophic forums over the right to be free versus the right to be rescued
from possible self-harm and also versus the competing rights of others. These
concerns are as old as civilization. *
Interferences with physical freedom are the most concretely obvious of
restrictions. Arrest and jailing; involuntary hospitalization; narrow confine-
ment or direct physical restraint (by holding or mechanical devices); and forci-
ble injection of medication against a person's will are all blatant and immediate
interruptions of individuals' freedom. Although the laws and regulations that
govern commitment are separate from those applying to restraint, it should be
clear that the issues in both are the same. All societies** show concern that such
acts be justified within rules and practices that become institutionalized until
periodic reviews revive the fundamental questions and may lead to widespread
efforts to reform.
We are in a period of reform today, an era of vigorous litigation, judicial
review, and regulatory legislation involving psychiatric hospitalization and the
use of restraints. This originated in the powerful civil rights movement of the
past three to four decades. In the beginning of this era of reform the atmo-
sphere was starkly ad versa rial and litigation prompted by conditions or prac-
tices that were undoubtedly in need of reform called into question some of the
fundamental tenets of psychiatric hospitalization. Involuntary mental hospi-
talization was regarded as the virtual equivalent of jailing without due process.
Although there has been a liberalization of attitudes towards restraint in
some states, many still base their regulations on fear of its abuse and tolerate
restraint of patients in mental hospitals only in cases of extreme danger and
proscribe the use of restraint for punishment, treatment, or prevention. These
limitations are not as straightforward as they may seem. Furthermore, relevant
laws and regulations have been changing and ambiguities and inconsistencies
make scrupulous adherence problematic.
In 1982 the Supreme Court decision in Youngberg v Romeo tilted the scales
toward the hospitals and medical staff by recognizing a clear distinction be-
tween restrictive decisions made as part of hospital care from those made in
other arenas.*** However, this reassuring ruling in support of professional
*Plato wrote about depriving madmen of their freedom, as well as of diminished responsibil-
ity for crimes. 2
**Oppressive societies do not differ markedly from democratic societies in their statutory
justification for abrogations of physical freedom, they differ primarily in their limitations
on protest, both its form and its content. Within mental hospitals ethical concern for proper
indications for restraint with reference to dangerousness is entirely analogous to our own. 3
***Wexler4 has extracted one of the central aspects in which Youngberg v Romeo supports
medical judgment, explaining that the decision "makes plain that if a lawsuit alleging
RESTRAINT OF CHILDREN AND ADOLESCENTS 347
judgment and pragmatic management does not preclude development of re-

strictive state laws and regulations that may directly bar what has been reason-
able psychiatric practice.
Youngberg would not bar, for instance, a law forbidding the use of any and
all forms of restraint of mental patients. Such a law would make it impossible
for some seriously psychiatrically ill people to be managed and treated in
mental hospitals both safely and legally. Fortunately, no law that extreme has
been passed. However, in 1979 a Massachusetts State Senator publicly declared
that he would pass legislation "to end seclusion and restraints for emotionally
disturbed and retarded children."5
Also in the 1970s, an attorney in Philadelphia, prominent in this area of
civil rights dispute, expressed the view that children are entirely equivalent to
adults in their right to self-determination. He wrote of his dream that all
children should be represented by attorneys to protect them from the arbitrary
decisions of their parents and teachers regarding such decisions as the child's
medical and dental care, placement in classrooms, even living arrangements
other than those wished by the children. 6 Not surprisingly, he also takes a
strong adversarial position challenging the justification for hospitalization and
restraint of children. 7
Such intense beliefs, so antithetical to necessary license to practice in hospi-
tals dealing with children with dangerous limitations in their self-control, are
still actively held. Currently there is an atmosphere of concern about litigation.
Documentation of psychiatric decision is increasingly geared to possible later
law suits more than to recording acts of medical judgment. Judgment and
clinical decision about the use of restraint involves many subtle factors, includ-
ing speculation about the state of mind of the patient. Not every component
part of such decisions can be readily translated into check-list form. The clinical
bias of Youngberg recognizes the fact that to subject every clinical decision to
adversarial debate would paralyze hospital management. However, as evi-
denced by a Massachusetts laws banning seclusion of children the perspective
of Youngberg does not yet prevail everywhere.
The intent of this chapter is to clarify the important issues involved in
order to facilitate compliance with laws and regulations, and also to help in
handling adversarial problems. Clarity about the problems involved helps to
defend one's position when necessary. It can also lead to modification of dispa-
rate beliefs and may even transform adversaries into allies.
constitutional deprivation is filed following the seclusion or restraint of a patient: The
decision, if made by a professional, is presumptively valid [andlliability may be imposed
only when the decision by the professional is such a substantial departure from accepted
professional judgment, practice or standard as to demonstrate that the person responsible
actually did not base the decision on such a judgment" (p. 2462 of the decision).
"Further, The Court defined 'professional' broadly and pragmatically, encompassing 'a
person competent, whether by education, training, or experience to make the particular
decision at issue ... necessarily ... in many instances by employees without formal train-
ing but who are subject to the supervision of qualified persons'" (p. 2462, note, of the
decision).
348 DONALD S. GAIR
THE NATURAL ABHORRENCE OF RESTRAINT
Discussion of restraints characteristically arouses strong emotions because

of a natural abhorrence of restraints. Although few disagree that dangerous
behavior must be stopped, humanistic recoil at the idea of restraint is universal.
It is an affront to the principles of freedom. When the psychiatric patients to be
restrained are children the repugnance is more intense because of the associa-
tion of childhood with helplessness and vulnerability. However, although chil-
dren who are hospitalized are vulnerable and do feel inner helplessness, their
symptomatic behavior may nonetheless be extremely dangerous.
A 10-year-old who is violently out of control may require as many as six
experienced adults to safely contain him or her. Many 14- and IS-year-old
patients are as big as or bigger than the mental health workers charged with
their immediate care and safety. Yet these facts do not eradicate the automatic
sentiment about the helplessness of the generic child, even among nursing staff
in high security hospitals where violence or serious risk of violence to self and
others by children and adolescents is a daily reality, and restraints must often
be applied.
An additional factor contributing to the emotional tension involved with
the subject of restraint is that violence begets violence. It is virtually a reflex
impulse to want to retaliate if hit, scratched, bit, kicked in the shins or spit at,
even by a child. Just hearing about unprovoked dangerous attacks on others
may elicit a vengeful feeling, such as, "they ought to lock them up and throw
away the key."
It is essential to the provision of humane care that such retaliatory tenden-
cies be neutralized in workers in mental health and related systems of care of
dependent persons. Well-run mental hospitals provide ongoing training and
supervision to address this continuous strain, for without such effort care
would be contaminated by retaliatory reactions and ultimately lead to the bru-
tality and dehumanization that existed before the historic reforms of the 18th
and 19th centuries. Even the most effective of such programs, however, are
unlikely to eliminate all of the mixed feelings generated by exposure to repeat-
ed crises involving violence and need for restraint.
To the degree that these internal conflicts are unrecognized, they contrib-
ute to difficulty in implementing and monitoring the proper use of restraint in
psychiatric hospitals and to a dispassionate consideration of the issues.
AMBIVALENCE ABOUT RESTRAINT
Ambivalence about the use of restraints with children and adolescents is, in
my experience, inevitable among the staff in psychiatric hospitals where fre-
quent restraint is justified, although the inner conflict is usually not recognized
by clinical staff. One of the ways that hospital staff deal with their mixed
feelings is simple projection of their negative feelings onto other settings, even
onto fellow staff members on other shifts or other wards. Furthermore, re-
pudiation of methods other than one's own is the rule. Workers accept rela-
tively comfortably the methods of restraint that they are accustomed to use but
tend to regard other methods as abusive. Staff used to one method will indict
other methods using language similar to determined critics of all methods of
restraint.
My recognition of this phenomenon crystallized at a workshop on the uses
of seclusion and restraint held some years agog where remarkably uniform
agreement among participants about the generic indications for restraint was
obscured by vehement denunciations of each others's individual methods. 1O
The use of seclusion was excoriated by one panelist who used four-point leath-
er restraints for his patients, whereas another decried the use of either while
promoting the alternate practice of physically immobilizing patients by having
staff hold them down. Each saw the others' methods as insensitive to the pa-
tients' needs and inhumane, whether excessively isolating, cruelly restrictive, or
overstimulating. Ultimately, the participants recognized that collectively their
statements amounted to an indictment of all forms of restraint, which was not
their belief. It seems self-evident that exaggerated endorsement of one's own
methods and denigration of all other masks an inescapable inner discomfort-
ambivalence-about the idea of restraint.
Lion drew attention to this problem in the management of aggressive adult
inpatients: "The topic of restraint and seclusion often evokes controversy and
provokes defensiveness among clinicians ... Repugnance surrounds the use of
physical restraint devices, and many practitioners prefer not to know of their
existence." 11
Gutheil, Applebaum, and Wexler 12 compared four authoritative sources'
opinions on relative restrictiveness of restraint procedures and found a ran-
dom distribution-strong evidence of an arbitrariness of conviction based on
psychological bias. This tends to support the idea of intrinsic abhorrence of
restraint. The opinions of a legal scholar, a psychiatric expert, and regulations
from two state departments of mental health were compared. Two classed
seclusion as the most restrictive form of restraint, and forced emergency medi-
cation was seen as most restrictive by the other two. Mechanical restraints
occupied second or third place for all. Seclusion and forced emergency medica-
tion were each identified as being the least restrictive by one of the expert
sources. Thus, among these four authoritative sources seclusion and chemical
restraint were ranked both as most restrictive and least restrictive.
Recoil from the idea of restraint is also revealed in the distortion of Pinel's
views that has developed over the years. Pinel set forth his beliefs and accounts
of his experiences very clearly in books that were widely available for some time
after the dramatic reforms he initiated in Paris 13 . He did not abolish restraint,
nor was he opposed to it. Pinel is correctly famed for having released patients
who had been cruelly chained indefinitely at the Bicetre hospital. But the
widely disseminated implication drawn from the legend that he abolished re-
straint is grievously misleading. He is said to have, "expounded the thesis that
humane understanding ... led to better results than brutal confinement."14
Pinel was certainly opposed to brutality, but, equally certainly, he was not at all
350 DONALD S. GAIR
opposed to confinement. He carefully explained his beliefs about the useful-

ness of restraints, including chains, and documented his practices, based on
these beliefs, in detail and with enthusiasm. In fact, one section of his book is
entitled, "The estimable effects of coercion." He was, however, vehement and
explicit in distinguishing the proper use of restraint based on psychiatric indi-
cations from indiscriminate use without systematic justification.
Similary, half a century later, in England, a strong nonrestraint movement
resulted in a Parliamentary Lunacy Commission, which is credited with having
abolished restraints. 15 Closer reading, however, reveals that restraints were
replaced by padded cells, which were called seclusion rooms. Again, as with
Pinel, what was abolished was indiscriminate chaining, torture, neglect, and
ridicule of mental hospital inmates and what replaced the old ways were treat-
ment methods and interventions based on psychiatric understanding. The new
methods, however, included restraining patients who needed it.
The English reformers used the word restraint to refer to abusive treat-
ment that had been meted out before the reforms. They coined the term
seclusion room to distinguish it from the word restraint, which had become
tainted by abusive practices. They endowed the new term with all of the ra-
tionality and humanity of their intent. It is a misreading of that history to use it
in support of modern opposition to seclusion.
It should not be surprising, in view of the persistent ambivalence about
restraint among those who know its value and necessity, that citizens interested
in the welfare of children and adults in psychiatric hospitals but who are
uninvolved in the day-to-day clinical details are likely to recoil with antipathy
from the idea of restraints with little opposing feeling coming from awareness
of the reality of the need. This can lead to a remarkable denial of the existence
of dangerous behavior in children coupled with a tendency to blame such
behavior on the hospital management of such children.
The very practical result of the prevalence of strong antipathy and unre-
cognized ambivalence about restraint is that the necessary and proper concern
about the ever-present risk of abuse of restraints tends to become an indict-
ment of all restraint-use becomes the equivalent of abuse. A striking example
of this is the official title of the Massachusetts bill that ultimately changed the
law governing seclusion in 1984: "An Act Prohibiting Abuse of Mentally III
Patients."
Under circumstances of vigorous opposition to restraint, those seeing its
vital need in psychiatric hospitals are forced into an adversarial position that
tends to distract their attention from proper monitoring of its use. Contribut-
ing to the problem is their own ambivalence, which leads to projection of their
concerns onto methods other than their own and onto those who mount unrea-
sonable attacks on restraint in general.
Such concern is not unfounded. As already mentioned, in 1984 a bill
banning seclusion (but not mechanical restraints) for all children under 18 in
licensed psychiatric hospitals went into effect in Massachusetts. 8 This proscrip-
tion caused great difficulties in those facilities with children who frequently
need restraint and where seclusion had been the primary means. Many of the
children who now had to be held or mechanically restrained instead of being
placed in a seclusion room vehemently protested the change.
Professional groups argued intensely for rescinding of the change. In time
the protest was effective and resulted in new legislation that would once again
permit seclusion for children under 18 after assuring that proper procedures
and monitoring are in place. The renewed legalization of seclusion is expected
to be implemented about 4 years following the introduction of the ban, though
it is still not in place at the time of this writing (October 1987).
THE NEED FOR LOCKED PSYCHIATRIC HOSPITALS FOR

CHILDREN
A leader in British child psychiatry responded to a recent inquiry about

regulations governing restraint of children and adolescents in Great Britain by
saying that restraint was virtually absent from child psychiatric hospitals in
England, not because of restrictive regulations but as "a matter of philo so-
phy."16 Further questioning revealed that there are residential facilities in
Great Britain that use restraints with disturbed children but that they are "not
psychiatric facilities." They are "high security units run by psychologists." This
is probably another example of repudiation of the idea that restraint may be
necessary, supported by a built-in selectivity of intake. Because diagnostic en-
tities cover a wide spectrum of degrees of manifest behavioral difficulties, open
institutions using little or no restraint can correctly claim that they can manage
children with serious diagnoses without restraint. That there are children who
cannot be managed in such facilities is regularly demonstrated by the pressure
for admissions to high security or locked hospitals, whereever they exist, often
on referral from the less secure psychiatric hospitals.
The essence of the problem is a tautology. Children who need secure
settings and restraints need secure setting and restraints, however abhorrent
this fact is to some. Most child patients do not need psychiatric hospitalization
and not all of those who are hospitalized require locked settings or restraints.
The children who do require secure settings and restraints do not differ in
their psychiatric diagnoses and their psychological conflicts from children who
can be managed in less secure settings. They do differ in their inner controls
and, therefore, in the severity of the management problems they present in the
areas of harm to themselves; physical danger to others; destructiveness to
property (firesetting, vandalism); chaotic, disruptive behavior (smearing, de-
nudativeness); determination to run away; and inability to cope safely.
Psychiatric facilities can be divided into two types. On the one hand are
those that either will not accept children presenting some or all of the above
risks beyond a certain level of difficulty or will quickly discharge them if the
behavior becomes too much for them to handle. On the other hand are the
facilities that will neither exclude patients because of these risks nor discharge
352 DONALD S. GAIR
them because they become maximally manifest. The latter are the secure psy-
chiatric hospitals with locked doors and the capacity properly to restrain as
needed. 17
SPECIAL ASPECTS OF CHILDHOOD RELEVANT TO RESTRAINT
Children's Need For External Control

Childhood is definable by its need for adult support. As soon as a baby can
crawl it needs constant observation or safe enclosure, as in a crib or playpen or
high chair. As the child grows more agile and can walk, reach, and run, paren-
tal overseeing becomes more arduous, reaching a peak during the child's 3rd
year, the time of the "terrible two's" known to all. This year is the crucible in
which is developed the inner framework of self-control and incorporation of
parental rules on which subsequent adoption of cultural mores will be built.
This critical development is not automatic. It requires an adequate degree of
consistent imposition of parental will to result in the child's recognition that
reality is not simply an extension of its own wishes I8 .
This emphasis on the limit-setting aspect of childrearing is not meant to
imply that there are no other important bases for personality development and
internalization of values and mores. It is, however, the view of the author that
without the internalization of the concept of controls derived from realistic
external limits, personality development is compromised. There is no single
blueprint to accomplish this. Some children have intrinsic assets or deficits that
contribute greatly to the ease or distress involved. Also, parent-child rela-
tionships vary enormously in the difficulties they have in this aspect of child
growth. The process, however, is a central developmental requirement.
It should be recognized that the process of internalization begins much
earlier than the 3rd year and continues throughout childhood, with increasing
numbers of adults becoming involved, but the major step is taken at that time,
and, as the process continues successfully, children require decreasing amounts
of external supervision. When too little is accomplished in the 3rd year, more
external controls become necessary, and the child is more likely to become
behaviorally disturbed.
When a child's behavior becomes disturbed the progressive increase in
supervision begins with additional parental efforts and progresses through
assistance from relatives; religious counselors; school teachers; guidance coun-
selors; child psychiatrists, psychologists, social workers, nurse practitioners;
special schools; day hospitals; open psychiatric wards and ultimately locked
psychiatric hospitals. A branch of this spectrum goes through police, juvenile
courts and court clinics, and detention centers.
The great majority of behavioral disturbances are reversed short of hospi-
talization. Those whose problems cannot be adequately managed with less
restrictive interventions become the children who require hospitalization.
These children and adolescents have the greatest functional deficits in their
internalized controls. This applies to self-destructive and to assaultive behavior,

which frequently coexist in children who require locked hospitalization. The
severity of the problems manifested by the children ultimately referred to
psychiatric hospitals often reflects long delays in accepting the idea of hospi-
talization. There is a strong tendency by many families and professionals to
avoid psychiatric hospitalization even when all less restrictive approaches have
proven fruitless.
Once the child is in a psychiatric hospital, his or her needs for additional
external control and limits do not necessarily end. But commitment of a child
to a psychiatric hospital differs significantly from commitment of an adult, as
will be discussed in the following section.
ALL CHILDREN ARE COMMITTABLE
Children's generic need for adult help to survive and develop leads to one
of the major descriptive parameters of any society: the set of rules, customs,
and laws governing child rearing and emancipation from childhood status. De-
pendency on specific caretaking adults is the defining characteristic of children
everywhere, although societies differ in the ages of various steps of emancipa-
tion from levels of supervision and in the degrees of freedom allowed at differ-
ent ages.
Adults committed to mental hospitals, even those who voluntarily commit
themselves, surrender their autonomy to the superintendent or director and
clinical staff of the hospital. When adults become psychiatric inpatients they
have custody imposed on them de novo. In striking contrast, when children
and minor adolescents are committed to mental hospitals they have their cus-
tody shifted from one set of adults to another. Their status does not change
with regards to autonomy. They are dependent minors under obligatory su-
pervision by parents or other adults both before and after admission to the
hospital.
Because of their intrinsic limitations, in the ordinary course of events
children in our society have extensive limits placed on their personal freedom,
with legally mandated monitoring of those limits by responsible adults. The
normative restrictions in place for the average preadolescent child living at
home and going to school with average middle-class expectations and monitor-
ing would be the equivalent of close probationary status of an adult on parole.
Although more and more independence accrues to children as they progress
through adolescence, some degree of surveillance persists and the last years of
adolescence are marked by classic disagreements between the child and super-
vising adults about the need for the adult supervision that remains. As regards
hospitalization and procedures undertaken during hospitalization, however,
for those too young to sign themselves in or out (under 16, in most states),
there is no legal ambiguity about the child's lack of autonomy.
The importance of this aspect of childhood and its difference from
adulthood, with specific reference to its relevance to psychiatric hospitalization
354 DONALD S. GAIR
and restrant cannot be overstated. This is of particular importance when con-

sidering the issue of loss of freedom, which is a central phenomenon in psychi-
atric hospitalization of adults.
There are three bases for commitment to a mental hospital: danger to
others, danger to self, and inability to manage oneself safely, secondary to
mental illness or defect. All children are intrinsically committable on the basis
of inability to cope safely, even though the factor of manifest mental illness is
not a characteristic of children. However, all children share a lack of adult
judgment, which is a functional mental defect.
When the need for additional limitations in freedom persists after children
have been hospitalized the children are restricted in their activities within the
hospital and ultimately they may require restraint. Again, the more severe the
problems have been allowed to become by delays in hospitalization, the less
likely that hospitalization alone will provide a sufficient prosthesis to make up
for the child's dangerous lack of control.
DUE PROCESS VERSUS MEDICAL JUDGMENT: LEGITIMIZATION

OF COMMITMENT AND RESTRAINT
Over the years there have been two divergent approaches to the general
problem of justified deprivation ofliberty, one dealing with criminal behavior
and one dealing with mental illness. They share a pattern of periodic swings
from emphasizing individual rights to emphasizing competing concerns. In the
case of criminal justice, the pendulum swings between the rights of the accused
and the rights of their victims. However, the basic commitment to the right of
the accused and to a fair trial taking precedence has grown enormously. There
is prevailing sentiment that prefers that a guilty person go free rather than an
innocent be imprisoned.
In the case of mental illness, the swing is between an individual's right to be
left alone to choose his or her own fate on the one hand and, on the other, the
obligation of the state to intervene on behalf of individuals incompetent to care
for themselves. The two arenas of concern and approaches to civil rights,
though analogous, are quite different but they do become confused at times,
particularly in controversies over restraint.
Emergency involuntary admission to mental hospitals shares with the use
of restraints the criteria of imminent danger and the abrogation of due pro-
cess. In Massachusetts and states with similar emergency commitment laws,
there is clear recognition of illness and danger taking precedence over civil
rights. The extent of the latitude given to psychiatrists, psychologist, or police
officers in Massachusetts who use the emergency involuntary so-called lO-day
paper, is summarized by a prominent mental health attorney:
Emergency psychiatric hospitalization by means of a 'ten-day' or 'pink' paper is a

powerful instrument which may be employed to compel involuntary hospitaliza-
tion at the expense of civil liberties. Physicians, psychologists, and police may
exercise a significant authority to intervene in the lives of individuals whom they
believe to be at risk of harm due to mental illness .... a 'ten-day' paper may
result in a person being picked up off the street or removed from home without
notice, restrained, taken to a psychiatric hospital, forced to undergo examina-
tion, forcibly medicated, and ultimately compelled to remain as an inpatient for
up to ten days."19
Beyond this IO-day period covered by the emergency commitment law in

Massachusetts, further hospitalization is subject to full judicial review with the
judge presiding over a trial of the merits of the psychiatric allegation of risk of
harm from mental illness if the person is not hospitalized. Even if a commit-
ment decision by ajudge is not challenged by the patient or guardians (who can
do so at any time), the commitment is valid for no longer than 6 months and
can only be extended following a review in the same court setting and with the
same safeguards as in the original hearing.
There can be no restraint in a psychiatric hospital without prior legal
commitment to the institution. That commitment is an official recognition of
an extraordinary need for external limits for each hospitalized child or adoles-
cent. However, restraint is often regarded much more critically than the com-
mitment to the hospital, which is its indispensable legitimizing basis. This is
particularly so in those states where prejudice against restraints has not yet
been tempered by the perspective of Youngberg.
Restraint procedures are initiated when a patient's self-control fails, lead-
ing to injury or threat of injury to self or others. Whether it results from
inability to function or deliberate choice, dangerous or threatening behavior
calls for intervention. This intervention represents provision of external con-
trols that are lacking from within the individual. When restraint of a hospi-
talized child patient is found necessary it is an extension of the relatively formal
system of external controls that all societies provide in recognition of the dan-
gers implicit in children's intrinsic limitations in judgment and self-control.
The official act of deprivation of a patient's freedom (beyond an emergen-
cy IO-day period) by judicial commitment to involuntary hospitalization gener-
ally occurs at most every 6 months (in a prolonged hospitalization). In contrast,
once in the hospital, acts of further restriction of freedom-restraints-may be
necessary as often as several times in one day. To subject each of these acts to
judicial review would be patently impossible. And yet the critics of restraints in
locked psychiatric hospitals seem, at times, to regard some such reviews as
necessary to safeguard the rights of patients. There is a confusion between
viewing restraint as resembling a sentence imposed after the trial of a criminal
rather than as a pragmatic response to disturbed and dangerous behavior. This
confusion is as prevalent when the patients are children as when they are
adults.
JUSTIFICATIONS FOR RESTRAINT AND PROBLEMS IN ITS

VALIDATION
The basic justification for imposing restraints on freedom is protection: of

the person restrained, or others, or of both. The need for restraints of people
who will harm themselves or others if they are not restrained is self-evident.
356 DONALD S. GAIR
The clinician's mandate and desire in the mental hospital is to prevent any
individual from harming himself or others and to have safety prevail so that
the therapeutic aims of the hospital may proceed unimpeded by violence or
extreme disorganization of behavior.
An authoritative elaboration of this view is the list of indications for seclu-
sion and restraint drawn up as part of the American Psychiatric Association
Task Force on Seclusion and Restraint. 2o
In that work, Gutheil and Tardiff listed the following five clinical indica-
tions for restraint of all patients. All of these arise with hospitalized children:
(a) to prevent imminent harm to the patient or other persons when other
means of control are not effective or appropriate; (b) to prevent serious disrup-
tion of the treatment program or significant damage to the physical environ-
ment; (c) to assist in treatment as part of ongoing behavior therapy; and,
(pertaining solely to seclusion); (d) to decrease the stimulation a patient re-
ceives; (e) to comply with a patient's request. In Massachusetts and some other
states, however, the only basis for restraint is the first, namely the presence of
violent behavior to self or others or its imminent threat.
The GutheillTardiff list will be reviewed below with comments on the
relevant problems involved.
Prevention of Harm to Others. It would seem that the one prima facie
basis for imposition of restraint on a patient would be the patient violently
attacking someone, either another patient or a staff member.
However, if the patient has stopped the attack, says that he or she is sorry
and will not do it again, and appears clam, there is no justification for restraint
on the basis of a present emergency. This is so even if he or she has hurt the
other patient badly unless there is reason to believe on the basis of past experi-
ence that, despite the outward calm, further violence is predictable if the pa-
tient is not restrained. This situation is described to point out that the most
overt manifestation of violence is not as clear-cut an indication for restraint
within the constraint of an emergency situation as it might seem at first. Justifi-
cation for restraint on the basis of emergency must always depend on the
likelihood of further violence, which is to say future violence.
A similar situation arises when a patient ceases struggling and cooperates
in the process of restraint, such as agreeing to walk into a seclusion room
without having to be physically held or carried in. This is not an infrequent
occurrence and the opinion was raised in the Boston State Case that such
persons are not in an emergency situation and that therefore, their restraint
cannot be justified. 21
Cooperation in the process of restraint does not mean that the patient is
fully in control. The clinical reality is that few patients, regardless of the se-
riousness of their mental illness and the fact that they have become violent, are
ever totally out of control. Furthermore, for few patients is the loss of control
felt as a totally desirable state. External control, however much it is fought
against, is also welcome. That there is a reassurance implicit in the reliability of
external controls is indicated when patients ask worriedly if they can be man-
aged when they are aware that there is a shortage of staff on a certain shift. It
has been reported that when structural damage to seclusion room doors at a
children's mental hospital made it easy for children to break out of seclusion
the incidence of episodes calling for restraint escalated dramatically. When the
doors were repaired, the incidence fell precipitously.17
Just as there are few children (or adults) who are totally out of control, the
progression into the range of acceptable self-control is rarely sudden, but
rather proceeds gradually. It is not an all-or-none phenomenon. Even if the
frequency of episodes requiring restraint remains the same for a given child,
the number of staff required to effect the restraint and the intensity of the
struggle may lessen.
If subtle indications of incipient loss of conlrol are ignored, however,
children's violence will emerge and increase. It it, therefore, of great impor-
tance that the behavioral sequences that lead up to children's loss of control be
learned and documented as carefully as possible. Those in the best position to
know are the staff who are with the children the most, the nurses and mental
health workers. Subtle precursors become reliable indicators for restraint when
it is known to a reasonable certainty that they will be followed by violence if the
child is not restrained.
Prevention of Harm to Self The justification for restraint to prevent
harm to the child is far less problematic than the issues involved in danger to
others. When children demonstrate suicidal or other self-abusive behavior the
first step is close monitoring without restraint. When they persist in overt self-
destructive behavior despite one-to-one attention and whatever indicated
therapeutic regimes are being provided, then their protection must be direct,
by adequate restraint.
The Prevention of Disruption of Program or Damage to Environ-
ment. Disrupting a program or damaging the environment are not in them-
selves permissible reasons for restraint in many states. However, the expecta-
tion that children will not be disruptive or destructive is one of the
requirements placed on patients. As staff properly persist in efforts to have a
child comply with minimal social expectations, the child may become voilent.
Under those circumstances the child would need to be restrained. Treatment
plans properly limit the number of such confrontations with potentially ex-
plosive children by limiting the child's activities and by expectations placed on
behavior, but if carried too far this leads to avoiding central clinical problems in
the child.
With children who have demonstrated that disruptive and destructive
behavior regularly precedes episodes of violence to self or others then such
behavior in itself may become a sufficient predictor of imminent danger to
justify restraint.
Assistance in Treatment as Part of Ongoing Behavior Therapy. In well-
run psychiatric wards, where the use of restraints is consistently applied when
children's behavior becomes dangerous, it is the rule that as the patient im-
proves, the rate of restraint diminishes and vanishes. It is also recognized by
clinicians on such wards that the regular imposition of predictable restraints
following episodes of undesirable loss of control has an observable effect on the
358 DONALD S. GAIR
patient's increasing self-control,26 often with the patient asking for periods in a
seclusion room rather than having to go out of control (see following). All of
this clearly suggests that there is a therapeutic effect of restraint procedures
when properly applied even in the absence of formally designated behavioral
programs. In many states, however, the law generally prohibits the use of
restraint as a treatment procedure. There are exceptions. In Georgia, Illinois,
Washington DC, Kentucky, and Nebraska l by statute, and in Massachusetts by
judicial review on a case-by-case basis, seclusion and restraint may be used as
part of a specific treatment program, as by a formal behavior modification
program.
The largest body of literature on the rationale for the use and prodecures
for effective application of physical restructions on disturbed and dangerous
mentally ill patients is that of the field of behavior analysis and therapy. How-
ever, there is a curious barrier to inclusion of their literature in general psychi-
atric discussions of the problem of handling violent patients in mental hospi-
tals. This is based on behaviorists' excessively differentiating their work from
that of others, as demonstrated in the following quote from a noted
behaviorist22 :
On theoretical and empirical grounds, behavioral analogues to seclusion

and restraint should be considered as distinct from their traditional counter-
parts.
Traditional and behavioral applications of restrictive interventions (e.g.,
seclusion and restraint) converge with respect to the behaviors that they deal
with, but diverge on the goals and implementation of treatments. Both ap-
proaches use seclusionary and restraint-like techniques to control highly ag-
gressive, destructive, self-injurious, and disruptive actions by patients. In a tradi-
tional framework, however, these procedures are emergency reactions with only
an immediate objective-to manage the present outburst and prevent injury or
property destruction. Behavioral applications, in contrast, are planned treat-
ment programs whose details are formulated beforehand and whose objective is
long-term change in the patient's pattern of responding. Because behavioral
applications are treatment-oriented, parameters of restrictive procedures are
adjusted to maximize their impact, and programs incorporating these pro-
cedures are monitored to evaluate their therapeutic efficacy.
One can understand the care the author of the previous quote takes to
dissociate himself and his field from bad psychiatric practice. But there is an
echo of the 19th-century British commission "abolishing restraints" while in-
stituting "seclusion rooms," and the misunderstanding of Pinel's abhorrence of
abuse of restrictive practices while he applauded the effectiveness of their
proper use. No proper psychiatric hospital is unmindful of the connection
between the symptomatic behavior requiring restraints and the reason for the
patient being in the hospital-the patient's need for treatment.
It is my belief that the current proprietary isolation of behavior therapy
will lessen as general psychiatric hospital practices become more rigorous and
consistent. Behavior therapists can be justifiably recognized as demonstrating
the need for and providing excellent models of consistency in procedure and
monitoring of goal achievements.
To Decrease Stimulation (Applies Only to Seclusion). This indication for
seclusion listed by Gutheil and Tardiff is, strictly speaking, an explanation of
one of the experiential effects of seclusion rather than an indication per se. A
corresponding indication would be behavior that stems from overexcitement,
which would be lessened by reducing sensory input. The discussion thus far,
however, would not justify seclusion under Massachusetts law and similar ones
in many states. The target behavior must pass the test of an emergency for
seclusion to be justified.
The stimulus-reduction aspect of seclusion may, however, account for the
effectiveness of seclusion in interrupting self destructive behavior in many
children and adults.
Seclusion Indicated in Response to Patient's Request. As mentioned
earlier, many children who have required repeated seclusion over a period of
time show increments in their development of self-control first by resisting
staff less and less and then by requesting seclusion on their own in order to
avoid getting out of control. In states where restraint requires manifest or
predictable violence, a child's request in itself is not justification for seclusion.
But if experience has shown that a child who is not secluded on his own request
will shortly become manifestly out of control and dangerous then the request
can be a concrete predictor of imminent danger and constitute a justifiable
indication for seclusion.
In states recognizing the therapeutic potential of restraint, a child's re-
quest for seclusion would not require the prediction of imminent violence to
allow compliance. There would be implicit recognition of the evidence that the
request represents a desired internalization of the controls previously provided
by the staff. An intermediate step in this process of internalization is the prac-
tice of sending a child to a room on his or her own to quiet down, equivalent to
the common practice in many families of sending a child to his or her bedroom
as a disciplinary or control practice. The child whose behavior can be brought
under control in this way is clearly much further along the road to developing
adequate inner controls than the child who must be forcibly taken to a room or
put in restraints.
Cooperating in the "go to your room" procedure requires that children
accept a degree of responsibility for themselves. Their role requires exercising
inner reflection on the alternatives to siding with adult rules and directives and
then making a conscious choice about whether or not to continue their prob-
lematic behavior and defy the order to go to their room.
A measure of the difference in views between the critics of seclusion and
restraint in Massachusetts and the clinicians who recognize its usefulness is the
redefinition of seclusion that took place in the year prior to the passage of the
law banning all seclusion for those 18 and under (in DMH facilities).
This new definition abandoned the old one that required a locked door
and substituted the combination of isolation and confinement. Confinement
360 DONALD S. GAIR
was now legally defined as having egress from a space blocked or even deterred
solely by the kind of admonishments parents give to children when sending
them to their rooms or that teachers give to pupils sent to sit in the hall outside
a classroom. Under the new definition the practice of having children sent to
stay inside an unlocked room for specified periods of time became legally
identical to being locked in the room and was therefore subject to the con-
straints applying to seclusion. This rewriting of the definition of seclusion
obliterated an important distinction between self-control and external re-
straint. In practice the issue has become moot because the element of isolation
required for the new legal definition of seclusion is eliminated by placing a staff
member where he or she can be seen if the child so wishes.
Children sometimes test limits in ways that result in their having to be
restrained when they first arrive on a new ward. This is a less overt form of
requesting seclusion. When first admitted, children are frequently frightened.
They are unsure of themselves and of their ability to manage in the new
environment. Fear is not infrequently handled by aggressive displays that, in
children with limited controls, can escalate to the point where restraint is neces-
sary. For many children, one such episode is sufficiently reassuring to enable
them to keep their subsequent behavior within limits so that they do not re-
quire further restraint.
There is a related pattern that occurs when children are transferred to a
less restrictive setting after having been in a psychiatric hospital for a long time.
If the child has required restraints but in decreasing amounts until they have
no longer been necessary, he may regress in the new setting. The new staff may
question the validity of the decision to transfer and doubt if they can manage
the child. If the new institution does not give up prematurely and does provide
necessary limits, including restraint, the child often will quickly resume the
level of development previously manifest. This testing of the staff in the new
facility is not a conscious, deceitful ploy to return to the old place that is missed
(although that is a frequent feeling of children after discharge), it is rather the
emergence of fear and the worry that the new place is not as safe. This precipi-
tates the pattern of disruptive and dangerous behavior that calls forth the
protective capacity of the institution. The institution's adequate response will
rekindle the security built up at the previous hospital so the child can resume
his or her development at the level already achieved.
Chemical Restraint. Chemical restraint is the forcible use of major tran-
quilizers as a part of the process of restraining a patient. Unlike mechanical
restraint and seclusion, chemical restraint is obligatorily an a priori medical
decision. It will be mentioned in brief outline only. The problems it presents as
a form of restraint are subsumed under the other discussions because it is
almost invariably preceded by physical restraint, at least by physical holding
(which may be short of the duration that is arbitrarily defined as constituting
legal restraint). It can only be given on the order of a physician who must be
adequately knowledgeable about the circumstances. In most jurisdictions, the
existence of an emergency will justify chemical restraint in the absense of
specific permission but if there is any doubt, it is advisable to get authorization

from a judge. In Massachusetts and many other states there are judges on 24-
hour call for such emergency decisions.
Chemical restraint should only be prescribed on strong indications be-
cause there is always a risk from any major tranquilizer. Self-multilating behav-
iors, such as lacerating one's tongue or by cheek biting even when in full
mechanical restraints, are indications. Persistent violent physical struggling
against mechanical restraints with the risk of exhaustion is another. When a
continuing excitement fits a diagnosis of catatonic excitment or mania, medica-
tion, although it may be forcible (with judicial authorization) will no longer be
chemical restraint but will be a specific treatment.
TRAINING OF STAFF IN ATTITUDES AND TECHNIQUE
Because restraint requires direct close physical contact between staff and
child it is among the most intense kinds of interpersonal interactions. A re-
straining episode is anything but an indifferent exchange. It follows that the
nature of the relationship between staff and children that precedes any episode
of restraint is of paramount importance.
Friendly openness, honesty and directness, plus maintenance of a respon-
sible and protective stance characterize the desirable staff attitudes. First in-
teractions have a long-lasting effect on the children and the family members
who may be present. Clear admission procedures are of great importance.
There should be full orientation to the routines and expectations of the ward,
with expressions of understanding that there have been problems in the child's
life and that the staff is there to help. There should be an explanation of the
child's rights and also of the expectation that the child will be helped to follow
the ward and staff rules and the specific program for the child that will be
developed as the admission diagnostic process progresses into the definitive
treatment plan. .
Most children are frightened at times of admission. Many respond to this
fear by becoming challenging and presenting a dangerous situation calling for
setting oflimits and raising early the possibility that restraint will be needed. It
is important that opportunities not be missed that might help a child calm
down without losing control to the point where restraints become necessary.
Even the most experienced and skillful personnel using all of the indicated
approaches with a new admission will still find times that they must apply
restraints. The fact that many other attempts to help were made first is rarely
lost on a child. Even if it is extremely likely that restraint will quickly be
necessary, omission of any less extreme intervention may lead the child to
perceive the restraint as retaliatory and tend to set up an adversarial rela-
tionship between child and staff.
Self-confidence in the face of threatening or out-of-control behavior is
362 DONALD S. GAIR
vital if clinical staff are to function as their best. It takes training and one's best
attention to be able to identify signs of vulnerability in children that give clues
as to what is likely to be helpful and what is likely to make matters worse. For
instance, a frequent problem when staff members are frightened is that they
themselves assume a challenging attitude in posture and tone that, particularly
with some adolescents, invariably provokes increasing hostility. Staffs recogni-
tion of these tendencies in themselves and learning to avoid them can be
dramatically effective in reducing ward tension.
When lesser attempts to set necessary limits on a child's behavior fail and
restraint becomes the proper choice, the message to be conveyed to the child is
the real one, namely that the restraint is applied in the absence of sufficient
control of the child's own. The way to convey this is to emphasize the expecta-
tion that the child will ultimately develop enough self-control so that the epi-
sodes of inner turmoil will be handled in other ways and external controls will
not have to be provided.
"We're going to hold you [or restrain you; or seclude you; or give you this
medicine;] so that you will not hurt yourself [or anyone]. When you are ready
to be in control of yourself again we will let you get back to the ward routine," is
a necessary and sufficient explanation. Times of restraint are almost never the
proper times to get involved in lenghy psychological formulations about the
child's problems, except under unusual circumstances where the clinical team
has determined that it would be advisable to do so and then usually either by
certain staff, or by statements limited to themes carefully worked out in
advance.
Sometimes, even experienced staff members become confused about the
justifiability of insisting on certain expectations when placing a demand on a
particular child is likely to lead to violent behavior as, for instance, holding a
child to a ward rule when it is known that the child is resentful and short-
tempered and likely to have an outburst of rage that may neccessitate restraint.
Although wise management limits the number of confrontations with such a
child's areas of greatest difficulty, it is not possible to treat patients without
placing some demands on their adaptive capacity. Endless diversion to avoid
sensitive issues neglects the very problems that the child must learn to handle.
The confusion arises in some staff members' minds because it seems as though
it is fruitless to make the demand if one is almost certain that the child is going
to go out of control and require restraints.
One does not make the demand in order to have the child end up in
restraint. Children must be measured against minimally acceptable standards
of behavior and all discharge plans include such requirements. Staff must call
for some effort by each child to comply and then try to help the child respond
with increases in his or her capacity to control and alter their maladaptive
responses.
The kinds of factors discussed earlier need to become part of the indoctri-
nation and education of the clinical staff. Adequate training in restraint pro-
cedures is an essential part of the orientation and continuing inservice training
of all clinical staff. To be adequate, training in restraint procedures should be
part of a broad approach to the problem of patient violence and include specif-
ic methods of defusing incipient violent situations, such as by leading children
away from a potentially explosive situation, "negotiating, avoidance of power
struggles, slow-down periods, talking a child down, relaxation techniques, self-
soothing skills and alternate coping and stress-reducing strategies."23
Common underlying psychological issues must also be part of the staffs
curriculum, issues such as the prevalence of fear and despair in psychiatrically
hospitalized children, often masked by threats and violence; the difficulty in
accepting help and kindness without losing face, and the particular importance
of saving face once committed to a show of violence. Feelings of staff involved
in restraint have also to be discussed and understood, including the general
issues elaborated earlier concerning abhorrence at the idea of restraint and the
problem of retaliatory feelings when attacked. The theme of the need for
setting of limits, which is part of the nature of all childrearing, is particularly
important as a sequence preceding the ultimate limit of restraint. For it is the
failure of lesser limits to abort progressive danger, or the certainty from pre-
vious experience that such limits will fail, that not only legally justifies but
pragmatically demands that restraints be imposed.
The training in approaches to violence and restraint procedures should
include not only all nursing staff and teachers but also child psychiatrists,
psychologists, social workers, and occupational therapists. Including all clinical
staff, and senior clinical administration, guards againat the emergence of the
undermining effects of ambivalence about restraint talked about earlier, and
well argued by Lion. II Also one of the most important aspects of the training is
that the entire staff shares in a cohesive understanding and approach to the
problems presented by violence and the need to restrain. This solidarity sup-
ports morale and enhances self-confidence in the members of the staff that are
most frequently involved in restraints. Without the knowledge that senior
clinical and administrative staff understand what they are dealing with and will
support them during times of adversarial criticism and review, ward staff will
feel increasingly isolated and, however excellent their training and experience,
their clinical functioning will suffer. Another essential benefit of this sense of
trust is that it allows the senior clinical staff to be more effective when they are
called on to be constructively critical of specific events or patterns of use of
restraint (see the following). There are also times when they may have to
participate directly in a restraint.
There are an increasing number of good instructional programs available
throughout the country and although particular emphases vary, it appears that
the general thrusts are similar. Although few of the existing training programs
focus on the special needs of children, once the staff of a child psychiatric
hospital receives the training, modifications can be added as part of the on-
going inservice training. Lion l l has called for training programs to be spon-
sored nationally by the American Psychiatric Association and I strongly en-
dorse his recommendation, adding that child psychiatry organizations should
see to it that there are suitable training programs for staffs dealing with
children.
364 DONALD S. GAIR
STAFF ROLES IN INITIATION, MONITORING, AND REVIEW

OF RESTRAINT
Initiation
The official parental surrogate to whom the custody is shifted from par-
ents or other legal guardians when a child is admitted to a psychiatric hospital is
the administrative director or superintendent of the hospital. The medical
authority becomes clearly vested in a child psychiatrist who becomes the physi-
cian of record and all other licensed professionals have clearly delineated legal
responsibilities. Without diminishing any of the importance of these roles,
however, it must be recognized that the adults who, for the most part, take on
the most emotional significance for hospitalized children are the ones who are
with them day in and out where they live on the wards.
These are the people in whose immediate presence the children live for
the majority of their time. The children have, to be sure, hours away from the
ward, at school, in various treatment sessions, in activities, but the mental
health workers are there when the children wake up, when they go to sleep,
when they go to meals and during all the times in between scheduled parts of
the program that take them away from the ward.
Mental health workers are the adults who, by virtue of their prolonged and
close contact, develop the keenest sense of when something may be going
wrong with groups of children and these are the adults who must act first when
a crisis develops. Many of the laws and regulations specifically identify the
superintendent or a designated physician or, in their immediate absence, a
senior registered nurse, as the person authorized to initiate a restraint, but, in
fact, the great majority of restraints are truly initiated by mental health work-
ers, because they are on the spot at the time the problem arises.
Increasing numbers of states, including Massachusetts, are recognizing
that the primary responsibility for initiation of restraints rests most naturally
with the nursing staff that are present with the children most consistently. The
responsible physician or other licensed clinician in charge retains the clearly
mandated role of subsequent review and authorizations of extensions of
restraint.
Monitoring
The nature of most of the problems that necessitate restraint is such that it
is not possible to avoid any definitive action until an authorized staff member
arrives to initiate action. If the dangerous situation is to be interrupted, then
some restraining activity will already have been initiated by the time the senior
nurse or designated physician arrives, even if it is within 5 minutes. Laws and
regulations increasingly recognize this fact although they vary as to the dura-
tion of time that restraining actions may be taken before they officially con-
stitute a restraint or before a designated professional with the requisite authori-
ty can legitimize the continuation of actions already taken.
The meeting of the reviewing clinician and the staff that have already
acted is of central importance. Care must be given not to undermine children's
confidence in their immediate caretakers' authority. If these personnel do not
have the de facto authority to act then the children are going to develop the
idea that the adults who are in charge of them have serious limitations in their
ability to carry out their responsibilities. It follows that the senior clinical au-
thority, in examining the child and reviewing the circumstances reported must
act primarily as a supportive extension of the authority of the mental health
worker. This does not mean that the child's critical comments will not be heard
and registered nor that other possible evidence of poor procedure will be
ignored, but that the impression conveyed will be that staff responsibilities for
the children overlap and that staff back each other up. In circumstances where
an investigation is done in response to a child's complaint and a mental health
worker is subsequently disciplined or dismissed, this approach will not have
been harmful to the child because it can be truthfully explained that the staff
member's eventually exposed misdeed includes a betrayal of this expected
shared responsibility.
There are two functions to monitoring of children while in restraints, first
to insure the child's continuing safety, and second to determine when the child
is ready to be removed. If a child is in mechanical restraints, then the child
must have a single staff person assigned to him or her at all times. One reason
for this is that some children are inordinately adept at removing themselves
from restraints and can cause themselves great damage if unobserved even
briefly. If they are in partial restraints, such as having their hands restrained to
prevent self-mutilation by scratching, they must be protected from other pa-
tients. If they are in four-point restraints on a bed there is a risk of aspiration
and choking if help is not immediately available.
Patients in mechanical restraints must be attended constantly. When seclu-
sion is the form of restraint used, the minimum safe interval between visual
monitoring is generally regarded as 15 minutes, although clinical indications
(such as a history of self-harm) may indicate more frequent viewing, and first
episodes of seclusion when the child's behavior in seclusion is an unknown,
constant monitoring can be justified. *
To minimize the intrusiveness of a person staring at the child through the
window, TV monitors are an advantage, but not every facility can afford this.
Most states specify every 15 minutes as the frequency of observation but pre-
scribed frequencies vary from constant observation (Delaware), to every 5 min-
utes (Massachusetts), to every 2 hours (New Jersey).l
States also vary in the prescribed frequency of breaks for water, food,
*It is clinically well known that many self-harming children (as well as adults) will stop when
secluded even though the opportunity remains to gouge oneself, and to harm oneself by
hitting the walls or floors with one's head or fists. Some, however, will harm themselves in
this way and for these children seclusion is not suitable and physical restraint by holding or
mechanical means is necessary. When seclusion is first used for a self-destructive child
frequent checks are necessary to insure that the self-destructive behavior has in fact been
interrupted.
366 DONALD S. GAIR
toileting, and exercise. Clearly, the relevant laws in each jurisdiction must be
obeyed, but staff should be trained and encouraged to intervene more fre-
quently than that prescribed by law or regulation when there is sufficient
indication. Clinically, too much interaction with children in seclusion or re-
straint can be provocative, overexciting, and detract from the calming down
process. However, there are some children and adolescents who have signifi-
cant interchanges with staff during periods of restraint. One must be on the
alert for evidence that the restraint process becomes sought after in a perverse
way by the child if this becomes the most rewarding form of interaction he or
she experiences. Such factors are the focus of regular review of restraint expe-
riences by the clinical teams involved.
In many states, including Massachusetts, it is now mandatory that a staff
person be visible to any child in seclusion if the child comes to the window in
the door. This is a separate requirement from the monitoring process, which
requires that the staff person observe the child in the room at specified inter-
vals and be assured that the child is not harming him or herself and talk to the
child as part of the determination of readiness to be let out of the room.
Regular Clinical Review by the Therapeutic Team

An isolated episode of violence necessitating restraint of a patient only
once in a long stretch of time on a psychiatric ward will naturally be reviewed at
the next meeting of the therapeutic team chaired by the child psychiatrist (or
other clinician) in charge. To the degree that labile and reactive emotionality is
a continuing problem with that child there will be discussions of all relevant
parameters of the child's functioning and experiences. However, unless there
are repeated incidents requiring restraint, the issues of restraint per se will not
be a focus of concern. When, in contrast, a child has frequent episodes of loss
of control resulting in restraint, then the specifics of the situation leading up to
these episodes become a primary focus of the team discussions.
There is a need to review and supervise the staffs handling of violent and
previolent behavior to minimize staffs personalizing conflicts, or getting into
peer-level squabbles with patients when staff have similar personal conflicts or
are frightened or exhausted. Becoming frightened of patients is a prime indi-
cator of incipient burn-out. When too many of the staff become frightened of a
patient, it is an indication for transfer of the patient to another institution. It
follows that such developments are best picked up early when they may be
reversed.
Team reviews of restraints from time to time bring to light deficiencies in
staff, either premature resorting to physical limitsetting, provocative rather
than calming attitudes by staff, or evidence of overtly inappropriate antag-
onism or sadistic qualities in a staff member in relation to a particular child.
The proper response to these issues will vary depending on the circumstances
but in all instances these problems must be addressed promptly and defini-
tively. Although there may be mitigating factors, such as fatigue or emotional
overload, and staff may be helped to overcome such tendencies, lapses of this
nature are serious breaches of the therapeutic environment. Whether or not

disciplinary action, such as suspension, has been taken, staff should not be kept
on in the same clinical setting if any doubt persists about their capacity to
measure up to acceptable expectations.
At these team meetings all aspects of the child's life can be integrated into
better understanding of the factors that may be involved in the child's difficulty
in developing increasing self-control. Not only can information about rela-
tionships with family be aired but the clinician working with the family can
better keep them apprised of the circumstances surrounding the child's need
for restraint. Some facilities have families come into the hospital to participate
in the limit-setting process. Others help families to develop practical extensions
of the principles involved into the time that the child is home on visits. These
procedures are not only clinically useful but are vital to prevent families from
feeling isolated and neglected and therefore more likely to become resentful
and litigious.
MAJOR AMBIGUITIES AROUND ASSESSMENT AND USE OF

RESTRAINT
In this section different aspects of restraint will be discussed to point out

persistent ambiguities that complicate the assessment of parameters of re-
straint, its indications and uses, as well as understanding of its proper role.
Reference has been made already to the landmark survey done by Fassler
and Cotton 1 of the laws and regulations relevant to psychiatric restraint of
children in the United States. The fact that thoughtful citizens and profes-
sionals in comparable states have widely divergent views is striking evidence of
the existence of ambiguities in this area of hospital practice.
I believe that one of the overriding reasons for this ambiguity is the fact
that restraint is not a scientific discovery. It originated in primitive societies24 as
a natural and untutored response to a real danger presented to the populace by
a deranged fellowhuman. Dangerously unpredictable humans were banished,
tied down, or caged. Later anyone demonstrating flagrant deviation from the
norm generated similar fear and was similarly likely to be excluded, restrained,
or abused.
As enlightened understanding of such humans became an ideal sought by
physicians and others, the barbaric element in the treatment of these unfortu-
nates w:;.s recognized as appallingly inhumane and was interrupted. But the
need fOi 30m~ form of physical control of some deranged fellowhumans per-
sisted. With tl,is there also has persisted the struggle between our recoil from
the shadow of the primitive origins of restraint on the one hand and our
recognition of the need for restraint on the other. The ambiguity that arises
from this does so, to my thinking, at the very site of our beginning thoughts
about restraint. Are we tying down someone or helping him?
To some the answer is clear. To them, we cannot tie people down and help
368 DONALD S. GAIR
them at the same time.* Those who care directly for these difficult children
must merge restraint and help.
Preceding sections of this chapter have addressed various aspects of con-
flicting beliefs, including whether or not seclusion can be therapeutic. In this
section I will address three other areas and their ambiguities: when to termi-
nate episodes of restraint, problems in determining the proper incidence of
restraint on a psychiatric ward for children, and the concept of punishment
and its relevance to restraint.
Issues Surrounding Termination of Episodes of Restraint

All branches of medicine and surgery, although seeking to identify clear
indications of specific diagnoses and specific treatments for each diagnosis, are
committed to exercising extreme caution to avoid automatic treatment based
on snap diagnoses. The practice of medicine is closer to being a continuing,
cautious, in vivo therapeutic experiment, guided by those signs and symptoms
and hints of response to justifiable interventions that resemble conditions pre-
viously studied and treated or read about.
Multisymptomatic and multifactorial states, of which severe psychiatric
illness and emotional disturbance in children and adolescents are prime exam-
ples, are the least amenable to check-list approaches, either prescriptive or
prohibitive. The main problem dictated by the restrictive rules and regulations
governing the use of restraints is that they are implicitly based on simplistic
models of deviant and destructive behavior and effects of restraint.
For instance, the restraint regulations of West Virginia state that restraint
"may be used only as is necessary for the patient to regain self control. Under no
circumstances may it be used as a preventive measure ... "1 The language of
this regulation implies a simple point at which a patient has regained self-
control when in practice it is often quite difficult to be sure. Furthermore, there
is something confusing about the regulation restricting the preventive aspects
of restraint.
Because a major rationale for restraint is to interrupt violent behavior,
intrinsic to this effect is the prevention of continuation of the behavior in the
short run. There are long-term preventive aspects as well. As has been pointed
out eariler, reliable, consistent, and predictable application of restraint for
legitimate indications on repeated occasions frequently has the effect of modi-
fying patients' behavior, fostering increased self-control. The effect of restraint
is thus likely to be preventive in outcome in each instance.
A regulation demanding that restraint should "never" be used as a preven-
*Senator Backman, in his press release quoted earlier in which he vowed to abolish all re-
straint of children and adolescence, stated: "I do not believe that it is therapeutic to lock up
children with emotional problems in cells without toilets or personal belongings. I do not
believe that it is therapeutic to tie them to beds, posts or other fixed objects as a means of
therapy. I do not believe that a psychiatrist or physcologist or social worker or priest or rabbi
can say to a child, 'I want to help you,' and then lock the child up. I intend to file legislation to
end seclusion and restraints for emotionally disturbed and retarded children."
tive measure when prevention is one of its desirable and predictable outcomes
is confusing at best and inhibiting at worst. It tends to give the ward staff and
clinicians the feeling that there is something illegal about what they are doing
when they restrain a child or adolescent if they know that it has a preventive
aspect. This promotes a tendency to avoid thinking about such aspects, which is
what makes such regulations confusing to clinicians.
The central problem of the West Virginia regulation is its wording. The
phrase "may be used only as is necessary for the patient to regain self-control,"
is quite different from, for example, "must be used until the patient has re-
gained self-control." The emphasis on restrictive rather than enabling lan-
guage is in the same direction as is the really illogical proscription of preventive
use. It reflects an underlying recoil from and mistrust of the motivation to use
restraint.
The proper timing of release from restraint is learned by experience with
individual children and adolescents. One of the advantages of seclusion rather
than mechanical restraints is that it allows a more gradual attenuation of the
containment, with the door being unlocked for a time, then opened, with the
patient being allowed out on trial for increasing periods of time until it is clear
that the episode of loss of control is over. With mechanical restraints, subtler
indications must be developed from observation of expression, muscle tension,
and, of course, what the patient says. Premature release with eruptive behavior
demanding return to restraints sharpens the observational accuracy.
The question, "How long is too long?" cannot be answered categorically.
Most states have rules about outer limits of duration of restraint and these vary
widely as do most of the other regulations. Most have a cutoff point beyond
which review by higher authority becomes mandatory. Those hospitals that
take care of the most seriously disturbed and mentally ill children and adoles-
cents periodically have patients that require some form of restraint for long
periods of time over many weeks, despite many consultations by the best avail-
able colleagues. Some of these children with prolonged violent disturbance are
ultimately helped by one or another medicine, but not all. Persistent need for
restraint should not be taken for granted. It should be a continuing concern
and regularly reviewed. However, long-term use of restraint is not a priori evidence
of therapeutic neglect or error by the clinical staff
Assessing the Proper Incidence of Restraint on a Psychiatric

Ward for Children
Critics of restraint of children in psychiatric hospitals regulary cite its high

incidence compared to that on wards of adult patients. At a minimum, they call
for a reduction in the incidence of restraint. The more zealous seek its aboli-
tion. The question of what is a proper incidence of restraint on a psychiatric
ward for children is important. It is not, however, a simple calculation. When
we contrast comparable groups of hospitalized children and adults, to the
extent that one can be sure about the comparability, the result is a 5: 1 ratio of
370 DONALD S. GAIR
incidence among children compared to adults.* This should not be a surprise,

considering children's developmental limitations discussed earlier in the
chapter.
The major issues involved in assessing incidence of restraint on psychiatric
wards for children in order to compare them with other settings or with an
arbitrary standard are tabulated in the following. The main contribution to the
incidence of restraint is the degree of disturbance of the patient population.
The recording of restraining episodes depends on legal definitions.
Outline Of Factors Involved in Assessing Comparable

Incidences of Restraint
I. Defining episode
A child who is out of control, manifesting or imminently threatening
violence to self or others, judged by ward staff caretakers to be safely
manageable only if restrained.
II. For each institution
A. Operating definitions of restraint
B. Severity of problems of self-control in the patient population
C. Physical characteristics of the institution
D. Staff factors decreasing restraint
1. Staff sensitivity to early indications of a child going out of con-
trol and skill in helping child express him or herself in non-
violent ways
a. staff selection and training
b. staff/patient ratio allowing optimum observation and interac-
tion
E. Staff factors increasing restraint
1. Limitation in opportunities to use adequate skills
a. Low morale, fatigue, overcrowding of wards, staff/patient
ratio that prevents optimum observation and interaction
2. Insensitivity to early indications of a child going out of control
and/or lack of skill in helping child express him or herself in
nonviolent ways
a. Poor selection and/or training
F. Program opportunities for children that enhance their self-control,
both short term and long term
1. Opportunities to express themselves cathartically, lessening inci-
dents of violent outbursts
2. Adequate array of relevant therapeutic interventions
*The figures for two state hospitals for children, one in Massachusetts and one in Texas
(surveyed in 1986)25 were remarkably similar and both were roughly five times the frequen-
cy of restraint for comparable adult patients. 26 Also, a private psychiatric hospital with a
locked unit for children and many wards for adults, although having a lower absolute rate of
restraint for all patients than the two state hospitals, had a similar ratio between restraint of
children and adults of 5: 127
The question of proper incidence of restraint depends on a definition of

its proper use in anyone instance but justifiably includes more than that. For
instance, if a child violently attacks a staff member and clearly requires re-
straint for safe management at that moment, it may still become clear on review
that the staff member had provoked the child by clinically inappropriate be-
havior. In such instances the actual incident of restraint was unavoidable at the
time but the conditions that contributed to the child's loss of control could have
been avoided and steps can be taken to avoid them in the future. Overcrowding
of wards for children, leading to less than optimum staff-to-patient ratios, is
unfortunately, a fairly common and potentially preventable condition that con-
tributes to a higher incidence of restraint episodes that are nonetheless indi-
vidually justifiable. Staff training, morale, fatigue, and individual talent are all
significant variables that are hard to quantify in attempting comparisons be-
tween institutions.
There is also the question of definition of what constitutes restraint. The
Fassler and Cotton surveyl reveals a wide range of differences in many param-
eters of restraint regulations. These reflect significant differences in the se-
riousness with which restraint is regarded. Requirement for a physician's writ-
ten endorsement is a clear example. Although most states mandate at least a
telephone order within an hour and a signed order by 12 or 24 hours, others
do not require a physician's signature at all for episodes of restraint lasting less
than a specified period: 15 minutes in Connecticut, 30 minutes in Utah and 1
hour in Florida and North Carolina.
Some states do not regard physical holding as a form of restraint. In other
states a locked door is required before restriction to a room is considered
restraint, whereas in Massachusetts an admonition to a child not to come out of
an unlocked room where he or she is alone constitutes seclusion as a form of
restraint. In Massachusetts also, physical holding for up to 5 minutes does not
constitute restraint but holding a child for longer than that does. The issues
involved in setting the 5-minute rule in Massachusetts are informative.
In 1984, following a new law on seclusion, physical holding became legally
identified as a form of restraint for the first time in Massachusetts and there
was discussion about how long it had to continue until it should be considered
restraint. Some clinicians argues that any physical holding, no matter how
brief, should be classified as restraint and therefore be subject to all of the
governing statues and regulations. However, an absolute ban on any hands-on
physical intervention unless a child required restraint would have eliminated
everyday interventions that are helpful to children. These interventions in-
clude such acts as momentary placing of a calming hand on a child's shoulder
or the brief use of moderate physical help in removing a child from the scene
of an incipient fight. The view prevailed that a distinction could be made
between restraint and nonrestraint use of physical contact.
The decision was made to distinguish restraint from nonrestraint solely on
the basis of a 5-minute time limit. It was recognized that some of the 5-minute
holdings would be in situations that could justify restraint. However, it was also
known that many other of the briefer holdings would be of the everyday
372 DONALD S. GAIR
interactional type. The amount of time necessary to identify and specify the
nature of each brief interaction was deemed inordinate.
The 5-minute holding criterion for restraint in Massachusetts gives a lower
incidence of restraint since the time that seclusion has been banned compared
to when it was in use. This is misleading, however, because many of the brief
instances of seclusion during the earlier period would be subsumed now under
physical holdings for less than 5 minutes and these do not show up as officaal
incidents of restraint.
The importance of the severity of behavioral problems in the patient pop-
ulation should be self-evident but is not always recognized. One child may be
subject to frequent violent outbursts involving assault to others and harm to
self for periods of weeks, with many episodes requiring restraint each day and
an accumulation of many hours in restraint. It is common on psychiatric wards
that admit and retain children with maximal behavioral difficulties that over
half of all episodes of restraint during any given time period are accounted for
by two or three patients (15% to 20% of a I5-patient ward).
In a study questioning the justification for restraints on psychiatric wards
for children and adolescents, Garrison 28 divides aggressive acts into "violent
acts," which involve "intense physical attacks" and "lesser aggressive acts" that
may be threatening but are nonphysical. He reports that not all "violent acts"
uniformly lead to restraint. He fails, however, to establish that the "violent acts"
that did not lead to restraint were equivalent to those that did.
Irwin 23 cited Garrison's "concerns about seclusion as a therapeutic inter-
vention"28 as a stimulus to his own report of managing young children on a
ward without a seclusion room. Irwin questioned the "prevailing assumption of
the need for seclusion rooms in child psychiatric inpatient units." The implica-
tion of his brief report is that restraint is not necessary if one has proper
staffing (his ward had one staff member for two children during waking
hours), and the proper approach. For instance, he writes, "Since seclusion was
not an alternative, staff was forced to use other techniques to resolve crises,
prevent escalation, and manage behavior." He does not characterize any of
these "other" techniques as being an alternate form of restraint even though he
includes holding on the list.
The Controversial Concept of Punishment

The concept of punishment is intertwined with restraint. The pumtIve
aspect of restraint is one basis for the abhorrence it engenders that has been
discussed at length earlier. The dilemma that arises in discussing this sensitive
area derives from the fact that punishment and pain are virtual synonyms. The
Latin word poena, (and its Greek antecedent) signifies both pain and punish-
ment. Although colloquially the two words, pain and punishment, can be used
interchangeably without great loss of meaning, punishment carries with it the
clear concept of intent.
In the conventional and legal meaning of punishment, something painful
to a person is inflicted as a consequence of the person breaking a rule or law.
There is a sense of exacting retribution for unacceptable behavior. The meta-

phor of Justice balancing her scales parallels the colloquialism, "getting even."
Although it is axiomatic that the goal of medical care, management, and
treatment is not the infliction of pain, it is also unavoidable that patients under-
going treatments of many kinds find the experience painful. The aphorisms of
Hippocrates begin, "primum, non nocere," ("first, do no harm"), but pain is
not synonymous with harm. In the vast majority of medical and surgical pro-
cedures where pain is experienced it is an unavoidable side effect of the
therapeutic activity. It is an eternal quest of the medical pharmacological fields
to find means to render treatments painless, but the treatments are provided in
the meantime despite the pain. *
Restraint in child psychiatric inpatient facilities is intended to prevent or
interrupt a dangerous activity that the child is bent on continuing or starting,
and it is rarely unambiguously welcomed by a child, even when there is evi-
dence that he or she is reassured by it. "Limit-setting is regularly protested by
those in need of it, but when development is compromised in this area, there
can be no effective undoing of seriously deviant behavior without the pain of
injured narcissism."l0
With restraint in a psychiatric hospital, as with any procedure under medi-
cal auspices, the intent is not the gratuitous dispensing of discomfort. However,
it is manifestly impossible for a child to experience restraint as other than what
it is, the imposition of staffs will over his or her own. For virtually all children,
this is felt as punitive. There can be no analgesia or anesthesia for this effect of
restraint, unlike the majority of medical and surgical procedures.
Punishment as Penalty, an Assigned Consequence. There are situations
in which legitimate use of restraint parallels punishment. It is common for
children on psychiatric wards to interpret restraints as part of a quasi-judicial
system of assigned penalties-just deserts for bad behavior. This develops
despite the fact that the staff of the ward has been scrupulous in using re-
straints only to interrupt violent behavior or to abort the clear threat of its
emergence. This basic belief in the concept of just punishment is rarely absent
from children on psychiatric wards even though they have serious problems
involving impulse control and superego deficiencies.
Fighting between children is a common precursor of the need for re-
straint, because one or both children may become dangerously out of control in
the process. When only one child in a fight is viewed by the staff as in need of
restraint when the fight is interrupted, the other often appears to expect that
his or her fighting behavior merited punishment too, even though he or she
would protest if restrained. Such a child, if not restrained, will often have a
subsequent outburst that necessitates restraint. When this is demonstrated to
be a pattern for a child then it becomes advisable to restrain the boy or girl as
soon as the fight is stopped, because not to do so would allow the likely develop-
*One of the exceptions to the general medical rule is the physical examination. Here it is
essential that painful signs of disease or disorder be elicited whether or not the patient has
presented with a complaint of pain. Even in routine physical examinations the fact that there
is no pain or tenderness in areas palpated is a necessary sign of normality.
374 DONALD S. GAIR
ment of a dangerous behavioral explosion. In such use of restraint one is acting

within the spirit and letter of the law but at the same time, in the child's mind,
one is applying restraint as a penalty for a misdeed-as a punishment.
Punishment in Behavior Modification Programs. The use of restrain-
ing procedures in behavior modification programs designed to eliminate vio-
lent behavior directed at self or others has been discussed earlier. The behav-
ioral mechanisms cited as contributing to the effectiveness of these procedures
are technically labeled "punishment." Technical definitions given are:
As a behavioral process, punishment only refers to the application of a class of events

that weaken or reduce the likelihood of maladaptive behavior. 22(p.38) [Punishment
is] a reduction of the future probability of a specific response due to the immediate
delivery of a stimulus for the response. 29 (p.6)
The effective use of punishment may be called "positive punishment"

although it "generally involves noxious and undesirable stimulation that fol-
lows a behavior." The physical discomfort aspect of restraint would be referred
to as "positive punishment." Behaviorists also refer to "negative punishment"
when focussing on the fact that the punishment will weaken behavior by caus-
ing "loss or prevention of pleasant and desirable stimulation." The confine-
ment aspect of restraint, taking the child away from activities that would other-
wise be enjoyed, fits this definition of negative punishment. 22
Another behavioral dynamic of restraint is that it removes the child from
stimulations that support the continuance of undesirable behavior. This is
another way of referring to the stimulus reduction aspect of restraint, listed as
one of the indications by Gutheil and Tardiff. 20 In behavioral terminology this
is called, "time out from reinforcement."
Restraint and the Issue of Accountability for Undesirable Behavior
An extension of the controversial aspects of the role of punishment in

restraint is the question of the degree to which the child in a mental hospital
should be regarded as responsible. The criminal justice viewpoint on criminal
responsibility applies equally to the adjudication of charges of delinquency
brought against minors. The standard tends to be all-or-none: if the child is
responsible then the child should be tried and punished; if the child is not
responsible by virtue of mental illness, then the child should be treated and the
event no longer regarded as one over which the child had any rational control.
But it is a rare child who is entirely devoid of grasp of the issues involved in
reprehensible acts and here, as in most areas of human biological functioning,
the all-or-none approach is inadequate. It is my firm belief that to fail to hold
children and adolescents accountable for their antisocial behavior to the full
extent of their capability is to miss major, perhaps unique opportunities to help
them become accultured to relevant values and to develop reliable self-control.
The successful pursuit of such a goal with mentally ill children will, of necessity,
address the child's major psychiatric problems. Failure to hold children
accountable, on the other hand, removes from the therapeutic field a m~or
portion of their maladaptation.
For these reasons the Gaebler Children's Center has developed the policy
of insisting on charges being pressed against children who have been referred
to the hospital as a consequence of their having committed a dangerous anti-
social act, one that is against the law. Having appropriate charges brought
against these children in court keeps in focus the important reality of their
dangerous act. Under these circumstances such children can be helped to
acknowledge what they have done and to deal with its significance. Without
such a procedure it is too often the case that the children and their families
come to deny the seriousness or even the fact of what has happened.
The Gaebler policy is not designed to exclude these children from treat-
ment. Quite the reverse, because a court-ordered admission based on a charge
of delinquency will almost always allow sufficient time for an evaluation and for
laying the groundwork for further hospitalization if that is indicated. When a
delinquent act is not recognized officially but a dangerous act leads to a child's
hospitalization "because of mental illness" it is not uncommon for that child to
be prematurely signed out by the parents. Characteristically the child per-
suades the parents he or she either did not do the delinquent act or will not do
it again and the parents, feeling guilty about the child's distress at being in the
hospital, sign him or her out, and will hire special counsel to fight an attempt at
commitment. Without an official charge against the child it is often not possible
to persuade a committing judge that the child should be held in the hospital
when that is clinically indicated, because one of the major criteria for commit-
ment is dangerousness. In the absence of the official recognition of this dan-
gerousness represented by a formal charge of delinquency, it is more difficult
to have the child committed for treatment against the defense mounted by the
child's attorney.
The relevance of the issue of accountability to the problem of restraint
should be clear. Restraint procedures call attention to undesirable behavior in a
way that cannot be readily ignored. They carry an unmistakable implication of
the child's responsibility, in the sense that the child's behavior has led to the
consequence of restraint. As long as there is minimal self-awareness on the part
of a child then the mandated use of restraint cannot but be recognized as being,
in fact, a consequence of the child's behavior. The restraint will thus inevitably
contain a punitive element in the two senses discussed earlier, the child's per-
ception of the restraint as punitive and the technical behavioral view of re-
straint as a punisher, decreasing the likelihood of repetitions of the dangerous
act.
When restraint is legally indicated it must be used and when it is not it
should not be used. If restraint is used whenever it is indicated as a consistent
response to a child's dangerous lack of control, the child's behavior will charac-
teristically be modified toward increasing self-control. Therefore, without any
change in laws and regulations that prohibit its therapeutic and punitive use,
restraint will inevitably be therapeutically punitive (in the behavioral sense)
when legally used.
376 DONALD S. GAIR
CLOSING COMMENTS
This chapter focuses on children who present serious problems of man-

agement, and the question becomes: To what extent should these children be
regarded solely as the victims of the very real problems they have suffered; and
to what extent must they be recognized as sources of trouble for others and be
held accountable? Even less problematic children pose the dilemma as to what
extent are they to be allowed management of their own lives and decisions and
to what extent must they be managed.
As a child I vowed that when I grew up I would never be as mean as my
teachers and parents and set such rules and inflict such indignities on children
as I fancied had been imposed on me, and I was far from being abused. Since
becoming a parent and acquiring responsibilities for many children other than
my own I poignantly remember that vow as I find myself breaking it repeat-
edly.
Properly brought up children will feel themselves victimized time and
again as necessary limits are brought to bear. Yet restrictions can be excessive.
There is a perpetual question parents and teachers and other mentors to
children must address: too much or too little direction and control; who knows
the right amount?
Some believe they know what is best for children, and are eager to take
over when parents are incapacitated. Sometimes there are too few who step
forward to help when children are neglected. Other times there are many
vying for the authority to decide what is in the child's best interest. In the Rogers
v Okin case the concept of substitutive judgment was developed. Under this
rule, judges must determine what mentally ill people would decide if returned
to their right mind. A subspecialty of law has developed to advocate for the
various protagonists.
The idea of substitutive judgment is difficult to apply to children because
the hypothesized judgment is that of a competent adult which the child has not
yet become. In the ordinary course children even as old as 16 do not exercise
decisive judgment in major events of their life. Premature enfranchisement of
a child, as suggested by Ferleger,6 would rob most children of the protection of
the mature judgment of caretaking adults. It must be recognized that protec-
tion of children's civil rights is much more complicated than simply treating
them as though they are adults. This applies most specifically to children who
are patients in mental hospitals. And yet uncertainty as to what may be best
dictates that there be adequate review of what the professionals recommend
and carry out.
Those of us whose responsibility it is to care for children who are mentally
ill and require the maximum of protection and adult involvement must strive
to minimize and reconcile the sharp differences that inevitably arise between
different groups and different individuals.
Laws and regulations and controversy over the role of restraint in psychi-
atric hospitalization of children reflect the dilemmas of child rearing. The wide
disparity between different jurisdictions about many of the definitions and
procedures involved sharply underscores ambiguities and uncertainties that

are inescapable.
Here, as in all of medicine and science: Truth is the fragile child of skep-
ticism, Dogma, the brutal spawn of certainty. The common ground to which all
should be able to subscribe is that all children need basic care and protection to
make it through childhood. Mentally ill and disabled children surely need even
more.
REFERENCES
1. Fassler D, Cotton N: Survey of Laws and Regulations Governing Seclusion and Restraint of
Children in the United States in 1987. Unpublished data on 34 States and the District of
Columbia distributed at Symposium on "A View from the Quiet Room: The Use of
Seclusion in the Psychiatric Treatment of Children," presented October 22, 1987, at the
Annual Meeting of the American Academy of Child and Adolescent Psychiatry, Wash-
ington, DC (Publication in preparation.)
2. Hamilton E, Cairns H (eds): The Collected Dialogues of Plato. Princeton, Nj, Princeton
University Press, 1961, pp 580, 1425.
3. Dabrowski S, Frydman L, Zakowska-Dabrowska T: Physical restraint in Polish psychiatric
facilities. Int] Law Psychiatry 8:369, 1986.
4. Wexler D B: Legal aspects of seclusion and restraint, in Tardiff K (ed): The Psychiatric Uses
of Seclusion and Restraint. Washington DC, American Psychiatric Press, 1984, pp 111-124.
5. Backman: Press Release at a public meeting held by the Special Committee to Investigate
Seclusion, Restraint and Deaths in State Supported Facilities, Chaired by Senator Back-
man, November 30, 1979.
6. Ferleger D: Kremens v. Bartley: the right to be free. Hosp. & Community Psychiatry 27:708-
712, 1976
7. Ferleger D: Children in a Bind: The Law and Physical Restraint of Young People in Inpatient
Facilities. Position paper presented at Annual Meeting of the American Academy of Child
Psychiatry, October, 1979, Atlanta, in a Workshop entitled, "The Use of Physical Re-
straints in Inpatient Management."
8. Massachusetts General Laws, Chapter 464, Acts of 1984.
9. Workshop on the use of physical restraints in inpatient management: Annual Meeting of
the American Academy of Child Psychiatry, Atlanta, Georgia, October 25, 1979 (un-
published proceedings).
10 Gair DS: Limit-setting and seclusion in the psychiatric hospital. Psychiatric Opinion 17: 15-
19, 1980.
II. Lion jR: Training for battle: Thoughts on managing aggressive patients. H osp Community
Psychiatry 38:882-884, 1987.
12. Gutheil TG, Applebaum PS, Wexler DB: The inappropriateness of "least restrictive
alternative" analysis for involuntary procedures with the institutionalized mentally ill.] of
Psychiatry and Law. 1:7-17,1983.
13. Pinel A: A Treatise on Insanity (orginally published by Sheffield, London, 1806, translated
by Davis DD). Republished in facsimile by the New York Academy of Medicine, New
York, Hafner Publishing Co, 1962.
14. Greenblatt M: Seclusion as a means of restraint. Psychiatric Opinion. 17:12-14, 1980.
15. Soloff PH: Historical notes on seclusion and restraint, in Tardiff, K (ed): The Psychiatric
Uses of Seclusion and Restraint. Washington DC, American Psychiatric Press, 1984. pp 1-9.
16. Kolvin I: Personal communication, june, 1987.
378 DONALD S. GAIR
17. Gair DS: Guidelines for children and adolescents, in Tardiff K (ed): The Psychiatric Uses of
Seclusion and Restraint. Washington DC, American Psychiatric Press, 1984, pp 69-85.
18. Spitz, RA: No and Yes. International University Press, New York, 1957.
19. Rosenberg, A: Ten-day emergency hospitalization-Questions and answers. The Advisor
19 [May], 1984.
20. Gutheil TG, Tardiff K: Indications and contraindications for seclusion and restraint, in
Tardiff K (ed): The Psychiatric Uses of Seclusion and Restraint. Washington DC, American
Psychiatric Press, 1984, pp 11-17.
21. Gutheil, TG: Rogers v. Commissioner: Denouement of an important right-to-refuse treat-
ment case. Am] Psychiatry 142: 213-216,1985.
22. Liberman RP, Wong SE: Behavior analysis and therapy procedures related to seclusion and
restraint, in Tardiff K (ed): The Psychiatric Uses of Seclusion and Restraint. Washington DC,
American Psychiatric Press, 1984, pp 35-67.
23. Irwin M: Are seclusion rooms needed on Child Psychiatric units? Am] Orthopsychiatry.
27:125-126,1987.
24. Westermeyer], Kroll]: Violence and mental illness in a peasant society: Characteristics of
violent behaviors and "folk" use of restraints. Br] Psychiatry 133:529-541, 1978.
25. Gair DS: Report to the Commissioner of Mental Health in Texas on Seclusion and Restraint at the
Children's Unit of the Austen State Hospital Unpublished manuscript, 1986.
26. Gair DS, Bullard DM, Corwin ]H: Residential treatment: Seclusion of children as a
therapeutic ward practice. Am] Orthopsychiatry 35:251-252, 1965.
27. Valentine, N: Seclusion data from McLean Hospital, personal communication, 1984.
28. Garrison WT: Aggressive behavior, seclusion, and physical restraint in an inpatient child
population. JAm Acad Child Psychiatry 23:448-452, 1984.
29. Matson ]L, DiLorenzo TM: Punishment and Its Alternatives, New York, Springer Publishing
Co, 1984.
v
Public Policy Issues
22
The Adolescent's Right to
Psychiatric Care
A VRON M. KRIECHMAN
The adolescent as psychological prototype evolves from a person dependent on

the family of origin to a more autonomous person capable of establishing an
identity, a system of values, and intimate, nurturing relationships with others.
The adolescent as psychiatric patient enters into a contract in which consent
has been given to a psychiatrist for treatment whose nature, benefits, risks, and
alternatives have been explained and whose details may not be revealed to
others without the adolescent's permission. The adolescent as minor may lack
the legal right independently to consent to psychiatric care or insure its confi-
dentiality by virtue of age alone. An individual adolescent may be fully compe-
tent to consent to the psychiatric treatment he or she independently requests.
What is their right to do so? Ideally, a parent consents to the psychiatric care
their son or daughter requires. Unfortunately, there are a number of circum-
stances in which a parent might object. Parents may find psychiatric care to be
socially unacceptable. They may resist ceding authority in family matters to a
perfect stranger. Parents may dismiss serious difficulties as 'just a phase
they're going through." They may have religious objections to certain aspects
of treatment (e.g., Christian Scientists who resist psychopharmacological treat-
ment). Or they may wish to conceal serious family psychopathology and/or
abuse from outside authorities.
On the other hand, adolescents may forgo psychiatric care involving such
sensitive areas as substance abuse and sexuality were their parents to be in-
formed. They may wish to limit parental involvement in treatment they see as a
bridge to greater independence and self-definition. There also may be emer-
AVRON M. KRIECHMAN • Division of Child Psychiatry, Schneider Children's Hospital,

Long Island Jewish Hillside Medical Center, New Hyde Park, New York, 11042; Department
of Psychiatry, State University of New York at Stony Brook, Stony Brook, New York.
381
382 AVRON M. KRIECHMAN
gencies involving adolescents whose parents cannot be found, who refuse to

reveal how their parents can be found, or who have not lived with their parents
for some time.
Though conflict between parent and teenager is not inevitable, it is more
than likely given the adolescent's developing values, heightened emotions, and
strivings for self-determination. To what degree is a psychiatrist able to provide
care over the objections or without the knowledge of parents? How much
information about the existence or nature of psychiatric treatment does a
parent have a right to know?
THE CONCEPT OF ADOLESCENT'S RIGHTS
Historically, anyone under the age of 21 had no legal protection against

parental decisions under the common law doctrine of parental sovereignty,
which held children to be the chattels or property of their parents. Parents
were entitled to the custody, control, services, and wages of their children.
Child abuse did not become a crime until late in the 19th century when legal
constraints on parental ownership were prescribed in situations where children
were considered to be in danger.
The age of majority in most states was later established by statute as 18 for
females and 21 for males. Only in the last two decades has the issue of the
rights of adolescents to represent their own interests emerged. This concept
was strengthened in 1971 with the ratification of the Twenty-sixth Amendment
giving 18-year-olds the right to vote in federal elections. Soon thereafter, most
states awarded adult status to those individuals over the age of 18. Unfortu-
nately, the transfer of adult rights and privileges on a categorical (chronologi-
cal) rather than individual basis may not fit the best interests and unique
circumstances of the particular person involved.'
There are four major exceptions to the requirements for parental consent:
emergencIes; emancipation; statutory law; and the doctrine of the mature
minor.
WHEN PARENTAL CONSENT IS NOT REQUIRED
Emergency Care
In cases of parental neglect or abandonment, adolescents are forced to

provide their own support in order to survive. Recognizing such instances, the
law confered capacity on a minor to contract for his or her "necessaries,"
including food, shelter, and clothing. This common law rule was then invoked
to allow physicians to treat a child without parental consent in life-threatening
situations. 2 The ability to provide emergency care is therefore a subjective
judgment by a medical practitioner that the requirement for parental consent
can be waived in the face of a genuine emergency.
THE ADOLESCENT'S RIGHT TO PSYCHIATRIC CARE 383
When Parents Refuse. Parents do not have the right to prevent physi-
cians from saving their child's life. The state can assert its paternalistic interests
in the welfare of children and intervene when necessary to protect them under
the doctrine of parens patriae. Even parental objections based on First Amend-
ment rights of freedom of religion, as in cases of blood transfusions for
Jehovah's Witnesses, cannot block lifesaving attempts by a physician.
Failure to provide medical care for a child is defined as child neglect by
child abuse statutes. The seriousness of the psychiatric disorder and the danger
to self or others would determine whether psychiatric treatment would be
ordered over parental refusal to consent. 3 Psychiatrists should consider initiat-
ing court action to protect the child's interests when parents refuse to give
permission for treatment the child needs. 4 Psychiatrists can also report parents
to child protective services for neglect of psychiatric, or medical, care. Unfortu-
nately, such actions rarely result in obtaining the desired treatment for re-
sistant parents and their children.
Juvenile court intervention would also be appropriate in situations where
parents prohibit psychiatric treatment required by the school in order to keep
the adolescent in the classroom. Federal law requires school systems to provide
whatever clinical services are needed to correct conditions that interfere with a
child's learning. 5 If the child cannot be maintained in the classroom becuase of
the parents' refusal of treatment, the child may be deemed educationally ne-
glected. This condition is also reportable to child protective services.
When Parents Sue. Parents can bring legal action predicated on the tort
of battery (an unauthorized touching of the body) against a physician treating
the emergency of a minor. The doctrine of implied consent arose to protect
physicians in cases where a delay to contact the parents might seriously threat-
en the child's health. Furthermore, some statutes specifically defend physicians
from liability on account of lack of parental consent in the provision of emer-
gency care to a minor. 6
Recovery in the case of unauthorized psychiatric care is predicated on the
tort of enticement and the alienation of affections.7 However, the physician
who declines payment is probably protected from any suit by the parents for
non negligent treatment of a minor.8
Emancipated Minors
Under traditional common law standards, an emancipated minor is one
who acquires the contractual capacity and common laws rights and respon-
sibilities of adulthood by virtue of willingly living apart from his or her parents
and achieving some degree of financial self-sufficiency. Parents free the child
from economic ties to the family by actively consenting or failing to object to
the child's departure. 9 The status of emancipations, depending on the jurisdic-
tion involved, may be awarded to those who are on active duty in the armed
forces; currently or previously married; widowed; divorced; parents them-
selves; pregnant; college students (even if they remain financially dependent
on their parents); or runaways who refuse to identify their parents.
Although a minor can demonstrate that he or she is independent from

parental control for most purposes, some states require that the court be peti-
tioned and a court order of emancipation obtained before medical treatment
can begin. Emancipated minors are able to authorize their own treatment
without the physician incurring liability to the parents.
Statutory Law
The requirement for parental consent is dispensed with in situations
where minors may deny themselves threatment rather than informing their
parents of the need for such treatment; where failing to treat the problem may
have severe ramifications for the individual and for society; and where the
medical problem is extensive. IO Statutory laws granting special rights to teen-
agers for the confidential treatment of venereal and other communicable dis-
eases, contraception, pregnancy-related conditions, and alcohol and/or sub-
stance abuse exist in most states. 6 Age requirements vary from state to state.
They also vary depending on the nature of the medical condition.
Presently, 18 states permit minors to consent to mental health care. Psychi-
atrists in these states can provide inpatient, outpatient, and substance abuse
treatment for adolescents without parental permission. Only psychiatric care
by physicians is authorized unless the specific statute designates otherwise.
Some statutes limit the number of psychotherapy sessions minors can authorize
on their own and many provide the age (typically 14 to 16) for authorization of
mental health care. 10 Judicial consultation is advisable if ECT is to be consid-
ered, as the law tends to consider ECT exceptionally intrusive. I I
Some states also authorize minors above a certain age to apply for admis-
sion to a mental health facility.l2 In New Mexico, a child 12 years of age or
older can become a voluntary patient on his own initiative. He or she must
consult with an attorney appointed to represent him who explains his or her
rights and ascertains whether the teenager truly wants to stay in the facility.
The lawyer informs the court if the child wishes to remain, in which case the
child may then be treated as a voluntary patient. The child is under no commit-
ment order and is free to leave treatment at any time unless the facility or
parents decide to seek his commitment. The adolescent retains the right to
periodic review, and his or her voluntariness will be recertified at regular
intervals. 13 Such statutes attempt to maintain the delicate balance between the
teenager's legal rights and his or her developmental abilities and treatment
needs. 14
The Doctrine of the Mature Minor

The jucicial doctrine of the mature minor provides the final major excep-
tion to requirements of parental consent for the treatment of non-life-threat-
ening emergencies. The medical treatment involved can be justified as neces-
sary as defined by conservative medical opinion; must pose no serious hazard;
and must be undertaken solely for the adolescent's benefit rather than that of a
third party (e.g., donation of a transplant organ). A mature minor is an emo-
tionally mature adolescent near the age of majority (15 years and up) who is
capable of making informed judgments (understanding the risks and benefits
of a medical procedure) and is thus capable of granting an informed consent.
He or she is mobile, independent, able to make decisions on his or her daily
and financial affairs, and able to initiate treatment on his or her own behalf.
The mature minor rule supports the clinical perception that the level of
developmental capacity of the adolescent, rather than arbitrary legal disposi-
tion, should be the deciding factor in the determination of competency for
consent to treatment. There is even some evidence that preadolescents con-
ceive of rights and obligations in a general way, though this is less likely for
children from lower-class backgrounds whose experience of choice and options
in life may be limited. 15 The ethical priciples of autonomy (individuals should
have a say on any action that is going to affect them) and beneficence (when-
ever something good can be done for a person, it should be done, or at least no
barriers should be placed to attaining that good) also support the mature minor
rule.
The mature minor is thus a subjective determination that must be carefully
documented by the physician, in contrast to the more objective determinants of
emancipation. Despite this, no physician has been sued successfully for negli-
gently assessing a patient's maturity in the last quarter century.8
Negligent Care. Psychiatrists are not immune to parental action merely
because the adolescent consents to the treatment. Parents may sue for malprac-
tice on behalf of their child if the psychiatric treatment is negligent. A psychia-
trist can be judged to have committed the crime of contributing to the delin-
quency of a minor should he or she advocate behavior such as running away
from home or using illegal substances. Parents also have the right to intervene
where a teenager is being treated by incompetent and/or highly unorthodox
practitioners. Therapists who are not physicians are more clearly at risk given
greater legal precedent for medical care.
INFORMED CONSENT
Parental consent is traditionally required for the treatment of minors be-

cause children are considered to be incapable of understanding the nature of
the condition being treated, treatment alternatives, the risks of treatment, and
probability of the treatment's success. Minor treatment statutes and the doc-
trines of emancipation and the mature minor share the recognition that an
individual's developmental capacity to give a truly informed consent is the
paramount criterion for obtaining consent to that treatment.
Several studies demonstrate that reaching the age of majority does not in
itself insure the capacity to give informed consent. Fifty-four percent of adult
Americans are not literate enough to understand a simplified consent form.I6
In one study, only eight of 100 psychiatric inpatients ages 16 to 73 admitted

voluntarily were rated as being fully informed of the terms of the contract at
the time of admission. 17
The concept of therapeutic privilege (permitting the psychiatrist to with-
hold information which, if divulged, might harm or distress the patient un-
necessarily) and the waiver doctrine (permitting patients to waive their right to
information by asking the physician to withhold it) are two exceptions to in-
formed consent applied in some instances with adult patients. If an adolescent
must be protected from full disclosure, it is probably best to obtain parental
consent except in cases of absulute emergency because the adolescent's capacity
to give truly informed consent would be seriously in doubt.
CONFIDENTIALITY
The Adolescent's Right to Privacy

Adolescents have a constitutional right to privacy within treatment sessions
and protection from breaches of confidentiality during and after treatment.
They also have the right to control the use of videotapes and audiotapes as well
as the use of their name, likeness, and/or clinical case histories in publica-
tions. 18 The criteria for informed consent to disclose are identical to those of
informed consent to treat: the adolescent must be informed as to what he is
consenting and be instructed about alternatives, risks, and benefits.
The Massachusetts statute on emancipation specifically provides that treat-
ment records of an emancipated minor are confidential and cannot be released
without the minor's consent. Breach of confidence in violation of a statute may
result in license revocation or criminal (e.g., the state of Michigan) proceedings.
Informing Parents
Minor treatment statutes entitle the adolescent to certain types of health
care without parental knowledge, as in care concerning pregnancy, abortion,
birth control, and substance and/or alcohol abuse. Confidentiality involves two
aspects: disclosure of the nature of treatment and disclosure of the existence of
the treatment once it has begun. The decision concerning the latter may de-
pend most on the practical issue of the parents' willingness to pay and condi-
tions for third party reimbursement. Legally, few states directly confront the
issue of such disclosure to parents. In those instances where law exists, parental
notification is left to the physician's discretion. 19
In the absence of legal standards, professional and ethical considerations
dictate that confidentiality must be maintained if informing the parents would
result in parental reprisals or the patient terminating treatment. Confiden-
tiality ought not be breached unless the patient has a reportable contagious
disease or may imminently endanger him or herself or others.
The adolescent should always be told at the start of treatment that the
psychiatrist reserves the right to break confidence should circumstances dic-
tate. Although disclosure of a patient's confidential communications without
his or her informed consent is grounds for a lawsuit based on breach of con-
tract and/or confidence, there have been no decisions in which a minor sued a
physician for disclosing information to his or her parents. 8 In contrast, psychia-
trists have been found liable for failure to alert parents of suicidal or homicidal
threats or the proper authorities of child abuse or neglect. 20
Building an Alliance with the Parents

Most adolescents will agree to inform their parents about the existence of
therapy once they understand the usefulness of involving their parents in
treatment. Maintaining secrecy in the home about the therapy may prove
burdernsome to the adolescent and hamper the therapeutic process. Any irra-
tional motives the adolescent may have to maintain nondisclosure should be
addressed in the therapy.
Once the parents have been informed that psychiatric treatment has be-
gun, it is important to enlist their cooperation in respecting the privacy of the
child's individual sessions. Parents who seem to be jeopardizing or interfering
in the treatment may be attempting to seek information out of a genuine desire
better to understand their child's behavior. They may feel frustrated by their
teenager's developmental need for secrecy as he or she strives to achieve great-
er autonomy and self-control. Parents may worry about the highly charged
nature of household information available to the psychiatrist. They may also
fear that they or their son or daughter will be labeled sick or crazy. Self-help
groups such as Parents Anonymous may prove invaluable in enlisting the sup-
port of parents suspicious of mental health professionals and mental health
care. 21
Where parents' wishes and the adolescent's treatment needs clash, the
psychiatrist's primary responsibility lies with the patient. Psychiatrists treating
adolescents often find themselves in a double bind: breaching confidence when
contrary to the clinical needs of the child is malpractice; alienating the parent
may result in the treatment being interrupted or withheld.
As in the case of breaching the adolescent's confidence in order to notify
parents of an emergency, the careful and judicious manner in which the psy-
chiatrist explains the rationale for preserving confidence is critical to the par-
ents' confidence in the psychiatrist and in the therapy. The psychiatrist needs
to convince parents that he or she is not their adversary when maintaining
nondisclosure, but is allied with the family in its desire to protect and restore
the adolescent's well-being. 22 Parents should also be informed that enhancing
the adolescent's experience of choice and participation may result in a number
of psychological benefits, including facilitation of moral development and legal
socialization, heightened achievement motivation, and an increased sense of
personal causation. 15
Informing Schools or Other Third Parties

Given the stigma of mental illness and psychiatric treatment, the adoles-
cent and his or her parents must provide truly informed consent to any dis-
closure about the existence or nature of the adolescent's psychiatric treatment
to school personnel. Such information may unduly prejudice the teacher in his
or her assessment of the student; it may also become a part of the adolescent's
permanent school record.
Both parents have coequal rights to provide informed consent in an intact
family or in a separated family where there is no court order as to child
custody. Although the custodial parent has the primary right to consent where
there has been a custody order, most acts do not distinguish between custodial
and noncustodial parents. 23
If the adolescent and his or her parents are not truly informed, the psychi-
atrist may be liable for defamation of character if the wrongfully disclosed
material is of an unflattering or embarassing nature and results in ridicule or
vilification. The psychiatrist is also liable for defamation or libel if the informa-
tion revealed is untrue, even in the presence of informed consent. As the
treatment of adolescents inevitably involves information about other members
of the family, it is important that the psychiatrist honor their rights to privacy
as well.
Whenever possible, the psychiatrist should encourage the adolescent to
participate actively in any discussions between the psychiatrist and third par-
ties. It is important that psychiatrists routinely report all communications with
third parties regarding the adolescent patient to the adolescent him or herself.
In doing so, the psychiatrist illustrates his or her respect for the patient's
autonomy and justifies the adolescent's trust in the psychiatrist's integrity and
reliability.
When Not Informing Is Informing. The issue of drug and alcohol abuse
illustrates the complexities of maintaining the adolescent's confidence. The
Confidentiality of Alcohol and Drug Abuse Patient Records Law provides that
information concerning treatment in certain programs can only be disclosed
with the signed permission of the patient: parental release is insufficient. If a
psychiatrist received releases of information signed by the parents only, failure
to respond would indirectly reveal the adolescent's abuse of alcohol and/or
drugs, because the psychiatrist would otherwise be obligated to release the
information the counselor requested. Requesting a release of information from
every adolescent would prevent such nondisclosure disclosures. 24
FINANCIAL LIABILITY
The greatest barrier to psychiatric care for the adolescent is often financial
rather than legal. Parents are not financially liable for psychiatric treatment
provided without their knowledge except in the case of a clear and acute
emergency. Teenagers are liable for their medical bills, but rarely have the
funds to pay for them. Adolescents who wish to conceal psychiatric care from
their parents thus have limited access to most private psychiatric care and are
more likely to seek treatment from facilities funded by public monies or char-
itable contributions. Psychiatrists who work in these facilities bear a special
responsibility to familiarize themselves with the legal issues detailed above.
THE INFORMED CONCEPT OF THE ADOLESCENT
Some adults, especially mental health practitioners, believe that normal

adolescence is a period of constant turmoil and psychological disturbance;
others tend to dismiss marked psychopathology as part of the process of grow-
ing up.25 Troubled teenagers should not be denied treatment because of their
parents' fears of misconceptions. The soaring rate of adolescent suicide dem-
onstrates the need for greater access to timely, affordable, and responsive
psychiatric care. Adolescents must also be protected from being mislabeled or
overpathologized by adults who wish to interfere with the teenager's right to
establish his or her own identity.
As the adolescent moves from dependency on his or her parents to greater
autonomy, it is not necessarily better either for the adolescent or society that
the state step in where parents fear to trend. Any attempt to expand the
adolescents' rights must acknowledge this dilemma in dealing with issues of
adult coercion and control. 26
Misconceptions are the adversaries of parents, not their children or their
children's psychiatrists. Recognizing that the informed concept of the adoles-
cent is best defined by the individual adolescent him or herself, psychiatrists
must help parents be mindful of the right of their son or daughter to achieve
an identity of their own making with a minimum of intrusion and a maximum
of respect.
REFERENCES
I. Solnit AJ: Children, parents, and the state. Am] Orthopsychiatry 52:481-495, 1982.
2. Foster HH: A "Bill of Rights" for Children. Publication number 927, American Lecture
Series. Springfield, ILL, Charles C. Thomas, 1974.
3. In re Carstairs, 115 N.Y.S. 2d 314 (1952).
4. Herr 55, Arons 5, Wallace RE: Legal Rights and Mental Health Care. Lexington, Mas-
sachusetts, Lexington Books, 1983.
5. P. L. 94-142, Education for All Handicapped Children Act of 1975.
6. Pilpel HF: Minor's rights to medical care. 36 Albany Law Rev 462, 1972.
7. Fraser BG: The pediatric bill of rights. 16 S Tex L] 245. 1975.
8. Holder AR: Legal Issues in Pediatrics and Adolescent Medicine, ed 2. New Haven, Yale
University Press, 1985.
9. Katz, Schroeder, Sidman: Emancipating Our Children: Coming of Legal Age in America.
8 Fam Law Q 211, 1974.
10. Christoffel T: Health and the Law: A Handbook for Professionals. New York, The Free Press,
1982.
11. Chandler D, Sellychild A: The Use and Misuse of Psychiatric Drugs in California's Mental
Health Program. Sacramento, California Assembly Office of Research, California Legisla-
ture, 1977
12. WilsonJP: The Rights of Adolescents in the Mental Health System. Lexington Mass, Lexington
Books, 1978.
13. New Mexico State Ann, Section 43-1-16 (Supp. 1979)
14. Ellis J: Commitment proceedings for mentally ill and mentally retarded children, in
Schetky DH, Benedek EP (eds): Child Psychiatry and the Law. New York, Brunner/Mazel,
1980.
15. Melton GB: Children's rights: Where are the children? Am] Orthopsychiatry 52:530-538,
1982.
16. Schetky DH, Cavanaugh JL: Child psychiatry perspective: Psychiatric malpractice.] Am
Acad Child Psychiatry 21: 521-526, 1982.
17. Olin GB, Olin HS: Informed consent in voluntary mental hospital admissions. Am]
Psychiatry 132:938-941, 1975.
18. Slovenko R: Psychiatry and the Law. Boston, Little Brown, 1973.
19. American Academy of Pediatrics: The implications of minor's consent legislation for
adolescent health care: a commentary. Pediatrics 54:481-485, 1974
20. Graff v Florida, (1980), 390 Sa 2d 361 Fla. Dist. Ct. App.
21. Fritz M: Parents Anonymous: helping clients to accept professional services, a personal
opinion. Child Abuse and Neglect 10: 121-123, 1986.
22. Silber TJ: Ethical considerations concerning adolescents consulting for contraceptive
services, in Silber TJ (ed): Ethical Issues in the Treatment of Children and Adolescents. Thor-
ofare, NJ, SLACK, 1983.
23. Nye SG: Legal issues in the practice of child psychiatry, in Schetky DH, Benedek EP (eds):
Child Psychiatry and the Law. New York, Brunner/Mazel, 1980.
24. Haller LH, Dubin LA, Buxton M: The use of the legal system as a mental health service
for children.] Psychiatry Law 7:7-48, 1979.
25. Offer D, Ostrov E. Howard KI: The Adolescent: A Psychological Self-Portrait. New York,
Basic Books, 198 I.
26. Uviller R: Children versus parents: perplexing policy questions for the ACLU, in O'Neill
0, Ruddick W (eds): Having Children. New York, Oxford University Press, 1979.
23
The Juvenile Transfer Hearing
and the Forensic Psychiatrist
LARRY H. STRASBURGER
The child's sob in the silence curses deeper

Than the strong man in his wrath.
Elizabeth Barret Browning
INTRODUCTION
The juvenile justice system in the United States is clearly in disrepute. Critics
point to the disturbingly high rate of violent crime among teenagers. In 1986
nearly 1 in 10 accused murderers in America was a youth under 18. Thirty-
three young men and two young women are currently sentenced to death for
crimes committed while they were juveniles.! One solution proposed for this
problem has been to do away entirely with the juvenile system for serious
offenders and try them as adults.
The boundary question is highly complex. Just who shall be retained in the
juvenile system and who tried as an adult? Forensic psychiatrists are often
asked to assist the court in addressing this difficult question. In order to fulfill
this role, it is important for the forensic psychiatrist to understand the opera-
tion of the juvenile system and, in particular, the transfer process.
THE JUVENILE JUSTICE SYSTEM
Special rules for treating children have existed for millenia. They were
present in Hebraic and other premedieval criminal justice systems. 2 Under
LARRY H. STRASBURGER· McLean Hospital, Belmont, Massachusetts 02178; Depart-

ment of Psychiatry, Harvard Medical School, Boston, Massachusetts 02115.
391
392 LARRY H. STRASBURGER
English common law children under the age of seven were deemed incapable
of committing crimes. Infancy, like lunacy and idiocy, was accorded special
legal consideration. In Puritan Massachusetts the age of criminal responsibility
was 16. The idea of a child's lesser capacity, and therefore lesser responsibility,
is contained in the definition of a juvenile as "a person who lacks either the
capacity or competence of being treated as an adult in the criminal justice
system."3
In the latter 19th century, the influence of organizations concerned with
the care of wayward youth, combining with prison improvement societies,
established state reformatories to provide guidance and education for young
offenders. Though often abusive and corrupt, these institutions at least pro-
vided legal recognition of the special needs of young offenders. A separate
judicial system for juveniles came into being in this country in 1899, concurrent
with compulsory education and child labor laws. By 1909 juvenile courts had
been established in 10 states and the District of Columbia, and by the 1920s
they had spread to all states.
With the ascendency of the positivist school in American criminology in
the 19th century, a new idea regarding the causation of criminal behavior
gained currency. Rather than merely exercising free will, criminal offenders
were thought of as manifesting either genetic or environmental influences that
required active modification. This theory provided a rationale for a juvenile
justice system with special goals. Intervention into the conditions that pre-
dispose to criminality required a "therapeutic" approach to delinquency. This
approach
is rooted in social welfare philosophy rather than in the corpus juris. Its proceed-
ings are designated as civil rather than criminal. The Juvenile Court is the-
oretically engaged in determining the needs of the child and of society rather
than adjudicating criminal conduct. The objectives are to provide measures of
guidance and rehabilitation for the child and protection for society, not to fix
criminal responsibility, guilt and punishment. The State is parens patriae rather
than prosecuting attorney and judge. 4
This idea of the state as benevolent parent is fundamental to all juvenile

codes. Children are regarded as essentially good creatures whose welfare must
be fostered and who must be protected from the trauma and stigma of criminal
conviction by the state acting in loco parentis.
To brand a child a criminal for life is harsh enough retribution for almost any
offense. But it becomes an all but inconceivable response when we realize that to
brand him may in fact make him a criminal for life. The stigma of a criminal
conviction may itself be a greater handicap in later life than an entire misspent
youth. More important, casting a youthful offender to the wolves who prowl
adult jails may well dash any hope that he will mature to be a civilized man. 5
In order to achieve the special goals of the juvenile justice system, special
procedures were established, different from those of the adult criminal justice
system. Informal procedures swept aside legal structures that might interfere
with individualized asessment and program planning. With the shift in philoso-
THE JUVENILE TRANSFER HEARING 393
phy toward treatment rather than punishment as the goal of the system, the
medical approach of diagnosis, prognosis, and treatment became the court's
model. Now the state offers rehabilitative treatment for the social ills of its
children, and protection from the hazards of the criminal justice system. Fami-
lies are included in the proceedings. Confidentiality is preserved to reduce
stigmatization, and juveniles are protected from the adverse effects of pub-
licity. They may be confined, but never in adult prisons, and only until they are
21 years of age. Their records are sealed, and they do not become disqualified
for public employment. 4 (p 556)
Special hazards attend this special treatment. In the tradeoff for a thera-
peutic approach, individual legal rights and due process safeguards were
deemphasized. If the goal of the court is helping, who needs protection? If the
guiding philosophy is one of meliorism, intervention in the lives of juveniles
before crimes have been committed becomes justified and the presumption of
innocence is irrelevant. "In a system which exalts informality, where pro-
cedural protections are slim, the danger of star chamber proceedings removed
from public scrutiny is substantial." The idea of proportional sentencing,
punishment which fits the crime, also gives way to a treatment, and treatment
proceeds however long may be required for the achievement of a cure. Petty
offenders in the juvenile justice system may lose their liberty for a longer time
than more serious offenders would lose theirs in the adult system. Although
the Supreme Court reduced the hazards of the juvenile justice system 7 by
requiring notice of charges, the right to counsel, a hearing, the right to remain
silent, the right to confront and cross-examine witnesses, and the right to proof
of guilt beyond reasonable doubt, some hazards continue to exist. The prevail-
ing attitude remains that, because juvenile proceedings are purportedly nonad-
versarial, the child is not entitled to all the constitutional rights and protections
of an adult criminal defendant. Juveniles do not, for example, have the right to
a jury trial.
The judge's discretion is an important issue in a system expressly created
to provide individual and particularized treatment for young people. Ajudge
must have wide latitude in order to tailor a program specifically suited to the
needs of the juvenile whom he is required to protect, foster, and change. This
broad discretion, however, is exercised with a relative lack of explicit guide-
lines. It has, at times, been subject to abuse through perfunctory, arbitrary, and
ill-informed decisions. Potential abuse of discretion may also allow judges to
legitimate essentially political decisions. 8
Extreme flexibility and individualization of the system provide loopholes
galore; the critics of the system, therefore, are legion. From the political right
come accusations that it does not deter crime. From the left come accusations
that it incapacitates without adequate procedural protections, and discretion of
judges runs unfettered. A federal court has stated that ')uvenile status is in
effect a basis upon which a youthful offender can plead diminished responsi-
bility for his unlawful acts."9
The Supreme Court comments that juvenile defendants have the worst of
two worlds:
While there can be no doubt of the original laudable purpose of juvenile courts,
studies and critiques in recent years raise serious questions as to whether actual
performance measures well enough against theoretical purpose to make tolera-
ble the immunity of the process from the reach of constitutional guarantees
applicable to adults .... [The juvenile] gets neither the protections accorded to
adults nor the solicitous care and regenerative treatment postulated for chil-
dren.4 (pp 555-556)
Social attitudes toward the juvenile justice system have always been am-
bivalent. There has been a tension between the goal of rehabilitation and the
goal of punishment. The issue is by no means settled. The importance of
society's right to protect itself through incapacitation of the offender looms
large. The high recidivism rate of juvenile offenders does not compare favor-
ably with the recidivism rate of the adult criminal population. "The system
doesn't work," say some. "It's never been adequately staffed and funded,"
respond others. Society does not like troublemakers, and the juvenile courts
are felt to be soft on them. There is much popular resentment that juvenile
offenders transferred to adult court (where they are treated leniently as first
offenders) still get off too easily.lO Politicians and the news media vigorously
exploit this complex problem, unfortunately producing more heat than light.
TRANSFER FOR TRIAL AS AN ADULT
As a social institution the juvenile justice system, as it has evolved, has been
clearly less than satisfactory. The public's dissatisfaction reflects, of course, the
ambivalence of wanting it both ways-treatment and just deserts. As an out-
come of society'S sometimes conflicting needs for rehabilitation of offenders,
retribution, and for simple public safety, statutes establishing juvenile courts
have contained provisions that exclude certain young offenders from juvenile
court jurisdiction. There is no constitutional right to be tried as a juvenile.
Despite the arrangements that have been institutionalized for the treatment of
juvenile offenders, minors have the right to be treated as juvenile delinquents
only to the extent which that right has been accorded by state legislatures.
Although it is a generally acknowledged preference that juvenile offenders
remain within the jurisdiction of the juvenile system, there is a class of cases
that the system rejects. These cases are determined by a judicial hearing, vari-
ously called ajuvenile transfer, waiver, certification, or referral hearing. It has
been said that:
Waiver of juvenile court jurisdiction is a compromise of principle dictated by the
unwillingness of society to pay the price necessary to find out whether our
theories of justice for the juvenile are at all valid. I I
The waiver decision has been termed "critically important"4 (p 556) by the
United States Supreme Court, and it is not difficult to see why this should be so.
"The waiver proceeding ... is, in essence, a sentence of 'death' as a juvenile,
with the subsequent proceedings in criminal court completing the execu-
tion."12 The positive side of this is that, once transferred, the juvenile has
additional constitutional rights; the negative is that he is in jeopardy of adult
punishment. "A young man between fifteen and twenty-five years of age is still
too young for the human trash pile."12(p 594)
As a matter of procedure, the burden of proof falls on the state's pros-
ecutor who initiates the motion that the juvenile should be transferred. AI-
though juvenile court procedures have traditionally been informal, the United
States Supreme Court4 (p 557) has defined additional procedural safeguards: (a)
A judicial hearing is required. (b) The juvenile has a right to counsel at the
hearing. (c) Counsel must be guaranteed a meaningful access to the records. (d)
The juvenile court must provide a statement of reasons explaining the deci-
sion. (e) Further, the Supreme Court also made it clear that a merely per-
functory inquiry into the factors for and against transfer would not be
acceptable.
If a juvenile defendant is transferred to adult criminal court, many states
require him to await the outcome of the criminal trial before making an appeal
from the transfer decision. The time required for a criminal trial plus delayed
appeals may cause the juvenile to lose the opportunity for treatment because
too little time remains before he turns 18.
The decision regarding transfer or waiver may be made by legislature,
judge, or prosecutor. Legislatures determine a maximum age beyond which
juvenile court jurisdiction does not extend. Also the legislature may determine
specific forms of criminal conduct over which juvenile court shall not have
jurisdiction, such as capital offenses. Juvenile courts have the power by their
own action to divest themselves of jurisdiction within certain defendant age
ranges. Also, the jurisdiction over older teenagers in some states rests with
adult criminal courts, which have the option of transferring the cases down-
ward to juvenile court. Passing from use, though still available in a few states, is
the option of the prosecutor to choose the court in which the juvenile'S case will
be heard. This locus of choice is problematic. Prosecutors are not expected to
be impartial. They are elected officials who respond not only to public pres-
sures but also to pressures from the police with whom they work.
The criteria for choosing whichjuveniles will be transferred to adult court
vary from state to state, but it is primarily the older teenager, in the 15 to 17
year age range, who becomes the subject of the transfer process. In addition to
age, seriousness of offense, seriousness of prior offenses, and discouraging
treatment prognosis are the most common criteria for determining which of-
fenders will be transferred. Specific criteria, in the order of reported frequency
of use, include the seriousness of the alleged offense; the record of the juve-
nile, including prior contacts with police, court, or other official agencies; the
manner (aggressive, violent, premeditated, or willful) in which the offense was
committed; the sophistication, maturity, and emotional attitude ofthe juvenile;
the proximity of juvenile'S age to maximum age of juvenile court jurisdiction;
whether more appropriate procedures, services, and facilities are available in
the adult court for the likelihood of reasonable rehabilitation; the possible need
for a longer period of incarceration; evidence apparently sufficient for a grand
jury indictment; whether the juvenile's associates in the alleged offense will be
charged with a crime in an adult court; the effect of judgment of waiver on the
public's respect for law enforcement and law compliance; and the community
attitude toward the specific offense. 12 (p 603)
Although the Supreme Court in Kent attempted to establish guidelines, the
existing highly subjective criteria do little to limit judges' broad discretion.
Statutory refinements of Kent have not corrected this-nor have attempts to
make firmer objective criteria for transfer. These attempts often single out
juveniles who on closer scrutiny do not appear to be serious offenders, such as
first-time offenders for whom no treatment has been attempted. They also fail
to identify persistently violent delinquents. 8(p 187) Objective criteria, when care-
fully examined, often draw on biased data, such as prior decisions regarding
arrest, prosecution, plea-bargaining, and disposition, which are often discre-
tionary and subjective, and may not reflect the child's actual behavior. 8(p 200)
Public interest is influential. There may be community indignation toward
the offense or the offender. Sometimes children are transferred "because the
court needs a scapegoat for itself and for the community."13 Heavy news media
coverage has appeared to influence decisions to transfer. 14 When the judge is
an elected, as opposed to appointed, official, it is clear that he must please the
public if he wishes to maintain his position on the bench.
Judicial transfer, then, remains fraught with ambiguity. Critics assert that
this ambiguous and discretionary waiver process does not provide the certainty
of punishment needed as a deterrent to crime. Still, however carefully legisla-
tures and courts attempt to define the standards, they tend to remain subjec-
tive. This area continues to be at least as much a governance by men as a
governce by law. Perhaps we demand too much of the judiciary. Critics ignore
the complexity of this process, which may not have a formulaic solution. It is
clear that empirical research is badly needed to clarify this area of social policy.
THE PSYCHIATRIC EVALUATION PROCESS
Operating in a complex system that, as it has historically developed, does

not itself provide clear guidelines, the psychiatrist must provide a compass for
uncharted waters. The primary role of the clinician in the juvenile transfer
hearing is to provide data that will assist the court in predicting the future. The
emphasis here is upon data, as unsupported opinions will be of little use. The
psychiatrist must provide extensive, relevant, and intelligible information for
the court to consider. The task is indeed difficult. The issues are some of
psychiatry's most problematic: prediction of dangerous behavior and predic-
tion of response to treatment. The predictions must be formulated individually
and uniquely for each child brought before the juvenile court, and the deter-
mination is an agonizing one. 6(p 295)
The diagnosis and prognosis of a child's amenability to treatment is delicate
work, to say the least. Even where treatment is concerned, diagnosis during the
early stages is very tentative and may be proven or disproven during the course
of treatment. Prognosis is, therefore, even more tentative, and one is forced to
conjecture about how any prognosis can be entertained in the absence of diag-
nosis and treatment.l 3 (p 162)
With the contemporary swing of emphasis from rehabilitation to punish-

ment, and the risk of punishments extending to the death penalty, the psychia-
trist will be acutely conscious of his responsibility. This responsibility has in-
creased in a context in which the psychiatrist must be well aware of the limits of
his scientific expertise.
Although critics call for the abolition of the amenability and dangerous-
ness standards because of the lack of empirical justification8(p 189) there is little
to offer in their place. Common sense, if nothing else, dictates focusing on the
prior record and character of the child.
Unfortunately, a realistic determination of these aspects would require extensive
psychological, psychiatric, and social evaluations of the child and his family. As
juvenile court staff are limited, often untrained, and under great pressure to
perform a variety of mandatory tasks, this psychological assessment may be
given short shrift as compared to an assessment of the seriousness of the
offense. 15
The senousness of the offense, however, appears to have little predictive

value. 16
It is well to bear in mind that "the diagnostic evaluation of the juvenile
offender is not a search for simple causes. It is, rather, an exploration of
vulnerabilities." 17(p 139) "These kinds of vulnerabilities may make him/her less
capable than his peers to cope with his emotionally stressful environment and
there to behave in socially appropriate ways."17(p 154) Finally, we are cautioned:
Conclusions as to juveniles' amenability to psychotherapy have little empirical
basis. The need for modesty may be accentuated by the observation that the best-
validated "treatment" of violent and anti-social behavior in juveniles is their
getting older! 18(p 306)
Three aspects of youthful behavior further complicate juvenile assess-

ment: 18 (p 300) (a) Juveniles, in contrast to adults, rarely wish to appear sick no
matter how advantageous this may be legally. Often assuming a "tough guy"
stance, they would infinitely prefer to be seen as "bad" rather than "mad." (b)
Inaccurately understanding the purpose of evaluation, juveniles may be sus-
picious. The teenager is more likely to be frightened by the process, and to
have magical ideas about it, believing that the examiner can read his mind. (c)
Because of the intrusiveness of the consequences into the lives ofjuveniles, they
may be realistically unmotivated to cooperate with evaluation. Because of these
parameters, it is clear that even more care must be exercised with a juvenile
than with an adult examination. Alliance building is very important.
In addition to focusing on the teenager's fantasies, the psychiatrist should
attend carefully to his own countertransference. His attitudes and feelings may
be an impairment that complicates the evaluation. Self-awareness of unreason-
able fears, denial, and rejection should be developed. 19 Fears of assault or
harm to the evaluator should be examined-are they based on fantasy or
reality? Real danger should not be minimized, and the use of a secure setting
for evaluation is recommended. A non provocative attitude is essential. Denial
of patient dangerousness by the psychiatrist can lead to failure to elicit infor-
mation about weapons, lethal skills, or past violent acts. An attitude of rejection
in the psychiatrist can be subtle, yet pronounced in its effects. In addition, the
alienation of the adolescent may be mirrored by the professional's inability to
identify in a productive way with the juvenile offender or the world he lives in.
The assessor must proceed with inquiry without unintentionally subjecting the
adolescent to interrogation bordering on degradation. There must be accep-
tance without moralizing. A different social class or ethnic background is not
an impediment to a successful interaction, provided that the interviewer gives
full attention and conveys respect and genuine interest to the teenager. Finally,
an attitude of humility and caution is recommended. 17 (p 140)
On beginning the evaluation, it is important that the forensic expert allow
adequate time to gather and assess the data required by this complex process.
The first step should be a review of all relevant documents, including police,
medical, psychiatric, social, and school reports. The areas for evaluation are
extensive. A carefully constructed developmental history will be a composite of
information gathered from home, school, workplace, and neighborhood. A
team approach may facilitate this, employing the resources of a social worker,
psychologist, and the attorney or court staff. A broad perspective in gathering
the information is important because context may be at least as relevant as
behavior.
The specific nature of the interviews should be clarified to the juvenile. It
should be explained that the evaluation is not a part of treatment, and the
juvenile must be warned that his confidentiality will not be preserved. The
expectation of a report to the court and possible court testimony about the
juvenile should be made explicit. This must be thoughtfully done, with sen-
sitivity to the child's comprehension of the situation. 20
Parents and other family members should be interviewed whenever possi-
ble. Family members can provide information to supplement that obtained
from the juvenile. A history of the mental health of other family members is of
crucial importance. Knowing about the presence of a genetically determined
psychiatric disorder may have important diagnostic and treatment implica-
tions. A clue to these may be medications used by other family members.
Understanding whatever psychopathology may be present in the parents is an
important underpinning to understanding the emotional makeup of the child.
The family atmosphere also will determine whether treatment is possible while
the child lives at home. The clinician should assess whether there is poor
familial control of hostility and aggression, physical punitiveness, or rewards
for a child's aggressive behavior. Identification with a paranoid or aggressive
parent may influence the child's behavior. Likewise, absence of family struc-
ture or poorly defined family boundaries may provide little in the way of
controls that can be internalized by the juvenile. Finally, abusive parents may
have produced a brain-damaged child, crucially altering his adaptation.
The community may be a source of information, as well as a potential

source of support.
However, it is doubtless true that the resources for significant change-or simply
for elaborate, if not necessarily effective, treatment plans-are increasingly less
likely to be available as the socioeconomic ladder is descended.18(p 305)
The academic world of the child is an important determinant of successful

adaptation. Here the basis for later work success is formed. Delinquent chil-
dren often have learning disabilities. These are even more common in violent
delinquents. 17 (p 150) Problems in auditory and visual processing and sequenc-
ing may be interfering with academic performance. An educational program
has been a strong element in successful rehabilitation efforts. Developing ver-
bal abilities enables verbalization rather than acting-out impulses. Learning to
conceptualize alternatives enables planning, which also reduces impulsiveness.
Learning how to cope more successfully with school forms a source of self
respect.
Work skills, too, are a foundation of self-esteem and economic survival.
Fellow workers and superiors are a valuable source of information regarding
interpersonal relations, coping style, and skills of mastery. This area deserves
careful focus in treatment planning, as employability reduces the motivation
for criminal activity.
Focusing on the individual's internal dynamics, the evaluation of indi-
vidual personality and psychological functioning requires a careful and wide-
ranging mental status. Apparent normality can mask a variety of clinical syn-
dromes. Attitudes, values, identifications, social perceptions, and interpersonal
skills are important to note. The evaluation should outline internal psychic
structure, including object relations, impulse control, the modulation of af-
fect-particularly anger and its expression, perception, and reality testing.
Inquiry should be made about hallucinations, dulusions, grandoise thinking,
feelings of endangerment or persecution (and acting on them by carrying
weapons or making preemptive attacks). Cognitive function should be tested,
including orientation and short-term memory. The most threatening part of
the mental status examination may be the testing of the child's ability to work
with numbers and remember digits backwards and forwards. These tasks will
be associated with schoolwork and the evocation of real impairments, such as
attention deficits and learning disabilities of which the child is partially
aware.17(p 148)
The clinician will want to understand whether previous treatments were
adequate or appropriate, and why such rehabilitative efforts may have failed.
In view of the generally unsatisfactory state of juvenile rehabilitative efforts
throughout the country, counsel for the child should always explore exactly what
has been done for the child in the past. What was the nature of prior treatment?
How frequent were efforts made to work with him? Was he really given a chance
to "resocialize," or was he placed on probation or in a "training" school and then
forgotten?12(p 605)
A careful medical history, including drug and alcohol use, is essential. Physical
and neurological examinations should be performed. A history of head injuries is
common in violent delinquents. One study showed 98.6% of extremely violent
delinquents to have one or more minor neurological signs. 17(p 152) Detailed neu-
rological histories should include questions about illnesses, accidents, injuries,
headaches, dizziness, blackouts, deja vu, macropsia, micropsia, and visual, audito-
ry, gustatory, and tactile hallucinations. Special studies-such as x-rays and other
imaging techniques, blood chemistries, electroencephalograms, neuropsycholo-
gical and projective testing-should be performed as indicated.
After all this investigation, as with adults, the clinician's report to the court
needs to be clear in form and concise in style. Medical and psychologicaljargon
should be avoided. Irrelevent data and undocumented assertions should be
eliminated. The report should contain identifying data, an introduction outlin-
ing the forensic issue (the psycho-legal question being addressed), the circum-
stances initiating referral for evaluation, the sources of information on which
the evaluation was based, a description of the offense, developmental, social,
educational, vocational, and legal history, medical history, mental status, spe-
cial studies, and conclusions to the forensic question. It bears repeating that the
psychiatrist's gift to the court is the careful reporting of observable data and the
conclusions derived therefrom. Where the data are insufficient to support an
opinion, no opinion should be offered.
CLINICAL CASE EXAMPLES
The following cases are intended to convey something of the atmosphere

of complexity, tragedy and pain that attends juvenile transfer evaluations.
Although the material has been altered to protect the identities of the children,
the stories are real, as were the consequences for their subjects.
Paul was a 16-year-old boy who was arrested for armed robbery. Previously he
had been convicted of several motor vehicle thefts, possession of burglar tools, petty
larceny, and unauthorized credit card use.
He was the third of five children in a multiproblem family. His mother was
chronically anxious and depressed. She had a "nervous breakdown" just before
Paul's first involvement with the courts, and she blamed him for her own condi-
tion. "Look what he's done to me." The mother was afraid to be home alone, and
relied on neighbors to be with her day and night. She ate little and was afraid of
death. The father was a chronic alcoholic, a weak, passive, ineffectual man who
had largely withdrawn from the family except to be verbally abusive to his wife.
He had been away at sea during most of Paul's early childhood. His one virtue was
his steady employment. The parents divorced when Paul was 14. Paul's brother
had been in residential psychiatric treatment for several years.
Paul's early growth and development had been unremarkable. He had done
average work in school until the eighth grade, when his work declined and he had
to repeat the grade. At 12 he had received a head injury in a fall from a motorcy-
cle, and at 13 he had been hit by a car and knocked unconscious for 2 days. At 14
he began to associate with an antisocial peer group-an apparent change in his
character.
Because of his prior convictions he had been placed in three different pro-
grams. He spent 6 months in a detention center, and 6 months in a Youth Forestry
Camp from which he ran away. For 2 years he was placed in a residential school,
where he showed some progress in impulse control in the context of a highly
structured sports and academic program; however, at the time of termination at
the residential school he began to abuse street drugs.
Small for his age, he was a feisty, pugnacious, argumentative boy who had
great difficulty accepting direction from anyone. Physically attractive and socially
likeable, he related easily to a variety of people, yet maintained a guarded attitude
and was always ready to go on the attack. Psychological testing was characteristic
of an impulse controle disorder, with loose, confused thinking characterized by
unconventional and aggressive fantasies. Mental status examination revealed that
his judgment, social perception, and reasoning were all impaired to some degree.
Based upon the pattern of Paul's escalating antisocial behavior, the endanger-
ment of his victims during the armed robbery, the paucity of family resources, the
failure of 3 years of residential programs to alter his delinquency, and the lack of
change in his character, the court ordered him transferred for trial as an adult.
Tanya was a IS-year-old girl who was accused of killing a male classmate by
shooting him. Tanya's conception had occurred as a result of a rape. Tanya's
mother, who had been repeatedly raped, and who was abused and abandoned by
her own alcoholic mother, had engaged in a well-documented pattern of child
abuse throughout Tanya's childhood. When Tanya was 10, the family's home in
the tropical country where she was born was destroyed by a storm. The family
moved to an urban ghetto in the United States, where two more homes burned
down. An older brother continually abused her physically. At the age of 14 she
was evaluated for suicidal thinking. That same year she was injured by leaping
from a third story window to escape a rapist.
A member of a fundamentalist religious sect, her mother set severe and
unrealistic limits on Tanya's behavior. There were continual fights with her moth-
er. Foster home placement had been recommended to the court, but not carried
out. At age 14 she began to be truant from school. She snatched a purse and was
apprehended by a mob who beat her. Briefly incarcerated, she was returned to
her home where she made a suicide attempt. A ready victim, at school she was
subject to gang violence. "Every day coming from school the gang beat me up.
Nobody would help me. They would come in the hallways and put guns to our
heads." Her efforts to protect herself resulted in fights at school. Misinterpreting
these as aggressive outbursts, a court officer had recommended probation which
was then not appropriately monitored.
On evaluation she was an attractive, emotionally available girl whose mood
was depressed. She was preoccupied with her chronic inability to solve the inter-
personal problems with which she was confronted. She felt confused and over-
whelmed, worried about physical survival in a persistently hostile and threatening
environment.
Because, despite her chaotic background, it was thought that she was able to
form a treatment relationship, that the long-term prognosis was good, and that
adequate efforts at rehabilitation had not been made, the juvenile court retained
jurisdiction. She was placed in a secure facility for the protection of public safety,
and a comprehensive educational and counselling program was arranged.
Bill was a 17-year-old boy who was accused of strangling an acquaintance

without apparent motivation. The assault occurred in a school dormitory where
the victim was perceived as "a disgusting weakling." Bill was one of three children
of professional parents. Their relationship was characterized by many verbal
fights, primarily about differences over sex roles and the father's infidelities. Two
relatives had served prison terms, and Bill felt himself to be like one of them-a
"bad seed."
A difficult, uncommunicative child, Bill had been slow in his motor develop-
ment. Bowel training had never been fully accomplished, so that he continued to
encopretic in adolescence. He engaged in stereotypical and ritualized early child-
hood behavior, was phobic, and had many temper tantrums. Unlike his siblings,
he did not make school friends. He described himself as having become in-
creasingly alienated from his family, and would "cringe" or "stiffen up" should
any family member attempt to hug him.
After his parents separated when he was 12, he began to engage in petty
theft. When 14 he made several sexual approaches to his younger sister. He wrote
notes that the family discovered, saying such things as "killing solves problems," "1
think I'll murder someone," and ''I'm proud 1 haven't been caught stealing."
Following a rejection by a girlfriend, he fled home, leaving a suicide note, and
wrecked the family car. After this episode he was seen for brief psychotherapy on
an outpatient basis.
On evaluation he was an affable but guarded adolescent boy, whose ex-
pression disclosed no feeling. He talked in a stilted intellectualized manner and
appeared internally preoccupied. Although there was no evidence of psychosis, he
showed evidence of depression and undue suspiciousness. A tendency to split,
control, and manipulate others was noted. CAT and MRl scans showed a uni-
lateral cerebellar hypoplasia. Neuropsychological testing showed graphomotor
incoordination and difficulty integrating visual-spatial material. Projective testing
was consistent with a borderline personality disorder.
Because of the severity of the crime of which he was accused, because at age
17 he could be retained in the juvenile system for less than a year, and because
suitable rehabilitative facilities were deemed not to be available, he was trans-
ferred for trial as an adult. It should be noted that the case received substantial
pretrial publicity and the judge was a candidate for reelection.
CONCLUSION
As juvenile courts struggle with their task of balancing the scales of justice,
adjusting the tares to reflect the import of both mercy (rehabilitation) and
retribution, the information provided by forensic psychiatrists assumes critical
importance. No one else is so uniquely qualified to integrate the biological,
developmental, and psychosocial data that the court needs. An understanding
of the background of the juvenile justice system, as well as the conditions that
govern its boundaries, will be a helpful addition to the clinical acumen of the
forensic psychiatrist, enabling him to make a genuinely useful contribution to

the judicial process.
REFERENCES
1. Gest T, Kyle C: Kids, crime and punishment: Police, prosecutors and courts get tougher
with chronic offenders, U.S. News and World Report, August 24, 1987, P 50.
2. QuenJM: Some historical notes on competencies and incompetencies of children. American
Academy of Psychiatry and the Law Newsletter 1987; 12: 13.
3. Black's Law Dictionary, ed 5, St. Paul, West Law Publishers, 1979, p 779.
4. Kent v United States 383 U.S. Supr. Ct. 554 (1966).
5. Bazelon D: Racism, class ism and the juvenile process. judicature 1970; 53:373.
6. SchwartzJS: The youth offender: Transfer to the adult court and subsequent sentencing.
Criminal justice journal 1983; 6:285.
7. In re Gault 387 U.S. I (1967).
8. Osbun LA, Rode PA: Prosecuting juveniles as adults. Criminology 188 1984; 22:188.
9. Kemplen v State of Maryland, 428 F.2d 169, 175 (4th Cir. 1970).
10. Golden D: Tried as adults youths escape justice: Studies show many teenage offenders get
stiffer penalties in the juvenile court system, Boston Globe, April 5, 1987, P 89.
II. President's Commission on Law Enforcement and Administration of justice Task Force Report on
juvenile Delinquency and Youth Crime, cited in Schwartz, p 307.
12. Schornhorst FT, The waiver of juvenile court jurisdiction: Kent revisited. Indiana Law
journal 1967-1968; 43:588.
13. Stamm, MJ: Transfer of jurisdiction in juvenile court. Kentucky Law journal 1973; 62: 155.
14. Mulvey EP,Judging amenability to treatment in juvenile offenders, in Reppucci ND (ed):
Children, Mental Health & the Law, Beverly Hills, Sage Publications, 1984, pp. 195-210.
15. Benedek EP: Waiver of juveniles to adult court, in Schetky DH, Benedek EP (eds):
Emerging Issues in Child Psychiatry and the Law. New York, Brunner/Mazel, 1985.
16. Feld B: Reference of juvenile offenders for adult prosecution: The legislative alternative
to asking unanswerable questions. Minnesota Law Review 1978; 62:515.
17. Lewis DO: Diagnostic evaluation of the delinquent child in Schetky DH, Benedek EP
(eds): Child Psychiatry and the Law, New York, Brunner/Mazel, 1980, pp. 139-155.
18. Melton GB, Petrila j., Poythress NG, et al. Psychological Evaluations for the Courts, New
York, Guilford Press, 1987.
19. Strasburger LH: The treatment of antisocial syndromes: The therapist's feelings, in Reid
WH (ed): Unmasking the Psychopath New York, W.W. Norton, 1986, pp 191-207.
20. Grisso T,juveniles' Waiver of Rights, New York, Plenum Press, 1981, p 131.
Index
Abandonment fear, in incestuous families, Admission to psychiatric hospital of

94,95 juveniles (Cont.)
Abscess of brain, 308-309 in emergency, 322, 354-355
Abstract thoughts of adolescents, 291-292 inappropriate, 328
affecting interviews, 204 of out-of-state adolescent, 324, 325
Abuse parental consent to, 319-322, 384
of children, 85-132, 272, 282-284. See racial factors in, 265
also Child abuse requirements for hearings in, 319-320,
of self, seclusion and restraint in, 357, 321, 322, 355
359, 361, 365 restraint use in, 361
of substances, 237-256. See also state laws concerning, 319, 320-322,
Substance abuse 324, 354, 355
Accidental i~uries of children, 285-286 Adolescence
in alcohol use, 296 of blacks, 257-270
death rate in, 272, 282, 285, 292 causes of death in, 292, 296-297
Accommodation, in child sexual abuse confidentiality and consent issues in,
syndrome, 111-112 297-298, 384, 386-388
Accountability for behavior definition of, 289
age as determinant of, 3-4, 5, 392 developmental issues in, 199-236,289-
of dangerously violent juveniles, 335, 292
340 medical issues in, 289-306
and externalization of blame, 67 neurologic disorders in, 307-316
and restraint use, 374-375 psychiatric hospitalization in, 319-331
Acting out right to psychiatric care in, 381-390
in conduct disorders, treatment of, sexual offenses in, 133-143
232-233 substance abuse in, 237-256, 295-
in depression, 224, 227 296
psychodynamic approach to, 45-46, suicide in, 296-297
49-50, 53 Adopted children, in research studies
of sexual abuse victim, 97 on hyperactivity, 78
Admission to psychiatric hospital of on violent behavior, 30-31
juveniles Advertisements, inappropriate use of chil-
compared to commitment of adults, dren in, 148
353-354 Affect regulation disorders of adolescents,
in dangerously violent behavior, 339- 222, 223, 224, 226, 228
340 Age
due process rights in, 319-322, 346, and accountability for behavior, 3-4, 5,
354-355 392
405
406 INDEX
Age (Cont.) -y-Amino butyric acid levels, and violent

and consent in sex between children behavior, 40, 41
and adults, 97, 145-180 Amotivational syndrome in marijuana use,
at initiation of conduct disorder, 73 249
and problems in evaluation of psycho- Amphetamines, abuse of, 239, 240, 251
pathology in adolescents, 220-221 Anger
of sex offender, 152, 154-175, 176, of adolescent sex offender, training for
177, 178-179 control of, 141-142
of sexual abuse victims, 109, 146 of psychiatrist, in interviews with ado-
legislation related to, 149, 152, 154- lescents, 204
175,176,177,178-179 Angiography, indications for, 316
and transfer for trial as adult, 392, 395 Anticonvulsant drug therapy, 41-42, 315
Age-of-consent laws, 145-180 in episodic dyscontrol syndrome, 38
historical, 5, 6 Antidepressant drugs, 228-229, 231
proposed model for, 150-151, 153, Antisocial behavior, 65-82
176-180 accountability of children for, 374-375
state differences in, 149, 153-153, 154- compared to attention deficit disorder
175 physiological similarities in, 65-66
Aggressive behavior. See Violent and ag- psychological similarities in, 66-67
gressive behavior of dangerously violent juveniles, 334,
Aichhorn, August, psychodynamic ap- 335, 340
proach of, 46, 50, 55 development from attention deficit dis-
AIDS, 145, 149,293-294,295 order, 68-71, 72-73
encephalopathy in, 309 deviant sexual behavior of adolescent
legislation on sexual activities in, 177, in, 135
178 diagnostic assessment of, 72, 221, 222
psychiatric hospitalization in, 328 inappropriate, 200-201, 203
Alabama, age-of-consent statutes in, 154 genetic studies on, 30
Alaska, age-of-consent statutes in, 154 physiological studies on, 65-66, 77
Alcohol use research statistics on, 72-75
of adolescents, 239, 295, 296 sexual abuse of children in, 122, 124
accidental injuries in, 296 in sexual abuse victims, 145, 147
assessment of, in medical interview, testosterone levels in, 31
302 transfer of juvenile for trial as adult in,
epidemiology of, 240, 296 401
intoxication in, 250 West and Farrington study on, 21
legal implications of, 237, 238 Anxiety of sexual abuse victims, 96-97
as moral and medical issue, 123 and post-traumatic stress disorder, 97,
patterns of, 245 98, 108, 113
psychoactive and adverse effects of, Arizona, age-of-consent statutes in, 155
249, 250 Arkansas, age-of-consent statutes in, 149,
psychological factors in, 243, 244 155
sexual offenses in, 137, 138 Armed robbery by juvenile, transfer for
sociological factors in, 242 trial as adult in, 400-401
treatment of, 248 Assertiveness, in psychodynamic approach
as facilitator of aggressive behavior, 40 to juvenile delinquency, 52-54, 59-60
of parents Assessment
of hyperactive children, 78 of black adolescent, 257-270
and incest, 89, 93 developmental considerations in, 199-
Alexander, Franz, psychodynamic ap- 236
proach of, 46-47 in medical care of adolescent, 300-305
Aliens, illegal, problems in psychiatric interview in, 300-303
hospitalization of, 323-324 physical examination in, 303-305
INDEX 407
Assessment (Cont.) Behavioral approach

in psychiatric hospitalization of adoles- to sexual abuse
cent, 320, 328-329 in assessment of offender, 90-91,
of psychopathology in juveniles, 183- 100, 125-126
197, 219-227 in juvenile offender, 139-142
of restraint use, 367-375 in treatment of offender, 125-126,
of sex offenders 139-142
adult, 90-91, 100, 119-132 to violent behavior, 337, 338
juvenile, 137-138 restraint use in, 357-359, 374
of sexual abuse victim, 11 0-111 Benzodiazepines
in transfer of juvenile for trial as adult, abuse of, 244, 249
396-400 in aggressive behavior, 42
Attention deficit disorder, 65-82, 223, Beverly v Snow, 5
226, 311-312 Biblical references
cholesterol serum levels in, 31 to incest, 86
compared to antisocial behavior, 65-67 to juvenile criminality, 5
physiological similarities in, 65-66 Biochemical studies on violent behavior,
psychological similarities in, 66-67 31-32
and conduct disorders, 65, 70, 71, 223 Biological factors
delinquent behavior in, 33-34, 78-79 in antisocial personality, 65-66
development into antisocial personality, in attention deficit disorder, 33-34, 65-
68-71, 72-73 66
deviant sexual behavior of adolescent as cause of delinquency, 29-44
in, 136, 137 biochemical studies on, 31-32
diagnostic criteria for, 67 genetic studies on, 30-31
family studies in, 76, 77-78, 312 in learning disability and retardation,
follow-up studies on, 72 34-35
incidence of, among school children, in neurologic disorders, 35-39
69, 70 neurotransmitters in, 32, 40-41
neurologic disorders in, 33-34, 65-66, physiological studies on, 22-23, 32-
67,223,311-312 33
offender rate in, 75-77 treatment of, 41-42
research statistics on, 72-77 in conduct disorders, 33-34
substance abuse in, 244 in sexual abuse, 90, 124
treatment of, 231 in defense of offender, 130-131
drug therapy in, 41, 72, 75, 78-79, in juvenile offender, 138-139
312 in treatment of offender, 126-129,
multimodal approach in, 75, 78-79, 138-139
80 Bird, Brian, psychodynamic approach of,
Attitudes 47
of public, affecting transfer of juvenile Birth control methods of adolescents, 294,
for trial as adult, 396, 402 295
social, toward juvenile justice system, assessment of, in medical interview,
394 302
of staff, on restraint use, 348-349, 361, confidentiality concerning, 384, 386
363 Birthrate for adolescent girls, 294
Autonomic reactivity in psychopathy, 23, in black population, 258, 294
32-33, 67, 77 Black adolescents, 257-270
arrest rate of, 259-260
Barbiturates, abuse of, 239, 240, 241, 296 and harassment by police, 262-263
psychoactive and adverse effects of, crime statistics on, 259-261
249-250 forensic assessment of, 257-270
Battered child syndrome, 108 case examples on, 262, 263, 264
408 INDEX
Black adolescents (Cont.) Central nervous system (Cont.)

forensic assessment of (Cont.) stimulants of, abuse of, 245, 246, 251-
cultural paranoia affecting, 262, 263, 252
265 Cerebral palsy, 308, 311
diagnostic considerations in, 265-267 Cerebrospinal fluid, serotonin levels in,
on intellectual functioning, errors in, and violent behavior, 30-31, 40, 41
264-265, 266 Character disorder in adolescence, struc-
incarceration of tured,222
compared to hospitalization of white Chemical restraint, 360-361
offenders, 265 Child abuse, 85-132, 272, 282-284
as stressful experience, 263 brain damage in, 223, 308, 398
lack of psychiatric literature on, 261 detection of, 282-283
pregnancy of, 258, 294 historical aspects of,S, 6
socioeconomic factors affecting, 258- history taking in, 283
259, 262-263, 266 incidence of, 282
stress of, 263 legal definition of, 282
unique problems of, 257-258 medical interventions in, 284
as victims of crime, 260, 261 psychiatric hospitalization of victim in,
Blame, externalization of, 67 97, 325
Body type and criminal behavior, associa- sexual, 85-132. See also Sexual abuse
tion of, IS, 17, 22-23 and violent behavior of victim, 38, 39,
Bohn, M.J., Jr., on personality traits of 401
offenders, 19, 20, 24-25 Child protection organizations, historical
Borderline conditions in adolescence, development of, 8
222-223 Child sexual abuse accommodation syn-
diagnosis of, 220-221 drome, III
and follow-up study of adults, 221 Chlamydial infections of adolescents, 293,
substance abuse in, 244, 245 305
treatment of, 231, 232 Chlorpromazine, in schizophrenia, 326
Brain disorders, 223, 307-309. See also Cholesterol levels in serum, and violent
Neurologic disorders behavior, 31
Breast Chromosome abnormalities
development in adolescence, 289 aggressive behavior in, 30-31
examination of, in medical care of ado- fragile X syndrome in, 308, 310
lescent, 303-304 mental retardation in, 308, 310
neurologic disorders in, 308
California, age-of-consent statutes in, 156 Cigarette use by adolescents, 296
Cannabis. See Marijuana use Cocaine use, 239
Capital punishment epidemiology of, 240, 241, 242
attitude toward, and stage of moral de- neurologic effects of, 244
velopment, 213 patterns of abuse in, 245, 246
for crimes committed as juvenile, 391, psychoactive and adverse effects of,
397 251-252
historical aspects of, 5-6, 7 psychological factors in, 244
Carbamazepine Cognitive approach to treatment
in epileptoid disorders, 42 of adolescent sex offender, 139-142
in episodic dyscontrol and aggressive of dangerously violent juvenile, 340,
behavior, 38 341
Central nervous system Cognitive development, 204-209, 291-
depressants of, abuse of, 244, 245, 249- 292
250 abstract thought stage in, 204, 291-292
disorders of, 223. See also Neurologic assessment of, in transfer of juvenile for
disorders trial as adult, 205, 399
INDEX 409
Cognitive development (Cont.) Conduct disorders (Cont.)

in concrete operational phase, 206-208 incidence of, among school children,
in formal operational phase, 204, 205, 69,70
207,208 treatment of, 231, 232-234
and impulsive behavior, 205, 208 limit setting in, 232-234, 236
and inconsistent functioning at higher role of courts and police in, 234
level,205 unsocialized, 68, 69
and McNaughten test for insanity, 205 Confidentiality
in mental retardation, 310 in assessment of juvenile sex offender,
and moral development, 214-215 137
and peer relationships, 207, 211-212 in juvenile justice system, 393
in preoperational phase, 205-206, 207 liability issues in, 387, 388
stages of, 205-208 in medical care of adolescents, 297-
and stress response, 205, 207, 208 298, 384, 386
Colorado, age-of-consent statutes in, 156 in correctional system, 299
Commitment to psychiatric hospital. See and notification of parents, 386-387
Admission to psychiatric hospital of and notification of schools and other
juveniles third parties, 388
Communication in interviews, 186-187, in psychiatric care of adolescents, 384,
201, 230 386-388
with black adolescents, 263-264 and right to privacy, 386
cognitive development of adolescent af- in substance abuse, 384, 386, 388
fecting, 204 in suspected child abuse, 284
nonverbal, 204 in transfer of juvenile for trial as adult,
in transfer of juvenile for trial as adult, 398
398 Congenital neurologic disorders, 308
Compensation of sexual abuse victims, Connecticut state laws
legislation concerning, 151, 180 on age of consent, 149, 157
Competence on restraint of children, 371
age as determinant of, 3-5, 392 Connors Teachers Rating Scale, 68, 70
historical aspects of, 3-5, 392 Consent
of juvenile to stand trial, 187, 194-195, to marriage, age at time of, 5, 6
201 in medical care of adolescents, 298
of legally disabled groups, 5 in psychiatric care of adolescents, 381,
and perfect insanity standard of Hale, 4 382-386
of professionals assessing juvenile psy- in admission to psychiatric hospital,
chopathology, 188-189, 195 319-323
Computed transaxial tomography, in neu- and capacity for informed consent,
rologic disorders, 315-316 385-386
Concrete operational phase of cognitive doctrine of mature minor on, 384-
development, 206-208 385
Conduct disorders, 33-34, 68-71, 72, 73 of emancipated minors, 383-384
acting out in, 232-233 in emergencies, 381-382, 383
age at initiation of, 73 and financial liability for treatment,
and antisocial personality, 73 388-389
assessment of, for legal purposes, 192- liability issues in, 383, 385
194 parent refusal in, 381, 383
and attention problems, 65, 70,71,223 statutory laws on, 384
of black adolescents, 267 in sex between children and adults,
in depression, 227 97
deviant sexual behavior of adolescent and age-of-consent laws, 145-180
in, 135 Continuing medical education courses,
diagnosis of, 221, 222, 224 188-189
410 INDEX
Contraceptive use in adolescence, 294, 295 Criminogenic traits, 13-28

assessment of, in medical interview, 302 body type as, 15, 17, 22-23
confidentiality concerning, 384, 386 corroborating studies on, 17-21
Control, external, need of children for, definition of, 13
352 Eysenck study on, 18, 23
and use of restraints, 352-353 Glueck study on, 14-17
Convulsions. See Seizures inheritance of, 25, 26
Cooperative behavior of juvenile institutionalization affecting, 20-22
in interviews, 200, 397 intelligence as, 14, 15, 24-25
for assessment of psychopathology, Megargee and Bohn study on, 18-20,
186, 187, 189 24-25
moral and cognitive development af- physiological factors in, 22-23
~ctin~ 20~ 211, 213 and predisposition for criminality, 23,
in restraint process, 356-357 25-26
in seclusion, 359 and Q score on Porteus maze tests, 17-18
Countertransference problems West and Farrington study on, 21-22
in psychiatric evaluation process, 397- Cultural factors
398 in attitudes toward juvenile criminality,
in psychodynamic approach to juvenile historical, 3-4
delinquency, 48-49, 51 in average age of menarche, 290
in treatment of dangerously violent ju- in incest taboo, 86-87
veniles, 340-341 in moral development, 209
Court for juveniles in paranoia of blacks, 262
historical aspects of, 9, 392 in risk for HIV infection, 294
role in treatment of conduct-disordered in substance abuse, 245
adolescent, 234 Custody disputes, allegations of child
and transfer for trial as adult, 391-403 abuse in, 113, 114
Courtroom testimony Cyproterone acetate, for sexual offenders,
of child, on sexual abuse, 109, ll4-117 127, 139
of expert, on sexual abuse of child,
109-ll0 Death
of psychiatrist of adolescents
on psychopathology of juvenile, 184, in black population, 260
187-188, 189 common causes of, 272, 292, 296-
on sexual abuse of child, 107-108 297
Covert sensitization technique, in treat- of infants, 271, 272, 282
ment of adolescent sex offender, sudden, 284-285
139, 141 Death penalty
Crack form of cocaine, 240 attitude toward, and stage of moral de-
psychoactive and adverse effects of, velopment, 213
251-252 for crimes committed as juvenile, 391,
Credibility of statements 397
of expert on child sexual abuse, 109- historical aspects of, 5-6, 7
110 Defense to prosecution
of juveniles, 20 I of insanity
in assessment of psychopathology, historical aspects of, 4
186, 187, 189-190, 191,201 in sexual abuse, 129-132
in sexual abuse, 109, 112, 113-114, in sexual abuse
115 of insanity, 129-132
in transfer for trial as adult, 397 legislation related to, 179-180
of psychiatrist Defiance, in psychotherapy of delinquent,
on psychopathology of juvenile, 184, 54
187-188, 189 Defining Issues Test, in assessment of
on sexual abuse of child, 107-108 moral development, 213-214
INDEX 411
Degenerative encephalopathy, 309 Developmental issues in adolescence (Cont.)

Delaware state laws affecting interviews (Cant.)
on age-of-consent, 157 in assessment of psychopathology,
on monitoring of child in restraint or 187, 191
seclusion, 365 cognitive, 204-209, 291-292
Delinquency, definition of, 29 emotional, 203, 208-209
Delirium tremens, 250 moral, 204, 205, 207, 209-216
Denial of sexual offense physiologic, 289-291
by adolescent, 137, 140 psychologic, 219-236, 291
in incest, 94, 108, 112 psychosexual, 5, 291
Dental problems of adolescents, 299, 303 social, 292
Dependence on drugs, 239-240, 245, 252 Deviant behavior
Depressant drugs, abuse of, 244, 245 psychodynamic approach to, 46, 47, 48
psychoactive and adverse effects of, sexual, 90-91
249-250 of adolescent, 135, 140-141
Depression, 19, 224-229 behavioral approach to, 90-91, 140-
acting out behavior in, 224, 227 141
assessment of, in medical interview, Devitalized damaged children, 226, 228
302-303 Devitalized deprived children, 225-226,
bipolar, 223, 226, 228-229 228
of black adolescents, 266 Dilantin
conduct disorders in, 227 in epileptoid disorders, 42
of dangerously violent juveniles, 334, in episodic dyscontrol and aggressive
340 behavior, 38
and devitalized damaged children, 226, Diplegia, spastic, in cerebral palsy, 311
228 Disabled groups, legal incompetence of, 5
and devitalized deprived children, 225- Discharge from facility, behavioral prob-
226, 228 lems in, 340, 360
diagnosis of, 224-225 Disclosure of sexual abuse
of everyday life, 225, 227 credibility of, 112
of incest victims, 97, 98 in medical interview with adolescent,
neurotic, 225, 227-228 302
reactive, 225, 227 Disruptive behavior, restraint use in,
schizophrenia-related, 226-227, 229 357
and substance abuse, 244 Dissociative phenomena in sexual abuse
treatment of, 226, 227-229, 230-231 victims, 151
drug therapy in, 228-229, 231 District of Columbia laws
unipolar, 223, 226, 228 on age of consent, 157
Deprivation in childhood on seclusion and restraint of children,
delinquency as result of, in psycho- 358
dynamic approach, 46 Divorce cases, allegations of child abuse
and depression of devitalized deprived in, 113, 114
adolescents, 225-226, 228 Doctrine of mature minor, and consent
Desertion, fear of, in incestuous families, requirements for psychiatric care,
94, 95 384-385
Destructive behavior, restraint use in, 357 Drive theory
Detoxification in substance abuse, 247 criminal behavior in, 45
Developmental issues in adolescence, 199- sexual behavior in, 92
236, 289-292 Drug abuse, 237-256. See also Substance
affecting assessment of psycho- abuse
pathology, 184-185, 187, 191, 192, Drug therapy
220 anticonvulsant, 41-42,315
affecting interviews, 200, 204-216, in episodic dyscontrol and aggressive
229-230 behavior, 38
412 INDEX
Drug therapy (ConI.) Ego

in attention deficit disorder, 41, 72, 75, in psychodynamic approach to juvenile
78-79, 312 delinquency, 46, 48, 49
and delinquency outcome, 78-79 sexual abuse affecting development of,
and development of antisocial behav- 96, 97
ior, 72 Egocentric stage of cognitive develop-
and offender rate, 75 ment, 205-206
as chemical restraint, 360-361 Elan program, 231
in depression, 228-229, 231 Electroencephalography, 314-315
in psychiatric hospitalization in aggressive and violent behavior, 37,
problems in, 329 38, 39, 334-335
in violent behavior, 340, 341 in seizures, 223, 314-315
in psychosis, 41, 231 Elmira Reformatory in New York, 8, 9
in schizophrenia, 326 Emancipated minors
for sex offenders, 127-129, 139 consent for psychiatric care of, 383-384
in violent behavior, 40, 41-42, 340, definition of, 383
341, 360-361 Emergency care
Due process rights in psychiatric hospi- admission to psychiatric hospital in,
talization, 319-322, 346, 354-355 322, 354-355
Duty to social order, and stage of moral exception to parental consent require-
development, 210, 211, 212 mentin, 381-382, 383
Dyscontrol syndrome, episodic, 36-38, liability for, in lack of parental consent,
312-313 383
Emotional development of adolescents,
Economic factors 203, 208-209
affecting black adolescents, 258-259, Employment
262-263, 266 assessment of
in comparison of therapeutic interven- in medical interview with adolescent,
tions in attention deficit disorder, 301
80 in transfer of juvenile for trial as
as determinant of substar.ce abuse, 243 adult, 399
in differential treatment of delinquents, of black adolescents, 258, 259
60 Encephalitis, herpes simplex, 308
in medical care, 272-273 Encephalopathy, 307-309
in psychiatric care progressive, 307, 308, 309
of adolescent without parental con- static, 307-308, 309
sent, 388-389 England
in health insurance coverage, 61 historical aspects of juvenile justice sys-
of illegal aliens, 323-324 tem in, 4, 6, 7, 392
Educational programs restraint of children in, 350, 351
anger control training in, for adolescent Entrapment phase, of child sexual abuse
sex offender, 141-142 syndrome, 111-112
assessment of adolescent interest in, Epilepsy, 313-314. See also Seizures
301 Epileptoid disorders
for dangerously violent juveniles in psy- aggressive behavior in, 37
chiatric hospital, 339 anticonvulsant drug therapy in, 41-42
in prevention and treatment of sub- Episodic dyscontrol syndrome, 312-313
stance abuse, 246-247 aggressive behavior in, 36-38
for prisoners, on morality, 211, 215 Erection response of sex offenders, 91,
for psychiatrist, on assessment of juve- 100, 125-126
nile psychopathology, 188-189, 195 adolescent, 138, 140-141
sex education classes in, for adolescent Ethical issues
sex offender, 142 in assessment of juvenile for legal pur-
for staff, on restraint use, 361-363 poses, 183-184,201
INDEX 413
Ethical issues (Cont.) Fathers. See also Parent(s)

in notification of parents of treatment. biologic and stepfathers, in incestuous
386 families, 88
Evoked response testing, in neurologic personality of, in incestuous families,
disorders, 315 110
Exhibitionism, of adolescents, 135, 136 sexual abuse of daughters by, 88, 93-
Expert testimony 95,99-100, 100. See also Sexual
on juvenile psychopathology, 184, 187- abuse
188, 189 sexual attractiveness of children to, 90
education and training for, 188-189 Fears
on sexual abuse of child, 109-110 in incestuous families, 94, 95, III
Explosive personality disorder, 223 of staff, in violent behavior of juvenile,
Externalization of blame, 67 366, 397-398
Extroversion and criminal behavior, asso- of violent hospitalized juveniles, of ho-
ciation of, 16, 18 mosexuality, 335, 336
Eysenck, S.B.G., on criminogenic traits, Femininity-masculinity scores, on Min-
18, 23 nesota Multiphasic Personality In-
ventory, 19
Family. See also Parent(s) Films, inappropriate use of children in,
of adolescent sex offender, 134, 138 148, 178
in treatment program, 139, 140 Financial aspects. See Economic factors
assessment of Flashback phenomena, in substance abuse,
in juvenile psychopathology, 190, 249, 253
191, 193 Florida state laws
in medical interview with adolescent, on age-of-consent, 157
301 on restraint of children, 371
in transfer of juvenile for trial as Foster homes, historical development of, 8
adult, 398 Fragile X syndrome, 308, 310
in attention deficit disorder, 76, 312 France, restraint use in, 349-350
of black adolescents, 258, 266, 267 Freud, Anna, psychodynamic approach
of dangerously violent juveniles, 334, of, 47, 52, 55
335 Freud, Sigmund, 45-46
of devitalized deprived children, 225- on effects of incestuous victimization,
226, 228 95
as factor in substance abuse by adoles- on incest taboo, 86-87
cents, 242, 243, 245 psychodynamic approach of, 44
of hyperactive child, 77-78 on sexual behavior, 92
involvement in restraint process, 367 Friedlander, Kate, psychodynamic ap-
sexual abuse of children in, 85-118. See proach of, 47
also Sexual abuse Friends. See Peer relationships
Family therapy, 202 Frotteurism of adolescents, 135
with adolescent sex offender, 139, 140 Functional assessment of juvenile psycho-
in incest, 98-99, 117, 139 pathology for legal purposes, 190-
Fantasies 192
of delinquent adolescents, in psycho- chart of, 191-192
dynamic approach, 48-49 developmental issues in, 192
sexual Functional juvenile delinquency, com-
of adolescent sex offenders, 135, 136, pared to structural type, 47, 48
137, 140-141
in behavioral approach to deviant Gaebler Children's Center, 375
sexual behavior, 91, 140-141 Gang behavior, psychodynamic approach
in psychoanalytic approach, 92 to, 47-48
Farrington, P.D., on criminogenic traits, Genetic factors
21-22 in neurologic disorders, 308, 310
414 INDEX
Genetic factors (Cont.) Hawaii, age-of-consent statutes in, 158

in predisposition for criminality, 25, 26 Headache, in brain tumors, 309
in violent behavior, 30-31 Head injury, 35, 315
Genitals of abused child, 223, 308, 398
development in adolescence, 289-291 Health care, 271-306. See also Medical
examination of, in health care of ado- care
lescent, 303 Health insurance coverage for psychiatric
Georgia state laws interventions, 61
on admission of child to psychiatric hos- Healy, William, on juvenile delinquency,
pital, 319-321 9-10
on age of consent, 158 Hearing tests, in health care of adoles-
on seclusion and restraint of children, cents, 303
358 Hearings
Glover classification of juvenile delin- for admission to psychiatric hospital,
quents,47 319-320,321,322,355
Glueck study on male delinquency, 14-17 for trial of juvenile as adult, 391-403
Gonorrhea, in adolescents, 293, 305 Heinz dilemma, in assessment of moral
Gratification development, 209-210, 211, 213
immediate, need for, of dangerously vi- Helplessness feelings of sexually abused
olent juveniles, 337 child, III
in psychodynamic approach to juvenile Hemiparesis in cerebral palsy, 311
criminality, 46, 47, 52, 53-54 Hemiplegia in cerebral palsy, 311
Group counseling Heroin use in adolescence, 246, 296
of dangerously violent juveniles in psy- psychoactive and adverse effects of,
chiatric hospital, 339 252-253
of sex offenders Herpes simplex infections, 293
adolescent, 141 encephalitis in, 308
adult, 127, 128 Hindeland, j., on intelligence and crimi-
Group homes nal behavior, 25
placement of devitalized deprived chil- Hirschi, T., on intelligence and criminal
dren in, 226, 228 behavior, 25
substance abuse treatment in, 248 Historical aspects, 3-11, 391-392
Growth and development in adolescence, of child protection organizations, 8
physiologic, 289-291 of competence standards, 4-5
Guilt feelings, in psychodynamic approach of incest taboo, 86-87
to criminality, 46-47 of legal rights of adolescents, 382
of legislation on juvenile criminality, 5-
Hale, Mathew, perfect insanity standard 7, 391-392
of,4 of psychodynamic approach, 45-48
Hallucinations of reformatory system, 8-9, 392
in alcohol withdrawal, 250 of restraint use, 346, 349-350, 367
of dangerously violent juveniles, 334, History taking
335 in child abuse and neglect, 283
psychiatric hospitalization in, in multi- in medical care of adolescent, 297, 300-
ple handicaps, 327-328 303
Hallucinogens, abuse, of 239, 245 reliability of information in, 189-190,
psychoactive and adverse effects of, 191
253-254 in transfer of juvenile for trial as adult,
Handicaps, multiple, problems in psychi- 398
atric hospitalization of adolescents HIV infection in adolescents, 293-294,
with, 325-328 305
Hare, R.D., on physiological factors in Homeless adolescents, problems in psychi-
psychopathy, 23 atric hospitalization of, 325
INDEX 415
Homicide Hospitalization, psychiatric (Cont.)

by juvenile in violent behavior, 333-343. See also
evaluation for trial as adult in, 401- Violent and aggressive behavior,
402 psychiatric hospitalization in
historical punishment for, 7 Hostility, in psychoanalytic approach to
incidence of, 391 sexual behavior, 92
juveniles as victims of, 272, 282, 285 Huntington's disease, 308
and adolescent death rate, 292 Hyperactivity, 33-34, 78
in black population, 260 attention deficit disorder with, 65-82,
and drug use, 296 223, 226. See also Attention deficit
Homosexuality disorder
of adolescents, 295 behavior and symptoms in, 74
assessment of, in medical interview, family studies in, 77-78
302 and psychopathy in adults, 74
fear of, in violent hospitalized juve- substance abuse in, 244
niles, 335, 336 treatment of, 231
pedophilia in, 128 and delinquency outcome, 79
Hormone levels Hypnotic drugs, abuse of, 239
and sexual behavior, 126-129, 138-139 psychoactive and adverse effects of,
and violent and aggressive behavior, 249-250
31-32 Hypochondriasis, 19
Hospitalism syndrome, 286 Hypoglycemia, aggressive behavior in, 31
Hospitalization, psychiatric, 317-378 Hypomania scale of Minnesota Multi-
admission of juvenile in. See Admission phasic Personality Inventory, 19,
to psychiatric hospital of juvenile 20, 23
adolescent as victim in, 319-331 of black adolescents, 266
of AIDS-exposed adolescent, 328 Hypothyroidism, 308, 310
of child abuse victim, 97, 325 Hysteria, 19
in conduct disorders, 233, 234 in parents of hyperactive children, 78
diagnostic problems in, 328-329
drug therapy in, 329 Idaho, age-of-consent statutes in, 158
in violent behavior, 340, 341 Idealization in therapeutic relationship, in
due process rights in, 319-322, 346, psychodynamic approach to juve-
354-355 nile criminality, 46, 50, 54, 56
in emergency, 322, 354-355 Illegal alien adolescents, problems in psy-
hearing requirements in, 319-320, 321, chiatric hospitalization of, 323-324
322,355 Illinois state laws
of homeless adolescents, 325 on age of consent, 158-159
of illegal alien adolescents, 323-324 on seclusion and restraint of children,
inappropriate, 328 358
in multiple handicaps, 325-328 Immunizations, in medical care of adoles-
of out-of-state adolescents, 324, 325 cent, 305
parental consent to, 319-322, 384 Immunodeficiency syndrome, acquired.
problems related to domicile in, 323-325 See AIDS
problems related to placement in, 325- Impulsive behavior
328 of adolescent sex offender, 136, 137
psychodynamic approach in, 50-52, 53 in chromosome abnormalities, 30
racial factors in, 38, 265 in conduct disorders, 323, 233
restraint use in, 345-378 of criminal population, 22
rights of adolescents in, 329 in hyperactivity, 33
substance abuse treatment in, 247 psychodynamic approach to
treatment problems in, 329 in current models, 49, 50
related to personnel, 329 in historical models, 46, 47, 48
416 INDEX
Impulsive behavior (Cont.) Interviews (Cont.)

and Q score on Porteus maze test, 18 with black adolescents, 263-264
and stage of cognitive development, communication in. See Communication
205, 208 in interviews
Incest, 85-118. See also Sexual abuse on competence of juvenile to stand trial,
origin of term, 85 194-195,201
Indecent exposure to minors, legislation cooperation of juvenile in, 200, 397
on, 177-178, 179 in assessment of psychopathology,
Indiana, age-of-consent statutes in, 159 186, 187, 189
Infants countertransference problems in, 397-
mortality rate of, 271, 272 398
prolonged hospitalization of, psycho- developmental issues affecting, 200,
social effects of, 286 204-216, 229-230
sudden death of, 284-285 in assessment of psychopathology,
Informed consent. See also Consent 187, 191
individual capacity for, 385-386 establishment of rapport in, 200, 201,
and withholding of information, 386 202
Inheritance ethical issues in, in assessment of psy-
of criminogenic traits, 25, 26 chopathology, 183-184,201
of neurologic disorders, 308, 310 honesty of interviewer in, 202, 204, 230
of violent behavior, 30-31 humor in, 230
Insanity inappropriate diagnosis of antisocial
cognitive test of, applied to adolescents, personality of juveniles in, 200-
205 201, 203
as defense to prosecution language and vocabulary used in, 186-
historical aspects of, 4 187, 201, 230
in sexual abuse of children, 129-132 in medical care of adolescent, 300-303
Insight-oriented psychotherapy, in ped- confidentiality issues in, 297
ophilia, 125 mistrust of adults by juvenile affecting,
Institutionalization 184,201,202
in attention deficit disorder open-ended questions in, 200
compared to multi modal therapy, 80 power struggles in, 203, 229-230
rate of, 75, 76, 77 rebellious attitude of adolescent affect-
effect on criminal behavior, 20-22 ing, 202
Insurance coverage for psychiatric care, 61 reliability of personal history in, 186,
Intellectual limitation, in neurologic disor- 187,189-190,191,201
ders, 223 role of family in, 190, 202
Intelligence quotient silent periods in, 200
of black adolescents, 264-265, 266 timing of interpretations in, 203-204
of criminal population, 24-25 in transfer of juvenile for trial as adult,
of juvenile delinquents, 14, 15, 34-35 397-398
in mental retardation, 34-35, 310 videotaping of, in sexual abuse, 110,
of violent juveniles, 34, 334, 339 116
Intercourse with minors. See also Sexual Intrafamilial child sexual abuse, 85-118.
abuse See also Sexual abuse
legislation on, 176-177, 178-179 Introversion, 19
Internal psychological structures, in psy- Iowa, age-of-consent statutes in, 160
chodynamic approach, 52, 53, 55
in historical models, 45, 47 Johnson, A.M., psychodynamic approach
Interviews, 199-217 of,47
anger of psychiatrist in, 204 Judges
in assessment of juvenile psycho- in juvenile justice system, discretionary
pathology for legal purposes, 186- powers of, 393, 396
187, 189-190, 191 in review of restraint use, 355, 358
INDEX 417
Justice, concept of, and stage of moral Legislation (Cont.)

development, 212 on seclusion and restraint of children,
Juvenile, definition of, 3 345, 346, 347, 350-351, 356, 358,
Juvenile imposter concept, 46, 55 359-360
Juvenile justice system on duration of, 371-372
goals of, 392-393 on initiation of, 364
historical aspects of, 3-11, 391-392 on monitoring of child in, 365, 366
rights of juveniles in, 393-394 on sexual abuse, 145-180
social attitudes toward, 394 need for uniformity in, 149, 150
and transfer of juvenile for trial as statute of limitations in, 151, 180
adult, 394-403 Supreme Court decisions on. See
Supreme Court decisions
Kansas, age-of-consent statutes in, 160 on treatment of juveniles as adults in
Kent decision, 396 criminal justice system, 333, 394-
Kentucky state laws 396
on age of consent, 160-161 Liability
on seclusion and restraint, 358 in lack of consent for emergency care,
Kindling phenomenon in seizures, 37 383
Kohlberg, 1., on stages of moral develop- in negligent care, 385
ment, 204, 205, 209-210, 211, 212, in notification of parents of treatment,
213,215,216 387
in wrongfully disclosed material, 388
Laboratory screening, in health care of Limit setting
adolescent, 304-305 in psychodynamic approach to juvenile
Laws. See Legislation criminality, 52
Lawyers restraint use in, 362, 363
affecting hospital treatment of delin- in treatment of conduct disorders, 232-
quent, 51-52 234, 236
and right of juveniles to counsel, 393, Lithium, antiaggressive effects of, 40-41, 42
395 Louisiana, age-of-consent statutes in, 161
Leadership, in psychodynamic approach LSD, psychoactive and adverse effects of,
to treatment of delinquent, 51 253, 254
Learning problems Lysergic acid diethylamide, psychoactive
in attention deficit disorder, 312 and adverse effects of, 253, 254
as criminogenic trait, 23, 25
evaluation of, in transfer of juvenile for Maconochie, Alexander, reformatory sys-
trial as adult, 399 tem of, 8-9
in psychopathy, 23, 33 Magnetic resonance imaging, in neu-
violent behavior in, 34-35, 334, 335, rologic disorders, 316
339 Maine, age-of-consent statutes in, 161-
Learning theory on deviant sexual behav- 162
ior, 90-91 Malingering, 39, 201
Legislation. See also Specific states evoked response testing in, 315
on admission to psychiatric hospital, Maltreatment of child. See also Child
319, 320-322 abuse
in emergency, 354, 355 legal definition of, 282
of out-of-state adolescent, 324 Manic-depressive disorder, 223
on age of consent, 149, 152-153, 154- average age at onset of, 220
175 Marijuana use, 295, 296
historical, on juvenile criminality, 5-7, epidemiology of, 240, 241, 242, 296
391-392 patterns of abuse in, 245, 246
on juvenile justice system, 391-394 psychoactive and adverse effects of,
on rights of adolescents to medical and 248-249
psychiatric care, 384, 386 and use of other drugs, 246
418 INDEX
Marriage, age for consent to, historical, 5, Medical care (Cont.)

6 in substance abuse, 295-296
Maryland, age-of-consent statutes in, 162 in sudden infant death syndrome, 284-
Masculinity-femininity scores on Min- 285
nesota Multiphasic Personality In- in suicidal behavior, 296-297
ventory, 19 Medroxyprogesterone acetate, for sex of-
Massachusetts state laws fenders, 127-129, 139
on age of consent, 162 Megargee, E.I., on personality traits of
on confidentiality of treatment, 386 criminal offenders, 18-20,24-25
on emergency involuntary admission to Menarche, 290, 291
psychiatric hospital, 354, 355 Meningitis, 308
historical, on age of criminal responsi- Menstruation
bility, 5-6, 392 onset of, 290, 291
on seclusion and restraint, 347, 350- and violent behavior in premenstrual
351, 356, 358, 359-360 week, 32
on chemicals in, 361 Mental retardation, 308, 309-310
on duration of, 371-372 in cerebral palsy, 311
on initiation of restraint, 364 in criminal population, incidence of, 24
on monitoring of child in, 365, 366 deviant sexual behavior of adolescent
Masturbation, in behavioral approach to in, 135-136
deviant sexual behavior, 91 misdiagnosis of, in black adolescents,
Mature minor doctrine, and consent re- 264
quirements for psychiatric care, psychiatric hospitalization in, in multi-
384-385 ple handicaps, 326, 327
Maze tests of Porteus, delinquency related sexual abuse of children in, 120-121,
to performance on, 17-18 122, 124
McNaughten test for insanity, 205 violent behavior in, 34, 326
Media coverage, and transfer of juvenile Mental status examination, in transfer of
for trial as adult, 396, 402 juvenile for trial as adult, 399
Medical care, 271-306 Mesomorphic body type and criminal be-
and accidental injuries and death of havior, association of, 15, 22-23
children, 272, 282, 285-286, 292 Metabolic encephalopathy, 308
in child abuse and neglect, 272, 282- Methadone use in adolescence, 296
284 Meyer, Adolf, psychobiological approach
confidentiality and consent issues in, of, 10
297-298, 384, 386 Michigan state laws
contraceptive services in, 295, 302, 384, on age of consent, 162
386 on confidentiality of treatment, 386
in correctional system, 298-299 Minnesota, age-of-consent statutes in, 163
developmental issues in, 289-292 Minnesota Multiphasic Personality In-
drug therapy in. See Drug therapy ventory, rating of
in homosexuality, 295, 302 of black adolescents, interpretation of,
and infant mortality rate, 271, 272 266
interviews with adolescents in, 297, in criminal behavior, 18-20,24-25
300-303 of incestuous fathers, 93
physical examination of adolescent in, Minors
303-305 definition of, 3
problems in, 272-273 emancipated, consent requirements for
prolonged hospitalization in, psycho- psychiatric care of, 383-384
social effects of, 286 mature, consent requirements for psy-
in pregnancy, 294 chiatric care of, 384-385
routine procedures in, 299-305 Mississippi, age-of-consent statutes in, 164
in sexually transmitted diseases, 292- Missouri, age-of-consent statutes in, 164-
294 166
INDEX 419
Monitoring of child during seclusion and Neglect of children, 282-283

restraint, 364-366 Negligent care, liability for, 385
Montana, age-of-consent statutes in, 166 Neurologic disorders, 35-39, 223, 307-
Moral development, 204, 205, 207, 209- 316
216 in abscess of brain, 308-309
and attitude toward capital punishment, affective disorders in, 223
213 antisocial behavior in, 65-66, 67, 77
and cognitive development, 214-215 assessment of, in transfer of juvenile for
and cooperative behavior, 209, 211- trial as adult, 398, 400
212, 213 attention deficit disorder in, 33-34, 65-
cultural factors in, 209 66,67,223,311-312
importance of positive experiences in, categories of, 307-309
215 cerebral palsy in, 311
and moral education for prisoners, 211, electroencephalography in, 37, 38, 39,
215 223, 314-315, 334-335
and motivation in moral decision mak- episodic dyscontrol syndrome in, 36-
ing, 214, 215 38, 312-313
and pedophilia, 123, 129-132 evoked response testing in, 315
and relationship between moral reason- forensic issues in, 309-314
ing and moral actions, 211, 214 in head injuries, 35, 223, 315, 398
and response to Heinz dilemma, 209- in inflammatory disease of brain,
210, 211, 213 308
scoring systems in assessment of, 213- intellectual limitation in, 223
214 mental retardation in, 309-310
stages of, 209-211 psychopathy in, 23, 32-33, 67, 77
of Kohlberg, 204, 205, 209-210, 211, psychosis in, 223
212, 213, 215, 216 schizophrenia in, 223
of Piaget, 211-212, 215 seizures in, 35-36, 223, 313-314
Mortality rate in tumors of brain, 309
of adolescents, 272, 292, 296-297 violent behavior in, 6, 29-30, 35-38,
in black population, 260 39, 77, 314, 334-335, 339
causes of death in, 272, 282, 292, 296- Neuroses of adolescents
297 depression in, 225, 227-228
of infants, 271, 272 diagnosis of, 220, 221, 222
Mothers. See also Parent(s) Neurotransmitters, role in violent and ag-
in incestuous families, 94, 99 gressive behavior, 32, 40-41
expert testimony on, 110 Nevada, age-of-consent statutes in, 166
Motivation New Hampshire, age-of-consent statutes
and amotivational syndrome in mari- in, 166-167
juana use, 249 New Jersey state laws
in moral decision making, 214, 215 on age of consent, 167
for participation in interviews, 200, 297 on restraint and seclusion of children,
in juvenile psychopathology, 186, 365
187, 189 New Mexico, age-of-consent statutes in,
of sex offender, 86 167-168
Murder. See Homicide New York, state laws in
on admission of child to psychiatric hos-
Narcissism pital, 321-322, 324
of dangerously violent juveniles, 334 on age of consent, 149, 168
and pedophilia, 92 on evidence of sexual abuse, 109
Nebraska state laws on right to refuse drug therapy, 329
on age of consent, 166 on treatment of juveniles as adults in
on seclusion and restraint of children, criminal justice system, 333
358 New York v Ferber, 147
420 INDEX
Nonverbal communication, in interviews Parent(s) (Cont.)

with adolescents, 204 biologic and stepfathers, in incestuous
North Carolina state laws families, 88
on admission of child to psychiatric hos- capital punishment offense for child
pital, 321 striking, historical, 5-6
on age-of-consent, 168-169 relationship with child. See Parent-child
on restraint use, 371 relationship
North Dakota, age-of-consent statutes in, 169 rights and authority of
Nuclear magnetic resonance imaging, in in admission of child to psychiatric
neurologic disorders, 316 hospital, 319-322
historical aspects of, 4, 6, 298, 382
Obedience, and stage of moral develop- in medical care of adolescent, 298
ment, 210, 212 in psychiatric care of adolescent, 381-
Odyssey Institute, Law and Medicine Divi- 387, 388-389
sion of, 147, 148, 149 Parent-child relationship
Ohio, age-of-consent statutes in, 169-170 in admission of child to psychiatric hos-
Oklahoma, age-of-consent statutes in, 170 pital, 319-322
Opiates, abuse of, 239, 244, 245, 246, 296 of adolescent sex offender, 134, 138
psychoactive and adverse effects of, in treatment program, 140
252-253 assessment of, 202-203
Oppositional disorder, 68-71 in juvenile psychopathology, 190,
diagnostic criteria for, 68, 69 191, 193
Oregon, age-of-consent statutes in, 170- in medical interview with adolescent,
171 301
Organizations for child protection, histor- in transfer of juvenile for trial as
ical development of, 8 adult, 398
Orphans, historical treatment of, 6, 8 in attention deficit disorder and anti-
Out-of-state adolescents, problems in psy- social personality, 70, 71
chiatric hospitalization of, 324, 325 categories of sensuality and sexuality in,
85-86
Palsy, cerebral, 311 of devitalized deprived children, 225-
Panic attacks, in hallucinogen use, 253 226
Papilloma virus infection in adolescents, essential elements of, 148-149
293 historical aspects of, 4, 5-6, 298
Paranoia, 19 in incestuous families, 93-95, 99. See
cultural, of blacks, affecting assessment also Sexual abuse
procedures, 262, 263, 265 limit setting in, 352
of dangerously violent juveniles, 334, in medical care of adolescent, 298, 300
335 in prolonged hospitalization of child,
in substance abuse, 249, 251 286
Paraphilia, sexual abuse of children in, in psychiatric care of adolescent, 381-
86, 120-122 389
by adolescents, 135 in psychodynamic approach to juvenile
differentiated from nonparaphilic sex criminality, 47, 48, 52, 54, 55
offenses, 120-121 clinical examples of, 57, 58, 59
Paraplegia, spastic, in cerebral palsy, 311 and substance abuse by adolescent, 242
Parens patriae obligations of government, Parham v J.L. and J.R., 319
4-5, 383 PCP (phenycyclidine) use, 239, 240, 241
Parent(s) psychoactive and adverse effects of,
abuse of child. See Child abuse 253,254
biologic and adoptive, in research Pediatric medicine, 271-288. See also
studies Medical care
on hyperactivity, 78 Pedophilia
on violent behavior, 30-31 of adolescents, 135
INDEX 421
Pedophilia (Cont.) Physiological studies

definition of, 88 of antisocial behavior, 65-66, 77
etiology of, 122-124 of attention deficit disorder, 65-66
homosexual, 128 of criminal behavior, 22-23
insanity defense in, 129-132 of growth and development in adoles-
insight-oriented psychotherapy in, 125 cence, 289-291
moral issues in, 123, 129-132 of pedophilia, 91
physiological studies in, 91 of psychopathy, 23, 32-33, 67, 77
psychoanalytic approach to, 92-93 of sexual arousal, 91
sexual abuse of children in, 86, 88-90, Physique and criminal behavior, associa-
119-132 tion of, 15, 17, 22-23
by adolescent, 135 Piaget, j., on stages of cognitive and mor-
surgery, drug therapy and counseling al development, 204, 205, 209,
in, 126-129 211-212, 215
in victims of sexual abuse, 124 Poisoning
Peer relationships death of children in, 285
assessment of encephalopathy in, 308
in juvenile psychopathology, 190, Police
191, 193 harassment of black adolescents, 262-
in medical interview with adolescent, 263
301 role in treatment of conduct-disordered
moral and cognitive development af- adolescent, 234
fecting, 207, 211-212 Pornography, children in, 146, 147, 148,
sexual, 151, 176 153
and substance abuse by adolescents, Porteus maze tests, delinquency related to
243, 245 performance on, 17-18
Pelvic examination in adolescents, 303 Positron emission tomography, in neu-
Penile erection response of sex offenders, rologic disorders, 316
91, 100, 125-126 Post-traumatic stress disorder, of sexual
adolescent, 138, 140-141 abuse victims, 97, 98, 108, 113
Pennsylvania, age-of-consent statutes in, Predatory activity of hospitalized violent
171 juveniles, 335, 338
Perfect insanity standard of Hale, 4 Predisposition for criminality, 23, 25-26
Personality Pregnancy of adolescents, 294
assessment of, in transfer of juvenile for in black population, 258, 294
trial as adult, 399 confidentiality issues in, 384, 386
criminogenic traits in, 13-28. See also and contraceptive use, 294, 295
Criminogenic traits Preoperational stage of cognitive develop-
of dangerously violent juveniles, 334 ment, 205-206, 207
of incestuous fathers, 93-94 patterns of thinking in, 206, 207
expert testimony on, 110 Pretrial diversion programs, in substance
parent-child relationship affecting, 148 abuse, 248
in pedophilia, 122 Prison
of sexual abuse victims, 151 juveniles in, historical aspects of, 6-7,
and substance abuse, 243-244 8-9
Personnel. See Staff moral education in, 211, 215
Perversions in sexual behavior, psycho- Privacy, right to, 386
analytic approach to, 92 and confidentiality of treatment, 386-
Phenycyclidine (PCP) use, 239, 240, 241 388
psychoactive and adverse effects of, Prostitution, participation of children in,
253,254 146, 147
Phenylketonuria, 308, 310 Psychasthenia, 19
Physical examination, in medical care of Psychedelic drugs, psychoactive and ad-
adolescent, 303-305 verse effects of, 253-254
422 INDEX
Psychoactive effects of common drugs of Psychopathology (Cont.)

abuse, 248-254 depression of adolescent in, 224-229
Psychoanalytic approach to incest, 92-93 Minnesota Multiphasic Personality In-
Psychodynamic approach to juvenile crim- ventory on, 19, 20, 23
inality, 45-63 physiological studies of, 23, 32-33, 67,
assertiveness in, 52-54, 59-60 77
clinical examples of, 56-60 and substance abuse, 244-245, 247, 248
current models of, 48-50 treatment of, in adolescents, 227-229,
historical aspects of, 45-48 230-234
in hospital treatment, 50-52, 53 Psychosexual development, 291
psychotherapy in, 54-56 historical view of, 5
role of therapist in, 55-56 Psychosis, 223
structuralization in, 55 in adults, childhood precursors of, 329
Psychogenic seizures, 314 substance abuse in, 244, 245
Psychological development in adolescence, in substance abuse, 251, 253, 254
219-239, 291 treatment of, 231
abnormal, psychopathology in, 219-229 drug therapy in, 41, 231
and substance abuse, 243-245, 246, 247 violent behavior in, 329, 334, 340
Psychological structures, internal, in psy- Psychosocial history, in medical interview
chodynamic approach, 52, 53, 55 with adolescent, 301
in historical models, 45, 47 Psychotherapy, 54-56
Psychomotor seizures, 314 amenability to, assessment of, 397
and violent behavior, 35-36, 39, 314 in conduct disorders, 232
Psychopathology, 219-229 for dangerously violent juveniles in psy-
in adults, childhood symptoms in, 74 chiatric hospital, 340
assessment of, in adolescents, 183-187, in depression of adolescents, 227
219-227 parental consent to, 384
areas of concern in, 185-186, 187,190 role of therapist in, 55-56
and borderline conditions, 220-221 sex offenders in, 139
case examples on, 192-195 in pedophilia, 125
chart of, 191-192 Puberty, onset of, 289
descriptive and fundamental levels of, physiologic growth and development in,
221-224, 225 289-291
developmental issues in, 184-185, Public policy issues, 379-403
191, 192, 220 in juvenile transfer hearings, 391-403
ethical issues in, 183-184 in right of adolescent to psychiatric
expert testimony on, 184, 187-188, care, 381-390
189 Puerto Rico, age-of-consent statutes in, 171
by forensic psychiatrist, 184, 188 Punishment
functional approach to, 190-192 behavioral definition of, 374
by general psychiatrist, 184-185, 188 of dangerously violent juveniles, 337
interview technique in, 186-187, death penalty in, 213
189-190, 191 for crimes committed as juvenile, 5-
for legal purposes, 183-197, 224 6, 7, 391, 397
motivation of juvenile affecting, 186, in juvenile justice system, 393, 394, 397
187, 189 moral development affecting attitude
nontherapeutic goals of, 183-184 toward, 210, 213
reliability of personal history in, 184, in psychodynamic approach to juvenile
189-190, 191 criminality, 49
sources of information in, 186, 189- restraint use as, 372-374, 375
190 as assigned penalty, 373-374
suggested reading and educational in behavior modification program,
programs on, 188-189, 195-197 374
INDEX 423
Punishment (Cont.) Restraint use (Cont.)

of sex offenders, minimum and max- on admission to hospital, 361
imum penalties in, 153, 154-175 ambiguities in, 367-375
Puritan legislation on juvenile criminality, attitudes of staff in, 348-349, 361, 363
5-6,392 in behavior therapy, 357-359, 374
Pushing back, in psychodynamic approach chemical, 360-361
to juvenile delinquency, 50, 51 clinical review of, by therapeutic team,
366-367
Q score of Porteus maze test, correlation in conduct disorders, 233, 234
with delinquent behavior, 17-18 cooperation of patient in, 356-357
Quadriplegia, spastic, in cerebral palsy, 311 in disruptive and destructive behavior,
Quarantine orders, for AIDS-exposed ad- 357
olescent, 328 duration of, 369, 371-372
emotional reaction to, 348
Racial factors explanation to child in, 362
in assessment of black adolescents, 257- in foreign countries, 349-350, 351
270 historical aspects of, 346, 349-350, 367
in average age at menarche, 290 incidence of, 369-372
in differential treatment of juvenile de- in children, compared to adults, 369-
linquents, 38, 60, 265 370
in intelligence test scores, 264-265 staff factors affecting, 366-367, 370,
Radiography techniques, in neurologic 371
disorders, 315-316 indications for, 355-361
Reactive depression, 225, 227 initiation of, 364
Recidivism rate introduction to, 346-347
of juvenile offenders, 394 judicial review of, 355, 358
and personality traits, 19-20 legal definitions of, 371
Recreational programs, for dangerously in limit setting, 362, 363
violent juveniles in psychiatric hos- monitoring of child in, 364-366
pital, 339 natural abhorrence of, 348
Rectal examination in adolescents, 304 and need of children for external con-
Redl, Fritz, psychodynamic approach of, trol, 352-353
48,52 physician approval of, 348
Referrals and need of children for external con-
confidentiality issues in. See trol, 352-353
Confidentiality physician approval of, 371
in suspected child abuse, 99, 131, 284 in prevention of harm to others, 356-
Reformatory system, historical develop- 357
ment of, 8-9, 392 state laws concerning, 368-369
Reporting in prevention of harm to self, 357, 365
confidentiality issues in. See as punishment, 372-374, 375
Confidentiality as assigned penalty, 373-374
to court, on evaluation of juvenile in in behavior modification program,
transfer for trial as adult, 400 374
of suspected child abuse, 99, 131,284 roles of staff in, 364-367
Residential treatment facilities in stimulus reduction, 359, 374
in conduct disorders, 233, 234 Supreme Court decision on, 346-347
in multiple handicaps, 326, 327-328 termination of, 368-369
Responsibility for behavior. See training of staff on, 361-363
Accountability for behavior Retraction of sexual abuse charges, by
Restraint use, 345-378 child, 112
and accountability of child for undesir- Rewards, in treatment of dangerously vio-
able behavior, 374-375 lent juveniles, 336, 337, 338
424 INDEX
Rhode Island, age-of-consent statutes in, School behavior

171 assessment of
Rights of juveniles in juvenile psychopathology, 190,
to confidentiality of care, 297, 384, 191, 193
386-388 in medical interview with adolescent,
to consent. See Consent 301
to counsel, 393, 395 in transfer for trial as adult, 399
in drug therapy, 329 of dangerously violent juveniles, 334,
to due process in psychiatric hospitaliza- 339
tion, 319-322, 346, 354-355 of male delinquents and nondelin-
historical aspects of, 5, 6, 298, 382 quents, comparison of, 15
of illegal alien adolescents, 323-324 School personnel, notification of, on psy-
in juvenile justice system, 393-394 chiatric treatment of adolescent,
to medical care, 298, 384, 386 388
to privacy, 386 Seclusion of children
to psychiatric care, 381-390 ambivalence of staff in, 349
and financial liability for treatment, in behavior therapy, 358
388-389 in England, 350
and requirement for parental con- explanation to child in, 362
sent, 381, 382-386 indications for, 356, 359
in psychiatric hospital, 329 judicial review of, 358
in restraint use, 347 legal definition of, 360, 371
in transfer for trial as adult, 395 monitoring of child in, 365, 366
Robbery, armed, by juvenile, transfer for patient request for, 358, 359-360
trial as adult in, 400-401 in prevention of harm to others, 356,
Role models 357
parents as, 149 state laws on, 345, 347, 350-351, 358,
staff as, in treatment of conduct disor- 359-360
ders, 233 for stimulus reduction, 359
Role playing, in treatment of adolescent termination of, 369
sex offender, 141 Secrecy phase, in child sexual abuse syn-
Rorschach inkblot test, in study of male drome, III
delinquents and nondelinquents, Sedative drugs, abuse of, 239, 246
15-16 psychoactive and adverse effects of,
Runaway children, 147, 149 249-250
problems in psychiatric hospitalization Seizures, 223, 313-314
of,325 in alcohol withdrawal, 250
anticonvulsant drug therapy in, 41-42,
Satiation technique, in treatment of ado- 315
lescent sex offender, 140 in brain tumors, 309
Satterfield, j., 34 electroencephalography in, 223, 314-315
on attention deficit disorder and anti- generalized, 313
social personality, 65, 72, 73, 75, partial, 313-314
79,80 psychiatric hospitalization in, in multi-
Schizophrenia, 19, 223 ple handicaps, 326
average age at onset of, 220 psychogenic, 314
of black adolescents, MMPI scale on, 266 psychomotor, 35-36, 39, 314
of dangerously violent juveniles, 334 and violent behavior, 35-36, 37, 39,
depression related to, 226-227, 229 314
drug therapy in, 326 Self-abusive behavior, seclusion and re-
psychiatric hospitalization in, in multiple straint in, 357, 359
handicaps, 326, 327-328 chemical restraint in, 361
sexual abuse of children in, 121, 122, 124 monitoring of child in, 365
INDEX 425
Self-image, development of, in adoles- Sexual abuse (Cont.)

cence, 291 disposition and outcome of cases on,
in black population, 266 117
Serotonin levels in cerebrospinal fluid, epidemiology of, 87-88, 108-109, 133,
and violent behavior, 30-31, 40, 41 282
Sex education classes, for adolescent sex etiology of deviant behavior in
offender, 142 in adolescent, 134-135
Sex hormone levels in pedophilia, 122-124
and aggressive behavior, 31-32 evaluation of offender in, 86, 119-132
and sexual behavior, 126-129, 139 in adolescent offender, 134, 136-138
Sexual abuse, 83-180 confidentiality issues in, 137
acts included in, 149-179 erection response in, 91, 100, 125-
age-of-consent laws related to, 145-180 126, 138, 140-141
age of offender in, 152, 154-175, 176, in nonparaphilic offenses, 120-121,
177, 178-179 124
age of victim in, 109, 146 in paraphilic offenses, 86, 121-122
legislation related to, 149, 152, 154- expert testimony on, 109-110
175,176,177,178-179 family dynamics in, 93-95, 99
and alcohol use expert testimony on, 110
by adolescent offender, 137, 138 family therapy in, 98-99, 117, 139
by adult offender, 89, 93 forensic psychiatrist in evaluation of
antisocial and drug taking behavior in and testimony on, 107-118
victims of, 145, 146 gender of victim in, 149, 150, 152, 153,
behavioral approaches to 154-175, 178
in assessment of offender, 90-91, historical aspects of, 86-87
100, 125-126 in indecent exposure to minors, 177-
in juvenile offender, 139-142 178,179
in treatment of offender, 125-126, in intercourse with minors, 176-177,
139-142 178-179
biological considerations in, 90, 124 intergenerational patterns of, 94, 95, 98
in defense of offender, 130-131 intrafamilial, 85-118
in juvenile offender, 138-139 by juvenile offenders, 133-143
in treatment of offender, 126-129, assessment of offender in, 134, 136-
138-139 138
body part involved in, 149-150, 151, cognitive behavioral treatment model
178 in, 139-142
compared to sexual experimentation confidentiality issues in, 137
among peers, 151, 153, 176 etiology of deviant behavior in, 134-
compensation of victims in, 151, 180 135
in contagious venereal disease of of- epidemiology of, 133
fender, 176-177, 178 lack of attention to, 133-134
courtroom testimony of child on, 114- relapse prevention in, 142
117 risk for reoffending in, 137
preparation of child for, 116 treatment considerations in, 138-142
defense to prosecution in, 179-180 types of behavior in, 135-136
of insanity, 129-132 juveniles as victims of, 85-118
definitions of, 85, 86, 282 legislation related to, 145-180
delayed consequences of, 97, 98, 108 need for uniformity in, 149, 150
and post-traumatic stress disorder, minimum and maximum penalties in,
97, 98, 108, 113 153, 154-175
and statute of limitations in civil ac- moral issues in, 123, 129-132
tions, 151, 180 motivation of offender in, 86
difficulty in diagnosis of, 96, 108 nonparaphilic offenses in, 120-121, 124
426 INDEX
Sexual abuse (Cont.) Sexual abuse (Cont.)

in paraphilia and pedophilia, 86, 88- treatment of offenders in (Cont.)
90, 119-132 in pedophilia, 124-129
of adolescents, 135 psychotherapy in, 139
and pedophilic orientation in victim, surgery in, 127, 138-139
124 treatment of victims in, 151, 180
personality of fathers in, 93-94 types of offenders in, 89
expert testimony on, 110 uniform sexual abuse of minors act on,
preconditions for, 89-90 178-180
proposed model for legislation on, 150- by victims of sexual abuse, 124, 135,
151,153,176-180 150-151
psychiatric consequences for victims of, Sexual contact with minors, legislation on,
86,95-98,111-113,145-147, 177, 179
150-151 Sexual development in adolescence
assessment of, for legal purposes, 194 assessment of
delayed onset of, 97, 98, 108, 113, in medical interview, 301-302
151 in physical examination, 303-304
in exposure and prosecution of of- and contraceptive use, 294, 295
fender, 11 0-111 health consequences of, 291, 292-295
psychoanalytic approach to, 92-93 and homosexuality, 295
reporting of, 99, 131,284 and patterns of sexual behavior, 291
role of mother in, 94, 99 and physiologic growth, 289-291
expert testimony on, 110 and pregnancy, 294
role of victim in, 94, 95, 96, 137, 138 and sexually transmitted diseases, 292-
sexual attractiveness of children to fa- 294, 295, 305
ther in, 90 Tanner staging of, 290, 303
in sexual contact with minors, 177, 179 Sexual Maturity Rating, 290
state differences in legislation related Sexual misuse, use of term, 85
to, 149, 152-153, 154-175 Sexually transmitted diseases, 292-294,
statements of child on 295, 305
accuracy of, 109, 113-114, 115 AIDS in. See AIDS
corroboration of, 109 confidentiality in treatment of, 384
in courtroom, 114-117 in correctional system, 299
differentiating false and true alle- legislation on sexual activities in, 176-
gations in, 113-114, 115 177,178
in medical interview with adolescent, Sheldon, W.H., body-typing system of, 15
302 Sibling relationships, assessment of, in ju-
out-of-court, 109, 110 venile psychopathology, 190, 191,
videotaping of, 110, 116 193
statistics on, 108-109 SIDS (sudden infant death syndrome),
statute of limitations in civil actions on, 284-285
151, 180 Skull X rays, in head trauma, 315
symptoms of, 96-97, 112-113 Smoking of cigarettes, by adolescents, 296
syndrome of victim reactions in, 97, Social attitudes toward juvenile justice sys-
108, 111-112 tern, 394
phases of, 111-112 Social development in adolescence, 292
as taboo, 86-87 Social skills training, for adolescent sex
treatment of offenders in, 98-100, 117, offender, 141
124-129 Socialization process, in psychodynamic
anger control training in, 141-142 approach to criminality, 47
drug therapy in, 127-129, 139 Sociological factors
group counseling in, 127, 128, 141 in black adolescence, 258-259, 262-
in juvenile offender, 138-142 263, 266
INDEX 427
Sociological factors (Cont.) Structural juvenile delinquency, compared

in differential treatment of delinquents, to functional type, 47, 48
60 Structures, psychological, in psycho-
in health care, 272-273 dynamic approach, 52, 53, 55
in substance abuse, 242-243, 247 in historical models, 45, 47
South Carolina, age-of-consent statutes in, Substance abuse, 237-256, 295-296
171-172 of alcohol. See Alcohol use
South Dakota, age-of-consent statutes in, assessment of, in medical interview, 302
173 in correctional system, 299
Spasticity, in cerebral palsy, 131 of dangerously violent juveniles, 334
Staff definition of terms in, 238-240
countertransference problems affecting. dependence in, 239-240, 245
See Countertransference problems epidemiology of, 238, 240-242, 296
fear of violent patients, 366, 397-398 problems in data on, 241-242
in psychodynamic approach, 50-52, legal implications of, 237-238
55-56 by parents, and psychiatric hospitaliza-
role in restraint use, 364-367 tion of children, 324, 327
and attitudes toward restraint use, patterns of abuse in, 237, 245-246
348-349, 361, 363 prevention and treatment of, 246-248
and incidence of restraint, 366-367, confidentiality in, 384, 386, 388
370, 371 model program of, 248
in initiation of restraint, 364 in pretrial diversion program, 248
in monitoring of child in restraint, problems associated with, 296
364-366 psychoactive effects of, 248-254
review and supervision of, 366-367 psychological factors in, 243-245, 246,
training for, 361-363 247
as role models in treatment of conduct and psychopathology, 244-245, 247,
disorders, 233 248
in treatment of dangerously violent ju- by sexual abuse victims, 145, 146
veniles, 336, 337, 338, 340-341 sociological factors in, 242-243, 247
treatment problems related to, 329 tolerance in, 238, 239
State laws. See Legislation withdrawal symptoms in, 239
Status offenses, 4 Sudden infant death syndrome, 284-285
Statute of limitations in civil actions, in Suicidal behavior, 272, 282, 285, 296-297
sexual abuse of minors, 151, 180 assessment of risk for, in medical inter-
Stepfathers, incidence of sexual abuse of view, 302-303
children by, 88 in correctional system, 299
Stimulant drugs, abuse of, 245, 246 of dangerously violent juveniles, 334,
psychoactive and adverse effects of, 340
251-252 of illegal alien adolescent, 323-324
Stimulation of out-of-state adolescent, 324
reactivity to, in psychopathy, 23, 33, 67, in psychosis, 329
77 restraint use in, 357
seclusion and restraint for reduction of, Superego, in psychodynamic approach,
359,374 46,55
Stress Supermales, aggressive and impulsive be-
of black adolescents, 263 havior of, 30-31
cognitive function in, 205, 207, 208 Supreme Court decisions
reactivity to, in psychopathy, 23, 32-33, on admission of children to psychiatric
67,77 hospitals, 319-320, 321
of sexual abuse victims, 96-97 on procedures in juvenile justice system,
and post-traumatic stress disorder, 393, 394
97, 98, 108, 113 on restraint use, 346-347
428 INDEX
Supreme Court decisions (Cont.) Tooth problems of adolescents, 299, 303

on transfer of juvenile for trial as adult, Toxic-metabolic encephalopathy, 308
394-395, 396 Training. See Educational programs
Surgery on sex offenders, 127, 138-139 Traits of offenders, criminogenic, 13-28
Sutherland, E.H., and intelligence and Tranquilizers
criminal behavior, 24 abuse of, 40
Sympthomimetic agents, abuse of, 239, as chemical restraint, 360-361
244 Transfer hearings, for trial of juvenile as
Syphilis, in adolescents, 293, 305 adult, 391-403
Szurek, S.A., psychodynamic approach of, age of juvenile in, 395
47 clinical case examples on, 400-402
criteria for transfer in, 395-396
Taboo of incest, 86-87 psychiatric evaluation in, 396-400
Tanner staging of sexual development, on amenability to psychotherapy, 397
290,303 areas of assessment in, 398-400
Team approach for prediction of future behavior,
to psychiatric evaluation of juvenile, for 396-397
trial as adult, 398 on previous treatments, 399
to review of restraint use, 366-367 report on, 400
Temporal lobe epilepsy, and violent be- sources of information in, 397, 398,
havior, 35-36, 37 399
Tennessee, age-of-consent statutes in, 172 public interest affecting, 396, 402
Testimony in courtroom. See Courtroom on seriousness of offense, 397
testimony Transfer of patient
Testosterone levels behavioral problems in, 360
and aggressive behavior, 31-32 in staff fear of patient, 366
and sexual behavior, 126-129, 139 Transference, in psychodynamic approach
Texas, age-of-consent statutes in, 173 to juvenile criminality, 46, 50, 52,
Therapeutic community model, in treat- 53-54
ment of dangerously violent juve- clinical examples of, 58, 59
niles, 335, 336 negative and positive types of, 54
Therapeutic privilege, 386 and role of therapist, 55-56
Therapeutic relationship, in psycho- Trauma
dynamic approach, 53, 54-56 and accidental injuries and death of
clinical examples of, 56-60 children, 272, 282, 285-286, 292,
in current models, 48-49, 50 296
in historical models, 46, 47, 48 in child abuse and neglect, 282. See also
in hospital treatment, 50-52 Child abuse
Thrill-seeking behavior, in psychopathy, neurologic disorders in, 35, 223, 308,
23, 33, 67 315,398
Tobacco use, 239, 245, 295, 296 and post-traumatic stress disorder of
Tolerance to drugs, 238, 239 sexual abuse victims, 97, 98, 108,
to alcohol, 250 113
and dependence, 239 Trial
to depressant drugs, 249 courtroom testimony in. See Courtroom
to hallucinogens, 253 testimony
to opiates, 252 defense to prosecution in. See Defense
to stimulant drugs, 251 to prosecution
To~ography determination of competence for, 187,
computed transaxial, in neurologic dis- 194-195, 201
orders, 315 of Juvenile as adult, transfer hearing
positron emission, in neurologic disor- for, 391-403
ders, 316 lack of right to, of juveniles, 394
INDEX 429
Trial (Cont.) Violent and aggressive behavior (Cont.)

and pretrial diversion program in sub- neurotransmitter levels in, 32, 40-41
stance abuse, 248 patterns of, in dangerously violent juve-
Tumors of brain, 309 niles, 335, 336, 338
Twins, in studies on criminal behavior, 30 psychiatric hospitalization in, 333-343
group dynamics in, 336, 377, 339
Unemployment rate of black adolescents, in multiple handicaps, 325-326, 327
258, 259 of out-of-state adolescent, 324
Uniform Sexual Abuse of Minors Act, patient characteristics in, 333, 334-335
178-180 predatory activity in, 335, 338
Unsocialized conduct disorder, 68, 69 treatment approaches in, 339-341
Utah state laws unit structure in, 335-339
on age of consent, 173 premenstrual, 32
on restraint use, 371 psychodynamic approach to, 47, 52-53
clinical examples of, 56-57
Vaccinations, in medical care of adoles- in psychosis, 329, 334, 340
cent, 305 restraint use in, 345-378. See also
Vascular brain disease, 309 Restraint use
Venereal disease. See Sexually transmitted and seizures, 35-36, 37, 39, 314
diseases and serotonin levels in cerebrospinal
Vermont, age-of-consent statutes in, 173 fluid, 30-31, 40, 41
Victims of crime staff fear of patients in, 366, 397-398
children as, 272, 282-284, 292, 296 in substance abuse, 251-252, 253, 254
in abuse. See Child abuse testosterone levels in, 31-32
in white and black populations, com- and trends in crime rate, 391
parison of, 260, 261 trial of juveniles as adults in, 333
compensation of, 151, 180 evaluation for, 400-402
Videotaping of testimony on sexual abuse, vulnerability to, 30
1l0, 116 Virginia state laws
Violent and aggressive behavior on age of consent, 173-174
of abused child, 38, 39, 401 on sexual abuse, 152
of adolescent sex offender, 133, 137 Vision Quest, 231
anger control training in, 141-142 Vision testing, in health care of adoles-
behavioral approach to, 337, 338, 357- cents, 303
359, 374 Vocational activities and plans, assessment
biochemical studies on, 31-32 of
biological factors in, 29-44 in medical interview with adolescent,
of black adolescents, 267 301
incarceration in, compared to hospi- in transfer of juvenile for trial as adult,
talization of white offenders, 265 399
cholesterol levels in, 31 Voyeurism of adolescents, 136
in chromosome abnormalities, 30-31 Vulnerability to violent behavior, 30
drug therapy in, 40, 41-42, 340, 341,
360-361 Waiver
electroencephalography in, 37, 38, 39, of juvenile court jurisdiction, 394, 396
334-335 of right to full information in medical
in episodic dyscontrol syndrome, 36- care, 386
38, 312-313 Washington, age-of-consent statutes in,
intelligence quotient in, 34, 334, 339 174-175
in learning problems, 34-35, 334, 335, 339 Washington, DC laws
in mental retardation, 34, 326 on age of consent, 157
in neurologic disorders, 6, 29-30, 35- on seclusion and restraint of children,
38, 39, 77, 314, 334-335, 339 358
430 INDEX
Werdnig Hoffman disease, 308 Work skills, assessment of

West, D.]., on criminogenic traits, 21-22 in medical interview with adolescent,
West Virginia state laws 301
on age of consent, 175 in transfer of juvenile for trial as adult,
on restraint use, 368, 369 399
Winnicott, D.W., psychodynamic ap- Wyoming, age-of-consent statutes in, 175
proach of, 48, 52
Wisconsin, age-of-consent statutes in, 175 X Chromosome, fragile, 308, 310
Withdrawal from drugs, 239 X rays of skull, in head trauma, 315
from alcohol, 250
from depressant drugs, 249 Y chromosome abnormalities, aggressive
from opiates, 252, 253 behavior in, 30-31
from stimulant drugs, 251 Youngberg v Romeo, 346-347

Biological Causes of Delinquency - Rosner &amp; Schwartz (1989)

Uploaded by

Document Information

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Biological Causes of Delinquency - Rosner &amp; Schwartz (1989)

Uploaded by

Copyright:

Available Formats

JUVENILE

Volume 1 Edited by Richard Rosner, M.D.

Volume 2 Edited by Richard Rosner, M.D.

Volume 3 GERIATRIC PSYCHIATRY AND THE LAW

Volume 4 JUVENILE PSYCHIATRY AND THE LAW

Volume 5 CRIMINAL COURT CONSULTATION

Volume 6 CORRECTIONAL PSYCHIATRY

PLENUM PRESS. NEW YORK AND LONDON

© 1989 Plenum Press, New York

All rights reserved

Promise Ahlstrom • Division of Adolescent Medicine, Montefiore Medical

Judith V. Becker • New York State Psychiatric Institute and Department of

Fred S. Berlin • Department of Psychiatry, Johns Hopkins University School

Eileen Bloomingdale • New York Medical College, Valhalla, New York

Lewis Bloomingdale • New York Medical College, Valhalla, New York

Judianne Densen-Gerber • Odyssey Institute Corporation of Connecticut,

John R. Dugan, Jr. • Research Foundation of the City University of New

Everett Dulit • Department of Psychiatry, Montefiore Medical Center, Bronx,

Richard A. Ellison • William S. Hall Psychiatric Institute, Columbia, South

Gloria Faretra • Queens Children's Psychiatric Center, Bellerose, New York

Donald S. Gair • Gaebler Children's Center, Massachusetts Department of

and Child Development, Boston University School of Medicine, Boston,

Gary J. Grad • Queens Children's Psychiatric Center, Bellerose, New York

Richard J. Herrnstein • Department of Psychology, Harvard University,

Sarla Inamdar • Department of Pediatrics, New York Medical College, Val-

Subhash C. Inamdar • Department of Psychiatry, New York University School

Avron M. Kriechman • Division of Child Psychiatry, Schneider Children's

Richard C. Marohn • Department of Clinical Psychiatry, Northwestern Uni-

Robert B. Millman • Departments of Psychiatry and Public Health, New York

Hart de Coudres Peterson • Departments of Pediatrics and Neurology, New

Jacques M. Quen • Department of Psychiatry, New York Hospital-Cornell

Richard A. Ratner • Department of Psychiatry, George Washington School of

S. Kenneth Schonberg • Division of Adolescent Medicine, Montefiore Medi-

Larry H. Strasburger • McLean Hospital, Belmont, Massachusetts; Depart-

Sheldon Travin • Department of Psychiatry, Bronx-Lebanon Hospital Cen-

Alan J. Tuckman • Forensic Psychiatry Clinic, Rockland County, New York;

Robert Weinstock • Department of Psychiatry, University of California-Los

I am not sure when a series of volumes becomes an "institution"; this is the

WILLIAM H. REID, M.D., M.P.H.

1. What is the psychiatric-legal issue?

to the general psychiatrist called upon to function as an expert in juvenile

SECTION I JUVENILE CRIME

1. The Historical Challenge of Juvenile Criminality 3

2. Some Criminogenic Traits of Offenders 13

3. Biological Causes of Delinquency 29

4. A Psychodynamic Approach to Understanding Juvenile Criminality 45

5. Childhood Identification and Prophylaxis of Antisocial Personality

SECTION II SEXUAL ISSUES

6. Psychiatric Aspects of Incest Involving Juveniles 85

7. Intrafamilial Child Sexual Abuse and Forensic Psychiatrists 107

8. Special Considerations in the Psychiatric Evaluation

9. Diagnosis and Treatment ofJuvenile Sex Offenders 133

SECTION III CLINICAL CONSIDERATIONS

11. Assessment of Juvenile Psychopathology for Legal Purposes 183

12. Emotional, Cognitive, and Moral Developmental Considerations in

13. Adolescent Psychological Development: Normal and Abnormal 219

14. Substance Abuse among Juveniles. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 237

15. Issues in the Forensic Assessment of the Black Adolescent 257

16. A Reintroduction to Pediatric Medicine for Forensic Psychiatrists 271

17. Issues of Adolescent Medicine 289

18. An Introduction to Child and Adolescent Neurology for Forensic

SECTION IV HOSPITAL ISSUES

19. The Psychiatrically Hospitalized Adolescent as Victim: Forensic Psychiatric

20. Special Considerations in the Inhospital Treatment of Dangerously Violent

Biological Causes of Delinquency - Rosner & Schwartz (1989)

Biological Causes of Delinquency - Rosner & Schwartz (1989)