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This review of the psychiatric, neuropsychological, and familial contributions to aggressive behavior makes clear that conduct disorder is not a single diagnostic entity. It is, rather, the final common pathway of the interaction among a variety of different kinds of intrinsic vulnerabilities and environmental stressors. In every aggressive child all of these vulnerabilities (none of which necessarily meets full criteria for a specific DSM-IV diagnosis) and stressors must be considered and, if present, addressed systematically. We know that psychotic symptomatology, especially paranoia, combined with neuropsychological vulnerabilities and a history of severe abuse become a recipe for violence, and the more impaired the child, if abused, the more violent the child will become as an adolescent and adult. The clinician must, therefore, think of himself or herself as the only knowledgeable adult who will ever take the time to discover these ingredients and deal with the violent child positively and therapeutically.

This article explores the moral implications of the previous articles in this volume. It looks at our knowledge regarding the neuropsychiatric and environmental influences on violence in light of concepts of justice, virtue, and responsibility.

The skepticism regarding the existence of dissociative identity disorder as well as the abuse that engenders it persists for lack of objective documentation. This is doubly so for the disorder in murderers because of issues of suspected malingering. This article presents objective verification of both dissociative symptoms and severe abuse during childhood in a series of adult murderers with dissociative identity disorder.This study consisted of a review of the clinical records of 11 men and one woman with DSM-IV-defined dissociative identity disorder who had committed murder. Data were gathered from medical, psychiatric, social service, school, military, and prison records and from records of interviews with subjects' family members and others. Handwriting samples were also examined. Data were analyzed qualitatively.Signs and symptoms of dissociative identity disorder in childhood and adulthood were corroborated independently and from several sources in all 12 cases; objective evidence of severe abuse was obtained in 11 cases. The subjects had amnesia for most of the abuse and underreported it. Marked changes in writing style and/or signatures were documented in 10 cases.This study establishes, once and for all, the linkage between early severe abuse and dissociative identity disorder. Further, the data demonstrate that the disorder can be distinguished from malingering and from other disorders. The study shows that it is possible, with great effort, to obtain objective evidence of both the symptoms of dissociative identity disorder and the abuse that engenders it.

The purpose of this paper is threefold: (a) to report an unusually high prevalence of encopresis in a sample of boys in psychiatric residential treatment; (b) to explore the possible relationship of sexual abuse to the development of encopresis in these cases; and (c) to discuss the diagnostic and treatment implications of our findings.

This article reviews the diagnoses with which dissociative identity disorder/multiple personality disorder (DID/MPD) is often confused, and it reviews ways to distinguish DID/MPD from these conditions. The article suggests techniques for tapping dissociative symptoms in children. It also provides figures to illustrate the way writing samples and drawings produced prior to evaluations can be used to confirm the diagnosis of DID/MPD.

Adults with dissociative identity disorder/multiple personality disorder often describe having had very vivid imaginary companions in childhood. Little is known, however, about the phenomenon of imaginary companions in children with dissociative disorders. This article explores differences in the number, nature, and functions of imaginary companions of abused, severely dissociative boys and of normal school boys.

There is a consensus in the literature that early, severe maltreatment antedates dissociative identity disorder/multiple personality disorder (DID/MPD). Most data on maltreatment, however, are gathered retrospectively from the patient only. This article presents the cases of six violent, incarcerated men with DID/MPD. It documents from records and family interviews their childhood and adult dissociative symptoms and signs and their abusive childhood experiences.

Anecdotal evidence points to a tendency for dissociative identity disorder/multiple personality disorder (DID/MPD) to run in families. This article reports on the prevalence of dissociation and other psychopathology in the families of 11 children with DID/MPD and dissociative disorder not otherwise specified. It describes the perpetuation of violent behaviors and dissociative defenses from one generation to the next.

Although many dissociative disorders originate in childhood, researchers and clinicians have given little attention to dissociative symptoms and syndromes, such as multiple personality disorder, in children and adolescents. This article describes dissociation in children, its behavioral manifestations, and its relationship to child abuse. Also discussed are the evaluation and treatment of children with dissociative disorders.

Children and adolescents have a limited repertoire of behaviors with which to express their misery; therefore, almost every neuropsychiatric disorder is at some time expressed as a conduct disorder. Neither intrinsic neuropsychiatric vulnerabilities nor particular stressors separately generates recurrent antisocial, aggressive behavior.

This article presents the development of a new assessment instrument for use with juvenile delinquents: The Juvenile Justice Assessment Instrument (JJAI). The term “juvenile delinquency” covers a multitude of antisocial behaviors engaged in by adolescents. Research indicates that certain intrinsic vulnerabilities may combine with environmental stressors to engender maladaptive behaviors. Unfortunately, these potentially treatable vulnerabilities often remain unrecognized in the delinquent population. Because of the sheer numbers of children entering the juvenile justice system each year, it is impossible to ensure that each child will receive a full evaluation from a trained clinician. The JJAI offers those who work with juvenile delinquents an economical, yet sophisticated, assessment tool for evaluating youngsters and recommending appropriate treatment and disposition. This paper also presents the results of two field trials with the JJAI. In a juvenile justice setting, data elicited by the JJAI was compared to data gathered by the court. In a residential treatment setting, data elicited by the JJAI was compared with information gathered by staff at the treatment facility. A discussion of the obstacles faced by those who interview delinquents, and strategies within the JJAI to overcome them, are discussed.

In a follow-up study of incarcerated Connecticut youth, 66 subjects participated in extensive personal interviews. This paper documents discrepancies between early data regarding abuse and retrospective self-reports of abuse given at the time of follow-up. It describes the development of an interview protocol in which inquiries regarding medical history, the general temperament of caretakers and their behaviors when intoxicated, and instruments and methods of punishment used in the home enabled subjects to describe abusive experiences not disclosed in response to direct questions about maltreatment. The paper also discusses the use of explicitly worded probes to flesh out a clear picture of subjects' experiences. The conflicts that underlie denial or minimization of abuse are discussed, along with interviewing strategies for overcoming them.

This paper reviews the psychophysiological literature related to violent behaviors. It explores the interactions of environmental influences, pain, stressors, hormones, and neurotransmitters. It presents ways in which maltreatment in the form of abuse or neglect exacerbates preexisting psychobiological vulnerabilities. It proposes that whatever forces increase impulsivity and irritability, engender hypervigilence and paranoia, diminish judgment and verbal competence, and curtail the recognition of pain in the self and others, will enhance violence, and presents evidence that maltreatment has all of these effects.

As clinicians become more sophisticated regarding MPD, we can expect many more cases to come to the court's attention, especially among violent offenders. This is because violence and MPD have very similar origins in early extraordinary physical and sexual abuse. As offenders become more knowledgeable, we can also expect to encounter more and better malingering. At this time, however, we are far more likely to overlook the problem than we are to overdiagnose it. Why is it that MPD is recognized so infrequently in the offender population? Probably because so many of its characteristics are similar to the symptoms associated with antisocial personality. For example, amnesia for behaviors is dismissed as lying, fugue states appear to be attempts to evade justice; finding things in one's possession looks like stealing; self-mutilation and suicide attempts seem manipulative; and the use of different names at different times and in different circumstances is interpreted as the conscious use of aliases in order to evade the law. Even the dramatic, at times heart-wrenching emotional catharses relating to abuse revealed during hypnosis are so painful that the average person has difficulty accepting that they happened and, therefore, dismisses them as exaggeration or total fabrication. Most often, the diagnosis is missed because the clinician does not even consider it a possibility. In this article we have reviewed some of the ways in which courts have approached the issue of MPD and some of the problems specific to its diagnosis in forensic settings. The clinician must keep in mind that in cases in which issues of mental illness are raised, the law reflects that which it is taught by alleged experts. The case law on multiple personality is still sparse, leaving much room for new data and new interpretations of these data. The current tendency to treat each alternate as though it were a whole and responsible individual as opposed to an imaginary construct, a symptom of a mental illness, reflects the confusion among clinicians as well as attorneys regarding the phenomenon of MPD. As we continue to learn more about the disorder and its forensic implications, we must be careful to avoid presenting to the court clinical impression as fact or mythology as truth.

Eighteen males condemned to death in Texas for homicides committed prior to the defendants' 18th birthdays received systematic psychiatric, neurologic, neuropsychological, and educational assessments, and all available medical, psychological, educational, social, and family data were reviewed. Six subjects began life with potentially compromised central nervous system (CNS) function (e.g., prematurity, respiratory distress syndrome). All but one experienced serious head traumas in childhood and adolescence. All subjects evaluated neurologically and neuropsychologically had signs of prefrontal cortical dysfunction. Neuropsychological testing was more sensitive to executive dysfunction than neurologic examination. Fifteen (83%) had signs, symptoms, and histories consistent with bipolar spectrum, schizoaffective spectrum, or hypomanic disorders. Two subjects were intellectually limited, and one suffered from parasomnias and dissociation. All but one came from extremely violent and/or abusive families in which mental illness was prevalent in multiple generations. Implications regarding the ethics involved in matters of culpability and mitigation are considered.

Objective This paper describes the adult adaptation of a group of 97 formerly incarcerated male delinquents. Method Follow-up clinical interviews were administered to subjects, approximately 9 years after discharge from uvenile corrections. The records of the correctional school, state police, FBI, state psychiatric hospitals, and state health department also were reviewed. Results All but six had adult criminal records, most for violent crimes. Only 10% were graduated from high school; 30% received minimal job training; most worked sporadically at unskilled jobs. Few married. Although 35 had fathered children, only 5 were living with them. Psychiatric treatment for identified vulnerabilities was negligible. Upon discharge, the most neuropsychiatrically impaired and violent subjects tended to be placed in adult corrections; the most intact were placed in special schools and psychiatric hospitals. Numbers of vulnerabilities continued to contribute most significantly to violent outcome regardless of placement. Placement in families was associated with fewer adult aggressive offenses than was institutional placement, even while controlling for vulnerabilities and early juvenile violence. Conclusions Based on their well-documented early vulnerabilities and needs, this sample of delinquents did not obtain the kinds of supports subsequent to juvenile incarceration that might have enabled them to function independently in society.

Twenty-one female delinquents, neuropsychiatrically evaluated while in a juvenile correctional facility, were followed up to 7 to 12 years later. Compared with a matched sample of male delinquents, they committed fewer and less violent offenses. Unlike the males, early biopsychosocial variables were not predictive of adult criminality; however, most females were seriously impaired neuropsychiatrically. Mortality rates were high. Having come from abusive households, the female delinquents became suicidal, alcoholic, drug addicted, enmeshed in violent relationships, and unable to care for their children.

This article reviews evidence regarding contributions of neuropsychiatric and psychological vulnerabilities to violent delinquency, and the interaction between intrinsic vulnerabilities and experiential factors in the genesis of antisocial juvenile behavior. Consideration is given to biochemical and physiological factors, genetics, medical status, and neurological, psychiatric, and neuropsychological factors. Implications for treatment are discussed.

The authors compared the medical histories of incarcerated and nonincarcerated delinquent children. Incarcerated delinquent children were significantly more likely than nonincarcerated delinquents ...

This study reports the high prevalence (42%) of physical abuse in the histories of 166 psychiatrically hospitalized children and adolescents and identifies those characteristics of abused patients that distinguish them from their nonabused counterparts. Although psychiatric symptoms were similar in abused and nonabused patients, injury to the central nervous system was more prevalent in the abused patients. The abused were significantly more violent and their parents were more psychiatrically impaired. Implications of these findings for identification and treatment are discussed.

This paper reports results of a study of medical histories of black and white delinquents and a matched sample of nondelinquents. Medical records were analyzed in terms of numbers and timing of hospital contacts, nature of services used, and reasons for contacts. Black delinquents made somewhat more hospital visits than white delinquents. White delinquents had significantly more hospital contacts and accidents, injuries, illnesses, and psychiatric problems than white nondelinquents. Findings are discussed in terms of the relevance of particular medical events to the development of maladaptive behaviors, the tendency of clinicians to dismiss as culturally expectable certain medical and psychological factors in black children and their families, and the failure of physicians to recognize the existence of severe family disorganization in black children with multiple hospital contacts.

Antisocial behavior in childhood is one of the most ominous predictors of future serious psychopathology (Robins, 1966). The purpose of this section is to present some of the current ways in which investigators are exploring the subject of antisocial behaviors in children. Unless we are able to increase our understanding of the etiology, treatment, and prevention of delinquency, it is a certainty that many of the children seen presently in child guidance clinics because of antisocial behaviors will be psychiatrically hospitalized or living marginal existences as adults (Robins, 1966). The psychobiological exploration of childhood deviance comes after a long period of time when psychoanalytic and social theories dominated the field of delinquency. Aichhorn (1925), Healy and Bronner (1936), Bowlby (1944, 1951), Anna Freud (1949), Johnson (1949), Glueck and Glueck ( 1950), Greenacre (1950), and others focused on the effect of intrapsychic mechanisms and parental attitudes on children’s deviant behaviors. Simultaneously, and perhaps in reaction to the failure of psychiatrists to pay sufficient attention to social influences on behavior, sociologists called attention to environmental factors contributing to delinquency. They encouraged the examination of cultural biases affecting the interpretation of deviance (Becker, 1963; Shaw and McKay, 1942). Sociological

On the basis of previously reported findings that a high percentage of court-referred children suffered from serious psychopathology other than sociopathy, attention is called to some essential, though often overlooked, elements of the diagnostic evaluation of delinquents. Emphasis is on a meticulous history, including careful attention to the significances of family histories of serious psychiatric and/or neurological disorders. The importance of a detailed perinatal and medical history, with emphasis on determining a possible history of significant insult to the central nervous system, is stressed. A systematic mental status evaluation is strongly recommended. Techniques for assessing the existence of significant hallucinatory and delusional experiences in children are suggested. The uses of psychological and neurological evaluations to augment the psychiatric are discussed. The poor social situation from which many delinquents come as well as the obvious intrafamilial psychodynamic factors influencing delinquent behavior are recognized as frequent impediments to the search for less obvious psychotic and/or organic vulnerabilities in the juvenile offender. Case histories of several children who had previously been dismissed as merely sociopathic, illustrate the thesis of the paper.

Matched samples of 31 incarcerated delinquents and 31 nondelinquents were compared neuropsychiatrically. The constellation of abuse/family violence, severe psychiatric symptomatology, cognitive impairment, minor neurological signs, and psychomotor symptoms correctly predicted group membership nearly 84% of the time. The most significant variable was abuse/family violence. This constellation also distinguished the more aggressive from the less aggressive subjects in each group. The existence of a syndrome characteristic of recurrently violent individuals composed of the above variables is suggested.

The authors present the results of clinical evaluations of 15 death row inmates, chosen for examination because of the imminence of their executions and not for evidence of neuropsychopathology. All had histories of severe head injury, five had major neurological impairment, and seven others had other, less serious neurological problems (e.g., blackouts, soft signs). Psychoeducational testing provided further evidence of CNS dysfunction. Six subjects had schizophreniform psychoses antedating incarceration and two others were manic-depressive. The authors conclude that many condemned individuals probably suffer unrecognized severe psychiatric, neurological, and cognitive disorders relevant to considerations of mitigation.

This report explores some associations among juvenile-delinquency, subsequent criminality, and subsequent psychiatric treatment. A sample of 255 males known to the juvenile court 25 years prior to the study is examined in terms of subsequent documented psychiatric treatment and/or criminal activity. Of the 255 former delinquents, 6% were known later to both criminal justice and psychiatric systems, 6% to psychiatric systems only, 28% to the criminal justice system only, and 60% to neither. Delinquents with later psychiatric histories were twice as likely to be known to the criminal justice system than were those without psychiatric histories. Those with adult psychiatric histories were also significantly younger at the time of their first delinquent offense and committed more juvenile offenses than the nonpsychiatric group. Only 2 of the 16 individuals later known to both systems were diagnosed sociopathic. The findings are discussed.

The author outlines some of the neurologic and psychiatric disorders prevalent in violent delinquent populations such as attention problems, psychomotor seizures, episodic psychoses, and others. The article serves to alert the clinician to the existence of potentially treatable neuropsychopathology and to give an awareness of the psychobiologic vulnerabilities of most violent delinquents.

The biopsychosocial characteristics of a sample of 13 juvenile murderers, evaluated after committing homicide, were compared with those of 14 violent, incarcerated delinquents and those of 18 nonviolent incarcerated delinquents. The juvenile murderers did not differ significantly from other very violent but nonhomicidal delinquents. A constellation of neuropsychiatric and family characteristics, however, distinguished the murderers from the nonviolent delinquents. The 13 juvenile murderers evaluated after their homicidal acts were also compared with nine juvenile murderers evaluated before committing homicide. Differences between these groups are described in relation to the timing of their evaluations.

This paper reports the results of a comparison of degrees of violence in adolescents psychiatrically hospitalized in the late 1960s and adolescents hospitalized 10 years later. The authors studied a random sample of 51 adolescents, including 26 boys and 25 girls in the late 1960s, and a random sample of 51 adolescents matched for sex and race 10 years later. Psychiatrically hospitalized girls in the 1970s were significantly more violent than psychiatrically hospitalized girls in the 1960s. The implications of these findings are discussed.

This study compares the neuropsychiatric, intellectual, and educational status of extremely violent and less violent incarcerated boys. The more violent children were more likely to demonstrate psychotic symptomatology (paranoid ideation and rambling, illogical associations) and to have major and minor neurological abnormalities. They were also more likely to have experienced and witnessed extreme physical abuse. The contribution of these factors to violent delinquency is discussed and implications for therapeutic intervention are suggested.

This study documents a high prevalence of medical disorders, especially head and face injury, seizures, and other neurological problems in violent incarcerated adolescent delinquents. It documents the failure of three different medical specialities—pediatrics, psychiatry, and neurology—to consistently elicit significant potentially treatable disorders during routine evaluations. It explores possible causes for overlooking significant medical factors in these youngsters and proposes ways to improve the health evaluations of delinquent adolescents.

The psychopathology of 29 delinquent and 25 nondelinquent psychiatrically hospitalized adolescent boys was similarly severe. Similar proportions had hallucinations, delusions, learning disabilities, and evidence of neurological impairment, and over half in each group had been diagnosed as being psychotic. Fire-setting, enuresis, and cruelty to animals did not distinguish the two groups. Significantly more of the delinquents had been psychiatrically hospitalized previously, and significantly more of the delinquents had engaged in violently aggressive acts. The household composition of both groups was similar, but more mothers of delinquents than of nondelinquents had been psychiatrically hospitalized. The authors discuss the issue of the treatment of psychiatrically ill violent adolescents. Language: en

The authors compared psychiatric symptoms, violent behaviors, and medical histories of an entire one-year sample of adolescents from the same community who were sent either to the correctional school or the only state hospital adolescent psychiatric unit serving the area. The initial hypothesis that the incarcerated group would be equally disturbed but more violent than the hospitalized group was contradicted. Violence as well as severe psychiatric symptomatology was equally prominent in the two groups. The most powerful variables distinguishing the groups were race, accidents, and injuries (especially head injury), and sex. The medical and social implications of the findings are discussed. Language: en

The authors studies the hospital records of 109 delinquent children and a matched comparison group of 109 nondelinquent children. The number, reasons for, and timing of hospital contacts significantly differentiated the delinquent from the nondelinquent children; perinatal difficulties did not. The authors hypothesize that an interaction of developmental factors and parental inadequacies accounts for the clustering of hospital contacts before age 4 and between ages 14 and 16 in the delinquent sample. They discuss the implications of their findings for prevention. Language: en

A consecutive sample of 16 women with laparoscopy-diagnosed endometriosis were evaluated for mood disorders. Twelve women met DSM-III criteria for a mood disorder: seven for bipolar disorder, mixed, three for bipolar disorder, manic, and two for major depression. Two women had equivocal diagnoses and two showed no evidence of mood disorder. Nine subjects had first-degree relatives with histories of severe mood disorders.

The results of a follow-up study of 95 formerly incarcerated delinquents are reported. Adult F.B.I. and state police records were used. All but six of the subjects had adult criminal records. The average number of adult offenses was 11.58. Juvenile violence alone did not distinguish well between those who would and would not go on to adult violent crime. Seventy-seven percent of the more violent juveniles and 61% of the less violent juveniles committed adult aggressive offenses. The interaction of intrinsic vulnerabilities (cognitive, psychiatric, and neurological) and a history of abuse and/or family violence was a better predictor of adult violent crime.

Recent increasing knowledge of the physiological underpinnings of a variety of serious psychiatric disorders has encouraged a number of investigators to study the relationship of psychobiological vulnerabilities to deviant behavior of children. Greater appreciation of the contribution of neurological, biochemical, psychopharmacological, and genetic factors to human behavior has given rise to renewed interest in the interaction of these variables in the creation of juvenile antisocial behavior.

In clinical practice the authors observed that many of the delinquent children of psychiatrically impaired and/or criminal parents had remarkably adverse health histories. To test their clinical impression they systematically compared the medical histories of 20 delinquent children with criminal parents and 85 delinquent children with less obviously maladapted parents. They found a strong association between paternal criminality and serious medical problems in these delinquent children. On the basis of this finding the authors suggest that the behavioral manifestations resulting from such physical illness or neglect, although they appear genetic in nature, may reflect the physical and psychological consequences of parental neglect and/or battering.

The authors compared the psychiatric symptoms, socioeconomic status, family structure, family size, and occurrence of treated parental mental illness in 136 children referred to a juvenile court and 82 children referred to a child guidance clinic. The prevalence of psychiatric and organic symptoms and treated parental psychopathology in both groups of children did not differ significantly. Juvenile court clinic children, however, tended to come from larger families and to lack a biological mother in the home. The authors explore explanations for the routing of sick children to the juvenile court rather than to a treatment facility.

Five problem areas in the management of the unwed pregnant minor are discussed in the context of a case presentation. These areas include the rights of the individual minor herself, the rights of her infant, the rights of her parents or parent, the rights of society, and the rights of the unborn fetus. The importance of helping the minor and her parents arrive at a resolution for themselves is evident. In the event of incompetence, a recommendation is made for the formation of an advisory group. Guidelines for the tasks confronting this advisory group are offered.

This paper describes the characteristics of girls referred to a consulting psychiatrist by the Young Mothers Clinic, part of a comprehensive service program for school-age mothers in New Haven, Conn. This program provided obstetrical, educational, and social services to the study group, which consisted of 180 patients who entered the clinic over a two year period. All of the study group were under 18 years of age and unwed when they registered for the clinic, and most were nonwhite. — Twenty-five of the 180 girls were referred to the psychiatrist. Common reasons for referral included lack of attention, delinquency, learning difficulties at school, withdrawn behavior, depression, suicidal threats, and chaotic home situations. Those referred were found frequently to have 1. a history of contact with juvenile court and/or 2. low scores on the Wechsler intelligence scales and poor scores on the Bender Gestalt test. — White girls were more likely to be referred than were nonwhite girls. Girls 15 years of age or under were more likely to be referred than older girls. These two groups (i.e. the younger group and the white group) tended to come from extremely disorganized homes. — Clinically, the psychiatrist was impressed by the repeated history of maternal deprivation among the referred patients. She hypothesized that the girls' unfulfilled yearning for closeness with their mothers may have driven them toward early physical relationships with boys, resulting in the pregnancies. Therapeutic recommendations were difficult to implement primarily because the girls, for various reasons, did not follow through with referrals to other sources of care.