JUVENILE DELINQUENCY
Considerations
of
Etiology
and
Treatment
By Ralph D. Rabinovitch, M.D.
Children’s Psychiatric Hospital, University of Michigan
Dr. Rahinovitch is Chief of Service, Childrens Psychiatric Hospital, University of Michigan, Ann
Arbor, Michigan.
AMERICAN ACADENIY OF PEDIATRICS 939
workimig iii the area projects imi Chicago. It I)ecame eminemitly clear that psychiatric
treatmuemit was imiappropriate amid illogical
for these sociologic antisocial groups. The
entire cultural idleals amid! mores of such
areas had! to be modified in accord with
the outside world!. This, too, is a formidable
task, requirimig improved! livimig facilities
audi miew leadlershiip.
SUMMARY
I t is highly dangerous in science to talk
al)Otlt (1 caumse, amid! our wish has beemi to enipliasize only outstamiding factors which we have observed operating in the etiology of the individ!ual d!elmquent or psychopath,
where the behavior is unconsciously
initi-lted! audI fostered by the parents. In addi-tion, I have described the conscious
permis-siveness I)\’ families amid! circumscribed en!-tural forces operating in limited areas to
Prl1mce the sociologic group delinquencies. That there is overlapping, on occasion, of
these two large categories seems
undeni-able.
REFERENCES
1. Johnson, Adlelaide NI. : Sanctions for
super-ego lacunae. Read! before the Chicago
Psychoanalytic Society, Chicago, Illinois, March 25, 1947.
I
NT PSYCIIJATBY, 05 lii aiiy other branch ofmedicine, diagnosis and as full as
possi-ble an und!erstand!ing of etiology and pa-thology are )rerequisites to the prescribing
of a treatment program. Umifortumiately, in
problemiis of d!elinquency, often the factors
at play are more complex than in most
dis-2. Johnson, Adelaide NT. : Sanctions for super-ego lacunae of adolescents, in Eissler, K.
R. : Searchlights on Delinquency: New Psychoanalytic Studies Dedicated to
Pro-fessor August Aichhormi, on the Occasion
of His Seventieth Birthday, July 27, 1948. New York, Internat. Univ. Press, 1949, pp. 225-245.
3. Johnson, Adlelaide M. : Individual antisocial
behavior. Am.
J.
Dis. Child., 89:472, 1955.4. Johmison, Adelaide NI., amid! Szurek, S. A.: The genesis of antisocial acting omit iii
children and adults. Psvchoanalyt. Quart.,
21:323, 1952.
5. Johnson, Adelaide M., and Szurek, S. A.: Etiology of antisocial behavior in
d!elin-quents amid psychopaths. J.A.M.A., 154:
814, 1954.
6. Szumrek, S. A. : Notes on the genesis of psy-chopathic personality trends. Psychiatry,
5:1, 1952.
7. Burke, E. C., and Johnson, Adelaide M.: Parental permissiveness and fostering in child rearing and their relationship to jumvenile delinquency. Proc. Staff Meet.,
Mayo Chin., 30:557, 1955.
8. Hirschberg,
J.
C., and Noshpitz, Joseph:Comments on sociopsychological aspects
of juvenile delinquency. Am.
J.
Dis. Child., 89:361, 1955.9. Shaw, Clifford, and McKay, H. D. : Social
factors in juvenile dehin ueuicy. National Commission 0mm Law Observance and Eu-forcement, 1931.
eases andi, therefore, treatment needs are
also more complex amid less clearly defined.
Delinquency, of course, is not a diagnosis
but a symptom. The delinquent act is like
fever or a swelling; the factors underlying
it are multiple and varied.
940 SYMPOSIUM ON JUVENILE DELiNQUENCY
to describe treatment needs in terms of
basic causes of delinquency. Our material
is drawn from experience in a large public
clinic in a medical school that serves the
State of Michigan, and provides
oppor-tunity for intensive inpatient as well as
outpatient stumd!y.
First, however, a note of caution : That
juvenile dehimiquency has increased in
re-cent years, especially acts of violence or
destruction, is indicated by the statistics at
hand. Reading many popumlar accounts
to-d!ay, one might well get the impression thiat
all teen-agors have “gone to the dogs,” that,
as a group, they are marauding vandals
without capacity for feeling or
responsi-bility. This is, of course, far from the truth.
Dehinqumency is a major social problem but
our understanding of it is not helped if in our concern for the more dramatic we
ox-aggorate and lose perspective. The
tend-ency in recent years has been to describe
the toom-ager in terms of only negatives. Some writers have gone so far as to stretch
absurdity to the point of representing the most vicious, sadistic crime of the year as
typical adolescent behavior. Our teon-agers will live up to the expectations that we sot for them and the maintenance of a realistic and fair attitude has importamit practical
im-plications.
This is not to sumggest that we be any the
less concerned about the problem of
do-hinquency. Many of the present
exaggera-tions in thinking and writing probably stem from reasonable concern nd anxiety that the whole problem engenders. Certainly,
everyone wants to find the solution, but
hysteria has never been a valid tool of
science.
In a large clinic simch as ours, dealing with patients of all social groups and
eco-nomic levels, we are able to plan specific
treatment for delinquent children and
adolescents on the basis of a large number
of etiologic factors. We can divide these into 2 major categories : the broad social-cultural and the individual. Mr. Bock has reviewed so ably for us the larger social
and community factors, and Dr. Johnson so
well, too, the ind!ivid!nal factors. it is, by the
way, difficult to follow these two
distin-guishied presentations as you realize. I will
try not to repeat too much hut attempt to
approach the problem from a somewhat
different point of view.
First of all, I would like to raise a point
about the cultural or social factors that has
not been touched! on very mmcli by our
other two speakers.
In relation to the broad! social influences.
reading some recent opinions, we might gather that the big social need! is to abolish
comic books amid!, having d!one so, expect a nondehinquent new generation. I wish it
were so hut, umnfortunately, reality d!ictates otherwise.
Certainly, the gory, sad!istic or sedhmctive
typo of comic book is neither appropriate
mior healthy for our chiild!remi, and we can
support every community effort to stem the
flood! of these monstrosities. Omi the other
hand, it is ridiculous to consider all comic
hooks in a general category just as it would
be to view all literature as either “good” or “bad.” The comic books most popular with children represent our modermi
Amen-can folklore, and! it is timiie we realized! that
Mighty Mouse flyimmg about in jet planes
and rockets heading off atomic destrumction
is as American as Univac, jet plamies and
the H-bomb. There is, in fact, some value
in the most popular spaceman heroes. In a
world uncertain amid! unpredlictable at least
the child knows, when lie opemi his comic book that, regard!less of the dIme threats at
hand, by the endi of the chapter his hero will have tniummphed over evil. This is niore than he can say about his neal world!.
Fantasy represents the poetry of
child!-hood and plays a wondrous role imi helping
the child bridge the gap between a grim
reality and an ideal. It might be productive
for us to devote more attention to the
realities that children have to face and less
to the fantasy media necessitated by the
realities.
One major reality is the world in which
the child lives, amid no attemiipt to
success-A\IERICAN ACADEMY OF PEDIATRICS 941
fuul without an appreciation of the social
realities to which our childiren, especially
our teen-agers. are eXI)Osedl. Children (ho
Hot grow uuii in a vacuumii dud! are not
im-inune to the moral climate of their society. A society that tolerates and! sometimes
en-courages the half-truth, the easy way of
expe(!iencv an(! the power of influence pays
a heavy price in the values and! stand!ards by vliich its chiid!remi grow and! live. It is
becoming increasingly embarrassing in our
clinics to answer the child! who says: “Why worry about me cheating in school; read
the news)apers and you’ll see I’m just imi
trainimig to lx’ a successful ad!ult. “ This
rd’presemits, imi ptrt, a ratiomialization but only imi P1rt. It is niost likely that our
teeui-agers are niumch more imiflumenced in their
be-havior I)>’ the headlines than by the comics.
There is convincimig evidence, apparent in otmr work with teen-agers, that many ef
them have felt let d!own by adults because ad!ults have failed to rise in protest against
pumblic d!emomistrations of unfairness,
in-justice and! framik dishonesty in recent years.
It would! seeni to niamw ad!olescents that we
ourselves have eschewed! old vahumes as too
sentimental imid! no longer valid or im-portamit for oumr sophisticated times, values oumtli mied, for example, in our Constitution.
As arm essential to amiy program of
proven-tion amid! treitmnent of delinquents, there is
a miee(I for us to reassert old! values, to step
forward amid d!ecrv the phiomiy and to be
even sentimental in our expression of love
of d!ecency amid truth. To (ho less is to offer
our chi!dremi a (lehimiquent heritage, and! they
are waiting for the lead from us.
ETIOLOGIC FACTORS
Amnong the major ind!ividual etiologic
factors imi dielinqumency, we may list the
following:
Biologic (listurhances in the child! that interfere with patterned functioning, that
lead! to inipulse (!isturbances and to
frims-trations lui(! that may find expression in destructive acting-out. Among the biologic
l)rllmiis is brain d!amage. \Ve are at a
point now of incomplete understamiding but
of growing interest in the total effect on per-sonahity development of encephalopathies
second!ary to such factors as prematurity,
anoxia at birth, or infections in the first year. We are suspecting more and more that these do have an influence on the total
integration of the child, on his capacity to handle impulses and to accept frustratiomi.
Stimulated by the work of Laumretta
Bender, A. A. Strauss and others we are at the beginning of a major research inter-est in these problems of brain damage.
Another point of stimulation has been the electroencephalographic findings. At least 70 per cent of severely !isturbed children,
regardless of diagnosis, are found to have
an abnormal EEG. What this means, we do not know, but that there is a physiologi-cal process or reaction underlying the
dis-turbanco, would seem likely. I would con-sider this whole area a challenge to pedi-atrics and to child psychiatry for further
collaborative study.
It is important to point out that usually, rather than the specific disorder itself, it is the personality reaction to the
encephalo-pathy with its attend!ant impulse (!ifficulties
and frustrations that loads to the delin-quency.
Now, in these cases, in terms of treat-ment, what can one do? Certainly, the first step is to help the child accept the problem;
to interpret it simply to parents; and often to provide special e(!ucation or special
handling, as the clinical situation dictates.
Recent work in the use of drugs points to a
miow area for research and application that
may hold! great promise in the
encephalo-pathies.
A second large group of delinquent chil-d!ren present what we call affectionless per-sonalities. These are children who have an imiabihity or a relative inability to establish meaningful relationships, close warm at-tachments to other people. In the past they have been called psychopathic personalities
or psychopathic conduct d!isorders but it
psycho-942 SYMPOSIUM ON JUVENILE DELINQUENCY
pathology. Through the work of David Levy, Lawson Lowrey, William Goldfarb, Lauretta Bonder, John Bowiby, Rene Spitz and others, we have come to recognize a specific psychogenetic cause for the
dis-order and! our understanding of these chil-dren has taught us much about the needs
of infants and about the primary sources of social awareness or superego. In many of these cases the child has been institu-tionahized in infancy, spending his first year,
or perhaps 2 or 3 years, in a hospital or
institution crib, receiving virtually no
mothering or continuity of relationship with
a mother person. In other cases the child at
home has been exposed to an isolating ox-perience-which, unfortunately, is quite
possible. The result is gross impairment in
capacity to establish later relationships. When we see these children at the age of
8 or perhaps 10 years, they show a startling
lack of anxiety or gumilt and have a shallow-ness of inner life and capacity for
intra-psychiic conflict. Direct psychotherapy is
usually ineffective because the child does
not establish a relationship through which
he can be treated. These are, in fact, per-haps the most tragic of all the children we see, for while time condition is virtually
un-treatable it is totally preventable. While in later years benign institutionalization for
children may be not only nontraumatic but therapeutic, it is always disastrous when it occurs in infancy. There is we feel ample data accumulated from longitudinal clinical research to indicate that the matrix for later
meaningful, affective relationships is the
op-portunity for establishing a primary mother relationship through physiologic
gratifica-tion of needs by one mother person. In re-cent years pediatrics has played a major role in the prevention of this syndrome by
insisting on early placement in foster homes of abandoned or neglected infants, by stressing early adoption, and, through
in-fant care practices, helping each infant enjoy sufficient gratification through
mothering.
A third major diagnostic group of de-linquent children we see in our clinics are
those presenting neurotic problems. TIme
specific dynamics are varied in these cases but in general time chiild!’s emotional
pro!)-hem stems from relationship (!istortiOfls
within the family and disturbed!
id!emitifica-tions. Dr. Johnsomi has described one group
so well for us today, those whose P1re1its
unconsciously influence their chiild!ren in the dhirection of delinquency to satisfy their
own needs. In other cases we find! the
re-verse occurring, the child!’s (!elinquency be-ing motivated! by his riced! to strike out
against the parent in diefiance of parental values. Here the (!elinquencv represemits an
act of counter-aggression in a child who feels a need to strike back l)ecause of actual or fantasied rejection or hostility that he
feels is directed! against hum.
In other children we fimid a need! for
1)uuuishment at the root of delinquent
actimug-out; the child! is nuotivated to be in trouhk’
because of a need1 for pummuishment.
In still other cases we fluid! id!entificatiomi
with a parent who is viewed as negative as
the underlying dynamic cause. Sometimes the child, k!entified with the aggressor, acts
out his feelings against time comnuunity. There are many more specific causes of
neurotic reaction in child!ren that lead to
d!ehinquency but these should suffice to
illumstrate the general problem.
In regard to prevention and treatment there are some obvious implications. The major prevemitive for delinquency motivated by neurotic comuflict is an opportunity for
normal family experience by all children. I
have the strong feehimig that through
guic!ance for parents and! cluild!ren,
atten-tion to the quality of famih’ relatiouishiips,
amid early case flnd!ing, the pd!iatriciami can
(10, and! many are doing, a major job of
pre-vention. Certainly early case find!ing with
preventive intervention is au important key to a solution. Imi psychiatric clinics we are still seeing too many problemuus that have
gotten out of hand because referral was de-layed too long. There are of course a num-ber of ways of referring a family for
psy-chiatric help, some mumchu more therapeutic
AMERICAN ACADEMY OF PEDIATRICS 943
when he feels referral is indicated, will
poimit out to the parents thuat the child needs
S1)ecial help amid that there are facilities
within the community in which he has
con-fidlemuce and! which will offer sympathetic
guid!ance. Another ped!iatniciami faced! with
the sanue prI)lem, will take the mother
a.Si(!e and! whisper in dime tones: “I hate to
have to tell you this but I have awful news. It looks to hid’ as though sooner or later
ve may have to send! Jimmy to the
guid-amice clinic or the child psychiatrist. Let’s
try to hold out a bit longer-nuaybe 3 or 4
‘ears, but-.”
A fourth etiologic factor is pumre simple neglect. There are many waifs wamidering
al)Out OUr streets, especially in the larger cities amid!, umisupervised, they wand!er imuto
trouble. Social pathology so often umnderhies
these situations-economic deprivation,
ill-ness imuthe family, mothers obliged to work. We still have a bug way to go to ensure to all children a reasonable level of care ami(l Op)ortumiity. In our public climuics we
see rnamuy situations of this type in which
sel)aration from the family is imnfortunately
necessary. In others, support for the family
may prove sumificiently remedlial to permit
keeping the child at home where he be-longs. There has been, I believe, a tendency
iii recent years to too readily sit in
judg-mont of these families and in fact of all
fanuilies of delinquemut children. Some courts
as you know have gone so far as to issue
blanket blame of every parent whose child
is imTt trouble, actually recommending that
Parents I)e arrested! indiscriminately in such
situatiomis. If the parent is not available,
then let’s arrest the grandparents, and! if
they are not around!, I presume you can
al-ways disinter the great grandparents. This
attitude of imidiscrimiuinate blame of parents requires re-evaluation. First of all it is
un-fair because often its premise is untrue.
Secondly, it tends to frighitemu the paremits
amid thus discourage them from seeking help early. In some communities parents
feel so guilty and frightened when early
(lifficulties arise in their children that
in-stead! of seeking help when it can be most
effective, they cover up amid hide problems
until they are out of hand.
Earlier I mentioned the problem of
work-ing mothers an(! I believe that a further
comment about this is appropriate. We
must face the fact that many mothers for
economic or psychological reasons must
work and at the same time care for chil-dren. We would! hope that no mother will
have to work at all outside the home while she attempts to care for an infant through
his first year or two and must exert every effort to ensure this freedom for her. Omi the other hand, there is no comitraindication
to mothers of older childremi working, pro-vided their schedule can be adjusted to
allow them to also care for their families. This is a real challenge to ind!ustry, to find
ways of allowing part-time schedules for
working mothers, adjusted to permit as
optimal as possible child rearing. Medicine and industry must, I believe, face this prob-hem together and find solutions if we are
to move, beyond pious words, into action in our delinquency prevention efforts.
Another cause of delinquency which Dr.
Johnson alluded to is identification of a child with overt delinquent standards in
the family. In these cases children’s be-havior is patterned after that of their
par-ents and it is probably most clearly seen in our delinquent adolescent girls. So often
We find a close identification of the girl with a sexually delinquent mother and, when this identification is strong, treatment can be very difficult. Treatment often requires separation fromn family and the providing of opportunities for normal social
experi-ences for the child.
Another causative factor is inadequate controls. Sometimes, I think, there is a tendency for us to take so seriously the
adolescent’s striving for independence that we fail to meet his need for guidance and direction. In some families it is as though
parents dare no longer to direct a child after he has reached the magic age of 16. This
fairly frequent problem of lack of adequate
guidance for adolescents today does not
pros-944 SYMPOSiUM ON JUVENILE DELINQUENCY
eiuce of delinquemicy on the part of parents. More likely, it bespeaks the high degree of confusion in which parents find them-selves in relation to child-care practices and
their role as parents. For a number of reasons many parents are over-introspective
and, having lost their feeling of confidence, have become immobilized before their
chil-dren. Some fear that they will lose the child’s love if they frustrate any of his
wishes, others feel that there is less risk of “harming” a child by doing nothing than
by asserting a parental role. I do not imply that this laissez-faire attitude is universal nor do I recommend rigid authoritarian or
punitive handling of adolescents. Heaven forbid! It is, however, a psychological truth that the adolescent must feel a sense of con-tinuity and will develop his own capacities for judgment and decisions on the basis of
his past reliances and attachments to par-ents. His strivings to be independent are to commamud respect, but no less attention is
due the need of his limited ego for support and direction. In some of our adolescent groups, as we see them in our communities
today, we may note frank seduction into
behavior inappropriate for the child’s age. In such groups there is a need to cut down on opportunities for inappropriate
be-havior amid this means adequate super-vision within the family, parents knowing
their children’s friends, knowing where they
spend their time, being aware of signs of over-rebelliousness and wildness, and step-ping iii when such indications of trouble first appear.
I would like to point out there is another problem closely related to this need for
adequate supervision for our adolescents, and that is the tendency on the part of so
many adolescents to assume patterns of
be-havior inappropriate for their age which
gives them a disturbing quality of phoniness
or pseudo-maturity. There appear to be
many pressures within communities that
foster this trend. For example, we find steady dating prevalent to a high degree
among teon.agers of some high schools. It is
not uncommomi miow for miue to ie consulted!
by a 17-year-old! boy who is worried about
how his 16-year-old girlfriend will react psychologically if he breaks off after 2 years
of going steady.
This whole trend should concern us and, in fact, involves many potentially serious
problems. It presumes a maturity whichu
these children do not huave. It dienies thienu
the opportunity’ to experiment socially amid!
sexumally in ways appropriate for their age
and to come to kmuow l)ovs and girls of
different types. It temud!s to exclumde the
unattached! girl or boy fromiu all social participatiomu. Out of this stead!y’ dating
many pseudo-marital relatiomuships have
evolved among virtual child!ren amid the rates of venereal disease amid!
out-of-wed-lock pregnancies have risemu. Early marriage
may be the result, but we have to give
further consideration to this whole problenu of readiness for marriage. It is certainly nice to grow up with one’s dhiildremi, but it is also wise to be nuore mattmre than one’s
child!ren. I, for one, am impressed with the
immaturity of mamiy of these voting couples,
their lack of readiness for parenthood, amid
the fred1umemut inevitai)le family instal)ility or d!issOlution that miuay lie ahead.
Now, pediatriciamis, I believe, have an iou-l)ortamt role to play in combatting this drive
toward phuomuiness or )se11(!-1u11tu1rity. The
pressures stem in part fronu a small group of aggressive, opportunistic paremuts who set the pace iii many comnuumnities. Some
of these parents appear to wamut a (1umick
re-turn on their investment amid! simply cannot
wait for their children to matumre
1pI)rpri-ately and gradually.
Clinical experience vi tim ad!olescents
indicates that mamly’ are muot happy nuder these circumstances amid are looking for
more controls of a benign, creative type and!
for more guidance. The situation calls for
interpretation to oumr communities, amid for realistic help for families when they need it.
Pediatricians have a place in the front line in
AMERICAN ACADEMY OF PEDIATRICS 945
is indicated! alomig with am integration of our efforts with those of school personnel and
other community agencies.
The last ind!ividual cause of delinquency
that I wish to mention is unfortunately at
this point quite common-”Cause Un-knoevn.” There are many cases in which
(!etailed StuId!ies still leave us in the dark
about basic causes of maladjustmrient and!
(k’liuiqueuicy. It is, I l)Clie%’O, true to say that
this grotm is becomuuimug smaller each year
but there is a great need for further
no-search in psychiatry and! huealthy indications
of a growing interest iii this direction. This has been a rather diffuse
presenta-tion touching omu a wide range of problems. We can, however, attempt to summarize
the qumestion of etiology with the following
geuueralization. Delinquency occurs in
chil-(iremi whemi there has l)een interference in
the normal growth pattern. This interference
may iIi\’OlV(’ either biologic or 1)sychologic
growth I)rocesses. \Vhen a child’s basic
needs are unnuet, whemu these are
ungrati-fled or only )artialiy gratified at any period
fronu iuufancv on, the’ seed!s of (!elinquency
are sewn.
TREATMENT
We have stressed the need for early case fimidling and! the role of pediatricians in this
effort. But the valid! question is always
raised h)y colleagumes referrimig cases for
psy-chiatric help: “Where can we find effective
clinical psychiatric services in sufficient
quantity to meet otmr community needs?”
Unfortunately there is still a dearth of
fa-cihities in this area, a major reason for
which is lack of trained! persouunel. Faced!
with this reality many of our medical
schools are concentrating effort Ofl training
for child! psychiatry and time allied
disci-I)hiIieS, audi this is especially true of the field! of imul)atient treatment for severely
dis-ttmrl)ed chul(!ren . That those developments
must h)e carrie(! oimt in close association with
I)e(hittnic5 is recognized! audi there is a nee(l
for imicreasing integration of our two
spe-cialties with mans’ of the old mutual
suspicions and prejudices buried! in the grave of professional immaturity.
As we plan jointly to find effective meas-ures to reduce delinquency and crime, with
their attendant human misery, it is, I be-hove, essential that we bear in mind a reality to which we have alluded earlier. In a culture as rapidly moving and
chang-ing as ours, with its numerous tensions and! uncertainties, we must expect that a sig-nificant number of families will be unable to meet the needs of their children for a
wide variety of reasons. This means that we
must find ways within our communities to
provide sympathetic support to these
fami-lies through our public and private social agencies. Beyond this we must recognize the need for offering many children and adolescents compensatory satisfactions
out-side the home-in school, in constructive
recreation programs, in part-time job op-portunities. When these measures prove
in-effective then we must face the fact that separation from family may be required! and!
have available placement facilities to offer
severely neglected children a chance to
realize themselves. Separation from family is always a tragedy for a child and
fre-quently for his family, and mimst be carried out with insight and skill to mitigate the traumma; it is a job for well-trained case workers of which we have unfortunately
an apparently growing shortage these days. Finally, I should like to refer to what I consider to be one of the commonest causes
of adult crime in America to-day-the
puni-tive handling of children and adolescents
at the time of their first delinquency. The
delinquent act so often represents an cx-pressiomu of counter-aggression by a child who feels a need to strike back. The
dehin-quent behavior may be the chik!’s way of telling us that he needs help, that he is troubled and confused. If he is handled punitively at the time of his first
SYMPOSIUM ON JUVENILE DELINQUENCY 946
and detention facilities are a first step in
any delinquency control program. It is the
responsibility of medicine to be certain that such facilities are available in our commun-ities, so that young delinquents can be
studied and offered sympathetic, benign care that will let them know we are
inter-ested in them and in their problems.
To a large degree we feel, today, that we can define the psychological needs of children and spot those children whose
needs are being left unmet. To develop within our communities sympathetic
re-sources to help families meet these mueed!s, and! where this is impossible, to find
corn-)onsatory O)pOrtumuities outsid!e the home,
is the job at hand. Pediatricians have a very
special place in these efforts.
There is no simple solution for the prob-hem of delinquency but one fact is certain:
