The Need for the Early Diagnosis and Treatment of Potential Delinquency in Cases of Mental/ Disorder and Defect
- Author:
Norwood East, M.D.
London; M.R.C.S. Eng., L.R.C.P., Lond: M.P.C.; Medical Officer H.M. Prison, Liverpool. (vv ith the permission of the Prison Commissioners.)
The study of certain cases of delinquency occurring early in the career of individ- uals, and also some cases met with in later life, emphasizes the fact that a definite, and perhaps not inconsiderable, amount of crime could be prevented from ever taking place if appropriate treatment was resorted to sufficiently soon.
Unfavourable economic conditions so frequently the forerunners of crime are not here referred to, but cases in which timely advice and medical treatment will prevent, or tend to prevent, the development of delinquency in the insane and mentally defective; and also in those who suffering from slighter degrees of mental disorder, instability, or defect, are recognised as borderline cases, and who find difficulty in adjusting themselves to their environment on account of mental states over which they have no control.
It is true that a large number of such offenders if convicted are appropriately dealt with in prison, others do not suffer any punishment, for enlightened magis- terial benches, constantly alert to the connection between physical or mental ill- health and crime, cause medical enquiries to be conducted to determine the possible existence of such connection, and deal with the case accordingly. But this can only be done after an offence has been committed. If such an investiga- tion could be carried out in a potential delinquent before any offence occurred the individual would gain to the extent that the stigma of guilt and arrest, in some a source of inner conflict, might be avoided, and the relatives and the community would gain if a criminal act was prevented.
If medical advice caused only a small amount of crime to remain undeveloped it would be worth while endeavouring to bring this about. For not only might the potential delinquent be checked in his career, but an explanation of the true condition and the result of treatment would bring understanding to the patient’s often severely tried relations, who, perplexed at his conduct may consider such as due to enmity or wickedness, with resulting discord, conflict, and aggravation of the underlying condition. Moreover much injury resulting to the victim of the crime would be obviated; injury not always pecuniary nor manifest at the time, but which may result in serious harm later. The shock of a serious assault, for instance, may have its sequel in certain personalities, and in certain condi- tions , at some future period.
There can be no doubt that already no small amount of crime is being con- tinually prevented from ever maturing by the action of relations, and sometimes of the individuals themselves in consulting their medical adviser. Many murders, assaults, suicides, attempts at suicide, thefts, sexual offences, arson, and the like, never occur as the potential criminal is certified as insane or mentally defec- tive beforehand, and society protected by his removal to a suitable institution. It is common knowledge that crime occurs frequently in cases of undeveloped insanity and borderline mental deficiency, and that insanity before it becomes clearly defined may have a preliminary phase, lasting maybe for months, during which crimc may be committed. There are very many cases where the attack of insanity fails to fully develop, and sound mental health is regained without the patient ever appreciating how nearly serious mental disorder and crime have been avoided. This cannot be satisfactory, and it is the less so because no medical man can be a specialist in every branch of his many-sided art, amongst which problems in mental diseases are not the least difficult, and the slighter degrees of mental disorder and defect may easily pass unrecognized. But if medical men when in doubt could send their patients to a clinic for mental diseases attached to at least one of the public hospitals in each city or town, they would soon be sending cases of potential delinquency there as borderline cases of insanity and mental deficiency; and the workers connected with social and charitable organ- isations would have a place to which they could refer their more difficult cases for diagnosis and treatment, and obtain material help in dealing with them.
The amount of delinquency or grave crime which is already prevented by existing clinics cannot be measured in concrete terms, but there can be little doubt it is considerable. At the same time success will not always be assured in the case of every wayward child, unstable adolescent, or borderline case of mental disorder or defect with delinquent tendencies, attending such clinics. Some cases will not respond to change of environment, advice, or treatment of any kind. The unstable delinquent adolescent may take years to reach a condition of settled equilibrium, perhaps not until a considerable period has been spent in prison, or in a Borstal Institution.
Many who applied at a clinic would be satisfactorily dealt with as out- patients. The physiological or psychological explanation in a simple manner of the patient’s difficulties would suffice in some cases to prevent delinquency, or grave crime. The writer has in mind a case of murder, committed by a youthful adolescent, with which he was connected and in which there was good reason to believe that no tragedy, resulting from insanity would have followed, had an opportunity been afforded in time for treating the offender by simple therapeutic means and psychological methods. More elaborate treatment in other cases would be necessary, but my concern here is to call attention to the fact that sufficient opportunities for early diagnosis and treatment do not at present exist, because in most districts clinics for the treatment of mental disease and mental defect are not attached to their hospitals. Some limitation to the utility of the mental department, or mental clinic, of the hospital would result from the in- ability to observe doubtful borderline cases, in whom prolonged observation is not infrequently essential. If a hospital ward could be attached to the clinic and in-patients be admitted this difficulty would be overcome, but the already insuffi- cient accommodation for ordinary cases in hospitals holds out little prospect of this being found practicable for some time. Small homes, opened and main- tained either by private individuals, or public bodies, should not be found a too expensive experiment for observing those borderline cases who were willing to accept voluntarily their hospitality, and in whom potential delinquency was anticipated. The work would necessarily occupy much of the time of the mental expert attached to the home, an unavoidable drawback, but his labours would be considerably lightened by the help of an intelligent person in charge of the home, if experienced in this class of case. Such clinics or homes the writer believes should not be used for the examination of the mental condition of persons who have already committed an offence, and are to re-appear at Court. Were this done sooner or later it must be reasonably feared they would fall into disrepute. As I have attempted to shew elsewhere,* for these cases the remand prison hos- pital affords an efficient place for observation and examination, and in certain cases of initial delinquency a special remand home may be considered advisable for this purpose.
I have already mentioned a case of murder which I believe could have been prevented, and I now append a few brief abstracts from my notes on some of the younger cases referred to me from the Courts for diagnosis in whom I believe delinquency would have been avoided had such opportunities, as are here advo- cated , been available for this purpose.
Case 158. Female, single, aged 23. Indecency. On arrest she appeared to the police to be confused and was remanded for evidence as to her mental condition. The family history contained nothing of importance except that her father died when she was a child, and her mother when she was about 17. Her attendance at school was bad on account of ill-health, and she had been treated in recent years for pulmonary tuberculosis, but had never been in an asylum or other institution previous to coming to prison. At the death of her mother she lived for a time with a near relation, who eventually made matters sufficiently uncomfortable to cause accused to leave. She went to a city and being without resources walked the streets, but very soon met a widower and went to live with him as his wife and looked after his family of five children, the youngest of whom was 6 years old. She was however never allowed to do any of the purchasing either of household articles, food, or clothing for the children, and was given 5s. per week for herself. She never bore any children. The police of the district had nothing against her during her stay of some years in that city, but her neighbours noticed she was eccentric, reticent, and unsociable. Shortly before arrest she left this home on account of some disagreement and came to this city.
Her few savings being spent she again went on the streets, and was soon arrested. On admission she was ill-develope’d, thin, physically weak and anaemic, and shewed evidence of old lung disease. She was also definitely mentally deficient, simple, childish, and easily confused, unable to carry out any but simple instruc- tions, her memory, attention, preception, judgment and reasoning were im- paired . She was ignorant on matters of ordinary interest and common knowledge, she lacked initiative and purpose in life, her moral perception was indifferent but she was not really vicious and she was an abstainer. Her response to intelligence ?Some Cases of Mental Disorder and Defect seen in the Criminal Courts. Journal of Mental Science, October, 1920, tests was very bad but this was in some measure due probably to her physical health, and the consequent ease with which she became fatigued. In spite of her mental defect being coupled with physical impairment, had she attended a clinic steps could have been taken to have dealt with her and so prevent the delinquency, and it seems likely that she might have been induced to attend, for she went willingly to the poor law institution for treatment on being discharged on my evidence at Court. She had been previously considered abnormal by her neighbours and might have been persuaded to seek treatment by them, for it is fair to assume that if the existence of mental clinics became known cases at present allowed to drift would be advised to attend by those in contact with them. An added danger to the community was present in the following case owing to the patient suffering from disease in a highly contagious form.
Case 122. Female. Single, aged 22. Charged with stealing and remanded for evidence as to her mental condition. She was apparently an illegitimate child, with a worthless idle mother. No definite family history of insanity, epilepsy, or intemperance was obtained. The accused had never before been in any institution, she had fits at rare intervals in childhood but none since she was 14 years old. She did not begin to walk until she was two, and was noticed to be dull and slow from her early school days, and attended a special school. A doctor who examined her about this time noted that she was dull, slow and apathetic, self-centred and slovenly. After leaving school she worked at laundries and step-cleaning. She had been working occasionally for some time at the latter, and had whilst so employed gone into the houses and when opportunity offered stolen money which she spent on sweets and cakes, and several charges of theft were outstanding. On admission her height was 62 inches, her weight 114 lbs. and her head circumference 20 inches. She was suffering from active contagious disease. She had a deformed palate and defective teeth, her expression was vacant.
She was mentally defective and graded below a 9 year old child with intelligence tests. She was grossly ignorant on matters of ordinary interest and common knowledge, was easily confused, with impaired memory, attention, perception, ideation, and volition; she lacked initiative, was apathetic, had no clear insight into her position and was some days before she realised she was in a prison and not a general hospital; she had no idea how long she was with us, nor when she should re-appear at Court. Her mental reaction was very slow and her emotional tone impaired, she had no remorse for her conduct, was quite unable to com- pete with her fellows, and her domestic accomplishments were almost nil. She could however do simple knitting. When about 16 years old her progress had been considered fairly satisfactory, but her entirely faulty home arrested further improvement. Had this girl, always recognised as more or less wanting, attended from time to time a clinic, there would have been every probability of her being sent to a defective institution before delinquency was committed, instead of after; this was done on her re-appearance at Court.
In the following case, sub-normal mentally and constitutionally inferior, the advice that might have been received at a clinic should have caused the parents to be apprehensive of delinquency, and to take what precautions they could to guard against it; and even now when a criminal offence has been com- mitted, occasional attendance at a clinic would give an opportunity for skilled observation as to the patient’s progress, and should he later become certifiably defective steps could be taken to deal with him, and any further possible offence be prevented.
Case 95. Male. Age 10. Charged with indecent assault on a small girl, and remanded for examination as to his mental condition. His parents, both of whom I saw, were thoroughly respectable, but of nervous temperament; there was no known insanity, epilepsy or intemperance in the family. Accused, the eldest child, born at 7 months, did not begin to walk or talk till he was about 3 years old, he had always suffered from night terrors and ill-health, and as a result of the latter was an irregular attendant at school, leaving eventually in a low standard. He had several different occupations, but remained for 12 months in one, and for 7 months in another. He was recognised at home as being weak mentally, and his father described him as lacking in courage and unable to defend himself against children many years his junior. On admission he looked much younger than his real age, his expression was childish, his general physical development bad, his height was 60| inches, his weight 80lbs. and the head circumference 21 inches. He presented stigmata of degeneration, the ears and eyes were markedly asymmetrical; his chest was ricketty. He graded as 12 years with intelligence tests; but his general information was poor, and he was unable to appreciate the difference between stealing food if hungry, with, or without, money in one’s pocket. He lacked initiative, prudence and foresight, and could make no friends or companions of his own age. His home environment was good but should it alter in the future it was clear the patient would not be able to stand alone, would soon deteriorate, and require institutional care. In the next case attendance-at a clinic would have shewn it to be one of con- flict and delayed development, and the fitting remedy could have been advised and delinquency prevented, as there is reason to believe has now been done, but not till after offences have resulted.
Case 31. Male. Age 17. Charged with stealing a pony and cart and remanded for evidence as to his mental condition. His mother stated in Court that he had weak moments when he did such things. The family history was unimportant, he had a good home, had sufficient food and was treated kindly by his parents. He left school in the IV. Standard, but his mother stated he never cared for school, that he had a clever head but did not put it to proper use, and had always been a nervous child; he gave no trouble at home and was somewhat hasty tempered. He was probably an excessive tea-drinker, and smoked as many cigarettes a day as he could get. He made friends and companions in a normal manner, but had a feAv bad companions who stole and talked much of their sex experiences, but these latter do not seem to have interested the lad overmuch. He stole a bicycle from the owner, for whom he worked, and after riding it some distance sold it. His next offence was to steal a pony and cart from a late em- ployer, drive it some distance into the country, returning with it and handing it back the same night. His present offence is similar, he stole a pony and cart from another employer with whom he had worked, took some provender and drove with it into the country; he returned the same evening leaving the pony and cart standing outside its stable. A simple analysis shewed this city lad had an intense desire for the country and was passionately fond of animals, and particularly horses; his ambition in life was to become a jockey, or live on a farm. He knew he was wrong in stealing the pony and cart, but was willing to suffer punish- ment for the temporary pleasure he gained, and described the delight he experi- enced at one occupation he had when he went with a pony and cart delivering goods for his employer. On examination his height was 54| inches and his weight 66 lbs., there was no growth of hair on the face or body, he had gained no weight in 12 months, he was mentally alert and well informed, and with intelligence tests graded above 12 years. Punishment offered no prospect of preventing his wish to get into the country and spend his time with animals, the real reason for his later delinquencies, and probably also his first offence. He was consequently, on his re-appearance at Court, and after my evidence was given, put on probation and sent into the country where for some months he has been happy and doing well.
A more serious charge than that of loitering might have resulted in the following case, and as his parents were afraid of him and recognised him as being mentally defective they would almost certainly have taken him to a mental clinic for diagnosis, and certification as a defective should have followed, Case 58. Male. Single. Aged 24. A grandmother and uncle both on the mother’s side were insane. He was the third child of a family of seven, and when 13 was sent to a reformatory for repeatedly sleeping out. On leaving at 16 years of age he went to sea for a short time, and then served in the Navy as cook’s mate, later he was in the Army for about 12 months during the war, but did not serve out of the country. On leaving the Army, where he was twice convicted for striking his superior officer, he became for a few months a bricklayer’s labourer, but had done no work for some time prior to arrest. His mother stated he had always been simple and childish and never like other children, but she could trace no reason ante-, or post-natal for this, He began to talk at 18 months and walk at 2 years, he could never learn to read and his mother added his brain could never grasp anything, that he was a good worker under supervision, but was helpless otherwise. He had been violent and threatening at home, and on account of his physique they were all afraid of him; he had threatened to cut his sister’s throat, had stolen her clothes and sold them and left home on the proceeds. On admission he was found to be powerful and of large build, he was in good general health, he graded below 9 years with intelligence tests, but was pro- bably not really trying his best. There was however no doubt that he was men’ tally defective, incapable of competing with his fellows, and was dangerous to others and impulsive, indolent, and untruthful. He was sent to an institution for defectives from Court on my evidence.
In the last case a career of prostitution and crime has been avoided by certification, and detention as a mental defective, but again not before delin- quency and consequent arrest.
Case 63. Female. Single. Aged 17. Charged with lodging out. Father died of consumption, four brothers and sisters died in infancy. When 12 years old she was sent to an industrial school for constantly wandering from home. On growing up she was considered untrainable and unteachable, she was found several situations in factories but was dismissed from each in a few days as unsuitable and too slow. She frequently left home for weeks, would sleep out, was quite un- manageable, lazy, violent and abusive. Her mother took her for advice to a lady interested in welfare work, and would have undoubtedly taken her to a clinic on her own initiative, or on the advice of this lady had one been available.
Shortly after she was arrested, and remanded for medical examination. She was a strong well built girl, a confirmed nail-biter, with sullen demeanour; her mental age was 9 years, and she clearly was interested in the tests and did her best at them. She was ignorant, generally lacked initiative and capacity for sustained effort, had poverty of ideas, shewed no remorse for her conduct, and was markedly anti-social. She was slovenly, untidy and incapable of appreciating kindness, she would not keep herself clean and her habits were dirty. There was some reason to consider she had been immoral.
The cases recorded above were chosen on account of their youth, as being simple in character, and of a common type. All were recognised as being abnor- mal before any offence was committed. More complicated and interesting examples might have been selected, but with the possible risk of diverting the reader’s attention from my main theme.
I am aware that it has been considered by some writers that a clinic for the maladjusted would be more suitably located apart from a hospital, but my own belief is that in this country the type of case here referred to would attend a hospital clinic more readily, and the work would there be conducted under the supervision of a recognised specialist in mental disease. The desirability of such clinics for the treatment of mental disorder and defect is of course nothing new, but the advantage which would result in preventing delinquency by this means does not appear to be so generally appreciated.
Disclaimer
The historical material in this project falls into one of three categories for clearances and permissions:
Material currently under copyright, made available with a Creative Commons license chosen by the publisher.
Material that is in the public domain
Material identified by the Welcome Trust as an Orphan Work, made available with a Creative Commons Attribution-NonCommercial 4.0 International License.
While we are in the process of adding metadata to the articles, please check the article at its original source for specific copyrights.