Neuropsychological Assessment of Seriously Delinquent Adolescents

Transcription

1 Neuropsychological Assessment of Seriously Delinquent Adolescents ARTHUR s. BRICKMAN, PH.D., MICHAEL McMANUS, M.D., W. LEXINGTON GRAPENTINE, M.D., NORMAN ALESSI, M.D. AND Neuropsychological tests (the Luria-Nebraska Battery) were administered to 64 male and female offenders in residential settings. were selected according to the seriousness of their offenses and the extent of their recidivism within the juvenile justice system. Pervasive abnormalities in the delinquent population are documented. Evidence documenting neuropsychological abnormalities in delinquent adolescents is cited and reviewed. Methodological issues and questions of interpretationare explored. Journal of the American Academy of Child Psychiatry, 23, 4: , standard neuropsychological test battery (HalsteadReitan). They cited prominent deficits in verbal mediation, concept formation, and perceptual organization, with only minimal deficits in memory and gross motor coordination. In other words, the higher cognitive capacities seemed most impaired. This finding accords with that of Monroe et al. (1977), who found gross motor functions actually superior among criminals, despite evidence of neurologic pathology. Yeudall and her colleagues in Canada (Fromm-Auch et al., 1980; Yeudall, 1978) have conducted extensive tests on neuropsychological and neurological correlates of delinquency. Their research has revealed frontal and temporal lobe deficits in their subjects, particularly in the dominant (usually left) hemisphere. They also cite abnormal neurological findings, including more frequent blackouts, more time unconscious, and more head injuries, among delinquents than among others. These findings parallel those of D. O. Lewis (1977,1979) and Pincus and Tucker (1978) regarding neurological pathology. With regard to lateralization, however, it is noteworthy that Yeudall does not cite levels of significance for her percentages of lateralization of deficit, as she does for other aspects of her research. Hurwitz et al. (1972) compared normal boys, delinquents, and boys with learning disabilities. They found specific deficits among the delinquents on tasks of sensorimotor rhythm and temporal sequencing, suggesting possible temporal lobe impairment. They did not find a comparable disparity on tests of spatial ability and perceptual restructuring. Similar results are reported by Spellacy (1977). He found neuropsychological testing more efficacious than personality testing with the MMPI in distinguishing violent from nonviolent institutionalized male delinquents. In particular, he found discrepancies in the dichotic listening skills of violent delinquents. In contrast to Hurwitz and Spellacy, however, Berman and Seigal (1976) found rhythmic processes to be among the few which Neuropsychological assessment of juvenile offenders has proved to be a fruitful approach to the evaluation of young criminals. Accumulating evidence utilizing a variety of instruments points to widespread neuropsychological abnormalities in these youth. Findings have focused in particular on violent and seriously delinquent adolescents. In some cases the tests have proved efficacious in distinguishing not only delinquents from nondelinquent youth, but also violent from nonviolent youth within the delinquent group. Nonetheless, the results have by no means been unequivocal, and the precise nature of any association between criminal acts and neuropsychological deficit is not yet fully understood. Krynicki (1978), studying 21 male inpatients, found greater similarities on neuropsychological testing results between the assaultive delinquents and patients with organic brain syndrome than between these same assaultive delinquents and their nonassaultive delinquent peers. The distinguishing features were frontal lobe EEG abnormalities, visual-motor perseveration, deficits in short-term memory, and more prevalent ambidexterity. The anterior lobe of the left hemisphere in particular was implicated in dysfunction among assaultive youth. Berman and Seigal (1976) compared delinquents with normal controls and found significant differences on virtually every item on a Dr. Brickman is Chief of PsychologicalServices, Huron Residential Services for Youth, Ann Arbor, Mich. Dr. McManus is an Instructor in the Child Psychiatry Services Division, Department of Psychiatry, University of Michigan Medical Center, Ann Arbor. Mich. Dr. Grapentine is Chief of Outpatient Services at Bradley Hospital, Providence, R.I. Dr. Alessi is. a Research Fellow at the Mental Health Research Institute, University of Michigan. This research was supported by grants from the State of Michigan Department of Mental Health (Grant 80-52) and the Michigan Office of Criminal Justice. Reprints may be requested from Arthur S. Brickman, Ph.D., Huron Residential Services for Youth, P.O. Box 2018, Ann Arbor, MI /84/ $02.00/ by the American Academy of Child Psychiatry. 453

2 454 BRICKMAN ET AL. were relatively unimpaired in delinquents, whereas perceptual organization significantly differentiated delinquents from controls. Tarnopol (1970) also found delinquents to have impaired visual-motor coordination, as well as impaired gross motor coordination. These indications, along with abnormal performance on the Bender Gestalt and disparities on WAIS and WISC scores, led Tarnopol to conclude that delinquent behavior may be correlated with symptoms of minimal brain dysfunction. It is thus apparent that the growing literature on neuropsychologicalpathology in violent delinquents is becoming increasingly rich and sophisticated, yet at the same time increasingly confusing. Contradictory findings are reported on such skills as visual-motor integration and coordination, gross motor skills, rhythmic sequencing, spatial cognition, and memory. Higher cortical functions, such as intelligence and planning, seem to be commonly associated with delinquent behavior. Studies, however, have tended for the most part to focus on male delinquents (with the notable exception of the work of Yeudall). Furthermore, the academic deficiencies of these youth, as well as their ages, have not been taken into account systematically in all studies. The current work is intended to address some of these difficulties. The Luria-Nebraska Neuropsychological Battery (LNNB) (Golden et al., 1980) is an instrument which has been receiving considerable attention as an economical, efficient, and accurate assessment device in the diagnosis of neuropsychological dysfunction. The instrument was developed by Charles Golden and colleagues following the theories of the Russian neuropsychologist A. R. Luria (1973,1980). Luria emphasizes the complexity and multidimensionality of mental processes. He discusses the evolution of cerebral functions and the overlapping functional units or systems which constitute any given mental process. In his view, the diagnosis of neuropsychological deficit can be achieved by the analysis of a function into its component parts, along with a convergent procedure by which different parts of that function can be assessed systematically. The developers of the LNNB have attempted to operationalize these theories in a valid and reliable instrument (Golden et al., 1978, 1982). In a series of recent studies, this battery has been.found to reliably distinguish brain damaged, schizophrenic, and normal individuals (Golden et al., 1980). The battery has gained particular attention because it attempts to operationalize the complex theories of Luria; because it is an economical, efficient, and transportable instrument; and because it takes less time than other neuropsychological batteries to administer. The organization of the battery, furthermore, is such that specific kinds of deficits can be detected where other instruments might prove less sensitive. The battery is undergoing continual reassessment and reevaluation (see e.g., Golden et al. (1982) and McKay and Golden (1981)). Sample in this study were delinquent adolescents housed in the State of Michigan. Male delinquents chosen from a population of 120 offenders involved in programs designed specifically for violent and recidivistic offenders. Female delinquents were chosen from among the 60 girls housed in the state's only residential facility for delinquent girls. Seventy-one subjects (40 male, 31 female) were selected according to a set of criteria designed to focus on the most serious offenders. The criteria included: 1. Commission of violent felonies (murder, rape, armed robbery, felonious assault, arson, kidnapping). 2. Commission of multiple (three or more) nonviolent felonies. 3. Multiple placements within the training school system. 4. Assaultive in-program behavior. requiring medical attention for the victim. The resulting sample of 71 youth had a mean age of ± 0.95 years (range: 14-18). The mean SES was 4.58 ± 1.15 on the Hollingshead-Redlich two-factor scale, indicating the low socioeconomic status of these youth. Mean time in the program was 8.82 ± 7.44 months; youth who had been in the program less than 1 month were excluded from the study to preclude possible reactive effects of incarceration. Thirty-nine of the subjects were white, 26 were black, 3 Hispanic, and 3 of mixed racial origin. Forty-five (63%) had committed at least one violent felony; 29 (40%) two or more violent felonies; 21 (30%) three or more nonviolent felonies. Twenty-five (35%) had previous training school placements; 22 (31 %) had a history of in-program assaultiveness; and 26 (37%) had prior psychiatric hospitalizations. During the course of the study, 7 subjects either dropped out of the training schools, were released from the program, or (in 1 case) refused to take the tests. As a result, from the 71 subjects included in the overall study, 64 are included in the present analysis: 36 male and 38 female. Method As part of a wider diagnostic assessment, the LNNB was administered to the subjects. Neuropsychological examinations were administered within the training school facilities where the subjects were housed. The examiner, an experienced neuropsychological tester,

3 455 NEUROPSYCHOLOGICAL ASSESSMENT OF DELINQUENTS was blind to all other aspects of the diagnostic assessment. Each neuropsychological assessment took about 2lf2 hours to complete. This testing was the final part of a comprehensive work-up which included psychiatric (interview), medical, and neurological assessment. The LNNB consists of 269 items, each scored 0, 1, or 2 indicating (respectively) normal, borderline, or deficient on the item. Items are grouped into 11 functional categories: Motor, Rhythm, Tactile, Visual, Receptive Language, Expressive Language, Reading, Writing, Arithmetic, Memory, and Intelligence. In addition, scales of Left and Right Hemisphere localization are extracted from among the items, as is a Pathognomonic scale particularly sensitive to organicity. One of the most valuable aspects of the LNNB is the development of the concepts of "critical level" and "cutoff score" to supplement the evaluation of raw and scaled scores. The "critical levels" are baselines developed for each subject on the basis of age and education. The correction factors help to eliminate potential biases in interpreting scores. Thus, subjects with less formal education now are less likely to be misdiagnosed because of their educational deficits. Determining educational levels for this population is itself a difficult task. Many of these youth could not say with specificity when they stopped attending school regularly, much less when they stopped paying attention. Some gradually became more frequently truant, others attended some classes, but not others, and some were expelled from school because of their behaviors. However, an acceptable solution was found for this problem. All youths who enter the juvenile justice system in Michigan are given the Wide-Range Achievement s in reading, spelling, and mathematics; many, but not all, also are administered the WISC or WAIS IQ tests. The WRAT grade-equivalents were used as the basis for calculation of critical levels in the present study. For ease in making clinical distinctions, Golden and his colleagues also have proposed a set of "cutoff scores" (Golden et al., 1980).According to the authors, individuals with scores above those "cutoff' levels may be diagnosed as having some organic pathology with considerable accuracy. The "cutoff" levels vary for individual scales, and are empirically derived. These "cutoff scores," as well as the "critical levels" for individual subjects, were employed in the current data analysis. Results Table 1 presents the mean scores on each LNNB scale for the total delinquent sample, and by sex. For the entire group, noteworthy evaluations occur on scales measuring rhythm, visual functioning, expres- sive speech, writing, reading, arithmetic, and general intelligence. Boys scored significantly worse than girls on the rhythm scale (t = 2.14, p < 0.05). On nearly every scale, for the entire sample and particularly for the male delinquents, these mean scores differ significantly from those in the standardization sample used by Golden et a1. (1980). However, due to demographic differences between that standardization sample and the current sample of delinquents, statistical comparisons may not be appropriate, and the differences may be taken as merely suggestive. The results of intelligence and achievement testing, used to compose "critical levels" for individual subjects, are presented in Table 2. The low grade levels indicate the severe educational deficits of these youngsters. They achieved a mean reading grade level of just below 7th grade, and a mean math grade equivalent of 5th grade. Consequently, the "critical levels" for these youth would have to be grossly adtable 1 Luria-Nebraska Neuropsyclwlogical Battery ing of Delinquents: Mean Scores (S.D.) Male (N= 36) Female (N= 28) All (N= 64) Motor Rhythm Tactile' Visual Receptive Language Expressive Language Writing Reading Arithmetic Memory Intelligence Pathognomonic Left Hemisphere Right Hemisphere (8.69) 9.65 (4.26) 6.81 (3.40) (3.34) (6.26) (9.17) (5.22) 8.06 (5.03) (7.90) 8.03 (4.82) (11.74) (6.65) 5.13 (3.24) 5.08 (3.17) (7.58) 7.36 (4.30) 5.96 (6.91) (4.30) (6.72) (10.46) 9.04 (3.48) 7.21 (4.27) 9.93 (5.96) 7.25 (4.72) (10.19) (6.06) 4.46 (5.62) 4.43 (4.87) (8.21) 8.66 (4.39) 6.45 (5.18) (3.79) (6.43) (9.73) 9.92 (4.58) 7.69 (4.70) (7.08) 7.69 (4.70) (11.00) (6.39) 4.84 (4.41) 4.79 (3.98) TABLE 2 Intelligence and grade equivalents IQ (WISC/WAIS) Verbal Performance Total Grade (WRAT) Reading Spelling Math All Male Female (N= 37) (N= 22) (N= 15) ±13.61 ±12.02 ± ± ±13.66 (N= 68) 6.98 ± ± ± ±14.9Q ±11.62 (N= 37) 7.17 ± ± ± ± ±16.34 (N= 31) 6.75 ± ± ±1.86

4 456 BRICKMAN ET AL. justed. It mustbe pointed out, of course, that the difficulties these adolescents experience in school may themselves be the result of neuropsychological impairment. Nonetheless, for purposes of the current stage of data analysis, the corrected scaled scores seem. to constitute a pertinent indication of neuropsychological dysfunction as defined by the authors of the LNNB. As indicated in Table 3, the greatest prevalence of dysfunction using the "critical level" criterion occurs on measures of rhythm, writing, arithmetic, and general intellectual functioning. Again, it must be kept in mind that these scores now have been adjusted to account for the actual educational deficits of the subjects. The delinquent group, in other words, is performing worse than it should on these scales even given the lack of formal educational achievement. Noteworthy as well is the high number of youths with problems in expressive speech. Since the administration accounts for pronunciation differences due to ethnic or cultural backgrounds, this finding represents a significantdifficulty in articulation for theseyouths. When the nature of offenses committed by the youths was taken into consideration, analysis revealed that the majority of those youths with scores above their own "critical levels" were violent youths (see Table 4). These were the subjects who had committed at least one violent felony. In general, violent youths were significantly more likley than nonviolent delinquents to have scores above their own "critical levels" (Fisher exact, p < 0.05). However the only individual scale which of itselfdiscriminated between violent and nonviolelff' subjects having scores above their own critical levels was the expressive speech scale (Fisher exact, P < 0.05). When the mean scores of the tests were compared, the memory scale also differentiated between violent and nonviolent subjects, with violent TABLE 3 Scoresabove "Critical Level" Male Female (N= 36) (N= 28) Total Motor Rhythm Tactile Visual Receptive Language Expressive Language Writing Reading Arithmetic Memory Intelligence Pathognomonic 1 1_ 2 Left Hemisphere Right Hemisphere TABLE 4 with Scoresabove Their Own "Critical Level" Total Violent" Percent Motor Rhythm Tactile Visual Receptive Language Expressive Language Writing Reading Arithmetic Memory Intelligence Pathognomonic Left Hemisphere Right Hemisphere "Violent youth: those who have committed at least one violent felony (murder; rape, armed robbery, felonious assault, arson, kidnapping). TABLE 5. with Scoresabove Cutofffor Brain Damage N Percent Motor Rhythm Tactile Visual Receptive Language Expressive Language Writing Reading Arithmetic Memory Intelligence Pathognomonic Left Hemisphere Right Hemisphere delinquents again scoring worse (t = 2.32; df = 41, 18; P < 0.05). Finally, the scores were viewedin the context of the "cutoff' levels designated by Golden and his colleagues. As presented in Table 5, the highest percentages of offenders having scores above these "cutoff' levels occur in the areas of rhythm and temporal sequencing, visual integration, expressive speech, math, and intelligence. Golden and colleagues make the further claim that subjects with scores above the cutoff on three or more scales may be classified as organically impaired with 90% accuracy (Golden et al., 1980). Fully half of our delinquent sample-32 subjects in all-were above the "cutoff" level on three or more scales. Violent subjects were more likely to have three or more scales exceeding the cutoff point for brain damage (Fisher exact, P < 0.05). As part of another phase of the study, it was determined that 27 subjects (17 male and 10 female), comprising 38% of the total sample, had a history of

5 NEUROPSYCHOLOGICAL ASSESSMENT OF DELINQUENTS previous psychiatric hospitalizations. Ofthese, 13 subjects (8 male and 5 female) had multiple hospitalizations. However, demographic, diagnostic, and neuropsychological assessment showed no systematic differences between the group with prior hospitalizations and those without. Discussion Results of this study confirm the validity and importance of neuropsychological evaluation of delinquent youth. Violent and recidivistic delinquents in particular show a distinctly abnormal pattern of functioning as measured by the LNNB. The pattern extends over a wide range of functions; it is not limited to the higher cortical "intellectual" functions often associated with school performance, although those functions also are implicated. While the results of the neuropsychological testing reveal a trend toward more serious impairment in the violent youth than in the nonviolent youth, the only subscales to differentiate of themselves between the groups at a significant level are the expressive speech and memory scales. This finding may reflect a diffusion of functional impairment; it could be attributable to problems in education or in concentration; or it could reflect a specific organic deficit. Item analysis of the scales, and particularly of the memory scale, will reveal exactly where the deficits occur (e.g.,visual recall, sensory trace recall, verbal recall), and will indicate areas for further research. Possible causes for the deficits and anomalies noted in this study can only be speculated about at this time. Preliminary examination suggests that, given the striking abnormalities in temporal sequencing, rhythmic functioning, and expressive speech, the temporal lobe may be implicated in neuropsychological dysfunction. It is important in this connection to note that the rhythm scale, which is elevated dramatically in these youths, is the most sensitive scale in the battery to disorders of attention and concentration. This may be an area of particular difficulty for the male delinquents who scored significantly worse than female delinquents on the rhythm scale. It is significant, as well, that, in a different phase of the study, the present researchers found widespread affective lability in this population (Alessi et al., 1984). Problems in concentration and attention, on the one hand, and difficulties with affective lability, on the other, could have reciprocal effects, or they could stem from a common source. That is to say, it may be that these youths do not develop the cognitive controls to manage their affects and moods, and the problems in establishing these controls and in learning may themselves serve as a source for affective lability, inattention, and delinquency (Gold and Mann, 1972; G. P. Lewis et al., 1979). On the other hand, difficulties in 457 discursive and abstract thinking, temporal sequencing, and concentration may contribute to this weakness in the development and application of cognitive controls (Pontius and Ruttiger, 1976). Further study of these issues seems essential in continued work regarding this troublesome, troubled population. References ALESSI, N., McMANUS, M., GRAPENTINE, L. & BRICKMAN, A. (1984), The characterization of depressive disorders in serious juvenile offenders. Journal of Affective Disorders (in press). BERMAN, A. & SIEGAL, A. (1976), Adaptive and learning skills in juvenile delinquents: a neuropsychological analysis. J. Learn. Disabil., 9: FROMM-AuCH, D., YEUDALL, L. T., DAVIES, P. & FEDORA, O. (1980), Assessment of Juvenile Delinquents: Neuropsychological, Psychophysiological, Neurological, EEG, and Reading Findings. Unpublished manuscript, Alberta Hospital, Edmonton, Canada. GOLD, M. & MANN, D. (1972), Delinquency as defense. Amer. J. Ortlwpsychiat., 42: GOLDEN, C. J., HEMMEKE, T. & PURISCH, A. D. (1978), Diagnostic validity ofa standardized neuropsychological battery derived from Luria's neuropsychological tests. J. Consult. Clin. Psychol., 46: (1980), The Luria-Nebraska Neuropsychological Battery Manual. Los Angeles: Western Psychological Services. -ARIEL, R N., McKAy, S. E., WILKENING, G. N., WOLF, B. A. & MACINNES, W. D. (1982), The Luria-Nebraska Neuropsychological Battery: theoretical orientation and comment. J. Consult. Clin. Psychol., 50: HURWITZ, I., BIBACE, R M. A., WOLFF, P. H. & ROWBOTHAM, B. M. (1972), Neuropsychological function of normal boys, delinquent boys, and boys with learning problems. Percept. Mot. Skills, 35: KRYNICKI, V. E. (1978), Cerebral dysfunction in repetitively assaultive adolescents. J. Ner v. Ment. Dis., 166: LEWIS, D. O. & SHANOK, S. (1977), Medical histories of delinquent and nondelinquent children: an epidemiological study. Amer. J. Psychiat., 134: , -, PINCUS, J. H. & GLASER, G. H. (1979), Violent juvenile delinquents: psychiatric, neurological, psychological, and abuse factors. This Journal, 18: LEWIS,G. P.,GOLDEN, C. J., MOSES,J. A., OSMON, D. C., PURISCH, A. D. & HAMMEKE, T. A. (1979), Localization of cerebral dysfunction with a standardized version of Luria's neuropsychological battery. J. Consult. Clin. Psychol., 47: LURIA, A. R (1973), The Working Brain. New York: Basic Books. - - (1980), Higher Cortical Functions in Man. New York: Basic Books. McKAY, S. & GOLDEN, C. (1981), The assessment of specific neuropsychological skills using scales derived from factor analysis of the Luria-Nebraska neuropsychological battery. Int. J. Neurosci., 14: MONROE, R R, HULFISH, B., BALIS, G., LION, J., RUBIN, J., McDONALD, M. & BARCIK, J. D. (1977), Neurologic findings in recidivist aggressors. In : Psyclwpatlwlogy and Brain Dysfunction, ed. C. Shagass, S. Gershon & A. J. Friedhoff. New York: Raven Preaa, pp, PINCUS, J. H. & TUCKER, G. J. (1978), Violence in children and adults. This Journal, 17: PONTIUS, A. A. & RUTI'IGER, K. F. (1976), Frontal lobe system maturational lag in juvenile delinquents shown in narratives test. Adolescence, 11: SPELLACY, F. (1977), Neuropsychological differences between violent and nonviolent adolescents. J. Clin. Psychol., 33: TARNOPOL, L. (1970), Delinquency and minimal brain dysfunction. J. Learn. Disabil., 3: YEUDALL, L. T. (1978), The Neuropsychology of Aggression. Clarence M. Hincks Memorial Lecture: Psychobiological Approaches to Aggression in Mental Illness and Mental Retardation. Alberta Hospital, Edmonton, Canada, November 1978.