Psychopathic Behavior Disorders in Children
Lauretta Bender’s paper was first published in the Handbook of Correctional Psychology in 1947. A psychiatrist, psychoanalyst, and inventor of the Bender-Gestalt test, Bender reviews the important observations of others concerning the psychopathologies of institutionalized children during World War II. She then offers her own cogent, experience-near observations of children at Bellevue Hospital. The beauty of this work, although she discounts biological contributions, is her insight into the interplay of attachment, identifications, affect, and intellectual development and her understanding of how aberrations in one domain of personality will dynamically change others.
In 10 years (1935–44) over 5000 preadolescent children (under 13 years of age) have been under observation on the Children’s Ward of the Psychiatric Division of Bellevue Hospital. The majority (65% to 75%) of these children have presented problems in behavior with neurotic mechanisms. The causative factors have been conflicts and aggressive reaction to frustrations common to all of us in our culture but exaggerated in these children. Unsatisfactory experiences in their personal relationships are due to (1) inadequate and distorted parent-child relationships in the early childhood period (before five or six years of age), because of at least one absent or seriously asocial, psychotic, defective, or otherwise unsuitable parent; (2) social-economic-emotional deprivation in social minority groups; (3) serious language handicap, such as a language disability, including reading disability and intellectual limitations or a relatively alingual home. Usually only one of these factors is not enough to cause a serious behavior disorder in a child, so wide is the margin of safety in the developmental urge for normalcy.
Another 10% to 20% of the children are handicapped by some organic brain disorder, such as developmental defects or one of the degenerative, inflammatory or traumatic encephalopathies. The brain disorder alone may account for the behavior disorder if it is associated with a considerable disturbance in brain tissue or a progressive process, or if it is associated with epilepsy. However, in many of the traumatic encephalopathies and non-progressive inflammatory encephalopathies and developmental deviations, a behavior disorder, if it is present, will be found to be related to the conflicts, frustrations and deprivations subsequent to the pathological process and any related or incidental disturbance in family, social and language background. Children with progressive encephalitis or encephalopathy (especially with epilepsy) may present a psychopathic type of personality. In contrast to the psychopathic behavior disorders, however, they usually manifest some neurotic reactions such as anxiety, feelings of guilt, and inadequacy in response to the frustration imposed upon them by the organic pathology, especially if the frustration involves their interpersonal relationships. Such neurotic features are an aid in diagnosis, make the prognosis more favorable and offer the therapist an approach to the child that is often very gratifying in its results. Schizophrenia in childhood appears to be closely related to the progressive encephalopathies.* A neurotic response with anxiety to the frustrations which the schizophrenic personality must face is evident in the early stages and often confuses the diagnosis. However, this neurotic reaction is at present our only means of a therapeutic approach to the personality while the patterned functions are being disorganized by the schizophrenic process.
There still remains a group of children representing 5% to 10% of the whole which we will refer to as psychopathic behavior disorders in children. This group of children presents a clinical picture which forms a syndrome in that the causative factors in the early life of the individual are known, the developmental course may be anticipated, the behavior pattern is typical and closely resembles the classical description of the so-called constitutional psychopathic personality. Moreover, psychological tests for personality show a specific patterning and the response to various treatment programs is known.
The study of these children has resulted in important contributions to modern psychopathology. It not only has thrown light on the question of the psychopathic personality, but has made possible a preventive program and also has brought new data to some controversial problems about the normal personality structure and the development of various personality functions and dysfunctions.
The cause of the condition is emotional deprivation in the infantile period due to a lack or a serious break in parent-child relationship, for example, the child who has spent considerable time in infancy or early childhood in an institution without any affectional ties, or a child who has been transferred from one foster home to another with critical breaks in the continuity of affectional patterns. The defect is in the ability to form relationships, to identify themselves with others and, consequently, in conceptualization of intellectual, emotion and social problems and asocial or unsocial behavior. The developmental processes in the personality become fixated at the earliest stage; there are no satisfactions derived from human experiences and no anxieties because there are no conflicts. The ego is defective and there is no superego. After a certain period this fixation in the development of the personality can no longer be overcome or corrected because a therapeutic or transference relationship can not be obtained. This is the reason for the difficulties in treatment. Prevention is possible by avoiding such deprivation in the early infantile period and insuring against critical breaks in the continuity of close personal relationships in a family circle, from the early weeks of life until the child is well out of the infantile period and in the middle childhood period.
Once a child can exhibit independent behavior, enter into new relationships with adults and children—as the child does when he goes to school at the age of 5 or 6 years—he can show that his personality has safely developed beyond the period when such breaks or deprivation will any longer be critical. Freud originally placed the superego development at 3 1/2 to 5 years. Melaine Klein (1932) shows that there is evidence of superego formation well inside of the first year. In general, it seems that the younger the child at the time of the deprivation, the more serious the effect upon the personality. The first year is, therefore, the most vulnerable, although prolonged or critical breaks in the continuity in parent-child relationship during the second, third and fourth years often distorts the personality in the direction of a social agnosia rather than in a neurotic reaction type. A critical break is one in which the child completely forgets the parent, or in which the relationship is completely broken and the new one does not establish itself on a similar pattern.
Margaret Ribble has shown the need of mothering to the new-born and young infant for its immediate well being and its future personality development. It has been known for a century that the hospitalized or institutionalized child might suffer even death, or marasmic physical states, and pronounced deficiencies, or deterioration in mental and personality development. Hans Christoffel (1939) (Switzerland) has quoted Parrot, a great infants’ clinician of the 19th century (1839–1883) in France, to this effect. Emperor Frederick the Second was said to have experimented in the fifteenth century with an attempt at raising infants without demonstrations of affection; and they all died because they were “without the appreciation, the facial expression, friendly gestures and loveable care of their nurses” (quoted from Salin Benes, the monk). Hildegard Dufree and Kathe Wolf (1934) found that infants raised in proletarian infants’ and children’s homes in Vienna could be in good physical condition where the emphasis was on physical hygiene, but suffered in mental and emotional development.
A large number of problem children at all ages have been brought to Bellevue for observation from the different child-caring institutions and foster home agencies. They have represented almost a laboratory experiment in personality structure. In many children there has been a profound inhibition in personality development, while in others various degrees of a similar personality defect. In children who have been in institutions for the first two or three years of their lives without a parent who visits frequently and takes an interest in them, we find the most severe type of deprived, asocial, psychopathic personality deviation. There is a lack of human identification or object relationship and an inability to experience such when therapeutic efforts are made to offer such a relationship to the child. There is a lack of ego or superego awareness. There is a lack of anxiety or any neurotic structure as a reaction pattern to conflicts or to frustration. There are no conflicts, and frustration is reacted to immediately by temper tantrums. There is an inability to love or feel guilty. There is no conscience. The unconscious fantasy material is shallow and shows only a tendency to react to immediate impulses or experiences, although there often are abortive efforts to experience an awareness of the ego or to identify the personality.
Their inability to enter into any relationship makes therapy or even education impossible. There is an inability to conceptualize, particularly significant in regard to time. They have no concept of time, so that they never keep pace with any schedule, have no attention span, cannot recall past experience and cannot benefit from past experience or be motivated to future goals.
This lack of time concept is a striking feature in the defective organization of the personality structure or patterned behavior. The biological instinctual needs and tendency to normal development drives the child to activity which never satisfies him and is the chief source of frustration. There is a drive to use perceptual patterns as a mode of experience, and it is thus that they tend to imitate the behavior or ideology or art expressions of other children. This gives us our best lead as to the care and training of such children.
They should be placed in a benign institutional setup, organized with well routinized and patterned social and educational activities, in small groups of children where they can fall into a routine and imitate other children. They should not be expected to take any responsibility for their behavior, to make any decisions, to profit by their or others children’s mistakes, or to be motivated to future goals. Corrective discipline or insight therapy have no place in their training.
Helen Yarnell and I (Bender and Yarnell, unpublished ms.) in a survey of 250 children under the age of six years who had been on the Children’s Ward during the five year period from 1934 to 1939, found that about 10% or 12% of this group were referred from child placing agencies because of this type of problem. One agency was without psychiatrically trained workers at that time. The boys were placed in foster homes and there was no effort to make them feel emotionally secure. In fact, it was felt that an attachment between the child and the foster parent should be discouraged, and frequent changes in foster home placement was a part of the program. These boys were usually referred to us between five and seven years of age when they failed to become part of a school or community group because of their extreme infantile behavior, the wild disorganized activity, their inability to relate themselves to anybody or any group, or to become satisfactory members of a foster home or school room.
Another group consisted of children who were placed in infancy in an infants’ home of one agency. The children were given the best physical and pediatric care and were well developed and healthy, but they were deprived of all affectional ties, social contacts and even play materials. As a result, they all appeared retarded in speech, in patterned behavior, even in motor functions, and in social and personality development. At a little over three years they were transferred to foster homes in which they usually could not adjust and were then moved to several other trial homes; each time they became more difficult. They appeared to be unable to accept love or the pattern of life in a home situation because of the deprivation of institutional life for the first three years. There were instances in which the deprivation was limited to within the first year, but these children showed the same personality retardation and distortion. It appears that some children of this type may be acceptable to a very tolerant foster mother if she either can give all her attention to the child or if she is insensitive to his unpatterned, impulsive, infantile, unresponsive behavior, and if there is no other child of a similar age with whom he must compete in the home. Even such children do not mature and their behavior never becomes patterned or acceptable when they reach school age.
These children do not develop a play pattern; they cannot enter into group play with other children, but abuse any child near them as frustrating objects to the satisfaction of their own impulses. They seek adults for constant contact but are never gratified by the contact and have temper tantrums when any impulse arising from instinctive needs is frustrated, or when any type of cooperation implying either interpersonal relationship or patterned behavior is expected. They are hyperkinetic, distractible, short in attention span, subject to uncontrolled mood swings, lacking any concepts of human relationships. They speak of having many mothers and fathers and say that everybody is their brother and sister. They love themselves or “God” or the nearest person to them, or “all the mothers and fathers and brothers and sisters.” These children do not respond to the group nursery care on the ward as children do who have had some sort of parent-child relationship.
Our follow-up study on 10 of these children in 1939 showed that some of them had settled down during the latency period in orphan homes and some had been accepted by particularly tolerant and undemanding foster mothers. All remained infantile, unhappy or affectless, and unable to adjust to children in the schoolroom or other group situation. At that time we classified these children as psychopathic personalities which had been caused by emotional or social deprivation during the formative infantile period. A failure to identify themselves in an interpersonal relationship was the essential psychopathological mechanism.
We also observed a characteristic curve of the Stanford-Binet intelligence quotient during the childhood period, indicating a specific intellectual retardation which results from the non-stimulating experiences of their infancy and the inability to utilize identification processes for psychic development. For example, Harry was placed at birth in the infants’ home. His physical development was normal. At three years he was examined in the home before placement and scored an I.Q. of 78. At four years, after failing to be accepted in two foster homes, his I.Q. was 83. At five he was back on our ward following six foster home experiences, and his I.Q. was 85. At eight years (in our 1939 follow-up study) his I.Q. was 88; he was failing to do any work in school. At eleven years his I.Q. was 75, and institutional care was the only possible recommendation. Albert’s I.Q. was 68 at four years when he was leaving the infants’ home; it was 75 at five years, 86 at six-and-a-half, 95 at nine, when he was placed in an institution, and 82 at 11. The child shows clear evidence of retardation as a result of three or four years of socially depriving institutional care, and then shows accelerated development of intelligence under the more stimulating influence of the foster home, community and school life to the eighth or ninth year, and then a retardation again because of his inability to apply himself to school work and to acquire learned techniques or social or verbal insight.
Maizie Becker (1941) made a follow-up study of 25 boys who had been on our ward and presented psychopathic behavior problems. Half of these boys came from the same infant home experience described above, the rest from other agency-type of care for the dependent child. Their ages were nine to fifteen at the time of the follow-up, and five to thirteen at the time they were first seen on the ward. Her conclusions were that the study confirmed Dr. Yarnell’s and my observations on the nursery-age children that
children who have been brought up in institutions where personal stimuli are lacking (or have experienced repeated breaks in affectional ties through frequent shifts in foster home placements), and are emotionally under-privileged, have no feelings for human relationships, are asocial in their behavior, and have no capacity for anxiety or guilt.
She found that
an institution regime seemed to afford the best facilities for the care of this type of child. In the majority of cases no change in the emotional structure had occurred. In a few instances boys had been able to form attachments to foster parents. In all these cases it was possible to confirm that the child had had a relationship throughout his institutional experience with a mother. There was one exception that could not be accounted for.
In 1940 Lawson G. Lowrey made a report on the children from this same agency under the title of “Personality Distortion and Early Institutional Care.” He reported 28 children from the same infants’ home who were subsequently referred to him for psychiatric advice because of serious problems in social adjustment. He stated that
the conclusion seems inescapable that infants reared in institutions undergo an isolation type of experience with a resulting isolation type of personality characterized by unsocial behavior, hostile aggression, lack of pattern for giving and receiving affection, inability to understand and accept limitations, marked insecurity in adapting to environment. These children present delays in development and intensification as well as prolongation of behavior manifestations at these levels. At the time of transfer (from institution to foster home at 3 1/2 years of age) they are at a stage where they can form only partial love attachments.
Lowery concluded that, if the transfer was to occur at this time, it should be cushioned by the experience of being in a small group intimately in contact with warm adults genuinely interested in them, but that preferably they should not be transferred from an institution to a boarding home when negativism is at its peak. More significant seems his conclusion that “infants should not be reared in institutions, or at least for the shortest possible time; otherwise the institutions should furnish such intimate personal planned contact with at least one adult.”
It is of interest that Anna Freud (1944), in her experiences with young children in nurseries in England during the war, also came to the conclusion that serious personality disorders in children might be prevented by creating a family-like situation in the institution with one adult relating herself closely with an expressed mother relationship to only two or three children. It is apparently true that some children are raised in institutions through the early infantile period and show a normal personality development. Usually it is possible to show that such children have been regularly visited by a parent (in one instance, at least, this was the father), or that someone in the institution took a warm and continuous interest in the child, acting as a satisfactory parent substitute. David Levy in 1937 used the term “affect hunger” in describing a group of problem children brought to his attention by the Child Guidance Clinic, a number of whom had suffered similar deprivations in their earlier lives, although some had been “rejected” children and others “spoiled” children of over solicitous mothers.
William Goldfarb (1943a, b) has made most important contributions to the study of the personality deviations in children by studying children who in their infancy had been in the same infants’ home we have referred to above. His first study was in 1943 on “Infant Rearing and Problem Behavior.” He based it on the
suggestive data that in 1938 children were referred by the foster home agency to Bellevue Hospital for observation because of extremely poor personal and social adjustment. Investigation of their background disclosed the startling fact that all had spent their infant years in an infant institution. The problem was described in six cases as a behavior disorder with symptoms of aggression, hyperactivity, quarrelsomeness, disobedience, destructiveness, restlessness, stubbornness and shallowness of affect. In one the problem was stubbornness and ease of emotional upset.
Goldfarb made a series of carefully planned and controlled studies of children who had spent their first three years in this institution and then were placed in foster homes under supervision of trained psychiatric social workers, comparing them with matched children who had been placed in foster homes from their earliest infancy. His studies included behavior, personality and intellectual development, using the case records and questionnaires of the social workers, interviews, observation, and clinical psychological tests on the children. He found important and sharp contrasts between the children who had spent their earliest years in infants’ homes and those who had been from the beginning in foster homes. The first group were more retarded in general. Behavior was characterized by destructiveness, consistent failure regarding privacy rights, antagonism and cruelty to other children as infantile modes of expression. There was speech retardation, relative mental retardation, poor school adjustment. It was noted that those children who had been cared for entirely in foster homes also had problems, but they were more heterogeneous and, specifically, there was more “passive anxiety” as compared to aggression in the institutional children. This may be interpreted to mean that there were more neurotic features or mechanisms in children who had always been in a home or family situation, and that the unpatterned impulsive overactivity of the institutional children showed no neurotic or anxiety mechanisms.
In Goldfarb’s (1943b) comprehensive paper, “The Effects of Early Institutional Care on Adolescent Personality,” he compared two groups of adolescent children then in foster homes, but the first group had been in an infants’ home for the first three or more years. He says,
it would appear as though the early group experience of the institution children was a highly isolating one. The emotional and intellectual deprivation resulting from the absence of adults produced a series of distinctive personality traits. These children continue to be different from a group of children with continuous family experience even as late as adolescence and even after a long period of foster family and community contact. They remain less well adjusted to the demands of the community group, more simple in their mental organization, less capable of making reflective and complex practical adjustments at school and more important, less capable of normal human relationships.
He attempted a general theoretical formulation, but his most important conclusions dealt with the
specific implications for the field of child care since all of the institutional children were reared in early infancy in what the field of child care has regarded as one of the better infant institutions and it is unlikely that other institutions have been supplying a more personalized type of care.
Significantly, the mean I.Q. (Bellevue-Wechsler) for the “institution” group was 72, and for the foster home group was 95, the difference being greater for verbal function than performance function. Conceptual thinking was especially defective and proportionally more so than in mentally defective children of a similar functioning level. Rorschach tests on this same group of children demonstrated that the “institution” children showed more deviations from the norms in that they were more concrete and inadequate in conceptualization, which indicated an apathy in relationship to the environment, behavior that is unaccountable and without conscious purpose.
From these children we have learned that the emotional deprivation which results from spending the first three years in an institution may produce an irreparable distortion of the personality with the features of infantilism, lack of patterned behavior with an aimless hyperkinesis, apathy, relative retardation in intellectual development most severe in the fields of conceptualization, language development, and inability to make an object relationship or to give and take in any human relationship.
It is needless to say that on the Children’s Ward at Bellevue Psychiatric Hospital there have been many other children with psychopathic behavior disorders besides those coming from this particular infants’ home. Some, indeed, may have spent no time in an institution, but may have been changed frequently in foster homes, so that the child was unable to maintain any continuous relationship or identification with any one parent or parent substitute. It appears that there may be two different causative factors. One is the absence or inadequacy of emotional, social or cultural stimuli which is a part of the institutional life of children and which is related to the intellectual retardation, apathy and lack of patterned behavior.
The other factor is the absence of, or critical or repetitious breaks in, an identifying close adult-child relationship. This alone may produce a severe and irreparable distortion in personality of the psychopathic type. In these children the intellectual retardation may not be so marked, but the children will never function intellectually at their maximum because of inability to identify themselves with a teacher or a school room situation or with social concepts, due to lack of motivation, poor attention span, poor work habits and techniques and defects in patterned behavior and conceptualization. Unsuccessful satisfaction-seeking behavior and a complete infantilism in personality is most characteristic of these children. They are overactive and socially and physically destructive without being hostile in their aggression. They show no neurotic features and are therefore without anxiety, guilt, or any positive or negative human emotions of love or hate.
From several children such as these, we have learned that the critical age is certainly under two years (the period of language development is undoubtedly critical); in some cases it is definitely under one year. A serious deformity in personality might occur in a child in whom there had been a critical change in parent relationship before the latter part of the first half year of life, because that is the period when children first identify their parents and show a definite and individual relationship to the people around them. However, it also appears that a very critical break in total family identification during the second, third, and fourth years may produce the same personality distortion. If there is no chance to carry on any of the earlier identification processes, all memory of them is lost or distorted and the normal processes of personality development cannot continue. It is probably true that in these instances severely traumatic experiences such as abusive or neglectful care, long periods in impersonal shelter care, or severe illnesses with hospital care, may be contributing factors. But these only serve to make the really critical factor, namely the break in identification processes, a telling one. Patterned behavior, conceptualization, depth and reality in object relationship in normal human development, are therefore dependent upon the continuation of such experiences through the early critical years of personality development.
Psychopathic behavior disorders are quite common among adopted children when the child has been adopted in this early childhood period especially from institutions, or after a period of neglectful care or too long a period in a hospital. This type of behavior disorder is also seen in children of the upper economic and social levels when the child has been left in the care of rapidly changing servants, and when the relationship to the mother and father due, in part perhaps, to their many business and social obligations, has been too scant to permit of any real opportunity for identification, normal interpersonal relationships, and personality development. The first case in Helene Deutsch’s (1942) paper on the “As if Personality” is an example.
SUMMARY
(1) These children impress us with their diffusely unpatterned impulsive behavior. At all levels it is unorganized and it remains unorganized. It is exceedingly difficult to find any educational or psychotherapeutic method whereby it can be modified into organized or patterned behavior. The child is clearly driven by inner impulses which demand immediate satisfaction; these impulses or needs show the usual changes with physical and chronological growth of the child, but even they do not add much pattern to the behavior. Motivation, discipline, punishment and insight therapy have little effect. Controlling the environment in which the child may act, to which he may respond by imitation, seems the only means of producing social patterns and even this is superficial.
(2) The behavior remains always infantile. It is true that there are some differences in different individuals as to the level of the infantile fixations. It is certainly pre-oedipal, pre-superego, and usually pre-narcissistic. It is as though a newborn infant had urgent needs which must be satisfied. Screaming, kicking or temper tantrums or disturbed behavior of which the larger child is capable continues when frustration occurs, as it must a good deal of the time. All kinds of oral activity, clinging, wetting, soiling, senseless motor activity, and genital manipulation may be observed. These are not neurotic traits and do not indicate regression but retardation in personality development. In some instances they may be given up through a quiescent period only to recur again when inner drives are great or outer satisfactions less. Psychopathic behavior disordered children are often attention-seeking, clinging, passively dependent, seductive and, with it all, amiable. This may be mistaken for an attachment or interpersonal relationship. Actually, there is no warmth, and the relationship can stand no separation or disappointments or demands: it shifts for the nearest new object as soon as the recipient is out of sight. It seems probable, however, that they finally find such a relationship upon which they can depend, especially after the strongest of the youthful impulses have subsided, as the psychopathic individual seems to disappear in early adulthood.
(3) The primary defect is an inability to identify themselves in a relationship with other people, due to the fact that they experienced no continuous identification during the early infantile period from the first weeks through the period when language and social concepts, and psychosexual and personality development, were proceeding. Related to this lack of capacity to identify or to form an object-relationship is a lack of anxiety and inability to feel guilt. It would thus appear that anxiety and guilt are not primary or instinctual qualities, but that they arise in reaction to threats to object relationships and identifications. This is of great theoretical significance in the whole area of the psychology and psychopathology of personality.
(4) There is a serious defect in language development. In the youngest child this is the whole field of language. Later it concerns itself more with the semantic function of language and especially with conceptualization and social concepts. Cleckley emphasized this semantic defect, while Reich referred to a “social agnosia.” Goldfarb has studied the conceptual difficulties and general interference in intellectual development. The earliest identification with the mother and her constant affectional care during the period of habit training, formation of concepts of the family unit, and language development, are necessary for the later higher semantic and social development.
(5) There are tendencies to rhythmical fluctuations in behavior which may be looked upon as mood swings and may sometimes be confused with manic-depressive states. This is particularly true of the adolescent period. The mood swings are related to internal biological drives which always tend to show some rhythmical behavior. It is as though the biological unit under the pressure of inner drives or needs could move along at a certain rate only so long before swinging into a new pace.
(6) There is an imitative, passive “as if” quality to the behavior of the older children and adolescents. This is because there is an inner drive to behave like a human being. Whereas behavior in the normal child arises from internal mechanisms, such as identification processes, object relationships, anxieties and symbolic fantasy life, the psychopathic child has no such inner life but still has the physiological or intellectual capacity to perceive and use symbols and patterned behavior. It, therefore, copies the behavior of other children, according to its maturation level and ability. This is done in an effort to understand what other children are experiencing. Confabulations have the same meaning. Ridiculing and caricaturing behavior of others is on the same basis.
(7) Once the early childhood has been passed without the adequate opportunity for normal relationships and personality development, the organization of the personality permits no modification. These children do not show a change in behavior by sudden confinement to a restricting institution as all other children do. Their behavior is not modified (in part because of the semantic defect) by insight therapy or transference therapy because they cannot relate themselves to anyone. Our experience has led us to the opinion that in early childhood there should be patient efforts to establish habit training, socially acceptable behavior and language by one attentive mother figure in the home situation. Once the defect is present, however, this will only accomplish a superficial effect, the underlying defect in personality will persist and assert itself. From about the eighth or ninth year into middle adolescence, the best program is a small closed institution with other children of a similar age. Here the psychopathic child can be expected to fall into the carefully controlled routine and to imitate the behavior of the other children about him. He need have no responsibility for making decisions about his behavior. Nothing is expected in regard to goals or ideologies. Later, if he can become attached in a dependent role to some institution, or person, it may be that he will not be socially destructive.
(8) The defect in time concept is one of the most significant problems.* This may be related to the lack of identification as a continuous temporal process. Even in those children where the problem was a lack of a continuous personal relationship, the same may be said. It appears that we develop our time concept from the passage of time in our earliest love relationships. These children do not remember the past, they cannot benefit from past mistakes; consequently, they have no future goals and cannot be motivated to control their behavior for future gains. There is a somewhat similar defect in spatial concepts. Thus, even when they become momentarily attached to a person, they loosen the attachment when the person is absent. This defect in time concept may be tested by suitable clinical tests. It is related to the problem of lack of pattern in all behavior.
(9) Finally, we come again to the origin of this specific defect in personality development in children. It is not a hereditary or constitutional defect. It is caused by early emotional and social deprivation, due either to early institutional or other neglectful care, or to critical breaks in the continuity of their relationships to mother and mother substitutes. We know that the critical time is the first three years, especially the first year; any sufficient break in parent relationship or period of deprivation under five years may be sufficient to produce this personality defect. Once the defect is created, it cannot be corrected. However, we know a good deal about what we should do to prevent such psychopathic behavior disorders.
No child during the first years of its life should be placed or left in an institution for any period of time, even a few weeks in the first year of life is probably too long. If an institution is to be used, it should furnish for each individual child an individual adult who will enter into a continuous, warm, human relationship with him and replace his parents in this relationship. When hospitalization is necessary for infants, it should be as brief as possible, and should provide regular parental visits. Babies put out for adoption should be accepted for adoption in the first weeks of life. They should not be placed in institutions or other foster homes for a period of observation and “preparation.” Changes in foster homes or any other radical changes which sever all relationships should be avoided for children under school age. Children who have had any of these experiences should not be considered adoptable until they have reached school age and have shown normal personality development and school adjustment. The care and treatment of such children, once the psychopathic personality defect is established, should not be therapeutic, corrective or punitive: it should be protective and should aim to foster a dependent relationship.
REFERENCES
Becker, M. (1941). Psychopathic Personality. A follow-up study of twenty-five boys of the Children’s Ward of the Psychiatric Division of Bellevue Hospital. A professional project completed in partial fulfillment of the requirements for diploma from the New York School of Social Work. Unpublished.
Bender, L. & Yarnell, H. (unpublished manuscript). An Observation Nursery. A study of two hundred and fifty children on the Psychiatric Division of Bellevue Hospital, New York City.
Christoffel, H. (1939). On some foetal and early infantile reactions. Internat. Z. Psychoanal. Imago, 24.
Deutsch, H. (1942). Some forms of emotional disturbance and their relationship to schizophrenia. Psychoanal. Quart., 11:301–321.
Dufree, H. & Wolf, K. (1934). Image, 20:253.
Freud, A. (1944). Infants Without Families. New York: Medical War Books.
Goldfarb, W. (1943a). Infant rearing and problem behavior. Amer. J. Orthopsychiat., 13:249–265.
Goldfarb, W. (1943b). The effects of early institutional care on adolescent personality. J. Exp. Educ., 12:106–129.
Klein, M. (1932). Psychoanalysis of Children. London: Hogarth Press.
Levy, D. M. (1937). Primary affect hunger. Amer. J. Psychiat., 94:643–652.
Lowrey, L. (1940). Personality distortion and early institutional care. Amer. J. Orthopsychiat., 10:576–585.
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*Editor’s Note: Subsequent research has not supported this idea.
*Editor’s Note: They are prisoners of the present. See Milton Miller, chapter 10.