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The authors document the childhood neuropsychiatric and family characteristics of nine male subjects who were clinically evaluated as adolescents and were later arrested for murder. Those subjects are compared with 24 incarcerated delinquents who did not go on to commit violent offenses. The future murderers displayed a constellation of biopsychosocial characteristics that included psychotic symptoms, major neurological impairment, a psychotic first-degree relative, violent acts during childhood, and severe physical abuse. The authors relate this combination of factors to prediction of violence and discuss ethical issues that are involved in intervention to prevent violence.

Murder is the most serious of all crimes. Therefore, knowledge that can help to predict and thus potentially prevent extraordinary violence is worth reporting. The purpose of this paper is to document the psychological, neurological, and experiential factors that consistently appeared in the cases of nine adolescents who later committed murder and to compare these adolescents with a sample of 24 delinquents who did not go on to commit violent acts within 6 years of discharge from a juvenile correction facility. With the exception of a single paper describing one young murderer , to the best of our knowledge all of the literature on the neuropsychiatric antecedents of homicide is retrospective.There is a controversy in the literature regarding the prevalence and severity of mental illness in murderers. McKnight et al.

found that 77% of 100 murderers received psychiatric diagnoses (schizophrenia, especially paranoid, manic-depression, psychopathic personality, and epilepsy). In fact, 55% were unfit to stand trial and 27% were found not guilty by reason of insanity.

That study was, however, skewed by the fact that the sample was taken from a prison hospital. Several other authors (–) have found murderers to have a higher prevalence of psychoses, especially the schizophrenias, than the general population. Wolfgang , on the other hand, found that only 3% of the murderers in Philadelphia prisons were insane.

Gillies found 90% of his Scottish sample of murderers to be normal and free of psychiatric diagnoses. Once again, results vary (, ).

Wong and Singer found that only 7% of the 621 murderers they studied in Hong Kong were mentally ill or not guilty by reason of insanity.The literature on homicidal aggression from the 1940s, 1950s, and early 1960s focused primarily on social and psychodynamic factors to the almost complete exclusion of neurobiologic factors (–). Sargent described five murderous children and hypothesized a family conspiracy in which the child who killed acted out an unconscious parental wish. Easson and Steinhilber presented eight cases of attempted homicide, none of which was successful. Their conclusion was similar to Sargent's: “All cases demonstrate that one or both parents had fostered and had condoned murderous assault.” Michaels , using Easson and Steinhilber's clinical data, highlighted factors that Easson and Steinhilber had minimized, namely, history of enuresis, epilepsy, and abuse.

Martin evaluated the psychodynamics of two adolescent murderers but failed to elaborate on several symptoms of organic brain impairment, which he mentioned only in passing. Smith , after evaluating eight young murderers, concluded that they suffered from early experiences of deprivation which resulted in underdeveloped egos and vulnerability to outbursts of violent aggression. Miller and Looney theorized that adolescents who tended to dehumanize others were at greatest risk of committing murder when their wishes were thwarted. In 1978 McCarthy discussed the psychodynamics of 10 adolescent murderers and found that “narcissistic disturbances, particularly an impaired capacity for self-esteem regulation and underlying narcissistic rage, were related to homicidal behavior.” Malmquist suggested that homicide “can serve the illusory function of saving one's self and ego from destruction by displacing onto someone else the focus of aggressive discharge.”Much has been written about the association of parental brutality and homicidally aggressive behavior (, –, –). King noted that the nine adolescent murderers he studied were “often singled out for abuse.” The presence of repeated violence and abuse in the environment of many adolescent murderers led Pfeffer to view much of the adolescent's assaultive and homicidal behavior as an attempt to master the trauma he has experienced by controlling and victimizing others. Sendi and Blomgren noted that an exposure to extreme violence or murder differentiated their group of 10 murderers from a control group.

They also reported that seduction by or sexual perversion of a parent was associated with homicidal youth.Duncan and Duncan and Lander and Schulman , in studies based on small numbers of cases, described destructive and nonnurturing parent-child relationships and hypothesized that these may have led to acting out of intense hostility and homicidal behavior. McCarthy asserted that early deprivation is often associated with homicidal behavior. Corder et al. (, ) reported severe psychopathology in parents of homicidal adolescents. They described “extreme maladjustment, e.g., chronic alcoholism, repeated hospitalization for psychosis, and many incarcerations for criminal acts.”There is a continuing debate in the literature about whether psychomotor epilepsy and violence are associated with each other.

Although some authors (–) have called attention to an association between the two, others (–) have questioned the relationship.King and others (, ) have reported extensive information pointing to the presence of a continuum of learning deficits and neurological problems associated with youthful homicide. Lower intelligence and mental retardation have also been reported to play a role in homicide (, ). King and Lion studied the effects of cognitive and language communication deficits in homicidal youths. Their studies showed that these adolescents may have an “inability” or “disinclination” to master language and basic communication skills.The studies we have cited can be characterized in two ways.

First, each study tends to focus on a single dimension of behavior (e.g., psychodynamic, neurological, experiential). Second, all of the studies of more than one subject are retrospective. That is, they reconstruct childhood factors after murder has occurred. For these reasons, we considered it important to report the neuropsychiatric and psychosocial characteristics of nine murderers examined before their commission of homicidal acts. SamplesOur subjects consisted of two groups. The first was a sample of nine boys who had been neuropsychiatrically evaluated when they were between the ages of 12 and 18 years (mean=14.5 years, median=14.0 years) and who subsequently were charged with murder.

Sources of Clinical DataOur clinical data for the nine subjects who murdered consisted of all available neuropsychiatric records that predated each subject's act of murder. Comprehensive psychiatric and neurological evaluations were available on eight of these subjects, including detailed medical and family histories. In the ninth case, the results of a preliminary psychiatric assessment and information from a parental interview were available; however, no neurological data or data regarding physical abuse were available.The clinical data for the 24 comparison subjects consisted of psychiatric evaluations performed 6 years before follow-up, which included detailed medical and family histories. In 22 cases, the results of neurological evaluations were also available. The nature of these neuropsychiatric evaluations has been described elsewhere.The use of records antedating each subject's act of murder has advantages and disadvantages.

Because the data on the murderers were gathered at different institutions (e.g., court clinic, psychiatric hospital) and under different conditions and were not intended specifically for the purpose of studying antecedents to homicide, they are not uniform. In the case of the 24 comparison subjects, the data were gathered in the course of a clinical study of neuropsychiatric and family characteristics of incarcerated delinquents and were more uniform. Follow-Up DataFor the nine murderers follow-up data were obtained as follows: in six cases data came from police arrest records, in two cases it came from newspaper reports, and in one case it came from a telephoned report by a corrections officer to the correctional school from which the subject had absconded. All follow-up data on the comparison sample came from state police arrest records.

Of note, the commission of adult violent crimes in the comparison group is undoubtedly an underestimate, since it was known that some subjects had moved from the state and their offenses therefore might not have been known to the state in which they were incarcerated as adolescents. ResultsThe nature of the homicidal acts of the nine murderers and the quality of their juvenile violent behaviors are summarized in. As can be seen, all nine had manifested extreme violence as children and adolescents. In most cases there was evidence that extreme violence had occurred several years before the commission of murder. For example, one boy had committed multiple sexual assaults at least 5 years before committing murder, another robbed at knifepoint 10 years before committing murder, and another assaulted a woman with a knife and robbed her 3 years before committing murder. At least four of the boys who later murdered were extraordinarily violent in early childhood: one burned his bed when he was 4 years old, another was too violent to be permitted into grade school and required instruction at home starting at age 10, another threatened a teacher with a razor at age 10, and another choked a bird at age 2 and threw a dog out of a window at age 4.

As can also be seen in, all nine of the murderers had a first-degree relative who had been psychiatrically hospitalized and/or demonstrably psychotic. Five had mothers who had been psychiatrically hospitalized, whereas of four fathers known to have been psychotic, only one was known to have been hospitalized. Given the fathers' violent behaviors, it is likely that they were incarcerated rather than hospitalized.That abuse and violence were rampant in the households of most of these boys is also illustrated in.

Of the eight for whom information on abuse was available, seven had been severely abused by one or both parents. Belt buckles, cords, broom handles, sticks, and shoes were used to inflict punishment. The mother of one boy broke his finger while she was under the influence of alcohol. The hospital record of another boy revealed that his father had attempted to kill him and his brother on several occasions. Records revealed that six of the boys had witnessed extreme violence within their households. They had observed their parents assaulting each other and other members of the family.

One boy had been present at the stabbing of his uncle. The father of another youth was constantly involved in fights outside the family, during one of which he inflicted brain damage on his victim by bludgeoning him with a metal pipe.Thus, all nine boys were severely neuropsychiatrically impaired, and all had close relatives who were psychotic and/or had been psychiatrically hospitalized. Most had both witnessed and been the victims of violence. Furthermore, all had been extraordinarily violent long before they committed murder. Comparison of Murderers With Ordinary DelinquentsThe results of the comparison of the nine murderers and the 24 incarcerated delinquents who did not go on to commit violent crimes can be seen in.

The most powerful individual variables distinguishing the groups were psychotic symptoms and neurological impairment. The difference between the groups in the proportion with first-degree psychotic relatives approached significance.

It is somewhat surprising that neither early violence alone nor a history of abuse strongly distinguished the groups from each other. Rather, the combination of all five variables most strongly distinguished the murderers from the ordinary delinquents. MurderersOrdinary DelinquentsWith VariableWith VariableChi-Square Analysis (with Yates' correction)VariableWith Data AvailableN%With Data AvailableN%χ 2 (df=1)pPsychotic symptoms05.1.05Serious violence as juvenile22.9.05All five variable867522299.9. DiscussionIndividually, each of the factors associated with the extreme violence of the nine homicidal subjects often exists to a greater or lesser extent in the backgrounds of other aggressive individuals. It was the coexistence of all of these neuropsychiatric and family factors and their severity that distinguished these youngsters most clearly from the comparison group of ordinary delinquents.It seems that severe CNS dysfunction, coupled with a vulnerability to paranoid psychotic thinking, created a tendency for the nine homicidal subjects to act quickly and brutally when they felt threatened. Living within psychotic households, they were frequently the victims of and witnesses to psychotic parental rages, experiences that undoubtedly further exacerbated their tendencies toward the physical expression of violence. Whether or not these youngsters dehumanized their victims, as Miller and Looney suggested, could not be determined.

If, indeed, they did, these objectively identified neuropsychiatric vulnerabilities undoubtedly contributed to their distortions of reality.The finding that the parents of these youngsters were often both psychotic and violent may shed light on earlier studies purporting to document a genetic predisposition to violence. Previous studies of large samples of antisocial individuals have revealed that their offspring are significantly more likely to become antisocial, even when raised apart from the biological parents. The parents of these nine murderers were violent and, although police records were not available, we suspect that many had come in conflict with the law. So, indeed, had their children. Were one to limit one's investigation to issues of violence, it would be easy to hypothesize an inherited predisposition to violence on the basis of the family violence of these murderous youngsters. Our greater knowledge regarding the neuropsychiatric characteristics of our subjects and their families suggests an alternative hypothesis. That is, if there was an inherited predisposition to maladaptive antisocial behavior in these nine boys, the inheritance probably was a predisposition to psychosis and/or neurological dysfunction.

These vulnerabilities in the context of violent households manifested themselves in uncontrolled violence. Indeed, in the case of our one adopted subject, his adoptive parents were not psychotic. His biological mother, however, was psychotic and was hospitalized and undergoing ECT at the time of his birth.The constellation of neuropsychiatric impairment, parental psychosis, a history of physical abuse, and prior acts of violence in delinquents who later murder raises the question of prediction. Does the finding of this constellation of factors in a given child justify a prediction of future violence and therefore a need for intervention? As Monahan has shown in his extensive review of the literature, clinicians are notoriously poor at accurately predicting violence. The major drawback to the use of clinical predictors is the tendency to overpredict and therefore to stigmatize needlessly.

This danger is especially true of studies purporting to predict violence early in life before it manifests itself in dangerous ways (–).Our research, in contrast to earlier clinical studies, identifies clinical and family characteristics of youngsters who have already demonstrated extreme aggression. One boy kidnapped while threatening his victims with a pitchfork, two had raped and physically assaulted their victims, one had menaced his victims with guns and knives, one had committed armed robbery, one was so violent in childhood he could not attend school, and one threw caustic liquid in the face of another child. Surely, when the constellation of psychotic symptoms, severe neuropathology, and the existence of psychotic, abusive family members is identified in an already violent youngster, responsible intervention is justified. Although it is impossible to predict that a youngster with these attributes will commit murder in the future, it seems safe to conclude that in the absence of appropriate intervention he will commit further acts of violence. Moreover, were the question of future violence not an issue, the serious psychopathology, neurological impairment, and family violence identified would justify intervention. This kind of youngster has an immediate need for help regardless of considerations of prediction. The appropriate interventions to meet the current needs of these youngsters and adolescents are also those most likely to diminish future violence.

Interpersonal therapy manual. Thus, they have value for prevention.To date, the most frequently cited studies of the youthful characteristics of seriously antisocial adults (, ) focus primarily on the number and nature of previous antisocial acts as predictors of future maladaptive behaviors and, in essence, point only toward a policy of preventive detention. Our findings suggest that violence alone is not as good a predictor of future aggression as is violence coupled with neuropsychiatric vulnerabilities, parental brutality, and parental psychosis.Each of the clinical factors identified in this study has implications for potentially therapeutic interventions. A recognizable constellation of biopsychosocial factors such as that described signals a need for specific medical, psychiatric, and social assistance.

In this way, these findings differ from those of Wolfgang et al. , who used immutable factors such as number and nature of past offenses and race for predictive purposes.Murder is the most serious of crimes. It is, therefore, the one we most need to learn to prevent.

The finding of a constellation of identifiable factors characteristic of violent youngsters before their commission of homicidal acts and the ability to differentiate them from ordinary delinquents challenges us to develop programs to recognize and treat these multiply handicapped children.