I.

INTRODUCTION

Research has allowed us to understand that the characteristics that determine the prevalence,

onset and course of mental and behavioral disorders encompasses a variety of factors including:

social and economic factors, biological influences, psychological and cognitive features,

demographic factors (i.e., sex and age), serious threats such as conflicts and disasters, the

presence of major physical diseases, and the family environment. An understanding of mental

functioning provides the necessary tools in which to form a more comprehensive understanding

of the development of mental and behavioral disorders (World Health Organization, 2001).

Moral development is the process by which a child acquires the values that allow him or her

to distinguish between what is right from wrong and accordingly, adhere to those same values.

By observing the progression of moral judgments Jean Piaget (1967) and Lawrence Kohlberg

(1963), cognitive moral theorists, determined that the process of moral development occurred

within a series of specific stages. As a direct result of interacting with the environment a person’s

perspective on an issue can change indicating that as a person matures their ability to understand

moral reasoning enhances (Vander Zanden, Crandell, & Crandell, 2007).

What causes or determines a child’s individual physical and behavioral traits has long been

debated to be either, the result of one’s individual qualities, also referred to as “nature” and one’s

personal experiences, referred to as “nurture.” What psychologists focus on is the nature or

biological make-up that we inherit from our parents (Vander Zanden, et al., 2007, p. 58).

Studies have never been able to prove one or the either and in the end, the only determination is

that both play a role. Siblings who are not raised together may exhibit similar mannerisms but

display strikingly different characteristic traits as is the case of my step-brother and me. Our

similarities are a product of nature and our differences are clearly the product of nurture. Trying
to determine which perspective trumps the other in the development of a child’s moral and

personality traits is not that clear.

One of the most debated issues pertaining to the nature theory is the existence of a “gay

gene” pointing to a genetic component to sexual orientation. Psychologists struggle to determine

the exact cause of gay men and lesbians emotional and sexual orientation towards members of

their own sex focusing on whether genetics contributes to some or all in sexual orientation (Bell,

1999). Since at least 50% of cases where genetics were identical, i.e., twins, so were their sexual

orientations concluding that data gathered showed that at least 50% of sexual orientation

expression is genetically determined (Id.). However, this does not rule out that environmental

factors come into play because the fact that 50% of twins did not match in sexual orientation

proves that genetics only contributes to behavioral traits (Id.).

II. DISORDERS

A. SEXUAL AND GENDER IDENTITY DISORDERS

i. Gender Identity Disorders

Gender Identity Disorder is an individual’s desire to be, or insistence that he or she is, of the

other sex due to a strong belief that he or she is trapped in the body of the wrong sex (DSM-IV-

TR, 2004, p. 576). This disorder strongly interferes with the individual’s ordinary activities and

can be socially isolating. The individual’s sexual orientation includes the following four

specifiers: either sexually attracted to males, females, both or neither. Men who are attracted to

neither gender are often isolated individuals with schizoid traits. Females almost always are

attracted to females (DSM-IV-TR, 2004, p. 578).

The disturbance is so constant that individuals find themselves mentally incapable of

focusing on anything else but ways in which to lessen gender distress. Associated Personality
Disorders are common among males as is the diagnosis of Transvestic Fetishism (DSM-IV-TR,

2004, p. 578).

1. Gender Identity Disorder:

According to the American Psychiatric Association’s Diagnostic and Statistical Manual

of Mental Disorders (2004), Gender Identity Disorder is diagnosed with the following:

A. Strong and persistent cross-gender identification, (not merely a desire for any

perceived cultural advantages of being the other sex). And the disturbance is

manifested by four (or more) of the following:

i. Repeatedly stated desire to be, or insistence that he or she is, the other

sex

ii. Preference for cross-dressing or simulating attire of the opposite sex

iii. Persistent preferences for cross-sex roles in make believe play or

fantasies of being the other sex

iv. Intense desire to participate in the stereotypical games and pastimes of

the other sex

v. Strong preference for the playmates of the other sex

B. Persistent discomfort with his or her sex or sense of inappropriateness in the

gender role of that sex

(In adults the disturbance is manifested by preoccupation with getting rid of the

sex characteristics possibly through surgery)

C. The disturbance is not concurrent with a physical intersex condition

D. The disturbance causes clinically significant distress or impairment in social,

occupational, or other important areas of functioning.

 (Must specify whether the disorder relates to children or adults and specify the

gender, if any that the individual is attracted to). (DSM-IV-TR, 2004, p. 576).

i. Intersex Condition:

Intersex Condition (also known as DSD or disorder of sex differentiation) refers to a

series of medical conditions in which a child's genetic sex (chromosomes) and phenotypic sex

(genital appearance) do not match, or are somehow different from the “standard” male or female.

(Menweb, 1999) Individuals diagnosed with Intersex condition are considered, under the

American with Disabilities Act, as qualified persons with a handicap and are therefore afforded

such protections (Pendo, 1994). The Association of Intersex Advocates explains that there is no

one “intersex body,” but rather a wide variety of conditions (Id.). According to the Association,

what make Intersex people similar are their experiences of medical treatment, not biology (Hull,

2004). Although they argue that transsexualism has a very different aetiology and certainly has

very different physical manifestations of the condition, current scientific evidence suggests that

the many factors that cause the disorder are biologically-based (Id.). Therefore, transsexualism

is an Intersex condition not of the body, but of the brain called, Congenital Neurological-Intersex

condition.

ii. Paraphilias

The DSM-IV-TR categorizes Paraphilia as “recurrent, intense sexual urges, fantasies, or

behaviors that involve nonhuman objects, the suffering or humiliation of oneself or one’s

partner, or children or other non-consenting persons that occur over a period of at least 6

months.” The individual Paraphilias diagnosed by the person acting on these urges are:

Pedophilia, Voyerism, Exhibitionism and Frotteurism. Whereas, Sexual Sadism, the diagnosis is

made if the person acts his urges out on a non-consenting person or the urges cause marked
distress. The diagnosis for the remaining Paraphilias: Fetishism, Sexual Masochism, Transvestic

Fetishism and Paraphilia Not Otherwise Specified, requires the urges to cause clinically

significant distress or impairment (DSM-IV-TR, 2004, pp. 566-567).

Child abuse, which is the term used to characterize various forms of maltreatment

including child sexual abuse, is a complicated and grave problem that affects the lives of children

and young people. The problem is that there is no universally agreed-on way to define

maltreatment nor is there just one basis used to understand the focal point at which intervention

should be commenced or how this intervention should proceed. That being said, theoretical

perspectives about child abuse and neglect etiologies address four general types of child

maltreatment: physical abuse, sexual abuse, psychological (emotional) maltreatment, and neglect

(California Department of Health Care Services, 2006).

Theoretical perspectives concerning the etiology of child abuse and neglect, as well as

different methods to prevent, intervene, and treat the problem have been analyzed and defined by

various discipline, including psychological, educational, legal, and social work. Predictably,

conflicts can be encountered amongst these various disciplines, but that does not change the fact

that child abusing is still prevailing (Id).

Emotional abuse refers to repeated inattention or unrelenting behavior aimed at a child;

it’s long-term effects on the child immeasurable (Crosson-Tower, 2007 at p. 69). Although

emotional abuse is not as dramatic as physical abuse, the results of this type of abuse leave

damaging effects to the child’s psychological, social, emotional, cognitive or intellectual

development or behavior (California Department of Health Care Services, 2006). More

importantly, continual exposure to domestic violence seriously compromises the wellbeing or

development of the child (Id.). Empirical research, albeit limited, conducted by specialists,
including Doyle (1997) support findings that there is a correlation between abuse of children and

domestic violence. The research also revealed that emotionally abused children are more likely

to attempt acts of self-harm, commit suicide, suffer from depression, develop eating disorders

and suffer aggressive disorders. Abuse, regardless if it is domestic, emotional or sexual, is

invariably about power, control, and self-gratification. The most susceptible victims of this abuse

are almost always women and small children (Miller, 2002 at p.567).

2. Transvestic Fetishism Paraphilia:

To be diagnosed with Transvestic Fetishism Paraphelia the DSM-IV-TR (2004) requires

two things: “1. over a period of 6 months, heterosexual male, recurrent, intensely sexually

arousing fantasies, sexual urges, or behaviors involving cross-dressing; and 2. the fantasies,

sexual urges, or behaviors cause significant distress or impairment in social, occupational, or

other important areas of functioning” (DSM-IV-TR, 2004, p. 574).

3. Pedophilia:

Pedophilia is the clinical term for child molestation and child sexual abuse. The DSM-IV-TR

defines pedophilia as “a condition lasting over a period of 6 months, recurrent sexually arousing

fantasies, sexual urges, or behaviors involving sexual activity with a prepubescent child

(generally age 13 years or younger) occur.” Pedophiles sexual attraction is divided by those

attracted only to children (Exclusive Type) and those who are sometimes attracted to adults

(Nonexclusive Type). Some are only attracted to girls or boys and others are attracted to both

genders. The DSM-IV-TR further specifies that “due to the egosyntonic nature of pedophilia,

many individuals with pedophilic fantasies, urges, or behaviors do not experience significant

distress” therefore, it is not necessary to experience such distress to be diagnosed. The individual

only needs to act out on these fantasies or urges with a child to qualify. The onset of this disorder
typically begins during adolescence and psychosocial stress can alter the frequency of pedophilic

behavior (DSM-IV-TR, 2004, p. 571).

According to a study by the Jewish Child Care Association (2009), parent/caretaker and

family characteristics that often are present in cases of maltreatment are:

“(1) was neglected or abused as a child; (2) has drug or alcohol problems (any family

member), (3) was sexually abused as a child or adolescent, (4) has little or no contact

with extended family or other supportive adults, (5) is unfamiliar with normal child

development or disciplinary techniques, (6) has chronic illness, physical or mental

disability (any family member), (7) has had multiple relocations or changes in house-

hold membership, (8) lives in overcrowded or inadequate housing, and (9) has had loss of

employment or other source of income.”

Self-reported data demonstrates that the majority of perpetrators, about 90 percent, are male

and many studies have shown that most child-abusing parents were themselves abused children

(Crimes against Children Research Center, 2005). Others note that abusing parents

unrealistically expect their children to fulfill their psychological needs; when disappointed, the

parent experiences severe stress and becomes violently angry and abusive. Sexual abuse is also

connected with other family problems, such as, marital conflict, alcohol abuse and rejection by

the parents (Id). In spite of this emphasis on parental and caregiver as being the perpetrators of

child sexual abuse, acquaintances’ and family members, usually an uncle, commit most of the

abuse (Id). Studies have shown a strong correlation between children of sexual abuse and lower

income backgrounds; however child sexual abuse cases reported to authorities are more likely

due to other types of maltreatment rather than low income (Crimes against Children Research

Center, 2005).
 i. Hebephelia:

Pedophiles are sexually attracted to either females, males, or both and such attraction should

be specified when diagnosing Pedophilia. The sexual contact between adult males with young

children is referred as Hebephelia. However, there is no distinct diagnostic difference (Bartol &

Bartol, 2008, p. 422).

B. SCHIZOPHRENIA AND OTHER PSYCHOTIC DISORDERS

According to the American Psychiatric Association’s Diagnostic and Statistical Manual of

Mental Disorders:

“The essential features of Schizophrenia are a mixture of characteristic signs and

symptoms (both positive and negative) with signs of the disorder persisting for at

least 6 months. Characteristic symptoms include two or more of the following: (1)

delusions, (2) hallucinations, (3) disorganized speech, (4) grossly disorganized or

catatonic behavior, and (5) negative symptoms (DSM-IV-TR, 2004, p. 298).

Individuals with this disorder may develop mood abnormalities (e.g., inappropriate

laughing, crying, or depression, anxiety or anger). Often there is day-night reversal (i.e., staying

up late at night and then sleeping late into the day). The individual may show a lack of interest in

eating or may refuse food as a consequence of delusional beliefs. Often movement is abnormal

(e.g., pacing, rocking, or apathetic immobility). Frequently there are significant cognitive

impairments (e.g., poor concentration, poor memory, and impaired problem-solving ability). The

majority of individuals with Schizophrenia are unaware that they have a psychotic illness. This

poor insight is neurologically caused by illness, rather than simply being a coping behavior. This

is comparable to the lack of awareness of neurological deficits seen in stroke. This poor insight

predisposes the individual to noncompliance with treatment and has been found to be predictive
of higher relapse rates, increased number of involuntary hospitalizations, poorer functioning, and

a poorer course of illness. Depersonalization, derealization, and somatic concerns may occur and

sometimes reach delusional proportions. Motor abnormalities (e.g., grimacing, posturing, odd

mannerisms, ritualistic or stereotyped behavior) are sometimes present (World Health

Organization, 2009).

Schizophrenia is found approximately equally in men and women, though the onset tends

to be later in women, who also tend to have a better course and outcome of this disorder.

Schizophrenia follows a variable course, with complete symptomatic and social recovery in

about one-third of cases. Schizophrenia can, however, follow a chronic or recurrent course, with

residual symptoms and incomplete social recovery. Individuals with chronic schizophrenia

constituted a large proportion of all residents of mental institutions in the past, and still do where

these institutions continue to exist. With modern advances in drug therapy and psychosocial care,

almost half the individual’s initially developing schizophrenia can expect a full and lasting

recovery. Of the remainder, only about one-fifth continues to face serious limitations in their

day-to-day activities (World Health Organization, 2009).

4. Delusional Disorder:

According to Bartol (2008), delusional disorders also called paranoid disorders are

characterized by prominent nonbizarre delusions that persist for at least one month and the

symptom criteria for Schizophrenia have never been met. Hallucinations may be present, but

auditory or visual hallucinations cannot be prominent. Olfactory or tactile hallucinations may be

prominent, but only if they are related to the content of the delusion. Psychosocial functioning

may not be impaired and any co-occurring mood episodes must be of relatively brief duration (at

p. 232).
 DSM-IV-TR (2004) delusional disorders diagnostic criteria include:

A. Nonbizarre delusions (i.e., involving situations that occur in real life, such as

being followed, poisoned, infected, loved at a distance, or deceived by spouse

or lover, or having a disease) of at least 1 month's duration.

B. Criterion A for Schizophrenia has never been met. Note: Tactile and olfactory

hallucinations may be present in Delusional Disorder if they are related to the

delusional theme.

C. Apart from the impact of the delusion(s) or its ramifications, functioning is

not markedly impaired and behavior is not obviously odd or bizarre.

D. If mood episodes have occurred concurrently with delusions, their total

duration has been brief relative to the duration of the delusional periods.

E. The disturbance is not due to the direct physiological effects of a substance

(e.g., a drug of abuse, a medication) or a general medical condition.

Specify type:

Erotomanic Type: delusions that another person, usually of higher status, is in

love with the individual

Grandiose Type: delusions of inflated worth, power, knowledge, identity, or

special relationship to a deity or famous person

Jealous Type: delusions that the individual's sexual partner is unfaithful

Persecutory Type: delusions that the person (or someone to whom the person is

close) is being malevolently treated in some way

Somatic Type: delusions that the person has some physical defect or general

medical condition
 Mixed Type: delusions characteristic of more than one of the above types but no

one theme predominates

Unspecified Type

5. Body Dysmorphic Disorder:

Body Dysmorphic Disorder is a pathological preoccupation with an imagined or slight

physical defect of one's body to the point of causing significant stress or behavioral impairment

in several areas such as work and personal relationships. The preoccupation cannot be better

accounted for by another mental disorder. When criteria for both this disorder and Delusional

Disorder are met then Body Dysmorphic Disorder and Delusional Disorder, Somatic Type, may

be diagnosed (DSM-IV-TR, 2004, p. 485).

C. PERSONALITY DISORDERS

6. Antisocial Personality Disorder:

Antisocial Personality Disorder is defined by the Diagnostic and Statistical Manual of

Mental Disorder as “a pervasive pattern of disregard for, and violation of, the rights of others that

begins in childhood or early adolescence and continues into adulthood” (DSM-IV-TR, 2004, p.

701). The description for ASPD found in the Diagnostic and Statistical Manual of Mental

Disorder, greatly parallels Hare’s description of a psychopathic person with ASPD. As a result,

persons with ASPD have often been referred to as psychopaths or sociopaths. However, APD

differs from primary psychopathy as it restricts its definition to behavior indicators (Bartol, 2008,

p. 188).

Individuals diagnosed with ASPD are not delusional and do know the difference between

right and wrong and are aware of society's punishments for the behaviors that they perform. The

present DSM-IV-TR manual notes that “lack of empathy, inflated self-appraisal, and superficial
charm are features that have been commonly included in traditional conceptions of psychopathy

that may be particularly distinguishing of the disorder and more predictive of recidivism in

prison or forensic settings where criminal, delinquent, or aggressive acts are likely to be

nonspecific” (DSM-IV-TR, 2004, p. 703).

i. Psychopathy

Robert Hare’s defines a true psychopath as “social predators that charm, manipulate and

ruthlessly plow their way through life completely lacking in conscience and empathy, taking

what they want and doing as they please.” The individual who demonstrates those behavioral

features that represent psychopathy – in contrast to secondary psychopaths, and dissocial

psychopaths, they are neither neurotic, emotionally disturbed nor display aggressive antisocial

behavior because it was learned (Bartol, 2008, pp. 188-189).

The most notable feature of psychopaths is their unalterable shortcoming to learn from

their mistakes. Much of the psychopath’s inability to control their needs looks to be related to

biological factors, but emotional, cognitive and behavioral factors also play an important role as

they differ from other types of offenders (Id. at p. 187). The most notable feature of psychopaths

is their unalterable shortcoming to learn from their mistakes. A true psychopath is impulsive,

dangerously charming, manipulative, selfish, and pathologically egocentric. Couple these traits

with the psychopath’s inability to learn from their mistakes is what differentiates true

psychopaths from all other disorders (Id. at pp.191-193).

Hervey Cleckley describes in Bartol, (2008) a clear and empirically useful list of the

major behaviors demonstrated by a primary psychopath:

a. Superficial charm

b. Pathological egocentricity
 c. Average to above-average intelligence

d. Usually impress others as friendly, outgoing, likable, and alert.

e. Often appear well-educated and knowledgeable

f. Verbally skillful and can talk themselves out of trouble.

g. Pathological lying

h. Manipulative

i. Lack of remorse or guilt

j. Emotional poverty (limited range or depth of feelings)

k. Failure to accept responsibility for own actions

l. Systematic study of their conversation reveals that they often jump “from

one topic to another and that much of their speech is empty of real substance,

tending to be filled with stock phrases, repetitions of the same ideas, word

approximations, abstract terms and jargon used in a superficial or inappropriate

fashion, logically inconsistent statements and phrases, and half-formed sentences.

7. Schizotypal Personality Disorder:

Schizotypal Personality Disorder (SPD) is characterized by the DSM-IV-TR (2004) as:

“a pervasive pattern of social and interpersonal deficits marked by acute discomfort with, and

reduced capacity for, close relationships as well as by cognitive or perceptual distortions and

eccentricities of behavior, beginning by early adulthood and present in a variety of contexts, as

indicated by five (or more) of the following:

a. Ideas of reference (excluding delusions of reference)

b. Odd beliefs or magical thinking that influences behavior and is inconsistent with

sub cultural norms (e.g., superstitiousness, bizarre fantasies or preoccupations)

 c. Unusual perceptual experiences, including bodily illusions

d. Odd thinking and speech (e.g., vague, circumstantial, metaphorical, over

elaborate, or stereotyped)

e. Suspiciousness or paranoid ideation

f. Inappropriate or constricted affect

g. Behavior or appearance that is odd, eccentric, or peculiar

h. Lack of close friends or confidants other than first-degree relatives

i. Social anxiety that tends to be associated with paranoid fears rather than negative

judgments about self”

(DSM-IV-TR, 2004, p.697).

According to the World Health Organization, (2001) SPD runs a chronic course with

fluctuations of intensity. Occasionally it evolves into overt schizophrenia. There is no definite

onset and its evolution and course are usually those of a personality disorder. It may have

increased prevalence in the relatives related to schizophrenics and is believed to be part of the

genetic “spectrum” of schizophrenia which includes: Borderline schizophrenia, Latent

schizophrenia, Latent schizophrenic reaction, Prepsychotic schizophrenia, Prodromal

schizophrenia, Pseudoneurotic schizophrenia, Pseudopsychopathic schizophrenia, Schizotypal

personality disorder (p. 80).

8. Narcissistic Personality Disorder:

Narcissistic Personality Disorder (NPD) is a personality disorder defined by the DSM-IV-TR

(2004) as “a pervasive pattern of grandiosity, need for admiration, and a lack of empathy

beginning by early adulthood and present in a variety of contexts, as indicated by five (or more)

of the following:
 a. has a grandiose sense of self-importance

b. is preoccupied with fantasies of unlimited success, power, brilliance, beauty or

ideal love (megalomania)

c. believes they are “special” and can only be understood by, or should associate

with,

d. people (or institutions) who are also “special” or of high status

e. requires excessive admiration

f. has a sense of entitlement

g. is interpersonally exploitative

h. lacks empathy

i. is often envious of others or believes others are envious of him or her

j. shows arrogant, haughty behaviors or attitudes

(DSM-IV-TR, 2004, p.714).

This individual can be described as being excessively preoccupied with issues of personal

adequacy, power, brilliance, and unlimited success (Id.).

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