Training Institute on Youth Who Sexually Offend

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(No Transcript)
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Safety Planning 101 Identifying Youth Who Act
Out What To Do About It

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Presenters

• Tanya L. Snyder, M.Ed., LMHC
• Timothy L. Sinn, M.A, LMHC
• Jessica McSparron-Bien, Senior Area Coordinator
  in North Dakota
• The Counseling and Psychotherapy Center, Inc.

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We developed the R.U.L.E. treatment program and
bring specialized services to people who have
sexually acted out.
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CPC Overview

• The Counseling Psychotherapy Center, Inc. (CPC)
  is an agency comprised of clinicians, victim
  advocates and criminal justice professionals who
  operate specialized management and treatment
  programs in many locations throughout the United
  States for those who have displayed sexually
  inappropriate and abusive behaviors. We
  specialize in setting up these services in
  communities who express a need to reduce risk.

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• We currently operate in 7 states- Oregon,
  California, Maine, Massachusetts, Rhode Island,
  New York and here in North Dakota. Services vary
  from state to state. We work with juveniles and
  adults, males and females, in institutions and
  outside in the community, on probation/parole or
  self-referred, including those that admit to
  their issues and those that do not. We provide
  family, individual, marathon sessions and/or
  group therapy. We tailor treatment to meet the
  clients individual needs and can include EMDR,
  PPGs, Abels, Behavioral Treatment, Polygraphs,
  etc. We refer to or partner with those that
  provide adjunct services when needed. We own and
  operate our own juvenile group home in CA.

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Our Treatment Model- R.U.L.E.
RULE CPCs evidence based practice is based on a
treatment model that those who act out sexually
can reduce their risk of repeating this
behavior. Treatment focuses on developing
competency in the following areas Responsibility
for the inappropriate or abusive behaviors and
understanding the impact of these behaviors on
others Understanding the factors that led to
sexually inappropriate or abusive behaviors
Learning skills and strategies to prevent future
inappropriate behaviors Experience the effect
of applying what is learned to improve ones life.
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Current Services in North Dakota

• Currently provide services to 70 adults, ranging
  in age from 8-69 of various ethnicities.
• Our Current Location Include Grand Forks, Fargo,
  Jamestown, Bismarck, Mandan, Minot
• Current referrals for North Dakota come from The
  Department of Human Services and The Department
  of Corrections and Rehabilitation.
• Offer various services based on risk level and
  needs. Assessment defines level of care.
• High Risk Offenders, determined through
  assessment, participate in a two hour long weekly
  group and one hour of individual therapy week, as
  well as one hour of family therapy a month.
• Low Risk Offenders, again determined through
  assessment, participate in a two hour long weekly
  group and two one hour long individual sessions
  (one of which can include family therapy) per
  month.

• .

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Current Services in North Dakota (Continued)

• Pre-release contact and immediate scheduling
• Containment Team Meetings Monthly in each area
• Monthly Progress Reports on each client
• Case Management by Senior Area Coordinator
• Ongoing training and supervision of Clinical
  Staff
• Physiological/psychological assessments
• Full Disclosure Polygraphs (upon entering
  program)
• Maintenance Polygraphs (every 3 to 6 months)
• ABELs
• PPGs
• Referrals to providers for other psychological or
  psychiatric assessments as needed.
• Utilize SAFE-R program which provides family and
  support networks with information, education and
  support to work with the offender to help hold
  them accountable, to take responsibility and to
  assess risk.

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North Dakota Services (Continued)

• We are working to involve a Victim Advocate with
  those victimized by each RULE CPC client to
  further ensure that victims rights are part of
  the treatment and containment process.
• We have found that for clients involved with CPC
  treatment and under corrections supervision, we
  have a 1.8 recidivism rate for sex offenses.
• Please feel free to speak to us later should you
  desire additional information about the programs
  we offer in North Dakota or any other state that
  may be of benefit to your organization.
• Take away note- with adults there is much more
  focus on accountability for offending behaviors,
  cycle development, relapse prevention plan
  development and victim impact than with younger
  populations, due to developmental maturity.

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Learning Objectives

• Learn about CPC, the RULE Treatment Model and the
  services we provide locally and in other areas.
• Learn what normative sexual behavior is in
  children and adolescents.
• To learn characteristics of inappropriate and/or
  abusive behavior in children and adolescents.
• To learn more about risk and needs assessment of
  sexual behavior problems in children and
  adolescents.
• To learn more about underlying issues related to
  sexual behavior problems.
• To learn how to treat contain these behaviors.
• To learn about public policy impact on these
  youth.
• To learn about safety plans and to utilize case
  studies to develop safety plans.

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Why learn about this?

• Quote adapted from, Everything you NEVER wanted
  your kids to know about SEX (but were afraid
  theyd ask) by Justin Richardson, M.D. AND Mark
  A. Schuster, M.D., PH.D.-
• A child will become a sexual person with
  or without your intervention. But a sexual child
  isnt enough. You want that child to be wisely
  sexual, to be healthily sexual, to be happily
  sexual. Thats where you come in- youre going
  to teach them.
• Quote from David Prescott, LICSW- Understanding
  the Sexual Behavior of Children NEARI
  Newsletter, May 2009

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• When healthy or normative sexual behavior is not
  understood, professionals and parents may worry
  that sexual behavior in a child is a sign of
  undetected sexual victimization. More recently,
  sexually aggressive behavior is sometimes viewed
  as a signal for perpetrating sexual violence. It
  is essential that professionals understand sexual
  behaviors in children to determine how best to
  respond to a child's behavior and, when
  appropriate, clarify what treatment is needed.

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What is Normal Anyway?
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Sexual Development Birth - Age 5

• Erections begin in infancy, so does lubrication
  in females.
• Interested in bathroom behavior of others, again
  as it relates to differences and function.
• Interest in own feces
• Plays house, role playing male female
  roles-marriage. May begin to play doctor.

• Taking off clothes- not modest.
• Rubbing/Touching own genitals (begins in infancy)
• Curiosity about familiar adults and childrens
  private parts-learning about male and female
  differences.
• May expose self to and try to look at or touch
  others who are familiar, but redirects easily.
• Asks about genitals, breasts and babies.

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Funny Quote(Taken from Everything you NEVER
wanted your kids to know about SEX (but were
afraid theyd ask) by Justin Richardson, M.D.
AND Mark A. Shuster, M.D, PH.D.

• Look at my wiener! I can make it stand up. I
  rub it and it stands up and it feels good.
  Sometimes I rub it a lot and it feels very, very
  good.
• -Three year old boy in the Masters and Johnson
  Files

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Sexual DevelopmentAges 6-9 Years Old

• Sexual behaviors begin to be more out of sight
  of others.
• Modesty begins around age 6- desire for privacy
  around bathing and dressing.
• Show interest in own and others bodies. May seek
  out understanding of organs and functions.
• Continue to play house, exploring relationships
  such as marriage, partnerships. Also play looking
  or touching games, like truth or dare or doctor
  without penetration or oral sexual contact.
  Increase in physical arousal (9)

• Touching/rubbing own genitals. Masturbation for
  age 9
• Feelings about opposite sex become more
  ambivalent. May begin to have relationships that
  are short-lived with little personal involvement.
  Feel attraction (9 years old).
• Imitate behaviors such as holding hands, kissing
  dating.
• May tell sexual jokes/use sexual words with
  peers-written or spoken. Often accompanied by
  giggling.

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Funny Quote(Taken from Everything you NEVER
wanted your kids to know about SEX (but were
afraid theyd ask) by Justin Richardson, M.D.
AND Mark A. Shuster, M.D, PH.D.

• The girls have gone upstairs to decorate their
  bonnets. You trot up there after a little
  downtime in the kitchen with some canteens of
  pioneer punch. There is giggling and merriment.
  You open your daughters door to find six girls
  (around age 8) almost entirely naked except for
  brightly painted bonnets. They are..stripping.
  Heres the punch. And youre out of there. Odds
  are you dont welcome the chance to confront the
  little ones sexuality. You might even prefer to
  imagine that it doesnt exist, and you would not
  be the first. You may wonder is this unusual?
  Is sheabnormal? Does this mean shes been
  abused? You might blurt out stop that or drop
  the punch and run. Or you might pretend nothing
  at all happened. This behavior however, is
  normal and a good opportunity to discuss with
  your child sexual behavior, respect and
  responsibility and to establish a role in their
  healthy sexual development.

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Sexual Development10-12 Years Old

• Masturbation
• Increased sexual drive and interest and fantasies
  involving acts.
• Increased sexual activity with same aged peers-
  sexual talking, touching, kissing genital
  rubbing. Some includes same sexed peer-this does
  not reflect sexual orientation- it is
  developmental.
• Some begin to view pornographic
  magazines/material with peers.

• Puberty begins around 9-10 years old for most
  girls. (6/7-13 typical range) Boys typically
  around 11, (average range 9-14 years old).
• Self-conscious about bodies.
• Desire for privacy when undressing.
• Increase in questions about sex, sex organs
  functions.
• Group dating, individuals pairing within the
  group, dancing, playing kissing games, dry
  humping.
• Increased sexual jokes and behaviors such as
  mooning.

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Funny Quote(Taken from Everything you NEVER
wanted your kids to know about SEX (but were
afraid theyd ask) by Justin Richardson, M.D.
AND Mark A. Shuster, M.D, PH.D.

• In 1943, one research group interviewed 291 boys
  to find out what it was that gave them erections.
  The boys dutifully provided and exhaustive list.
  It included, among other highlights, sitting in
  class, sitting in church, sitting in warm sand,
  and setting a field on fire. The national anthem
  was also responsible for a few erections. So was
  finding money (understandable) and, for a few
  unfortunates, begin asked to go to the front of
  the class. Good grades and hurricanes do indeed
  give Max erections, but at age ten, there are a
  few new items on the list. Like underwear ads.
  (By the way the same applies to girls.)

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Sexual DevelopmentAges 13-18 years old

• Masturbation (Up to once/day)
• Engaging in oral sex and intercourse with
  partners, much like adults.
• Use of pornographic materials.

• Relationships with others are the focus
• More focus on establishing emotional attachments
  in relationships as one matures. Romantic Love.

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Types of Inappropriate Behaviors

• Physical touching
• Visual pornography, exhibitionism, voyeurism,
  sexting
• Verbal obscene phone calls, inappropriate talk
• Emotional abuse of relationship

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How to Identify Inappropriate Sexual Behavior

• Using sexual language beyond age- may mean
  exposure to sexual material.
• Sexual acting out behavior in school other public
  place.
• One of the children was more than 2 years older.
• One of the children was bigger or more powerful
  than the other, regardless of age.
• One of the children was more aggressive than the
  other, regardless of age.
• One of the children used bribes, tricks, force or
  threats to gain compliance.

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How to Identify Inappropriate Sexual Behavior
(Continued)

• One of the children has been involved in sexual
  behaviors previously and continued even though
  told to stop.
• Children are simulating adult sexual behaviors.
  Trying to get another child or adult nude or to
  engage older children/adults in sexual behaviors.
• The sexual contact was intrusive such as oral,
  vaginal or anal penetration
• Excessively provocative behaviors.
• Children engaging in non age appropriate sexual
  behaviors.
• Children involved do not have an ongoing
  relationship of any kind.

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How to Identify Inappropriate Sexual Behavior
(Continued)

• Overly attentive behavior towards younger
  children (3 years younger or more).
• Adolescents who make repeated calls to sex talk
  lines or talk to others using extensive sexual
  talk.
• Stealing of underwear
• Exposing of genitals to others
• Adolescents who are regularly seen masturbating.
• Behavior that appears to be obsessive or
  compulsive
• Adolescents encouraging the use of drugs/alcohol
  in order to obtain sexual contact with peer aged
  partner.

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How to Identify Inappropriate Sexual Behavior
(Continued)

• Others are complaining about the behaviors.
• When anger is a part of the sexual behaviors.
• When a child uses distortions to explain
  behaviors (for example, she liked it- although
  crying)
• Sexual contact with animals
• Viewing pornography or others having sex, prior
  to age 11.
• Secrecy is involved. This is different than
  privacy.
• Presence of STDs- may be being molested.

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RECOGNIZING HEALTHY AND UNHEALTHYSEXUAL
DEVELOPMENT IN CHILDRENby Phil Rich, Ed.D.,
LICSWExcerpt taken from Selfhelp Magazine
Online- Dated 4/29/02

• However, normative (or expected) sexual
  behaviors are usually not overtly sexual, are
  more exploratory and playful in nature, do not
  show a preoccupation with sexual interactions,
  and are not hostile, aggressive, or hurtful to
  self or others.

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Take away points

• Adolescents (13-17) who act out sexually are NOT
  mini-adults and should NOT be treated as such.
• Children with sexual behavior problems (12 and
  under) are a whole different category as well.
  These are NOT mini adolescents either and
  should NOT be treated as such.

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Children with Sexual Behavior Problems (Under 12
years Old)Information taken from- Report of the
ATSA Task Force on Children With Sexual Behavior
Problems

• The Task Force defines children with SBP as
  children ages 12 and younger who initiate
  behaviors involving sexual body parts (i.e.,
  genitals, anus, buttocks, or breasts) that are
  developmentally inappropriate or potentially
  harmful to themselves or others. Although the
  term sexual is used, the intentions and
  motivations for these behaviors may or may not be
  related to sexual gratification or sexual
  stimulation. The behaviors may be related to
  curiosity, anxiety, imitation, attention seeking,
  self-calming, or other reasons (Silovsky
  Bonner, 2003).
• It is important to distinguish SBP from normal
  childhood
• sexual play and exploration.

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Children with Sexual Behavior Problems (Under 12
years Old)Information taken from- Report of the
ATSA Task Force on Children With Sexual Behavior
Problems

• In determining whether sexual behavior is
  inappropriate, it is important to consider
  whether the behavior is common or rare for the
  childs developmental stage and culture the
  frequency of the behaviors the extent to which
  sex and sexual behavior has become a
  preoccupation for the child and whether the
  child responds to normal correction from adults
  or continues to occur unabated after normal
  corrective efforts. In determining whether the
  behavior involves potential for harm, it is
  important to consider the age/developmental
  differences of the children involved any use of
  force, intimidation, or coercion the presence of
  any emotional distress in the child(ren)
  involved if the behavior appears to be
  interfering with the child(ren)s social
  development and if the behavior causes physical
  injury (Araji, 1997 Hall, Mathews, Pearce,
  1998 Johnson, 2004).

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Children with Sexual Behavior Problems (Under 12
years Old) ContinuedInformation taken from-
Report of the ATSA Task Force on Children With
Sexual Behavior Problems

• Childhood sexual behavior problems (SBP) can
  range widely in their degree of severity and
  potential harm to other children. Although some
  features are common, virtually no characteristic
  is universal and there is no profile or
  constellation of factors characterizing these
  children.
• Given the diversity of children with SBP, most
  intervention decisions including decisions about
  removal, placement, notifying others, reporting,
  legal adjudication, and restrictions on contact
  with other children should be made carefully and
  on a case-by-case basis. Because children and
  their circumstances can change rapidly, decisions
  should be reviewed and revised regularly.

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Children with Sexual Behavior Problems (Under 12
years Old) ContinuedInformation taken from-
Report of the ATSA Task Force on Children With
Sexual Behavior Problems

• Despite considerable concern about progression on
  to later adolescent and adult sexual offending,
  the available evidence suggests that children
  with SBP are at very low risk to commit future
  sex offenses, especially if provide with
  appropriate treatment. After receiving
  appropriate short-term outpatient
• treatment, children with SBP have been
  found to be at no greater long-term risk for
  future sex offenses than other clinic children
  (2-3)
• On the whole, children with SBP appear to respond
  well and quickly to treatment, especially basic
  cognitive-behavioral or psycho-educational
  interventions that also involve
  parents/caregivers. Intensive and restrictive
  treatments for SBP appear to be required only
  occasionally or rarely.

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Children with Sexual Behavior Problems (Under 12
years Old) ContinuedInformation taken from-
Report of the ATSA Task Force on Children With
Sexual Behavior Problems

• Children with sexual behavior problems are
  qualitatively different from adult sex offenders.
  This appears to be a different population, not
  simply a younger version of adult sex offenders.
  Public policies, assessment procedures and most
  treatment approaches developed for adult sex
  offenders are inappropriate for these children.
• Policies placing children on public sex offender
  registries or segregating children with SBT may
  offer little or no actual community protection
  while subjecting children to potential stigma and
  social disadvantage.

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Why do kids develop sexual behavior problems?
Information taken from- Report of the ATSA Task
Force on Children With Sexual Behavior Problems

• Children who have been sexually abused do engage
  in a higher frequency of sexual behaviors than
  children who have not been sexually abused
  (Friedrich, 1993 Friedrich, Trane Gully,
  2005), and sexual abuse histories have been found
  in high percentages of children with SBP
  (Johnson, 1988,1989 Friedrich, 1988)
• The last decade of research suggests that many
  children with broadly defined sexual behavior
  problems have no known history of sexual abuse
  (Bonner, Walker, Berliner, 1999 Silovsky
  Niec, 2002).

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Why do kids develop sexual behavior problems?
Information taken from- Report of the ATSA Task
Force on Children With Sexual Behavior Problems

• Current theories emphasize that the origins and
  maintenance of childhood SBP include familial,
  social, economic and developmental factors
  (Friedrich, 2001, 2003). Contributing factors
  appear to include sexual abuse but also physical
  abuse, neglect, substandard parenting practices,
  exposure to sexually explicit media, living in a
  highly sexualized environment, and exposure to
  family violence (Friedrich, Davies, Feher,
  Wright, 2003).
• Hereditary also may be a contributing factor
  (Langstrom, Grann Lichtenstein, 2002).

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Why do kids develop sexual behavior problems?
Information taken from- Report of the ATSA Task
Force on Children With Sexual Behavior Problems

• For some children, SBP may be one part of an
  overall pattern of disruptive behavior problems
  (Friedrich, in press Friedrich et al. 2003
  Pithers, Gray, Busconi, Houchens, 1998), rather
  than an isolated or specialized behavioral
  disturbance.

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Assessment of Youth with Sexual Behavior
Problems (Parenting Assessment A Tool For
Youth Offending Teams, developed by Clem
Henricson, Dr. John Coleman, Dr. Debi Roker for
the Trust for the Study of Adolescence, March
2000 and Report of the ATSA Task Force on
Children with Sexual Behavior Problems

• Should include a parental assessment- one such
  tool is the Parenting Assessment A Tool For
  Youth Offending Teams, developed by Clem
  Henricson, Dr. John Coleman, Dr. Debi Roker for
  the Trust for the Study of Adolescence, March
  2000.
• Addresses such areas as supervision/monitoring,
  discipline, communication and support, living
  arrangements, substance use, health, mental
  health, victimization, parenting style,
  marital/couple issues, child rearing practices,
  sibling issues/safety, parents own struggles,
  needs of family and child in regard to income,
  education and employment. Protective factors
  such as positive aspects of relationship, other
  supports to child and family. Parents should be
  included in treatment, if appropriate.

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Assessment of Youth with Sexual Behavior
Problems- Continued (Parenting Assessment A
Tool For Youth Offending Teams, developed by Clem
Henricson, Dr. John Coleman, Dr. Debi Roker for
the Trust for the Study of Adolescence, March
2000 and Report of the ATSA Task Force on
Children with Sexual Behavior Problems

• Additionally important to look at other aspects
  of the childs life such as extended family,
  community, school and peer influences. Can also
  involve these parties in treatment.
• Focus should be on what factors are involved in
  maintaining the inappropriate behavior, what
  factors serve to help the client to refrain from
  behavior and future concerns in these regards.
• Failing to admit is not necessarily an indication
  of poor prognosis or being in a pathological
  state of denial. May bring up own trauma or may
  have forgotten about it or fear getting into
  trouble.

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Assessment of Youth with Sexual Behavior
Problems- Continued ( Report of the ATSA Task
Force on Children with Sexual Behavior Problems)

• The Child Sexual Behavior Inventory - III
  (CSBI-III Friedrich,1997) is designed for
  children ages 2 12 and measures the frequency
  of both common and atypical behaviors,
  self-focused and other-focused behaviors, sexual
  knowledge and level of sexual interest. Since the
  development of the third edition of the CSBI,
  Friedrich has added four items that assess
  planned and aggressive sexual behaviors
  (Friedrich, 2002). Age and gender norms are
  available for the CSBI, and can help discriminate
  between developmentally normal and atypical
  sexual behavior. None of the four added
  planned/aggressive items were endorsed by current
  normative samples.

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Another measure is the Child Sexual Behavior
Checklist (CSBCL 2nd Revision), which lists 150
behaviors related to sex and sexuality in
children, asks about environmental issues that
can increase problematic sexual behaviors in
children, gathers details of childrens sexual
behaviors with other children, and lists 26
problematic characteristics of childrens sexual
behaviors (Johnson Friend, 1995). The
CSBCL-2nd Revision also gathers a broad range of
information that is useful for assessment and
treatment planning. The CSBCL-2nd Revision for
children 12 and under can be completed by anyone
who knows the child well (Johnson Friend,
1995).
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Assessment of Youth with Sexual Behavior
Problems- Continued ( Report of the ATSA Task
Force on Children with Sexual Behavior Problems)

• A shorter instrument appropriate for tracking
  week-to-week changes in general and sexual
  behavior among young children is the Weekly
  Behavior Report (WBR Cohen Mannarino, 1996a).

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Assessment of Youth with Sexual Behavior
Problems (Report of the ATSA Task Force on
Children with Sexual Behavior Problems)

• Should be considered time limited due to
  developmental changes.
• Time not engaging in behaviors in more recent
  past, must be considered.
• When out of home placement is being considered,
  carefully consider the negatives of this
  arrangement, along with benefits to the child and
  protection of others. The younger the child, the
  more consideration is needed.

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What treatment for kids who display sexually
problematic behaviors? (Report of the ATSA Task
Force on Children with Sexual Behavior Problems)

• It appears that improvement in SBP is the rule
  over time, at least when some sort of detection
  and adult intervention is provided.
• Second, it appears that focused treatment helps,
  and structured, SBP-focused CBT approaches that
  include parent/caregiver involvement have been
  found to work better than unstructured supportive
  therapy or unstructured play therapy approaches.
• Third, it appears that blended CB Treatments
  targeting both traumatic stress symptoms and SBP
  can be successful in helping both problems in
  cases where both are present.
• Group and/or individual and family work.
• Needs to be concrete, demonstration, practice and
  reinforcement driven. Abstract principles such
  as emotional regulation might be best suited for
  10-12 range.
• Address most pressing treatment issues first and
  intersperse SBP treatment or add in later.

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What treatment for kids who display sexually
problematic behaviors? (Continued)(Report of the
ATSA Task Force on Children with Sexual Behavior
Problems)

• Treatment Components- Identify, recognize
  inappropriateness of behavior and apologize for
  violating rules (not usually for kids under 7),
  learning and practicing basic, simple rules about
  sexual behavior and physical boundaries,
  age-appropriate sex education, coping and
  self-control strategies, basis sexual abuse
  prevention/safety skills, social skills.
• Parent/Caregivers focus on developing and
  implementing a safety plan modification of
  safety plan, address supervision and monitoring,
  communication with other adults about issues,
  education about appropriate sexual development,
  how to implement rules related to privacy and
  boundaries, how to maintain environment that is
  not overly sexual, sex education strategies,
  relationship strategies, parenting strategies,
  supporting childs self-control strategies,
  helping child develop appropriate peer
  relationship, addressing parental stress and
  increasing supports for all family members.

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Challenging Long-Held Notions about Sexual Abuse
by Adolescents NEARI Newsletter, November 2008
by David S. Prescott, LICSW

• 2005, Elizabeth Letourneau and Michael Miner
  published an influential article in Sexual Abuse
  A Journal of Research and Treatment   In it, they
  describe and dispute three myths that strongly
  influence legal and clinical interventions 1.)
  There is an epidemic of juvenile offending,
  including sexual offending, 2.) Juvenile sex
  offenders have more in common with adult sex
  offenders than with other juvenile delinquents.
  3.) In the absence of sex offender-specific
  treatment, juvenile sex offenders are at
  exceptionally high risk of re-offending.
• In fact Juvenile offenses have decreased over
  the last 10 years.  (see Dodge, 2008 for a
  review).  Second, Letourneau and Miner note that
  the rate of known sexual re-offense is much lower
  than many believe.
• Adolescents who have sexually abused have more in
  common with other juveniles than adult sexual
  offenders.

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• Sexual recidivism rates of juvenile sex offenders
  are low--both statistically and as compared with
  nonsexual recidivism rates. In fact, with proper
  interventions, sexually abusive adolescents are
  very unlikely to persist in sexual harm into
  adulthood.
• Research that shows the most effective treatment
  in the areas of delinquency and adolescent
  substance abuse focus on risk factors across
  youths' natural ecologies (i.e., family, peers,
  school) and substantially include caregivers in
  treatment (Elliott, 1998 National Institute on
  Drug Abuse, 1999).  Effective responses to sexual
  abuse by adolescents require that the adults in
  young peoples' lives understand both the abusive
  behavior and the environment in which it occurs.
  
• Letourneau, E.J., Miner, M.H. (2005).
  Juvenile Sex Offenders A Case Against the Legal
  and Clinical Status Quo. Sexual Abuse A Journal
  of Research and Treatment, 17, 293-312.Dodge,
  K.A. (2008, October). Framing public policy and
  prevention of violence in American youths.
  American Psychologist, 573-590.
• Prescott, D.S. Longo, R.E. (2006). Current
  perspectives Working with young people who
  sexually abuse. In R.E. Longo D.S. Prescott
  (Eds.), Current perspectives Working with
  sexually aggressive youth and youth with sexual
  behavior problems. Holyoke,MA NEARI Press.
•   Ryan, G. (1999). Treatment of sexually abusive
  youth The evolving consensus. Journal of
  Interpersonal Violence, 14, 422-436

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Who are the Adolescents Who Sexually Offend?

• In the United States it is estimated that
  juveniles account for up to 20 of all forcible
  rapes and almost 50 of all cases of child
  molestation committed each year.

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Adolescents Who Act Out Sexually

• Are a heterogeneous group.
• They often differ according to victim and offense
  characteristics and a wide range of other
  variables, including types of offending
  behaviors, their own history of child
  maltreatment, their sexual knowledge and
  experiences, academic and cognitive functioning,
  mental health issues and social and family
  functioning.
• Typologies once used are no longer used in
  practice. Why? Because adolescents mystify the
  adults that try to define them. What else is
  new?

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What are the factors that drive sexually
inappropriate behavior?

• Curiosity Experimentation- may have seen things
  and want to try them too.
• Impulsivity
• Mental health issues
• Developmental delays
• Poor boundaries
• Not reading social cues appropriately, responds
  inappropriately to flirtation and sex talk.
• As part of a conduct disorder profile-poor sense
  of self, disregard for social rules, poor moral
  development.

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What are the factors that drive sexually
inappropriate behavior?Continued

• Few, but some older juveniles may have a true
  offense pattern and victim profile, deviant
  arousal and paraphilic sexual arousal.
• Reacting to own abuse history.
• As part of poor peer group behaviors.

51
Youth Who Sexually Abuse

• 45 of adjudicated offending adolescents admitted
  to sexual offending prior to age 12.
• Youths who commit penetrative acts tend to commit
  acts of fondling and exposure first. Not all who
  fondle penetrate, but most who penetrate have
  exposed.
• Those who continuously act out are more highly
  correlated with sexual, and emotional abuse and
  trauma.
• Trauma resolution is an important and relevant
  factor in treating child and adolescents who act
  out sexually.

52
The Development of a Sense of Self

• There is a drive to be seen as important and
  affirmed by someone who is admired and represents
  the ideal self.

53
Attachment

• Several studies have examined attachments in
  people who are sexually abusive and show a
  correlation between insecure childhood attachment
  and coercive sexual behavior.
• In Hudson and Ward (1997) applying Bartholomew
  and Horowitzs study of attachment found
• Securely attached individuals (/) have high
  levels of self-esteem and view self and others
  generally positively and experience high levels
  of intimacy.
• Preoccupied individuals (-/) generally view self
  as negative and others positive. They are
  sexually preoccupied and prone to sexualizing
  their need for security and affection.
• Fearful individuals (-/-) have a negative view of
  self and others and desire social contact but
  avoid interactions and have a passive-aggressive
  personality style.
• Dismissing individuals (/-) have a positive view
  of self and negative view of others and have a
  narcissistic personality style with a tendency
  towards overt anger and hostility towards others
  (Bartholomew, K., Horowitz, L. M, 1991).

54
Object Relations Theories

• The Relational Models examine the interpersonal
  realm of experience throughout development and
  the role attachment plays (rather than
  intrapsychic conflicts) in the development of a
  sense of self/self-esteem.
• To victimize another is a narcissistic act a
  devaluing of another. The formation of a
  narcissistic relational style can be seen as a
  defense against a fragile self-esteem and a
  vulnerability to shame.
• The study of Narcissism, pioneered by Kohut,
  organizes much of the understanding about
  sexually deviant behavior by suggesting that
• Traumatic disruptions in early attachments
  derails the development and regulation of
  self-esteem and the formation of intimacy.
• Severe instability in self-esteem is a risk
  factor for sexual exploitation.

55
Other Classifications

• Adolescents who sexually act out can fall into
  two major types
• Those who abuse children
• Those who abuse peers or adults
• There are characteristic distinctions between
  these two groups of adolescents who sexually act
  out.

56
Comparing Two Sub-Groups Adolescents Who
Sexually Abuse Against Children

• Higher number of male victims (almost 50 of this
• group have at least one male victim).
• Higher number of victims to whom they are related
  (as
• many as 40 are siblings or other relatives)
• The sexual behaviors tend to reflect a greater
  reliance
• on opportunity and guile rather than injurious
  force.

57
These youth may trick the child into
compliance, use bribes, or threaten the child
with loss of the relationship.The youth are
often characterized as suffering from deficits in
self-esteem and social competency.Many of these
youth, particularly those with victimization
histories, show evidence of depression.
58
Comparing Two Sub-Groups Adolescents Who
Sexually Act Out Against Peers or Adults

• Predominantly assault females and strangers or
  casual acquaintances
• The assaults are more likely to occur in
  association with other types of criminal activity
  (e.g., burglary)
• More likely have histories of non-sexual criminal
  offenses, and appear more generally delinquent
  and conduct disordered
• More likely to commit their offenses in public
  areas
• Generally display higher levels of aggression and
  violence in the commission of their sexual crimes
• More likely to use weapons and to cause injuries
  to their victims

59
Other Characteristics of Adolescents Who Sexually
Abuse

• Adolescents who assault children, and those who
  target peers or adults share certain common
  characteristics
• High rates of learning disabilities and academic
  dysfunction (30 60)
• The presence of other behavioral health problems,
  including substance abuse, and conduct disorders
  (up to 80 have some diagnosable psychiatric
  disorder)
• Observed difficulties with impulse control and
  judgment.

60
Co-Morbid Diagnoses Youth with Mental
Retardation

• Mental retardation (MR) defined as a
  significant sub-average IQ score (75 or less)
  deficits in adaptive behavior
• Offenders with MR are likely to be insufficient
  in adaptive skills and sexual knowledge
• They may exhibit low frustration tolerance and
  impulsiveness
• May be vulnerable to sexual abuse and the
  perpetrators, in many cases, were also
  individuals with MR
• May have been sexually abused in either
  institutional or familial settings.

61
Additional Co-Morbid Diagnoses to Consider and
Address in Assessment and Treatment

•       Aspergers Disorder Pervasive
  Developmental Disorder NOS
•        Impairment in social interaction
  social/emotional reciprocity.
•      Attention-Deficit/Hyperactivity Disorder
•      Difficulty with inattention and/or
  hyperactivity and impulsivity
•     Conduct Disorder    
• Repetitive and persistent pattern of
  behavior in which the basic rights of
• others or major age-appropriate societal
  norms or rules are violated.
•   Oppositional Defiant Disorder
•     Pattern of negative, hostile and defiant
  behavior.
• Reactive Attachment Disorder
• Markedly disturbed and developmentally
  inappropriate social
• relatedness in most contexts beginning
  before age5, as a result of
• pathogenic care. Two types inhibited
  and disinhibited.
•   

62
Additional Co-Morbid Diagnoses to Consider and
Address in Assessment and Treatment (continued)

• Bipolar Disorder
• Substance Related Disorders
• Depressive Disorders
• Anxiety Disorders
• Adjustment Disorder

63
Additional Co-Morbid Diagnoses to Consider and
Address in Assessment and Treatment (Continued)

• V Codes that may be focus
• Parent-Child Relational
  Problem
• Sibling Relational Problem
• Physical Abuse of Child
  (focus on victim)
• Sexual Abuse of Child
• Neglect of Child (focus on
  victim)
• Bereavement

64
What Do We Know About Adolescents Who Have Acted
Out Sexually?

• They are a very manageable population
• Treatment programs built on the
  cognitive/behavioral model supported by
  supervision can greatly reduce the chance of a
  re-offense (victimization)
• Low rates of recidivism reported.
• More likely to be re-incarcerated for a non-sex
  offense then a sex offenses

65
How Abuse and Trauma Effect Sexually
Inappropriate Behavior

• Recent research has documented the high incidence
  of trauma exposure among juveniles who sexually
  act out, including
• Childhood physical and/or sexual abuse
• Experiencing serious life threats and/or death of
  another, or witnessing severe injury or death of
  another
• Gang violence
• Youth may have a high risk for developing PTSD

66
How Abuse and Trauma Effect Sexual Acting Out
Behavior

• The severity and number of trauma exposures
  combined with their vulnerabilities and lack of
  protective factors will increase the chances of
  developing PTSD and trauma re-enactment.
• Over the past 10 years numerous studies have
  shown a clear relationship between youth
  victimization and a variety of problems in later
  life, including
• Mental health problems
• Substance abuse
• Impaired social relationships
• Suicide
• Delinquency

67
Victims of Sexual Abuse who later Act Out Sexually

• Risk factors compared to those who have been
  sexually abused and DONT become perpetrators
• Victims who were in close relationships to the
  abuser, often intrafamilial.
• Victims who were frequently abused with intrusive
  acts over a long period of time.
• The use of force or threats.

68
Elements of Treatment with Youth Who Sexually
Abuse

• Fundamental principles of human behavior
• Stimulus and Response It is from this principle
  that the acting out cycle has been developed.
• Stimulus (trigger) Triggers are thoughts,
  feelings, or events that create unmanageable
  stress and initiate a chain of reactions.
• Response (reaction) The response or reaction to
  a trigger for those who act out sexually are
  deviant thoughts, feelings, and/or behaviors that
  are attempts to manage or respond to the
  initiating stress.
• The younger the child the less likely an
  identifiable chain, more helpful with older
  adolescents.

69
Is Specialized Assessment and Treatment for
Adolescents Really Needed? NEARI Newsletter,
October 2008by David S. Prescott, LICSW

• This study, by Michael Caldwell, compares the
  recidivism patterns of a cohort of 249 juvenile
  sexual offenders and 1,780 non-sexual offending
  delinquents who were released from secured
  custody over a 2-1/2 year period. The prevalence
  of sex offenders with new sexual offense charges
  during the 5-year follow-up period was 6.8,
  compared to 5.7 for the non-sexual offenders, a
  non-significant difference.
• Juvenile sex offenders were nearly 10 times more
  likely to have been charged with a nonsexual
  offense than a sexual offense.
• Eighty-five percent of the new sexual offenses in
  the follow-up period were accounted for by the
  non-sex offending delinquents. None of the 54
  homicides (including 3 sexual homicides) was
  committed by a juvenile sex offender.

70

• If the data shows that so few adolescents persist
  in sexual abuse, why have we developed such a
  specialized field? Even small risks for
  significant harmful events make comprehensive
  assessment necessary. Not only can it identify
  treatment needs, it can rule out areas that don't
  apply to a particular adolescent. High-quality
  assessments have the potential to identify those
  who are less likely to abuse again, thus
  protecting them from unnecessary long-term
  consequences. It is essential that all treatment
  of adolescents take into account their entire
  life and future. Although abuse-specific
  treatment is important for those who have abused,
  it must also take place within a whole-person
  framework
• Caldwell, M.F. (2007). Sexual offense
  adjudication and sexual recidivism among juvenile
  offenders. Sexual Abuse A Journal of Research
  and Treatment, 19, 107-113.

71
Professionals May Be Able to Identify High-Risk
Adolescents NEARI Newsletter, April 2009 by
David S. Prescott, LICSW

• In 2008, Michael Hagan and his colleagues
  completed a five year study that examined the
  accuracy of risk assessment applied to
  adolescents who had sexually abused. The study
  followed a group of 12 adolescents recommended by
  experts for civil commitment in Wisconsin, but
  who were not committed. They found that 42 of
  these 12 adolescents had sexually offended again
  after five years. The results are similar to a
  Washington State study (Milloy, 2006) in which
  33 of a small group adolescents assessed as
  high-risk sexually re-offended within two years.
  The number of young adults in this study (as well
  as the study by Milloy) is too small to allow any
  firm conclusions. However, the results suggest
  that the ability of evaluators to assess high
  risk in adolescent males may be better than many
  believe. Of note, the youth who re-offended very
  often had previous histories of known sexual
  abuse. They also had been unable to complete
  treatment. Often, their continued general
  behavioral problems interfered with their ability
  to participate in treatment.Most research
  studies find very low sexual re-offense rates in
  adolescents.Practitioners working with sexually
  abusive adolescents have an extremely difficult
  challenge--to protect the community and ensure
  that adolescents are given the chance to live a
  healthy and safe life.  As research begins to
  tell us how to best differentiate our clients, we
  must also ensure that we treat kids as
  kids--using risk assessment instruments that are
  normed for youth and then followed with
  age-appropriate treatment options.Without further
  research, it is imperative that all practitioners
  hold in constant tension the risks to re-abuse
  for any adolescent and the harm done to these
  youth when we assume they will offend again.
• Hagan, M.P., Anderson, D.L., Caldwell, M.S.,
  Kemper, T.S. (in press). Five-year accuracy of
  assessments of high risk for sexual recidivism of
  adolescents. International Journal of Offender
  Therapy and Comparative Criminology, Online
  First, October 28, 2008).

72

• Most research studies find very low sexual
  re-offense rates in adolescents. Practitioners
  working with sexually abusive adolescents have an
  extremely difficult challenge--to protect the
  community and ensure that adolescents are given
  the chance to live a healthy and safe life.  As
  research begins to tell us how to best
  differentiate our clients, we must also ensure
  that we treat kids as kids--using risk assessment
  instruments that are normed for youth and then
  followed with age-appropriate treatment options.
  Without further research, it is imperative that
  all practitioners hold in constant tension the
  risks to re-abuse for any adolescent and the harm
  done to these youth when we assume they will
  offend again.
• Hagan, M.P., Anderson, D.L., Caldwell, M.S.,
  Kemper, T.S. (in press). Five-year accuracy of
  assessments of high risk for sexual recidivism of
  adolescents. International Journal of Offender
  Therapy and Comparative Criminology, Online
  First, October 28, 2008).

73
What are the Risk Factors to Acting Out Sexually?

• Risk Factors
• The STATIC DYNAMIC traits creating
  susceptibility to triggers leading to the
  inappropriate responses.
• Treatment Interventions
• Treatment in older adolescents addresses the
  chain of thoughts, feelings, and decisions that
  lead to sexually acting out.
• In younger children work more to external factors
  and teach rules- developmentally appropriate.
• And identify the risk factors that predispose
  youth to act out sexually.

74
Types of Risk Factors

• Static Factors (historical variables, e.g.
  criminal history)
• Dynamic Factors (changeable and used in
  treatment)
• Stable Dynamic Factors
• Change in these factors is associated with an
  enduring reduction in recidivism risk.

75
Identification of Static Risk Factors for
Adolescents

• Taken from J-SOAP II-
• Prior sex offense charges
• Number of sexual abuse victims
• Male child victims
• Duration of sexual offense history
• Planning in sexual offenses
• Sexualized Aggression
• Evidence of sexual preoccupation
• Sexual victimization history, physical abuse
  history and/or exposure to family violence.
• Caregiver consistency/stability
• History of expressed anger
• School behavior problems
• History of conduct disorder before age 10
• Juvenile antisocial behavior (10-17)
• Ever charged/arrested before age 16
• Multiple types offenses

• Taken from the ERASOR-
• Prior adult sanctions for sexual assault(s)
• Ever assaulted 2 or more victims
• Male victim
• Ever assaulted same victim 2 or more times
• Threats of, or use of excessive violence/weapons
• Child victims
• Stranger victims
• Indiscriminate choice of victims
• Diverse sexual assault behaviors

76
Dynamic Risk Factors in Adolescents

• Based on J-SOAP-II
• Accepting responsibility for sex offenses
• Internal motivation for change
• Understanding risk factors and management
• Evidence of empathy
• Evidence of remorse and guilt
• Presence of cognitive distortions
• Quality of peer relationships.
• Management of sexual urges and desire
• Evidence of poorly managed anger in community
• Stability of current living situation
• Stability in school
• Evidence of support system in community

• Based on ERASOR
• Deviant sexual interest
• Obsessive sexual interests
• Attitudes supportive of offending
• Unwillingness to alter deviant sexual
  interest/attitudes
• Antisocial peer orientation
• Lack of intimate peer relationships/social
  isolation
• Negative peer associations and influences
• Interpersonal aggression
• Recent escalation in anger or negative affect
• Poor self-regulation of affect and behavior
  (Impulsivity)
• High-stress family environment
• Problematic parent-offender relationships/parental
  rejection
• Parent(s) not supporting of sexual offense
  specific assessment/treatment
• Environment supporting opportunities to reoffend
  sexually
• No development or practice of realistic
  prevention plans/strategies
• Incomplete sexual offense specific treatment

77
Public Policy regarding Children with SBP (under
12 years old)(Report of the ATSA Task Force on
Children With Sexual Behavior Problems- 2005)

• Although some adult offenders report a childhood
  onset to their sexual aggression, we should avoid
  the logical fallacy of reasoning backwards and
  assuming that all or most children with SBP are
  therefore on a path toward serious sexual
  aggression.
• Given appropriate treatment, children with SBP
  were no more likely to have future arrests for
  sexual or nonsexual offenses than children with
  other behavioral problems. (A ten-year risk of
  2-3 for both groups)
• Children lack the experience, education and
  wisdom to make decisions in the ways that adults
  do. Also their behaviors are highly susceptible
  to environmental influences- behaviors can be
  related to own trauma or witnessing sexual
  materials.
• Unfortunately some jurisdictions adjudicate and
  register children as young as 8-9 years old.
  This label can create stigmatization and impede
  appropriate development. It doesnt appear to
  make sense from a public safety point of view
  either, given their low risk to harm other,
  especially with treatment.

78
Public Policy regarding Children with SBP (under
12 years old)(Report of the ATSA Task Force on
Children With Sexual Behavior Problems- 2005)

• Unfortunately some jurisdictions adjudicate and
  register children as young as 8-9 years old.
  This label can create stigmatization and impede
  appropriate development. It doesnt appear to
  make sense from a public safety point of view
  either, given their low risk to harm other,
  especially with treatment.
• Mandated reporting issues- check your states
  rules and professional guidelines and follow
  them. May need to do so to protect child from
  abuse in the home or to prevent the client from
  seriously harming others.
• Placement decisions should be carefully
  considered and avoided if possible. If not
  possible then aim for the least restrictive,
  closest to home where parents can continue
  involvement in childs life and treatment. A
  relative might be a good choice with precautions
  taken such as own bedroom, dressing and bathing
  alone, appropriate media/internet use,
  discouragement of hands on behaviors.
• May need to inform others of behavior, do so in a
  way to support child, and only if necessary.
• Collaboration is key- work together for the
  benefit of the child!

79
Risk Assessment and the Risk Principle

• Research indicates that providing high intensity
  treatment to low risk offenders may increase
  their risk level by extensively exposing them to
  higher risk offenders who may contaminate them
  with anti-social attitudes, thinking and behavior.

80
Caveats to Risk Assessments with Juveniles

• These are empirically-informed guides for the
  systematic review and assessment of a uniform set
  of items that may reflect increased risk to
  reoffend. These are NOT actuarial scales (yet).
• A tool that should be used as part of a
  comprehensive risk assessment and never be used
  exclusively to make decisions about reoffense.
  Must be skilled and use a variety of tools and
  resources, as well as assess multiple aspects of
  functioning.
• Used for adolescents 12-18, J-SOAP-II is only for
  Boys, ERASOR can be used on both

81
Caveats to Risk Assessments with Juveniles

• Remember that adolescents are in a developmental
  and situational flux
• They are still developing social and emotional
  skills, attitudes and beliefs, abstract thinking
  and reasoning skills
• They have shorter attention spans and greater
  impulsivity.
• Self-focus and narcissism are developmentally
  normal
• More dependent on social environment
• Traumatic effects may be immediate and ongoing

82
JUVENILE Risk
Assessments-Static Dynamic Factors
83
Other Assessments Used
in the field
84
J-SOAP-II

• There are many items in the J-SOAP-II related to
  the risk of general juvenile delinquency
• The J-SOAP-II provides ratings of sexual
  re-offence risk using 28 items across four scales
  
• two static scales Sexual Drive/Preoccupation and
  Impulsive, Antisocial Behavior
• two dynamic scales Clinical/Treatment and
  Community Stability/Adjustment

85
JSOAP II Scoring Form

• I. Sexual Drive / Preoccupation Scale
• 1. Prior Legally Charged Sex Offense
• 2. Number of Sexual Abuse Victims
• 3. Male Child Victim
• 4. Duration of Sex Offense History
• 5. Degree of Planning in Sexual Offense(s)
• 6. Sexualized Aggression
• 7. Sexual Drive and Preoccupation
• 8. Sexual Victimization History
• Sexual Drive Preoccupation Scale Total
• II. Impulsive, Antisocial Behavior Scale
• 9. Caregiver Consistency
• 10. Pervasive Anger
• 11. School Behavior Problems
• 12. History of Conduct Disorder
• 13. Juvenile Antisocial Behavior
• 14. Ever Charged/Arrested Before Age 16

• III. Intervention Scale
• 17. Accepting Responsibility for Offense(s)
• 18. Internal Motivation for Change
• 19. Understands Risk Factors
• 20. Empathy
• 21. Remorse and Guilt
• 22. Cognitive Distortions
• 23. Quality of Peer Relationships
• Intervention Scale Total
• IV. Community Stability/ Adjustment Scale
• 24. Management of Sexual Urges and Desire
• 25. Management of Anger
• 26. Stability of Current Living Situation
• 27. Stability in School
• 28. Evidence of Support Systems
• Community Stability Scale Total

86
RSVP The Risk for Sexual Violence Protocol

• Assesses sexual risk and risk formulation among
  adult male sex offenders over the age of 18. It
  can also be used for adolescents 15 or older and
  females
• Predecessor was SVR-20 and has static dynamic
  items
• Should be scored by clinical staff and uses a
  weighted key

87
MASA- Multidimensional Assessment of Sex and
Aggression

• Assesses social competence, sexual attitudes,
  behaviors, cognitions, and fantasies
• Items (static dynamic) are presented in a
  self-report format
• Adult and adolescent populations

88
ERASOR, Version 2 The Estimate of Risk of
Adolescent Sexual Offense Recidivism

• Assesses sexual re-offense risk among juvenile
  sex offenders
• 23 items scored by clinical staff or case manager
  using a weighted key
• The ERASOR 2.0 has 9 identified static items (5-
  13), with the majority (64) of its questions
  tapping dynamic risk factors (i.e.,16 of 25
  questions). Scales should be re-assessed at 6
  month intervals and sooner if risk-relevant
  changes have occurred

89

ERASOR 2.0 vs. J-SOAP-II

• ERASOR 2.0 The ERASOR 2.0 has 21 more dynamic
  risk items than the J-SOAP-II that could give
  this instrument a slight edge as the protocol of
  choice for treatment providers conducting
  repeated evaluations across time to determine
  treatment progress.

90

J-SOAP-II vs. ERASOR 2.0

• J-SOAP-II The J-SOAP-II has 21 more static risk
  items than the ERASOR 2.0 that could give this
  instrument a slight edge as the protocol of
  choice for forensic examiners conducting a one
  time evaluation to determine an initial risk
  level for the purpose of recommending an initial
  level of treatment care (i.e., outpatient
  services, Foster Care, or residential placement).
  

91
JSORRAT-II - Juvenile Sexual Offense Recidivism
Risk Assessment Tool-II

• The JSORRAT-II was developed using an actuarial
  approach. It is for male juveniles who have
  offended sexually, recognizing the potential for
  accurate risk assessment to inform a range of
  decisions, including placement, programming, and
  supervision.
• The JSORRAT-II is a 12-item (static) actuarial
  risk assessment tool initially developed for Utah
  Juvenile Justice Services to provide
  empirically-based estimates of risk for future
  juvenile sexual offending by male juveniles.

92
SAVRY Structured Assessment of Violence Risk in
Youth

• The SAVRY is useful in the assessment of either
  male or female adolescents between