Counseling and Psychotherapy Center

3. Presenters

5. 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.

6. 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 client’s individual needs and can include EMDR, PPG’s, 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.

8. . Current Services in North Dakota

9. 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.

10. North Dakota Services (Continued) We are working to involve a Victim Advocate with those victimized by each RULE CPC client to further ensure that victim’s 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.

11. 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.

12. Why learn about this? Quote adapted from, “Everything you NEVER wanted your kids to know about SEX (but were afraid they’d 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 isn’t enough. You want that child to be wisely sexual, to be healthily sexual, to be happily sexual. That’s where you come in- you’re going to teach them.” Quote from David Prescott, LICSW- “Understanding the Sexual Behavior of Children” NEARI Newsletter, May 2009

13. “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.”

14. What is “Normal” Anyway?

15. Sexual Development Birth - Age 5 Taking off clothes- not modest. Rubbing/Touching own genitals (begins in infancy) Curiosity about familiar adults and children’s 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. 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.

16. Funny Quote(Taken from “Everything you NEVER wanted your kids to know about SEX (but were afraid they’d 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

17. 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 other’s 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.

18. Funny Quote(Taken from “Everything you NEVER wanted your kids to know about SEX (but were afraid they’d 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 daughter’s door to find six girls (around age 8) almost entirely naked except for brightly painted bonnets. They are…..stripping. Here’s the punch. And you’re out of there. Odds are you don’t welcome the chance to confront the little ones’ sexuality. You might even prefer to imagine that it doesn’t exist, and you would not be the first. You may wonder is this unusual? Is she…abnormal? Does this mean she’s 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.”

19. 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.

20. Funny Quote(Taken from “Everything you NEVER wanted your kids to know about SEX (but were afraid they’d 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.)

21. 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.

22. Types of Inappropriate Behaviors Physical – touching Visual – pornography, exhibitionism, voyeurism, sexting Verbal – obscene phone calls, inappropriate talk Emotional – abuse of relationship

23. 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.

24. 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.

25. 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.

26. 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 STD’s- may be being molested.

28. 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.

29. 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.

30. 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 child’s 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).

31. 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.

32. 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.

33. 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.

34. 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).

35. 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).

36. 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.

37. 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.

38. 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 child’s 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.

39. 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.

40. 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 children’s sexual behaviors with other children, and lists 26 problematic characteristics of children’s 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).

41. 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).

42. 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.

43. 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.

44. 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 child’s self-control strategies, helping child develop appropriate peer relationship, addressing parental stress and increasing supports for all family members.

45. Challenging Long-Held Notions about Sexual Abuse by Adolescents 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.

46. 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

47. 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. This may be a good time to talk about all of the juveniles under the supervision of residential care providers, who may not have been formally adjudicated for a sexual offense, but may exhibit sexual offending behaviors. This may be a good time to talk about all of the juveniles under the supervision of residential care providers, who may not have been formally adjudicated for a sexual offense, but may exhibit sexual offending behaviors.

48. 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?

49. 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.

50. 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.

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. Within the overall population of juveniles who sexually assault children, there are certain youths who display high levels of aggression and violence. Generally, these are youths who display more severe levels of personality and/or psychosexual disturbances (e.g., psychopathy, sexual sadism, etc.)Within the overall population of juveniles who sexually assault children, there are certain youths who display high levels of aggression and violence. Generally, these are youths who display more severe levels of personality and/or psychosexual disturbances (e.g., psychopathy, sexual sadism, etc.)

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

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)

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 These slides are based on adult populations!These slides are based on adult populations!

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 DON’T 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? 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.

71. Professionals May Be Able to Identify High-Risk Adolescents 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.

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 doesn’t 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 doesn’t 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 child’s 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!

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

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 15. Multiple Types of Offenses 16. Physical Assault / Exposure to Family Violence Antisocial Behavior Scale Total 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

101. Is Denial a Risk Factor? NEARI Newsletter May 2009by David S. Prescott, LICSW From the victim's point of view, it is critical that society does not deny the victim's experience. But does denial affect treatment and is it a risk factor for re-offense? To date, there are only limited studies directly examining denial and re-offense among adolescents. These focus on the important role that families can play in denial. Be extremely careful in considering denial as a risk factor. Easy to conclude that those who deny abusive behavior are more likely to continue it. However, the roots of denial are multi-faceted- some denials may be manipulative, while others reflect a psychological defense against the anguish of admission, while for some it ma be an initial coping mechanism. Denial may simply mean that professionals have not yet provided a context where the adolescent can tell the truth. Rather than think of denial as a risk factor, it may be more helpful to consider the adolescent's motivations for denying or admitting. An adolescent's denial may mean that they do not yet trust the professional who is working with them. The role of denial is still far from clear. It may be that an adolescent's unwillingness to acknowledge his or her behavior reflects an underlying risk. On the other hand, we should not expect that someone would decide to re-offend in the future just because they said, "I didn't do it" today. What is clear from the research is that the practitioner must look at the context in which the adolescent lives (e.g., their family, school, etc.) and address the adolescent and this larger system when looking for a road to a healthy situation.  

102. A New Tool Helps Assess Treatment ProgressNEARI Newsletter, October 2008 by David S. Prescott, LICSW Oneal, B.J. Burns, G.L. Kahn, T.J., Rich, P., & Worling, J.R. (2008). Initial Psychometric Properties of a Treatment Planning and Progress Inventory for Adolescents Who Sexually Abuse. Sexual Abuse: A Journal of Research and Treatment, 20, 161-   The Treatment Progress Inventory for Adolescents Who Sexually Abuse (TPI-ASA) was designed to monitor common elements of specialized treatment for youth with sexual behavior problems. The TPI-ASA measures nine dimensions relevant to the evaluation and treatment of adolescents with sexual behavior problems (inappropriate sexual behavior, healthy sexuality, social competency, cognitions supportive of sexual abuse, attitudes supportive of sexual abuse, victim awareness, affective/behavioral regulation, risk prevention awareness, and positive family caregiver dynamics). Helpful in planning and assessing treatment. Rather than focus only on stopping the abusive behaviors, the tool expands the focus to include helpful assets, such as healthy sexuality and social competency.  The authors have taken care that the wording for each item in the inventory is positive and strengths-based. Members of the Association for the Treatment of Sexual Abusers completed the TPI-ASA with 90 male adolescents with sexual behavior problems as part of a psychosexual evaluation. The preliminary findings provided support for the internal consistency and convergent and discriminant validity of the dimensions.

103. A New Tool Helps Assess Treatment ProgressContinuedNEARI Newsletter, October 2008 by David S. Prescott, LICSW The authors are the first to admit that no one study, tool, or other contribution can answer every question. With the exception of stopping the sexual behaviors, no single treatment goal necessarily applies to every adolescent.  Missing are strengths relevant to understanding an adolescent's progress such as academic performance or employment success. There needs to be a focus on how can our treatments better produce the changes in thought and behavior that create safety, success, happiness, competence, inner peace, and a sense of belonging?

104. The Value of Asking Adolescents to Self-Report Sexual Arousal and Sexual Interest James Worling (Worling, J.R. (2006). Assessing sexual arousal with adolescent males who have offended sexually: Self-report and unobtrusively measured viewing time. Sexual Abuse: A Journal of Research and Treatment, 18, 383-400.) studied three ways to measure sexual arousal and interest among adolescent males who acknowledged having sexually abused:a computerized analysis of how long the adolescent looks at each of a series of pictures of clothed people of both genders and varying ages, a self-report rating form for each of the same photographs , a simple graph in which the adolescents rated their sexual arousal for eight age categories, with one graph for each gender The study found similar patterns of responses to all three assessment techniques. The two self-report procedures distinguished those adolescents who abused children from those who abused peers or adults. The computerized assessment was able to distinguish those who had abused male children, but no technique accurately identified adolescents who had abused female children exclusively. In this study, Worling found that the adolescents typically did not find any of the methods upsetting.

105. The Value of Asking Adolescents to Self-Report Sexual Arousal and Sexual InterestContinued NEARI Newsletter , February 2009by David S. Prescott, LICSW What did we learn? Adolescents can be truthful, using the least intrusive method would be the better practice (most cases, need to ensure a person-centered practice- focus on the person,not just the behavior. Worling cautions that the adolescent's choice of victim does not necessarily indicate a fixed pattern of sexual interest. In fact, sexual arousal can change significantly across adolescence. Although some sexually abusive adolescents exhibit patterns of offense-related sexual interest and arousal, the majority do not. For this reason, clinicians should use a careful assessment to take a more comprehensive look at all of the issues the adolescent is facing. There is much we don't know about adolescent sexual interest and arousal. They are related but different, e.g., many adult men experience sexual arousal to adolescent female stimuli in assessment conditions but are not interested in having sex with them. Sexual abuse against children does not mean that the person is a pedophile. Likewise, sexual assault of a same-age peer does not necessarily indicate a preference for sexual violence. To date, there is little research into adolescent sexuality generally and limited comparisons of the sexual interests and arousal of those who have and haven't abused.

106. Group Treatment Process: Examining interactional patterns between group members through the group process brings into awareness patterns and provides a supportive peer environment to work through issues. The group process is facilitated by the leader through empathic listening and understanding Content: Comprehensive psycho-education with the interpersonal dimension. Goals: Responsibility Understanding Learning Experience

107. Individual & Family Therapy Explore issues more completely in preparation for group discussions Address mental health issues Address trauma history Address family dynamics Address family environment issues Address boundaries and safety planning Reunification work if appropriate Etc.

108. Primary Treatment Issues Stop abusive touch Increase impulse control Improve coping skills Help child to experience safe, nurturing, non-abusive relationships Develop non-abusive ways to meet needs Increase responsibility taking for behaviors. Understand and regulate thoughts and feelings Sexual education Arousal control Perspective taking and empathy

109. Primary Treatment Issues (Continued) Child’s own victimization history (physical, sexual and/or emotional) Drug/alcohol use/abuse (if relevant) Gang/street affiliation or other negative peer influences Self-esteem development Communication/assertiveness skills Development of appropriate activities/structure of time. Referral for medication and medication monitoring, if appropriate. Family issues

111. Working collaboratively in the Treatment First and foremost make sure all necessary releases are signed by guardians. Protect the child’s confidentiality as much as possible, need to ensure safety of others as well. Use releases to disclose, but don’t over disclose. Try to learn what underlying issues exist and help to monitor them. Be willing to name and address any inappropriate behaviors. Report to therapist and family any and all concerns. Encourage regular meetings with providers and family to discuss progress in all areas. Offer opportunities for the child to improve his/her self-esteem, develop healthy attachments and pro-social skills in home, school and community.

113. Components of a Effective Treatment Program Modifying Interpersonal Relations - Therapeutic Community Exploration of Roots of Problem - Group Enhance Coping Skills - Psycho Educational Classes Building Empathy - Group, Experimental Identifying Cognitive Distortions - Group, Classes Modifying Deviant Arousal - Behavioral Developing Relapse Prevention Plan Transitioning to Community - Prerelease, Work Release Maintaining Recovery - Aftercare Groups

114. The “Containment Approach” is one of the most effective models in managing those who have acted out sexually within the community

115. Containment Model

116. Treatment and Management Components EXTERNAL INTERNAL CONTROLS CONTROLS Family Responsibility Probation Competence Placement Victim Empathy Registration Relapse Prevention Networks Cognitive Distortions

117. Team Alliance Mutual Goal: No more victims Benefits: Increases flow of communication Cuts Fragmentation Facilitates information on specific cases Decreases manipulation/splitting System Problem Solving Holds each other accountable

118. Results of Team Alliance ENHANCED COMMUNITY SAFETY HIGHER QUALITY SERVICES PROVIDED

119. Probation Supervision Goal: Achieving a balance between relationship/ change and monitoring/limit setting – don’t want to tap negative emotions of shame and isolation. Apply pressure to cooperate in treatment Use youth’s support network for information and motivation Knowing the youth: awareness of triggers and being alert for changes Case discussions with team members Having relationships with criminal justice elements: use in the best interests of the youth

120. Probation Focus with Juveniles Who Sexually Offend Constantly assessing and working with the following: Motivation for Change Sexual Interests Sexual Drive Social Skills Personal Maltreatment History Victim Empathy

121. Probation Focus with Juveniles Who Sexually Offendcontinued Attitudes/Beliefs Emotion/Impulse Management Positive/Stable Self-Image Responsible Behavior Family Relationships/Supports Positive Peer Relationships Community Supports/Supervision Risk Management Strategies (Relapse Prevention)

122. Probation Conditions Obey all laws. Report to the Probation Officer as directed. Notify the Probation Officer of any change of address or telephone number immediately. Obtain the prior approval of the Probation Officer before leaving the state. Attend school or be employed Live with and obey the lawful and reasonable rules and regulations of parents, legal guardian or approved placement. SPECIAL CONDITIONS

123. So What is a Lapse? Not a re-offense A “stumble’ or step in the wrong direction A series of lapses may lead to re-offense A goal of treatment and supervision is to identify a youth’s lapse behavior to prevent a re-offense Close monitoring and communication with treatment is essential

124. Responses to Lapses System of “graduated sanctions” Increase in monitoring, contact with the PO and treatment sessions Restrictions on movement Curfew

125. How Probation Officers Can Support Relapse Prevention Help the youth learn his cycle, triggers Correct the youth’s thinking errors Promote the use of coping skills Support the development of internal controls

126. Does Registration for Juvenile Offenders Work and Is It A Good Idea? Information from Recidivism Rates for Registered and Nonregistered Juvenile Sexual Offenders by Elizabeth J. Letourneau & Kevin Armstrong. Printed in Sexual Abuse: A Journal of Research and Treatment. Volume 20, Number 4. December 2008 393-408 During the past decade, many state and federal policies (SORNA- Title 1 of the Adam Walsh Child Protection and Safety Act of 2006) originally developed for repeat adult offenders were applied to adolescents to reduce recidivism in this group, resulting in long-term public registration for some of these individuals. “Although widespread (Levenson, Brannon, Fortney & Baker, 2007) this belief of high recidivism risk is not supported by available evidence, especially with respect to juveniles who offend.“ “Fortune and Lambie (2006) reported that sexual recidivism rates for treated youth ranged between 0% and 40%, but tended to fall below 10%. Previous reviews have reached similar conclusions (e.g. Caldwell, 2002), and even you subjected to registration have low sexual recidivism rates”.

127. Does Registration for Juvenile Offenders Work and Is It A Good Idea? (Continued) Information from Recidivism Rates for Registered and Nonregistered Juvenile Sexual Offenders by Elizabeth J. Letourneau & Kevin Armstrong. Printed in Sexual Abuse: A Journal of Research and Treatment. Volume 20, Number 4. December 2008 393-408 Alternatively, some have argued that public registration might increase recidivism rates (although not necessarily sexual recidivism; see Letourneau & Miner, 2005) by creating barriers to the successful societal reintegration of offenders (Jones, 2007; Michels, 2007; Oliver, 2007). Study designed to look at effects of public registration to juveniles. Used South Carolina due to it being the first state to respond to the federal registration requirements which provided a longer follow-up of youth than states with recent enactment of policies. Also policy is similar to SORNA policy in that both require long-term public registration of some minors. Might provide insight regarding effects of SORNA based policies being enacted in other states.

128. Does Registration for Juvenile Offenders Work and Is It A Good Idea? (Continued) Information from Recidivism Rates for Registered and Nonregistered Juvenile Sexual Offenders by Elizabeth J. Letourneau & Kevin Armstrong. Printed in Sexual Abuse: A Journal of Research and Treatment. Volume 20, Number 4. December 2008 393-408 Sample of 222 minor boys (17 or younger) found guilty of a registry (index) offense between 1/1/95 and 12/31/05. 111 of these were required to register, the remaining 111 were matched with this group bases on date of offense (within one year), age of arrest (within one year), race (white or minority), a dichotomized indicator of prior convictions (0=none, 1=any), a dichotomized indicator of prior convictions for nonperson offense (0=none, 1=any) and type of index offense. Prior convictions for sexual offenses were rare and matches could only be found for registered youth with no such priors. Data came from sex offender registry records, juvenile justice records and adult criminal history records. Even though S.C. has registration triggered solely by conviction offense, a judge will occasionally instruct a juvenile to NOT register, even though the law does not permit this discretion. Recidivism was defined as new guilty dispositions (whether in juvenile or adult court) for sexual, nonsexual person or nonperson offenses that occurred during follow up. Any type of sexual offense conviction (whether or not the offense was a “registry” offense) was counted as sexual recidivism. The majority of nonsexual person offenses were assault (I.e. A&B, simple assault, domestic violence), robbery and lynching. Nonperson offenses were categorized as property offenses and public order violations. Status violations were not included here (such as curfew violations).

129. Does Registration for Juvenile Offenders Work and Is It A Good Idea? (Continued) Information from Recidivism Rates for Registered and Nonregistered Juvenile Sexual Offenders by Elizabeth J. Letourneau & Kevin Armstrong. Printed in Sexual Abuse: A Journal of Research and Treatment. Volume 20, Number 4. December 2008 393-408 Results: Sexual Offense Recidivism Rates of 2 of 222 or 0.9%. Too low to compare between groups. The 2 events occurred to registered youth. Fails to support the effectiveness of this policy- that is to reduce recidivism.

130. Punishment Does Not Prevent AbuseNEARI Newsletter, July 2008 Paula Smith, Claire Goggin, and Paul Gendreau (2002) examined 117 studies from 1958 to 2002 involving 442,471 criminal offenders. This study expanded previous analyses by examining the effects of sanctions on over 50,000 juveniles as well as with females and minorities. They studied the impact of various punitive approaches on recidivism.  The punitive approaches included: length of incarceration, institutional placement and receiving an intermediate sanction (such as “scared straight”) The study found that the use of punitive sanctions did not decrease recidivism under any of these conditions.  If anything, some initial findings showed a slight increase in recidivism with an increase in length of incarceration. Consider this research when making recommendations that could affect sentencing or interventions.  Ensure that you use these findings to differentiate between measures that are punitive-only and interventions that enable a youth to develop their own reasons to live a life free of abuse. Given the reality that many young people who sexually abuse come from backgrounds in which abuse is commonplace (Schwartz, Cavanaugh, Prentky, & Pimental, 2006), interventions must involve adults who will teach and model accountability and offer a positive alternative for living a healthy life.  Professionals should advocate for treatment as a means of preventing further abuse. The stakes are too high to ignore these findings. A summary of this study appears at: www.publicsafety.gc.ca   The complete study is available:publications/corrections/200201_Gendreau_e.pdf

131. What Is a Safety Plan and Why have a safety plan? Adapted from Carrie Craft at About.com guide to adoption What is a Safety Plan? An organized set of rules and guidelines used to supervise and structure time and space, due to behavioral issues. Designed for the safety and well-being of person acting out, as well as those around him/her, in addition to pets and property. Why have one? To address publicly sexually inappropriate behavior (I.e. masturbating, etc.) To address sexually inappropriate or violent behavior with pets. To address sexualize play. To address acting out with siblings or other children in the family, neighborhood or school, this may include – sexualized talk or inappropriate touch. To address verbally and physically abusive behavior towards others. To address harm to property when angry, which may result in harming the child or others. To address night time wandering. To address fire safety issues. Etc.

132. How to create a safety plan Adapted from Carrie Craft at About.com guide to adoption Define the issue or problem. Be precise and clear with the definition. (ex. J. stares at little girls when out in the community. Occurs 3/week or more.) Be clear about who you need to protect. (ex. This makes the girls and their families uncomfortable and fuels J’s inappropriate thoughts..) Pinpoint when the behavior occurs, if possible and predictable. (When in the community, during visitation, while not closely supervised) Determine who is involved in the safety plan and specifically how they will help. (Parents, school staff, client, milieu staff, treatment staff, J.) (ex. Parents, school personnel and staff will be one to one with client while in the community and monitor J.’s staring. J. will report to staff any desires to stare immediately)

133. How to create a safety plan Adapted from Carrie Craft at About.com guide to adoption What tools/plans might be utilized as part of the safety plan (I.e. door alarms, house alarm systems, baby gates, locks high on outside doors (never lock a child in a bedroom), discipline tools/techniques, no shut doors, no unsupervised time with peers, sibling or pets, no bedroom sharing, no overnights, locked matches/lighters/knives) (ex. J. will develop an urge control contract and educate his support system about it. He will carry this contract with him and utilize it. He will report and discuss effectiveness in therapy) Set how achievement is being measured (ex. J. will report using his plan 2/3 times per week, J. will decrease staring to 2/3 times, per staff and self-report.) Set a time limit for the safety plan to be revisited, say at least every 3-6 months. (Review what is working and what is not, what other help may be needed and implement new changes to plan) What if the safety plan fails? (Report to therapist and revise, consider underlying issues or other strategies and re-work the plan. If there was harm to self or others, need to report to case workers and/or the police.)

134. Safety PlanFor:_______________ 1.) Issue & Frequency: Impact: Goal: Players and Roles: Timeframe: 2.) Issue & Frequency: Impact: Goal: Players and Roles: Timeframe:

135. Case Study- J.J. J.J.- DOB: 6/7/88. Time of Discharge: 18 years old. J. reportedly touched the breast and buttocks of his foster parent’s three year old granddaughter, on at least four occasions, when he was fifteen years old. He reported that this occurred while playing tag with her. He also bathed her once when he was in charge of caring for her and touched her during this process. He admits all behaviors toward the granddaughter of his foster parent. He also reportedly rubbed the feet of two other young girls in the neighborhood and became sneaky in order to have contact with these girls. He has gone back and forth on accepting responsibility for this behavior. Watched pornography prior to offense so he could learn how to sexually touch a girl, said he chose a young girl because the thought touching an older girl might get him into trouble and that he would gain experience with younger girls that would make older girls date him. He had one relationship with a somewhat limited partner that was very chaotic.

136. Case Study- J.J. (Continued) Allegations existed that he may have sexually assaulted the foster parent’s dog; although he acknowledged torturing the dog he does not admit to sexually assaulting the dog. J. reported sexual abuse by mother’s boyfriend on one occasion at around age 6- this man fondled J’s penis. Denied history of physical abuse or neglect, but witnessed domestic violence in the home. DCF records indicate physical abuse by mother’s boyfriend and neglect by his mother. Also observed substance abuse by father and stepfather. Step-father had criminal history. He continues to stare at young girls in the community and to fantasize about offending them. Ambivalent about these feelings.

137. Case Study- J.J. (Continued) Tends to perseverate. This maintains thinking errors as well. Diagnoses: 299.80 PDD NOS, V61.21 Sexual Abuse of a Child (focus on victim) History of Full Scale IQ of 56, a single Verbal Subtest Score of 71, presents as higher functioning. Medication history- Prozac, Zyprexa & Risperdol. Currently on Prozac for depression and Depakote for mood stabilization and to decrease irritability and hostility. Some level infractions for not following staff directions, being out of location, group refusal, peer provocation, violating personal boundaries, one incident of sexualized threat, splitting staff & staff disrespect. Prior history of aggressive/assaultive behaviors prior to medication.

138. J.J.- Case Study- Continued Difficulty with personal hygiene. Continuing in therapy, some supportive services in place, as well as ongoing case management. Denied DMH and DMR services; however, client is looking for employment with help of Mass Rehab. Connected with a program called Community Connections, has a day program. Has driver’s permit. Graduated from high school. Loves school. Socially, difficulty taking the perspective of others and thinking how they might feel. Difficulty with reading social cues and with the concepts of reciprocity. “Awkward and socially immature” describe him. At school he is noted to make friends easily but to have difficulty maintaining these relationships due to rigid thinking, desire to control interactions and boundary issues, as well as understanding their point of view.

139. J.J. Case Study (Continued) Limited understanding of cycle risk factors- sees no issues of having internet in bedrrom at home, despite history of looking at child pornography. Also spends time with brother and his younger female friend while at home and admits to her violating his boundaries, but does nothing to remove himself from situation. Mother doesn’t always report things that occur on visits, such as arguments in the home;however, client does report issues. J. has contact with his mother and is being discharged to her care. She has a new boyfriend with whom she resides, as well as his younger half-brother whom has behavioral issues. J.’s father is remarried in FL and has a new baby. Contact with his bio-father is limited. Client loves country music and often puts on “shows” singing to this music, will choose songs for staff that are romantic in nature. Seems oblivious to this fact.

140. J.J.- Case Study (Continued) Abel Screening (for boys)indicated high level of sexual attraction to females ages 2-4. The next highest degree of attraction was found to be girls ages 8-10 years old. Appropriate sexual attraction was also noted in the following categories (in order from highest to lowest degree of attraction): adult females, adolescent females, adolescent males and adult males. He did not self-report attraction to males. Social desirability score of 99%, a high score in this area may indicate the client’s inability to respond truthfully to others. An elevated score in this area was also noted in his Jesness Inventory. This calls into question his general motivation to change his thought patterns and behaviors. On again off again relationship with age and developmentally appropriate girlfriend. Superficial in nature. Denies any sexual thoughts about her. Denies masturbating. Has completed treatment tasks, but hasn’t internalized it. Still lacks awareness of victim impact and displays cognitive distortion, especially when under stress.

141. J.J. Case Study (Continued) J-SOAP-II- a risk assessment tool that looks at both static and dynamic factors. Not an actuarial asessment tool but empirically informed tool. He scored 25 out of 56- moderate risk range. May reflect secure setting for last 10 years. Concerns noted in presence of planning and multiple sexualized behaviors including while supervised, problematic expression of anger, changes in caregivers prior to age 10, cognitive distortions, lack of internalization of treatment work, lack of substantial positive peer relationships. ERASOR (Estimate of Risk of Adolescent Sexual Offense Recidivism) assessment tool also utilized. Concerns include sexual attraction to young girls and behaviors that indicate this- horseplay with young girl on bus, fantasizing about young girl that lives in mother’s building, viewing child pornography at school, accused of fondling 2 female peers as school- 1st occurred with girlfriend, claims a massage- issue because of setting. 2nd peer more concerning because more delayed than James- accused of trying to fondle her breasts while putting on a necklace. He denies sexual intent/behaviors of both incidents.

142. J.J.- Case Study- Continued Another area of risk factors assessed by the ERASOR is “psychosocial functioning”. Due to diagnosis of PDD, he is more developmentally like a 12 year old. Difficulty relating to same aged peers, difficulty taking the perspective of others, difficulty conceptualizing what people are talking about, difficulty entering and exiting a conversation. He has difficulty thinking about how another person might feel, displays a limited range of feelings himself and has an overall poor ability to understand emotions. When ending a year long relationship with his girlfriend he reported not being sad and asked why we would assume that he might be. In regard to sexual behaviors, he struggles to understand impact. In the milieu he struggled with anxiety and would perseverate on issues, leading him to become irritable, agitated and verbally assaultive and to invade boundaries (kicking at them and stomping on their feet). Questions of delusions when angry.

143. J.J. Continued Another category of concern from ERASOR is “Family/Environmental Functioning”. His mother is supportive and compliant with recommendations. She supervises him during day visits and doesn’t allow him unsupervised time on the computer or in the community. However, because she hasn’t observed any concerning behaviors she categorizes him as “low risk”. Both she and her boyfriend feel that because he has a girlfriend he is not at risk around the mother’s boyfriend’s infant granddaughter. Family therapy has worked to shift this perspective. A final category from the ERASOR is Treatment- he has completed treatment tasks; however, has not yet internalized this, despite a simplified version being created for him. He continues to state that he would babysit if it was truly necessary. Questionable diagnoses- PDD, MR and question of NVLD In our program from 9/12/06-4/12/08, prior placement in a SAY residential program. Returning to live as a “free” adult with his mother, mother’s boyfriend and step-brother. Whew….now onto a safety plan for home, job and community!

144. Case Study- B DOB: 2/11/90 Intake: 3/5/06, came to our group home from a residential treatment program for sexually abusive behavior. April, 2001- Age 11, exposed penis to two 8 year old foster sisters, got on top of them and touched their vaginas through clothes. September, 2001-Age 11, exposed penis to 8 year old foster sister and fondled her over clothing 2-3 times. Had 6 year old foster sister (in same home) touch his penis over his clothing on 2 occasions. January, 2004-13 (almost 14) years old- while visiting with male cousin, he touched his penis and buttocks with his hands. Allegations of trying to anally penetrate the male. Discloses on own in 12/04 that he fondled 2-3 additional young girls (sister) and had one perform oral sex on him. He also indicated that when he was 12 he also approached a peer from behind, hugged her without her permission and rubbed her thighs.

145. Case Study- B (Continued) Admitted to all behaviors and seemed to understand impact on them and their families and display remorse for behaviors.. Completed treatment work (cycle, RP Plan and clarification work) and seemed to have good internalization of this work.No self-reported or observed issues with deviant arousal. History of being physically and emotionally abused by parents and by aunt from age 6-9. Sexual abuse by three older male and one female cousin who ranged in age from about 11-15, he was 6-8 years old at time, reportedly occurred one time with each. Parents have substance abuse history. Mother is in Puerto Rico in jail for stealing. Father has no contact, may live in Boston. Older brother shot and killed in PR while client was in care with us. Some viewing of pornography while in aunt’s care at age 11-12, pay-per-view/cable. Began masturbating at age 13. History of stealing CD’s.

146. Case Study- B. Continued No drug/alcohol history Strong family connections- an older sister that had a baby and a younger brother in foster care that was struggling behaviorally- able to see about 1/month if no issues on their end. No issues on his end related to visits. No psychotropic medication needs. Transitioned from alternative to traditional high school and was doing well in that setting, graduated while in foster care. Good social skills in this environment involved in sports and went to dances with peers. Applied for jobs while in placement, and followed up appropriately, but unable to find work. Worked at McDonald’s while in foster care, they would recommend him for another job. Did well in this home as well. Desires to become an electrician and currently pursuing entrance into a program.

147. Case Study B.- Continued Diagnosis: 313.81 Oppositional Defiant Disorder, V61.21 Sexual Abuse of a Child, No Axis II, Medical- Asthma, Allergies and Perforated Ear Drum, Mild psychosocial stressors and GAF: 60 at intake and 70 at discharge. J-SOAP-II Scores-was 14, with high scores in the areas of static factors: number of sexual abuse victims, male child victim, duration of sex offense history, sexual drive and preoccupation, school behavior problems in K-8th grade, juvenile antisocial behavior 10-17 years old, charges prior to age 16 years old, physical assault history/exposure to family violence & caregiver consistency. In terms of stable factors: he scores low (no issues) ERASOR indicated the presence of the following static factors: 2 or more victims, having sexually assaulted the same victim 2 or more times, prior adult sanctions for sexual assault, sexual assault of a child (victim under 12 and 4 years younger than B), male and female victims (indiscriminate choice of victims), male victim, diverse sexual assault behaviors. The ERASOR indicated the following stable factors: high stress family environment (birth of niece/loss of contact briefly with sister, murder of brother, behavioral issues in younger brother), partially problematic parent-offender relationships (father lives in area and has contact with his sister, but not him), it is unclear if they support treatment, environment supporting opportunities to reoffend sexually (in that he currently attends public school, plays on a sports team and is discharging to foster care affording him more opportunities for community contact. No Abel screening done due to lack of evidence and self-report to warrant such assessment. Client discharged to foster care on 12/5/07- Safety Plan?