Sexual Behavior Problems in Adolescents with…

1. Sexual Behavior Problems in Adolescents with… Autism Spectrum Disorders & Cognitive Delays

2. Training: University of Oklahoma Health Sciences Center: Children & Adolescents- SBP/Child Maltreatment Wichita, KS, Prairie View Center for Sexual Health: Children & Adol. & Adol with Dev. Disabilities with SBP’s UAMS: Children/Adol. With ASD’s Currently: Behavior Management Systems, Inc.: Child & Adol, with SBP’s and Child Maltreatment; PEERS Program for Adol. Adam Benton, PhDBehavior Management Systems, Inc. www.arbms.com www.ahbentonphd.com

3. Overview of Autism Spectrum Disorders (ASD’s) • Sexual development and problems unique to adolescents with ASD’s • Assessment and treatment components • Specific behavioral interventions Overview

4. DSM-IV-TR Classification

5. Autism Spectrum Disorder adapted from Koegel & Koegel (2006)

6. Cognitive Delays • Executive Functioning Deficits • Language Delays • Fine and gross motor delays • Learning Disabilities • Poor Social Skills • Sensory issues • Anxiety • Inattention and hyperactivity • Disruptive behavior problems Associated Features

7. How are they developing? • Cognitively • Speech/Language • Motor • Socially • Emotionally • Sexually • Sexuality is a continuum of development influenced by many factors (e.g. education, development, hormones, exposure, social influence) Typical Development

8. “Adolescets with ASD have difficulty understanding social rules of conduct and may act upon a variety of urges – not just sexual ones- in settings not appropriate for that behavior.” • (ex. 15 yr-old dressing up as Naruto characters for group) Their lack of perspective taking may make them insensitive to how their behavior effects others. • (ex. John’s attempting sex behaviors with peers at church) The resulting social faux pas often leads to social isolation, interfering with the normal developmental pathway of learning social and sexual boundaries. Blasingame, 2011 The Problem of Social Development

9. Teens with Asperger’s have unique vulnerabilities…. Impulsivity Social isolation Obsessive Interests Misunderstanding social cues Poor interpersonal boundaries Lack of sex education Victimization Lack of Empathy/Socio-emotional Insight

10. Higher rates of ADHD- a disorder of self-regulation • Preoccupations- hypersexuality or obsessive attractions • Ex. in the mini van; • Ex. Jason 15yrs- obsessive interest in Hanna which led to depression….and still exists!) • Lack of Sex Education- immature, incomplete understanding, which lacks connection to emotion, romance and the progression of intimacy • Ex. Abe Met younger ASD girl, w/n five minutes they had decided to wait for her to turn 18 and then get married ….Unique Vulnerabilities

11. Higher rates of victimization they may lead to inappropriate sexual behavior • Ex. Rob- 15yrs trading sexual favors for friendship with the neighbor • Vulnerability to bullying • Ex. John 14- convinced it would be hilarious to kiss another child’s bare feet in the bathroom • Difficulty reading facial expressions and non-verbal body language, which provide live feedback for social behaviors ….Unique Vulnerabilities

12. Attwood Study • 28 Adults (19 men 9 women) (ages 18-64) • Derogatis Sexual Functioning Inventory (DSFI) • Information, Experience, Desire, Symptoms, Affect, Sexual Roles, Fantasies, Body Image, Satisfaction, General Satisfaction. ASD’s & Sexuality

13. Results • Significant lack of information, regarding physiology, behavior, and health. Source of information was primarily media • Negative body image, men more than women • Fewer sexual experiences • Higher rates of anxiety and depression • Sexual desires: typical levels or desire, but less frequent opportunities • Fantasy life resembles the general population • Positive attitudes toward sexuality • Women were less satisfied with diversity, frequency, and quality of sexual relations than men, even when men’s frequency was limited ASD’s & Sexuality

14. Results • Satisfaction can exist even with low frequency • Some reported 1-2 sexual experiences and were satisfied • Some reported never having a sexual experience and were concerned that they never would • Quote- Exemplifying the connection between social behavior, interpersonal skills and sexuality • “Situations with lovers are quite delicate. It is as if my solitude and lack of experience is visible. Many look at me and laugh….how can I help but feel inferior and unhappy?” ASD’s & Sexuality

15. Sexual development that gets off track…. • These unique vulnerabilities increase their risk for unhealthy sexual lives, (i.e. sexual behavior problems and/or dissatisfaction with sexual lives as adults) • From 25 to 33% of children and teens with ASD’s in clinical populations could be expected to develop sexual behavior problems. Blasingame, 2011. ….Healthy sexual development starts in childhood and progresses through adulthood, even old age ASD’s & Sexuality

16. Inappropriate verbal or nonverbal gestures or sounds • Masturbating in public places • Excessive masturbation/pornography • Seeking out younger children in person or internet • Touching others' sex parts • Asking others inappropriately to engage in sex activity • A range other illegal sexual behaviors Problematic Sexual Behaviors

17. Continuum of Sexual Behavior Problems • Natural and healthy • Sexually reactive • Often in view of adults. • May be self or other directed • Usually no coercion or force • Confusion, fear or anxiety about sex, stemming from history of sexual abuse, typical drive the behavior • Some report arousal, others do not • This is the most common of the three groups

18. Continuum of Sexual Behavior Problems C. Children who engage in extensive mutual sexual behavior • Often frequent or habitual • May include adult-like behaviors • May have a hx of broken attachments with adults • Sexual behavior may be a way of coping with feelings • SBP may be more difficult to stop • May use persuasion but not likely to coerce or force • Like find other children who will collude with them to avoid being caught • The second largest group

19. Continuum of Sexual Behavior Problems D) Children who molest • Frequent and pervasive sexual behaviors • A growing patter of SBP's is evident in hx • Intense sexual confusion • Sexuality and aggression are closely linked • Generally use coercion, bribery, an/or force • May select vulnerable individuals to victimize • SBP's may have impulsive and aggressive qualities • Smallest group, but in need of specialized help

20. Curiosity/Experimentation • Impulsivity/Immaturity • Coercive/Delinquent/Aggressive behavior • Psychological problems • No model for healthy intimacy • Reactivity from exposure to sexual material and behaviors • Sexual Abuse • Deviant sexual attractions Barbera Bonner, 2009 Development of Problematic Sexual Behavior in Neurotypical Teens

21. Assessment

22. Social Environment • Training and Experience • Age Equivalence • Regulation Skills • Knowledge Base Assessment

23. Biological • IQ; Processing, Executive function, ADHD, Autism. Psychological • Hx. of Maltreatment, Emotional / Behavioral Functioning; Personality assessment; Reading ability; Adaptive Functioning Sociological • Family environment, Family sexuality; Family Resources; Association with negative peers; Parental support and attachment; Parental sexual abuse history; exposure to sexuality and violence Assessment

24. Sexuality focused interview: Sexual Behavior Screening Questionnaire, Blasingame, 2011 • Socio-sexual Knowledge and Attitudes Assessment Test- Revised (SSKAAT-R) • Estimate of Risk for Adolescent Sexual Offense Recidivism • Juvenile Sexual Offender Assessment Protocol –II • Multiphasic Sex Inventory (Nichols and Molinder, 1984)  Sexuality Assessment

25. Penile plethysmograph • Polygraph tests • Sexual interest inventories based on visual response, such as the Abel Assessment of Sexual Interest • Self-report of sexual interest, such as Adolescent SexualInterestCard Sort Controversial Assessment Procedures

26. Sample Assessment Battery • Interview • WASI • WJ-III, Screener • BASC-2 Self, Parent & Teacher • ERASOR / JSOAP • Family Environment Scale • Interpersonal Competence Questionnaire / Social Responsiveness Scale Sexuality Assessment

27. Assessment Should Ask... • Is the child teen safe from maltreatment? • Do other children need protection? • Is there reason to think that sexual abuse is a contributing factor? • What is the nature of the parent-child relationship and family environment? Sexuality Assessment

28. Was the behaviorsocially inappropriate or stemming from deviant interests? • Are other behavior/emotional problems present? • To what degree is the family open to treatment? • What barriers to treatment exist? • What was the nature and severity of sexual behaviorproblems...where do they fall on the continuum? • In what situations does the SBP seem to occur? • Are the behaviorsself-focused, other-focused, planned aggressive, coercive? • How does the child interact… social functioning? • What purpose did the sexual behavior serve for the child? Sexuality Assessment

29. Identifying the function of the inappropriate sexual behavior is essential to individualized treatment….. Some examples: • Inappropriate attempt to establish intimacy • Sexually reactive • Lack of self-regulation • Lack of understanding of boundaries • Deviant interests Sexuality Assessment

30. John- 14, Showing friends a youth group his “trick” then thrusting up against them Rob- 15, On-going sexual relationship with 12 year-old neighbor boy, in order to play video games Abe- Tickling the bellies of toddlers while parents were out of room and becoming fully aroused before getting caught Case Examples

31. Sexual abuse of same gendered person Diverse sexual assault behavior Anti-Social interpersonal orientation Lack of intimate peer relationships Negative peer association Interpersonal aggression Recent escalation in anger or negative affect Poor self-regulation High stress family environment Problematic parent-offender relations (parental rejection)‏ Parent not supporting offense tx Environmental opportunities to re-offend sexually No realist prevention plan Incomplete tx • Arousal to younger children • Use of violence in offense • Sexual preoccupation • Attitudes supporting abuse • Unwilling to complete tx • Sexually assaulted two or more victims • Multiple offenses against the same victim • Prior adult sanctions • Use or threats of violence when offending • Intentional sexual abuse of child • Intentional sexual abuse of stranger • Indiscriminate choice of victims Empirically Identified Risk Factors for Adolescents (Taken from the ERASOR)‏

32. Variable Protective Factor Potentiating Factor Sexual Abuse No hx History Sex. Behavior Self-Focused Other Focused Mutual Coercive Spontaneous Premeditative No contact Penetration Same age Age difference Single victim Multiple victims No status diff Status difference Not arousal focused Arousal and genital focus Family No other maltreatment Hx of maltreatment Secure attachment Insecure attachment No parent abuse hx Parental sex abuse hx No domestic violence Witnessed domestic violence Family Stability Family instability Child Internalizing Oppositional Defiant Disorder Positive peer relations No positive peer relations Risk and Protective Factors for ChildrenWilliam Friedrich, 2007

33. The goal of a sexuality evaluation for teens with ASD’s is to… • Ensure Safety • Identify areas of Need/Risk • Identify lack of socio-sexual knowledge and boundaries ….in order to help promote the development of health sexuality in the future. Sexuality Assessment

34. Treatment for Teens Research on treatment outcome for teens concludes that... • SBP improve over time... • That focused, rather than general, treatment helps... • Some treatments are more effective than others in both short and long-term • Parent involvement should be emphasized... • And that blended CBT treatments targeting both traumatic stress symptoms and SBP can be successful in helping both problems

35. Compared to those with typical development, treatment for teens with ASD’s should be more: • Developmentally focused • Concrete…. concrete…. concrete • Experiential (role plays and activities) • Interpersonal focus (social skills; increased involvement) • Behavior based vs Insight oriented • Increased focus on emotion regulation • Include repetition, rehearsal, & modeling • Caregiver involvement “Engaging Children/adolescents with ASD requires managing the case first as an ASD case.” Blasingame, 2011 Treatment for Teens with ASD’s

36. Initial Intake • Sexuality Evaluation to ID specific treatment needs, areas of risk, knowledge of healthy boundaries and self-control • Treatment and Supervision Recommendations • Group Therapy(parents and youth)‏ • Individual Therapy • Re-assess Risk/Need ‏ • Aftercare Treatment Process

37. Complete the Foot Prints or Roadmaps workbook. • Score in the Moderate to Low risk range on the ERASOR • Successful involvement in an ongoing, age appropriate social activity • No incidents of inappropriate sexual behavior for six months • Identify high risk areas or “danger zones” and Create and adhere to appropriate safety plans to address them • Client will demonstrate understanding of healthy sexual knowledge and socio-sexual boundaries • Individual Objective: Client is to demonstrate increased self-control by reducing arguing with parents and increasing compliance with parental requests • Individual Objective: Client is to participate in the PEERS program and demonstrate improved interpersonal skills and social functioning Treatment Plan – Integrating Tx of ASD and SBP’s

38. Assessment of protective and potentiating factors • Create a safety plan • Sexual behavior rules and Safety Strategies • Right touching and wrong touching • Sexual history • Emotion / Self-regulation • Sex education and healthy sexual behavior • Healthy relationships, friendships and romance • Engaging in new social activities • Right/Wrong Thinking • Triggers / Danger zones • Empathy, taking responsibility and restitution • Relapse prevention plans • Follow-up Parent Involvement Components of Treatment

39. Assessment of protective and potentiating factors • Create a safety plan • Sexual behavior rules and Safety Strategies Treatment

40. Danger Zones 1. 2. 3 Sexual Behavior Rules • It is not OK to touch other peoples private parts with out their consent. • It is not OK to look at other peoples private parts with out their consent. • It is not OK to show other people your private parts with out their consent. • It is not OK to use sexual language or behavior that makes others feel uncomfortable. • It is OK to touch your own private parts as long as you are in a private place and it does take too much time. • Safety Strategies • Avoid It • Leave It • Get Help! • Blasingame, 2005 Safety Plans

41. 4. Right touching and wrong touching (Footprints Book) 5. Sexual history (Footprints Book) • Education • Socialization • Victimization • Experiences 6. Emotion / Self-regulation (Parent involvement) • Emotion awareness (CBT Activities) • Coping strategies (Relaxation & emotion management skills) • Empathy (understanding emotions in family members) • Anger control (Develop, role-play, practice with parents) • Managing sexual feelings (Develop open dialogue about sexual feelings • Self-Control (Avoid it; Leave it; Get Help) • Ex. John interrupting, hw, arguing; Abe’s interrupting, ranting, over explaining, boundaries- over asserting self with disregard for others) Concrete. Creative Interventions… Role Plays, Modeling, Examples, Repetition, Practice, Practice, Practice Treatment

42. 7. Healthy relationships, friendships and romance 8. Sex education and healthy sexual behavior Sex education (Detailed) Masturbation Healthy intimacy/fantasies Puberty Sexual behavior rules Laws about sexual behavior www.siecus.org: Talk About Sex http://www.seriouslysexuality.com/ • Social skills (PEERS) • Boundaries / Personal space • Friendships (Skills) • Dating (knowledge) • Self-care (e.g. Assertiveness, Independent Living Skills and hygiene) • Teasing / Bullying http://www.semel.ucla.edu/peers Treatment

43. Hygiene Report Card

44. Engaging in new social activities • Parent support • Supervision • Age appropriate • Develop mastery • Right/Wrong Thinking (Footprints Book & CBT Triangle…thought-feeling connection, Thinking Errors- Black/white, Denial, Universality) • Triggers/Danger zones (Addressing specific risk factors….utilizing safety strategies: Avoid it; Leave it; Get Help!) Our goal is to help them get back on track to developing healthy social and sexual lives. Treatment

45. Cognitive Triangle

46. Empathy, taking responsibility and restitution (Footprints Workbook) • Letters to victims and parents • Goal is to unify family members and understand the impact of SBP on others • Relapse prevention plans (Footprints Workbook) • Follow-up • Assess decision making and mental / emotional / behavioral functioning • Review all treatment components • Assess social and sexual health • Assess and encourage parents Treatment

47. Video Modeling (Movies, cartoons, TV, YouTube etc.) http://www.youtube.com/watch?v=qjlSA-u8KUI Visual Strategies(Picture Calendars, Schedules, Rules Etc.) Social Stories(by Carol Grey) http://www.thegraycenter.org Role Plays Game Shows (Build group cohesion, Competition to demonstrate knowledge and to invite social acceptance of new skills) Peer Modeling Parent Accountability and Support for Treatment Interventions that Work! Treatment

48. Picture schedules

49. Aversion Therapies (shock, buzzers, etc) • Humiliation • Offense Cycles in treating first-time offenders • Arousal Conditioning • Psychopharmacologic Therapies  • Interrogatory treatments • Forced or pressured statements of responsibility Controversial Treatments with Youth

50. How to use appropriate conversational skills • How to find common interests by trading information • How to appropriately use humor • How to enter and exit conversations between peers • How to handle rejection, teasing, and bullying • How to handle rumors and gossip • How to be a good host during get-togethers • How to make phone calls to friends • How to choose appropriate friends • How to be a good sport • How to handle arguments and disagreements • How to change a bad reputation Curriculum Topics Program for the Education Enrichment of Relationship Skills (PEERS)