This blog, like last weeks by Jon Brandt (New
Research: Juvenile Sexual Recidivism < 3%), is linked to a recent publication by Michael
Caldwell on the declining rates of juvenile sexual recidivism. Kieran
When I first started working with juveniles who sexually
offend (JSO) in 2001, the focus was on sexual deviancy and compulsions. Our
knowledge about this population has increased since then, and this population
has likely changed as well, all of which has implications for practice and
policy. The following is a personal view of how things look in 2016.
Knowing the prevalence rates of outcomes is an important
starting point for assessment. Caldwell's (2016) article cited a weighted mean
sexual recidivism rate of 2.75% for JSO youth, and a nonsexual recidivism rate
of 30.00%. Measures of both sexual and nonsexual recidivism should be included
in JSO assessment. The latter is a more recent development, and warranted given
the high prevalence level noted by Caldwell and others. Nonsexual crimes also
cause harm to victims.
Caldwell's study also suggests that the results from sexual
risk measures, given a base-rate of 2.75%, may need to be qualified. For
example, if a risk measure puts youth in the highest risk level, with say a
risk of twice the base-rate of 3%, 94% of these "high risk" would be
predicted to not sexually reoffend.[i]
One study (Borowsky, Hogan, Ireland, 1997) examined rates of sexual offending behaviours
reported in non-forensic, community samples, and found this rate for juveniles
to be 4.8%, higher than the base-rate reported for reoffending of 2.75% by
Caldwell. These considerations suggest decisions regarding out of home or secure
placement, let alone civil commitment, may not be justified based primarily on
findings from risk measures of sexual recidivism.
Developmental outcomes are also important to assess. These
include psychiatric factors (depression, anxiety, etc.), neuropsychological
conditions (ADHD, autistic spectrum, learning and intellectual disabilities,
etc.), substance abuse, violence and trauma related conditions. The high
prevalence of these conditions in this population, and also the availability of
evidence-based treatment approaches to address them, argues for the inclusion
of such factors in assessments. Also neighborhood, socio-economic, ethnic,
cultural, and family factors are also important.[ii]
Prevalence rates of psychiatric conditions in outpatient setting are likely
lower than in residential or secure settings.
In 2001, the priority as I recall it for JSO youth was
treating what was assumed to be an underlying sexual pathology. For most of
these youth, however, I found there wasn't evidence of a pattern of enduring
sexual deviancy. While there are such youth, they are rare in my experience.
Impulsivity, poor judgment, supervision problems, and sometimes a history of
sexual victimization, seemed to be the best explanations, rather than a primary
disordered sexual behavior pattern.
This led me to believe that treatment approaches which
promoted better social judgment and skills, along with family education, and a
psychosexual education component, was optimal for most JSO youth. The theory
and techniques of Moral Reconation Therapy and Aggression Replacement Training
provided the framework for approaches to promote more mature social judgment
and skills. One recent study (Ralph, 2016), documented deficits in prosocial
reasoning for JSO youth, and three previous studies (Ralph, 2015a; Ralph, 2015b)
documented the effectiveness of these approaches with JSO youth, including
reducing sexual misbehavior.
In 2001, evidence-based practice with JSO youth wasn't in
widespread use in my experience. Now it is a major consideration in treatment,
and in California, some probation departments require evidence-based practices
to obtain funding. In my view, evidence-based practice should include an
evaluation of outcomes for treatment programs. You should be able to track your
therapeutic outcomes so you can see not only if a given client improves, but
also whether the program as a whole shows positive outcomes. Every surgery
center in the USA has to do outcome studies (mortality and morbidity), and so
should JSO treatment settings. In my experience highly committed, but rarely is
any program evaluation done in JSO programs to document these admirable
efforts. Worling, Littljohn, and Bookalam's (2010) study on a 20-year follow-up
from the SAFE-T program in Toronto is probably the best known example of such
research. A more modest effort was my own recent follow-up study of 129 youth
in a residential JSO program (Ralph, 2015b).
The ultimate outcome to be tracked for JSO interventions had
been sexual recidivism. This may not be the best measure to use in an era of
recidivism less than 3%. Is a good program now one that reduces recidivism from
2% to 1%? Other outcomes might be tracked including non-sexual recidivism,
reduction in psychiatric symptom ratings, and increases in prosocial reasoning
and skills. Righthand's (2005) treatment progress scale is a useful tool with
some normative information available. Examples of such measures are also found
in my recent article (Ralph, 2016).
Norbert Ralph, PhD, MPH
Licensed Clinical Psychologist
References
Borowsky IW, Hogan M, Ireland M. (1997). Adolescent sexual
aggression: risk and protective factors. Pediatrics. 1997 Dec;100(6):E7.
Caldwell, M. F. (2016). Quantifying the Decline in Juvenile
Sexual Recidivism Rates.
Psychology, Public Policy, and Law. Advance online
publication. http://dx.doi.org/10.1037/
law0000094.
Epperson, D., Ralston, C., Fowers, D., DeWitt, J., &
Gore, K. (2006). Actuarial risk assessment with juveniles who sexually offend:
Development of the Juvenile Sexual Offense Recidivism Risk Assessment Tool-II
(JSORRAT-II). In D. Prescott (Ed.), Risk Assessment of Youth who have Sexually
Abused: Theory, Controversy, and Emerging Strategies. (pp. 118 169). Oklahoma
City, OK: Wood & Barnes.
Ralph, N. (2015a). A Follow Up Study of a Prosocial
Intervention for Juveniles who Sexually Offend." Sex Offender Treatment.
Retrieved from http://www.sexual-offender-treatment.org/140.html
Ralph, N. (2015b). A longitudinal study of factors
predicting outcomes in a residential program for treating juveniles who
sexually offend. Sex Offender Treatment. Retrieved from
http://www.sexual-offender-treatment.org/145.html
Ralph, N. (2016). An instrument for assessing prosocial
reasoning in probation youth. Sex Offender Treatment. Retrieved from
http://www.sexual-offender-treatment.org/150.html
Righthand, S. (2005). Juvenile Sex Offense Specific
Treatment Needs & Progress Scale. Retrieved from
http://www.csom.org/pubs/JSOProgressScale.pdf
Worling, J. R., Litteljohn, A., & Bookalam, D. (2010).
20-Year Prospective Follow-Up Study of Specialized Treatment for Adolescents
Who Offended. Behavioral Sciences and the Law, 28, 46–57.
[i] When
three categories of risk are used for the Iowa validation sample for the
Juvenile Sex Offender Assessment Protocol-II (JSORRAT-II), the highest risk
category (7 or higher) has about twice the risk of the middle level category
which is at about the base-rate.
[ii] Ralph (2015) documents in a JSO residential setting
55.8% had an Individual Education Plan, 43.2% had prior mental health
treatment, and 83.1% had used psychiatric medications at any time. Using DSM-IV
TR criteria, the rates for various diagnoses are as follows: attention deficit
disorder 39.7%, posttraumatic stress disorder 34.9%, depressive disorders
30.2%, conduct disorder 27.8%, anxiety disorders 11.9%, bipolar and mood
disorders 8.5%, adjustment disorders 4.8%, and oppositional defiant disorder
1.6%. One youth, 0.8%, had a DSM-IV TR diagnosis of pedophilia, and no other
sexual disorders were diagnosed for this sample.
Great article, thank you for addressing this.
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