Adolescents who sexually offend present difficult and complicated demands for clinicians. The gravity of sex offending cannot be ignored, however, because adolescent offending does not necessarily presage adult offending, intervention must not preclude normal developmental opportunities. However, most adult persistent offenders begin offending during adolescence. Thus, clinicians have to provide effective treatment for the potentially serious adult offender while preventing negative second order effects that might create iatrogenic developmental consequences. The essential conclusions about the etiology of juvenile sex offending are that the processes are multi-factorial, complex and developmentally organized. Based on this analysis, assessment of the individual adolescent is critical to establishing an articulated treatment plan and five domains are identified as critical areas for the clinical picture. These are: (1) offender’s victimization and abuse history; (2) social skills deficits, social isolation, and attachment difficulties; (3) deviant sex arousal and/or sexual preoccupation; (4) aggression and general delinquency; and (5) an exaggeration of “normal” adolescent sexual curiosity or exploration in a context of opportunism and weak supervision. Given the complexity of developmental pathways, no single model for intervention provides a sufficiently comprehensive approach for the treatment for juvenile sex offenders. Instead, treatment should be organized by a risk-need-responsivity paradigm that provides a useful algorithm for clinical treatment formulation. Additionally, the intervention must eventuate in the development of a non-stigmatized identity for the developing adolescent. Based on the notion that a risk-need-responsivity analysis should inform treatment, clinicians need to have a strong grasp of developmentally sensitive assessment, competency in navigating the social and legal contexts in which adolescent offenders are found, and be able to serve as a social and legal advocate based on a solid understanding of the empirical findings about adolescents who have sexually offended.
56.1 14.1 Overview
Barbaree and Marshall (2006) define a juvenile sex offender as “[a] person who has been convicted of a sexual offense and who is considered by law to be old enough to be held criminally responsible for the crime, but not so old as to be subject to the full range of adult criminal sanctions” (p. 3). While concise, this definition brings into focus a number of critical practical and conceptual issues having clear implications for professionals who work in this area. The first implication being that the cardinal criterion for identifying the client is not a specific behavior; it is an interaction between the client’s behavior and the actions of the juvenile and criminal justice system. Given the difficulties of defining what is, or is not, a deviant sexual behavior for adolescence (Barbaree & Marshall, 2006; Bancroft, 2006) combined with the vagaries of the justice system, which vary by national and state jurisdiction and even to the level of the local court, what is defined as juvenile sex offense is so unreliable and elastic that it defies description. Moreover, this is not a context where clients can be counted on to provide veridical information.
Juveniles with markedly dissimilar behaviors often will have the same legal charge and those with the same behavioral event will have different legal charges. Moreover, the consequence of this variability is that clinicians may be working under profoundly different psychological and legal contexts depending on the charge applied to the client. For example, in the state of Alabama, if the charge is Sex Abuse 1st degree, then the client, even if only 12-years old, may be incarcerated for treatment, forced to go back to court after treatment, and be registered as a sex offender and placed on the notification register which would be available to anyone who had access to the Internet. If the charge is Sexual Misconduct (a misdemeanor charge), even if it is for the same behavior, then none of these sanctions may apply.
In different jurisdictions, even the same age child may be exposed to a profoundly different legal, correctional, and treatment process depending on the definitions in the law and the availability of treatment options. In some states, adolescent offenders may be treated on an outpatient basis, whereas in other states, with the same level of risk and offense, they will be incarcerated for treatment.
Moreover, the juvenile justice system has undergone large swings in philosophical stance with relation to how juvenile sexual crimes should be defined. The traditional philosophy of seeing adolescents, as a group, distinctly different from adults and, thus, requiring a very different judicial and correctional policy is now being threatened by the conservative movement to define all sex offenders as more alike than different, including obscuring or even obviating the distinction between juveniles and adults. Particularly with the passage, at the federal level, of the Adam Walsh Act, treatment providers are seeing the historic protection of juveniles from many of the adverse effects of the criminal justice system being eroded (Caldwell, Ziemke, & Vitacco, 2008). The developmental implications of being registered and subjected to adult notification in the life of an adolescent can hardly be imagined, though there is already some empirical evaluation of these pernicious outcomes (Letourneau & Armstrong, 2008).
Recently, Calley (2009) has demonstrated that one of the unintended consequences of the Adam Walsh act is that local judges are attempting to circumvent the notification consequences of the law by altering usual dispositional decision making to avoid charges that compel compliance with the registration requirements of the Adam Walsh act. In so doing, juveniles often are precluded from access to otherwise mandated treatment programs. Thus, the unintended consequence of the attempt to protect juveniles from an onerous and developmentally inappropriate community notification processes, is that juveniles who could benefit from treatment, are denied critical treatment opportunities. This outcome, in the context of the empirical demonstrations that treated juvenile sex offenders are at significantly lower risk for reoffending (Reitzel & Carbonell, 2006; Walker, McGovern, Poey, & Otis, 2004), is worrisome and illustrative of the negative, though unintended, second-order effects of poorly constructed policies and laws.
These legal and definitional issues are too extensive to be covered in this chapter, but, in the long run, may have more to do with defining and shaping the field than our evidenced-based judgments. The cardinal implication of this analysis of these social and legal processes is that clinicians may be required to be involved in political and social debates, if the opportunity for the best practices approach is even to be possible. In the remainder of this chapter, the focus will be on defining and describing what, currently, is seen as best practices for assessment and treatment of juveniles with sex offending behaviors; however, the recognition that the possibility and opportunity to provide these practices is inextricably bound up with what happens in national and state legislatures should be part of the awareness of all providers who work with these children.
56.2 14.2 Recognition of Symptoms and their Assessment
The “symptoms” of adolescent sex offending are the behaviors which bring them to the attention of the court. What is required for professionals is a solid understanding of the epidemiology of these behaviors. Perhaps the most important core facts to appreciate about the epidemiology of juvenile sex offending are that: (1) juveniles commit a substantial proportion of sex crimes, particularly with children as victims (Pastore & Maguire, 2007); (2) by far the majority of adolescents who commit sex offenses do not continue to offend as adults (Worling & Curwin, 2000). In addition, a corollary of this fact is that treated adolescents have a significantly lower likelihood of committing another offense than untreated adolescent offenders (Hanson et al., 2002; Reitzel & Carbonell, 2006); and (3) a majority of adult sex offenders acknowledge that their first offenses began during adolescence (Gray & Pithers, 1993), and, for some of these offenders, the lifetime prevalence of victims they create is astounding (Abel et al., 1987).
These facts, taken together, have several important assessment and treatment implications. However, when considered separately, these facts can lead to very different and contradictory conclusions. Thus, conclusions must be drawn, carefully, and in relationship to each of the other facts. As these facts are reviewed, some of these contradictions and the important conclusions will be outlined.
The first fact, that adolescents are directly responsible for a large number of the sexual crimes committed, has clear implications for the necessity of preventing or treating juveniles who offend. According to Pithers and Gray (1998), 40% of the perpetrators of sexual crimes against children are children or adolescents. This fact represents a substantial sum of suffering and harm to innocent children and the implications to be drawn are that: (1) much more work needs to be done in the area of primary prevention and (2) early intervention is important, adolescents who offend should be promptly identified and provided appropriate treatment. The old judicial and clinical style of denying or downplaying sexual crimes against children when committed by other children/adolescents is not a good idea.
The second fact that most adolescent offenders discontinue sexual offending and do not persist as adult offenders, likewise is important to appreciate, particularly as it leavens the first fact. The modal number of reported victims of male adolescents adjudicated as juvenile sex offenders and placed in a large state residential treatment program is one and the mean is two (Burkhart, Cook, & Sumrall, 2008). Moreover, even though these boys were placed in a secure setting based on this conviction, over 50% had no previous commitment in the juvenile system. Additionally, though strong decreases in many of the identified areas of need were found as a function of exposure to treatment, particularly with internalizing symptoms, an increase in dimensions related to delinquency predisposition was noted (Burkhart et al., 2008). These findings parallel those of Bonta, Wallace-Capretta, and Rooney (2000), in which they found that low-risk, untreated offenders recidivated at lower rates than low-risk offenders exposed to a high-intensity treatment. This is a finding well recognized by other researchers (Dishion, McCord, & Poulin, 1999). Adolescents are learning machines who learn from adults and their peers, and, in fact, peers may well be more efficient teachers.
What this means is that treatment, though important, must not otherwise disrupt the normal developmental trajectory of juveniles who have offended sexually against children. Specifically, we must be alert to the possibility of iatrogenic effects which increase the social and psychological burdens for boys who are being treated for their offenses, most of whom are likely to spontaneously desist. Directly stated, the unintended side effects of treatment must be measured and considered as part of the decision making in evaluating the impact of treatment. Langton and Barbaree (2006) drawing on the work of Andrews and Bonta (2003) have outlined a useful conceptual algorithm in which initial risk levels, area of treatment needs, and responsive treatment form the crucible within which treatment for any specific offender can be organized. Langton and Barbaree further suggest that the recognition of treatment by need interactions should drive the research enterprise and that interaction designs, even on a post hoc basis, must be the prototype for effective and useful research. Thus, though treatment might be necessary to ensure that juveniles who sexually offend discontinue their sexual misconduct, the intervention must be sensitive and nondisruptive to a normal developmental trajectory. The least burdensome and restrictive treatment necessary to effectively treat the early adolescent offender is the model course.
There is an additional consideration which has been highlighted by the findings from longitudinal recidivism studies. Although the rate of sexual offending recidivism is relatively low, particularly in treated groups of offenders, the rate of general delinquent offending is high. For example, Reitzel and Carbonell (2006), across both treated and untreated samples, found that recidivism rates for nonsexual violent offending were 24.73%, for nonsexual nonviolent cri-mes, it was 28.51%, and for unspecified nonsexual crimes, it was 20.40%. These finding were based on an average follow-up length of 59 months. It should be noted that the rate of recidivism for sexual crimes was 12.53%. These data are typical of other follow-up studies which show a high rate of general delinquency in groups of adolescents who were originally identified as sex offenders. Smallbone (2006) reported that, in fact, juvenile sex offenders were two to four times more likely to recidivate for nonsexual crimes than for sexual crimes. Moreover, up to 10% of juveniles who were originally convicted of nonsexual crimes end up being reconvicted for sexual offenses (Rubenstein, Yeager, Goodstein, & Lewis, 1993).
Thus, if we adhere to the model explicated by Langton and Barbaree (2006), treatment of adolescent sex offenders must accommodate to the fact that there are far more likely to recidivate for nonsexual delinquency. Thus, the risk of such delinquent offending should be identified prior to treatment so that treatment components can be articulated to this identified risk. In our treatment facility, adolescents with sex offending problems have been separated from the general delinquent population based on the recognition that the general delinquents were quite a bit more antisocial and delinquent, qualities which negatively impacted the sex offending adolescents with modest delinquent histories (Burkhart, Peaton, & Sumrall, 2009; Burkhart et al., 2008).
However, fact number three moderates the above discussion. By the sheer number of victims created those few adolescent offenders who continue as adult offenders can have the impact of a typhoid-infected well on the public health. Abel, Mittleman, and Becker (1985) reported that the majority of adult sex offenders indicated that the onset of their sexual offending occurred prior to age 18. In addition, the lifetime prevalence rates reported by adult offenders who were guaranteed confidentiality are astounding and alarming. Moreover, even more alarming is the finding of a 25:1 ratio of self-reported sexual offenses to actual arrests among adult sex offenders (Elliott, Huizinga, & Morse, 1985). This fact has to be a part of policy and practices in the management and treatment of adolescents who sexually offend against children.
Given these data, the consequences of failing to effectively treat adolescent sex offenders, specifically those at high risk for adult persistent offending, are potentially disastrous.
The compelling implication of these facts, considered conjointly, is that we must be able to make empirically valid distinctions which “carve nature at her joint.” We must be able to identify adolescents who are at risk of sexual offending and, for those who have begun to offend, we must then be able to inhibit their beginning trajectory, but not so bluntly that we cause other harm. Also, we must be able to capture in our risk analyses those who are likely to persist as adult offenders so that we can prevent the further development of an adult persistent offense cycle. The recognition that many adult offenders began as adolescents makes it necessary that those adolescents who are at risk for life course persistent offending be identified and that their pernicious developmental trajectory must be aborted.
The problem is that our current state of knowledge does not provide a scientific base to be successful at making these critical distinctions. Though there are no validated risk assessment procedures currently available (Rich, 2009), there is some recent evidence that experienced clinicians can identify, with a moderate level of accuracy, those high-risk adolescents who reoffend (Hagan, Anderson, Caldwell, & Kemper, 2008).
One additional critical general observation must be emphasized: adolescents who have sex offending problems are not alike (Rich, 2009). Thus, recognition of the heterogeneity of this population is one of the key starting points and guiding precepts of treatment. The exception to this observation is gender; boys are, by a factor of 20 to 1 or more, the more likely offenders in sexual misconduct. The practical implication of this fact is that the usual client will be a teenaged boy. Moreover, though there are some data relevant for evaluation and treatment of girls (Hunter, Becker, & Lexier, 2006), the bulk of the research is addressed to the functioning and status of boys.
A global, comprehensive, post-adjudication assessment, therefore, should be the essential starting point for treatment professionals working with adolescents with sexual behavior problems (American Academy of Child and Adolescent Psychiatry, 2000). Rich (2003), also, provides an excellent outline of assessment domains and a guideline to organizing the relevant clinical data. To inform case conceptualizations, formulate treatment plans, and assess treatment progress (or lack thereof), the numerous strengths that standardized assessment measures provide including their comparative and predictive abilities must be used to the clinicians’ advantage. Furthermore, an accurate assessment establishes an individualized baseline point in which change can be tracked throughout and following treatment. Finally, a solid foundation utilizing empirical assessment measures allows treatment professionals the ability to empirically test factors for which there may be a differential response in treatment (Langton & Barbaree, 2006). This ability to “test” hypotheses at both the individual and group level provides data that can be fed back into the treatment process to better improve treatment interventions. (Burkhart et al., 2008; Rich, 2009).
Working with juvenile sexual offenders in a forensic context presents additional unique concerns worth considering (Rich, 2003). Forensic assessments are unique in that those being assessed have an increased motivation to engage in deceptive behaviors (e.g., denial, minimization, malingering) in order to achieve some desired outcome. Juvenile sexual offenders are commonly mandated to complete treatment, are frequently resistant to be an active par-ticipant throughout treatment, and thus, typically cannot be considered to be collaborative agents throughout the assessment and treatment process. In fact, their motivations to ob-scure the “truth” regarding their offense behaviors may be considered to be both a natural and self-protective response, given the negative outcomes associated with full and complete disclosure. Despite being relatively unsophisticated, many of these individuals report a great degree of shame and embarrassment related to their behaviors. The likelihood for adjudicated juvenile offenders to engage in some type of deceptive behavior is quite common, yet little empirical evidence exists examining the prevalence of such behaviors prior to the onset of treatment. For example, over 90% of juvenile sexual offenders who were interviewed following the completion of treatment reported being deceptive when initially describing their adjudicating offense (Burkhart et al., 2008). Offenders were most likely to underreport the total number of sexual offenses that occurred, the duration in which the offending behaviors occurred, and the total number of victims.
56.3 14.3 Maintenance Factors of Adolescent Sex Offending
Data from assessments of juvenile sex offenders have served as the empirical foundation for addressing etiological and maintenance issues regarding this population of offenders (Becker, 1998; Calder, 2001). The broad conclusions are: (1) that etiology is complex, multidetermined, and developmentally based and (2) no single model or factor has been definitively linked to the onset or maintenance of this behavior. Rich (2003), in an effort to provide a comprehensive account of this complexity, has listed 46 motivating and maintaining factors for juvenile sex offending. These 46 factors, he suggests, can be clustered into ten categories representing core domains in the etiology and maintenance of the behavior. These hypothetical categories represent a good conceptual summary of those domains to be studied; however, little specific research has been devoted to examining, in a theoretically driven process, the contributions of each these domains to the development or maintenance of adolescent sex offending.
At this point in the literature development, there are five areas which are consistently identified as high-probability predicates to juvenile sex offending. These are: (1) offender’s victimization and abuse history; (2) social skills deficits, social isolation, and attachment difficulties; (3) deviant sex arousal and/or sexual preoccupation; (4) aggression and general delinquency; and (5) an exaggeration of “normal” adolescent sexual curiosity or exploration in a context of opportunism and weak supervision.
56.3.1 14.3.1 Offender’s Victimization and Abuse History
A significant history of prior victimization is often found among individuals who go on to abuse others (Jonson-Reid, 1998). Thus, the notion of a “cycle of violence” or “victim to victimizer” has been applied to juvenile sex offenders as research clearly indicates that many juvenile sex offenders have been victims of abuse; however, the causal role in the etiology of subsequent offending behaviors has not been delineated.
Victimization as a child is related to subsequent delinquent acts during adolescence and adulthood. For example, Widom (1995) using a matched-sample design examined arrest rates during adolescence and adulthood for 908 children who were abused or neglected prior to age 11. Using official records documenting substantiated cases of physical and sexual abuse and neglect during childhood, 26% of those who experienced maltreatment were later arrested as juveniles compared to 16.8% of those not abused, with 28.6% of abused and neglected children arrested as adults compared to 21.0% for those in the control group (Widom, 1995). Furthermore, sexually abused children, compared to nonabused control subjects, were 4.7 times more likely to be arrested as adults for a sex crime. In addition, physically abused boys were more likely than sexually abused and neglected children, as well as nonabused children, to be arrested as adults for rape or sodomy. As Widom highlights, an adult rapist may be motivated by violence rather than sexual gratification alone.
Sexual victimization during childhood, also, has been associated with subsequent acts of sexual perpetration. For example, Ryan, Miyoshi, Metzner, Krugman, and Fryer (1996) re-ported on a sample of juvenile sex offenders consisting of 1616 youth whose data were provided by treatment professionals from 90 members of the National Adolescent Perpetrator Network (NAPN) located across 30 states. Of these youth, ranging in age from 5 to 21 years of age (mean age 14-years old), 41.8% were victims of physical abuse, 39.1% were sexually abused, and 25.9% of the sample experienced neglect as reported at intake.
Worling (1995) compiled data on 1268 male juvenile sex offenders from eight studies that reported pretreatment and posttreatment accounts of sexual abuse. Across studies, histories of sexual abuse varied considerably as 19–55% of juveniles reported a history of sexual abuse. Of note, the rate of sexual abuse reported following treatment (52%) was significantly greater to the rate reported prior to the onset of treatment (21%). Worling (1995), citing clinical observations (e.g., Becker, 1988; Kahn & Lafond, 1988), postulated that the increase may be the result of a trusting therapeutic relationship allowing a greater level of disclosure or that the increase report of sexual abuse may be a treatment-learned justification/minimization behavior. Further-more, Worling reported that juvenile sex offenders with child victims reported being twice as likely to be sexually abused compared to juvenile sex offenders with peer-aged or adult victims (29.90% versus 14.94%, respectively). In addition, Worling grouped 87 juvenile sex offenders according to victim age and gender and examined the rate of sexual abuse according to groups. In total, 43% of the sample reported a history of sexual abuse; however, rates var-ied considerably according to the group with male, child victims reporting the greatest rate of abuse (75%), followed by those with male and female, child victims (74%), those with female child victims (24%), and finally, those who offended against peer-aged or adult, female victims (26%).
Burton, Miller, and Shill (2002) reported that 79.4% of 272 institutionalized juvenile sex offenders (mean age = 16.9-years old; SD = 1.47) were sexually victimized based upon self-reported responses on the Sexual Abuse Exposure Questionnaire. Of note, subjects were described to be mid-treatment when abuse information was collected. Of those who reported being sexually abused, the average age of onset was 8.8 years (SD = 3.97) with the average duration of sexual victimization lasting 5.6 years. Here, researchers speculated that high rate of sexual victimization (79.4%) compared to other empirical investigations with abuse prevalence rates of approximately 40% (e.g., Cooper, Murphy, & Haynes, 1996; Hunter & Figueredo, 2000) may be a function of the anonymous data collection process or that the data were collected after a treatment relationship had been formed; thus subjects may have been more willing to report abuse.
A history of abuse has been consistently linked to juvenile sex offenders; however, it is important to reiterate that most sexually abused juveniles do not go onto sexually abuse others and that the majority of male, juvenile sex offenders do not have a history of abuse. Nonetheless, victimization and the burden of other forms of abuse and neglect are clearly part of the treatment needs of juvenile sex offenders.
56.3.2 14.3.2 Social Skills Deficits
A significant portion of male, adolescent juvenile sex offenders has been described as lacking appropriate social skills (Davis & Leitenberg, 1987; Becker & Kaplan, 1988). These social deficits are believed to potentiate poor peer relationships, contribute to a burden of social apprehension, and, in some instances, lead to isolation. In fact, commonly used instruments designed to measure risk of reoffending with juvenile sex offenders address social support when determining level of risk. Furthermore, the observed deficits with adult sex offenders have been extended downward to juvenile sex offenders. For example, adult sex offender literature has identified, among a portion of these offenders, difficulty relating with peers and an inability to form and engage in consenting heterosexual relationships (Marshall, 1996). Therefore, adolescent sex offender researchers and treatment providers have attempted to empirically ascertain the relationship between social skill deficits and sex offending behavior during adolescence.
For example, Fehrenbach, Smith, Monastersky, and Deisher (1986) examined 256 male juvenile sex offenders and observed that a significant portion of these offenders (65%) were described as being seriously socially isolated. When male, adolescent child molesters (n = 31) were compared to delinquent, nonsex offending peers (n = 34) and nondelinquent adolescents (n = 71), child molesters endorsed feeling alone and socially isolated to a greater degree than nondelinquent subjects. Furthermore, results indicated that child molesters reported less assertion, greater anxiety and distress when in a social situations, lower self-esteem, and greater social maladjustment compared to nondelinquent subjects and less confidence regarding adequacy in hetero-social situations when compared to delinquents. Awad and Saunders (1991) reported that 33% of those male juveniles who committed hands-on, sexually assaultive off-enses and 62% of child molesters were described as socially isolated, compared to 22% of delinquent control subjects, Furthermore, Miner and Crimmins (1995) reported that juvenile sex offenders had fewer peer attachments to that of delinquent, nonsex offender peers and nondelinquent subjects.
In regards to sexual recidivism by male, juvenile offenders, Kenny, Keogh, and Seidler (2001) reported data on 40 first-time offenders (mean age = 15.86 years; SD = 1.64) and 30 recidivists (mean age = 15.40 years; SD = 1.40). Here, researchers measured a greater frequency of “poor social skills” among recidivists (50%) when compared to newly adjudicated offenders (15%). Therefore, poor social skills is not only a construct of interest related to the etiology of juvenile sexual offending, it, also, may be related to subsequent acts of sexual offending by recidivists; thus, potentially having a significant role in maintenance of nonoffending status.
The aggregate of these results indicate that a significant portion of male, juvenile sex offenders experience deficits in social functioning. Additionally, the greater social deficits measured among juvenile sex offenders with child victims may be a function of their failed attempts to “connect” with peer-aged individuals. However, these results are not universal as several studies reported no differences in social competency skills relative to other delinquent and nondelinquent adolescents (e.g., Rowe-Lonczynski, 1992; Ford & Linney, 1995). These discrepancies suggest that poor social skills may be related to general adolescent delinquency and antisocial behaviors rather than specific to male, juvenile sex offenders alone. Therefore, causal relationships between social deficits among offenders and subsequent sex offending behaviors may exist; however, research has not established strong, direct causal links. Whether there is such a direct link, the bulk of the evidence suggests that, particularly for child target adolescent offenders, some quality of social or attachment deficit is likely and remediation of these deficits should be a part of any comprehensive treatment evaluation. Thus, most treatment programs include treatment modules or components aimed at addressing and remedying measured socialization deficits.
56.3.3 14.3.3 Deviant Sex Arousal and/or Sexual Preoccupation
Cognitive-behavioral theorists, utilizing associative learning principles, hypothesize that deviant sexual arousal can be developed with the pairing of previously innocuous stimuli and stimuli that produce a sexual response (Alford, Morin, Atkins, & Schoen, 1987). Frequent parings of deviant sexual fantasies along with sexual arousal, including masturbation and orgasm, are hypothesized to contribute to the maintenance and strengthening of deviant sexual interests (Hunter & Becker, 1994). The pathway of deviant sexual arousal leading to action is poorly articulated within juvenile sex offender literature; however, deviant arousal patterns are considered to be one of the mechanisms by which problematic sexual behavior can be established and maintained which is a clinical focus when working with this population (Hunter & Becker, 1994), especially given the downward extrapolation from adult offenders. For example, a significant portion of 561 adult sex offenders reported their deviant sexual interest was established during adolescence (Abel & Rouleau, 1990) and deviant sexual fantasies were found among 29% of an outpatient sample of child molesters prior to age 20 (Marshall, Barbaree, & Eccles, 1991). However, a significant portion of males among a general population sample (31.1%) reported deviant sexual fantasies of forced sexual contact (Leitenberg & Henning, 1995) making the specificity of these fantasies difficult to establish with sex offenders. Further complicating the role regarding deviant sex fantasies are findings by Daleiden, Kaufman, Hilliker, and O’Neil (1998) who measured similar levels of deviant fantasy among juvenile sex offenders when compared to controls. Furthermore, Worling (2004) examined studies that relied on physiological measures of deviance (e.g., penile plethysmograph) and reported that only a fraction (25–36%) of juvenile sex offenders responded to sexual stimuli. Therefore, the emphasis on deviant sexual arousal as a “concrete” etiological factor of juvenile sex offending behavior has abated to some degree since first applied to juvenile sex offenders during the 1980s.
In an attempt to better understand the relationship between deviant sexual arousal and behaviors, researchers have relied upon self-report data regarding deviant sexual thoughts and fantasies given the ethical concerns of using physiological measures of deviancy with juveniles (e.g., Veneziano & Veneziano, 2002; Fanniff & Becker, 2006). Thus, the ability for treatment professionals to accurately identify deviant arousal patterns reliably among juvenile sex offenders is a current challenge given the questionable veracity of self-report data. Yet, identifying deviant arousal remains an important goal given the paraphilic interests of some juvenile offenders (Fanniff & Becker, 2006). For example, DiGiorgio-Miller (2007) compared 66 inpatient and outpatient male, juvenile sex offenders (mean age 15.2 years; SD = 1.45) on the Sexual Fantasy Questionnaire with inpatient residents reporting a greater number of deviant fantasies compared to outpatient offenders. Furthermore, positive correlations between deviant sexual fantasies and the number of victims, offenses, and measure of hostility were reported suggesting that more deviant fantasies were related to greater victimizing behaviors and offenses.
Using another distinction, Kenny et al. (2001) compared 40 male, first-time juvenile sex offenders with 30 recidivists. Group comparisons revealed that those offenders charged with more than one sex offense reported deviant sexual fantasies as a major offense feature (60.7%) versus those charged with a single sex offense (29.4%). Furthermore, of the recidivists, 60% were rated by their therapist as having deviant sexual fantasies, whereas only 32.5% of the first-time juvenile sex offenders were seen as having such fantasies. Lastly, significant, positive correlations were measured between rearrest for a sexual offense and deviant sexual fantasies.
Daleiden et al. (1998) reported that youthful sexual offenders endorsed more typical/nonconsenting sexual experiences than nonsexual offenders and college males. Furthermore, sexual offenders reported fewer typical/consenting sexual experiences when compared to de-linquent, nonsex offending peers. Next, juvenile sex offenders reported more frequent paraphilic interests compared to delinquent, nonsex offenders and college males. It may well be that paraphilic interests are one of the mediators of adult persistent offending and, therefore, may require new research attention as the transition from adolescent offender to adult offender becomes more closely tracked in research.
56.3.4 14.3.4 Delinquency and Aggressive Behavior
A significant portion of juvenile sex offenders have a history of prior delinquent, nonsex offending criminal behavior. Estimates of criminal behaviors preceding a sex offense have been reported to range from 40% to 63% for these offenders (e.g., Fehrenbach et al., 1986; Kahn & Chambers, 1991; Ryan et al., 1996; Smith & Monastersky, 1986). Furthermore, the severity of these prior delinquent criminal behaviors varies considerably from minor offenses (e.g., misdemeanors) to violent acts against others (e.g., felony assault). In addition, a significant portion of juvenile sex offenders have had numerous prior arrests. Of the 1661 juvenile sex offenders examined by Ryan et al. (1996), 27.8% were measured to have committed four or more nonsex offenses. Thus, in addition to committing a sexual offense, a sizable portion of these offenders have a significant history of antisocial behavior.
Not only do many of these offenders have a history of previous delinquency, of those who recidivate following adjudication or treatment for a sexual offense, the majority will also commit crimes of a nonsexual nature. Measured recidivism rates for nonsex offenses range considerably as sample estimates of 35–54% have been reported (e.g., Rasmussen, 1999; Miner, 2000; Schram, Milloy, & Rowe, 1991; Vandiver, 2006). Of note, the rate for nonsex offending rearrest greatly eclipses the likelihood of rearrest for an additional sex offense as sex offense recidivism rates range between 8% and 14% (e.g., Kahn & Chambers, 1991; Miner, 2002; Rasmussen, 1999). The rate of rearrest and severity of crimes committed also ranged considerably. For example, Vandiver (2006) reported that the majority of 300 juvenile sex offenders followed into adulthood (52.7%) were rearrested ranging between 1 and 11 arrests. Furthermore, of this sample, the majority of rearrests were for property offenses (36.7%) followed by drug offenses (32.3%), but ranged in severity including one arrest for capital murder.
As a significant portion of juvenile sex offenders commonly have a history of general delinquency as well, they are at an increased risk at posttreatment for nonsex offending delinquency, these findings increase the complexity of treatment concerns to include general delinquency issues, as well as sex offending specific components. The necessity of individual risk-needs analysis is highlighted by these findings.
56.3.5 14.3.5 Situational or Opportunistic Offending
One of the findings evident to many researchers is that the relatively high frequency of adolescents who were caught, having initiated sexual contact with a younger child, presents with little evidence of significant co-morbid psychopathology and no previous delinquent history. In our large sample representing most of the adjudicated adolescents in the state of Alabama (Burkhart et al., 2008), one of the largest groups were boys with one offense, no previous charges, and relatively benign psychometric test results. This group represents a subtype of the population of adolescent sex offenders who appear to be primarily situational or opportunistic offenders. When deconstructing their offenses, the modal pattern is that, having had some type of exposure to adult forms of sexuality, often video pornography, they are left with little supervision and access to a younger, vulnerable child. They attempt some kind of sexual contact, are discovered, and, as the Alabama state code requires treatment for adjudicated juvenile sex offenders, they are referred to treatment.
It is important to consider these offenders in light of the slowly accumulating knowledge about normative sexual experiences among children and adolescents (Bancroft, 2006). Even given the significant gaps and limitations in reliable information about sexual behaviors in childhood and adolescence, it is clear that children and adolescents have considerable sexual exposure and experience. Consider the findings of Reynolds, Herbenick, and Bancroft (2003), in which a sample of university students provided retrospective accounts of childhood sexual experiences with peers; 87% of the males and 84% of the females reported such an experience during childhood. These were most common during elementary school years and the subjects reported that the usual motivation was curiosity. Moreover, it should be noted that these experiences more frequently involved genital touching as the age of the child increased. With such a high base rate of childhood sexual experiences, it is not surprising that a subset of these boys and girls trespass legal boundaries and end up being caught up in the legal system.
The implications of these data have been not extensively considered in the literature. The necessity for a careful risk–need analysis, and crafting of a adequate, but not overdone, response to these adolescents seems clear, but there is so little information available about what are the specific development trajectories of the different types of adolescents with sexual offenses that it is difficult to draw the apparently clear implication that a policy of benign neglect might be appropriate for some of these cases.
56.4 14.4 Evidenced-Based Treatment Approaches
Many juvenile sex offenders have never been in good health, emotionally or behaviorally, so rehabilitation is more a process of creation that renewal or restoration. Either way, the broadest purpose of treatment is increased functional ability and enhanced sense of well being, and, in the case of sexual aggression, public safety. This is no simple task, however. In fact, as complex and critical as evaluation is, it is far easier to evaluate, formulate, and diagnose individuals than to treat them effectively. (Rich, 2003, p. 218)
Moreover, at this point in the development of the literature, few, if any of the basic clinical questions about how sex offending adolescents should be treated have been asked or answered. There is a very modest foundational evidence for most treatment decisions. In fact, what once was thought to be a core and validated foundation for treatment, the relapse prevention model, has failed to be supported in two large treatment trials with adult sex offenders (Marques, Wiereranders, Day, Nelson, & van Ommeran, 2005). As a consequence, this model of treatment, though once considered the only standard form of treatment for both adults and adolescents, is now questioned with sex offending adolescents, given the lack of empirical support in adult populations and the absence of cohesive and coherent conceptual match with contemporary analyses of treatment needs of adolescents (Thakker, Ward, & Tidmarsh, 2006). Thus, there is no overarching or foundational conceptual model for treating sex offend-ing problems. Unlike some areas, like anxiety problems, where there is reasonably solid understanding that exposure, however accomplished, must be a part of the treatment, there is no foundational conceptual principle which has solid theoretical and empirical support in the treatment of juvenile sex offenders. This leaves providers with little in the way of solid support for treatment decisions. We do not know what modes of treatment are best (groups, individual, or family) or even what methods (relapse prevention, empathy training, victim clarification, etc.) should be used, based on empirical foundations. Moreover, the ability to match juvenile offenders to specific treatments by clinically relevant dimensions (Langton & Barbaree, 2006) is, despite the clear need for such, simply not available. So, while there are numerous shibboleths about how treatment should be provided, there are few empirical validated guidelines for treatment.
Despite the absence of strong support for specific treatment approaches, there is a reasonably strong support that treated adolescent sex offenders typically fare much better than untreated adolescents in terms of sexual offending recidivism (Walker et al., 2004). In a recent meta-analysis of all the comparative outcome studies by Reitzel and Carbonell (2006), adolescents who had been treated had a sexual offense recidivism rate of 7.37%, whereas untreated controls had a sexual recidivism rate of 18.98%. These findings support the general value of treatment, even if little is known about specific treatment by aptitude interactions. Particularly, given public safety and public relations considerations, it is important that evidence supporting the effectiveness of treatment exists. Of course, these findings are weakened by the recognition that general delinquent recidivism is relatively high for treated sex offending adolescents. It is clear that all research must examine both sexual and nonsexual delinquency to provide a true estimate of positive clinical and social effects.
A significant exception exists to this summary, however. Two randomized clinical trial studies have found Multisystemic Therapy (MST) to be considerably more efficacious than comparison treatment of individual therapy (Borduin, Henggeler, Blaske, & Stein, 1990) or cognitive behavioral group and individual treatment provided in typical outpatient contexts (Borduin, Schaefer, & Heiblum, 2009). Although two studies cannot define a field, these findings deserve careful consideration. First, the current zeitgeist of the field is such that group-based cognitive behavioral treatment organized by relapse prevention concepts is ubiquitous and almost the standard method of treatment. For example, McGrath, Cumming, and Burchard (2003), in a survey of community programs, found that a large majority (91%) based their treatment on relapse prevention informed, cognitive behavioral treatment. Such a monolithic approach in the absence of any compelling empirical support for differential and enhanced efficacy represents a prescription for failure, particularly if there are few data supporting the paradigmatic treatment. Borduin et al.’s (2009) results combined with the absence of support for the conventional relapse prevention model of treatment with adults suggests that, at least, there should be an open approach to determining what kinds of treatment fits best with this population. In addition, MST has considerable conceptual appeal which will be reviewed in the following section.
A second new treatment approach, also, with considerable conceptual appeal is the Good lives model (Word & Mann, 2004). More a theoretical orientation than a discrete set of techniques, the Good lives model rests on the several theoretical, empirical, and developmental observations about adolescents who offend sexually. First, numerous writers have opposed the downward extension of treatment methods developed for adult offenders to adolescents (Miner, 2002; Thakker et al., 2006; Trivits & Reppucci, 2002). Arguing that there are profound and deep differences between the psychological characteristics of adult and adolescent offenders, that these differences are exacerbated by the developmental differences between adolescents and adults, and that the initiating and maintaining factors between adult and adolescent offending demonstrate little overlap (Miner, 2002), Ward and others (Ward, 2002; Ward & Mann, 2004; Thakker et al.) have argued that a fundamentally different approach must be developed for adolescents.
For example, a core component of the adult approaches to treatment is based on the concept of overcoming offender denial to enable the adult offender to take responsibility for identifying and controlling the essential cognitive and behavior patterns which characterize the offense cycle (Pithers, 1990; Pithers, Marques, Gibat, & Marlatt, 1983). Thus, the adult offender must accept and acknowledge that his or her behavior is the result of an ingrained and repetitive pattern in order to learn to disrupt and prevent the execution of the offense. Ward et al. argue that what defines adolescence is the opposite of a fixed pattern. Instead, adolescentsare characterized by change, transformation, and, fundamentally, the absence of fixed or ingrained patterns. Instead, Ward argues that the core task of adolescence is to develop a set of core guiding assumptions about the world and, eventually, as a result of the cumulative effect of the adolescents’ developmental experiences, a theory of self. Thus, Ward suggests that the fluidity and openness of the adolescent to developmental input create a developmental opening within which a positive model of the self must be created. In effect, one of the central tasks in treatment is to assist the “adolescent to change his conception of himself from that of a developing sex offender to someone trying to live a different life” (Ward, Polaschek, & Beech, 2006, p. 315). What must not happen is that the treatments have the effect of fixing in the adolescent that he is indeed a sex offender who is caught up in an addictive, lifelong process which he will have to guard against for the rest of his life.
56.5 14.5 Mechanisms of Change Underlying the Intervention
may be due in part to its explicit focus on ameliorating key social-ecological risk factors that are related to problem sexual behaviors and place youths on a developmental pathway (or pathways) for sexual offending. Specifically, MST interventions (a) targeted important socialization processes that contributed to or maintained problem sexual behaviors and (b) promoted healthier (i.e., prosocial, strength focused, and age appropriate) interpersonal transactions in family, peer, and school contexts. (p. 35)
improved family support, peer relations, and academic performance allowed MST participants to experience increased success in accomplishing educational, occupational, and other important developmental tasks (e.g., the formation of healthy romantic relationships) during the late adolescence and early adulthood. We suggest that a major limitation of typical treatments for juvenile sex offending is their relatively narrow focus and failure to account for the multidetermined nature of problem sexual behaviors and other serious antisocial behaviors. (p. 35)
Thus, treatment success depends on the ability of the therapist to intervene in multiple contexts in the lives of adolescent offenders and successfully promote alternative ways to meet the developmental demands associated within each of the critical life domains.
At this point in the development of the literature, there is an insufficient empirical baseto declare any winners or losers. However, a sufficient nomological net of empirical and conceptual development does support a framework of treatment that is based on the principles of risk, needs, and responsivity (Langton & Barbaree, 2006), and that is responsive to the developmental, social, family, and environmental contexts of adolescents.
Thus, what appears to be critical in the treatment of adolescents is not a particular technique, but the ability to address complex, multi-factor problems through comprehensive, developmentally sensitive, and ecologically responsive methods. Thus, given the core finding of hetero-geneity among juvenile offenders, it is reasonable to expect that a complex and dynamically responsive model of treatment such as MST would be a strong candidate for effectiveness.
Moreover, the conceptual articulation between the precepts of MST and the Good lives model is impressive. Both approaches coalesce around a common set of principles founded on an awareness of the complex, multidetermined etiology and maintenance of the problem behaviors and a flexible, developmentally sensitive, growth-oriented treatment and intervention procedure. Thus, future development of a rapprochement between the technological strengths of MST and the conceptual framework and promise of the Good lives model may well be the next important conceptual paradigm. In addition, Koss, Bachar, and Hopkins (2006) have suggested that there is possible rapprochement between MST and concepts drawn from restorative justice theory.
Given the complexity of pathways to juvenile sex offending problems, comprehensive assessment of the identified adolescent patient is critical (Rich, 2003, 2009). At a minimum, awareness of the critical developmental areas associated with adolescent sex offending must inform treatment and a risk, needs, and responsivity analysis (Langton & Barbaree, 2006) must be part of the development of any treatment program or protocol. The principles of risk, need, and responsivity provide the conceptual blueprint which ensures that the heterogeneity of adolescent with sex offending problems will inform treatment.
Given the heterogeneity of adolescents with sex offending problems and the variability of risk and severity of offending behavior, a one-size-fits-all approach is not likely to work. At least, there needs to be a continuum of care in which low-risk offenders can be treated in a least restrictive and nonintrusive context and, for the fewer, high-risk adolescent, a safe, secure, and, likely, intensive model of treatment must be available. In particular, the areas of empirically relevant risk factors, etiology, and maintenance factors must be accounted for in any treatment plan. For some at risk offenders, this may need to include residential treatment. However, this is an empirical question which should be a focus for research efforts. The cost–benefit analysis of even intensive outpatient treatment (Borduin et al., 2009) compared to residential costs makes the case that only in the interests of community safety and clear treatment advantage should residential treatment be the preferred protocol.
The core development task of self-definition for adolescents requires that, whatever and wherever treatment is accomplished, intervention must be supportive of a self-development that is positive and noncontaminating, of a normal developmental trajectory. Moreover, the likelihood of iatrogenic effects mandates that a broad spectrum of outcome domains should be collected as a basic tenet of treatment outcome measurement.
56.6 14.6 Basic Competencies of the Clinician
Given that treatment of juvenile sex offenders is complex, has profound legal and social consequences, and is often embedded in multiple social, legal, and correctional contexts, it is unlikely that a new clinician could ever start self-training as the only pathway to competency. This is an area where an apprentice model of training seems imperative. Thus, it is likely that the skills essential to functioning as clinical provider for juveniles with sex offending problems should be acquired in a training context where the specialized assessment and treatment skills can be witnessed, modeled, and performed under close supervision and feedback. It would seem unwise to take on these cases absent a mentor or a training context supportive of the novice clinician.
As articulated by the above analysis, a core basic competency of clinicians in this area is the ability to conduct an appropriate assessment and organize a treatment plan based on a solid risk-level evaluation and a comprehensive treatment needs assessment. Clinicians need to be familiar with the process of risk assessment (Rich, 2009) and adept at using these data to define treatment needs and craft an appropriately articulated and responsive treatment plan.
Rich (2003) has an exhaustive framework for a comprehensive psychosocial evaluation and report. Beginning clinicians would be wise to consult his outline. At a minimum, clinicians have to be able to conduct a thorough forensic clinical interview covering the following areas (American Academy of Child and Adolescent Psychiatry, 1999).
1. Assessment of the sexually abusive behavior. It is necessary to have the client describe the behavior which brought them into treatment. Although unlikely to be entirely truthful or transparent, the child’s level of disclosure provides significant insight into his accommodation to his offense. It should be noted that denial or defensiveness is normative and the goal of the assessment is not to wring a confession out of the child. Instead, this is an opportunity to evaluate mechanisms for coping with his offense and the consequences which have accrued. At the same time, all relevant forensic and court documents should be obtained. The degree of discrepancy between self report and police reports can be astonishing.
2. Sexual history. What is important is this section of the interview is to ascertain how the child has arrived at this point in their sexual development. The child’s exposure to developmentally inappropriate sexuality is particularly important, as there appears to be some link between developmentally inappropriate sexual exposure and risk of sexual offending. ( REF) In addition, a full sexual history should be obtained, including both appropriate peer and autoerotic expression as well as inappropriate sexual behaviors and expression. It is important that the examiner be comfortable and forthright in this inquiry. Adolescents rarely answer a question not asked directly.
3. Developmental, family, and social history. It is often the case that children do not know the circumstances of their birth, or developmental milestones, or any of the usual components of a developmental or psychosocial history. Collateral interviews with parents or guardians are extremely valuable and should be obtained if at all possible. The circumstances of the child’s attachment history, abuse and neglect history, and family functioning are critical. Children with significant attachment disruption and burdens of abuse and victimization are common in samples of adolescents with sexual behavior problems and knowing the details is valuable in developing articulated treatment plans.
4. Medical and psychiatric history. The base rate of previous psychiatric treatment in adolescents with sex offending problems is very high (REF) and co morbid psychiatric diagnosis is usual. Often, the degree of involvement in various medical and psychiatric settings is an indication of the difficulty of managing these clients; thus, this information becomes significant in the risk/needs analysis informing treatment. A significant part of the risk-needs assessment is identifying the burden of psychological/psychiatric problems and crafting a plan to ameliorate these problems. In particular, the prevalence and extent of depression should be carefully monitored. Suicidal status often is a powerful marker revealing the overall mental health functioning of these adolescents.
5. Academic history and cognitive functioning. Academic and intellectual functioning are core components of the capacity and course of treatment. Often, in fact, usually, these adolescents have histories of outright academic failure or very marginal performance as well as school behavior problems. If there is to be a chance for a good life, academic or vocational success is a critical component. In residential programs, considerable emphasis is placed on being able to be competent in the school environment. Successful outpatient programs such at MST, likewise, place a good deal of emphasis in enhancing the adolescents functioning in their schools. Thus, a thorough and targeted treatment plan will be based on the result of this component of the evaluation.
6. Standardized assessment. In our program (Burkhart & Cook, 2008), we have relied on several standardized tests and interviews. The extent and quality of information available has been useful in planning and evaluating treatment, and in creating a foundation for our local science. In the population of juvenile in our programs, we have been able to delineate the large differences between the regular delinquent adolescents and those committed for sex offenses. Based on these data, we create different treatment tracks and have been able to create a better fit between the treatment needs of the boys and treatment resources. Finally, having an extensive pretreatment data base will allow for the development of local actuarial predictions based on follow-up analyses of treatment completion and recidivism.
7. Communicating risk levels. The work of evaluation in this population has far reaching effects as these evaluations provide the foundation for court decisions having lifetime consequences for the adolescent offender and for his community’s safety as most jurisdictions have some element of risk informed registration or notification. In Alabama, for example, following completion of treatment, the clinician must provide a statement to the court outlining the adolescent’s history and functioning in several behavioral domains, outline the client’s response to treatment, and, based on this analysis, provide a recommendation for risk level. Typically, this recommendation is given great weight by the court and becomes the foundation for the court’s assignment of a level of risk. The assigned level has profound consequences for how the adolescent will be treated in the justice system. Thus, it is imperative that clinical providers have a basic understanding of the literature on empirically relevant and reliably assessed risk factors and be able to communicate to the court the intricate nature of predicted risk.
Though there is a reasonable consensus that general cognitive behavioral approaches have utility, there is considerable support for the idea that responsive treatment will be defined by explication of the unique and particular needs of the individual adolescent. A boy with an intense burden of victimization and trauma in his history is likely to require considerable work at stabilizing his affective reactivity and inner turmoil before he will be receptive to recognizing his responsibility for his own sexual misconduct. An adolescent with a delinquent history and an early predisposition to an antisocial style may require a strongly structured and boundary-limiting intervention with a strong focus on evaluating violence-producing attributions in order for him to begin to recognize the impact of his behavior on his own life as well as others.
An additional core competency is the ability to work in nontraditional contexts. Clinicians working with adolescents with sex offending problems are going to find themselves having to broker interactions in forensic contexts, correctional settings, foster and child welfare agencies, as well as the usual gamut of academic and social contexts in which adolescents are embedded. Moreover, the work in forensic and correctional settings often require that clinicians provide courts, probation, and child welfare agents with risk analyses about their clients. In fact, this may well be one of the most frequent referral questions.
Thus, in addition to the usual competencies required of those who work with adolescents, a strong grounding in developmental psychology, flexibility in methods, and the ability to work in family and social contexts outside of the consulting room, clinicians have to be familiar with the language and methods of the legal system. Moreover, they have to be able to recognize the value and limits of risk analysis and actuarial procedures of all sorts.
Competencies also vary by setting. Clinicians working in residential setting, particularly, correctional contexts, have to be aware of the tendency for such settings to become cus-todial rather than truly correctional. There has been considerable evidence in the news about the corruption of correctional settings in which the drift toward coercive control has effectively obviated the practice of any genuine treatment. Inevitably, clinicians in these settings become the guardians of the principles of noncoercive, nonabusive, psychologically sensitive treatment.
56.7 14.7 Transition from Basic Competence to Expert
The most critical skill in the transition from basic competence to expert level of functioning is the ability to perform a well-articulated and accurate risk, needs, and responsivity analysis. To accurately blend the data from actuarial assessment with the data from history and clinical evaluation to create a comprehensive and operational treatment plan is both difficult and essential to the successful result of treatment. In our facility, we invest a great deal of upfront clinical work in the forging of such a plan and rely on it to guide our interventions and keep the adolescent on track (Burkhart et al., 2008). An important corollary skill is to be able to translate this treatment plan into an operational plan for the client. Adolescents have to be engaged, they have to buy into the plan or an adversarial process can evolve. Expert clinicians can speak the language of youth, help them envision a self-worth working for, and pull them into the process of change without this appearing to be a loss of dignity or autonomy. A hallmark of expert clinicians is that they are able to create a relationship of close attachment, but one that allows for the adolescent to have a sense of his own autonomy and choice.
Being able to manage the complex systems and have the different stakeholders all on the same path is an additional level of expertise necessary for work with adolescents with sexual offenses. Clinicians often have to interact with judges, probation officers, school personnel, and district attorneys and influence or persuade them to share a common plan. Such correspondence is difficult as often these stakeholders have different constituencies and very different values relative to the treatment needs of the client. It is not unusual for clinicians to have to function as advocates. The danger in such advocacy is that the risk analysis has to be accurate and the clinician must not distort the level of risk as attached.
Given the variability of settings, populations, and legal pathways by which these clients are sorted, the ability to conduct local science to define, evaluate, and manage the specific clinical needs of the adolescents for whom the clinician is responsible is a very important, advanced skill. Particularly given that, in most contexts, treatment is mandated; thus, little to no possibility to do broad based, randomized clinical trials, the necessity of being able to do within group evaluations, know the base rates of co-morbid conditions, have some access to effectiveness in terms of treatment response, both immediate, intermediate, and ultimate, seems to provide the only genuine foundation for self evaluation and program review. The value of having a spreadsheet of all the data for all the clients in a program cannot be overstated. Our ability to hold ourselves accountable depends directly on our ability to humble ourselves before the data.
56.8 14.8 Summary
Given that adolescence is the critical period for onset of adult persistent offending; all intervention with adolescents with sexual behavior problems can be considered as early secondary prevention as well as tertiary prevention of adolescent problems. Moreover, the costs of inadequate or insensitive treatment can be steep. The necessity and complexity of being able to match treatment needs to the individual circumstances of each child or adolescent and the further implication that incorrect matches of treatment to individual needs can have iatrogenic consequences render this work critically important for the individual child and the society into which he will mature. A core research agenda should be to provide clinicians with reliable and valid tools that will allow for the accurate judgments necessary to match the adolescent with the best articulated treatment and develop the methods and principles by which effective interventions can be crafted.
The finding that nonsexual delinquents sexually reoffend at the same rate as treated sex offenders is one with considerable social and legal consequences. There are many more general delinquents moving out of correctional and treatment contexts than sex offending adolescents. If the rates of recidivism are the same, then the overall number of sexual offenders from the delinquent group must be that many times more frequent. Thus, it may well be that general delinquents account for far more victims than released juvenile sex offenders. The obvious implication is that sex offence prevention intervention efforts should be included for general delinquents as a component of their program of treatment.
Perhaps, the most important form of prevention will occur in legislative contexts in which the legal structure for managing adolescents with sex offending behaviors will be created (Zimring, 2004). There is a very likely consequence that failure to distinguish juveniles with sex offending behaviors from adult sex offenders, combined with the increasingly punitive and destructive handling of sex offenders in general, will lead to creating adolescents whose identity will be forged in the crucible of a legal context which condemns them to the stigmatized identity of a lifetime sentence as a sex offender.
Critical issues in the formation of social and legal policy have to be formulated. The downward extension of policies and procedures from adult offenders to juveniles must be thwarted. There is an accumulating conceptual and, recently, empirical literature that has identified the pernicious consequences of these policies (Letourneau, 2006). Developing developmentally appropriate and empirically informed policy is perhaps the most significant work to be accomplished in this area.