Clinical Issues with Sexually Abusive Youth:

Assessing Risk and Needs

Sean Hiscox, Ph.D.

Associates in Psychological Services, PA

Recent Data

• Juveniles commit 20% to 30% of reported rapes and 30% to 60% of child molestation (Hunter, 1999; Weinrott, 1996).

• Juveniles account for approximately 20% of the individuals charged for a sexual assault in the United States and Canada (Barbaree, Hudson, & Seto, 1993; Federal Bureau of Investigation, 1993; Statistics Canada, 1997; Weinrott, 1996).

• In one meta-analysis with 1,025 juveniles, recidivism rates were 5.8% for rapists, 2.1% for child molesters, and 7.5% for an unspecified group (Alexander, 1999).

• Recidivism rates generally vary from 2% to 19% depending on the study and length of follow up.

• Recent JRAS study with 231 juveniles found that 38 (16%) recidivated sexually and 119 recidivated nonsexually (52%) (unpublished dissertation, Haran, 2006) .

Key Concepts(Epperson et al. in Prescott, 2006)

• Risk

– Internal characteristics that make an individual more or less likely to commit a sexual offense in the future

• Desire to engage in deviant sexual acts• Deviant sexual interests• Poor\good impulse control• Poor\good judgment• Presence\absence of psychopathology, such as an antisocial

orientation.

• Risk management

– External factors

– Interventions designed to reduce the danger to the public

• Treatment• Supervision• Setting• Drug testing• Legislation

• Relationship between risk and risk management

– The danger/threat to the community is the likelihood, relative to risk, of an offender reoffending given the level of risk management in place

– If there is no risk management or it is poorly applied, the danger to the public is equal to the risk inherent in the individual

– Risk assessments are most helpful when put in the broader context of risk management

• Good risk assessments match the level of risk management to the level of risk inherent in the individual

• For a low risk offender, intensive supervision wastes resources on an individual who’s threat to the public is already so low that it cannot be reduced much further

• May increase risk for low risk offenders when exposed to higher risk peers

• Risk Reduction\Needs Assessment

– Risk is inherent in the individual but it is not Static

– We can facilitate change in the individual through treatment and provide additional supervision

– Treatment targets• Increasing impulse control• Decreasing deviant sexual interest• Decreasing distorted attitudes• Increasing lifestyle stability and community adjustment• Increasing social skills

• Needs assessment, also called assessment driven treatment, is the opposite of a “one size fits all” approach

• Majority of sexually abusive youth reoffend nonsexually, so treatment should target those nonsexual areas, if appropriate (e.g., lifestyle instability)

• Segregating low risk offenders from high risk offenders

Problems

• Methods for assessing risk are only beginning the validation process

• Low base rates

• Risk assessment can cause harm\unintended consequences

• Young people are changing rapidly

• No profiles exist

• Risk assessments often neglect protective factors that mitigate risk

• Unaided clinical judgment has consistently been found as not much better than chance

• Risk assessments by treatment providers become less effective the longer the therapist is in contact with the person

• Evaluators should anticipate resistance. We’re asking them to disclose embarrassing\shameful things.

– Resistance should be put in this context and not necessarily made a “risk factor.”

(Prescott, 2006)

What we know (and what we don’t) (Prescott, 2006)

• Diverse group of young people

• Sexually abusive youth (SAY) are more likely to come in contact with the legal system again for something OTHER than sex offending.

• Minority of SAY show deviant sexual arousal.

• Remorse, empathy, and denial are not well established predictors of reoffense

– These issues, however, provide information about the youth’s motivation and readiness for treatment

– Research has struggled with assessing these variables, so part of the problem might be how they are defined

• “Instant Offense” is not as predictive as once thought

– Instant offense involves the youth’s willingness to abuse on one occasion. It doesn’t necessarily capture persistent behavior, which is predictive.

• Penetration also is generally not predictive of sexual reoffense.

– It has been found, however, to predict future violence.

Early onset• Research often uses age 12 as cut off

Persistence• continuing sexually abusive behavior after being detected and

sanctioned

– Established deviant sexual preference

– Stranger victims

– Psychopathy• a callous disregard for the feelings and welfare of others, and

an egocentric, antisocial personality

Significant Risk Factors:(Prescott, 2006)

Risk Factors

• Static:– Historical factors not subject to change

• Number of prior sexual offenses• Characteristics of prior sexual offenses• Prior victim selection• Prior nonsexual antisocial behavior• Sexual history• Family history• Past psychiatric history

• Dynamic: – Factors subject to change over time, either slowly (stable

dynamic factors, such as personality) or rapidly (acute dynamic factors, such as substance abuse)

• Motivation • Acceptance of responsibility• Level of victim empathy• Quality of peer relationships• Level of sexual self regulation• Level of general self regulation• Current substance abuse• Current symptoms of mental illness

Risk Assessment Methods

• Unstructured clinical

– Based on review of records and unstructured clinical interview;

– No explicit prediction formula;– Rough, inexact prediction, sometimes without articulation

of rationale;– Advantage of convenience;– May be inaccurate;– May have relatively low level of agreement between

independent evaluators who examine the same individual (i.e., low level of interrater reliability).

• Structured clinical

– Use of standardized list of risk criteria;– Criteria not necessarily empirically supported;– Criteria may be derived solely from the developer’s

experience and opinions;– Unclear which criteria are best predictors of sex offending;– Advantage of increased interrater agreement;– Examples include informal risk checklists used in various

correctional institutions or by parole and probation authorities.

• Empirically guided

– Use of standardized list of risk criteria and specific formula or method for combining these criteria;

– Reliance on research literature– Although the individual criteria have support in the

empirical literature, the instrument as a whole does not have tested predictive validity;

– Examples include JSOAP, ERASOR.

• Clinically adjusted actuarial

– Use of actuarial scale to provide foundation for prediction;

– Adjustment of prediction based on clinical factors;– Advantage of firm foundation in actuarial scale

with flexibility of clinical adjustment;– Potential disadvantage if reasons for clinical

adjustment are not well founded or not clearly articulated.

• Actuarial

– Prediction based entirely on scale that has been validated with a predictive validity study (i.e., a study linking present scale scores with varying levels of future recidivism);

– Advantage of strong empirical foundation with explicit recidivism levels for different scores on scale;

– Disadvantages of inflexibility, heavy reliance on static, historical risk factors such as age of offender, prior criminal history, sex offense history, characteristics of victims), and inability to take into account variables beyond limited set used in scale.

Pre-Adjudication Evaluations

• Assessment occurs throughout the legal process and beyond.

• Requested by multiple referral sources; prosecutor, defense attorney, judge, and DYFS.

• Often requests for evaluations are post adjudication, but pre-disposition to help the judge make sentencing decisions.

• Pre-Adjudication assessments include special circumstances and are a matter of debate

• What factual basis to evaluate risk? There are typically conflicting accounts of what illegal sexual acts the defendant allegedly performed.

• Some believe that evaluation and treatment should begin only after the court has reached a finding-of-fact. Others believe that, despite the factual ambiguity, evaluation and treatment should begin as soon as possible.

• As long as the assessment does not address the ultimate issue—guilt or innocence—you can assess a number of things, including risk.

• Conclusions should clearly state what factual assumptions are being used, and both sets of factual assumptions need to be included in the analysis (allegations, defendant’s account).

• There is no test or procedure that leads an evaluator to a guilt or innocence finding other than the defendants’ own self-report or a finding by a judge/jury.

Tools

• Varying stages of development

• Different sample characteristics

• Evaluators need to clearly state limitations

• Current state of science indicates that we cannot yet rely on total scores

Juvenile Sexual Offense Recidivism Assessment Tool-II (JSORRAT-II)

(Epperson et al. in Prescott, 2006)

• Actuarial scale intended for risk classification, although currently it is considered a screening instrument

• Comprised of 12 items from seven ‘families’: 1) sex offending history; 2) offense characteristics; 3) sexual offense treatment history; 4) abuse history; 5) special education history; 6) school discipline history; and 7) nonsexual offending behavior

• Sample consisted of 636 males, ages 12 through 17, adjudicated for a sexual offense in Utah. Majority of sample, 76%, were white.

• 84 (13%) recidivated sexually, 126 (20%) nonsexually

• charges were used as recidivism measure and follow up was 13 to 14 years

• Two main factors; high persistent drive to engage in deviant sexual behavior and an antisocial orientation

• Excellent predictor of sexual recidivism (ROC = .89) and nonsexual recidivism ROC = .79) with the development sample. Needs a cross validation study.

JSOAP-II(Prentky & Righthand, 2003)

• Age range of 12 to 18 who have been adjudicated for sexual offenses, as well as nonadjudicated youths with a history of sexually coercive behavior

• Small sample size (N=76), short follow up, and low base rate (3)

• 27 items, both static and dynamic variable, and assesses four factors:

– Sexual drive/preoccupation– Impulsive/antisocial behavior– Clinical/intervention– Community stability/adjustment (past 6 months)

Estimate of Risk of Adolescent Sex Offender Recidivism (ERASOR)

(Worling & Curwen, 2001)

• The ERASOR is an empirically guided scale. 25 criteria grouped into five broad domains supported as risk factors.

• 12 to 18 year-olds who have previously committed a sexual assault

• Five domains:– Sexual interests, attitudes, and behavior– Historical sexual assaults– Psychosocial functioning– Family/environmental functioning– Treatment

• In a comprehensive manual, the authors provide a rationale and empirical support for each of the 25 criteria. The manual itself is a useful, well-organized review of the adolescent sexual offending risk assessment literature.

Juvenile Risk Assessment Scale (JRAS)(Haran, unpublished dissertation, 2006)

• Modified version of the RRAS; used to place juveniles in risk tiers in accord with Megan’s Law

• Diverse sample; 45% African-American, 43% White 10% Hispanic, and 1% as other

• 14 items sub-divided into three broad areas: sex offense history, antisocial

behavior, environmental characteristics

• Predictive validity study (2006)– 231 subjects – 38 reoffended sexually (16%)– 119 reoffended nonsexually (52%) – 74 did not reoffend (32%)

• Two factors: antisocial, unstable lifestyle and sexual deviance

• JRAS tier was found “moderately” predictive of sexual recidivism (ROC=.656)

• Antisocial factor “moderately” predicted nonsexual recidivism (ROC=.699) and sexual recidivism (ROC=.669)

• Sexual deviance factor alone was not predictive

• STATIC-99 ROC’s: sexual recidivism = .71, violent = .69; MnSOST-R = .73; RRASOR = .68

Structured Assessment of Violence Risk in Youth (SAVRY)

(Borum, Forth & Bartel, 2002)

• Samples static and dynamic risk factors associated with violent recidivism in juveniles, including sexual violence

• Four domains:

– Historical risk factors (such as history of violence, early initiation of violence, past supervision/intervention failures, and poor school achievement)

– Social/contextual risk factors (such as peer delinquency, peer rejection, poor parental management, and lack of personal/social support)

– Individual/Clinical risk factors (such as substance use difficulties, anger management problems, psychopathic characteristics, and low commitment to school)

– protective factors (such as prosocial involvement strong social support, strong attachments and bonds (to positive figures), and a strong commitment to school

– Two validity studies of the SAVRY, both of which support its positive relationship with future serious delinquent acts

Take Home Points:

• Diversity of population

• Importance of not using a “one size fits all” approach

• Conservative approach when making conclusions about risk

• Tying evaluations to a needs assessment

• Importance of environment, such as peers and home