WELCOME

1. Clinical Issues in the Treatment of Adolescents Who Have Engaged in Sexually Abusive Behavior and the DJJ Treatment ModelMay 9, 2014

2. WELCOME • Topics for discussion: • Traditional treatment model • Current research • DJJ SBTP structure and components • Measuring impact

3. What People Imagine When They Hear “Sex Offender”

4. But who are they really?

5. Still providing treatment sometimes feels like….

6. Juvenile and Young Adults vs. Adults Traditionally put into 1 category A wide body of knowledge clearly shows that these groups are dramatically different. Research now promotes the need to approach treatment with juveniles differently.

7. Traditional Treatment Approach Use of “cookie cutter” treatment from adult model. Family therapy and possible reunification was not advised. Success was solely the responsibility of the youth. Little focus on healthy living models. Lack of treatment resources to address individual treatment issues.

8. What We Know Today CBT-based models continue to have evidence of effectiveness. Evidence that use of motivational techniques are effective to help with engagement. 3 factors are significant indicators of successful outcomes: 1) Therapeutic intervention philosophy 2) Serving high risk offenders 3) Quality of implementation (i.e., standardization, fidelity)

9. What We Know Today • Interventions that quickly bring behavior under control have greatest potential for efficacy. • Interpersonal skill development through CBT is effective in addressing sexual behavior problems. • Interventions during teen years have greatest impact since this is highest risk time.

10. Evidenced Based Practice for Juveniles • Research is “weak” in the area of juveniles. • No comprehensively defined EBT currently exists specifically for JSO, yet several E-B components have been identified for juveniles. • Family work appears to be the most important to help reduce delinquency and sexual aggression. • Mentoring has shown moderate effects especially in the areas of school, drugs and some aggression.

11. Using what we know about Juveniles • Sexual recidivism rates between 7-14% • General recidivism rate 53% • Offense specific treatment lowers recidivism • BUT need to fill in the gaps.

12. Using what we know about Juveniles • Confrontational styles not as effective. • Therapeutic relationship important to developing a trusting environment for disclosure. • Treatment should target skill development, not focus solely on discussing the offense. • Offense specific issues can be addressed individually.

13. Understanding Adolescence “” Youth are heated by Nature as Drunken men by wind.” Aristotle “I would that there were no age between 10 and 23, for there’s nothing in between but getting wenches with child, wrongdoing the ancestry, stealing, fighting…” Shakespeare

14. Adolescent Development Abstract thinking and reasoning are developing Developing social and emotional skills Evolving attitudes and beliefs Shorter attention spans Greater impulsivity Self-focus and narcissism are developmentally normal More dependent on their social environment Traumatic effects of maltreatment may be immediate Maltreatment may be ongoing

15. Adolescent Development • Adolescent brain development plays significant role in offending behaviors—impulsivity and differential perceptions of risk-reward. • Sexual deviance & ingrained sexual behavior patterns inconsistent with adolescent development research. • Criminal behavior peaks at 15-17 yrs.

16. Adolescent Development Offenses more opportunistic, less “predatory”. Arousal patterns appear less set. Motivations of juveniles may be more curiosity based, related to social problems, less due to compulsivity or cycle patterns.

17. Development Factors Cognitive Brain Social Moral Sexual

18. Cognitive Development Youth in early stages of development are not capable of complex planning. Difficulty understanding perspective of others. Limited coping strategies.

19. Cognitive Development • Increasing capacity for abstract thought. • Expanding intellectual interests. • Mostly interested in the present with limited thought to the future. • As youth approach 18 and older they begin to develop the ability for moral reasoning, have thoughts about the meaning of life, and are more able to delay gratification.

20. Brain Development It is no accident that insurance rates are reduced for youth when they turn 25 years old. The brain has not completed full maturity until around the age of 25 or later.

21. Brain Development • 3 major regions – brain stem, limbic and cortex. • Frontal lobes, essential to problem solving and reasoning and the inhibition of emotion and behavior are not fully developed until early adulthood.

22. Brain Development and Risk Taking • Juveniles have a greater tolerance than adults for ambiguous or unknown risks.

23. Brain Development and Risk Taking • Youth will more likely make decisions based on perceived benefits, particularly social rewards, than on negative consequences.

24. Theories on Risk Taking: All Drive and No Brakes • Increased need for risk taking in breaking away from parents. • May be caused by immature connections between the limbic system (the emotional driver) and the pre-frontal cortex (the brakes). • Teens have more difficulty making up their minds as compared to adults.

25. Teaching the Remodeling Brain • With the right rewards, youth will spend more time attempting to make the right decision. • It has been shown that young adolescents use more of their pre-frontal cortex to a greater extent when evaluating positive performance feedback. • Older adolescents have been shown to use more of the pre-frontal cortex during negative performance feedback.

26. Teaching the Remodeling Brain • Help youth understand their shifting emotions and mood swings. • Educate them about the changes that are happening in their brains. • Ask open ended questions to allow them to talk about their feelings. • Help them to understand how others may be feeling as they shift from self-focused to other focused.

27. Encouraging Pre-Frontal Cortex Development • Help youth create written or visual systems to manage their time and organize tasks. • Use interactive exercises such as role play, forced choice scenarios, and value discussions. • Incorporate physical activities to emphasize learning.

28. Encouraging Pre-Frontal Cortex Development • Give youth concrete examples and utilize more abstract thinking as they mature. • Use visual aids whenever possible to assist in creating connections in the brain.

29. Brain Development and Trauma Studies show both structural and functional neurological differences between traumatized and non-traumatized individuals. Effects depend on age trauma occurred, frequency of traumatic exposure and availability of caregivers to provide supportive resources. Base-line changes in resting heart rate for individuals with significant trauma experiences.

30. So What Does This Mean • This impacts: • Emotions and attitudes towards self and others • Attachment - unable to trust self and environment • Moral perceptions - right/wrong is skewed/distorted • Thinking and behaviors - socially and sexually • Decision making and problem solving

31. So What Does This Mean • Youth will have: • Greater difficulty analyzing their own behavior and behavior of others. • Greater risk of demonstrating anger and depression. • Decreased ability to develop coping skills. • Increases in mood shifts and reduced emotional balance. • Difficulty learning and processing information in situations that are emotionally charged. • Right and persistent thinking/attitudes/beliefs despite negative results.

32. Social Development Relationship to caregiver affects the development of emotional regulation. Trauma/neglect impact the ability to develop positive relationships and ways to deal with intimacy and loneliness. Healthy vs. unhealthy attachment to others

33. Social-Emotional Development • Struggle with sense of identity • Feel awkward about one’s self and one’s body • Increasing conflict with parents • Shift from parent focus to peer focus • Increased moodiness • Tendency to return to ‘childish’ behavior when stressed

34. Moral Preschool to middle school involves learning to follow rules, avoid punishment, and learn to be obedient. Adolescents/young adults involves a desire to do greatest good to greatest number of people, adherence to self chosen ethical principles. Adolescents very good at pointing out hypocrisy.

35. Sexual Development • The stages of sexual development coincide with social, moral, cognitive, and attachment development. • Trauma/neglect impact the natural development of sexuality. • Sexual behavior can become used as way of coping and self-soothing.

36. Sexual Development • Tradition model of avoidance is not appropriate. • Sexual behavior should be assessed in the context of “normal” sexual development. • Important to normalize appropriate sexual thoughts and behavior. • Creating an treatment environment that allows for discussions about appropriate sexual behavior is key in helping youth develop healthy sexual identities and behaviors.

37. Sexual Development • What is “normal”? • YouTube Generation • Internet and smart phones = 24/7 access

38. Research and Risk • Our understanding of how adolescents and adults differ should play an important role in how we assess risk to reoffend.

39. Understanding Risk What is it - sexual vs. non-sexual Why it is important to treatment High, moderate and low risk

40. Understanding Risk • Risk Prediction relies on “static” factors Goal: predicting violent behavior • Risk Management relies on “dynamic” factors Goal: determining what increases or reduces an existing or preexisting condition

41. Understanding Risk Adolescents are moving targets when it comes to predicting risk. A comprehensive assessment is necessary when trying to determine risk. Limitations should be addressed and an “expiration date” provided. Risk factors vary in the course of development for an adolescent. Therefore, what was a risk at age 14 may not be a risk at age 16. Protective factors play an important role when looking at the complete picture of risk.

42. Understanding Risk Typically, the younger the individual, the more important dynamic risk factors are and the less important static risk factors. Risk factors do not operate in isolation, they are complexly interactive. The more “dynamic” the risk picture, the harder it is to predict - education, treatment, family, social, trauma impact etc.

43. Static Risks to Reoffend Prior convicted sexual offenses Multiple victims Stranger victims Prior treatment failure

44. Dynamic Risks to Reoffend • Deviant sexual interest • Sexual preoccupation/obsession • Environments supportive of reoffending. (2012) • Attitudes supportive of offending* • Social Isolation • Difficulties establishing peer relationships • Family dysfunction

45. General Risks to Reoffend • Prior legally charged offenses • Family functioning • School achievement and behavior • Negative peer relationships • Substance use and abuse • Use of recreation time • Antisocial/pro-criminal attitudes • Out of home placements

46. Factors Not Likely Related to Reoffending • Denial • Victim empathy • General psychological problems

47. Protective Factors • Having strong attachments and bonds • Good self-regulations and impulse control • Positive self-perception • Self-efficacy • Connections to pro-social peers • Connections to pro-social environments

48. Therefore… There are several important considerations research has shown should be taken when treating youth who sexually offend.

49. A Holistic Treatment Approach

50. Developing a “Whole” Person Treatment Approach • Confrontational styles not effective. • Therapeutic relationship important indeveloping a trusting environment for disclosure. • Treatment focused on helping youth develop skills to become a healthy adult, not solely on discussing the offense.