ADOLESCENT SEX OFFENDERS Issues in Research and Treatment A Research Monograph from NCOCTI National Center for the Prevention and Control of Rape | edited by Emeline M. Otey, Ph.D. National Center for the Prevention and Control of Rape National Institute of Mental Health Gail D. Ryan C. Henry Kempe National Center for the Prevention and Treatment of Child Abuse and Neglect U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES Public Health Service Alcohol, Drug Abuse, and Mental Health Administration National Institute of Mental Health 5600 Fishers Lane Rockville, Maryland 20857 The papers appearing in this volume were presented at the Adolescent Sex Offender Work Group meeting, spon- sored by the National Center for the Prevention and Con- trol of Rape and conducted by the C. Henry Kempe Na- tional Center for the Prevention and Treatment of Child Abuse and Neglect under contract number 84MO52503801D from the National Institute of Mental Health. All material in this volume except pp.180-183 may be reproduced without permission. Citation of the source is appreciated. The opinions expressed herein are the views of the authors and do not necessarily reflect the official position of the National Institute of Mental Health or any other part of the U.S. Department of Health and Human Services. N20 85) 90 DHHS Publication No. (ADM) 85-1396 Printed 1985 Table of Contents \aG ¢ Page PrefaCe@ ec cevsevveesncecss cea 2UBL v Work Group Participants . . . cc ccc veeeeeeen vi Introduction by Richard D. Krugman . « ¢ ec eevee ee eee vii Chapter | Recent Developments in the Treatment of Adolescent Sex Offenders by Fay Honey Knopp « « « « ee eevee vs 1 Appendix A: Adolescent Sex Offender Treatment Providers, June 1985 ........ 28 Appendix B: Identifying Adolescent Sex Offenders: Family Incest Treatment Programs as Source by Susan Thompson ....... ceeees 38 Appendix C: Department of the Youth Authority--Sexual Offender Task Force... 84 Appendix D: Treatment Services for Sexual Offenders--Division of Juvenile Rehabilitation « cvvcvonws sass oven ne 89 Appendix E: Summary Paper: Violent Juvenile Sex Offender Project by JulieBlackburn « « cc ccc ess eesss 102 Chapter 2 Methodological and Ethical Issues In Evaluating and Treating Adolescent Sexual Offenders by Judith V. Becker and Gene G. Abel «cccevvssnreee.. 109 Chapter 3 The Adolescent Sexual Offender: Background and Research Perspectives by Robert E. Freeman-Longo . ...... 130 Chapter 4 Adolescent Sexual Offenders: An Outpatient Program's Perspective on Research Directions by Michael O'Brien + « «ec eve evs eee 147 iii Page Chapter 5 Juvenile Sexual Offenders: A Family Systems Paradigm by Caren Monastersky and Wayne Smith .eeevvcvvevevens 164 iv PREFACE Over the past few years the seriousness and extent of the problem of sex offenses committed by adolescents have begun to be recognized by mental health professionals and paraprofessionals, juvenile justice and correctional system professionals, researchers, and policymakers. Although the number of programs designed to treat adolescent sex offenders is rapidly increasing, there is, as of yet, little research or treatment literature for professionals to draw upon in understanding the etiology of the problem and identifying the population at risk, in selecting and assessing the effectiveness of alternative intervention and treatment strategies, or in formulating and implementing policies affecting this population. This monograph is intended to begin to fill this gap by presenting discussions of the current state of knowledge with regard to causes and treatment alternatives; methodological considerations to be addressed in designing program evaluations and research; and research questions of greatest salience to those delivering treatment and mental health services. The papers presented in this monograph reflect authors' opinions and conclusions based on their extensive experience as researchers and practi- tioners working with adolescent sex offenders. The success of the Adolescent Sex Offender Work Group meeting at which these papers were first presented is in large measure due to the efforts of the coeditor of this monograph, Gail D. Ryan, Facilitator of the Network of Professionals Encountering Adolescent Perpetrators of Sexual Molestation of Children, C. Henry Kempe National Center for the Prevention and Treatment of Child Abuse and Neglect, 1205 Oneida Street, Denver, Colorado 80220. Emeline M. Otey, Ph.D. National Center for the Prevention and Control of Rape National Institute of Mental Health ADOLESCENT SEX OFFENDER WORK GROUP Participants Judith V. Becker, Ph.D., Associate Professor of Clinical Psychology, Department of Psychiatry, Columbia College of Physicians and Surgeons, New York Robert E. Freeman-Longo, M.R.C., Director, Sex Offender Unit, Correctional Treatment Programs, Oregon State Hospital, Salem Fay Honey Knopp, Coordinator, Prison Research Education Action Project (PREAP), Orwell, Vermont Caren Monastersky, M.S.W., Director, Juvenile Sex Of- fender Program, Division of Adolescent Medicine, University of Washington, Seattle Michael J. O'Brien, Coordinator, Program for Healthy Adolescent Sexual Expression (PHASE), East Community Family Center, Maplewood, Minnesota Moderator Richard D. Krugman, M.D., Director, C. Henry Kempe National Center for the Prevention and Treatment of Child Abuse and Neglect, Department of Pediatrics, University of Colorado Health Sciences Center, Denver vi INTRODUCTION On May 23, 1984, the C. Henry Kempe National Cen- ter for the Prevention and Treatment of Child Abuse and Neglect and the National Center for the Prevention and Control of Rape hosted a work group on adolescent sexual offenders at Keystone, Colorado. Five papers were com- missioned for presentation, providing an overview of the present status of treatment programs for adolescent sexual offenders, methodological and ethical issues in research on etiology and treatment, and perspectives on research from those working with these adolescents in both ambulatory and residential settings. In the first chapter, Fay Honey Knopp, of the Vermont Prison Research Education Action Project (PREAP), pro- vides an overview of the status of treatment facilities for adolescent sexual offenders in the United States. She points out that the number of treatment programs is far outdistancing the research data on which such efforts should be based. She also plants herself firmly on the side of restorative rather than punitive approaches to adoles- cent sexual offenders. Judith V. Becker and Gene G. Abel report on the results of carefully designed studies to assess the magni- tude of the problem. The data on the numbers of sex crimes committed by adolescent and adult offenders are staggering. Becker and Abel also discuss the problems of classification, defining normal versus abnormal adolescent sexual behavior, and some outcome studies on adult offend- ers and then describe the ethical issues that arise in doing research on offenders. Robert E. Freeman-Longo presents the perspective of one working in a closed treatment facility at the Ore- gon State Hospital. He again points out that most adult sexual offenders began their "careers" in adolescence and that many adolescents pass through a juvenile justice sys- tem revolving door, often having their sexual deviancy unrecognized. He finds both prior abuse and "deviant thinking patterns" in his patients. He suggests that re- search on etiology is most crucial and would focus on prior abuse, parental bonding, role modeling, social skill defi- ciencies, emotional development, thinking patterns, sexual vii development, moral development, self-concept, value structures, social relatonships, and deviant cycles of arousal patterns among others. Areas of research in treatment issues are also discussed. Michael O'Brien then describes an outpatient treat- ment program (PHASE--Program for Healthy Adolescent Sexual Expression). He also offers a useful classification of various types of adolescent offenders: Naive Experi- menters, Undersocialized Child Exploiters, Sexual Aggres- sives, Sexual Compulsives, Disturbed Impulsives, and Peer Group-Influenced Offenders. These are clinically based distinctions; and once again, although believing the PHASE treatment approach is working, he leaves us with the "need for rigorous research." Caren Monastersky and Wayne Smith, of the Univer- sity of Washington Juvenile Sexual Offender Program, review some accepted principles by those working in the field: first, that there are many types of offenders; and second, that there are strong family influences on the development of this behavior. They describe the Seattle approach and provide a "sexual offense continuum" that has been useful in designing appropriate therapy. In approaching these papers it is clear that the par- ticipants of this conference have a bias—that adolescent sexual offenders should be approached from a restorative rather than a punitive posture. Discussion Unanimity exists on certain issues that need to be ad- dressed by researchers in the field: ° We must have a better classification or taxon- omy. "Sexual abuse" or "sexual offender" does not adequately describe the complexity of of- fenders and offenses. ® We need normative data. What are the limits of "normal sexual exploratory behavior" in adolescents? viii ® Incidence data are totally inadequate. We need better data and better reporting systems. ® Longitudinal and other approaches are needed to define the "natural history" of adolescent sexual offenders. What are environmental influences? What are family influences? Are there biologic influences? Is there a "critical event"? ° Treatment programs need to be evaluated for outcomes. ° Techniques and methodologies being used in the field need to be validated. It is clear that many professionals are ignoring the se- riousness of adolescent sexual offenders, while those who recognize the problem are "flying by the seat of their pants." The relative lack of data can lead only to problems if not corrected, but the "youthful nature" of the field is a big stumbling point. Each year should improve our recognition and manage- ment of the problem. Most importantly, even though all adolescent of- fenders may not be treatable, many are; and it appears to be the best chance we have as a society to have a signifi- cant impact on future incidents of sexual exploitation. We will know more next year. Richard D. Krugman, M.D. ix CHAPTER 1 RECENT DEVELOPMENTS IN THE TREATMENT OF ADOLESCENT SEX OFFENDERS Fay Honey Knopp It is exciting to be involved with the C. Henry Kempe Center's efforts to facilitate the treatment of adolescent sex offenders. In 1975, when the Prison Research Educa- tion Action Project (PREAP) first surveyed treatment pro- grams for sex offenders and interviewed untreated, incar- cerated sex offenders, we found that many of these men had themselves experienced great pain and emotional and economic deprivation. As children, they had often been victims of physical and/or sexual abuse. Imprisonment was the least appropriate intervention for helping them break their cycle of violence. We also discovered there was appallingly little re- search that justified the scope and severity of prison punishment as it was--and is--automatically used by the criminal justice system. The fact that no coherent body of literature or system of thought advocating more restora- tive social practices had yet been developed attested to society's ready acceptance of violent, punitive methods for altering behaviors that were themselves violent. Thus, it was thrilling to encounter for the first time the writings of Brandt Steele and C. Henry Kempe, which advocated non- punitive and restorative approaches to child batterers. Kempe said that helping such parents to become adequate moms and dads had been successful: "We have had very good results...by protecting them from this old system of crime and punishment" (Knopp et al. 1976, p. 54). The "old" system of punishment does not benefit soci- ety. On the contrary, it causes further harm by contribut- ing to the offender's violent behavioral cycle, already fueled by cultural, familial, and societal patterns. The recognition by child advocates, such as Kempe and Steele, that human needs are met best through restorative prac- tices serves as a useful model for our involvement with "new" responses to the sexually aggressive behaviors of adolescents. The public's increasing awareness of and concern for victims of sexual aggression are encouraging developments; however, the public is not well informed about perpetrators of sexual abuse and is even less knowledgeable about ado- lescent perpetrators. Our work of restoration, therefore, goes hand in hand with educating people about the issues involved in these behaviors. This is a difficult task. Al- though practitioners are aware that the sexually offensive and violent behaviors of adolescents are widespread and serious, the problem has generally been hidden and thus ig- nored and neglected (Knopp 1982, pp. 4-9). Adolescent sex offenses are significantly underre- ported in official data, not only the most serious crimes of rape but especially offenses involving the molestation of children (Knopp 1982, pp. 9-12). The amount of systematic research on this issue has been minimal. From State to State and in official record keeping, legal definitions of sexual offenses are not standardized. Marked differences exist in the procedures of reporting offenses and the fre- quency of offenses; and in the absence of any adequate typologies of sex offenders, such offenders are often viewed erroneously as a homogeneous rather than an ex- tremely heterogeneous group. The development of a sci- entific understanding of adolescent sex offenders would now be greatly aided by treatment providers' willingness to work together to standardize and classify adolescent of- fender characteristics and histories, their offenses, various treatment approaches, and outcomes. We need to design some simple instruments to accomplish these important tasks. Despite the lack of coherent theoretical models and problems of definition, treatment programs for adolescent sex offenders are multiplying so rapidly that it is difficult to report accurately on their numbers and even more chal- lenging to report on their quality. I discuss what we have learned at PREAP about recent developments in this bur- geoning discipline. Since it is by no means an exhaustive account, I invite you to add to this information. I report briefly on the ten following issues: l. 2. 4, 5 8. 2. 10. some figures on the numbers of programs and services for adolescent sex offenders identified by PREAP the importance of new data from the New York State Psychiatric Institute that support the rationale for early intervention the importance of evaluation and assessment in determining community risk the development and functions of networking evidence of progress in statewide planning for services community-based treatment programing, includ- ing an example of a program with a strong focus on positive sexuality and family work the implications of housing adolescent sex of- fenders in separate units or cottages in residen- tial programs the needs of a neglected population, low- functioning or mildly retarded adolescent sex offenders the need for a training capability a few examples of treatment success in terms of reported recidivism Growth of Adolescent Treatment Programs Until the fall of 1975, when the University of Washing- ton School of Medicine's Adolescent Clinic was asked to evaluate and treat a group of adolescent sex offenders from all over the State, evaluation of sex offenses and treatment for this age group had not been undertaken in the United States in a coherent and comprehensive fashion (Brecher 1978, pp. 33-36; Knopp 1982, p. 39). Since that time, treatment programing for adolescent sex offenders has increased steadily and is evolving rapidly into a highly specialized discipline. PREAP's current listing of treat- ment providers for adolescent sex offenders (see appendix A), although far from exhaustive, reflects the unprece- dented growth of treatment for these people. Identified are 4] residential programs with specific groups for sex offenders, 112 community-based programs offering group and individualized treatment, and 75 programs providing only individual treatment. In addition to these 228 service providers, several dozen other programs are under develop- ment. Adolescent sex offenders are also treated in tradi- tional, mixed-offense therapy groups, a practice that most specialists consider less effective than using offense- specific groups. PREAP has not been able to locate any specialized adolescent treatment programs in 10 States, | though efforts are underway to develop services in some. States with the greatest number of identified services for this clientele are Washington (45), California (31), Minnesota (22), and Oregon (13). Ten States? and the District of Columbia are listed as providing one such service each. In addition to a greater awareness of sexual victimi- zation, there are many other reasons why adolescent sex offender services have increased: (1) the availability of more descriptive literature about treatment programs for this age group; (2) the dedication of human service provid- ers to filling a felt need, even though additional resources may not be available; (3) the willingness of treatment pro- viders to train others; and (4) the gradual recognition of the need for early intervention with this age group by key I Alabama, Arkansas, Kentucky, Mississippi, New Hampshire, North Carolina, Tennessee, Vermont, West Vir- ginia, and Wyoming. 2Alaska, Connecticut, Delaware, Georgia, Indiana, Louisiana, New Mexico, Ohio, Rhode Island, and South Carolina. actors in the mental health and criminal justice systems and by staff of victim assistance programs. New Data Supporting the Rationale for Early Remedial Intervention The rationale for treatment of adolescent sex offend- ers is laid out clearly in two PREAP publications: Reme- dial Intervention in Adolescent Sex Offenses: Nine Pro- gram Descriptions (Knopp 1982) and A Preliminary Survey of Adolescent Sex Offenses in New York: Remedies & Recommendations (Jackson 1984). These include such is- sues as the early onset of these behaviors, the potential for increase in both the severity and number of offenses by some sex offenders as they grow older, the multiplicity of sexually deviant behaviors practices by a single offender, and the economy of early intervention. Studies cited (Groth 1981; Groth and Birnbaum 1979; Groth et al. 1982), while empirically important, rely on samples of incarcer- ated adult rapists and child molesters. These retrospective self-reports may not reveal the full extent of the incarcer- ated offenders’ histories and sexually aggressive behaviors, for many reasons. Their admissions of sexual criminality might incur new charges, be added to their records, or contribute to the denial of parole or release. However, recent studies by Abel, Mittelman, and Becker (1984), of the New York State Psychiatric Institute, provide new and startling data that should be integrated into presentations made to legislatures, decision-making bodies, and funding agencies when funds are requested for treatment or re- search programs for adolescent sex offenders. These data will be reported in more detail by Judith V. Becker. The information is important not only for its sub- stance but also because of the circumstances under which it was collected. A system of strict confidentiality was 3In a recent PREAP survey (Thompson 1984, appen- dix B, this volume) of 56 family treatment programs for incest, 23 of 26 programs that presently treat adolescent sex offenders indicated that the need for such programing emerged as a result of treating the incestuous family and discovering one or more adolescent members acting out sexually. employed with sex offenders who volunteered for outpa- tient programs in Memphis, Tennessee, and in New York City over a period of 12 years. A few pieces of informa- tion from this very compelling research follow: ie These data support the view that offenses in- crease remarkably as the sex offender grows from youth to adulthood. Of 240 youths under age 18, each had an aver- age of 6.75 victims as a youth compared to an average of 380 victims as an adult, an increase of more than 55 times as many victims. 2. These data support the view that sex offenses are vastly underreported in official statistics, particularly as they relate to child molestations. Data on 232 child molesters whose victims were less than 14 years of age re- vealed that they attempted a total of 55,250 molestations and completed 38,727. Their total number of victims was 17,585. They averaged 238 attempted and 167 completed child molestations each. Their average number of victims was 75.8 each. 3. These data support the notion that a sex of- fender is often involved in a number of different types of paraphilias. Nearly 50 percent of the persons in this study had multiple deviations. For instance, of the child molest- ers, almost 17 percent were involved in rape, 30 percent were exposing children and adults, and 22 percent were involved in voyeurism and frottage. Of rapists, more than 50 percent were involved with child molestation, more than 11 percent were sadists, 29 percent were exhibitionists, and 20 percent were voyeurs. Thus, Abel et al. (1984) sug- gest that interviews with clients include questions about activities other than the presenting behaviors. 4. These data confirm that the age of onset of these behaviors is very early. Forty-two percent of the paraphiliacs had deviant arousal by age 15 or before and 57 percent, by the age of 19 or before. The paraphilia with the earliest onset was attraction to little boys (same-sex pedophilia). Fifty-three percent reported arousal by age 15 and 74 percent by age 19. Since these are crimes that begin at a very early stage, we have to develop a system that allows us to access these adolescents earlier, because most of these people develop arousal patterns far anterior to their actually committing the crime. Many potential paraphiliacs have deviant interest and fantasies when they are 12 or 13 years of age, but have yet to commit a crime. If we are able to stop child molestation and rape, we should treat such young people before the de- viant behavior becomes reinforced and habitual. [Abel et al. 1984, p.6]. These reports also include data that reinforce the view that child molestation is much more frequent than sug- gested in the literature in cases where the target was a male child outside the family. These offenses by men against young males suggest that much greater and earlier efforts need to be made to intervene with these molesters and that victim services must be made available for young male victims. New data from the Hennepin County Home School's Sexuality Therapy Group (Haversack 1984) reflect similarly high incidences and varieties of sexual offenses among their residential sex offender population. These adoles- cents reported anonymously on the number of times they engaged in specific types of behavior (there is no way of knowing whether it was with the same victim). Rape is defined as penetration of the vagina or mouth with the penis; indecent liberties are short of that type of penetra- tion, though they may involve digital penetration: 4Hennepin County Home School's reports of the in- cidence of sexual offenses by a single perpetrator may be much higher than those in similar residential programs for adolescent sex offenders for two reasons: (1) elsewhere there may be no mechanism for anonymous self-reports, and (2) the community may have fewer adolescent sex of- fender treatment programs than Hennepin County. The composition of residential treatment populations is in part a reflection of the types of alternative dispositions avail- able to judges. Where there are many community-based programs, less serious sex offenders can be siphoned off; where there are no community-based alternatives, less se- rious offenders are incarcerated. Hennepin County Home School attracts those who have failed previous treatment or have been involved in more serious offenses. Client 1 Rape (victim 3 or more years younger) 30 times Indecent liberties (victim 3 or more years younger) 30 times Voyeurism (dad and brother) 3 times Incest (father/son) 10 times (brother /brother) 15 times (uncle/nephew /niece) 30 times Client 4 Rape (victim 3 or more years younger) 20-30 times Rape (victim, a peer) 6-7 times Indecent liberties (victim 3 or more years younger) 20-30 times Indecent liberties (victim an adult or peer) 20-30 times Voyeurism 4 times Exhibitionism 3 times Client 9 Committed at least 200 rapes with young victims and at least 100 cases of incest; hit victims at least 20 times. Client 14 Committed rape on young, peer, and adult victims; inde- cent liberties with youth and adults; voyeurism; exhibi- tionism; obscene telephone calls; and incest. He used weapons at least 5 times and hit the victim at least 10 times. Client 26 Committed at least 123 rapes on victims 3 or more years younger; peeped, flashed, and was involved with 120 dif- ferent incest offenses. These data reaffirm what treatment providers know empirically--that the scope and seriousness of adolescent sex offenses are greater than previously acknowledged, and that Federal, State, and local officials need to take im- mediate steps to increase the capability and quality of specialized service delivery both private and public, at the earliest point of recognition. Evaluation and Assessment: A Community Safety Issue There is increasing recognition that competent clinical assessment and evaluation, in addition to determining treatment needs, are closely bound to community safety, particularly in terms of determining which offenders get treated in the community and which do not. The criminal justice system is more consistently requiring formal psy- chological evaluations regarding repetition and dangerous- ness at various points in the judicial process. As a result, assessment and evaluation of the adolescent sex offender have become a speciality area, particularly for experienced private practitioners. Substantial differences exist between the assessment and evaluation of the adolescent sex offender and of cli- ents with more traditional mental health problems.” Within the traditional mental health profession, there is a tendency toward seriously underestimating the risks in- volved in evaluating and assessing the adolescent sex of- fender. Such errors are often made by yielding to pressure from defense lawyers, prosecutors who wish to plea bar- gain, other interested professionals, the offender, and his family. Dreiblatt (1982) cautions evaluators of sex of- fenders to remain extremely vigilant in resisting such pressures. One major difference between assessing and evaluat- ing adolscent sex offenders and other mental health clients lies in the type of referral questions asked. Referral ques- tions about sex offenders usually request information on such issues as legal diagnosis, dangerousness, seriousness or Slrwin Dreiblatt of Seattle, Washington, is one of the principals in the privately owned Pacific Psychological Services. There, 150 to 200 adolescent and adult sex of- fenders are evaluated and/or treated each year. Dreiblatt cites six distinctive issue areas that contribute to the uniqueness and complexity of evaluating sex offenders. See Dreiblatt (1982) and Knopp (1984). relevancy of the offending behavior, amenability to treat- ment and specific recommendations for case disposition. While the mental health professional is often taught to focus on why behavior has occurred, the assessment of sex offenders is more effective if there is a strong focus on what happened. This focus requires indepth and detailed personal interviewing aimed at collecting as broad a data base as possible, with as much collateral information as is available. Policy and victim reports, as well as informa- tion from family members and other social agencies, should be included. Psychological and intelligence testing and physiological monitoring of arousal patterns are means by which the examiner can broaden the data base, thus in- creasing the reliability of information through cross- referencing (Dreiblatt 1982). In addition to such indepth clinical interviews, evalua- tion and assessment instruments should include Groth and Loredo's list of 8 key issues for the adolescent sex offender (see Knopp 1982, pp. 27-30) and the 37-point checklist of clinical risk criteria compiled by Wenet and Clark (see Knopp 1982, pp. 32-33). They also usually include some or all of the following: Minnesota Multiphasic Personality Inventory (MMPI) Millon Adolescent Personality Inventory Thematic Apperception Test Sentence completion tests Beck Depression Scale Draw-A-Person Bender Gestalt Test Rorschach Sexual Profile and Inventory Various intelligence and scholastic tests Various instruments to measure family dynamics Compared to those who work with adults, fewer evalu- ators of adolescent sex offenders use physiological meas- urements. Those who do, however, insist that for ages 14 and upward (a few measure deviant sexual arousals of youth as young as 12), assessments are more accurate and economical in terms of time consumed and range of para- philia identified. Many practitioners do not use the penile plethysmograph, because (1) they cannot afford the tech- nology, (2) they are not familiar with the technology, (3) reluctance exists among State youth divisions to use 10 this type of technology with youth in their care, and/or (4) they are not enamored of this type of assessment. This is an area where dialogue is needed between those who consider this type of assessment useful and those who are apprehensive or uninformed. The Importance of Networking During the last few years we have been struck by the lack of interaction among treatment providers within the same county or State and sometimes, and more surpris- ingly, even within the same city. Staff of many programs often are unaware of other treatment providers in their region. Whenever PREAP receives an inquiry from a blos- soming treatment program, we share with them the names of all the victim, offender, and prevention programs we have identified in their State. We believe such networks should be promoted consistently and even subsidized by youth and mental health divisions. There are many benefits: l. Networking validates an offense-specific treatment approach that is evolving into a specialized discipline. 2. Network members educate and support one another as they exchange information and treatment approaches. 3. A network identifies the professionals who comprise a ready constitutency for offense- specific training. 4. Networking provides an opportunity for standardizing the collection of data. 5. Networking produces a constituency ready to lobby for public policy change and fiscal support at the county and State levels. 6. A network has a potential for educating and furthering the concept of restoring rather than punishing adolescent sex offenders. 11 Networking usually includes four models: (1) an inter- agency approach to the adjudication and treatment of adolescent sex offenders; (2) a county approach for imple- menting treatment services where none exist; (3) county or statewide networks of treatment providers for adolescent sex offenders; and (4) nationwide networks that contribute to the growth and development of adolescent treatment and research for adolescent sex offenders. An Interagency Approach The Montgomery Center Juvenile Sex Offender Com- mittee (Maryland), formed in July 1982 as an outgrowth of the concerns of a number of county agencies, is one exam- ple of an interagency approach. The prime mover was the Sexual Assault Service, a county-funded program of the Health Department, which had become increasingly aware of and concerned about the number of adult and minor- aged victims who had been sexually assaulted by juveniles, and about the disposition of these cases by the criminal justice system. The committee meets monthly and includes represen- tation from Sexual Assault Services, Child Protective Serv- ices; police departments, the Youth Division, the State's attorney's office, treatment providers, the Health Depart- ment, the Juvenile Services Administration, the juvenile court, and the Division of Children and Youth (see appen- dix B). The objectives of the committee include: (1) initiating a dialogue among the agencies that serve juvenile sex offenders; (2) determining the size of the juvenile sex of- fender population in Montgomery County; (3) determining the dispositions of juvenile sex offense cases in the legal system; (4) assessing local treatment resources; (5) evalu- ating the need for additional treatment resources; and (6) stimulating the development of a countywide approach to the treatment of juvenile sex offenders. Developing a countywide, interagency approach to the adjudication and treatment of juvenile sex offenders is an admirable and necessary goal. 12 A County Model for Implementing Treatment In Bellefonte, Pennsylvania, a countywide ad hoc group representing private and public agencies has been ap- pointed to develop comprehensive adolescent and adult treatment programs. The court and the county paid for A. Nicholas Groth, treatment specialist, to facilitate a 2-day education and training workshop on sex offender treatment. During this workshop, the court was closed so that all the judges could attend. The ad hoc group is plan- ning a conference to lay the groundwork for implementing services. Treatment Provider Networks Treatment provider networks are the most common models. They have been identified in the middle Atlantic region, Minnesota, Virginia, Texas, Washington, and Ore- gon. The Oregon Juvenile Sexual Offender Treatment Network for Prevention of Sexual Assault is a recently formed, statewide, nonprofit organization that meets monthly, developing and sharing treatment tools and philosophies and swapping data and reading resources; it also publishes a newsletter. The network is dependent on the Lane County Juvenile Department and out-of-pocket funds. Plans include addressing both the Oregon Circuit Court Judges' Association and the Oregon Juvenile Judges and Directors. Nationwide Networking Since 1981, PREAP has made nationwide efforts to network treatment programs for adolescent sex offenders. In addition, the C. Henry Kempe Center has been facilitat- ing a Network of Professionals Encountering Adolescent Perpetrators of Sexual Molestation of Children since 1983. The cooperative newsletter Interchange and the first na- tional network meeting to focus on clinical and program considerations with adolescent perpetrators, held at the C. Henry Kempe Center on May 21, 1984, represent signifi- cant contributions to the development of treatment and research in this field. These local and national networking efforts enhance and support the idea that treatment of 13 adolescent sex offenders is an important and rapidly evolv- ing discipline. Progress in Statewide Planning Various states, such as Delaware, Florida, New York, and Vermont, are beginning to study comprehensive state- wide designs for serving the adolescent sex offender popu- lation. California provides an interesting model for bringing this issue to public attention, and the State of Washington offers the most comprehensive approach to sex offender treatrnent services. Department of Youth Authority, California California's Department of Youth Authority has iden- tified 800 adolescent sex offenders under its care. A Youth Authority Sex Offender Task Force has 12 people assigned to study the sex offenders now under their juris- diction and to make recommendations to Director James Rowland on treatment and public protection ideas. The group is traveling to several sites in California to hear testimony from youth authority staff and outside resource persons on these issues. This special project, directed by Sharon English, also is circulating an eight-page question- naire (see appendix C) to all youth authority groups and programs that may be treating adolescent sex offenders, asking for their treatment theories. The goal of this ex- ercise is to bring the issue of competent treatment for adolescent sex offenders under discussion and to validate offense-specific treatment. Two seminars on treatment of adolescent sex offenders were held in October 1984 in the southern and northern regions of the State. Over 1,000 specialists from treatment, law enforcement, the judiciary, and other professions participated. These are highly appropriate activities for a State that has 500 committed (mostly rapists) and 300 paroled adoles- cent sex offenders. These figures do not count "hiddens"-- those whose cases were plea bargained down from sex of- fenses or who are incarcerated for homicide where sexual violence was also involved. 14 Division of Juvenile Rehabilitation, Washington It is fitting that Washington, the State that developed the first comprehensive program approach to treating sex offenders, has the most highly developed and sophisticated planning and data collection system and the greatest num- ber of treatment programs. The Division of Juvenile Re- habilitation's April 1983 publication, Treatment Services for Sexual Offenders (appendix D) states its commitment to comprehensive program planning. The division's sum- mary paper on its Violent Juvenile Sex Offender Project (appendix E) describes the need and projects plans for a residential treatment program for the most serious sex offenders. The division sponsors six county projects in five re- gions to place, evaluate, and treat adjudicated adolescent sex offenders. As of November 30, 1983, the Division of Juvenile Rehabilitation's residential population of adoles- cent sex offenders numbered 119, or 12.8 percent of the total residential population. Community-Based Treatment Programs Community-based services for sexually abusive youths can be found in such diverse settings as converted houses or schools, hospital outpatient wings, mental health cen- ters, universities, religious social service centers, and pro- fessional office buildings. New programs usually are modeled on the formats or specialties of the persons who initiated them, or they may take on the characteristics of the "regional specialty." For instance, Oregon and Wash- ington seem to have the greatest cluster of programs with a behavioral treatment orientation, although there is only a scattering of such programs in other areas of the country. Minnesota programs have the strongest focus on positive sexuality. In the wake of A. Nicholas Groth's many train- ing sessions nationwide, his psychosocioeducational models appear to flourish. Thus, people who do the bulk of train- ing for adolescent sex offender treatment can influence considerably the direction of this type of therapy. The duration of community-based treatment of adoles- cent sex offenders usually ranges from a low of 6 to 15 9 months to an average of | year.6 On some occasions programs will extend beyond | year for certain clients. Length of treatment sometimes is equated with the number of sessions involved. For instance, individual intake and evaluation usually account for a low of 2 to a high of 6 ses- sions, followed by 25, 30, or up to 36 weeks of group, indi- vidual, and family therapies. Sessions generally range from a low of | hour to 3 or more hours per week, plus time spent on homework and additional sessions where family therapy is involved. Cli- ents are usually from 9 to 18 years of age, predominantly in the l4- to 17-year old range. Lately PREAP has been receiving a number of calls for referrals for programs or treatment approaches for youths as young as 7 and 8 years of age. There is a need to share information on methods of treating these extremely young sexual aggressors. The most common components of psychosocioeduca- tional programs used in community-based treatment are social skills training; education in human sexuality and val- ues; victim awareness, responsibility, and empathy; anger management; sex role expectations and stereotyping; and-- where clients have suffered emotional, physical, or sexual trauma--victim counseling approaches. Most programs do not deal with drug-dependent cli- ents. They either refer them to programs that specialize in such treatment or require that these adolescents com- plete or be involved in drug treatment before joining the sex offender program. Most community-based sex offender programs use a combination of guided peer group therapy, individual therapy, and family therapy. Programs that do not include the important component of family treatment cite, as reasons for this omission, lack of staff, unavailability of parents, or inability to cope with family therapy. Gener- ally, the treatment approach is eclectic and may combine gestalt therapy, transactional analysis, psychodrama, rational emotive therapy, and Samenow and Yochelson's identification of thinking patterns. It may also include 6Where the incident was a "borderline" sexual of- fense, treatment may be reduced to as little as 4 weeks. 16 behavioral treatment employing counterconditioning meth- ods of covert and assisted covert sensitization, recondi- tioning to appropriate sexual outlets, masturbatory recon- ditioning, and simple impulse control exercises. Methods may include intensive journal and log keeping (of fantasies, offense syndromes, or anger-evoking situations), role plays, and field trips to the scene of the sexual crime. The Personal/Social Awareness Program (PSA), which is described in some detail in Remedial Intervention in Adolescent Sex Offenses: Nine Program Descriptions (Knopp 1982, pp. 51-63), provides a unique community- based model integrating the themes of positive human sex- uality and family therapy. This 8-year-old program has served over 100 families and youths. PSA resists using the label "sex offender" and instead describes its 11- to |8- year-old male and female clients’ as those "who have violated sexual norms to the extent it is causing the family or some public agency considerable concern." The program has expanded so that it now can serve 32 families (125 cli- ents) at one time in an intensive treatment program that usually takes 9 to 12 months to complete but may take longer. For each client, the program includes a weekly 3-hour adolescent therapy group (two for boys and one for girls). Cotherapists lead the groups and combine peer interaction with therapist intervention. The members of the group in- troduce themselves in terms of their specific sexually of- fensive behaviors and their family situations. Group mem- bers are responsible for bringing up personal issues they need to work on and must ask for help on these issues and solicit feedback from the group. The group also addresses specific educational needs, such as male/female sexuality, venereal diseases, contraception, and so forth. Every 2 months on a rotating basis, each group em- barks on a 27-hour marathon session held overnight at a retreat center. This provides an intensive therapeutic ex- perience governed by the same therapeutic principles as the weekly group sessions. Each client brings a list of 7PSA is one of two programs in the country that have separate groups for females who are involved in sexually aggressive behaviors. 17 therapeutic goals that are posted on the walls and provide the basis for group evaluation that occurs at the end of the marathon. The retreat center has a pool, whirlpool, and sauna that, along with massage sessions, help participants get in touch with their bodies and senses in a positive, healthy way. A parents' therapy group meets weekly in the evening for its own session, led by cotherapists who are also par- ents. The groups are governed by the same principles that guide that adolescents' groups. Parents often continue in groups even after their children leave the program. Once every 2 weeks, the adolescent and his family meet with one of the PSA staff counselors skilled in family therapy. These meetings may be supplemented by individ- ual therapy sessions with family members, but the family unit is the primary focus of change efforts. Family Learning Experiences are educational events held in evening sessions once every 2 months. They provide a lecture /workshop format led by a guest expert on such topics as shame and guilt, spirituality and values, family sex education, relaxation and stress, and so forth. The Family Journey, a weekend event held twice a year, invites all participating families to an exploration of feelings, attitudes, myths, realities, and values surrounding sexuality in our culture and in the lives of program partici- pants. These are SAR (Sexual Attitude Reassessment) for- mats, and presentation topics include male/female rela- tions, same-sex relations, masturbation, sex and aging, sexuality and handicaps, puberty, rape and sexual violence, and sex education. The journey is led by a staff of approxi- mately 15, and sessions are evaluated by the participants. An exit interview is conducted, and client progress is measured through a 2l-item description of behaviors and attitudes ranked by the therapist on a scale from 1 to 5. Also included are staff consultations, discussions with the client and his or her family, and consultations with proba- tion officers and social service workers. Progress is meas- ured along a set of four overarching goals: | The adolescent will accept responsibility for the problem behaviors 18 2. The adolescent's knowledge and understanding about sexuality will be significantly improved and reduce the problem behaviors 3. The adolescent will evidence positive self-control 4. The families will provide an improved environ- ment for the development of healthy sexuality of family members. Groups are open to the adolescent after graduation from the program. Forty-eight clients completed all phases of the pro- gram; of these, only 2 are reported to be recidivists. While these reported successes are impressive, this program is of interest because its emphasis is not only on sex education and values but on positive sexuality within the family context. It is becoming increasingly apparent to me (and I have no data to validate these remarks other than my own per- ceptions) that because of the adolescents' stage of physio- logical and sexual development, an impressive number of their offenses appear to be sexual in nature but acted out through power. This is in contrast to our understanding of adult sex offense patterns, which are characterized as power and anger acted out through sexuality. I invite others' reaction to this statement. Behavioral Treatment At the time I wrote Remedial Intervention in Adoles- cent Sex Offenses, which was based on research conducted in 1981 and 1982, 1 was unable to locate programs using behavioral approaches with adolescent sex offenders with the exception of thought-stopping or very nonintrusive im- pulse control exercises. I found no adolescent programs using the penile plethysmograph, aversive conditioning, or masturbatory reconditioning. PREAP has currently identi- fied almost two dozen programs (primarily but not exclu- sively in the Northwest) that use behavioral methods in combination with some of the psychosocioeducational methods mentioned previously to evaluate and/or treat 19 adolescent sex offenders. While in the future I hope to visit and interview program principals utilizing these meth- ods more extensively, I report briefly now on the results of recent telephone interviews with five clinicians using be- havioral methods. Four of the clinicians use the penile plethysmograph to measure deviant arousals at intake, during treatment, and before graduation. The majority limit its use to clients at least 14 or 15 years old; however, one clinician uses physio- logical measurements with clients as young as 12. A few of the clinicians use the least intrusive inter- vention. To decrease arousal, one clinician uses only sim- ple thought-stopping and thought-changing exercises as a first step. If needed, he progresses to covert sensitization with aversive imagery to decrease arousal, using aversion tapes of police sirens, sounds of persons vomiting, sounds of someone being chased, and so forth. These tapes are used in conjunction with olfactory aversion (usually am- monia or placenta culture) to disrupt the arousal. Other clinicians use more intrusive behavioral methods from the very beginning of treatment; all use covert and assisted covert sensitization. Only one of the clinicians interviewed uses electric shock with adolescents. The treatment is applied to the fingers and is described as "mild." This behaviorist recom- mended the combination of olfactory conditioning (using either ammonia, placenta culture, or valeric acid) and electric shock as an effective method for treating adoles- cent sex offenders. All but one of the behaviorists favored increasing appropriate arousal by encouraging masturbation to age- appropriate pictures and fantasies. One clinician teaches the young people how to monitor themselves on the ple- thysmograph while using age- and sex-appropriate slides and tapes. Another encourages masturbation as a sexual outlet but does not encourage fantasizing to any particular theme. The clinician who does not favor using masturba- tory reconditioning or satiation cites the therapist's inabil- ity to project the effects of this approach. Oregon clinicians indicate that behavioral assessment and treatment are not frowned upon by the Children's 20 Services Division of that State, but other States are ex- tremely apprehensive about using behavioral methods with children who are in community or residential custody, es- pecially in closed settings. Issues of consent, permission, and legal liability are no doubt involved, but other factors may also influence these attitudes. Dialogue is needed be- tween clinicians who favor behavioral treatment and those who do not. However, the controversy is a reflection of a larger problem: we lack effective tools with which to measure the benefits of various approaches and, therefore, lack the means to combine the most successful approaches into our training mechanisms. Segregating Sex Offenders in Residential Programs Most residential treatment programs do not provide separate cottages or quarters for sex offenders. Usually, they live in the general population but meet in separate, offense-specific groups at least once per week. A program of great interest is the 7-year-old Hennepin County Home School in Minnetonka, Minnesota. Until fall of 1982, the sex offenders were mixed in with the general population. Since that time, they have been housed separately--first, in a single cottage and, more recently, as the sex-offender population has expanded, in two cottages. Gail Haversack, lead social worker at the school, re- ports considerable advantages for both staff and residents to housing sex offenders in separate cottages. Before sex offenders were separated, staff were somewhat intimi- dated by the offenders' manipulative and victimizing be- haviors. They found that sex offenders could divide staff very successfully with issues regarding their treatment. Efforts to train staff to exercise the knowledge, confi- dence, and comfort needed to deal with these youngsters had to cover the entire institution. Presently, though all staff are trained to relate to the sex offender population, training is intensified in the sex offender cottages and staff are eager to become specialists. Haversack reports that sex offenders have a far stronger treatment culture when all the residents are working on similar issues. In effect, it permits them to implement their program 24 hours a day. When all the 21 youngsters are dealing with their manipulative and intimi- dating behaviors, they can recognize them more readily in one another and help one another deal with them. Because the treatment culture is stronger and the focus can be on sexual or abusive issues all day, Haversack believes a resi- dent's stay is shortened considerably. Another real plus in having all the sex offenders in separate cottages is that they are more comfortable in dealing with their sexual issues; for example, they can talk more openly about homosexuality or masturbation. An at- mosphere is created that allows them to receive and give nurturing to other people. They can hug one another and they can cry, which is often difficult in a generalized treatment program for adolescent males. New residents often express surprise at an older, stronger, and higher status youngster asking a peer for support and a hug. This type of modeling gives other residents permission to have their needs met in a positive way, too. Haversack says these sex offenders put very little en- ergy into "beating the system." For example, all the resi- dents who have needed to have their stays extended have supported those extensions when they appeared in court. The mentality that considers the residents the "good guys" and the staff the "bad guys" is absent. Hennepin County Home School is one of six PREAP- identified programs that will take adolescent sex offenders from out of State if they have space and if the clients ful- fill certain criteria. The need for residential treatment is great. States lack the type of homelike residency that gives more struc- ture than many families provide but not as much structure as a medium-security unit demands. In a few instances, atternpts to fill this need have resulted in a small number of beds in group homes being set aside for sex offenders who then attend community-based outpatient programs for 8These include the Special Care Unit, North Idaho Children's Home; the South Idaho Girls Home (adolescent female sex offenders); Nexus; the High Risk Offender Program, Lincoln Regional Center; and the Ethan Allen School. See appendix A. 22 sex offenders. A hopeful note is the effort being made to replicate for adolescents one of the most compelling adult treatment models identified by PREAP. A private corpo- rate entity, Alpha Human Services, is an intensive thera- peutic program for 26 adult sex offenders who reside in a homelike setting in a quiet neighborhood in Minneapolis. (see Knopp 1984). Thus far, psychologist Gerald Kaplan, Alpha's director, has not been successful in locating a suitable site for an adolescent program. Such models are sorely needed. Too many adolescent sex offenders wind up in adult maximum-security prisons where there are no services, little hope for restoration, and a high potential for sexual victimization. A Neglected Population: The Low Functioning Sex Offender PREAP has long been concerned about the lack of spe- cific treatment for the low-functioning or mildly retarded adolescent sex offender.” Though some treatment pro- viders include such youth among their clientele, PREAP has not found any specialized groups or tested methods for serving these clients. Most programs will not treat low-functioning or mildly retarded adolescent sex offenders. Some may include 1 or 2 in the group but admit such clients rarely get very much from the program; one program treats up to 12 such per- sons a year. The program we discovered with the deepest interest in, and the most data on, this clientele uses an Al- coholics Anonymous inodel with professional leadership, very concrete treatment, sex education, social skills train- ing, and a support/insight focus. Other programs report that individual treatment with occasional group work seems most helpful. These clients need a longer period of treatment, more impulse control work, more assertiveness training, and a great deal of social skills training. Everything needs to be made IQ's usually range from high 60s through 80s. 10An adult residential program serving this clientele is described by Knopp (1984). 23 concrete. It is important to work with parents so new behaviors can be reinforced. Community networking is encouraged so neighbors can help monitor these low- functioning clients. Everyone working with this population is hungry for information and effective treatment approaches. It is an area that requires an intensive exchange of information so that skills can be transferred to professionals who work with these needy clients. The Need for Comprehensive Training We are all aware of the need for training traditional mental health and other service providers in the treatment of adolescent sex offenders. Training has been carried on informally in the following ways: l. Some treatment programs provide internships for persons who wish to learn the program's techniques. 2. Some specialists travel to various sites and con- duct seminars and training sessions, usually for | or 2 days. 3. Special training sessions have been included in planning conferences on these issues. 4. Experienced persons serve as consultant/trainers to individuals and groups. - 5. More recently, some of the local networks we mentioned earlier have been helping to keep treatment people aware of new techniques and approaches. More formal arrangements need to be developed by Federal, State, and local agencies responsible for mental health, corrections, child sexual abuse, public health, and public safety services. Schools and departments of medi- cine, pediatrics, psychology, social work, nursing, and public health should include in their curricula mandated courses in human sexuality and victimology, electives in 24 sex offender treatment,!l and internships in established treatment programs for sex offenders. Treatment of sex offenders should be emphasized as a recognized and valid discipline in the mental health field. Treatment Success Longitudinal studies of sex offenders who have com- pleted treatment programs have not yet been undertaken; however, preliminary program results are encouraging in terms of low recidivism rates. As of spring 1985, three programs provided the following data. The Closed Adolescent Treatment Center (CATC) in Denver, Colorado, is highly structured, secure residential program for the most serious offenders who have commit- ted sexual and/or other violent crimes. Since 1979, CATC has released 12 sex offenders who completed the program, and none have reoffended. They have kept in touch with the program, so there has been a reasonably good check on reported reoffenses. The second, the Hennepin County Home School in Minnetonka, Minnesota, is a low-security residential pro- gram for serious sex offenders. Of the 62 offenders who completed the Sexuality Therapy Program since 1979, only two are known to have committed a sexual offense after release. One asked to be returned to the program, and it was only after his return that staff learned what the young man had not been able to disclose previously: he had been brutally raped by his brother when he was much younger. The Program for Healthy Adolescent Sexual Expression (PHASE) in Maplewood, Minnesota, is a community-based program serving "hands-off" and "hands-on passive" sex offenders. Among the 80 sex offenders who completed the lIpREAP has identified one such university course, entitled "Sex Offender Rehabilitation" and beginning in the fall of 1984 at Nova University, Fort Lauderdale, Florida. It is to be taught be Ed Sczechowicz, Ph. D., formerly on staff at the Geraldine Boozer Sex Offender Rehabilitation Program and now in private practice. 25 6-month program, no subsequent offenses have been reported. Summary Although the incidence of adolescent sex offenses con- tinues to be significantly underreported in official statis- tics, there is an increasing and discernible awareness of the extent of the problem. This is especially noticeable in the marked growth in the number of treatment services avail- able to these clients nationwide. Many States, however, are still identified as offering only one or no such services to adolescent sex offenders. Though treatment for adolescent sex offenders ap- pears to be evolving rapidly into a specialized discipline, its growth is not guided by any systematic development and testing of treatment approaches and outcomes. Further, only recently developed, largely informal networks, occa- sional conferences, and sporadic training sessions provide the means for exchanging information and advancing treatment techniques. The magnitude of the problem of adolescent sex offenses as a public safety issue warrants more formal arrangements and fiscal commitment by Federal, State, and county agencies to both enhance and standardize research and treatment possibilities for these young clients. References Abel, G.; Mittelman, M.; and Becker, J. "Sexual Offenders: Results of Assessment and Recommendations for Treatment." Unpublished manuscript available from New York State Psychiatric Institute, Sexual Behavior Clinic, April 1984. Brecher, E. Treatment Program for Sex Offenders. Wash- ington, D.C.: U.S. Department of Justice, January 1978. Dreiblatt, I. "Issues in the Evaluation of the Sex Of- fender." Unpublished paper available from the author, presented at the meeting of the Washington State Psy- chological Association, May 1982. 26 Groth, A. Lecture delivered to the annual ineeting of the New England Council on Crime and Delinquency, Burlington, Vt., September 10, 1981. Groth, A., with Birnbaum, H. Men Who Rape: The Psy- chology of the Offender. New York: Plenum Press, 1979. Groth, A.; Longo, R.; and McFadin, J. Undetected recidi- vism among rapists and child molesters. Crime and Delinquency 28: 450-458, July 1982. Haversack, G. Letter to F.H. Knopp, April 26, 1984. Jackson, I. A Preliminary Survey of Adolescent Sex Of- fenses in New York: Remedies & Recommendations. Syracuse, N.Y.: Safer Society Press, 1984. Knopp, F. Remedial Intervention in Adolescent Sex Of- fenses: Nine Program Descriptions. Syracuse, N.Y.: Safer Society Press, 1982 Knopp, F. Retraining Adult Sex Offenders: Methods and Models. Syracuse, N.Y.: Safer Society Press, 1984. Knopp, F.; Boward, B.; Brach, M.J.; Christianson, S.; Largen, M.A.; Lewin, J.; Lugo, J.; Morris, M.; and Newton, W. Instead of Prisons. Syracuse, N.Y.: Safer Society Press, 1976. 27 APPENDIX A Adolescent Sex Offender Treatment Providers, June 1985 The following State listings of individuals and agencies providing specialized services for youthful male sex of- fenders do not include incest programs that treat young sex offenders in the context of the incest family. One asterisk (*) indicates that treatment in groups is not provided. Two asterisks (¥*) denote specialized treatment provided in residential settings. All other listings represent the avail- ability of group and other adjunctive treatment compo- nents in a community-based setting. The Prison Research Education Action Project (PREAP) maintains nationwide files of agencies and indi- viduals serving adolescent and adult sex offenders. Our referral capability will be enhanced if we are informed of additional adolescent sex offender treatment services not included in this listing; write to PREAP, Shoreham Depot Road, Orwell, Vermont 05760; or phone (802) 897-7541. ALASKA *¥ CHILD SEXUAL ABUSE TREATMENT PROGRAM 209 Fortymile Fairbanks, AK 99701 Wendy Warnick ARIZONA ADOLESCENT SEX OFFENDER TREATMENT Youth Services Bureau, Inc. 2333 North Third St. Phoenix, AZ 85004 Theron Weldy *¥ JUVENILE SEX OFFENDER PROGRAM Adobe Mountain School P.O. Box 35,000 Phoenix, AZ 85069 Paul S. Duda 28 CALIFORNIA »* * KH ¥*% PARENTS UNITED/TEENS UNITED 11519 B Ave. Auburn, CA 95603 Sharon Sloper YOUTH TRAINING SCHOOL 15180 Euclid Ave. Chino, CA 91710 Otis Brantley SERENDIPITY DIAGNOSTIC & TREATMENT CENTER 6441 Matheney Way Citrus Heights, CA 95610 Robert Elliot CHILD ABUSE PREVENTION COUNCIL P.O. Box 2243 El Centro, CA 92243 Peggy R. Devay JUVENILE INTERVENTION EDUCATION & PREVENTION PROGRAM 165 E. Lincoln Ave. Escondido, CA 92028 David McWhirter PSYCHOLOGICAL DIAGNOSTIC & THERAPY CENTER 1523 E. Valley Pkwy. Suite 305 Escondido, CA 92027 Raymond G. Murphy CHILD SEXUAL ABUSE TREATMENT PROGRAM 929 Koster St. Eureka, CA 95501 Ron Kokish YOUTH OFFENDER GROUP 2575 Harris Eureka, CA 95501 Mike Yeager 23 ¥* CHILD SEXUAL ABUSE TREATMENT PROGRAM Family Counseling Service of Coachella Valley 82-380 Miles Ave. Indio, CA 9220! Pat Marzicola AMADOR COUNSELING CENTER P.O. Box 271 Ione, CA 95640 Gary Lowe OAK COUNSELING PROGRAM Preston School of Industry 201 Waterman Rd. Ione, CA 95640 Gary Lowe FAMILY SUPPORT PROGRAM University of California at Los Angeles Neuropsychiatric Institute C9-933 760 Westwood Plaza Los Angeles, CA 90024 Virginia Cruz SPARK Children's Institute International 711 S. New Hampshire Ave. Los Angeles, CA 90005 Bonnie Yankowitz CHILD & FAMILY THERAPY CENTER 1210 Alhambra Ave. Martinez, CA 94553 Donald J. Cotton INCEST TREATMENT OF ADOLESCENT OFFENDERS 1127 13th St. Modesto, CA 95354 Susie Winston SISKIYOU COUNTY MENTAL HEALTH P.O. Box 557 Mt. Shasta, CA 96067 Arthur Silverman 30 ** ¥*¥ MARSHALL PROGRAM Southern Reception Center /Clinic 13200 S. Bloomfield Ave. Norwalk, CA 90650 Saul Neidorff DAVID CORWIN, M.D. 11 Moraga Way #3 Orinda, CA 94563 POSITIVE INTERVENTION 1041 East Green St. Suite 206 Pasadena, CA 91106 W. W. Robinson FORENSIC SERVICES GROUP 718 Alhambra Blvd. Sacramento, CA 95816 Richard Paul Mahoney SEX OFFENDER GROUP Wintu Intensive Treatment Program 3001 Ramona Ave. Sacramento, CA 95826 Rick Jeffries GROUP THERAPY FOR ADOLESCENT SEX OFFENDERS 426 Pennsylvania Ave. San Diego, CA 92103 Larry Corrigan ADOLESCENT SEX OFFENDER PROGRAM P.O. Box 952 San Jose, CA 95108 Henry Giarretto INTERACTION 925 W. Hedding San Jose, CA 95126 Stewart B. Nixon 3] ¥*¥ *% MURIEL WRIGHT RESIDENTIAL CENTER 298 Bernal Rd. San Jose, CA 95119 Denise Glavaris CASA DE AMPARO 4070 Mission Ave. San Luis Rey, CA 92068 Julie Mennen PARENTS UNITED JUVENILE OFFENDER GROUP 2400 Las Gallinas, Suite C San Rafael, CA 94903 Cheryl Barnes ADOLESCENT SEX OFFENDER TREATMENT GROUP 325 W. Los Olivos #C Santa Barbara, CA 93105 Keith Mar Kathleen Baggarley VALLEY COMMUNITY COUNSELING SERVICES 845 N. California Ave. Stockton, CA 95202 David Love TULARE COUNTY CHILD SEXUAL ABUSE TREATMENT PROGRAM P.O. Box 202 Tulare, CA 93275 Shirley Panitz CHILD SEXUAL ABUSE TREATMENT PROGRAM Mendocino County Mental Health Service 564 S. Dora Ukiah, CA 95482 Garry Hunt COLORADO * ARAPAHOE COUNTY JUVENILE DIVERSION PROGRAM 15400 E. 14th PL, #329 Aurora, CO 80011 William Beene 32 *% ¥** *% ADOLESCENT YOUTH SEX OFFENDER PROGRAM Moffat County Social Services 221 W. Victory Way Craig, CO 81625 Nancy Newport CLOSED ADOLESCENT TREATMENT CENTER 3900 S. Carr St. Denver, CO 80465 Vicki Agee DARROW CLINIC 1619 Gilpin St. Denver, CO 80218 David Becker James Selkin Walter Simon CLOSED TREATMENT UNIT Lookout Mountain School Golden, CO 80401 Connie Isaac John Davis REDIRECTING SEXUAL AGGRESSION, INC. P.O. Box 1572 Golden, CO 80402 Connie Isaac John Davis BLUE SPRUCE TREATMENT UNIT Lookout Mountain School Golden, CO 80401 Tom Leversee Susan Law ADOLESCENT BOYS GROUP Arapahoe County D.S.S. 5334 S. Prince Littleton, CO 80166 Judith Powers-Smith ARAPAHOE COUNTY JUVENILE DIVERSION 5304 S. Datura Littleton, CO 80120 Jenni King 33 CONNECTICUT FORENSIC MENTAL HEALTH SERVICE OF CONNECTICUT New London Exchange B 190 Governor Winthrop Blvd. New London, CT 06320 Peter Loss Jonathan Ross DELAWARE ADOLESCENT PERPETRATORS GROUP/PARENTS UNITED 124D Senatorial Dr. Greenville Pl. Wilmington, DE 19807 Joanne M. Kassees DISTRICT OF COLUMBIA JUVENILE ABUSER TREATMENT PROGRAM Children's Hospital 111 Michigan Ave. N.W. Washington, DC 20010 Paul Mitchell FLORIDA * ¥*% BROWARD COUNTY SEXUAL ASSAULT TREATMENT CENTER 1526 S. Andrews Ave. Ft. Lauderdale, FL 33316 Joanne G. Richter S. FLORIDA ADOLESCENT OFFENDER PROGRAM Westland Professional Bldg., #492 1490 W. 49th PL Hialeah, FL 33012 Edward S. Sczechowicz YOUTHFUL SEX OFFENDER PROGRAM 1000 S.W. 84th Ave. Hollywood, FL 33025 Edward S. Schzechowicz 34 ADOLESCENT SEX OFFENDERS PROJECT Advocate Programs, Inc. 1500 N.W. 12th Ave., #702 Miami, FL 33136 Robert A. Ameo S.T.0.P. A & A Professional Counseling Association 7241 S.W. 63rd Ave., #200 Miami, FL 33143 William R. Samek BAY COUNTY GUIDANCE CLINIC 615 N. MacArthur Blvd. Panama City, FL Dan Kiczerow GEORGIA * CHILD & FAMILY COUNSELING CENTER 114 Hospital Dr. Warner Robins, GA 31093 Mary Doby HAWAII JACK S. ANNON, PH.D. 1380 Lusitana St., #909 Hoonolulu, HI 96813 SEXUAL IDENTITY CENTER P.O. Box 3224 Honolulu, HI 96801 David Bohn IDAHO KOOTENAI TREATMENT ASSOCIATES 2110 Ironwood Pkwy., #208 Coeur d'Alene, ID 83814 John Farley REGION II MENTAL HEALTH SERVICES 1118 F St. Lewiston, ID 33501 Steve Lindsley 35 ¥*¥% * KH SPECIAL CARE UNIT N. Idaho Children's Home P.O. Box 319 Lewiston, ID 83501 Mark Hopper DEPT. OF HEALTH & WELFARE P.O. Box 749 McCall, ID 83638 Sandra Strange S.A.N.E. Community Health Center 1504 3rd St., N. Nampa, ID 83651 Pam Bekkedahl Seiders COMMUNITY TASK FORCE AGAINST CHILD SEXUAL ABUSE c/o Daughters & Sons United P.O. Box 4193 Pocatello, ID 83201 Walter D. Haworth, Jr. S. IDAHO GIRLS HOME Box 4669 Pocatello, ID 83201 Jeannette Grimmette IDAHO YOUTH SERVICES CENTER Box 40 St. Anthony, ID 83445 Dick Kendell ILLINOIS * ERIK B. SKAMSER, A.C.S.W. 5330 N. Kenmore Ave. Chicago, IL 60640 ERIK B. SKAMSER, A.C.S.W. 6125S. Archer Rd. Summit, IL 60501 36 INDIANA * HUMAN SEXUALITY PROGRAM Southlake Center for Mental Health 8555 Taft St. Merrillville, IN 46410 Marcella Wachowiak IOWA ADOLESCENT PERSONAL AWARENESS PROGRAM Story County Juvenile Court Services Central Iowa Mental Health Program 713 South Duff Ames, IA 50010 Daisy McCartney PERSONAL/SOCIAL AWARENESS PROGRAM Catholic Social Service 315 W. Pierce St. Council Bluffs, IA 51501 Danielle Griffin KANSAS * N. E. KANSAS MENTAL HEALTH & GUIDANCE CENTER 1301 N. 2nd Atchison, KS 66002 Kerry Marvin ADOLESCENT SEX OFFENDERS AND THEIR VICTIMS Wyandot Mental Health Center 36th at Eaton Kansas City, KS 66103 Judy Holley SEXUAL ABUSE TREATMENT TEAM N.E. Kansas Mental Health & Guidance Center 818 N. Seventh St. Leavenworth, KS 66048 Wayne C. Witcher 37 LOUISIANA EDWARD SCHWERY, PH.D. 3456 Cleary Ave. Metairie, LA 70002 MAINE * ¥*¥ CRISIS & COUNSELING CENTER 79 Sewall St. Augusta, ME 04330 Judy Brooks Jonathan Brown TRI-COUNTY MENTAL HEALTH SERVICES c/o The Depot 73 Pine St. Lewiston, ME 04240 Frank J. Walsh COMMUNITY COUNSELING CENTER P.O. Box 4016 Portland, ME 04101 Stephen Thomas THE INTENSIVE CHANGE SEX OFFENDERS PROGRAM Maine Youth Center 675 Westbrook S. Portland, ME 04106 David Berenson MARYLAND * WALTER P. CARTER CENTER 630 W. Fayette St. Baltimore, MD 21201 Margi E. Okum THE CHESAPEAKE INSTITUTE 10315 Kensington Pkwy., #213 Kensington, MD 20895 Linda Canfield Blick 33 MASSACHUSETTS * * FAMILY CRISIS PROGRAM Tufts New England Medical Center 20 Ash St. Boston, MA 02111 Michael Doran SEXUAL ABUSE TREATMENT UNIT Coastal Community Counseling Center 482 Washington St. Braintree, MA 02184 Lynn Sanford PARENTS UNITED/SONS & DAUGHTERS UNITED P.O. Box 579 Brockton, MA 02403 Mary Devlin SEXUAL ASSAULT DIVERSION PROGRAM 53 River PL Dedham, MA 02026 Patricia Nigrelli VALLEY COUNSELING ASSOCIATES 175 State St., #303 Springfield, MA 01103 William Hobson MICHIGAN ASSAULT RECOVERY ASSOCIATES 1100 Cramton N.E. Ada, MI 49301 Robin Zollar-Smietanka CHILD SEXUAL ABUSE TREATMENT PROJECT P.O. Box B Bay City, MI 48707 Luke Stephan STEVEN D. SHERBEL, PH.D. 111 S. Woodward #250 Birmingham, MI 48011 39 COPPER COUNTRY MENTAL HEALTH CENTER 920 Water St. Hancock, MI 49930 David Dill SEXUAL ASSAULT UNIT Associated Therapy Consultants 209 S. Niles Paw Paw, MI 49079 Zoe Schuitmaker SEXUAL ASSAULT UNIT Riverwood Community Mental Health Center 2681 Morton Ave. St. Joseph, MI 49085 Josephine Cassare COUNSELING ASSOCIATES 25835 Southfield Rd., #101 Southfield, MI 48075 Robert Klotz MINNESOTA ¥*¥ WELCOME HOME, INC. 10001 Lyndale Ave. S. Bloomington, MN 55420 Earl J. Barrett FIVE COUNTY HEALTH CENTER P.O. Box 287 Braham, MN 55045 Josh Kaplan NORTHERN PINES MENTAL HEALTH CENTER County Service Bldg. Brainerd, MN 56401 Jim Morrison ADOLESCENT SEXUALITY TREATMENT PROGRAM Psychology Network Ltd. 14300 Nicollet Ct. Burnsville, MN 55337 James Wright 40 *¥ *¥* FAMILY SEXUAL ABUSE TREATMENT PROJECT 2 East 5th St Duluth, MN 55805 Inez Wagner Cathy Lowry RELATES Center for Behavioral Development 740 E. Superior St. Duluth, MN 55802 Stephen Olmsted PHASE East Communities Family Center 1709 N. McKnight Rd. Maplewood, MN 55109 Michael O'Brien NEXUS 5915 Eden Prairie Rd. Minnetonka, MN 55343 Trudy Patterson Julian Foss SEXUALITY THERAPY GROUP Hennepin County Home School 14300 County Rd. (67) Minnetonka, MN 55343 Gail Haversack CENTER FOR BEHAVIOR THERAPY 606 24th Ave. S. Minneapolis, MN 55454 William W. Duffy PARK PLACE CLINIC 2445 Park Ave. Minneapolis, MN 55406 Michael O'Brien Jeff Brown PERSONAL SOCIO-AWARENESS PROGRAM Lutheran Social Services of Minnesota 2414 Park Ave. S. Minneapolis, MN 55404 William Seabloom 4] ¥*¥ HH *% SEASONS Program in Human Sexuality Research East Bldg. 2630 University Ave. S.E. Minneapolis, MN 55414 Janis Bremer UPTOWN MENTAL HEALTH CENER 2215 Pillsbury Ave. S. Minneapolis, MN 55404 Carl Marquit SEXUALLY RESPONSIBLE TEENS The Center for Parents & Children 810 4th Ave. S. Moorhead, MN 56560 John Molinaro THE MALE ADOLESCENT SEX OFFENDER GROUP Storefront Youth Action 7145 Harriet Ave. S. Richfield, MN 55423 Mike Wolf PORT OF OLMSTED CO. 2112 E. Center St. Rochester, MN 55901 Ronald Omdahl SEX OFFENDER PROGRAM Minnesota Correctional Facility Box C Sauk Centre, MN 56378 Dennis Rykken CENTRAL MINNESOTA MENTAL HEALTH CENTER 1321 N. 13th St. St. Cloud, MN 56301 David Baraga LEO A. HOFFMANN CENTER 100 Freeman Dr. St. Peter, MN 56082 David Compton 42 *% ADOLESCENT TREATMENT Willmar State Hospital Box 1128 Willmar, MN 56201 Mary Thalberg FAMILY SEXUAL ABUSE TREATMENT PROGRAM W. Central Community Services Center P.O. Box 787 Willmar, MN 56201 Autumn Cole MISSOURI * CENTER FOR BEHAVIORAL DEVELOPMENT 411 Nichols Rd., #217 Kansas City, MO 64112 Jack R. Alvord DIAGNOSTIC-TREATMENT CENTER St. Louis Juvenile Court 920 North Vandeventer St. Louis, MO 63108 Henry Hummert Rachel Tompkins MONTANA YELLOWSTONE PSYCHOLOGICAL SERVICES 2303 Grand Ave., Suite 7 Billings, MT 59102 Phillip Russell SEX OFFENDER TREATMENT PROGRAM S.W. Montana Mental Health Center 512 Logan Helena, MT 59601 Greg Barisich CHILD SEXUAL ABUSE TREATMENT PROGRAM N.W. Montana Human Resource Council Ist & Main Kalispell, MT 59901 Pamela Jeffcock 43 * BITTERROOT PSYCHOLOGICAL SERVICES 128 S. 6th W. Missoula, MT 59801 Paul Moomaw NEBRASKA *% HIGH RISK OFFENDER PROGRAM The Lincoln Regional Center P.O. Box 80499 Lincoln, NE 68501 Leslie Margolin Suzanne Bohn ADLERIAN COUNSELING SERVICES 256 N. 115th St. Omaha, NE 68154 Janet Guilfoyle PERSONAL INTERRELATIONSHIP & SEXUAL AWARENESS GROUP Y.W.C.A. 222 S. 29th St. Omaha, NE 68131] Mary Larsen PERSONAL/SOCIAL AWARENESS 1210 Golden Gate Dr. Papillion, NE 68046 Rosalyn Trumm NEVADA ¥*¥ PSYCHOTHERAPEUTIC ASSOCIATES 1020 E. Desert Inn, Suite A Las Vegas, NV 89109 Nadine Bleeker ADOLESCENT SEXUAL OFFENDERS PROGRAM 480 Galletti Way Reno, NV 89512 Diane Merier uy N. NEVADA CHILD & ADOLESCENT SERVICES 2655 Enterprise Rd. Reno, NV 89512 Wilford Beck NEW JERSEY WARREN COUNTY SEX ABUSE TREATMENT TEAM 323 Front St. Belvidere, NJ 07323 Alice Carducci ** ADOLESCENT PROGRAM Pinelands Residential Group Center Star Route, Box 53 Chatsworth, NJ 08019 Kim Zelley NEW JERSEY PSYCHOLOGICAL INSTITUTE 93 West Main St. Freehold, NJ 07728 Martin I. Krupnick FAMILY GROWTH PROGRAM Catholic Welfare Bureau 39 N. Clinton Ave. Trenton, NJ 08607 Ed Rosado SEXUAL ABUSE TREATMENT PROGRAM Family Guidance Center of Warren County 21 W. Washington Ave. Washington, NJ 07882 Terry Powell NEW MEXICO SEX OFFENDER TREATMENT PROGRAM S.W. Psychological Services 839 Paseo De Peralta, Suite D Santa Fe, NM 87501 Susan Cave 45 NEW YORK ¥*¥ ¥*% ¥*¥* ADOLESCENT PRACTICE 346 Quail St. Albany, NY 12208 Linda Frye, Patricia Foscato THE JUVENILE SEX OFFENDER PROJECT St. Anne Institute 160 Main St. Albany, NY 12206 Richard Hamill MACCORMICK SECURE YOUTH CENTER South Rd. Brooktondale, NY 14817 Kay Scharoun BROOKWOOD SECURE CENTER Box 265 Claverack, NY 12513 Francis Zanghi CHOICE PROGRAM Family Service Society of Corning I'l East Pulteney St. Corning, NY 14830 Program Coordinator SPECIAL NEEDS UNIT--CHODIKEE CENTER RD I-N Chodikee Lake Rd. Highland, NY 12528 Howard Holanchock SEXUAL BEHAVIOR CLINIC New York State Psychiatric Institute Box 17, 722 W. 168 St. New York, NY 10032 Judith Becker NORTH DAKOTA ¥* % CHARLES HALL YOUTH SERVICES, INC. P.O. Box 1995 Bismarck, ND 58501 Jeffrey Hanson 46 SEXUAL ABUSE TREATMENT TEAM W. Central Human Service Center 600 S. 2nd St. Bismarck, ND 58501 Paul Ronninger OHIO SERVICES FOR PHYSICAL & SEXUAL ABUSE Eastway Mental Health Center 400 Wilmington Ave. Dayton, OH 45420 Joan M. Evans OKLAHOMA * KELLY SHANNON, PH.D. 541 S. University Norman, OK 73069 FAMILY MENTAL HEALTH CENTER 1536 S. Sheridan Tulsa, OK 74112 Lise Moulton OREGON ¥* CLAISOP COUNTY ADOLESCENT SEXUAL OFFENDER PROGRAM P.O. Box 302, Courthouse Astoria, OR 97103 Chuck Sybrandt SEX OFFENDER PROGRAM St. Mary's Boys Home 16535 S.W. Tualatin Valley Hwy. Beaverton, OR 97006 Emma Dennis FAMILY OFFENDERS PROGRAM P.O. Box 189 Grants Pass, OR 97526 Phil Backus 47 ROBERT STAUNTON, M.S.W. 1050 N. First St., Suite 110 Hermiston, OR 97838 WASHINGTON COUNTY ADOLESCENT SEX OFFENDER PROGRAM 1665 S.E. Enterprise Circle Hillsboro, OR 97123 Jenna Coleman JACKSON COUNTY SEXUAL ABUSE TREATMENT PROGR AM 650 Royal Ave., #3 Medford, OR 97501 Sandra Mead CASCADE CHILD & FAMILY S.T.E.P. CLINIC 924 S.E. 45th St. Portland, OR 97214 Stuart Brown CENTER FOR BEHAVIORAL INTERVENTION 1225 N.W. Murray Rd., #215 Portland, OR 97229 Steven Jenson TONI FARRENKOPF, PH.D., & ASSOCIATES 2256 N.W. Pettygrove Portland, OR 97210 BARRY MALETZKY, M.D. 8332 S.E. 13th St. Portland, OR 97202 RESPONSIBLE ADOLESCENTS & PARENTS GROUP Morrison Center 3355 S.E. Powell Portland, OR 97214 Connie McCutcheon Bruce Jones 48 %*¥* *¥ CHILD & ADOLESCENT SECURE TREATMENT CENTER Oregon State Hospital 2600 Center St., N.E. Salem, OR 97310 Robert J. Benning SEX OFFENDER TREATMENT PROGRAM MacLaren School 2630 Pacific Hwy. Woodburn, OR 97071 Bob Lee PENNSYLVANIA ¥*¥ ¥** ¥*% VISION QUEST 1501 Liberty Ave. Franklin, PA 16323 Robert Craig CONCERN Professional Services for Children & Youth R.D. I, Box 183 Lehighton, PA 18235 Kevin E. Stichter SEX OFFENDER PROGRAM Youth Development Center P.O. Box 7029 New Castle, PA 16107 William Snyder TREATMENT OF YOUNG SEX OFFENDERS WITHIN THE CONTEXT OF THE FAMILY Philadelphia Child Guidance Clinic 34th and Civic Center Blvd. Philadelphia, PA 19104 Ruth Sefarbi TOGETHER WE CAN 429 Forbes Ave. Pittsburgh, PA 15219 Carolyn Russell 49 * YORK COUNTY CHILDREN & YOUTH SERVICES 108 Pleasant Acres Rd., R.D. 7 York, PA 17402 Betty Pinkernell RHODE ISLAND ¥*% JUVENILE SEX OFFENDER PROGRAM Rhode Island Training School 300 New London Ave. Cranston, RI 04910 Carol D. Censo SOUTH CAROLINA ¥*% BIRCHWOOD SEX OFFENDERS PROGRAM 5000 Broad River Rd. Columbia, SC 29210 Wallace Meggs SOUTH DAKOTA CHILD & FAMILY GUIDANCE CENTER P.O. Box 1572 Rapid City, SD 57709 Larry Creswell CHRYSALIS 4116 Canyon Lake Dr. Rapid City, SD 57702 Allen Winchester KATHLEEN PEIL, M.A. 628 1/2 6th St., #208 Rapid City, SD 57701 CHILDREN'S HOME SOCIETY OF SOUTH DAKOTA E. River School 1000 W. 28th Sioux Falls, SD 57105 Norma Finnell 50 * E. RIVER SEXUAL ASSAULT TREATMENT CENTER 1728 S. Cliff Sioux Falls, SD 57105 Gloria Houle Dick Seaman TEXAS ABUSE AND NEGLECT TREATMENT SERVICES Community Guidance Center 2135 Babcock Rd. San Antonio, TX 78229 Margot B. Zuelzer GRID PROGRAM 4200 Westheimer, Suite 280 Houston, TX 77027 Jerome B. Brown UTAH PARENTS UNITED 622 23rd St. Ogden, UT 84401 Duane Johnson YOUTH PROGRAM Weber Mental Health Center 550 24th St. Suite 107 Ogden, UT 84401 B. Mathews Hill DR. ROBERT CARD 24 "M" St. Salt Lake City, UT 84103 VIRGINIA PENINSULA PSYCHIATRIC HOSPITAL 2244 Executive Dr. Hampton, VA 23666 George Deshazor 51 COMMUNITY MENTAL HEALTH CENTER & PSYCHIATRIC INSTITUTE 721 Fairfax Ave. P.O. Box 1980 Norfolk, VA 23501 Fae Deaton SEXUAL TRAUMA PROGRAM R.I.A. Psychiatric Associates 735 Newtown Rd. Norfolk, VA 23502 Yvette Iglecia DOMINION PSYCHIATRIC ASSOCIATION 1709 First Colonial Ct. Virginia Beach, VA 23453 Dan Sandlin WASHINGTON ¥*% SEX OFFENDER PROGRAM Eastside Community Mental Health Center 1609 116th Ave., N.E. Bellevue, WA 98004 Marcia Jimenez NORTHWEST TREATMENT ASSOCIATES 2509 Cedarwood Bellingham, WA 98225 Mike Isbell JOHN M. GUZA, PH.D. 3306 Perry Ave. Bremerton, WA 98310 SEX OFFENDER PROGRAM Maple Lane School 20311 Old Hwy. 9, S.W. Centralia, WA 98531 M. Kathleen McBride ROBERT S. FLEMING, M.D. 21616 76th Ave., W. Edmonds, WA 98020 52 MICHAEL O'CONNELL, M.S.W. 8625 Evergreen Way, #203 Everett, WA 98204 SNOHOMISH COUNTY SEX OFFENDER PROJECT Snohomish County Juvenile Court 2801 Tenth St. Everett, WA 98201l Brad Garner NORTHWEST THERAPY ASSOCIATES 33919 9th Ave. S. Federal Way, WA 98003 Erick Desselle LUTHERAN SOCIAL SERVICES OF WASHINGTON 320 N. Johnson, #700 Kennewick, WA 99336 Mary Miles-Rockenfield TRI-CITY CHAPLAINCY 1149 N. Edison Kennewick, WA 99336 Barry Ceating SEX OFFENDER PROJECT Benton-Franklin Juvenile Justice Center 5506 W. Canal Kennewick, WA 99336 Shirley Hassberger RICHARD INGRAHAM, PH.D. Rt. 1, Box 45! Kingston, WA 93346 THURSTON/MASON COUNTY COMMUNITY MENTAL HEALTH CENTER P.O. Box 592 Olympia, WA 98507 Candace Vogler PENINSULA COUNSELING CENTER 603 E. 8th St., #4 Port Angeles, WA 98362 Gary Carlson 53 ¥*¥ UMBRELLA COMMUNITY SERVICES Midway Business Center, #28 Port Angeles, WA 98362 Larry Brietten GRIFFIN HOME Friends of Youth 2500 Lake Washington Blvd. N. Renton, WA 98056 Claude Carlson DANIEL L. MCIVOR, PH.D. 1776 Fowler, #13 Richland, WA 99352 MID-COLUMBIA MENTAL HEALTH CENTER 1175 Gribble Ave. Richland, WA 98301 Mike Henry PHILIP G. BARNARD, PH.D. 750 Swift Blvd. Medical Arts Bldg., #4 Richland, WA 99352 DAVID B. COPPEL, PH.D. 2200 24th Ave. E. Seattle, WA 98112 PETER FEHRENBACH, PH.D. 1507 Western Avenue, #403 Seattle, WA 98101 GARY WIEDER, PH.D. 1507 Western Ave., #403 Seattle, WA 98101 JUVENILE SEX OFFENDER PROGRAM Adolescent Clinic #CD287 University of Washington Hospital Seattle, WA 98105 Caren Monastersky 54 ¥*¥ SEXUAL BEHAVIOR PROBLEMS PROGRAM Child Development & Mental Retardation Center University of Washington Seattle, WA 98195 Jeff Snow LUTHERAN SOCIAL SERVICES OF WASHINGTON 19230 Forest Park Dr., N.E. Seattle, WA 98155 Stephen J. Stephenson MICHAEL L. MILLER, PH.D. 9730 3rd Ave. N.E., #202 Seattle, WA 98115 LESLIE H. RAWLINGS, PH.D. 550 16th Ave., #300 Seattle, WA 98122 STEPHEN J. STEPHENSON, PH.D. 1818 Westlake Ave. N., #429 Seattle, WA 98109 PETER THOMAS, M.A. 5806 Latona Ave. N.E. Seattle, WA 98105 MCHUGHS ASSOCIATES COUNSELING CENTER P.O. Box 1326 Sequim, WA 98382 Margaret A. McHughs William T. McHughs PAUL A. WEINSTEIN, PH.D. 14216 Thornas Dr. Silverdale, WA 98383 SEX OFFENDER THERAPY PROGRAM Echo Glen Children's Center 33010 S.E. 99th St. Snoqualmie, WA 98065 Mary Lafond JOHN COLSON, M.A. WwW. 508 6th Ave., #612 Spokane, WA 99204 55 DRIECUS ASSOCIATES W. 1609 Garland Spokane, WA 99205 Betty McQuirk BERT POWELL, M.A. 5th & Browne Medical Bldg., #330W Spokane, WA 99202 KAREN UTHEIM, M.ED., & PAUL M. WERT, PH.D. S. 601 Division St. Spokane, WA 99202 GARY WOODS, M.S. S. Center Medical Bldg., #418 W. 105 8th Ave. Spokane, WA 99204 COMMITMENT ALTERNATIVE PROGRAM Pierce County Juvenile Court--Remann Hall 5501 6th Ave. Tacoma, WA 98406 Kathy Lyle GIBBS & ASSOCIATES 1919 70th Ave., W. Tacoma, WA 98466 Sandra Gibbs TIM TAYLOR, PH.D. 915 1/2 Pacific Ave., #309 Tacoma, WA 98405 ALLEN TRAYWICK, PH.D. 401 S. Broadway Tacoma, WA 98402 DEAN V. HARRIS, PH.D., & ASSOCIATES 2011 St. Johns Blvd. Vancouver, WA 98661 Albert Bernstein 56 ELAHAN CENTER FOR MENTAL HEALTH & FAMILY LIVING 1950 Fort Vancouver Way, Suite A Vancouver, WA 98663 Roger Meinz C. KIRK JOHNSON, PH.D. 2012 Broadway Vancouver, WA 98663 PATRICK KIRKPATRICK, PH.D. 6108 N.E. Hwy. 99 Vancouver, WA 98665 JUDY Ww. WEBER, PH.D., & HENRY N. WEBER, PH.D. 2300 E. Mill Plain Blvd. Vancouver, WA 98661 WISCONSIN * ¥*¥ BRIEF FAMILY THERAPY CENTER 6815 W. Capitol Dr. Milwaukee, WI 53216 Insoo Berg SEX OFFENDER PROGRAM OF RECOVERY & THERAPY 2130 Oakridge Ave. Madison, WI 53704 Nancy Rau Heckman ETHAN ALLEN SCHOOL Box WX Wales, WI 53183 Ron Patros MARATHON HEALTH CARE CENTER 1100 Lake View Dr. Wausau, WI 54404 Mary Boyce 57 APPENDIX B Identifying Adolescent Sex Offenders: Family Incest Treatment Programs as Source (A PREAP Survey, May 1, 1984) Susan Thompson Summary The purpose of this survey was to identify the number and types of treatment programs for adolescent sex of- fenders that evolved as a result of treating the incest family. Twenty-six programs responded positively to the survey. They reported the following: 88.4 percent stated that awareness of the need for a treatment program for adolescent sex offenders emerged as a result of treating the incest family 100 percent offer outpatient treatment (15.3 per- cent also have a residential component) 92.3 percent provide group treatment; the majority have three to eight participants and meet once a week for 90 minutes 34.6 percent provide treatment to female adolescents 19.2 percent provide treatment to developmentally disabled adolescents 92 percent treat child molesters; 73 percent treat exhibitionists and voyeurs; 46.1 percent treat rapists 13 programs have no project descriptions; 12 do not collect program data 58 Survey Method and Purpose On December 20, 1983, surveys (see attachment 1) were mailed to a list of 99 Child Sexual Abuse Treatment Programs in 29 States (see attachment 2.1 The purpose of this survey was to identify the number and types of treatment programs for adolescent sex offenders that evolved as a result of treating the incestuous family. Results Of the 99 surveys mailed, three (3 percent) were re- turned (wrong address/nondeliverable); 57 (57.5 percent) responses were received. Of these 57 responses, 31 (54.3 percent) indicated they had no adolescent sex offender treatment program. However, three (5.2 percent) of these programs stated they were currently developing such pro- grams. A fourth program was considering development of such a program. Two additional programs stated they recognized the need for adolescent sex offender treat- ment. Another reported they "are seeing some cases but not enough to warrant a program." One other program said the "problem [adolescent sex offenses] has begun to mani- fest itself." Of the 57 respondents, 26 (45.6 percent) indicated they have services in their program for adolescent sex offend- ers. All 26 programs offer outpatient treatment for ado- lescent sex offenders. Of these 26 programs, four (15.3 percent) have a residential component for adolescent sex offenders (though these residential centers are not exclu- sively for adolescent sex offenders). None of these resi- dential programs accept out-of-state referrals. Eleven (42.3 percent) of the 26 programs also treat adult sex offenders; one of these programs has an adult group in the local jail. One program did not respond to this section. 1 This listing of Child Sexual Abuse Treatment Pro- grams and Parents United chapters was provided to PREAP by the Institute for the Community as Extended Family, P.O. Box 952, San Jose, California 95108. 59 Of the 26 programs treating adolescent sex offenders, 23 (88.4 percent) stated that awareness of the need for a treatment program for adolescent sex offenders emerged as a result of treating the incest family. Specific Findings Group Treatment Of the 26 programs, 24 (92.3 percent) offer group treatment to adolescent sex offenders. The 2 other pro- grams stated that they saw the need for groups but cur- rently did not have a sufficient number of clients. Twenty (76.9 percent) of the 26 programs also provide individual (one-to-one) treatment for adolescents. Six progams (23 percent) stated they also offer family treatment for ado- lescent sex offenders. Number in each group. Of the 24 programs offering group treatment, the majority service three to eight ado- lescents in each group. The lowest reported number in a group was two (reported by one program); the largest num- ber of participants was 15 (reported by one program). The modal group numbers were four, five, and eight (three programs each). Two programs did not respond to this question. Age range of participants. The age range of par- ticipants in treatment for adolescent group sex offenders was from Il to 21. The majority of adolescents in these groups were between the ages of 12 and 18. Ten programs did not respond to this question. Length and frequency of meetings. Only 15 pro- grams reported the length of time involved in group treatment of adolescent sex offenders. Of these 9 meet for 90 minutes; 2 meet for 2 hours, plus an additional hour in a group with the participants' parents; 2 other programs meet for 2 hours; and 2 programs reported their groups meet for | hour. Eighteen programs reported that their groups meet weekly. Only one program stated that their group meets 60 every other week. Seven programs did not respond to this question. Criteria for group participation. Of the 24 pro- grams that offer group treatment for adolescent sex of- fenders, 17 (70.8 percent) listed at least one criterion for participation. Six stated the participant must be a male adolescent. Four programs reported they would treat only nonviolent sex offenders or persons with no history of physical violence. Two programs stated that the group participant must be known to the court or to children's protective services. One program stated they treat only first-time offenders. Another program reported they treat only adolescents who had committed abuse within the family. One program stated that their criteria for group participation included individual treatment as well as in- volvement in family therapy. Seven programs listed no criteria. Female Adolescent Sex Offender Treatment Of the 26 programs that provide treatment for adoles- cent male sex offenders, 8 (30.7 percent) also provide serv- ices for female adolescent sex offenders. Eighteen pro- grams (69.2 percent) stated they do not treat female adolescent sex offenders. However, 2 of these programs reported they were not presently treating female adoles- cent sex offenders because of the limited number of these clients. Another program stated they had previously treated females with male adolescents in group treatment but currently had no females in treatment. Treatment for the Mentally Retarded and Developmentally Disabled Adolescent Sex Offenders Of the 26 programs treating adolescent sex offenders, 4 (15.3 percent) reported they treat mentally retarded or developmentally disabled adolescent sex offenders. Only 1 respondent specified that they treat the developmentally disabled. Twenty (76.9 percent) stated they do not treat this category of offender. However, 3 programs stated they would treat such persons if they received referrals. One of these programs stated that they would probably 61 have a separate group or program for such individuals when they received referrals. Another program, not presently treating this category of offender, stated that they do serve a developmentally disabled population in a prevention program. Two programs did not respond to this question. Categories of Sex Offenders Treated Of the 26 programs, 19 (73.0 percent) stated they treat the "less serious" (exhibitionist, voyeur) adolescent sex offender. Five programs (19.2 percent) reported they do not treat this category of offender. Twenty-four (92.3 percent) of the 26 programs re- ported they treat the "more serious" (molester) offender. Of the 26 programs, 12 (46.1 percent) stated they also treat the "most serious" (rapist) sex offender. Two other programs reported they would treat the most serious sex offenders conditionally. Ten programs (38.4 percent) stated they would not treat this category of sex offender. Two programs did not indicate the categories of offenders they treat. Program Descriptions and Data Collection Of the 26 programs treating adolescent sex offenders, 5 sent descriptions of their projects. One program stated their description was undergoing revision; another program reported their description was not specific to juvenile of- fenders. Thirteen programs (50.0 percent) reported they did not have descriptions of their projects. Eight programs did not respond to this section. Three of the 26 programs stated they collect data on their programs. Another 5 reported they would have data in the future. Four programs stated their programs were too new for any data to be compiled. Twelve programs stated they had no program data. Three programs did not respond to this section. 62 ATTACHMENT 1 Dear Friends; PREAP maintains a nationwide file of programs that treat adolescent and adult sex offenders and victims of sexual abuse. We are in the process of updating our files on treatment programs for adolescent and adult sex offend- ers. We are particularly interested in adolescent treat- ment programs that have emerged from programs treating sexually abused children and their families. Would you please respond to the following questions: i. 24 4. 3. Do you have a program for adolescent sex offenders? Title of program Address Phone Contact person Type of program: Adolescent Adult Outpatient Residential Group One-to-one Other Did the need for a program for adolescent sex offenders emerge as a result of treating the in- cest family? Yes No Comments: If group program, briefly describe: Number in each group } age of participants 3 frequency /length of meetings ; and special criteria for group participation: Do you have a program for female adolescent sex offenders? If this program differs from the male adolescent sex offender program, please describe: 63 10. 11. Does your program service developmentally dis- abled or mentally retarded sex offenders? Please describe if this is a separate program component: If this is a residential program, do you accept out-of-state adolescent sex offenders? Do you have criteria for acceptance? Please list: Please indicate which category of sex offender you treat in your adolescent program: a. Less serious (exhibitionist, voyeur) b. More serious (molestation) c. Most serious (rapist) [penetration] Is there a project description available? (Please enclose) Are program data available on age, type of of- fense, history of offenses, and recidivist rate? If yes, could you please enclose? Thank you for your assistance. For your convenience, we have enclosed a self-addressed envelope. Sincerely, Susan Thompson Research Assistant PREAP Shoreham Depot Road Orwell, Vermont 05760 (802) 897-7541 64 ATTACHMENT 2 Child Sexual Abuse Treatment Programs and Parents United Chapters ALASKA Anchorage Ray Clements, Ph.D. Parents United 303 E. 15th, Suite B Anchorage, AK 95501 907/267-6440 Fairbanks Blanche Brunk Fairbanks Interagency CSATP 809 College Rd. Fairbanks, AK 99701 907/456-2868 ARIZONA Coolidge Dave Wigton Dept. of Economic Security P.O. Box 377 Coolidge, AZ 84228 602/723-5351 Phoenix Richard F. Johnson DES, Dist. 1, CPS 3727 E. McDowell Rd. Phoenix, AZ 85008 602/244-8855 65 Tucson Carmen Preciado Child Protective Services 4901 E. 5th Tucson, AZ 84228 602/723-5351 Yuma Charlene L. Hicks Children's Village 257 South Third Ave. Yuma, AZ 85364 602/703-2394 ARKANSAS Kinley Sturkie Barbara Bender CSATP P.O. Box 1766 Little Rock, AR 72203 501/370-5806 CALIFORNIA Alameda County Emergency Response Unit La Vista Unit 2 2300 Fairmont Dr. San Leandro, CA 94578 415/483-9300 Contra Costa County Glen Austad Parents and Families United 735 Alhambra Martinez, CA 94553 415/229-4090 66 Humboldt County Ron Kokish 929 Koster Eureka, CA 95501 707/445-6180 Mail to: P.O. Box 3752 Eureka, CA 95501 Imperial County Sylvia L. Strickland, M.D. Imperial County Child Abuse Prevention Council 480 Olive Ave., Suite 4 El Centro, CA 92243 619/353-4780 Kern County Trish Massa Kern County Mental Health 1960 Flower St. Bakersfield, CA 93305 805/861-2251 Los Angeles County Lancaster Fred Sassoon Dept. of Public Soc. Serv. P.O. Box 922 Montebello, CA 90640-0922 213/727-4285 Los Angeles Esther Gillies Chief Coordinator Greater L.A. Area P.O. Box 922 Montebello, CA 90640-0922 213/727-4270 67 Long Beach Carol Reed Dept. of Public Soc. Serv. P.O. Box 922 Montebello, CA 90640-0922 213/727-4285 Montebello Anita Davis Dept. of Public Soc. Serv. P.O. Box 922 Montebello, CA 90640-0922 213/724-0100 X1814 Paramount Carol Reed /Charles Glenn Dept. of Public Soc. Serv. P.O. Box 922 Montebello, CA 90640-0922 213/727-4286 Pomona Amaryllis Watkins Dept. of Public Soc. Serv. P.O. Box 922 Montebello, CA 90640-0922 213/727-4283 Marin County Cheryl Barnes 2400 Las Gallinas Suite C San Rafael, CA 94903 415/499-8490 415/499-7172 63 Mendocino County Dave Cook c/o Parents United 747 S. State St. Ukiah, CA 95482 707/468-4351 Zena Marks Mental Health 860A N. Bush St. Ukiah, CA 95482 Napa County Sharon Zimmerman Mental Health Out Patient Services 2344 Old Sonoma Rd. Napa, CA 94558 707/253-4306 Ed Cole CPS 2261 Elm St. Napa, CA 94558 707/253-4261 Nevada County Marcia Rogers Dept. of Soc. Serv. 10433 Willow Valley Rd. P.O. Box 1210 Nevada City, CA 95959 916/265-1340 Orange County Suzanne Long, Coordinator O. Robin Rowell, M.A. Family Service Asst. PH/DSU 17421 Irvine Blvd. Tustin, CA 92660 714/838-7377 69 Placer County Sharon Sloper Tom Stacey 11519 Avenue B Auburn, CA 95663 916/783-0401 Riverside Roy E. Lilos 7177 Brockton, Suite 339 Riverside, CA 92506 714/682-7844 San Bernardino County San Bernardino Verna Modrano Family Service 1669 N.E. St. San Bernardino, CA 92405 714/886-6502 Victorville Christine Doud High Desert Chapter Child Protective Services 16534 Victor St. Victorville, CA 92392 619/243-2280 San Diego County San Diego Peggy Fowler Gary Vernon Dependent Children Dept. of Public Welfare 6950 Levant St. San Diego, CA 92111 714/560-2236 714/560-2371 70 San Luis Rey David Lamski, Ph.D. Center for Family Development 800 Grand Ave. Carlsbad, CA 92008 619/729-9255 David Laratoney 619/757-1200 San Joaquin County William O. Hunt Child Protective Services Drawer F. Stockton, CA 95210 209/944-2069 San Mateo County Kasandra Dills Dept. of Health & Welfare 225 W. 37th Ave. San Mateo, CA 94033 415/573-2041 Bill Tideman Family Service Agency 1870 E1 Camino Real Burlingame, CA 94010 415/692-0555 Santa Barbara County North County Don Conroy Santa Barbara Mental Health Service 207 S. Broadway Santa Maria, CA 93454 805/925-0911 74 Santa Barbara Jeanette Green 339 Hotsprings Rd. Santa Barbara, CA 93108 805/969-1155 Santa Cruz County Bill Minkner 532 Soquel Ave. Santa Cruz, CA 95061 408/426-7322 Shasta County Patricia Bay Welfare Dept. P.O. Box 6005 Redding, CA 96099 916/246-5626 Siskiyou County Sandra Dixon 916/926-5753 Peter Silverman Siskiyou County Mental Health 1109 S. Mt. Shasta Blvd. Mt. Shasta, CA 96069 916/842-3569 Sonoma County Lorain Cardenas DSS/CPS P.O. Box 1539 Santa Rosa, CA 95402 707/527-2933 Martha Hyland Teter Holbrook 707/527-2763 72 Stanislaus County Pat Sherman Incest Treatment Team Stanislaus Mental Health 1127 13th St. Modesto, CA 95350 209/571-6100 Tulare County Shirley Panitz Tulare Youth Service Bureau P.O. Box 202 Tulare, CA 92374 209/688-2044 Tuolumne County David Peters, Children's Advisory Council c/o Tuolumne County Welfare Dept. 105 E. Hospital Rd. Sonora, CA 95370 209/533-5860 Ventura County Herman Kagan, Ph.D. Sr. Psychologist Program Director Simi Valley Mental Health Center Children's Services 3150 Los Angeles Ave. Simi Valley, CA 93065 804/527-6430, x1375 COLORADO Mike Hartman Boulder County Sexual Abuse Team Dept. of Soc. Serv. 3400 N. Broadway Boulder, CO 80302 303/441-1240 73 DELAWARE Karen Williams 22nd & Baynard Blvd. Wilmington, DE 19802 302/658-2071 FLORIDA Alachua County Laura E. Head Parents United 606 SW 3rd Ave. Gainesville, FL 32601 904/377-7273 Miami Mercedes Bustillo Advocates for Sexually Abused Children 1515 NW 7th St., Ste 112 Miami, FL 33125 305/547-7033 HAW AII Linda Santos Catholic Social Service 250 S. Vineyard Honolulu, HI 96813 808/537-6321 Priscilla Minn, Coordinator Oahu Br. Admin. 1060 Bishop St., 5th Fl. Honolulu, HI 96813 808/548-5344 IDAHO Tom Stoelting Bannock Youth Foundation P.O. Box 4166 Pocatello, ID 83201 208/236-6082 74 ILLINOIS Bolingbrook Shirley Robinson Child Sexual Abuse Treatment & Training Center of Illinois, Inc. 345 Manor Court Bolingbrook, IL 60439 312/739-0491 La Salle Lori Nelson, M.A. Mental Health Center 1000 E. Norris Dr. Ottawa, IL 61350 815/434-4727 IOWA Ames Jeanne M. Beardsley Central Iowa Mental Health Center 713 S. Duff Ames, IA 50010 515/232-5811 Dennis Tobin Iowa DSS 12 Scott St. Council Bluffs, IA 50501 712/328-5689 Garner Dolphine Justin Counseling Assoc. of N. Central Iowa 215 State St. Garner, IA 50438 515/923-3478 75 West Branch Mike D. Ryan, Executive Director, Families, Inc. 101 E. Main St. West Branch, IA 52358 319/643-2532 KANSAS Debi Courtney CSATP Coordinator Johnson Co. Mental Health 15580 South 169th Olathe, KS 66062 913/782-2100 LOUISIANA Pam Cohen New Orleans Police Dept. Child Abuse Unit 715S. Broad., Rm 301A New Orleans, LA 70119 504/586-3184 MAINE Stephen P. Thomas Community Counseling Center P.O. Box 4016 Portland, ME 04101 207/774-5727 MARYLAND Baltimore Mary Reagan 5735 New Holme Ave. Baltimore, MD 21206 301/488-1789 76 Kensington Linda Blick 1605 Concord St. Suite 207 Kensington, MD 20895 301/949-3960 MASSACHUSETTS Terrence Flynn Mary Devlin Incest Specialists Dept. of Soc. Services 143 Main St. Brockton, MA 02401 617/584-0980 MICHIGAN Bay City Luke Stephan Lutheran Child and Family Service P.O. Box 8 522 N. Madison Bay City, MI 48707 517/892-1539 Grand Rapids Teri Hatfield YWCA Child Sexual Abuse Center 25 Sheldon Blvd., S.E. Grand Rapids, MI 49503 616/459-4601 NEBRASKA Grand Island Rose Pfieffer 507 S. Locust Grand Island, NE 68801 308/304-1831 77 Kearney Dr. Terry Scritchlow S. Central Comm. Mental Health 3710 Central Ave. Kearney, NE 68847 308/237-5951 Omaha Katherine Druley Parents Anonymous 711 N. 21st St. Omaha, NE 68102 402/346-6311 Papillion Susan Oakes PU Coordinator Sarpy County Soc. Serv. 1209 Golden Gate Dr. Papillion, NE 68046 402/339-4294 NEW JERSEY Mt. Holly Stephen Carroll Marsha Cavendar Div. Youth & Family Services 50 Cancocas Rd. Mt. Holly, NJ 08060 609/267-7550 Trenton Bernice Trioche Kathy Rae Div. Of Youth & Family Services 1901 N. Olden Ave. Trenton, NJ 08618 609/984-6300 Ken Singer 609/984-6300 78 NEVADA Las Vegas Stuart Fredlund Nevada State Welfare Div. 700 Belrose St. Las Vegas, NV 89107 701/385-0133 Reno Marlene Chrissinger Washoe County Welfare Dept. P.O. Box 11130 Reno, NV 89520 702/785-5611 NORTH DAKOTA Bismarck Mary Lee Steele West Central Human Service Center 600 S. 2nd St. Bismarck, ND 58501 701/253-3090 Devils Lake David G. Haugen Lake Region Human Service Center Highway 2 West Devils Lake, ND 58301 701/662-4943 OREGON Eugene Sandra Sulliger Childrens Service Div. 1102 Lincoln St. Eugene, OR 97402 503/686-7535 79 Grants Pass Phil Backus P.O. Box 189 Grants Pass. OR 97526 503/474-3120 Medford David S. Cogswell Childrens Services 650 Royal Ave. Medford, OR 97501 503/775-6120 Ontario Lucy Hutchins CSD P.O. Box 927 Ontario, OR 97914 503/889-9194 Portland Ellen Fallihee Parents United of Portland, Inc. 3905 S.E. Belmont Suite 1 Portland, OR 97214 503/238-9714 Roseburg Howard Anderson District Attorney Court House Roseburg, OR 97470 503/672-3845 Stephen W. Voris Corrections Division Parole & Probation 1937 W. Harvard Blvd. Roseburg, OR 97470 503/440-3373 80 St. Helens Raymond White Childrens Service Div. 202 Sykes Rd. P.O. Box 807 St. Helens, OR 97051 503/397-3292 PENNSYLVANIA Shirley Devine Project Coordinator Parents United 429 Forbes Ave. Suite 1718 Pittsburgh, PA 15222 412/562-9440 SOUTH CAROLINA Sylvia Whiting Mental Health Nurse Specialist People Helpers 206 W. Richardson St. Summerville, SC 29483 803/873-8483 TEXAS San Antonio John Dauer Family Service Association 230 Perodia St. San Antonio, TX 78210 512/226-3391 Amarillo Ann K. Ray Potter-Randall County Child Welfare P.O. Box 3700 Amarillo, TX 79106 806/376-7214 81 Houston Liz Holmes Family Service Center 3635 W. Dallas Houston, TX 77019 713/524-3880 713/522-6017 UTAH Logan Roberta Hardy Child & Family Support Center 149 West 300 North Logan, UT 84321 801/752-8880 Ogden Duane Johnson Family Support Center 6222 23rd St. Ogden, UT 84401 801/393-3113 VIR GINIA Fairfax Susan L Watson, A.C.S.W. Fairfax County Child Protective Services 404] University Dr. Fairfax, VA 22044 703/385-8883 Norfolk Wendy Moore Family Services 920 S. Jefferson Roanoke, VA 24016 703/344-3253 32 Tri-City Chesapeake Tom Gregory 700 North St. Portsmouth, VA 23704 804/398-3688 Virginia Beach Fae Deaton 1176 Pickett Rd. Norfolk, VA 23501 804/623-3890 Dan Sandlin Dominion Psychological Association 1709 First Colonial Ct. Virginia Beach, VA 23453 804/481-2298 WASHINGTON Donald Berg Cascade Islands Comm. Mental Health Center 1321 King St. Bellingham, WA 98226 206/676-9158 WISCONSIN Sharon Hanson Parental Stress Center 1506 Madison St. Madison, WI 53711 608/251-9464 This listing of Child Sexual Abuse Treatment Programs and Parents United chapters was provided to PREAP by the Institute for the Community as Extended Family, P.O. Box 952, San Jose, California 95108. 83 APPENDIX C Department of the Youth Authority Sexual Offender Task Force Format for Submission of Written/Verbal Information Scope and Nature of Problem How do you define "sex offender"? What types of sex offenders are you encountering? What do we need to know about sex offenders? Age at first offense, done in concert or alone, etc.? How many have sex offenses in their background but not as a committing (or adjudicated) offense? How many were victims themselves (physical or sex- ual abuse, neglect) and was the history of abuse documented? 84 Ie How do you account for the dramatic increase in the incidence of sex offenses? Are there significant cultural factors to be considered? Have you experienced situations where families have encouraged deviant sexual behavior (i.e., incest, bestiality, prostitution, pornography)? Treatment Services What major components should be present in a model sex offender treatment program? Is there an optimal length of time for the institutional phase? Upon what literature/theory is your program or ap- proach based? Provide indicators of effectiveness. Does the youth authority need more programs and/or services specifically for sex offenders? 35 5. Zs is 2. What community resources do you utilize? Which are most effective? What is a good measure of effectiveness? What needed community resources are not available? Residential care and supervision, therapy, etc.? What kinds of aftercare services and followup are needed? What types of coordination between institutional and parole and/or community services are needed? Surveillance and Control Are some sex offenders, in your opinion, not treat- able? Which are the most difficult to treat? Should they be segregated and otherwise controlled in the institutional setting? 86 3. I. 2. Can sex offenders be profiled by their patterns of vic- timization and/or their method of operation? Please describe. Should juvenile sex offenders be required to register? Following discharge from parole, what surveillance/ control measures are available (i.e., notification of law enforcement)? What other criteria or factors to minimize risk should be considered? Training What type of training have you had in this area? Who provided it? Was it effective? What additional training resources are needed? Where are they located? 87 Victims I. How can the youth authority work with victims of sex offenders? 2. What kinds of victim-offender reconciliation activities are realistic and appropriate for the youth authority? Developed by California Department of Youth Authority, 1984. For further information, contact: Youth Authority 4241 Williamsbourgh Drive Sacramento, CA 95823 88 APPENDIX D Treatment Services for Sexual Offenders Division of Juvenile Rehabilitation DEPARTMENT OF SOCIAL AND HEALTH SERVICES WASHINGTON STATE April 1, 1983 Contact Person: Judy Ramseyer Sex Offender Specialist Mailstop OB-32 Olympia, WA 98504 (206) 753-7598 SCAN 234-7598 Introduction The foundation of treatment programming for youth committed to a term of confinement within the Division of Juvenile Rehabilitation is the residential facilities oper- ated by, or under contract with, the division. All of these programs are conducted on a behavioral modification model that emphasizes the learning of responsible daily living skills. Each juvenile offender is assigned a counselor who develops an individual treatment plan for that person. This counselor is responsible for guiding the treatment process for the youth. These responsibilities include pro- viding individual counseling and other counseling opportu- nities as necessary, school and/or work programming, discipline and daily youth supervision, interaction with collateral resources for the youth, and maintenance of the procedural standards and reports required by the agency. All of these programs, institutional and community based, work to help juvenile offenders gain skills to manage their lives more effectively without resorting to criminal or destructive behavior. Interpersonal and social skills, anger management, substance abuse programs, academic and work skills, and many other specific skill building 89 activities comprise the total milieu of each of these resi- dential programs that house juvenile offenders during their term of confinement. (See Table D-1.) Sex Offender Model The juvenile sexual offender enters this milieu upon commitment to DIR. All of the programs and resources available to any juvenile offender are available to the sex- ual offender. In addition, separate standards apply for the youth charged with a current or prior sex offense that dic- tate that the sex offender receive treatment services that directly address the offense behavior. These standards are in place throughout the agency so that any sex offender, regardless of placement or length of sentence, is receiving offense-specific case management. This model states that all sex offenders must be iden- tified and receive a diagnostic evaluation that addresses factors characteristic of the sexual offender. All reports must document treatment goals related to that offense and specific strategies being used to pursue those goals. All interventions should be designed to move the offender toward broad treatment goals, specifically defined by the individual case. These broad goals are: L. increased responsibility for one's sexual behavior; 2. increased awareness of the impact of sexual abuse on the victim; 3. increased understanding of the emotional and psychological processes that led to the offense; and 4. increased skill in meeting one's sexual and inter- personal needs without victimizing others. Significant program decisions should reflect consideration of the youth's investment and progress in the treatment process. If progress is minimal, supervision should continue as it would for a high-risk offender. 90 16 Table D-1. Sex offenders in DIR residential population (February 28, 1983): Distribution of offense /institution Percent of Statutory Statutory Indecent residential Institution Rape | Rape 2 Rape 3 rape | rape 2 liberties Incest TOTAL population Echo Glen 4 2 1 9 0 44 0 60 32.6 **R - 184 Maple Lane 3 2 1 4 0 21 1 32 22.0 R = 145 Green Hill 5 0 0 0 0 4 0 9 6.4 R= 14] Mission Creek 0 0 0 0 0 1 0 1 1.6 R=62 Naselle 0 0 0 0 0 2 0 2 2.2 R = 92 VIR Group Homes 2 1 0 0 0 2 0 5 4.7 R = 106 CRPs 2 3 0 1 0 4 0 10 5.0 R= 199 16 3 2 14 0 78 1 119 12.8% of of total DIR residential Percent of sex population offender population (119) 13.4 6.7 L7 11.8 0 65.5 0.8 Note: Total residential population = 929 Youth committed for sex offenses* = 119 (12.8% of DIR residential population) * Does not include prior adjudication for sex offenses ** R = residential population of facility Extensive training has been offered to staff in all DIR programs to provide them with the basic information needed to comply with these standards. Ongoing training and case consultation are available throughout the agency. A program manager in DIR's Central Office has primary responsibility to direct the development and monitoring of these services throughout the agency. Institution Services Three major institutions--Green Hill School, Maple Lane School, and Echo Glen Children's Center--and two youth forestry camps--Naselle Youth Camp and Mission Creek Youth Camp--are the institutional facilities oper- ated by DIR. Case managers in each of these facilities should be providing individualized treatment plans that specifically address the offense behavior for any sex of- fender on their caseload. Specialists are available for case consultation and evaluation purposes. Green Hill School, Maple Lane School, Echo Glen Children's Center, and Naselle Youth Camp each have one staff person designated to oversee and coordinate treatment services for sex of- fenders on that campus. (See Table D-2.) A wider variety of treatment services for sex offend- ers is available at Maple Lane School and Echo Glen Chil- dren's Center. Sex offenders committed to DJR tend to be concentrated at one of these institutions. Therapy groups for sex offenders are offered, as well as the individual counseling provided to all. Specialists are readily available for consultation. Private therapists in the community are used for youth on an outpatient basis if this is felt to be necessary. Family counseling is encouraged if the offend- er's family is at all receptive to this. A variety of educa- tion experiences is available to the sex offender, such as sex education, assertiveness training, anger management, drug and alcohol management, and so on. These special services augment the daily milieu program, which is also designed to confront issues directly related to the offense behavior. 92 £6 Table D-2. Various services available for sex offenders Echo Miss. Green Maple Glen Naselle Creek Hill Lane Child. Youth Youth Cascade Wash Services for sex offenders School School Center Camp Camp Program Prog. Il. Offense-specific diagnostic evaluation X 2. Offense-specific individual counseling X X X X X X X 3. Oftfense-specific group counseling X X 4. Offense-specific family counseling X 5. Specialist available for Case consultation & xX X X X X X X technical assistance 6. Private specialist available for outpatient therapy X X 7. Sex education X X X 8. Specific skill building activities (anger manage- ment, assertiveness X X X X X X X training, drug/alcohol management, etc.) 9. University of Washington Juvenile Sexual Offender X X X Program 10. Sex Offender Project through county juvenile court h6 Table D-2. continued Services for sex offenders Reg. | Gr. Home/ Cmty. Sup. Reg. 2 Gr. Home/ Cmty. Sup. Reg. 3 Gr. Home/ Cmty. Sup. Reg. 4 Gr. Home/ Cmty. Sup. Reg. 5 Gr. Home/ Cmty. Sup. Reg. 6 Gr. Home/ Cmty. Supq 2. Otfense-specific diagnostic evaluation Offense-specific individual counseling Offense-specific group counseling Offense-specific family counseling Specialist available for case consultation & technical assistance Private specialist available for outpatient therapy Sex education Specific skill building activities (anger manage- ment, assertiveness training, drug/alcohol management, etc.) University of Washington Juvenile Sexual Offender Program Sex Offender Project through county juvenile court Community Services It is fully expected that offense-specific services for the sex offender will be extended through placement in a community facility and supervision on parole status. The extent to which these specialized services are provided is dependent on the skill level of individual counselors and the availability of community resources for the juvenile sex of- fender. It is not unlikely for offense-specific services to intensify when a sex offender enters the community, espe- cially if that youth comes from an institution with fewer specialized services or is felt to be at high risk to reoffend. The Juvenile Sexual Offender Program at the Univer- sity of Washington is available to staff and youth through- out the division but, realistically, is most often used by those located in King County. The Juvenile Sexual Of- fender Program offers evaluations, family therapy, and a group for DIR youth on residential or parole status. King County (Region 4) also contracts with other community specialists who provide treatment for sex offenders. Spo- kane (Region 1), Benton-Franklin (Region 2), Snohomish (Region 3), and Pierce (Region 5) counties also have private therapists available to provide treatment for juvenile sex offenders under contractual agreements. Snohomish and Benton-Franklin counties both operate Juvenile Sex Offender Projects through the juvenile court. These two programs differ in some ways, but each provides the same basic services: I. knowledgeable and consistent evaluation and prosecution of sex offenders; 2 alternatives to institutionalization for the low- to moderate-risk sex offender that consist of various combinations of detention, supervision, and treatment; and 3. a structure for the extension of responsible supervision and treatment of the sex offender upon release from a term of confinement. The development of these projects has required the coop- eration of law enforcement, legal, social service, and therapy professionals in the community who recognize the 95 need for just and responsible disposition of juvenile sex offenders. These projects represent an excellent example of local network development around a special need. Conclusion What has been described here is not a discrete pro- gram for juvenile sex offenders, but instead an accounta- bility model that directs the delivery of specialized services for the sex offender, designed to reduce that of- fender's risk to the community. There are no guarantees that treatment will be exhaustive and complete. Each case is entirely unique. One youth may make a great deal of progress in a short period of time, presenting a consider- ably reduced risk to the community upon release. A second youth may make little or no progress over a very long pe- riod of time, being discharged from DJR supervision as great a risk to the community as when originally submit- ted. It is DIR's responsibility to use the time a youth is in our custody as productively as possible to facilitate the juvenile offender's successful return to the community. Specialized services for the sexual offender increase the possibility that critical factors contributing to the offense behavior will be addressed, reducing that offender's risk of reoffending sexually in the future. Community Corrections Program Model for Juvenile Sex Offenders Purpose It is essential that the Division of Juvenile Rehabilita- tion take a leadership role in the creation of juvenile jus- tice networks throughout the State of Washington. A com- bination of State, county, Federal, and private funds enables a more comprehensive array of program services to develop than a single funding source could produce. The concept of community corrections is designed to facilitate the creation of these networks, tailored by local needs to meet statewide objectives. The goals of community cor- rections programs as set forth in the Community Correc- tions Program Standards are to: 96 l. coordinate program strategies based on identi- fied juvenile offender needs that promote just handling of the juvenile offender at the commu- nity level; 2. develop comprehensive community plans for the delivery of services to juvenile offenders via broad-based professional /citizen input; 3. encourage development of a unified system among State and local resources; and 4. set forth a clear administrative structure that ensures monitoring and evaluation of the de- livery system. A program that focuses on the special needs of the juvenile sexual offender is highly compatible with these goals. Juvenile sexual offenders are often identified as different from the average delinquent population. A lack of extensive criminal history and emotional immaturity are common. Society has tended to view sex offense behavior as "sick" as well as criminal, therefore warranting thera- peutic treatment. The Juvenile Sexual Offender Program at the University of Washington, the first nationally recog- nized program to address specifically the needs of the juvenile sex offender, maintains that sex offense behavior by a juvenile is indicative of problems in the family sys- tem. Based on their research to date, it is proposed that the most effective strategy for treating these offenders is within the context of the family. A community corrections model provides the opportunity to work within the family system while fulfilling the legislative mandate for juvenile justice. Community protection can be achieved through the use of varying levels of structured supervision. All re- source people become participants in this network for supervision. The family, the probation/parole counselor, schools, employers, therapists, and so on all provide structure and supervision for these youth. Such a model encourages the development and collaboration of local resources. Each community must define its own capacity for serving these youth. Criteria for offender eligibility and the development of service networks will vary accordingly. 97 A community corrections program for juvenile sexual offenders can be a cost-effective use of State and local resources. Population in State-operated juvenile institu- tions is over capacity, and this trend is expected to con- tinue. If it is possible to supervise and treat certain sexual offenders effectively in a less restrictive and less expen- sive setting, this should be encouraged. Institutional pro- grams are better used for those offenders who present a clear risk to the community. If, as postulated, treatment of the whole system in which the youth lives is the most effective therapeutic intervention, the benefits to local communities of reducing victimization and the resulting trauma cannot be estimated. This model outlines the basic framework of a commu- nity corrections program for the juvenile sexual offender. For demonstration purposes, specific examples from the current Snohomish County Community Corrections Pro- gram have been used to define eligibility criteria and supervision requirements. Each county must modify and enlarge this basic framework to fit its own unique characteristics. Program Description I. Program development A. Identify community need B. Define network of services providers C. Train service providers Il. DJR training and technical assistance 2. Local experts 3. Shared expertise between communities II. Assessment A. Standardized pre-dispositional evaluation l. Performed by person(s) who understand cri- teria and intent of program 2. Recommendations regarding disposition 98 B. Criteria for eligibility l. 2. 3 4. 5. Minor or middle offender Nonviolent offense No criminal history of sexual offenses No previous treatment for sexual offenses Family of offender willing to participate in treatment III. Supervision A. Mandated activities l. 2. Be. 4, 5. Probation/parole counselor contact at least three times weekly 20 to 30 days in detention to be served on weekends following the disposition hearing (10 to 15 weekends) At least 72 hours of community service to be worked 8 hours per weekend (1 day) fol- lowing completion of detention time Court-ordered to maintain a combination of the following activities totaling 40 hours per week of incapacitation® a. regular school attendence b. alternative school attendance c. Youth Resource Center attendance d. full-time employment e. part-time employment f. counseling g. drug/alcohol treatment h. other organized and structured activi- ties as ordered An alternative community program that provides comparable incapacitation to item 2 above (e.g., The Washington Program, Outward Bound) B. Degree of incapacitation i. 2. At least 40 hours of organized and moni- tored activities each week 2-1/2 to 4 months of complete incapaci- tation on weekends *Incapacitation defined as organized structured activ- ity in which a youth's attendance can be monitored. 99 IV. 3. At least 2 months of partial incapacitation on weekends 4, Ability to detain additionally if necessary C. Postinstitution supervision of sexual offenders l. Probation/parole counselor contact at least three times weekly 2. Maintain a combination of the activities listed in Il.4.a-h, totaling 40 hours per week of incapacitation D. Monitoring/evaluation lI. Probation/parole counselor responsible for regular contact with collateral agencies 2. Degree of incapacitation can be amended based on ongoing evaluation of offender's performance in all areas Treatment A. Offense-specific treatment by qualified thera- pist(s) required B. Family participation in one or more of the following: lI. Therapy with the offender 2. Remedial programs: a. parenting skills b. individual counseling c. alcohol/drug treatment 3. Provision of supervision and structure for the offender C. Probation/parole counselor responsible for regu- lar contact with therapist(s) l. Degree of offender's incapacitation can be amended based on treatment progress D. Offense-specific treatment mandated activity for postinstitution parolee Monitoring and evaluation A. Community network of service providers l. Monthly information-sharing meetings 2. Contact as required for client supervision 100 B. Training and consultation I. General topic areas 2. Specialized topic areas 3. Policies and procedures C. Program review and evaluation Conclusion A community-based program designed for juvenile sex- ual offenders truly embodies the concept of community corrections. Local communities can design a program that defines criteria for offender eligibility and degree of supervision/incapacitation based on the resources available to them. It requires a desire to respond to the needs of the juvenile sexual offender and the belief that local agencies can work cooperatively. It is the responsibility of the DIR to identify this program as a priority and include it in each regional request for services. Technical assistance in pro- gram development and ongoing training must also be of- fered by the division. The ideal opportunity exists to offer a viable alternative to institutionalization that is compati- ble with the characteristics of the juvenile sexual offender and the goals of community corrections. The Division of Juvenile Rehabilitation has a commitment to improve serv- ices for this special offender group. DJR must extend this commitment by promoting the development of community corrections programs for the juvenile sexual offender. 101 APPENDIX E Summary Paper: Violent Juvenile Sex Offender Project Julie Blackburn, Program Supervisor Division of Juvenile Rehabilitation Department of Social and Health Services Washington State Need Statement The Division of Juvenile Rehabilitation has made significant progress over the last few years in addressing the needs of the adolescent sex offender. However, the strongest emphasis to date has been on treatment inter- ventions for the relatively less aggressive offender. By contrast, the violent juvenile sex offender has received far less attention in terms of innovative program development. The majority of institutionally based treatment re- sources for our sex offenders are concentrated at Echo Glen and Maple Lane School. However, the most violent of our sex offenders are often sent to Green Hill School. This is particularly true when the youth is older and more in- volved in other delinquent behaviors; Green Hill's overall program is better equipped to meet the needs of the more "delinquently sophisticated" youth. Statistics recently compiled from Green Hill reveal that there are 12 youths currently in residence for a sex offense and that nearly half of these are under sentence for the most serious sex crime possible--rape in the first degree. (This number is thought to be an underreport, as it does not contain crimes charged with other titles when the motive is clearly sexual, such as certain assaults and kid- nappings.) These same statistics also show that we have these youths in our system for long sentences: the average sentence range of the sex offenders presently at Green Hill is 2-1/2 to 3 years. Simply put, this is our situation: our most dangerous sex offenders generally are sent to Green Hill for long 102 sentences, yet there are fewer treatment resources at this facility for sex offenders than at other major institutions. Project Intent It is this project's intent to provide intensive offense- specific treatrnent for violent juvenile sex offenders who are under court commitment. The program model would use a variety of interventions featuring "state-of-the-art" approaches. It would build on the sex offender expertise extant within the DJR. It would incorporate additional techniques and technologies that have demonstrated ef- fectiveness at Western State Hospital, Northwest Treat- ment Associates, and the Closed Adolescent Treatment Program in Denver. Because of the factors cited above, Green Hill School is seen as a logical location for this project. The primary long-term goal is to reduce recidivism. To document this and to learn which specific interventions are most effective, a significant evaluation component will be built in. It will be a short-range objective to provide treatment in a secure setting to l4 youths during the first project year. It will be an objective to provide for effec- tive community protection during the entire time of the youth's involvement in the project. Finally, an additional first-year objective includes development of staff exper- tise in treatment of the violent juvenile sex offender. This project would target for its population youth at least 16 years of age who have received a minimum sen- tence of 1 year when the committing delinquency was a sex offense or when motives of sexual aggression were present. Assignment would be made based on the seriousness of the youth's behavior, with those youths whose behavior shows a pattern of escalation and risk of recidivism being given the highest priority. It is the intent of this project to take as many such youths as possible without overcrowding the facility. 103 Project Implementation The project is conceived as a residential treatment model with three phases. The first and most treatment- intensive phase would occur on the institutional grounds. The second phase would occur during the period of group home placement within the community. The third phase would occur during parole supervision. Phase One would be the longest; the exact length of stay would depend on the individual youth's progress, division policies pertaining to security levels, and per- ceived risk to the community. It is anticipated that most youths would serve at least the first two-thirds of their sentence within the institution. This phase would immerse the youth in offense-specific treatment within a secure, structured setting. One specific cottage with the capacity for maximum security would house all project youths (and only these youths) during Phase One. Phase Two placement would occur in any one of a number of State group homes or CRPs. The goal of this phase would be to deal with transition and community reentry issues while building a network of services for the youth (and for his family or release placement). This network would include appropriate clinical counseling services, educational/vocational resources, and a rela- tionship to Juvenile Parole Services. Ideally, Phase Two placement would be in or accessible to the locale of the youth's intended release placement. At present, various communities throughout the State are involved in efforts to develop their own locally based programs for juvenile sex offenders. Such communities would provide a natural environment for developing these networks. Thus, flexi- bility in placement possibilities during the reentry phase would exist. Phase Three of the program would occur during a period of intensive parole supervision. Project youths would automatically be placed under such supervision for at least | year. Continuation in treatment would be a universal condition of parole. Emphasis on the use of the community network would be stressed. The foundation of the provision of services for the youth, his family, and often for his victim as well (i.e., when the victim was a family member) will have been laid during the Phase Two 104 stage, so that the movement to parole status will be a smooth transition. Phase One Components Accurate assessment of specific treatment needs for each youth will occur. A psychological evaluation will be conducted on any youth who has not had this done prior to commitment. Sex offense-specific evaluation will be com- pleted for all youths following DJR guidelines currently in place. In addition, the DJR tool, Inventory of Sexual Ag- gression, will be administered. Each project youth will be screened at entry via plethysmograph testing. This technology measures the presence of deviant arousal patterns, such as pedophilia and arousal to themes of aggression. It is postulated that the population of youths in our project will be more likely to exhibit such deviant patterns. A local treatment pro- gram (Northwest Treatment Associates) that specializes in adult sex offenders states that plethysmograph testing re- veals deviance in the vast majority of their clients, and that most of these men began their patterns in adoles- cence. By determining the specific nature of such patterns when they exist, an individualized behavior modification program can be constructed. Reoffense risk will be assessed and documented at entry. The Decision/Risk Criteria tool developed by the University of Washington will be used in that process. Each youth will be involved in a minimum of 21 hours of group therapy per week. There will be much emphasis on the development of a pro-treatment group norm. Ap- proximately 15 hours a week will be spent in group sessions using an adapted version of the WSH model (this uses much structure and incorporates sharing of offense and sexual/ masturbatory fantasy details, among other topics). The remaining 6 hours per week will be spent in skill-building group work. Video equipment will be used here, giving the youth a clear "picture" of how his new skills look in action. One-to-one therapy will also occur; the focus will be individualized. Youths who have demonstrated deviant 105 arousal patterns will receive treatment, such as covert sensitization and masturbatory satiation. All other resources of the institutional program (e.g., vocational, educational, recreational) will be available to the youths, based on security level consideration. The youths' investment and progress in treatment will be a criterion in deciding movement from Phase One to Phase Two; this is to assure the DIJR's accountability to community safety issues. Determination of progress will be done as objectively as possible. This will always involve reevaluation of risk factors and may often include change as measured via plethysmograph retesting. Staffing and Roles The Phase One cottage will follow the standard cot- tage staffing pattern, with the addition of one JRC II posi- tion. This additional staff member will allow for a higher staff /youth ratio, which is seen as necessary in such an intensive program. Reallocation of current staff could account for all but that one position. The staffing pattern would be: 1 IRS III (Program director) 8 JRC IIs 2.4 JRC Is 11.4 Total staff The Program Director would work closely with the Divi- sion's Sex Offender Specialist in implementing and moni- toring the project. The Sex Offender Specialist would also assist in team building, staff training, and consultation and will facilitate project evaluation and program component research. Training and Consultation A strong emphasis will be placed on initial and ongoing staff training. Use will be made of existing resources in the DIR and State system (including use of the Sex Of- fender Specialist as cited earlier). The Adolescent Clinic 106 at the University of Washington will also be involved in providing training and consultation. A project steering committee comprised of the Pro- gram Director, Sex Offender Specialist, consulting psy- chologist, Adolescent Clinic staff, administration from Green Hill, and two other DIR staff with expertise in sex offender treatment will assist the implementation of the model. A 2-week "start-up" period will be established for all project staff to be oriented and receive initial training. A psychologist with special expertise in juvenile sex offenders will be hired on contract to provide 6 hours per week to the project. His or her role will be to train staff, provide consultation on a regular basis as part of the treat- ment team, assist in implementing the treatment model, and provide individual evaluations as needed. A clinician with skill in behavior modification tech- niques for sex offenders will also be hired on contract to teach selected project staff these skills and to monitor their use. An estimate of time contracted is 20 hours of initial training, with 3 hours of monthly consultation thereafter. Data Gathering/Evaluation Design Data gathering and program evaluation would occur on an ongoing basis. In addition, a long-range study of the project's effectiveness would be made. There would be three major directions for the research efforts: 1. Pre-post measurement of each client's function- ing on multiple dimensions. These would include sexual arousal pattern (i.e., plethysmograph test- ing), social skills, sexual knowledge, sex role at- titudes, aggressive ideation and behavior, locus of control, attitude toward victims, and degree of responsibility accepted for the offense and its consequences. These would be assessed at entry and at the time of transfer from the residential phases. They would also be assessed during Phase Three (community supervision) 6 months into the parole period. Additional followup 107 testing would occur after discharge at 1-, 2-, and 5-year intervals. 2. Relationship of change in each dimension to re- cidivism. Multivariate analysis would be made of the degree of change in each area as corre- lated to the rate of reoffense. This would be done both on an individual basis (i.e., looking at these data for each project "graduate") and as a group (examining the relationship for groups as a whole who have changed on various dimensions to recidivism). This analysis would be done after each youth's discharge from the program at I-, 2-, and 5-year intervals. 3. Overall impact of the project on recidivism. This would be accomplished by comparing the project youths' overall rate of reoffending to the rate of reoffending of similar offenders who did not have the same treatment exposure. This would be done at l-, 2-, and 5-year intervals when aspects cited in items | and 2 were also being analyzed. In addition, this aspect of the project would be reexamined 10 years after the first group had completed treatment, providing a meaningful longitudinal evaluation of project impact on sexual assaultive behaviors. For further information, contact Judy Ramseyer, Sex Offender Specialist, Mailstop OB-32, Olympia, WA 98504. 108 CHAPTER 2 METHODOLOGICAL AND ETHICAL ISSUES IN EVALUATING AND TREATING ADOLESCENT SEXUAL OFFENDERS Judith V. Becker, Ph.D., and Gene G. Abel, M.D. The exact incidence of sex crimes committed by adolescent offenders is unknown. Incidence figures are available from several sources. Using victim reports, the National Crime Survey indicates that for 1979, adolescent males committed 21 percent of the forcible rapes in this country. That amounts to 200 forcible rapes per 100,000 adolescent males. The Uniform Crime Report arrest data through 1980 indicate 50 arrests for forcible rape per year per 100,000 adolescent males. These statistics, however, only reflect crimes of forcible rape. Adolescent offenders engage in other deviant sexual behaviors involving victims that do not meet the criteria for forcible rape, such as child molesting, exhibitionism, frottage, and sodomy. Ageton (1983) conducted a survey using a national probability sample of male adolescents aged 13 to 19. For purposes of her study, Ageton defined sexual assault as all forced sexual behavior involving contact with sexual parts of the body. Included in the definition was rape, incest, sodomy, and fondling. Exhibitionism and any other act that was not a "hands-on" experience was excluded. Of a sam- ple of 863 adolescent males, the rate of sexual assaults per 100,000 adolescent males ranged from 5,000 to 16,000. The highest rate was for 17-year-olds. The incidence rates varied as a function of the definition of sexual assault and whether one relied on arrest rates or self-report data of the offenders. Even though we do not have the exact incidence figures for sex crimes committed by adolescents, we do The research reported in this manuscript was in part sup- ported by National Institute of Mental Health Grant ##MH 36347, Treatment of Child Molesters. 109 Vv know that the average adolescent sexual offender may be expected to commit 380 sex crimes during his lifetime (Abel, Becker, Cunningham-Rathner, Rouleau, Kaplan, Reich 1984). These figures indicate that it is imperative to develop effective assessment and treatment strategies for adolescent sex offenders. In designing research proposals and implementing treatment strategies for adolescent sexual offenders, there are several methodological and ethical issues that must be addressed. Methodological Issues Normative Adolescent Sexual Behavior A crucial issue in working with adolescent males who have been charged with committing a sexual offense is determining what normative sexual behavior is for them. A goal for the clinician is to differentiate DSM III- diagnosable paraphiliacs from nonparaphiliacs who are engaging in exploratory sexual behavior. Major confusion surrounds the identification of adolescent sexual offend- ers. Some surveys (Finkelhor 1981; Roberts et al. 1973) suggest that adolescents charged with sexual offenses may have been involved in innocent sex play. Others have demonstrated that adolescents have committed violent sexual offenses (Deisher et al. 1982; Groth 1977; Markey, 1950). An important research issue relates to defining normative adolescent sex behavior and those variables that predispose the adolescent to develop a deviant sexual in- terest pattern and to reoffend. Defining the Issue To Be Studied Many of the studies conducted to date in the area of sexual assault either have failed to define what is meant by a sexual assault, have combined all forms of assault under one heading, or have failed to count some deviant behav- iors as assaults because they have not met certain legal criteria. In conducting a survey or assessing adolescent sex offenders, the behavior to be studied must be defined specifically. 110 If one wishes to determine the number of deviant sex- ual behaviors or offenses committed by adolescents, the adolescents should be questioned about all the possible paraphilias, not just the behavior that has come to the attention of others. For example, an adolescent should be asked whether he has made obscene phone calls, worn or used objects for sexual purposes (fetishes), engaged in voyeurism (peeping through windows), masturbated in pub- lic, exposed himself, engaged in frottage (rubbing up against a victim for sexual satisfaction), touched a younger child in a sexual manner or had a younger child touch him or her, engaged in incestuous behavior, forced sex on a peer or older person, or engaged in sadistic behavior. If the adolescent is asked general questions, he is very likely to respond with general answers, concealing the various paraphilias in which he has participated because the behav- ior is illegal and he may feel embarrassed by or at risk about disclosing such behavior. Of the 306 sexual offenders we have evaluated whose first deviant arousal began before age 18, 15.4 percent had the primary diagnosis of female nonincest pedophile; 21.2 percent were male nonincest pedophiles; 8.8 percent were female incest pedophiles; 2.6 percent were male incest pedophiles; 4.9 percent had the primary diagnosis of rapist; 13.1 percent were exhibitionists; 7.2 percent were voyeurs; 5.9 percent were frotteurs; and 20.9 percent had other paraphilias (Abel, Becker, Cunningham-Rather, and Lucas 1983). The data also indicate a tremendous overlap across diagnoses (Abel, Mittelman, Becker, Cunningham-Rathner, and Lucas 1983). These findings suggest that clinicians should conduct a very thorough assessment of all sex of- fenders to identify other types of undisclosed sexual of- fenses. Unless a thorough assessment is conducted, the extent and frequency of the deviant behavior will not be determined. At the Sexual Behavior Clinic, we question the sub- ject/patient on several points: (1) whether he has actually engaged in any of the DSM III categories of paraphilia; (2) whether he has attempted a deviant act but not com- pleted it; (3) what percentage of his fantasies are deviant; (4) how many deviant acts he has committed on how many 111 victims; and (5) whether or not he has been arrested for any of the deviant behaviors. Sample Population Incidence and frequency figures vary depending on the sampling procedures. Most of what we know about sex of- fenders comes from studies of incarcerated offenders. One could be misled by relying on the verbal reports of incar- cerated offenders or those offenders under a mandate to receive assessment or treatment since such offenders are caught in a Catch-22 situation. If they tell the truth about their sex offenses, they may be charged with other crimes and have their prison sentences extended. Researchers and clinicians should consider whether the adolescent is under the supervision of criminal justice serv- ices or is not known to criminal justice and has volunteered for assessment/treatment on his own or at the request of his parents. The degree of the adolescent's willingness to volunteer for assessment or treatment will have an impact on the information to be disclosed. A Model and Test of the Acquisition of Deviant Behavior The reasons that adolescents first commit sex crimes as well as how they maintain their deviant behaviors are unknown. Lacking in the field of adolescent sex offenders is a model empirically derived and tested. We propose a social learning theory model to explain the acquisition and [> maintenance of deviant sexual arousal. According to this theory, individuals are not born with complex repertories of behaviors but learn them (Bandura 1973). The behavior can be learned by a number of modes. For example, the sexual offender may have observed aggressive behavior within his family or peer group or by characters depicted in the mass media (Bandura 1983; Wolfgang and Ferracuti, 1967; Zillman 1983). A survey of 131 adult sex offenders seen at the Sexual Behavior Clinic indicates that 89.3 per- cent had been hit as children by their parents and 42 per- cent had parents who fought violently. Being the victim of physical or sexual aggression may also predispose an indi- [> vidual to model that behavior. We found that 29 percent of 112 our subjects had sex forced on them when they were chil- dren (Abel, Becker, Cunningham-Rather, and Lucas 1983). Since not everyone who has been physically or sexually abused develops a deviant arousal pattern, other events must occur to facilitate the development of these aberrant interest patterns. A second factor relates to recall of the initial deviant sex act during masturbation-orgasm activi- ties. Pairing or bonding of the deviant fantasy and sexual excitement during masturbatory activity gives the fantasy greater erotic power (Abel, Becker, and Skinner 1983; Abel and Blanchard 1975). A third element relates to the person's ability to re- late to other members of society. If an adolescent has grown up in a home without good role models for func- tional, social, and assertive behavior, he will have diffi- culty relating to his peer group on a functional level. The isolation and possible rejection that occur may lead the adolescent either to socializing with young children and then eroticizing his interest in them, or to using force in sexual interactions because of his deficit in obtaining consensual sexual relations with a peer. Critical to the development of a deviant sexual inter- est is what the offender says to himself about his behav- ior. Before the offender translates his fantasies into acts, he anticipates that positive consequences will result from his behavior and that negative consequences to himself or his victim will be minor. These cognitive distortions are a result of limited sexual knowledge, a lack of empathy for the victim, a limited understanding of sexual values, and faulty perceptions about his own experiences as a victim. If the sexual offender engages in a deviant sexual act and there are no negative consequences for that behavior, the behavior is rewarded and the offender is motivated to com- mit further offenses. (7) The following case is offered in support of this model: David was first seen at the Sexual Behavior Clinic at age 16. During the clinical interview, David reviewed that at age 10 he had been sodomized by his 30-year- old uncle. David reported that he had not disclosed the assault to his mother or any other family member because he was terrified of his uncle and feared that 113 he would do him further harm. David had continuous nightmares about the assault and experienced flash- backs of the event. When David reached puberty, he began to have sexual fantasies about sexual involve- ment with 8- to 10-year-old boys and girls. At age 15, he was arrested for sexual abuse of one female child and two male children. During the clinical interview, David related that his nightmares about his own vic- ar the victimizer. David had an identical twin brother named John. We requested that John come to the clinic for the inter- view. John had not been victimized by the uncle or by any other adult, nor had he engaged in any deviant sexual behavior or used deviant sexual fantasies. David, however, had been sexually victimized and then went on to use deviant sexual fantasies and to act on those fantasies. The behavior appears to be related to David's memories of his own victimization and mas- turbatory fantasies. Maintenance of his interest was associated with his continued masturbation. To test the social learning theory model or any other model, one must develop measurement instruments or use instruments with demonstrated reliability or validity. With such instruments, the treatment needs of adolescent sex offenders can be deterinined, as well as the treatment outcome. Clinical interviews. The clinical interview is the most popular and relied-upon method for both diagnosing and assessing clients and for assessing treatment outcomes. The major problem in relying solely on the clinical inter- view is that the adolescent offender may underreport the extent of his deviant acts or deny the existence of a devi- ant arousal pattern. An attempt to establish the reliability of the information obtained involves having a colleague conduct a second interview or reinterviewing the adoles- cent at a later date. At the Sexual Behavior Clinic, we have used a stand- ardized, structured clinical interview with adolescent of- fenders to obtain various information: 114 l. number of categories of deviant sexual interests 2. order of importance of deviant sexual interests 3. number of reported victims of sex crimes by category 4. number of completed sex crimes by category 5. duration of deviant sexual interests by category 6. reported use of sexually deviant fantasies 7. personality characteristics 8. effects of alcohol and pornography on deviant sexual behavior 9. quality of social, assertive, and empathic skills 10. presence of nondeviant sexual behavior and interest 11. degree of force used during the commission of sexual crimes by category 12. reported ability to control deviant sexual interests Information obtained during a clinical interview may be checked for validity against arrest records or with the offender's parents if they are reliable informants. A major problem in using the first form of validation, however, is that adolescents are likely to have engaged in considerably more offenses than the number for which they have been arrested. And since the adolescent keeps his deviant sex- ual interest pattern secret, it is highly unlikely that the adolescent's parents or guardians will be able to provide the type of information necessary to validate the offend- er's statements. There are other assessment techniques, however, that may be used to validate information ob- tained during the clinical interview. Paper and pencil tests. Since sex offenders have distorted cognitions about the appropriateness of a vari- ety of sexual interests, it is important to evaluate their 115 cognitions about their behavior. A method of doing this is to survey adolescents about their most common cognitive distortions, then tabulate the distortions and convert them into a scale. The statements may deal with such issues as the ability of children to give consent to sexual activities, the dangerous consequences of child molestation to the victim, and so forth. The scale should then be administered to a comparison group of nonoffending adolescents and to the sex offenders to determine if the scale discriminates between the two groups. If it does, then it can be used as an assessment in- strument and a therapy outcome measure. There will be a problem in finding a comparison group of nonoffending adolescents, however, since most school systems will not permit recruitment of adolescents to participate in re- search where they may be asked questions about sexual thoughts or practices. This, of course, is a major obstacle in validating many of the assessment procedures for use with adolescent sex offenders. Clinicians have commented on adolescents' deficit in sexual knowledge. In working with adolescent sex offend- ers, the McHugh Sexual Knowledge Inventory, Form Y, can be used. This test has been validated on high school stu- dents and can be used as an assessment of adolescents' sex knowledge, as well as an outcome measure for those test- ing programs with a sex education component. A quick, valid, reliable, and inexpensive method of as- sessing various deviant sexual interests is a card sort of sexual interests. This instrument may be developed by col- lecting from sex offenders brief phrases that they report as reflecting their deviant interests and that they find most arousing. The card sort should cover all DSM III paraphil- ias, and the sex offender would rate on a Likert scale how arousing the phrases were. To assess social and assertiveness skills in offenders, one may videotape their responses to structured scenes in- volving a confederate. The tapes can then be rated using a Heterosocial Skills Scale (Barlow et al. 1977). This scale has norms for a nonoffender population. Various paper and pencil assertiveness and social competency scales may be administered. 116 For those working from a biological or genetic model of sexual deviancy, appropriate neurological tests with known validity and reliability should be administered. For example, Berlin and Meinecke (1981) report that of 17 con- secutively referred patients with sexual disorders, 14 had either a genetic, hormonal, or neurologic anomaly, includ- ing elevated testosterone levels, brain damage, dyslexia, and Klinefelter's syndrome. Berlin suggests that biological vulnerabilities may predispose some individuals to develop deviant sexual arousal patterns. Berlin notes, however, that further confirmation with a control group must be attained. Thomas and Rogers (1983) describe a treatment pro- gram for intrafamily juvenile sexual offenders. These clin- icians conceptualize the problem as being multifaceted, complex, and indicative of interpersonal dysfunction as well as disrupted family functioning. Accordingly, their assessment battery includes the WISC-R or WAIS, Bender- Gestalt, Rorschach Ink Blot Test, Thematic Apperception Test, Minnesota Multiphasic Personality Inventory, and the Family Adaptability and Cohesion Evaluation Scale. These are standard psychological assessment tests. It would be intriguing to see if those tests with a known sensitivity and specificity reveal different profiles for nonoffenders and offenders and whether therapy effected a change in those profiles. In summary, regardless of the model one is testing, assessment procedures should have a known reliability and validity and should either discriminate between offenders and nonoffenders or be sensitive as a therapy outcome measure. Psychophysiologic assessment. As noted previously, accurate clinical interviews are hampered when sex of- fenders attempt to conceal their true deviant interest pat- terns. Paper and pencil testing, on the other hand, also has limitations in that it can be falsified depending upon the subject's degree of cooperation. The most accurate and objective means of evaluating male sexual arousal is to measure penile responses directly while presenting various stimuli depicting deviant sexual interests (Abel et al. 1981; Zuckerman 1971). It is possible to measure and differen- tiate objectively a variety of deviant interests using this technique. 117 At the Sexual Behavior Clinic, we have been using two forms of physiologic assessment: Slow Physiologic Assess- ment (SPA) and Rapid Physiologic Assessment (RPA). SPA consists of presenting 2-minute audiotaped descriptions of various sexual behaviors while the patient's erection re- sponse is measured with a penile transducer. We have used this method with more than 800 sexual offenders, including 30 adolescent offenders. Recently we evaluated the relia- bility of a subset of stimuli with 108 adult sex offenders. The Cronbach's Alpha coefficient of reliability for all but one factor was .89. The RPA involves presenting film slides of 10 catego- ries of behavior: (1) adult female, (2) adult male, (3) young female, (4) young male, (5) neutral, (6) frottage, (7) exhibi- tionism, (8) sadomasochism, (9) adolescent female, and (10) adolescent male. These slides are presented for a 7-second interval while the subject's erectile response is measured. To date, we have administered this assessment procedure to 244 adult male sex offenders. The reliability of each category was calculated. Rotation of the factor mean yielded three factors: a female factor reliability = 94; a male factor = .90; and a neutral factor = .56. These data indicate that the procedure is a reliable tool with which the clinician can elicit information about sexually deviant arousal. Both these assessment techniques can also be used to increase the validity of sex offender diagnosis (Abel, Cunningham-Rathner et al. 1983). We recently completed an experiment in an attempt to improve the validity of the traditional clinical interview (Abel, Cunningham-Rathner, Becker, McHugh 1983). Ten adolescent males, aged 13 to 17, and 80 adult males who received an evaluation at the Sexual Behavior Clinic were (1) reinterviewed using the structural interviews, (2) re- minded that data were protected by the Certificate of Confidentiality, (3) given feedback on their paper and pen- cil and psychophysiologic test results, and (4) asked to ex- plain the discrepancies between test results and initial clinical history. Of the 90 subjects, 50 reported additional paraphiliac arousal following this debriefing. Additional diagnosis showed that l.l percent of the arousals were re- vealed because of reiteration of confidentiality; 18.9 per- cent because of feedback on card sort responses; 20 per- cent as a result of being reinterviewed with the structured 118 clinical interview; and 62.2 percent because of feedback on the psychophysiologic assessment. Ideally, in validating an assessment instrument, one would want to have a nondeviant (normal) comparison group to whom to administer the procedures. In working with adolescent sex offenders, it is difficult if not impossi- ble to gather such a comparison group and obtain permis- sion to assess their arousal patterns. In our society, adults are uncomfortable with the notion of childhood and adoles- cent sexuality, even though there is literature to indicate that children are sexual at a very early age (Langfeldt 1981). There is also an ethical issue related to exposing nonoffender adolescents to deviant sexual stimuli. For those interested in further information on how to operate a behavioral laboratory to evaluate sexual offend- ers, Laws and Osborn (1983) provide detailed instructions. Freund (1981) has written an excellent review on assess- ment of pedophiles and addresses the issue of deception (faking arousal responses), as do Earls and Marshall (1983). Treatment Strategies Unfortunately, a controlled group outcome study has not been conducted to date to assess the effectiveness of a specific treatment strategy for adolescent sex offenders. For the past 8 years, we have been conducting federally funded research projects to develop an effective treatment for adult sex offenders, with the ultimate goal of reducing sex offenses. As cited previously, we found that approxi- mately 58 percent of our adult offender population has the onset of their paraphiliac arousal pattern prior to age 18. If we are to reduce the incidence of sexual victimization in this country, we must treat sex offenders early in their careers of paraphiliac behavior. Evaluating the effectiveness of treatment programs for adolescent sex offenders is difficult for several rea- sons: (1) there are a limited number of treatment pro- grams for sex offenders in this country; (2) valid dependent measures have not been reported by any adolescent treat- ment program; and (3) there have only been two controlled group outcome studies conducted with sex offenders to date. 119 Knopp (1982) describes nine treatment programs for adolescent sex offenders. These programs outline what the originators feel are the clinical treatment needs of juvenile sex offenders. They include (1) getting the adolescent to admit his problem, (2) working through the offender's own victimization extensively, (3) sex education and values clarification, (4) cognitive restructuring, (5) disruption of the offender's use of deviant fantasies antecedent to com- mitting sexual offenses, (6) assertive and social skills train- ing, (7) reenactment of the crime with a mannequin, and (8) generation of guilt to reduce the likelihood of recurrence. Only two outcome studies have been completed with sex offenders. Doshay (1943) treated 256 juvenile sex of- fenders; and although some of his cases do not fit the cur- rent DSM III classification of paraphilia, his study is impor- tant in that he treated a large number of offenders and determined recidivism at least 6 years later. The main element of his treatment was generating guilt in the offender. The treatment involved bringing the boy's family and the boy into an open discussion of the youth's sexual of- fense, then mobilizing the cultural forces taught the ado- lescent through the acculturation process and the family. Although Doshay and no control group and relied only on arrest records as a dependent measure, he found that of 108 people who were exclusively sex offenders, only 2 had reoffended prior to adulthood and none had committed sex offenses as adults. Only 14 of the adolescent offenders who were not exclusively sex offenders reoffended prior to adulthood, and only 10 reoffended as adults. Although these are probably underestimates since not all sex of- fenses lead to arrest, the results are still impressive. The second controlled outcome study was conducted by the authors. One hundred and ninety-four child molest- ers were entered in a behaviorally oriented treatment pro- gram. Treatment was conducted on an outpatient basis and lasted for 30 sessions, each 90 minutes long. Treatment consisted of six specific elements, and each element was completed during five 90-minute sessions. The elements were covert sensitization, satiation, sex education, cogni- tive restructuring, social skills, and assertiveness skills training. Subjects were treated in groups, and each group 120 was randomly assigned to treatment components. Subjects were assessed pretreatment and after every 10 therapy sessions. They were also evaluated at 6-month and 12- month followup interviews. For a detailed description of the treatment program, see the manual. The Treatment of Child Molesters (Abel et al. 1984). All subjects volunteered for treatment, and confiden- tiality was protected by a Certificate of Confidentiality. At this writing, 106 subjects have completed treatment, and only | subject has reoffended (99.1 percent success rate). Six months after completion of treatment, 58 sub- jects had been reevaluated and 52 had stopped engaging in deviant sexual behavior (89.7 percent success rate). Thirty-three subjects had completed the 12-month reeval- uation, and 25 of them had not engaged in deviant sexual behavior (75.8 percent success rate). These data indicate that sexual offenders can be treated effectively in an outpatient program. Lacking in the literature is a controlled group outcome study with adolescents. A modification of the adult treat- ment package needs to be assessed with an adolescent population. Any research conducted to evaluate the effectiveness of treatment strategies should (1) use a homogeneous sam- ple, (2) use a standardized measure of treatment outcome, (3) utilize a control or comparison group, (4) not rely exclu- sively on arrest records as an outcome measure, (5) ensure adequate followup, and (6) evaluate whether the offender is in an environment where reoffending is possible. Ethical Issues Disclosure of Information That Is Unknown to the Criminal Justice System In working with adolescent sex offenders, the issue of confidentiality is particularly crucial because of the nature of past criminal offenses they may have committed with- out being apprehended. The following case exemplifies such an issue: 121 Rich was an 18-year-old boy who was referred by Dr. B., a colleague, for voyeuristic behavior. Rich had been treated by Dr. B. for | year, and therapy then terminated. Several months after the termination, Rich was rearrested for voyeurism. He then contacted Dr. B., who referred him to this writer. During the initial interview, Rich related that the deviant sexual behavior began when he was 15 years of age. He had been arrested approximately 2 years after the onset and began therapy at that time. Rich reported that even while he was in therapy, he continued to engage in voyeuristic behavior. Leaving his home in the eve- ning and looking in windows while masturbating, Rich continued the behavior while in therapy and denied engaging in it even though his therapist questioned him about it. From the age of 15 until 18, Rich engaged in voyeuris- tic behavior three times a week. Yet he had been arrested only twice. In disclosing that information during the initial interview, Rich would have been at risk had a prosecutor elected to subpoena the records. The criminal justice sys- tem could have obtained information about Rich that they did not previously have. Some therapists have dealt with this issue by not keep- ing any written records. While this method safeguards the client's confidentiality, it places a burden on the therapist to have to recall the fine details of each patient's history. Furthermore, if the client elects to reenter therapy several years later, no record exists, and both the client and the therapist must again rely on recall. Rada (1978) reports that some therapists and institutions keep two sets of rec- ords, one for their personal use and one for public use. For the past 5-1/2 years, we have conducted clinical research projects involving the assessment and treatment of sexual offenders on an outpatient basis. To handle the issue of confidentiality, we have used the following sys- tem. All history and material disclosed by our clients are coded, using a special identification number. The client's name and identification number are held by a colleague who resides in another country. Thus, if the client forgets his identification number, his coded file can be retrieved by contacting our colleague. Consequently, sensitive in- formation will not be available to anyone unless the client 122 discloses his code number. All coded files are kept in locked file cabinets. Clients are also instructed not to tell anyone con- nected with their evaluation/treatment about the specifics of any illegal acts. For example, we request that clients not tell us when the illegal act occurred, what time of day, where, who the victim or victims were, and what they looked like. By not recording the specific details of an il- legal act, we safeguard the client's confidentiality. Fur- thermore, we have a Certificate of Confidentialty from the National Institute of Mental Health that has protected us from testifying in any court about the specifics of any evaluation or treatment conducted in our clinic. Disclosure of Detailed and Specific Information Unknown to the Parents That They May Wish to Access It is not uncommon for adolescent sex offenders to fail to reveal their behavior to their parents or guardians and to deny totally the crimes with which they are charged. It is imperative that the clinician ascertain what the adoles- cent has revealed to his parents or guardians. Once the adolescent has revealed what his fears are-- specifically, what the parents would do or how they would respond if they knew--his permission should be sought to discuss these fears with the parents or guardians. If the parents assure the therapist that they will not act on the adolescent's fears, permission should be obtained to discuss the undisclosed information with the parents. If the ado- lescent does not give permission for disclosure of the infor- mation, such disclosure to parents/guardians is not recom- mended since this might jeopardize the client-therapist alliance. This issue may be addressed, however, by having the adolescent and his parents sign a consent form before eval- uation and treatment are initiated. Such consent forms specify that information revealed to the therapist will be coded and held in confidence and that only the adolescent will know the code number. This procedure informs the parents/guardians in advance that specific history given by the adolescent will be held in confidence and not made available to them. 123 Permission may be sought from the adolescent to give his parents general feedback on the results of the evalua- tion and/or treatment. We have never had a parent/guard- ian request specific feedback. Usually, when parents ac- company their adolescent to a session, they ask only gen- eral questions, such as "How's my son doing?" Working With the Adolescent Sexual Offender Under a Mandate to Receive Treatment In working with adolescent sex offenders, therapists may find themselves faced with patients who are mandated to receive treatment. Sometimes the adolescent will be remanded to an institution for therapy or to an outpatient facility. In such cases, the right of society to be protected must be weighed against the rights of the individual. Fre- quently, therapists in institutional settings are faced with having to serve the needs of the patient as well as those of the institution. From an ethical point of view, it is advisable that the therapist develop a contract with the adolescent or with him and his parents. Such contracts establish what behav- iors are expected of the patient and what the therapist's function will be. In this manner, the patient and his family know exactly what to expect in terms of treatment. The therapist should also inform the patient how reports to the criminal justice system will be handled. At the Sexual Behavior Clinic, we have a policy of sharing with the pa- tient all reports that have been requested about him. A major ethical issue for those adolescents under a mandate to receive treatment is that they indeed receive the most efficacious treatment strategies to aid them in learning to control their deviant sexual arousal patterns. Readers are referred to two excellent chapters on ethical issues in working with children and youth in group-home treatment settings (Timbers et al. 1981) and legal and eth- ical issues in mandatory treatment (Bohmer 1983). 124 Possible Risks in Assessment and Treatment of the Adolescent Sexual Offender In assessing sex offenders, we have identified four risks: 1. information unknown to the criminal justice sys- tem may be disclosed; 2 the adolescent may feel uncomfortable or anx- ious or may become depressed as a result of discussing his deviant sexual interest pattern; 3 the adolescent may contract a venereal disease in the course of the psychophysiologic assess- ment; and 4, the adolescent may feel uncomfortable in com- pleting the various paper and pencil tests. To minimize these risks, we have taken the following steps. In regard to risk 1, all history data and other material dis- closed by our patients are coded. Regarding risk 2, pa- tients do in fact feel uncomfortable, anxious, and occa- sionally depressed about disclosing their deviant behavior. Consequently, any individual treating adolescent offenders should be skilled in treating anxiety or depression in case those symptoms develop. Regarding the third risk, none of the more than 850 patients we have assessed has developed a venereal infection from the penile transducer, because we have developed and followed a sterilization process. With respect to risk 4, some patients are indeed uncomfor- table in responding to the subjective assessment because they are, in fact, revealing their deviant arousal and be- havior patterns. Again, it is important that the clinician be trained to handle such problems. A final issue regarding assessment relates to exposing the adolescent to explicit sexual cues. We do not expose the adolescent to material any more violent than what is presented daily on television and in the movies. To ensure that patients do not acquire any faulty cognitions or devi- ant behaviors, we recommend that adolescents be de- briefed following the assessment. 125 The only risk we have identified for the adolescents who have participated in our treatment program is discom- fort in carrying out the masturbatory satiation treatment. If an adolescent or his parents find masturbation objection- able for moral, physical, or religious reasons, we have not required the patient to perform that therapy. Instead, the adolescent satiates his deviant fantasies by just talking them into the tape recorder without masturbating. Conclusion Assessment and treatment of adolescent sex offenders are a relatively new but enormously important field. If we are to reduce victimization in this country, we must pay attention to prevention and treatment for those individuals at risk of offending and reoffending. Research efforts should focus, first, on defining the extent of the problem and, second, on evaluating assessment and treatment strategies. There will be some difficulty in developing re- liable and valid assessment instruments since comparison groups will probably not be readily available because of the sexual nature of the area under study. Treatment designs will be limited since it is unethical to deny or withhold treatment to adolescents at risk of reoffending. Given these limitations, there is still room for factors that in- stigate and maintain deviant sexual arousal patterns. Primary prevention measures can then be directed at eliminating the causes of sexual aggression. References Abel, G.G.; Becker, J.V.; Cunningham-Rathner, J.; and Lucas, L. "Recent Advancements in the Treatment of Sexually Violent Men." Workshop presented at the World Congress on Behavior Therapy, 17th Annual Convention of Association for the Advancement of Behavior Therapy, Washington, D.C., December 1983. Abel, G.G.; Becker, J.V.; Cunningham-Rathner, J.; Rou- leau, J.; Kaplan, M.; and Reich, J. The Treatment of Child Molesters (a manual), 1984. 126 Abel, G.G.; Becker, J.V.; and Skinner, L.J. Treatment of the violent sex offenders. In: Roth, L., ed. Clinical Treatment of the Violent Person. Crime and Delin- quency Issues. A Monograph Series. Rockville, Md.: National Institute of Mental Health, in press. Abel, G.G., and Blanchard, E. The role of fantasy in the treatment of sexual deviation. Archives of General Psychiatry 30:467-475, 1974. Reprinted in: Frank, C.M., and Wilson, G.T., eds. Annual Review of Behav- ior Therapy: Theory and Practice. Vol. 2. New York: Brunner /Mazel, 1975. Abel, G.G.; Blanchard, E.; and Barlow, D. Measurement of sexual arousal in several paraphilias: The effects of stimulus modality, instructional set and stimulus con- tent. Behavior Research and Therapy 19:25-33, 1981. Abel, G.G.; Cunningham-Rathner, J.; Becker, J.V.; and McHugh, J. "Motivating Sex Offenders for Treatment with Feedback of Their Psychophysiologic Assess- ment." Paper presented at the World Congress of Behavior Therapy, Washington, D.C., December 10, 1983. Abel, G.G.; Mittelman, M.; Becker, IJ.V.; Cunningham- Rathner, J.; and Lucas, C. "The Characteristics of Men Who Molest Children." Paper presented at the World Congress of Behavior Therapy, Washington, D.C., December 10, 1983. Ageton, S. Sexual Assault Among Adolescents. Lexington, Mass.: Lexington Books, 1983. Bandura, A. Aggression: A Social Learning Analysis. Eng- lewood Cliffs, N.J.: Prentice-Hall, 1973. Bandura, A. Psychological mechanisms of aggression. In: Green, R., and Donnerstein, E., eds. Aggression: Theoretical and Empirical Reviews, Vol. |, “ELS and Methodological Issues. New York: Academic Press, 1983. Barlow, D.; Abel, G.G.; Blanchard, E.; Bristow, A.; and Young, C. Heterosocial skills checklist for males. Be- havior Therapy 8:229-239, 1977. 127 Berlin, F., and Meinecke, C. Treatment of sex offenders with antiandrogenic medication: Conceptualization, review of treatment modalities, and preliminary find- ings. American Journal of Psychiatry 138(5):601-607, 1981. Bohmer, C. Legal and ethical issues in mandatory treat- ment: The patient's rights versus society's rights. In: Geer, J., and Stuart, L, eds. The Sexual Aggressor. New York: Van Nostrand Reinhold, 1983. Deisher, R.W.; Wenet, G.A.; Paperry, D.M.; Clark, T.F.; and Fehrenbach, P.A. Adolescent sexual offense be- havior. Journal of Adolescent Health Care 2:279-286, 1982. Doshay, L.J. The Boy Sex Offender and His Later Career. Montclair, N.J.: Patterson Smith, 1943. Earis, C., and Marshall, W. The current state of technol- ogy in the laboratory assessment of sexual arousal patterns. In: Greer, J., and Stuart, I., eds. The Sex- ual Aggressor. New York: Van Nostrand Reinhold, 1983. Finkelhor, D. Sex between siblings: Sex play, incest, and aggression. In: Constantine, L., and Martinson, F., eds. Children and Sex. Boston: Little, Brown, 1981. Freund, K. Assessment of pedophilia. In: Cook, M., and Howells, K., eds. Adult Sexual Interest in Children. New York: Academic Press, 1981. Groth, N. The adolescent sexual offender and his prey. In- ternational Journal of Offender Therapy and Compara- tive Criminology 21:249-254, 1977. Knopp, F.H. Remedial Intervention in Adolescent Sex Of- fenses: Nine Program Descriptions. Syracuse, N.Y.: Safer Society Press, 1982. Langfeldt, T. Sexual development in children. In: Cook, M., and Howells, K., eds. Adult Sexual Interest in Children. New York: Academic Press, 1981. 128 Laws, R., and Osborn, C. How to build and operate a be- havioral laboratory to evaluate and treat sexual devi- ance. In: Greer, J., and Stuart, l., eds. The Sexual Aggressor. New York: Van Nostrand Reinhold, 1983. Markey, O.B. A study of aggressive sex misbehavior in adolescents brought to juvenile court. American Jour- nal of Orthopsychiatry 20:731, 1950. Rada, R. Legal aspects in treating rapists. Criminal Jus- tice and Behavior 5:369-378, 1978. Roberts, R.E.; Abrahams, L.; and Finch, J.R. Delinquent sexual behavior among adolescents. Medical Aspects of Human Sexuality 7(1):162-183, 1973. Thomas, J., and Rogers, C. A treatment program for in- trafamily juvenile sex offenders. In: Greer, J., and Stuart, L., eds. The Sexual Aggressor. New York: Van Nostrand Reinhold, 1983. Timbers, G.; Jones, R.; and Davis, J. Safeguarding the rights of children and youth in group-home settings. In: Hannah, G.; Christian, W.; and Clark, H. Preser- vation of Client Rights. New York: Free Press, 1981. U.S. Department of Justice, Bureau of Justice Statistics. Criminal Victimization in the United States 1979. National Crime Survey Report. Washington, D.C.: U.S. Government Printing Office, 1981. U.S. Department of Justice, Federal Bureau of Investiga- tion. Uniform Crime Reports. Washington, D.C.: U.S. Government Printing Office, 1977-1980. Wolfgang, M., and Ferracuti, F. The Subculture of Vio- lence. London: Tavistock, 1967. Zillman, D. Arousal and aggression. In: Greer, R., and Donnerstein, E., eds. Aggression: Theoretical and Empirical Review. Vol. I: Theoretical and Methodo- logical Issues. New York: Academic Press, 1933. Zuckerman, M. Physiological measures of sexual arousal in the human. Psychological Bulletin 75:297-329, 1971. 129 CHAPTER 3 THE ADOLESCENT SEXUAL OFFENDER: BACKGROUND AND RESEARCH PERSPECTIVES Robert E. Freeman-Longo, M.R.C. A National Concern and Problem In recent years more concern and attention have fo- cused on the juvenile offender than at any other time in this Nation's history. It is no surprise that a major focal point is the adolescent sexual aggressor. If one were to trace the case types in the juvenile justice system, it would become apparent that juveniles are entering the system in increasing numbers for committing sexual offenses. In 1890 we found no record of juveniles committed to the Oregon juvenile justice system for sex crimes. In the nineteen sixties there were just a few adolescent sex of- fenders. In the nineteen seventies we began to see an in- Crease in juveniles committed for sexual crimes. Here in the nineteen eighties we are shocked to find adolescents committed not only for rapes and child sexual abuse charges but rape murders as well (Neilson 1984). National figures indicate that 90 percent of all crimi- nals begin their deviant behaviors between the ages of 12 and 16. Abel (1984) reports that of the paraphilias, those offenders under the age of 18 commit an average of 6.75 crimes per offender, while adults committing similar crimes commit an average of 380 crimes per offender. O'Shaughnessy (1984) states that most violent crimes are committed by offenders between 16 and 25 years of age. Prior to 1975, few if any specialized programs for treating adolescent sex offenders existed in the United States. By the nineteen eighties several States had devel- oped adolescent sex offender programs in both inpatient and outpatient settings (Knopp 1982). Even with such ef- forts, these programs have only begun to scratch the surface of the treatment problem. As is true of programs 130 in existence since the nineteen sixties that treat adult sex offenders, neither enough programs nor beds are available for the increasing numbers of these offenders. Programs that currently treat adolescent sex offenders are, in many cases, just part of a larger facility treating juvenile of- fenders of all kinds and have limited space assigned for sex offender treatment. The majority have anywhere from 8 to 20 spaces and a long waiting list. The greater number of States are at a loss for funds and/or resources to develop specialized programs for the adolescent sexual offender (ASO). Training centers, juve- nile detention centers, and similar facilities have tradition- ally been ineffective in treating the ASO (Freeman-Longo 1981). Case | Bill is a 15-year-old white male charged with sexually abusing a teenage girl. He was arrested and convicted in juvenile court. Bill was sent to a training school for l year but, because of the lack of specialized treat- ment programs, was released with little attention paid to his sexual deviancy. Within a few months, Bill had cut off his sister's underwear with a pair of scissors and attempted to rape her. While faced with significant numbers of juvenile of- fenders (Uniform Crime Reports and other national crime reporting sources indicate that nearly 20 percent of sex of- fenses are committed by offenders under 18 years of age), political red tape and bureaucratic blocks have all too often tended to prevent institutions and agencies from de- veloping separate and specialized programs. In addition, staff in these agencies and institutions either lack the necessary knowledge and training to treat these offenders or have not chosen to view the problems of ASOs as serious enough to warrant specialized programs or treatment. Of even greater concern and consequence is the juvenile jus- tice system, which, in many States, hosts inadequate laws to address the problem of ASOs. As recently as April 1984, an adolescent in Oregon was charged with multiple sexual crimes and assaults and was released to the community be- cause juvenile laws prevented him from being held. All too often, these offenders are labeled as having an "adolescent 13} adjustment reaction," and their sexually assaultive behav- iors are written off as experimentation, nuisance behav- iors, and the like. In such instances it is not uncommon to find the disposition of these cases resulting in minimal to nonexistent intervention or supervision. Another area of concern is the undetected ASO being processed through the juvenile justice system without the problem being identified. This often happens when ASOs are processed for other crimes or problems, such as de- pendency cases or ungovernables (Honorable Jeanne Dawes Crenshaw 1982). Case 2 Martin is a l&4-year-old white male. He was referred to juvenile court for unruly behavior. While obtaining a history on Martin, it became apparent that he was acting out sexually on his sisters. As the case was to determine the presence of ungovernable behaviors and make a disposition, the sexual acting out was not ad- dressed. Martin was referred to a foster home with no recommendations for counseling or treatment. A trained social worker may obtain a detailed history reflecting sexual deviancy in the adolescent's past as well as a background of sexual abuse. As a result of overloaded court dockets and a need to process cases in a timely fash- ion, these issues are seldom addressed in the final disposi- tion of such cases. Other warning signals indicating the adolescent's potential to become or continue to be a sexual aggressor are often overlooked, ignored, or not even recognized. Case 3 Sam is a 12-year-old black male with a history of mak- ing obscene phone calls and voyeurism of his sisters. His parents tried everything from locking him in his room to counseling. Finally he was arrested for expos- ing himself and was required to obtain counseling by the juvenile court. He was terminated by the thera- pist 1 month later and diagnosed as "adolescent 132 adjustment reaction." By the age of 15 he had com- mitted his first rape. As this trend continues, we find an increasing number of ASOs going through a judicial revolving door, only to be tried as adults for a violent sexual offense or returning to the justice system as adults for committing numerous sex offenses. Researchers and clinicians working with sexual aggres- sors have found that over 50 percent of adult sexual of- fenders began their sexual deviancy during their adolescent years and, in some cases, during childhood (Abel 1984; Groth et al. 1982; Longo 1982; Longo and Groth 1983). Studying a sample of 137 convicted sex offenders in Con- necticut and Florida, Groth, Longo, and McFadin (1982) found that the average age at first offense among rapists was 18.78 and among child molesters, 23.8 years. The same study revealed that the age range for first offense for both groups was 8 to 50; the modal age was 16. Abel, Rouleau, and Cunningham-Rathner (in press) found that over 50 percent of sexual offenders had developed their deviant arousal pattern prior to the age of 18 In some geographic locations, figures indicate that over half of child sexual assaults are perpetrated by offenders under 18 (Groth and Loredo 1981). In an unpublished study of con- victed rapists and child molesters, Freeman-Longo (1983) found that the average age at which sexual offenders began to have deviant sexual fantasies was 15. Longo (1982) found that the average age when juvenile sexual offenders began to masturbate was 12. In a study of 231 adult, con- victed sexual offenders, Longo and Groth (1983) found that 30 percent reported a history of compulsive masturbation. In addition to finding that most sexual offenders begin their abusive and deviant behaviors during adolescence, re- search indicates that the majority have also been sexually, physically, and/or emotionally abused or neglected during the developmental years. A study of 90 convicted sexual offenders, both adolescents and adults, revealed that 95 percent experienced some form of abuse or neglect reeman-Longo 1981). Several ongoing studies are con- firming that the majority of sexual offenders had been sexually abused or traumatized (Groth 1979; Groth and Longo 1985; MacFarlane 1983; Prendergast 1979). In a study of 156 convicted sexual offenders and 49 drug 133 k abusers, Groth and Longo (1985) found that! 80 Jpercent of convicted sexual offenders reported a history of sexual abuse or trauma in their lives compared to 29 percent of the drug abusers in the same study. Fifty-six percent of the sexual offenders reported a hands-on victimization. MacFarlane found that 80 percent of incestuous fathers had been sexually abused or traumatized during their life- times. One noticeable difference between males who are sexually abused and eventually become sexual abusers themselves and those who are sexually abused and do not become abusers is the frequency of victimization. Clinical observations indicate that male sexual offenders who re- port sexual abuse in their histories experienced multiple victimizations. This phenomenon appears less prevalent in the histories of males who, although sexually abused, did not engage in sexually abusive behavior toward others. Thus, it appears that sexual abuse is a key risk factor in the etiology of sexually aggressive behavior. In addition to abusive factors in their histories, this author finds that the majority of sexual offenders have de- viant thinking patterns. The adolescent offender, sexual aggressive or otherwise, also displays thinking errors com- mon to criminals who develop during early childhood (Goodman 1983; Samenow 1984a; Yochelson and Samenow 1976). In The Criminal Personality, Yochelson and Same- now identify 52 separate thinking errors common to crimi- nals. These 52 thinking errors have been condensed and reduced to 17 common errors readily identifiable in sexual offenders, both adolescent and adult, by Bush (1983) and Conner (1984). Samenow (1984b) says that "the habitual offenders' twisted moral outlook is firmly rooted by the time they are six or seven years old, and early treatment in programs has the best chance of success". . .. "If you want to change them, you're going to have to help them change the way that they think" (1984b). As early as the preschool years, patterns begin to un- fold that become part of the criminal life style. As a child, the delinquent is a dynamo of energy, a being with an iron will, insistent upon taking charge, expect- ing others to indulge his every whim. He takes risks, becomes embroiled in difficulties and then demands to be bailed out and forgiven. No matter how much his parents try to understand and guide him, they are thwarted at every turn. They assume that this 134 waywardness is merely a stage of development and therefore do not perceive that this is a pattern that is evolving. . . . Most of those who flirt with danger do not become outlaws. They discover that breaking away from legal and moral restraints exacts too high a price. For a criminal, it's just the opposite (Samenow 1984b, p. 7). The presence of criminal thinking errors has a direct link to development and maintenance of deviant sexual thoughts and fantasies. As already mentioned, the onset of deviant thoughts and fantasies is often at puberty and, in some cases, even earlier. If one agrees to the theory that deviant sexual behavior is learned, then the observation of deviant sexual fantasies and criminal thinking patterns at an early age becomes even more significant. When behavior is ad- dressed, there are accompanying thoughts and attitudes that cannot be overlooked. If an adolescent has been en- tertaining deviant sexual fantasies, it becomes apparent that the offender has a distorted thinking process that con- dones the continuation of deviant thoughts, fantasies, and behaviors. Case 4 Wayne was 5 years old when he recalls having his first thoughts about strangling women. He attempted to strangle a friend's mother prior to the onset of adoles- cence. When the woman reacted, he lied by telling her he was just playing. He recalls having these thoughts throughout his developmental years until he raped and strangled his first victim at the age of 17. This distortion in thinking makes it easier for the ado- lescent to do away with the morals and values that would otherwise result in feelings of guilt or disgust with his or her own deviant thoughts and fantasies. When thinking er- rors are present and fantasies occur, which are then rein- forced by masturbatory activity, a very powerful learning process takes place. As one offender stated: I remember I used to relieve my feelings of anger by masturbating. One time I was caught masturbating by 135 my parents and they called me a "little bastard" while spanking me. As soon as they left my room I began to masturbate again, saying to myself "I'll show you... I'll show you" and I can remember the good feeling I had in relieving my anger in this fashion. Later I be- gan to pair this feeling with masturbating to fantasies of molesting little boys" (Freeman-Longo 1980). The incidence of abuse in the histories of ASOs and the development of criminal thinking patterns would have to be written in many volumes to address these issues in detail. These particular areas appear to be key risk factors in the origination of sexual aggression. Other historical and environmental factors that may put the individual at greater risk also need to be acknowledged. One such fac- tor is the placement of juveniles in agencies, institutions, foster care, group homes, training schools, and the like. A child is often labeled a behavioral problem or ungov- ernable or is removed from a home because the parents or primary care takers are discovered to be abusive or ne- glectful. When placement in a relative's home is not possi- ble, the child is placed in an institution or setting such as those just mentioned. While the actions of the courts and social service agencies are supposedly in the best interest and welfare of the child in question, the end result of such placement is often disastrous to either that child or other children. If an abuser is placed in such a setting, there will usu- ally be other children in that setting for different reasons who, if not already victims, may become victims in time. Many ASOs are readily able to target potential victims, and children who have been victimized before are often the easiest marks. Cases of physical or sexual abuse by one child on another are commonplace in these settings. In a study of 41 convicted sexual offenders, Freeman-Longo (1983) found that 90 percent had been abused in some fashion. Nine offenders, or 22 percent of the sample, had been sexually abused in foster homes and institutions. In addition, national figures reveal that as many as 75 to 80 percent of runaway children, often placed in these settings, have been the victims of sexual abuse or attempted sexual abuse. 136 If we in fact put child victims at a greater risk of be- ing victimized by placing them in such settings, and if placing ASOs in these settings supplies them with more victims, it is clear that this process must change. These data support the notion that victims of abuse need to be housed separately, despite labels of ungovernable, runaway, and so forth. As a society we need to begin to examine the possibility that ungovernable behavior, runaway behavior, truancy, and the like may very well result from abuse. This premise generally holds true with the ASO. If an ado- lescent has a documented history or even a strongly sus- pected one of sexually abusing others, we must begin to push for separate and specialized housing and treatment. Mixing these two populations together only stands to vic- timize abused children further while perpetuating the sexual deviancy of the ASO, as the following case illustrates. Case 5 Brian is a 16-year-old white male who was placed in a training school for sexually abusing other male chil- dren. On numerous occasions Brian was caught being aggressive with other male children and adolescents in the boys' bathroom and shower areas. As it turned out, Brian was housed with other male children who had been sexually abused. Eventually, through infor- mal talks and group discussions, Brian found out about some of the other male residents’ victimizations. Brian saw these children as easy targets and finally admitted to being sexually aggressive toward them. Cases such as the preceding one are common. If we are ever to break the abusive cycle and work toward help- ing the ASO, we have to recognize and acknowledge real problems and the errors we have made in the past; we must accept the reality of this most serious issue. Research Perspectives Studies such as those cited in the preceding section are only a fraction of the research conducted and the in- formation made available to professionals, agencies, and government programs looking to address the problem of 137 ASOs. Concerned professionals and agencies unfortunately report all too often that while they are aware of the prob- lems and some of their causes, their hands are tied when it comes to taking some form of action. With the multitude of information delivered in the media and in seminars, lec- tures, and so forth, one is still faced with headlines such as "State Shields Teen Accused of Sexually Molesting Child" or "Youth Acquitted in Rape of Girl." Legislation passed to address this problem seldom mandates research, nor does it appropriate moneys to conduct research or gather data. Programs and agencies constantly complain about increased caseloads and lack of time, resources, and sup- port to gather and publish data. Although local and State programs and agencies are trying to address the problem of ASOs, little national at- tention has been drawn to this issue. If we are to under- stand this problem and begin to combat it, we must make a national effort to establish programs and research the area extensively. A great deal of information has been pub- lished on the adult sexual aggressor, but little has been written on the adolescent perpetrator of sexual crimes. The following addresses suggested research areas with re- spect to the ASO in terms of etiology, identification, and treatment. Most clinicians working with sexual aggressives would probably agree that the problem usually begins in childhood or during adolescence. We are able to point out numerous risk factors in the making of a sexual offender, although little can be determined as definitive causes. Therefore, etiology needs further investigation. Samenow (1984) sug- gests that criminal thinking patterns begin during child- hood. Numerous authors report that abuse in the back- ground of offenders is commonplace. Clinicians usually agree that sexual deviancy is a learned behavior. The question arises of how these and other factors interrelate and culminate in sexual aggression. It appears that this question could best be addressed by research on both the ASO and the adult sexual aggressor. The adolescent whose experience is fresh and problems acute can offer us insight into how he feels as a teenager with multiple problems and what childhood events may have led to his deviancy. The adult offender can tell us what he recalls about his child- hood and adolescent years and its carryover into adulthood. 138 Etiology is therefore a key area in understanding both adolescent and adult sexual aggressors and what leads to sexually deviant behavior. Key research areas follow. The spectrum of abuse. How does sexual, physical, and emotional abuse or neglect tie into the individual turn- ing toward sexual aggression? What differences, if any, are there between the child who is abused and does not grow up to be an abuser and the one who is abused and does become an abuser? Parental bonding. Is there a lack of parental bond- ing that is a risk factor in sexual abusers? What differ- ences, if any, are there between sexual offenders, nonsex- ual offenders, and a "normal" population? Role modeling. If sexual aggression is indeed a learned behavior, what are the negative influences with respect to role models that have an impact on the ASO's behavior? Social skills deficiencies. Most sex offenders, both adult and adolescent, are socially maladjusted and come from chaotic backgrounds. What social skills deficiencies are common among sexual aggressors? Are there differ- ences between perpetrators who assault children and those who assault adults? At what stage of development do these deficiencies become apparent? Emotional development. What emotions are ar- rested in the sexual offender? At what ages? Special at- tention should be paid to anger and fear. Would an androg- ynous upbringing affect sexually aggressive behaviors in males? Thinking patterns. What types of thinking errors ap- pear in sexual offenders? When do the errors begin, and how are they maintained? What roles do these thinking er- rors play in the development and maintenance of deviant sexual thoughts and fantasies? Sexual development. How does the offender learn about sex? What types of distortion and mislearning take place? What kinds of experiences occur that lead to ag- gressive sexuality? What types of sexual interests develop 139 and under what conditions? What are the arousal patterns? What is missing in the offender's overall understanding of human sexuality? How does sex education at an early age affect sexually aggressive behavior? Many appear to have polymorphous sexual interests and/or histories of being sexually precocious. Self-concept. When does the offender's self- concept take a turn for the worse and under what condi- tions? What key factors lead to the development of a low self-concept, which in turn affects sexuality and aggres- sion? What deficient areas of self-concept are common among sexual offenders? Moral development. What problems in moral devel- opment are evident in sexual aggressors? These areas can be explored in the works of noted experts such as Piaget and Kohlberg. Value structures. Many offenders have different value structures than "normals." Their value structures are distorted, minimal, or nonexistent. How does value struc- ture affect aggressive and sexually aggressive behavior? Social relationships. The majority of sexual offend- ers are isolates. To what degree do these individuals lack relationships with parents, siblings, and peers? Other Theories About Causes of Sexual Deviancy Some researchers, such as Fred Berlin, suggest that sexual deviancy is a biomedical problem. Others suggest that it is linked to mental illness, organicity, and so on. What percentage of sexual aggressors can attribute their problems to such causes? Deviant cycles. All adult sexual offenders have a preassault cycle and a deviant cycle. Are there similari- ties or differences among these cycles, and are they ap- parent in ASOs? To what extent are they similar or dif- ferent from those of adult sexual offenders? Arousal patterns. Are arousal patterns present in the adolescent sexual offender? When do deviant arousal patterns begin to develop? Is there arousal to their own 140 sexual victimization, as occurs in the adult offender? What percentage of ASOs show arousal to their own sexual victimization? Why do some ASOs become aroused at their own sexual victimization while others do not? These areas need to be explored further to determine their relationship to the etiology of sexual aggression. To form more conclusive data, such research should be aimed at six target groups: (1) the adolescent sexual offender, (2) the adult sexual offender, (3) the adolescent nonsexual criminal, (4) the adult nonsexual criminal, (5) the noncrimi- nal adolescent, and (6) the noncriminal adult. To refine these data further, it will be important to conduct such research with various minority groups and with both males and females. These types of data can best enable profes- sionals to begin identifying the potential sexual aggressor through observing early warning signals. Another promising area for research is early warning signals for identification, especially if standardized tests are developed and validated, tests that would help target sexual aggressives or potential sexual aggressives. There- fore, subsequent research areas might include the following: Criminal background. Are there criminal charges or illegal activities in the histories of sexual aggressors that precede sexually deviant behaviors? Progression of sexually deviant behaviors. Different schools of thought exist in this area, too. Some research- ers find little progression in sex crimes, while others find progression to be the rule. Data in this area vary, and in some cases the variation is large. Is there, in fact, a no- ticeable progression from "nuisance" behaviors, such as frottage, obscene phone calling, exhibitionism, and the like, to the more serious, hands-on assaults? Is this pro- gression evident in the ASO? Deviant behavior patterns. What types of deviant behaviors, assaultive or otherwise, are exhibited by the offender? At what ages do these behaviors become evi- dent? How frequently are they exhibited? What have the parental, institutional, legal, and societal responses been to such behaviors? Have they been reinforcing? 141 The victims of these behaviors. What age groups and sexes are most frequently targeted by ASOs? Are the same individuals revictimized? Does the ASO tend to tar- get strangers rather than individuals he knows? The thinking patterns and fantasy structures of the ASO. Are there significant data to indicate that the ASO begins to develop deviant thinking patterns during child- hood and adolescence that are directly linked to sexually aggressive behavior? At what ages do these offenders begin to have thoughts or fantasies of a sexually deviant nature? Are there identifying behaviors that accompany these thoughts and fantasies? Sexual deficiencies and abnormalities. While the sexual revolution is touted as having made America a sex- ually permissive society, many ASOs do not feel they have permission to be completely open and honest in talking about their sexuality, especially if there are deviant com- ponents. With respect to deficiencies in sex education, which are prominent among ASOs? Various types of sexual dysfunction, such as impotence and premature ejaculation, and sexual practices such as masturbation, especially com- pulsive masturbation, are present among ASOs. What links are there between these behaviors, problems, and practices and deviant thoughts and fantasies? Pornography, violence, and the media. Although researchers find more and more links between pornography, violence, and the inedia (e.g., TV), there is no universal agreement that these are causative factors in sexually de- viant behavior. What do convicted ASOs and adult sexual offenders claim about using these materials and the roles they play in their deviance? How does this compare to nonsexual criminal groups and noncriminal groups? Does this material affect criminal and deviant thinking patterns, or do deviant and criminal thinking patterns distort this material, encouraging its misuse? Social behaviors. What types of social behaviors ap- pear to be central to ASOs? What types of activities should they be engaging in that they are not? What types are they participating in that they should leave alone? What can we do, if anything, to effect needed changes in children and adolescents to avoid major social skill deficiencies? 142 Literature on the treatment of sexual aggressives is scarce. What there is focuses primarily on the adult of- fender. This indicates one of two major problems: (1) lit- tle research is being focused on treating sexual aggres- sives; or (2) though studies on treating sexual aggressives are being conducted, either formally or informally, few researchers or clinicians are writing about their work. One major problem common to most programs that treat sexual aggressives is the lack of program evaluation and followup studies. Such programs continually face extinction when they cannot justify their effectiveness. Research on treat- ing ASOs and followup studies are now essential as we be- gin to address the ASO problem. Several research areas should be considered: Physiological assessment. The majority of sexual aggressives are aroused by deviant sexual stimuli, and many have polymorphous interests. Physiological assess- ment with the penile plethysmograph has been done on adult offenders for years. 'Jse of physiological assessment with ASOs is not as common, and no standards or norms have been established for assessment. Ethical considera- tions must also be addressed with this procedure. Aversive counterconditioning. Behavioral treatment methods can be employed in conjunction with the penile plethysmograph. Ethical considerations and types of treat- ments also need to be researched and tested. Behavioral therapy. Behavioral therapies, including covert sensitization, assisted covert sensitization, mas- turbatory satiation, masturbatory reconditioning, sensate focus, and the like, have all been proven effective with adult sexual offenders. Two concerns about using these treatments on ASOs need to be addressed: (1) What are the ethical concerns surrounding such treatment with ASOs? (2) How effective are these methods with ASOs? Offender age. In developing and maintaining treat- ment programs for ASOs, the questions of age differences and which age ranges to treat create continuing debate and concern. Should one mix preadolescent offenders with ASOs? Many institutions classify youthful offenders as being between the ages of 16 and 24. Should people of this wide an age range be mixed in the same program? At what age should we begin to treat children and preadolescents? 143 Other treatment methods employed with both adoles- cent and adult sex offenders, such as psychotherapy and educational modules, are relatively standard and proven both necessary and effective. Summary It is apparent that we can gather the most information and broaden our data base and knowledge by doing research with both adolescent and adult sexual aggressors. In addi- tion, clinicians must begin to focus on (1) long-term follow- up with treated and untreated sexual offenders and (2) the development of standardized program evaluation criteria. Richard Freeman (1984) suggests that evaluations should indicate three major components to any effective sex of- fender treatment program: l. program continuity and consistency in treatment 2. a multiple treatment modality approach 3. a drug and alcohol treatment /education component If in fact this position is true, it seems apparent that initial research should include the following: (1) Client fol- lowup with programs that have been in existence for at least 5 years and have maintained a consistent approach to treating sexual aggressives, both adolescents and adults. Programs using a multiple modality approach should be given priority consideration for followup studies. (2) Eval- uation of programs that meet the criteria of item | should be conducted to evaluate the effectiveness of treatment modalities. Questions to be addressed are: (a) Is there any specific order in which treatment methods are executed? (b) Are treatment methods delivered in a consistent fash- ion? (c) What modalities and methods appear most effec- tive in treating sexual aggressors--specifically, the ASO? (d) What selection criteria, if any, are used in determining which offenders are treated in that particular program? If the answers to these questions and those cited ear- lier about etiology are found, our knowledge will guide us properly in addressing the problem of adolescent sexual of- fenders and related social issues. Our final concerns may very well regard whether attention will be paid to this 144 problem nationally and whether funds will be made avail- able to combat it. References Abel, G.G. Presentation at the Sexual Aggressives Treat- ment /Research Symposium, Vancouver, British Colum- bia, Canada, March 25-28, 1984. Abel, G.G.; Rouleau, J.; and Cunningham-Rathner, J. Sex- ually aggressive behavior. In: Curran, W.; McGarry, A.L.; and Shah, S.A., eds. Modern Legal Psychiatry and Psychology. Philadelphia: F.A. Davis, in press. Bush, J. Personal communication, 1983. Conner, K. Personal communication, 1984. Crenshaw, J.D. Presentation on child sexual abuse at Ala- chua County Council on Child Abuse, Inc., Gainesville, Florida, September 25, 1982. Freeman, R. Presentation at the Sexual Aggressives Treatment /Research Symposium, Vancouver, British Columbia, Canada, March 25-28, 1984. Freeman-Longo, R.E. Interview with 35-year-old con- victed child molester, 1980. Freeman-Longo, R.E. Unpublished study on the background histories of sexual aggressives, 1981. Freeman-Longo, R.E. Unpublished study on developmental histories in sexual offenders, 1983. Goodman, D. Do juvenile offenders have "criminal per- sonalities"? Corrections Magazine 9(1):30-35, 1983. Groth, A.N. Sexual trauma in the life histories of rapists and child molesters. Victimology: An International Journal 21(1):10-16, 1979. Groth, A.N.; Longo, R.E.; and McFadin, J.B. Undetected recidivism among rapists and child molesters. Journal of Crime and Delinquency 28(3):450-458, 1982. 145 Groth, A.N., and Loredo, C.M. Juvenile sexual offenders: Guidelines for assessment. International Journal of Offender Therapy and Comparative Criminology 25(1): 31-39, 1981. Knopp, H.F. Remedial Intervention in Adolescent Sex Of- fenses: Nine Program Descriptions. Syracuse, N.Y.: Safer Society Press, 1982. Longo, R.E. Sexual learning and experience among adoles- cent sexual offenders. International Journal of Of- fender Therapy and Comparative Criminology 26(3): 235-241, 1982. Longo, R.E., and Groth, A.N. Juvenile sexual offenses in the histories of adult rapists and child molesters. In- ternational Journal of Offender Therapy and Compara- tive Criminology 27(2):150-155, 1983. MacFarlane, K. Personal communication, 1983. Neilson, G. "Theory and Treatment of Adolescent Sex Of- fenders." Paper presented at the Child Well Fair Workshop, Salem, Oregon, April 4, 1984. O'Shaughnessy, R. Presentation at the Sexual Aggressives Treatment/Research Symposium, Vancouver, British Columbia, Canada, March 25-28, 1984. Prendergast, W.E. The sex offender: How to spot him be- fore it's too late. Sexology, October 1979. Samenow, S.E. Inside the Criminal Mind. New York: Times Books, 1984a. Samenow, S.E. Is it always the parents' fault? Family Weekly, Jan. 15, 1984b, pp. 7-8. Yochelson, S., and Samenow, S. The Criminal Personality. Vols. I and II. New York: Jason Aronson, 1976. 146 CHAPTER 4 ADOLESCENT SEXUAL OFFENDERS: AN OUTPATIENT PROGRAM'S PERSPECTIVE ON RESEARCH DIRECTIONS Michael O'Brien The conspiracy of silence that for so long hid the tragedy of sexual victimization has been broken. We are /V witnessing a national revolution in our awareness of the problem and in the mobilization of professionals from many disciplines to combat it. The sexual abuse of children, in particular, has lately received unprecedented media atten- tion in contrast to an earlier time, when the notion of chil- dren as victims of sexual abuse was unthinkable because it was believed unlikely. This attention has largely focused on adult perpetra- tors of incest and child molestation and on child victims of the same. Coming to the attention of legal and human services professionals just recently is the problem of ado- lescents who engage in sexually victimizing behaviors. There has been a longstanding reluctance to view the issue of adolescents who rape, molest, or commit other sexual crimes as a serious social concern. The adolescent who committed a sexual offense was typically considered an awkward explorer in the unknown territory of his emerging sexuality. Consequently, acts for which adults faced prose- cution and imprisonment were dismissed if perpetrated by adolescents. This emerged from misguided beliefs about the behaviors being temporary developmental anomalies or from equally misguided atternpts at sparing adolescents a social stigma. The phenomenon of adolescent sexual offending is not an insignificant one. While accurate incidence statistics are understandably lacking, some figures do point to its prevalence. Ageton (1983) estimates that over 500,000 adolescents commit sexual assaults in this country every 147 year. This figure underestimates total adolescent sex of- fenses since her definition is limited to the use of force in committing acts that involve contact with sexual parts of the body. Excluded are reports of exposing, voyeurism, obscene phone calls, and other "hands off" offenses. Vic- tims of sexual abuse seen at Children's Hospital in Wash- ington, D.C., report that adolescents represent the majority of their assailants (Groth and Loredo 1981). Data from the St. Paul, Minnesota, Police Department reveal a steady increase in the number of adolescents ar- rested for sexual offenses. Number of Adolescents Year Arrested* 1979 38 1980 50 1981 75 1982 70 1983 92 *These figures do not include prostitution or incest arrests. Between 1979 and 1983, there was a 142 percent increase in the number of male adolescents arrested for committing a sex offense. In 1983, juveniles accounted for 40 percent of the total arrests for sexual offenses excluding prostitu- tion in St. Paul and 61 percent of the total arrests for sex- ual offenses other than rape. The overwhelming majority of these involved child molestation. The seriousness of the problem is further underscored by studies indicating that nearly half of adult sexual offenders report their offense history began when they were adolescents (Groth and Loredo 1981). The increase in awareness of the problem has resulted in an unprecedented interest nationwide in establishing treatment programs. Efforts have generally been frus- trated by the paucity of professional literature, especially empirical research, on the subject. One recent, computer- generated literature search (Med-Line) on the topic of child sexual abuse, cross-referenced with the topics of sexual offenders and pedophilia, revealed only one refer- ence on adolescent sex offenders from over 100 articles 148 indexed. A great deal of research needs to be carried out in this area so that efforts at intervention, treatment, and prevention can be effectively designed and evaluated. Useful information has been gathered by the few treatment programs that have been serving this popula- tion for the past several years. Their experience in assess- ing and treating sexually offending adolescents and their families point to research topics and concerns that need to be studied. The purpose of this chapter is to draw from our experience in treating male adolescent sexual offenders in a community outpatient setting to raise research questions and suggest research directions. Program for Healthy Adolescent Sexual Expression (PHASE) The Program for Healthy Adolescent Sexual Expres- sion (PHASE) was begun in 1981 in response to increased recognition in the communities of urban and suburban St. Paul, Minnesota, of the extent of the problem and the lack of appropriate resources to deal with it. PHASE is an out- patient program of a small, suburban private mental health clinic (East Communities Family Center) that historically had served primarily delinquent youth and their families. The program has two basic components: The Education- Assessment Program and the Treatment Program. The Education-Assessment component lasts 5 weeks and involves individual and family interviews, the comple- tion of various psychological instruments, and four 2-hour groups made up of approximately 10 adolescent males, ages 13 to 18. The groups focus on issues in adolescent sexual- ity, with primary emphasis on sexual attitudes, values, and social influences on behavior. The program provides an education in sexual victimology and the differentiation between healthy, appropriate sexual behavior; unhealthy, inappropriate sexual behavior; and criminal sexual behav- ior. Each adolescent is required to share his story a num- ber of times with the group, to explain why his behavior was inappropriate, and to describe how it affected his victims. In addition, each member assesses his need for further treatment and begins to formulate treatment goals. He is helped in this task by soliciting feedback from 149 each of the other group members. Parents also meet in the Parents' Group to offer support to one another and to learn some of the same information being taught their sons. The Education-Assessment Program culminates in a diagnostic conference involving the juvenile probation officer, social worker, and/or other involved professionals. There, the case manager reports on his or her assessment of the adolescent and his family and makes treatment recommendations. A formal comprehensive assessment report is also completed at this time and forwarded to the court or referring social agency. Assessment dispositions include: (1) termination from the program because the Education-Assessment Program is believed sufficient; (2) termination and referral to other outpatient programs (i.e., family counseling, social skills groups, etc.) or to treatment (inpatient or outpatient) for chemical depend- ency or mental illness; (3) referral to an inpatient or residential program for adolescent sexual offenders be- cause the youth is considered too risky for outpatient treatment or in need of more intensive long-term treat- ment; and (4) referral to the PHASE treatment program. The Treatment Program lasts an average of 6 addi- tional months and involves individual, family, and group pyschotherapy. The adolescent moves through a four-stage treatment model in this program. Stage I--Acceptance-- requires him to assume primary responsibility for his sex- ually abusive behavior. This stage involves breaking through defense mechanisms so the adolescent arrives at an understanding of how his behavior hurt the victims and why it is a serious problem. Stage II--Consequences-- increases the adolescent's understanding of the impact of his sexual offenses on the victims by requiring him to write and share a letter to his victim(s). He is also asked to con- front his own experience as a victim of sexual, physical, or emotional abuse and must demonstrate appropriate em- pathy for others in family and group therapy. Stage III-- Understanding and Change--involves increasing the youth's awareness of his own emotional, psychological, and situa- tional processes that led to his offenses and requires him to develop appropriate alternative behaviors. During this stage, he develops a context in which to view his offending pattern more clearly through exploring the influences of his family, peer, and social systems on his behavior. He must clarify the cognitive, behavioral sequences that led to 150 his sexual acting out (i.e., arousal patterns, reinforcers, and fantasies) and must learn ways to "short-circuit" the sequences to prevent the offending behaviors. During this stage, he learns to identify the underlying needs for affec- tion, competency, power, acceptance, dominance, nurtur- ance, etc., that the sexually abusive behavior may have been serving. He learns to identify and report stressful, high-risk situations and their accompanying feelings. The final goal of this stage is to develop a number of alterna- tive behavioral options to his previously inappropriate at- tempts at meeting his needs and to rehearse these alterna- tives in individual, family, and group therapy. Finally, Stage IV--Support--encourages the adolescent to increase his knowledge of and ability to meet his own sexual and interpersonal needs without victimizing others. He must learn appropriate, need-fulfilling strategies and demonstrate them in treatment. General areas for skill building during this stage include assertiveness, communi- cation, expression of feelings, impulse control, academic and vocational interests, and social skills, including dating and involvement in peer activities outside of treatment. At PHASE, we view the involvement of the family in the treatment process as crucial, since the family provides the major context in which the sexually victimizing behav- ior is learned and expressed. The family is also likely to be the key source of conflict and tension for the adolescent. Family therapy follows from the family assessment com- pleted during the Education-Assessment Program. Typical goals include developing effective family communication; increasing family intimacy, especially between father and son; restructuring interpersonal boundaries; realigning fam- ily roles; working through unresolved abuse issues in the family; and enhancing family esteem. Since the summer of 1981, PHASE has worked with over 250 male adolescent sexual offenders in providing as- sessment and treatment services. The majority of the youth (80 percent) were direct referrals from the juvenile courts. An additional 10 percent were police "court diver- sion" referrals, and 10 percent were referrals from other social services agencies or treatment programs or were self-referred. The average age of the client is 15.5 years, but there are virtually equal proportions of youths aged 14, 15 16, and 17. Ninety percent are white; 10 percent are 151 black or Hispanic. At intake, 72 percent of the referrals were living with one or both birth parents, while 28 percent were living in residential facilities, group homes, foster homes, or with other relatives. The residential locations of our clients were 37 percent urban, 27 percent suburban, and 36 percent rural or small town. The referring offenses involved noncontact offenses (obscene phone calls, exhibitionism, voyeurism) (14 per- cent); molestations involving sexual contact (i.e., fondling, oral-genital contact) (53 percent); and more aggressive sexual assaults involving penetration (33 percent). The majority (64 percent) of the victims of the adoles- cent perpetrators were younger children, whose average age is 6. Twenty-four percent of the victims were peers, and only 12 percent were adults. In 17 percent of the cases, the victim was a member of the perpetrator's family. School performance was above average in only 5 per- cent of the clients, average in 32 percent, and below aver- age in 63 percent. The majority had been involved in some prior treat- ment or therapy (53 percent) (not sex offense-specific) and had had contact with some aspect of the social service sys- tem prior to their sexual offense (52 percent). Assessing the Problem When first confronted with the adolescent offender, the clinician must begin to assess the nature and scope of the problem. The first question is, Does the particular behavior or set of behaviors exhibited by this adolescent reflect relatively normative exploration, given develop- mental imperatives; or does it represent the early stages of an emerging sexual deviance syndrome or sexual maladjust- ment? The terms sexual offense and sexual offender are legal designations, not clinical ones. The fact that a law has been broken and an adolescent apprehended and adjudi- cated ought not to be prima facie evidence of psychopath- ology. In Minnesota, an adolescent who is more than 36 months older than a person with whom he has sexual contact is, by law, a sexual offender. In such a case, a particular sexual act, while criminal by legal definition, 152 may represent a single episode of relatively benign sexual exploration that does not call for the perpetrator's par- ticipation in a lengthy course of treatment. A brief sexu- ality education program may be entirely appropriate. On the other hand, a behavior that appears relatively benign on the surface may, after more extensive investigation, represent a serious developing sexual problem that requires a comprehensive treatment program. Clearly, a set of guidelines must be developed to differentiate those ado- lescents whose behavior signifies a more serious problem and who are at higher risk for reoffending from those whose behavior reflects developmentally normal drives, perhaps inappropriately expressed, requiring, at most, an educational rechanneling. Once it is determined that a significant sexual offense problem exists, the next major question is, What types of treatment methodologies in which treatment setting are appropriate for this particular case? This raises the issues of outcome research. The question gets translated into, How effective are we with which kinds of clients in which settings after which therapeutic procedures, and how does the change occur? There are many methodological, ethi- cal, and pragmatic concerns that outcome studies gener- ate; suffice it to say that this ought to be a primary focus of the research. The clinician must be careful in working with adoles- cent sexual offenders not to reduce the phenomenon to a single explanation or a single diagnostic category, and so must researchers. We must guard against making simplis- tic assumptions about the homogeneity of the population and about parallels to adult sexual offenders that are not warranted or supported by data. Adolescent sexual vic- timization is a multifactor, multicausal phenomenon. What is called for is the development of an empirically based, differential classification typology to guide clinicians in formulating treatment goals and planning treatment strategies. The adolescent males we have treated in PHASE ap- pear to fall into six broad groups based on their behaviors and associated personal and family variables. These are: I. Naive Experimenters 2. Undersocialized Child Exploiters 153 3. Sexual Aggressives 4. Sexual Compulsives 5. Disturbed Impulsives 6. Peer Group-Influenced Offenders Naive Experimenters Peter, age 13, was asked to babysit his mother's friend's 4-year-old girl Alicia. This was Peter's first experience with babysitting since he was an only child who had not previously been afforded the opportunity to care for a younger child. At bedtime, while helping Alicia to dress in her pajamas, he found himself be- coming curious and having "urges." He then laid on the bed with her, kissed her on the lips, and gently began to stroke her stomach, working his way down into her pajamas. After a brief period of genital fondling, he stopped because he felt guilty. The next morning Alicia nonchalantly told her mother that Peter had kissed her and touched her between her legs. Alarmed, the mother called Peter's mother and the local sexual assault center, who reported the in- cident and referred the family to PHASE. The adolescent naive experimenters generally are younger boys (aged 12 to 15) who have no previous history of acting-out problems and who have adequate social skills and peer relationships. They are usually members of fairly stable families who are unlikely to have been victims of physical or sexual abuse. They tend to be sexually naive and unsophisticated young people who engage in a single event or a few isolated events of opportunistic sexual ex- plorations with a young child (usually 2 to 7 years of age). The event is situationally determined (i.e., often while babysitting) and is effected without recourse to any force or threats. When confronted, the naive experimenter may deny his offense but usually comes to admit his responsi- bility shortly, feeling remorseful and embarrassed in the process. These adolescents are typically dismissed at the end of the Education-Assessment Program. 154 Undersocialized Child Exploiters Jerome, age 16, could best be described as a loner. He had virtually no close peer friendships and only a few casual peer acquaintances. He spent a good portion of his time watching television or playing video games on his home unit. When outside playing, he was likely to be off by himself or with considerably younger chil- dren. He was viewed by the adults in the neighborhood as polite and quiet--a nice boy. They didn't know that he had been involved sexually with seven of the neigh- borhood children. The sexual abuse involved fondling and oral-genital contact, which he tricked and manipu- lated the younger boys into doing with him. While no force or threats were used, he did maintain secrecy with the children by warning them that they would be in trouble with their parents if they told. The secret was broken by one of the children, and Jerome was apprehended, charged, and adjudicated and referred to the PHASE program as a condition of his probation. The undersocialized child exploiter also engages in sexual behavior with younger children, but his behavior goes beyond mere experimentation and exploration. It is likely to reflect a more chronic pattern of sexual behaviors with children, a pattern that is effected through manipula- tion, trickery, enticement, or entrapment and that involves primarily fondling and oral-genital sexual contact. The hallmark of this group is their chronic social iso- lation. They are not accepted by their peers and are un- likely to have a best friend agemate. They may have been the victim of frequent family moves in their formative years that precluded the establishment of close friend- ships. Since they lack adequate social skills, they remain isolated from their peers and then gravitate to younger children, who accept them and even admire them. These boys evidence an abysmally low opinion of their own worth as a result of alienation from family and friends; they are likely to perform poorly in school. There is rarely a history of other antisocial behaviors or problems with police or school authorities. Involvement with drugs or alcohol is unusual. 155 For this youth, feelings of inadequacy and insecurity predominate, and there is a distinct tendency toward with- drawal and depression, especially when stressed. Recur- rent anxieties and irritabilities typify his emotional life. His apparent apathy and passivity represent attempts at concealing his extreme sensitivity and resentfulness. The undersocialized child exploiter is a sad young man who feels misunderstood, unappreciated, and demeaned by others. He has a generally pessimistic and disillusioned outlook for his future. Unless his self-esteem can be en- hanced and appropriate peer relationships established, he runs the risk of continuing to be attracted to young chil- dren as sources of fulfillment of his needs for affection, acceptance, competence, and power and would likely act out sexually with children as well. His family is characterized by an emotionally and often physically distant or absent father and an over- whelmed, anxious, or depressed mother. There is likely to be little expression of emotional warmth or nurturance in the family. Generally, the family system could be de- scribed as intact but disengaged. A comprehensive treatment program involving individ- ual, group, and family therapy is called for with this type. Generally speaking, an outpatient program providing these components is appropriate unless the pattern of offending suggests a high likelihood that the client will act out again if left in the community even though undergoing treat- ment. A residential program is then most appropriate. Sexual Aggressives Tony, age 15, is a victim of physical abuse at the hands of his alcoholic father. His mother is passive and ineffectual and suffers from the physical beatings of her husband as well. Tony has been involved in fre- quent brushes with the authorities for fighting, theft, vandalism, and truancy. After school, he assaulted a 14-year-old girl under the stairwell and forced her to perform fellatio on him at knifepoint. He was ar- rested that night, detained, and later convicted of first-degree criminal sexual conduct. He was referred to PHASE for assessment. 156 These adolescents use force or violence in committing sexual assaults against peers, adults, or older children. They are usually products of disorganized and abusive families. Differentiating them most clearly from the former type is the fact that they are likely to be very much in- be somewhat charming and socially gregarious. They are likely to have girlfriends and to be socially and sexually active. They are typified by a history of antisocial behaviors stemming from early childhood. They have difficulty hand- ling aggressive impulses and deal poorly with anger, getting themselves in frequent fights with family members and peers. They are also prone to be heavily involved with al- cohol and other mood-altering substances. The sexually aggressive adolescent acts out sexually to express anger or to humiliate, dominate, and control There is a high probability that he learned to connect vio- lence with erotic arousal, so that more violent sexuality is preferred to a gentler expression. He may fantasize about committing rape and acts of cruelty, torture, or even murder. The sexually aggressive adolescent generally has poor impulse control, is often tense and anxious, and may ex- perience vacillation of powerful moods and emotions. He has a difficult time accepting criticism, being overly sensi- tive to others' opinion of him. He has a tendency to use denial and projection to avoid accepting responsibility for his self-destructive and victimizing behaviors. In short, the sexually aggressive adolescent could be described as an antisocial, character-disordered young man who, in all probability, will continue to act out without intensive long- term treatment, most appropriately in an inpatient or resi- dential setting. Sexual Compulsives David, age 16, by most accounts was considered an exceptional teenager—a straight A student, active in 157 church youth activities, star of the high school foot- ball team. However, David was identified by three different women as the man who had exposed himself to them while they were having their morning jog. While at first denying their accusations, David gave in to the weight of evidence against him and admitted that he had exposed himself regularly to a number of women while performing his morning 5-mile run. This behavior had gone on unabated for over 8 months be- fore he was apprehended and referred for treatment. The sexually compulsive adolescent engages in repeti- tive, sexually arousing behaviors that become compulsive or addictive in nature. The offenses are usually hands-off behaviors, such as voyeurism (window peeping), obscene phone calling, exhibitionism (exposing), and fetish burglary (i.e., stealing women's underwear). Most adolescent sexual compulsives are quiet and withdrawn. Often, they are quite bright and studious as well. They tend toward over- achievement and perfectionism and are likely to be over- conforming to social standards and conventions. This hypersensitivity to failure results in a constant state of tension and anxiety from which they seek emotional release. Another related characteristic of this group is their inability to express negative emotions, especially anger, in an appropriate manner. The profound emotional constraint and accompanying anxiety result in tension-reducing, acting-out behaviors that involve sexual arousal. The be- havior becomes patterned, cyclical, and repetitive because it is self-reinforcing. It is also self-generating in that it ultimately results in increased anxiety, fear, and self- condemnation from which the adolescent feels compelled to escape. The family systems of such youths are generally rigidly enmeshed, with closed external boundaries. Parents are often emotionally and behaviorally repressed and are likely to adhere to a rigid and fundamentalist religiosity. Disturbed Impulsives George, age 17, was becoming more reclusive and strange with each passing day. In the night he heard 158 "satanic voices" that told him to do evil deeds. He tried to resist; he prayed for angelic assistance but to no avail. Each night he walked into his 14-year-old sister's room and uncovered a part of her body-—usu- ally a hand or foot--and then masturbated, until he ejaculated on the exposed appendage. He was also driven impulsively to dress occasionally in his mother's or sister's underwear. He was referred for evaluation after his sister reported him to a counselor at school. The disturbed impulsive type of adolescent sexual of- fender is a category reserved for those adolescents whose impulsive, sexually offending behavior signifies an acute disturbance of reality testing due to mood-altering chemi- cals or mental illness. The offense may be a single, unpre- dictable, uncharacteristic act, or it may be one of a pat- tern of bizarre and ritualistic acts. The sexual offense reflects a malfunction of normal inhibitory mechanisms due to a thought disorder caused by psychosis (either en- dogenous or drug induced). This young person needs an inpatient program that can treat his chemical dependency and/or mental illness. Medications may be required to control this adolescent's psychotic thinking. XK Peer Group-Influenced Offender Todd, age 15, was pleased with the fort he and his friends had just completed. While returning from a trip to the store for pop and candy, he and his friend Jason met Barb, a l#4-year-old girl in whom Todd had recently taken considerable interest. Barb agreed to have a look at their fort. After a few minutes inside, the three were joined by Tim, Mark, and John, who had assisted in the fort project. Without warning, Tim lunged at Barb and ordered Mark to block the door. John held Barb's legs while Tim pulled up her shirt and began fondling her breasts. He then unfastened her pants and began to fondle her genital area. Barb kicked and screamed. Todd, fearing the censure of his peers, joined in the victimization. He did not realize the seriousness of the behavior in which he was engag- ing. All the boys were arrested and adjudicated in 159 juvenile court on sexual assault charges. Todd was referred to PHASE as a condition of his probation. The distinguishing feature of the peer group- influenced offender is that his sexually victimizing behav- ior, which is acted out in a group setting, is a function of peer pressure. This adolescent responds to the influence of social conformity in engaging in sexual offenses. The mo- tivation for the behavior derives from a desire to gain peer attention, recognition, or approval. Even when he under- stands the behavior to be wrong, he feels pressure to go along with the gang so as not to risk social censure or ridicule. The peer group-influenced offender is typically a youth who has a normal social background and who likely has little history with the criminal justice system. More importantly, he seldom brings to the assessing clinician much of a history of other sexually deviant acts. The presenting offense is most likely his first offense of a sexual nature. The clinician must be careful, however, to carry out an extensive and comprehensive evaluation of the client when conducting assessments on youth in this group. There are some perpetrators, especially the group leaders (i.e., Tim in the illustrative case), who may more accurately be classified as sexual aggressives in light of other past be- haviors and personality and family dynamics, even when their behavior occurred in a group context. There is a tendency for group offenders to deny or dilute their own responsibility for their behavior by parceling it out among the other participants. They reason that if the whole group participated in the behavior, that somehow makes _it less serious and less wrong. The sexually aggressive adolescent may attempt to legitimize his own deviant behavior by in- fluencing others to engage in it with him. If this is a single, isolated event with few other associ- ated offender dynamics, the youth may be appropriate for a shorter therapeutic intervention, such as the Education- Assessment program, provided other legal consequences are applied as well. However, if the assessment reveals that there is evidence of other sexually aggressive events, then more extensive treatment may be required. 160 It must be stressed that we view this as a working typology that seems to reflect the various adolescent sex- ual offenders that have been referred to our program in the past 3 years. It has undergone expansion and refinement from an initial two-type classification (i.e., undersocial- ized--nonaggressive and socialized--aggressive offenders; see O'Brien 1982) and is certain to be refined and defined further. In one sense, it is merely one way of slicing up the pie. A classification schema could be based on a number of different factors, such as personalities, types of offenses, types of victims chosen, family dynamics, attitudes, and so on. Still, it is a starting point for beginning to answer some basic research questions about this population. Several other research questions have been stimulated by our work with the clients of PHASE. l. What is the role of family dynamics in the etiology of adolescent sexual offenders? Why does the role of the father appear so critical among this population? A com- mon thread that seems to connect the various types is the generally poor relationship between father and son, if it exists at all. How different is this from nonoffending teens or delinquent teens in general? What implications does this issue have for the increase in female-headed households and for minority, especially black, families where this is a prevalent condition? What impact does this have on atti- tudes toward women, sexuality and sexual roles, parenting, and so forth? 2. What roles does pornography play, if any, in the development of sexually deviant behaviors of adolescents? The majority of adolescent males admit to having some ex- perience with so-called soft-porn magazines. Many of our adolescent offenders have had easy access to hard-core pornography, and many, having access to VCRs, have viewed XXX-rated movies at home or in the homes of friends and relatives. What influence does this have, if any, on attitudes toward women, violence, and sexuality, and on sexual behaviors? 3. A related issue requiring study is the whole ques- tion of the influence of sexual attitudes on the commission of sexually victimizing behaviors. Do the sexual attitudes of the adolescent offenders differ significantly from those 161 of their nonoffending peers? from those of other delin- quent adolescents? from those of the various types of offenders? How are their attitudes formed, and how do they influence sexual acting-out? 4. Our society has undergone a shift toward greater tolerance and acceptance of premarital sex and sexual variations in the past few decades. Do adolescents feel an increased pressure to become sexually active with their peers? If so, what impact does this have on the less well socialized teens who do not have the opportunity for sexual experimentation? What is the media's impact on the sex- ual values and behaviors of adolescents? 5. Taking off in quite a different direction, what is the impact of sexual repression on sexual victimizing be- haviors? Might repression of sexual feelings, thoughts, and urges play a significant factor in sexual offense behaviors? For instance, the sexual aggressives in our program are sig- nificantly less likely to admit to regular masturbation than the child sexual exploiters. Is this merely denial, or does the blocking of sexual urges result in a greater likelihood of committing certain sexual offenses? 6. Closely related to sexual repression is the whole issue of sexuality education's impact on adolescent sexual behavior. While most of our adolescents report that they had a sexuality education course in their schools, sexual myths and misinformation abound in this population. Would a better sexuality education curriculum--one that goes be- yond the anatomical "plumbing" to discuss sexuality in more detail and to raise the issues of sexual values and ethics--affect sexual behavior among adolescents in a posi- tive direction? Might such a curriculum prevent some sex- ually abusive behaviors? 7. What role does the adolescent's own experience as a victim of sexual abuse and physical abuse play in his of- fenses? It has been a commonly held belief among many professionals that the adolescent sexual offender is merely a sexual victim working out his own victimization experi- ences. Yet the majority of our offenders are not victims of sexual abuse. Clearly other factors are at work with them. 162 Those of us who have been working with adolescent sexual offenders over the past several years have been playing it by ear for the most part. We have drawn from our experiences with adult sexual offenders and our clinical work with adolescents and families to create hypotheses and develop models to assess and treat them, and we feel we are doing a good job of it. Now we must begin to validate our hunches, hypotheses, and models by undertak- ing sound and comprehensive research. Our clinical ex- perience has generated some ideas and raised some inter- esting questions for further exploration. The answers to these questions can only be provided through rigorous re- search. The research, in turn, will point the way for clinicians designing effective treatment models and for educators suggesting prevention strategies. References Ageton, S.S. Sexual Assault Among Adolescents: A Na- tional Study. Final report to the National Center for the Prevention and Control of Rape. Rockville, Md.: National Institute of Mental Health, May 1983. Groth, A.N., and Loredo, C.M. Juvenile sex offenders: Guidelines for assessment. International Journal of Offender Therapy and Comparable Criminology 25(1): 31-39, 1981. O'Brien, M. Adolescent sexual offenders: A community faces reality. Change--A Juvenile Justice Quarterly V(3):16-18, 1982. 163 CHAPTER 5 JUVENILE SEXUAL OFFENDERS: A FAMILY SYSTEMS PARADIGM Caren Monastersky, M.S.W. Wayne Smith, Ph.D Interest in the area of sexual abuse and assault has significantly increased over the past 10 years. Issues of victimology are now serious clinical and research topics, and one of the results has been the expanding focus on the adult sexual offender. Recognition of the need for service and research in juvenile sexual offenses has been much slower to gain the recognition and attention the field requires. An accurate number of adolescent sex offenses is not available, although various sources show that adolescent males account for a range of 21 to 30 percent of rape (Na- tional Crime Survey 1979; Uniform Crime Report 1980). Both these sources account for forcible rape and do not measure the number of youth involved in child molesting, exposing, voyeurism, and acquaintance or "date" rape. Services for and research on this population are impor- tant for several reasons. First, juvenile sexual offending behavior often reflects the early stages of an ongoing pat- tern of sexual offense as an adult. The data to support this view come primarily from retrospective, self-report stud- ies of convicted adult sexual offenders indicating that nearly 50 percent committed their first offense during adolescence (Groth et al. 1982). Evidence of escalation from nonviolent sex crime during adolescence to serious sexual offenses in adulthood also exists (Longo and McFadin 1981). These data are consistent with information from the University of Washington Juvenile Sexual Of- fender Program. From a sample of 440 males with a mean age of 14.7 years, 65 percent had committed a sexual of- fense prior to the referring offense. Victim agencies are also documenting that adolescent offenders account for led one-quarter to one-half the reported offenses (Sexual As- sault Center, Seattle, Washington; and Children's Hospital, Washington, D.C.). These data suggest that a portion of adult offenders begin a pattern of sexually offending be- havior during adolescence, as well as acknowledging that sexual offenses by youth are not the exception. The ne- cessity for effective clinical intervention and research cannot be overstated. Since the field of adolescent sexual offenders is rela- tively new, there are no models of conceptualization and etiology available. A sound paradigm is essential in assess- ing the sexually offending adolescent and in planning inter- vention strategies. The lack of a framework is both excit- ing and potentially difficult. While the field is open to original thinking, the tendency to adopt adult models of sexual offense in assessing and treating adolescents is a concern. The literature on adult sexual offenders is vast and ranges from analytical interpretations to behavioral orientations. Psychoanalytical theory may offer explana- tions for sexual deviancy, but it does not offer a treatment plan with measurable outcomes. Family systems theory does not hold the offender accountable and also does not assess for a pattern of sexual offense outside the family. Behavioral intervention offers specific treatment with measurable outcome, which makes it attractive to some clinicians. However, it is a theory that is limited to a linearly based cause-and-effect m that categorizes all sexual offenders as sexual deviants. Finkelhor offers a more complex, four-factor theoretical model of adult pedophilia that deals specifically with pedophilia and builds on an integrated theory of the strengths developed in other models (Finkelhor and Aroji 1983). Given the richness of the work started on understanding the psychology of the adult sexual offender, it is important for the adolescent specialist to recognize that adolescents who commit sexual offenses are in their own unique stage of development that must be incorporated in building a theoretical model. The challenge is to identify youth who are at risk of continuing their sexually assaultive behavior and to intervene before the behavior becomes chronic and another generation of adult sexual offenders is produced. The majority of studies on juveniles are retrospective descriptive studies of convenience samples of convicted adolescent sexual offenders, usually without comparison 165 groups or adequate description of the criterion offending behavior. There is rarely a recognition in these studies of the broad variety of subtypes of sexual offending behavior or of the possibility that some offenders have a pattern of general, nonsexual delinquency, while others have a pattern of only sexual offenses and otherwise bear little resem- blance to adolescents who display a chronic pattern of general delinquency. Few studies attempt to identify sys- tematically the formative and maintaining influences on the offending behavior, much less design their study with the objective of evaluating a theory-based explanatory model. Some agreement exists, however, regarding certain facts about juvenile sexual offending behavior. First, juvenile sexual offending behavior is not a unitary class of behavior. At the very least, a distinction needs to be made between relatively noncoercive, somewhat passive, sexual assault between an adolescent and often a younger child on one hand and, the more threatening and aggressive sexual assault on the other (Deisher 1982; Groth 1977; Shoor 1966). Other types of juvenile sexual offending behavior identified in these studies include the adolescent offender whose mental illness is apparent in the act (Shoor 1966); the adolescent offender who has no physical contact with the victim (e.g., indecent exposure, stealing underwear, or peeping; Deisher et al. 1982); and the adolescent sexual psychopath who displays a general pattern of aggressive- ness, manipulativeness, and lack of guilt or remorse (Markey 1950). Evident is a need to establish a compre- hensive typology of juvenile sexual offending behavior, a typology that provides a theoretically sound basis for understanding the antecedent and consequent events surrounding the offending behavior. Second, the studies of juvenile sexual offending behav- ior are virtually unanimous in identifying the family as a crucial influence in the development or elicitation of the offending behavior. Workers suggest a variety of mecha- nisms ranging from increased family trauma (Markey 1950), to failure to provide adequate emotional support (Maclay 1960), to confused family relations, including unwitting parental participation in the offense or seductive maternal behavior (Shoor 1966), to abuse by parents (Lewis 1979), and to scapegoating within the family (Deisher 1982). A recent study suggests that the number of family crises 166 reliably differentiates the juvenile sexual offender from the nonoffender delinquent (Ageton 1983). Denial and minimization by parents of the adolescent's previous sexual offenses are also frequently mentioned (Deisher 1982; Groth 1979). Research from general juvenile delinquency may well be considered in building a model for the juvenile sexual offender. Several studies suggest a relationship between family functioning and general delinquency. A 5-year study of children who exhibited antisocial behavior (i.e., lying, truancy, and stealing) showed that an increase in the number of antisocial behaviors correlated with parental rejection of the child (Langer 1979). Further studies dem- onstrate that parents of juvenile delinquents have poor family management skills and show the importance of fam- ily functioning variables in predicting delinquency (Farring- ton 1972; Loeber 1983). Predictions of adult criminals were more accurate when based on home atmosphere variables than on the adult's juvenile criminal record (McCord 1979). None of the studies categorized sexual offending behavior, and whether juvenile sexual offense is similar to juvenile delinquency is open to question. Yet the role of the family cannot be ignored by adolescent special- ists, regardless of what aspect of the family they wish to emphasize. The Juvenile Sexual Offender Program at the Univer- sity of Washington is a community-based evaluation and treatment program that began 7 years ago, when the sexual abuse field had no models for working with this population and when the "It's just experimentation" and "Boys will be boys" assessment approach prevailed. At this point the program has evaluated and treated over 600 adolescents who are referred mainly by Children's Protective Services and juvenile court. While officially the ages extend from 12 to 18 years old, clients as young as 8 who have exhibited aggressive sexual behaviors have been accepted into the program. A brief description of the clients seen in the program, based on a sample of 305 males between the ages of 11 and 18, breaks down to 23 percent committing rape, 57 percent committing indecent liberties, 11 percent exposing them- selves, and 18 percent committing voyeurism, peeping, stealing women's underwear, and other "nuisance" acts. 167 Twenty-two percent of the rape and 37 percent of the indecent liberties occurred while babysitting. Overall, 85 percent of the victims were known to the offenders, and 34 percent were relatives. Fifty-three percent had a prior sexual offense, and 44 percent had prior nonsexual of- fenses. The victims' interpretation of the degree of force indicated that 33 percent reported physical force was used and 12 percent threatened force or weapons; 22 percent continued the offense after the victims' expression of hurt. The conceptual model used for assessment and treat- ment by the Juvenile Sexual Offender Program draws from two areas: the first considers the adolescent within a de- velopmental framework, and the second is a family model that addresses the structure of the family as a growing and changing system. Several typical case examples follow that indicate the need to include an assessment of the family of the juvenile sexual offender. Jerry, age 14, was legally charged with breaking and entering and was found nude in the home of a neigh- bor. He left when confronted by the woman. Jerry has a 2-year history of exposure and peeping. The latest incident is an escalation of his previous of- fenses. Jerry has an identical twin brother, who has been involved with some of the peeping with his brother. It is significant to consider why Jerry was identified as the offender and not his brother. The evaluation of the family included his mother and father and 17-year-old brother and revealed that Jerry was the scapegoat in this family. When he and his brother took a book from an aunt, Jerry "stole" it and his brother "borrowed" it. Other interesting factors include Jerry's father offering that he always had a fantasy of flashing, so he could understand his son's behavior without approving of it. Further, the family described their home as having no doors except in the bathroom and a curtain on the parents' bedroom be- cause it's being remodeled (for the past 10 years). The hypothesis is that this family has no boundaries and that messages about sexuality from father to son encourage the sexual acting-out on some level. 168 John, age 16, has a 3-year history of masturbating with his sister's and mother's underwear. He came to the attention of the court for breaking and entering to steal women's underwear. The family includes his parents, and his 18-year-old and |l-year-old brothers. The family has known of John's behavior for the last 2 years and offered to buy him underwear so he wouldn't have to steal it. Two years ago the father moved out of the bedroom. The ll-year-old son sleeps with his mother alone after sleeping with both parents since birth. Mother states she can't tell John and her hus- band apart. The hypothesis is that parents do not have appropriate boundaries with sons, who get mixed mes- sages about sexuality. The mother is enraged at the father and directs her anger at her son, who does not overtly confront her. The assessment component is crucial in determining the risk that this client will sexually reoffend. The assess- ment involves approximately 4 hours of clinical interviews, including individual and conjoint sessions; psychological testing, including the Minnesota Multiphasic Personality Index (MMPI) for youths 14 and up, the Rorschach Inkblot Tests, the Thematic Apperception Test, the Incomplete Sentences Blank, the Family Adaptability and Cohesion Scale (FACES) for the family, and the Dyadic Adjustment Scale (DAS) for the parents; and collaborative information from the school and the courts. The victim's statement is crucial in addressing the minimization and denial many offenders maintain. The youth's abstract knowledge of the behavior is explored. At 12 years old, responding with, "What I did was wrong because I wasn't married" has dif- ferent implications than if a 17-year-old responds with that statement. The evaluation process considers the age dif- ference between the victim and offender, the number of victims, the duration of assaultive behavior, the nature of the abuse, the type of force involved, evidence of escala- tion, the history of victimization of the offender, and masturbatory and nonmasturbatory fantasies. Other as- sessment issues include academic history; history of delin- quency and aggressive behavior in school, at home, and in the neighborhood; peer relationships (looking for a pattern of playing with younger children); drug and alcohol usage; and evidence of impulsive behavior. 169 The family unit including all the siblings is included in the assessment. How the parents have responded to their son's behavior is important, as it will reflect how the of- fender responds. Do they minimize the offense? Do the parents insist their other children not be told? If the of- fender has victimized smaller children outside the family, not telling younger siblings may put them at risk for sexual victimization. How willing are the parents to monitor their son's behavior? History of violence in the family and sexual abuse of family members is explored. The underly- ing hypothesis is that what is not working in the family sys- tem has created the environment for adolescent sexual as- sault to occur (see appendixes A and B for assessment outline). Disposition of the case is by consensus of the Juvenile Sexual Offender Program (JSOP). The client is twofold, including, first, the adolescent and his family and, second, the community. What is the risk that the adolescent will sexually reoffend? Does the client require institutionali- zation for the safety of the community? Certain variables (i.e., use of a weapon or threat of a weapon) and an aggres- sive, predatory assault require serious consideration of placement in a secure facility. Overall, the lack of knowl- edge about the etiology of this behavior and what predis- poses continuance of the behavior hampers a scientific assessment of the probability of reoffense. The JSOP has developed decision-making criteria (see appendix C) to as- sess risk with the question of what the risk is that this adolescent will reoffend in the next 2 years without treatment. Adolescent sexual offenders who engage in nonaggres- sive acts may be considered for treatment in the commu- nity. Aggressive sexual offenders are referred to institu- tional settings. Rather than the legal terms of rape and indecent liberties, which reflect plea bargaining instead of behavior, the continuum on the following page is used to characterize offending behavior. Treatment at the Juvenile Sexual Offender Program uses group and family therapy. The group members are offenders who have committed a variety of hands-off and hands-on offenses, as well as offenders in institutional settings. Briefly, group goals are to facilitate the adoles- cents' understanding of their sexual offense behavior both 170 emotionally and cognitively. The group is process oriented and co-led by a male-female cotherapy team for a 6-month period. An adolescent whose family is not willing to be in concurrent family treatment is not accepted into group therapy. Family therapy goals are individualized for each family, but generally the expectation is to facilitate appro- priate boundaries between family members and to increase flexibility, cohesiveness, and nurturance, as well as accep- tance of individual differences. Specific issues of scape- goating the adolescent sexual offender and sexuality and aggression are important focuses. Family typologies are needed, as well, so that etiological factors can be addressed. Sexual Offense Continuum Nonaggressive hands-off Exposure, voyeurism, obscene phone calls and letters, masturbating with women's underwear Aggressive hands-off Breaking and entering for the purpose of stealing women's underwear, any activity from first category that increases victim proximity Nonaggressive hands-on Fondling, oral-genital contact, may include penetration, uses authority as older person to gain access to victim, proximity Aggressive hands-on Fondling, oral-genital contact, penetration, uses force, weapon or threatens to, doesn't stop with victim distress Clinical work with this population has created a seem- ing plethora of issues. Basically, if prevention of sexual abuse is a priority, research with juvenile sexual offenders can provide answers so that primary prevention efforts can be designed. Several specific questions arise: (1) Why does 171 a particular adolescent engage in a sexual offense as op- posed to nonsexual delinquency such as theft? (2) What causes a less coercive versus a highly coercive sexual of- fense? (3) Why does the offense occur when it does? (4) To what extent does the family impact the develop- ment of an adolescent sexual offender? (5) What causes some adolescents to develop a pattern of sexual deviancy while some do not? (6) What is the impact of the juvenile justice system? While our individual biases are rooted in clinical experience and how we theoretically understand human behavior, the necessity for multitheoretical inves- tigations with the juvenile sexual offender is a priority in the sexual abuse field. 172 References Abel, G.G., Blanchood, B., and Djenderdendjiar, A. Dif- ferentiating sexual aggressiveness with penile meas- ures. Criminal and Justice Behavior 5:315-332, 1978. Ageton, S. Sexual Assault Among Adolescents. Lexington, Mass.: D.C. Heath and Company, 1983. Children's Hospital. Unpublished statistics, Washington, D.C., 1932. Deisher, R.D.; Wenet, G.A.; Papeny, D.M.; Clark, T.F.; and Fehrenbach, P.A. Adolescent sexual offense behavior: Role of the physician. Journal of Adolescent Health Care 2:279-286, 1982. Farrington, D.P. Delinquency begins at home. New So- ciology 21:495-497, 1972. Finkelhor, D. Sexually Victimized Children. New York: Free Press, 1979. Finkelhor, D., and Aroji, S. "Explanation of Pedophilia: A Four Factor Model." University of New Hampshire, Family Violence Research Program, Durham, N.H., 1983. Groth, A.N. The adolescent sexual offender and his prey. International Journal of Offender Therapy and Com- parative Criminology 21:249-254, 1977. Groth, A.N. Men Who Rape. New York: Plenum Press, 1979. Groth, A.N.; Longo, R.E.; and McFadin, J.B. Undetected recidivism among rapists and child molesters. Journal of Crime and Delinquency 28(3):450-458, 1982. Hetherington, E.M.; Stowie, R.J.; and Ridberg, E.H. Pat- terns of family interaction and child-rearing attitudes related to three dimensions of juvenile delinquency. Journal of Abnormal Psychology 78:160-176, 1971. 123 Lewis, D.O.; Shankok, S.S.; and Pincus, J.H. Juvenile male sexual assaulters. American Journal of Psychiatry 136:1194-1196, 1979. Loeber, R. The stability of antisocial and delinquent child behavior: A review. Child Development 53:143]- L446, 1982. Loeber, R., and Dishion, T. Early predictors of male de- linquency: A review. Psychological Bulletin 94:68-99, 1983. Longo, R.E. Sexual learning and experience among sexual offenders. International Journal of Offender Therapy and Comparative Criminology 26(3):235-241, 1982. Longo, R.E., and McFadin, J.B. Sexually inappropriate be- havior: Development of the sexual offender. Law and Order, December 1981, pp. 21-23. Maclay, D.T. Boys who commit sexual misdemeanors. British Medical Journal 5167:186-190, 1960. Markey, O.B. A study of aggressive sex misbehavior in adolescents brought to court. American Journal of Orthopsychiatry 20:719-731, 1950. McCord, J. Some child-rearing antecedents of criminal behavior in adult men. Journal of Personality and Social Psychology 37(9):1477-1486, 1979. National Crime Survey Report. Washington, D.C.: U.S. Government Printing Office, 1981. Olweus, D. Familial determinants of aggressive behavior in adolescent boys: A causal analysis. Developmental Psychology, 1981. Quay, H.C., and Quay, L.C. Behavior problems in early adolescence. Child Development 36:215-220, 1965. Sexual Assault Center. Unpublished statistics, Seattle, 1983. 174 Shoor, M.; Speed, M.H.; and Bartelt, C. Syndrome of the adolescent child molester. American Journal of Psy- chiatry 122:783-789, 1966. U.S. Department of Justice, Bureau of Justice Statistics. Criminal Victimization in the U.S. 1979. Wydra, Marshall, Earl, and Barbaree. Identification of cues and control of sexual arousal by rapists. Behavior Re- search Therapy 21(5):469-476, 1983. 175 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. APPENDIX A Juvenile Sexual Offender Program University of Washington--Adolescent Clinic Sexual Offense Assessment Questions Where did you get the idea to do it? What were you thinking (or fantasizing) about when you decided to sexually abuse her/him? How did you pick the victim? Do you think the victim wanted to do it? How do you know? Who else would you have picked if she/he wasn't there? How many times, when did it start, where did it take place? Did the victim cry or ask you to stop? Did that sur- prise you? What did you do when she/he cried or asked you to stop? How did you stop? Why didn't you do more with the victim? Why didn't you do it more often? What do you think is wrong with this behavior? What do other people think is wrong with this behavior? Why are there laws against it? How did the victim feel? How do you know? What did the victim enjoy about the sex abuse? What did you do to the victim? Did you have an erection? Ejaculation? What part did you enjoy? How did you make sure the victim would not tell? Who else did you abuse? How often do you masturbate? How old were you when you started? What kind of fantasies do you have when you masturbate? What kind of fantasies do you have when you are just daydreaming? 176 l. 2. 5. 6. 7. 9, 10. Sexual Offense Assessment Issues How is the reality of the offense being dealt with, i.e., court, CPS? What is the age difference between the victim and offender? What is their social /power relationship? What type of sexual activity is exhibited? Does it re- flect knowledge that is advanced for the age of the sex offender? Does the sexual activity have any symbolic meaning? Determine degree of denial or minimization. Evaluate for evidence of a developing pattern of devi- ant sexual behavior, i.e., repetitive nature of offense, fantasies, number of offenses, number of victims. Level of control sex offender has of his/her sex of- fense behavior. Determine absence or presence of predatory behavior. Evaluate for evidence of increased aggression or vic- tim involvement. 177 APPENDIX B Juvenile Sexual Offender Program University of Washington--Adolescent Clinic Family Assessment Issues I. Sexual Offense and Sexuality 1. z 3. 4. 5. 6. 7. 8. History of sexual or physical abuse in the nu- clear and extended family. How sexuality is handled, level of comfort. Each family member's opinion of the sex of- fense and what they think should be done as a consequence. Level of denial or minimization of the sex of- fense by each family member. Which family members know about the sex of- fense, and who does not? If the victim is in the family, how will she/he be protected? Can the parents control the sex offender's ac- cess to other victims or potential victims? Who are potential victims in the family? IL. Family Structure 1. WO NAW E WN fe oO . 11. Flexibility regarding situational and develop- mental issues. How family decisions are made. How family members disagree and argue. How affection is shown. Who speaks for whom. Who protects whom. Secrets, what the family does not discuss. Level of comfort with individual differences. Recognition of conflicts and differences. How much input from outside of the family is allowed. Strength and consistency of the parent/execu- tive system. 178 12. 13. 14. 15. 16. 17. 18. How or if the children detour the conflict be- tween the parents. Who else is closely involved with the family, i.e., church, grandparents, etc. Determine intrafamilial alliances. Strength of boundaries between generations. Overt and covert family rules. Strength of sibling subsystem. What is not working in the system that is pro- ducing sexually abusive behavior. 179 APPENDIX C Juvenile Sexual Offender Decision Criteria Juvenile Sexual Offender Program University of Washington Seattle, Washington 98195 Instructions: The following criteria are to be used as clini- cal guidelines in evaluating the juvenile sexual offender. The criteria relate both to risk for offending as well as ap- propriateness of outpatient versus residential treatment. Code "1" if item is true, "0" if item is not true, and leave blank only if information is missing. LOW RISK I. First documented offense, without evidence of a developing pattern 2. Offender willing to explore offense in a non- defensive manner 3. Offender acknowledges and understands the negative impact of the offense on victim (empathy) 4. Offender willing to accept responsibility for committing the offense without blaming others or circumstances 5. Offender is guilty and remorseful because of the negative impact of offense on victim 6. Offender understands the exploitative nature of the offense and reasons for its wrongfulness 7. Offender admits to committing entire offense for which he was charged 8. Offender has healthy attitudes about sexuality 9. Offender has no history of behavior disorder involving physical aggression 10. Offender has adequate social adjustment, in- cluding presence of a peer support group and participation in peer group activities 180 11. 12. 13. 14. 13, leé. 17. Offender has no history of behavioral and/or academic school problems Parents/guardians acknowledge and understand the negative impact of the offense upon victim Parents/guardians hold adolescent responsible for offense without externalizing blame onto others or circumstances Parents/guardians acknowledge adolescent committed entire offense for which he was charged Family supportive of treatment and willing to become involved in therapy Family identifies problems within family unit and among members other than the deviant sexual behavior of offender Offender's family unit is functional MODERATE RISK 1. 2. 10. 11. 12. Offender has committed two or more docu- mented offenses Discontinuation of offense behavior if/when victim showed distress Offender resists describing and exploring of- fense in a non-defensive manner Offender does not understand the exploitative nature of the offense or reasons for its wrongfulness Offender minimizes the negative impact of the offense on victim (little empathy) Offender has little or no guilt or remorse be- cause of the negative impact of the offense on victim Offender externalizes blame for offense onto others or extraneous circumstances Offender minimizes extent of involvement in the offense, admitting to only part of the offense Offender resists participation in the evaluation without refusing altogether Offender has negative self-esteem Offender has depressive symptomatology Offender has unhealthy attitudes about sexuality 181 13. Offender has been a victim of sexual or physi- cal abuse, though this has not been a chronic or repetitive pattern 14. Offender has a history of behavior disorder in- volving physical aggression 15. Offender shows poor social adjustment, includ- ing isolation from peers and few peer group activities 16. Offender has history of behavioral and/or aca- demic school problems 17. Parents/guardians minimize the negative im- pact of the offense on the victim 18. Parents/guardians externalize blame for of- fense onto others or extraneous circumstances 19. Parents/guardians minimize extent of offend- er's involvement in offense, holding him respon- sible for only part of offense 20. Parents/guardians are resistive to participation in the evaluation without refusing altogether 21. Mother or father is a sexual offender 22. Mother or father has been a victim of sexual and for physical abuse 23. Family unable to identify problems within fam- ily unit or among members other than the devi- ant sexual behavior of offender 24. Family is dysfunctional in response to transient situational factors HIGH RISK I. Offender has been treated for commission of a previous sexual offense 2. Offense was predatory 3. Offense was ritualistic 4, Offense was sophisticated, involving precocious knowledge of sexual behavior 5. Offense resulted in physical injury to the victim 6. Offense was associated with the use of drugs or alcohol 7. Offense involved violence, physical force, use of weapon, or threat to use a weapon 8. Continued offense behavior despite victim's ex- pression of distress 9. Evidence of progressive increase in the force used to commit repeated offense | 1] 182 10. 11. 12. | 13. 14. 15. 16. 17. 18. 19. 20. 21. Offender completely refuses to participate in the evaluation Offender completely denies the referral offense Offender engages in compulsive masturbatory fantasies involving deviant sexuality or offense behavior Evidence of thought disorder History of firesetting History of torturing animals History of chronic substance abuse Offender has been a victim of chronic and re- petitive sexual and/or physical abuse Parents/guardians refuse to participate in the evaluation Parents/guardians deny that offender com- mitted the offense Parents/guardians deny that offender has any psychosocial problems Offender's family unit is chronically dysfunctional Code risk for re-offending: (1) low risk, (2) moder- ate risk, (3) high risk Code prognosis/amenability of treatment outcome: (1) good, (2) fair/moderate, (3) poor Code disposition: (1) outpatient family therapy at CDMRGC, (2) group therapy at CDMRC, (3) individual therapy at CDMRC, (4) group home placement, (5) correctional institution, (6) outpatient treatment referral to facility other than CDMRC Not to be reproduced or otherwise published without per- mission of Juvenile Sexual Offender Program, University of Washington. (Note: This is not a validated research tool.) 183 <81 GENERAL LIBRARY - U.C. BERKELEY BOODS500R233