Risk Assessment and Treatment in the DD Sex Offender: Who has ...

Risk Assessment and Treatment in the DD Sex Offender: Who has ...

Risk Assessment for Challenging Behaviors in those with Intellectual Disability Randy Shively, Ph.D. Director of Research and Clinical Development, Alvis Columbus, Ohio Quotes He who is not courageous enough to take risks will accomplish nothing in life Mohammad Ali Living with fear stops us taking risks, and if you dont go out on the branch, youre never going to get the best fruit Sarah Parish

Supervision like risk should be a dynamic, fluid concept Needs to regularly be evaluated Needs to be least restrictive Needs to promote safety Needs to be faded as appropriate skills are taught

When to do a risk assessment? Client has a pattern of unstable, potentially harmful behaviors to self or others Question of whether restrictive measures are still necessary to protect client/others from harm Life circumstances have changed which could directly impact risk, ie. death of loved one, trauma, major health issue, charged with

crime Ask Specific Questions in Referral for Risk Assessment Environment- How close does supervision need to be at home? In Community? At work? Type of Supervision- Does client need visual, arms length, auditory supervision? Risk Level- What level of risk does ___ present

in community? In the home? In the work setting? Team Importance with Risk/Supervision An effective team produces a support plan with supervision guidelines which are more comprehensive and creative than any one person on the team could produce independently. The team has the responsibility to monitor the effectiveness of the plan and meet frequently enough to make well thought out changes which balances the independence of the individual with the safety of the community Randy Shively Increased Risk of Sex Offending Adjudicated individuals with intellectual

disability and problematic sexual behaviors offer percentages 10-15 times higher than suggested by normal distribution- Petersilia, 2000; Guay 2005 It is estimated that up to a third or more of the total number of individuals with adjudicated sexual offense histories also have an intellectual disability- Jones, 2007 Why more sex offenses? Fewer dating opportunities Belief in ID world that those with cognitive

delays are asexual Less tolerance of sexual deviance in community Poor social skills-poor decision making Sex Offender Facts Percentage of Sex Offenders who will commit another sex offense- 2.7%

Percentage of Sex Offenders who will commit another crime- 70% Percentage of sexual offenses that occur while living in a supervised setting- 60% NCMEC, 2013 DD Sex Offenders in Treatment Underage victims- Pedophilia and poor discrimination of age

Impulsive in general- violate rules and people impulsively Anger/control/rape- retaliation or control of others drives their offending Pornography- internet violations Clinician Adaptations

Use simple vocabulary words Create short sentences Ask one question at a time Wait for an answer before proceeding Confirm client understood question

Requires Specialized Testing Assess intellectual challenges looking closely at literacy, problems with memory, problems with expressive and receptive language and social abilities Reduce reliance on verbal materials and processes Evaluate knowledge and education needs in all aspects of life but specifically sexuality

Evaluate external/environmental factors exerting influence on the individual Blasingame, et al 2014 Staff Response to Brain Damage Repetition of requests Concreteness in giving requests

Multiple senses to teach, ie. taste, smell, touch, see, hear Patience, patience, patience Risk Principle- Risk, Need , Responsivity Model- Andrews and Bonta Target those offenders with higher probability of recidivism Provide more intense services to higher-risk offenders-more dosage hourscognitive/behavioral

Targeting lower risk offenders can lead to increases in recidivism rates University of Cincinnati Ohio Risk Assessment SystemORAS Need Areas Family/Marital Accommodation Companions Alcohol/Drug Problems Emotional/Personal Antisocial/Criminal Attitudes Model for Risk Assessment 1. Intellectual Disability- How does it impact risk?

Impulsivity, verbal comprehension, memory, perceptual reasoning, processing speed? 2. Mental Health- Medication compliance? Diagnoses accurate?; Reality testing- delusion and/or hallucination? Does decompensation precede risk incidents? 3. Offending Behavior- Risk areas? What are Static and Dynamic risk predictors? What is needed supervision level? What settings present greatest risk? Does direct staffing impact risk? Randy Shively,

Case Study #1 IQ of 67-age 45 Diagnoses of Pedophilia, Foot Fetish and Major Depression Molested reported 50 boys in a small town-solicited victims by volunteering at little league and childrens camps Lives in Supported Living with arms length supervision in

community and Bathroom Monitoring Still plays a lot of manipulative games and will tries and defy and argue with staff/authority Still tries to access childrens materials at work-cycle of admitting and denying attraction to boys Case Study #2 Age 60; IQ of 105

Diagnosed with Aspergers, Alcohol Use Disorder, moderate and Recurrent Depression Passive, lonely man with addiction to pornography Numerous charges of downloading underage pornography- 5 years in

prison History of Alcohol binging and cutting on self Restricted to staff supervision when on internet, only uses laptop during day No computer access at work due to losing job looking up pornography Observed Risk Issues Often anger and sex get paired- emotions difficult to manage in our population Physical aggression becomes a way to gain control in an uncomfortable/misunderstood situation

Passive individuals who bury their anger can act it out in aggression and/or fire setting- revenge Aggression can be linked to medication/biochemical imbalances or MH episodes Goal is to Manage Risk PREDICTION OF WHO IS GOING TO ACT OUT AND IN WHAT WAY IS POOR: THE KEY IS LOOKING FOR EFFECTIVE WAYS TO MANAGE RISK FACTORS. EFFECTIVE RISK ASSESSMENT IS ONE IMPORTANT TOOL

Risk Information for County Boards Risk Evaluation by Licensed Professional Behavior Assessment Report Restrictions and Strategies contained in Individual Program Plans (IPP)

Service Coordinator create Restrictive Measures and target fades Behavior Modification We must create an environment that is geared towards consistent reinforcement of positive or pro-social skills that compete with offending behaviors . This may mean a culture change. In changing our environment by reinforcing prosocial behavior on a regular basis, we will find ourselves having to punish less and

create a more positive environment for our staff and clients to work in. Meaningful interactions with intellectually disabled clients is the foundation they need to trust the change process! High Quality Relationships Improve Likelihood of Behavior Change Behavior is reinforced through environmental

cues Demonstrate respect Demonstrate enthusiasm Demonstrate concern Teach Reward Punish only when necessary Professional rapport with individual is also key when assessing individual! Sexual Disorders: Assessment

Due to limited verbal skills difficult to express sexuality People with ID limited sexual knowledge and/or experience Sexuality Needs have been ignored historically

ID individuals seen as asexual Ertophobia (negative fears to explore sexuality) Promising Instruments Socio-sexual Knowledge and Attitudes Assessment Tool-Revised (Griffiths and Lunsky)-2003 Identifies with concrete pictures the understanding and preferences in the areas of : Anatomy, Mens and Womens Bodies, Intimacy, Pregnancy, Birth Control, Healthy Boundaries Promising Instruments

Assessment of Risk and Manageabilty of Individuals with Developmental and Intellectual Limitations who Sexually Offend (ARMIDILO-S) Boer et al, 2012 Stable items: supervision compliance, treatment compliance, sexual deviance, sexual preoccupations, emotional coping, relationships, impulsivity, substance abuse, mental health ARMIDILLO-R: Acute

Acute items: changes in clients compliance with supervision and treatment; changes in sexual preoccupation, changes in victimrelated behaviors, changes in emotional coping, changes in the use of coping strategies, changes in monitoring, changes in social relationships, situational changes, changes in victim access Deviance or Disability? Are the behaviors being assess representative of a sexual pathology (paraphilia) or are they symptomatic of environmental factors and/or poor understanding of sexual situations and social consequences?

Labeling someone sexually deviant can be a life sentence! Assessing Paraphilias: Questions Is the behavior (problems) part of a preferred sexual pattern? Are the behaviors present when there is no active mental health disorder?

Is the behavior(s) part of a recurrent pattern? Was the onset earlier in life? Promising Instrument Phenix and Sreenivasan (2009) list of DD specific risk factors Social skills deficits; Committing violent offenses; being unemployed; psychiatric history; substance use disorder; easily susceptible to the influence of others; history of delinquency; poor response to treatment;

antisocial attitude; low self-esteem; impulsivity to sexual acting out; high static risk Client Lacks Understanding of Risk Providers need to educate on: - Natural Consequences - Social Impact -Thinking Errors QUESTIONS TO ASK DD CLIENTS What do you have to lose by continuing the risky behavior?

What do you have to gain by learning socially appropriate behaviors? Are you aware of how your behavior impacts others? QUESTIONS TO ASK CLIENTS Do you intend to change your behavior(s)?

Do you want to be supervised more closely? What is your motivation for engaging in the behavior? How are staff helping or hindering you in changing your behavior(s)? STAFF VIEW OF RISK Where can I safely take the client?

Where can I not safely take the client? Who is the client safe to be around? Who is the client not safe to be around? STAFF VIEW OF RISK Which staff does the client work well with client?

Which staff does the client not work well with client? What do I not know about the client related to their risk? What triggers the client acting out? What would I do if the worst risk issue occurs? STAFF VIEW OF RISK

How do I supervise the client at home? How do I supervise the client in the community/work setting? Who do I give information to and how do I report it if the client is not cooperating or does something risky when I am supervising? STAFF VIEW OF RISK

Do I feel safe working with this client? If not what are my options? What is the worst thing this client has ever done? Under what circumstances did the behavior(s) occurred? What makes the client feel safe? What makes the client feel unsafe?

Team Monitors and Regulates Safety Community Access Media Access Supervision Levels

Daily Living Skills/Activities of Daily Living Understanding Offense Cycle Triggers set off the process of offending. Sex offenses are planned Culmination of a series of events (ie. planning/grooming)

Offending behaviors are sometimes rationalized and planned (ie. thinking errors) Understanding The Offense Cycle Adapted Offense Cycle Thought Blockers TEACHING KEY SKILLS Interpersonal Skills :

Boundaries/internal and external controls/accepting supervision Conflict Resolution Intimacy Pro-Social Behaviors

Individual Attributes Self-control and Behavior Regulation Self-confidence Empathy Cognitive Strategies

TOC-Think of Consequences TOP- Think of other People CAP- Consent, Age Appropriate, Privacy Thinking for a Change Think Ahead: Check Before You Wreck! Thinking Errors- Equip Curriculum

Replacement Thoughts Social Behavior Problems- Thinking for a Change Social Behavior Problems Philosophy of DBT DBT is: Dialectical-opposite responding to negatives Supportive Cognitive Behavioral Skill

oriented Balances acceptance and change Requires a collaborative relationship All the features of a therapy well suited to people with learning disabilities Aims of DBT

DBT aims to decrease extreme emotions, thinking and behaviours into more balanced responses to current situations. DBT teaches clients to develop and refine skills in order to change problematic behavioural, emotional and thinking patterns that are causing misery and distress.

Behaviours to decrease Behaviours to increase Self dysregulation Core mindfulness skills Interpersonal dysregulation

Interpersonal effectiveness skills Emotional dysregulation Emotional regulation skills Behavioural and cognitive dysregulation Distress tolerance

skills Contact Information Randy Shively, Ph.D.- Director of Research and Clinical Development, Alvis [email protected]; 614-252-8402 www.SaferSociety.org http://www.selfhelpwarehouse.com/ LET'S TALK - SOCIAL SKILLS (CARD GAME)

A Game to Promote Social Communication! Let's Talk Social Skills cards are designed to build stronger communication skills. The social skills topics can be used as a therapeutic activity, a warm-up exercise, or a closing game. Communication partners practice engaging in conversation with peers and adults by addressing statements or asking and answering questions that are typically discussed in a variety of social settings. The cards are divided into six social skills topics:Self-perception and knowledge Friendships Social responsibility and interaction

Conversational skills Non-verbal skills Social negotiation and flexibility References, Contd Center for Clinical Interventions: http://www.cci.health.wa.gov.au/resources/infopax.cfm?Info_ID=51 SocialSkillsTraining.Manual for Severe Mental Disorders A Therapist manual

http://www.cci.health.wa.gov.au/docs/SocialSkillsTraining.pdf CEP Character Education Partnership http://www.character.org/ Intensive Aftercare for High-Risk Juveniles: Policies and Procedures https://www.ncjrs.gov/pdffiles/juvpp.pdf References Ashford, J., Sales, B., and Reid, W. (2001). Treating adult and juvenile offenders with special needs. American Psychological Association: Washington, DC. Blasingame, G., Boer, D., Guidry,L.,Haaven, J. and Wilson, R. (2014). Assessment, treatment, and supervision of individuals with intellectual

disabilities and problematic sexual behaviors. Beaverton, OR: ( www.atsa.com). Boer et al. (2012). Assessment of risk and manageabilty of individuals with developmental and intellectual limitations who sexually offend (ARMIDILO-S). Bush,J., Glick, B. and Taymans, J. (2011). Thinking for a Change: Integrated Cognitive Behavior Change. National Institute of Corrections References

Center for Sex Offender Management. (2000). Myths and facts about sex offenders. (csom.org/pubs/mythsfacts) Dornin, C. (2010). Facts and fiction about sex offenders. University of Cincinnati. (corrections.com/news/article/24500facts-and-fiction-about-sex-offenders). Finkelhor, D and Jones, L. (2004). Explanation for the Decline in Child Sex Abuse Cases. Office of Juvenile and Delinquency Prevention. (ncjrs.gov/pdffiles1) Gibbs, J., G. Potter and Goldstein, A. (1995). The Equip

Program: Teaching Youth to Think and Act Responsibly through a Peer Helping Approach. Research Press. References Griffiths, D. and Lunsky, Y. (2003). Socio-sexual knowledge and attitudes assessment tool-revised. Wood Dale, Illinois: Stoelting Co. Guay,J., Quinet, M., and Proulx, J. (2005). On intelligence and crime: A comparison of incarcerated sex offenders and serious non-sexual violent crimes. International Journal of Law and Psychiatry, 28, 405-417.

Heil, P., Ahlmeyer, S., and Simons, D. (2003). Crossover sexual offenses. Journal of Research and Treatment, vol 15(4). Harris, J., and Hanson, RK. (2004). Sex offender recidivism: A simple question. Public Safety and Emergency Preparedness: Canada.(www.psepc-sppcc.gc.ca) References Jones, J. (2007). Persons with intellectual disabilities in the criminal justice system: Review of issues. International Journal of Offender

Therapy and Comparative Criminology, 51, 723-733. Lindsay, W., Taylor, J., and Sturmey, P. (2004). Offenders with developmental disabilities. John Wiley and Sons, Ltd.: West Sussex, England. Lindsay, W. (2009). The treatment of sex offenders with developmental disabilities: A practice workbook. WileyBlackwell: Malden, MA. Lindsay, W., Hogue, T., Taylor, J. Risk assessment in offenders with ID: A comparison across three levels of severity.

Itnernational Journal of Offender Therapy and Comparative References National Association for the Dually Diagnosed. (2007). Diagnostic manual- intellectual disability: A clinical guide for the diagnosis of mental disorders in persons with intellectual disability. Kingston, NY. Petersilia, J. (2000). Doing justice? Criminal Offenders with Developmental Disabilities. Berkeley, CA: California Policy Research Center, University of California.

Phenix, A. and Sreenivasan, S. (2009). A practical guide for the evaluation of sexual risk in mentally retarded sex offenders. Journal of American Academy of Psychiatry Law, 37:4, 509-524. Quinsey, V., Harris, G., Rice, M., and Cormier, C. (1998). Violent offenders: Appraising and managing risk. American Psychological Association: Washington, DC. References Seligman, L. (1998). Selecting effective treatments: A comprehensive guide to treating mental disorders. JosseyBass, Inc.: San Francisco, CA.

Sexual Offenses. A Journal of Research and Treatment, vol 15(4). Shively, R. (2015). Risk assessment for individuals with intellectual disabilities. In Arcs National Center on Criminal Justice and Disability, Sex Offenders with intellectual/ developmental disabilities. Washington, DC.,: The Arc, 2015). US Dept of Justice. Full Report of the Prevalence, Incidence and Consequences of Violence against Women.

(ojp.usdoj.gov/nij).

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