Risk Assessment of Adolescents with Intellectual Disabilities Who ...

Journal of Child Sexual Abuse

ISSN: 1053-8712 (Print) 1547-0679 (Online) Journal homepage: http://www.tandfonline.com/loi/wcsa20

Risk Assessment of Adolescents with Intellectual Disabilities Who Exhibit Sexual Behavior Problems or Sexual Offending Behavior Gerry D. Blasingame To cite this article: Gerry D. Blasingame (2018): Risk Assessment of Adolescents with Intellectual Disabilities Who Exhibit Sexual Behavior Problems or Sexual Offending Behavior, Journal of Child Sexual Abuse, DOI: 10.1080/10538712.2018.1452324 To link to this article: https://doi.org/10.1080/10538712.2018.1452324

Published online: 30 Mar 2018.

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JOURNAL OF CHILD SEXUAL ABUSE https://doi.org/10.1080/10538712.2018.1452324

Risk Assessment of Adolescents with Intellectual Disabilities Who Exhibit Sexual Behavior Problems or Sexual Offending Behavior Gerry D. Blasingame University of California, Davis, University Extension, Davis, California ABSTRACT

ARTICLE HISTORY

Adolescents with intellectual disabilities are known to engage in various sexual behavior problems or sexual offending behaviors. This article provides a review of important aspects of risk assessment within the context of a broader, more comprehensive and holistic assessment of these individuals. Pertinent risk and sexual interest assessment tools are identified along with their strengths and limitations. Issues that are often unattended to are addressed, including consideration of the behavioral implications of the young person’s diagnosis and level of cognitive functioning, need for sexual knowledge and sexual interest assessment, and issues related to making a mental health diagnosis. Recommendations for future research are also offered.

Received 4 April 2017 Revised 18 September 2017 Accepted 11 March 2018 KEYWORDS

Adolescent offenders; sexual offending; intellectual disabilities; evaluating adolescents; assessment tools; adapting assessment methods

When compared to their adolescent counterparts without disabilities, adolescents with intellectual disabilities (ID) who exhibit sexual behavior problems and/or sexually offending behaviors (SPOB) represent both similar and unique challenges for risk assessment. IDs are commonly identified as having an intellectual quotient (IQ) that is two standard deviations below the norm (American Psychiatric Association, 2013) as well as adaptive skills deficits. The anacronym SPOB is used to describe the range of problematic sexual behaviors that are exhibited by adolescents with ID, some of whom are adjudicated and others who are not. Because family members and many case mangers reject the label of “offender” or “sex offender” applied to non-adjudicated individuals, use of SPOB intends to diminish the acrimony over the label assigned while describing sexual behaviors that may be unhealthy, harmful to one’s self or others, or may be illegal. SPOB include a range of behavioral problems with sexual nuances (such as a youth with autism spectrum disorder who disrobes in public places) and immature sexual behaviors (such as exhibiting behaviors typically done by much younger children). SPOB may include engaging in behaviors that are sexually offensive (e.g., asking sexual questions to strangers) or they may involve engaging in more egregious (i.e., using female family members’ undergarments CONTACT Gerry D. Blasingame Box 491525, Redding, CA 96049. © 2018 Taylor & Francis

[email protected]

Program Development and Consultation, PO

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for masturbation) or sexual offending behaviors that are illegal (such as touching the sexual parts of a much younger child or forcing someone else to engage in sexual activity). Many characteristics of the ID itself can contribute to the incidents of SPOB as well as add to the challenges in interviewing and assessment. Examples of these include lower cognitive functioning, poor social skills, behavioral dysregulation, and problems with comprehension of complex questions (Blasingame, 2014a). The cognitive and other developmental challenges associated with ID are quite variable from person to person. Some of the cognitive challenges involve goal setting, problem solving, poor situational perception, problems dealing with others, dealing with difficult situations, dealing with feelings, and dealing with internal and external triggers (Asscher, Van Der Put, & Stams, 2012). Other challenges are higher levels of impulsivity, exploitability, and a desire to fit in with peers who may coax them to engage in delinquent or problematic behaviors (Douma, Dekker, De Ruiter, Tick, & Koot, 2007). Making clinical applications of research is also challenging as different authors use different labels to describe ID. In the United States, the current phrasing is ID. In the United Kingdom, the term learning disabled is used. Different authors have used various terms associated with limited cognitive functioning. Some studies include individuals with full-scale intellectual quotients (FSIQ), when assessed with a Wechsler scale, up to 80, whereas others limit inclusion to an FSIQ of 70 or lower (Blasingame, 2014a; Blasingame, Abel, Jordan, & Wiegel, 2011; Craig, Stringer, & Sanders, 2012). There is a dynamic interaction and mutual influence between the youth and the youth’s familial, social, cultural, and physical environment (Darling, 2007; Lounds Taylor, Burke, Smith, & Hartley, 2016). Social class and family stability, or instability, have a profound influence on the youth and the relational interactions with parents. For example, cognitive development in early childhood has been reported to vary depending on the age and educational level of parents, particularly mothers (Schoon, Jones, Cheng, & Maughan, 2012). Schoon et al. also found that being in a single-parent home or in a home with overcrowding also appears to contribute to lower cognitive capacities. The frequency of abuse among children and adolescents with intellectual or other developmental disabilities is known to be higher than for the general population (Blasingame, 2005; Byrne, 2017). Young people with ID or other developmental disabilities are vulnerable to sexual abuse for a variety of reasons (i.e., they are often socially isolated, have communication deficits, and have a limited peer and support group) (Van Dyke, McBrien, & Sherbondy, 1995). Each of these challenges, and more, affect the risk assessment process with adolescents with ID who have exhibited SPOB. Depending on the planned usage of the assessment outcome, overlooking these issues can diminish the value of the information or lead to misguided recommendations. This article seeks to identify challenging assessment issues and offer some possible solutions.

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Adolescents with ID and SPOB Several life changing processes occur during adolescence beyond physical development, including developing an integrated sense of self, individuation, separation from parents, and personal identity formation (National Research Council, [NRC], 2012). Adolescence is often characterized behaviorally by increased experimentation and risk taking, a tendency to discount long-term consequences, heightened sensitivity to peers, and other social influences. Experimentation and novelty-seeking behaviors—such as experimentation with alcohol and drug use, sex and unsafe sex, or reckless driving—are thought to serve adaptive functions despite their inherent risks (NRC, 2012). It is unknown how many adolescents with ID engage in SPOB as there are no data tracking of the ID status in the criminal justice system. Holland (2004) described filter points or decision points that affect who is criminally charged or otherwise held accountable. These include whether a criminal behavior is detected or identified, whether that behavior is reported to the authorities, whether law enforcement action follows the report or if it is dropped, whether the alleged offender is arrested, and whether the individual is charged, taken to court, and if found guilty. Sexual offending behaviors among adolescents with ID have been associated with low verbal intellectual quotients (VIQs) (McCurry et al., 1998). Low VIQs represent significant impairments in executive functioning, such as problem solving, poor social comprehension, planning, and self-regulation (Danielsson, Henry, Messer, & Rönnberg, 2012). Youth with ID function more closely with younger persons albeit those who are the same developmental age (Danielsson, Henry, Ronnberg, & Nissson, 2010), reflecting a significant degree of psychosocial immaturity. Adolescents with ID have exhibited SPOB that are quite like those of typically developing adolescents and adults. The behaviors often include sexual touching of younger children, coerced or forced sexual contact with other age mates, inappropriate sexualized comments or touching of peers or staff members, exposing one’s genitals to persons who don’t want to see them, public masturbation, voyeuristic behavior, urophilic behaviors, bestiality, fetishism, and frottage (Blasingame et al., 2011; McCurry et al., 1998; Miccio-Fonseca & Rasmussen, 2013). The range of these behaviors can complicate risk assessment. Because of this, risk assessment needs to be multidimensional.

General considerations for assessments Sexual risk assessments for adolescents without ID may not always include evaluation of cognitive and adaptive skills functioning, yet these are needed for adolescents with ID. These are routinely assessed by way of the Wechsler Intelligence Scale for Children—4th edition (Wechsler, 2003), the Wechsler

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Adult Intelligence Scale—4th edition (Wechsler, 2008), or similar measures. Adaptive skills are commonly assessed using the Vineland Adaptive Behavior Scales—2nd edition (Sparrow, Cicchetti, & Balla, 2005) or the Adaptive Behavior Assessment System—3rd edition (Harrison & Oakland, 2015). Most adolescents with ID will have had cognitive assessments through their school programming and are usually available for review. The index and individual scale scores from IQ testing can be much more informative than considering the FSIQ score alone (Blasingame, 2014a). Discrepancies between subscale scores or uniquely low index scores should be noted as these can inform the assessment process. For example, individuals with very low verbal comprehension will require particular attention to the vocabulary and structure of questions being posed, or individuals with a very low working memory index score will require more concrete and parsimonious communications. Understanding the individual’s cognitive functioning is important in the actual assessment process and treatment planning. As with all adolescents, assessments should include environmental as well as individual risk factors. Friends in their neighborhood and school, family member relationships, and levels of parental supervision each influence the adolescents’ social development. Although many adolescents who exhibit SPOB are moved into out-of-home placements, associating with antisocial peers or negative relationships with caregivers may become confounding factors when completing these assessments (Blasingame, Creeden, & Rich, 2015). These types of environmental factors can either support or undermine the adolescents’ functioning and need to be understood. Protective factors that may serve to reduce the effects of risk factors including access to healthcare and social support services (Blasingame, 2014a; Blasingame et al., 2015; Worling, 2017) should also be assessed. These may include the level of parental supports, parental education level, parental involvement and communication with teachers, or the adolescent’s involvement in community activities (Blasingame, 2014a).

Legal considerations Although beyond the scope of this article to fully explore, it should be noted that several legal elements need consideration when working with adolescents with ID who exhibit SPOB. These include, but are not limited to, the following: ●

Informed consent for treatment by the parent or legal guardian, and the adolescent when possible. Professionals need to ascertain the degree of competence each individual with ID holds regarding participation, particularly assessment and treatment procedures that are intrusive, such as


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questions about sex fantasies or atypical behaviors, and which nonsex offender clients would not be subjected to (Blasingame, 2005). Competency to stand trial requires the individual to be able to participate or assist in his or her own defense. To be considered competent to stand trial, the individual needs to possess several abilities, including understanding the charges and possible consequences, relating and communicating with one’s attorney, assisting one’s attorney in one’s own defense, understanding the nature of the legal proceedings, and understanding the potential outcomes of the legal proceedings (Roesch, Zapf, Golding, & Skeem, 1999). Culpability or the level of guilt or condemnation attributed to any person who has committed a wrongful act involves several factors. Culpability involves whether an individual acted knowingly, purposefully, recklessly, or negligently (Clark, 1999). Criminal intent involves the individual knowing the nature of the criminal act and doing it anyway.

These capacities should be considered when working with adolescents with ID. Adaptations for interviewing and testing The diagnostic criteria for ID reveal predictable challenges for interviewing individuals with ID. Clinicians assessing these individuals are challenged to adapt their intervention styles and strategies when working with individuals with ID (Blasingame, 2014b). One necessary adaptation is to modify the vocabulary of written materials and verbal communications to a level consistent with the individual’s assessed ability level. Making this adaptation is complicated by the reality that adolescents with the same FSIQ score, for example 65, do not have the same reading or word recognition skills. Evaluators need to consider each adolescent’s capacities and modify the verbiage used in interviewing (Blasingame, 2014a). Reading questionnaires aloud may be helpful as the evaluator can observe for the individual’s degree of comprehension or ask the individual to describe what is being asked. As many adolescents with ID also experience expressive and receptive language challenges, it is important that the evaluator allows time for the adolescent to take in and consider what is being asked. Providing multiple choice options or answer options of yes, sometimes, no, or I don’t know are also helpful. Formal assessment instruments are not necessarily standardized for reading aloud; evaluators should review the instrument’s manual before proceeding and make note if the administration method varies from the manual. Evaluators need to use consistent methods of administration to reduce errors and explain those methods when reporting findings.

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Challenges with executive functioning are yet another area of concern for individuals with ID (APA, 2013). Executive functioning includes the ability to be thoughtful, plan, problem solve, update memory, shift attention from one task to another, and organize behavior. When these tasks are combined, executive functioning is a process that controls thought and action (Danielsson et al., 2012). It is helpful to reduce extraneous stimuli during sessions, particularly while the individual is learning a new concept and encoding new information is critical (Danielsson et al., 2010). In interview and assessment sessions, it is helpful to have a quiet space and to allow longer response times after posing a question. It is also helpful to inform the individual when a line of inquiry is changing, such as “next I have some questions about alcohol and drugs” or “next are questions about what kinds of things are sexy for you.” These transition statements provide scaffolding for the individual’s thinking and reorganize information retrieval to switch to the new topic. Emotional dysregulation is yet another challenging area for individuals with ID (American Psychiatric Association, 2013). Lacking in social understanding, limited verbal expression, and few problem-solving skills can contribute to inadequate strategies to cope with one’s emotions. Many individuals with ID have difficulty labeling their own emotions and interpreting other’s emotions or behavior. Asking feeling questions can sometimes lead to the individual using the same emotion label or simply saying “I don’t know.” Interview, assessment, and therapy are social, interactive experiences. Establishing rapport and a collaborative partnership may be challenged by an adolescent’s past experiences of relationship failures, available emotional vocabulary to express needs and feelings, experiences with being in the dependent role, or by a clinician misguidedly assuming a parental style of interaction (Jahoda, Dagnan, Stenfert Kroese, Pert, & Trower, 2009). It can be helpful to use positive reinforcement strategies to support even the smallest efforts to participate in the interview or testing. As an example, the evaluator might extend a specific verbal praise when the individual exhibits willingness to participate or to offer a high-five or fist bump for getting through a specific series of questions. Structured risk assessment procedures Risk assessments have become commonly used in criminal justice settings (e.g., court decisions, probation supervision priority decisions, and placement decisions). Additionally, risk assessments are being used in some states in decisions about sex offender registration and possible civil commitment (Nelson, 2011). This makes it all the more important to ensure that the risk assessment procedures used are valid and reliable. Evidence-based, structured risk assessments are considered best practice in the field of sexual offender assessment and management (Blasingame et al., 2015). Assessing professionals need to complete


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training on the risk assessment tools they are using and comply with the parameters specified by the authors of the tools when employing them. Sadly, there are few instruments fitting this description for assessing adolescents with ID. Risk assessment of adults who have offended sexually improved significantly with the development of actuarial tools. For example, the Rapid Risk Assessment of Sexual Offense Recidivism (RRASOR; Hanson, R.K.) was developed in 1997. Hanson (1997) identified 69 variables associated with a known adult sex offender’s risk for re-offense, although many of the items had low correlations. Hanson used regression analyses to narrow the number of items to only four. The RRASOR was soon replaced by the Static 99 (Hanson & Thornton, 1999), a 10-item actuarial tool with a greater emphasis on antisociality. A later revision of the Static 99, the Static 99-R, was validated and cross-validated for use with adults with ID, using modified coding rules due to poor documentation within the criminal justice and developmental disability systems (Hanson, Sheahan, & Van Zuylen, 2013; Tough, 2001). Unfortunately, there are limited risk assessment tools validated and crossvalidated for adolescents who have offended sexually. Few researchers, discussed below, have developed instruments based solely on empirically derived studies of adolescents, much less adolescents with ID. The issue becomes even more complicated when considering the varying developmental issues associated with younger adolescents versus older adolescents and whether assessing males or females. Another challenge in developing these tools is the fact that many adolescents with ID who exhibit SPOB are not adjudicated rather are handled through developmental disability service agencies. Given the limited resources available, evaluators are forced to use clinical judgment when using tools that are not developed for a specific population (e.g., adolescents with ID who exhibit SPOB). This of course may lead to over- or underestimating an individual adolescent’s risk level and thereby lead to inappropriate case management and intervention decisions (Miccio-Fonseca, 2016). There are few risk assessment tools developed for mainstream adolescents, two of which are highlighted here—the Juvenile Sexual Offender Recidivism Risk Assessment Tool, second edition (JSORRAT-II) and the Multiplex Empirically Guided Inventory of Ecological Aggregates (MEGA♪). MEGA♪ is the only instrument validated and cross-validated for mainstream children and adolescents, for those with low intellectual functioning, for all genders (i.e., male, female, and transgender), and for different age groups from 4 to 19. An additional assessment procedure designed for adults—the Assessment of Risk and Manageability for Intellectually Disabled Individuals Who OffendSexually (ARMIDILO-S)—is also described, as its concepts may be helpful in assessing the manageability characteristics for adolescents with ID who are in out of home placements.

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JSORRAT-II (Epperson, Ralston, Fowers, DeWitt, & Gore, 2006; Ralston, 2008; Ralston, Sarkar, Philipp, & Epperson, 2017). The JSORRAT-II was developed on a large sample (n = 636) of adjudicated adolescents in Utah and cross validated on two additional samples, one in Utah (n = 566) and another in Iowa (n = 529) (Ralston, Epperson, & Edwards, 2016). The area under the curve (AUC) statistics were .89, .65, and .70, respectively. The JSORRAT-II provides risk estimates with statistical cut-scores differentiating levels of risk. The JSORRAT-II is used with males aged 12–18. JSORRAT-II items were derived through statistical analysis after the researchers retrospectively reviewed official case files of adolescent males who were adjudicated for sex crimes. A limitation of the JSORRAT-II is that its development samples did not identify how many individuals with ID were in the sample. This limits the degree of confidence that could be attributed to the outcome scores when applied to those individuals. Although the JSORRAT-II is recommended, it should be used with caution and within the context of broader assessment processes. Estimate of Risk of Adolescent Sexual Offense Recidivism (ERASOR; Worling, 2004; Worling & Curwen, 2001). Worling (2017) recently recommended discontinuing use of the ERASOR as the tool did not “provide an adequate degree of predictive accuracy to assist with forensic decisions, the research support regarding predictive accuracy for the ERASOR has not been consistently strong.” The ERASOR should not be used for making forensic decisions. The MEGA♪. The MEGA♪ was found to be valid for use in risk assessment and treatment planning for those with low intellectual functioning as well as youth without cognitive challenges (Miccio-Fonseca, 2009, 2010, 2013, 2016). The MEGA♪ is described as a developmentally sensitive, multidimensional instrument developed for assessing children and adolescents, aged 4–19, who exhibited what the author refers to as coarse sexual improprieties and/or sexually abusive behaviors. The MEGA♪ is a 75-item inventory completed after reviewing the available client file and possibly interviewing the youth, although not necessary. The MEGA♪ validation studies included adjudicated and non-adjudicated children and adolescents. The MEGA♪ was cross-validated (Miccio-Fonseca, 2013, 2016) on an extremely large sample (N = 1056) that included 222 children and adolescents with low intellectual functioning (i.e., borderline intellectual functioning, learning disabled, and intellectually disabled). The MEGA♪ cross-validation study also included 102 females, making the MEGA♪ the only sexual risk assessment tool validated for females who have exhibited these behaviors. The Risk Scale of the MEGA♪ for individuals aged 13 and older produced an AUC of .71 in a 24-month follow-up (Miccio-Fonseca, 2013). At this time, the MEGA♪ has a limited number of independent


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studies. One study is Fagundes’ (2013) 4-year longitudinal study examining the relationship between risk levels on MEGA♪ and JSORRAT-II and Diagnostic and Statistical Manual of Mental Disorders (4th ed.; American Psychiatric Association, 1994) diagnoses utilizing a sample of 98 adjudicated sexually abusive youth in a secure residential care facility. The findings showed no significant differences. Although the study did not examine the prognostic utility of the tools, it was nevertheless informative. The second is Rasmussen’s (2017) study of 129 adjudicated male adolescents in a secure residential facility for sexually abusive youth. It is the first study comparing the predictive validity of JSORRAT-II and MEGA♪. Findings showed that the MEGA♪ was predictive whereas the JSORRATII was not. The ARMIDILO-S (Boer, Tough, & Haaven, 2004) is an adult male risk management assessment tool that takes a number of environmental characteristics into consideration. Although the tool is designed for adults with ID, the concepts are believed to apply to adolescents as well (Blasingame et al., 2015). The applicable concept that underlies the ARMIDILO-S is that the individual’s risk is affected positively or negatively by his environment. Examples include the degree of awareness the staff members have regarding the individual’s risk characteristics, their level of attention when supervising the individual, and the stability or lack of stability in the individual’s environment. Another aspect of the ARMIDILO-S is its focus on the manageability of the individual in a given situation. Gathering this type of information can inform case managers and behavior plan developers regarding the need to increase or decrease levels of supervision as well as identify problem areas in the individual’s environment that may increase his risk for SPOB. Use of the ARMIDILO-S for adolescents with ID has not been studied; potential users should contact the developers and discuss any proposed alterations and solicit the authors’ input and the limitations of such alterations. These precautions are necessary to ensure that the adolescents will not be harmed by decisions made using the adapted adult tool. Nonetheless, the underlying concepts of the ARMIDILO-S raise important points for consideration in the overall risk assessment process for adolescents with ID.

The tools for assessing risk for sexually abusive behaviors in youths that are available have exhibited only modest accuracy in forecasting risk; considering the developmental changes, most authors of risk assessment tools for youth indicate that the assessed levels are for 6 months to a year (MiccioFonseca, 2013; Prentky & Righthand, 2003; Worling & Curwen, 2001). These tools should not be over-relied upon when making long-term decisions. Until further research provides more evidence-based tools designed specifically for

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adolescents with ID, evaluators will need to thoughtfully use available resources to guide their decision-making process and identify the limitations of the tools and their outcomes to prevent over- or underestimations of risk. Measuring sexual knowledge, interests, and expression Some studies have identified that individuals with ID have lower levels of sexual knowledge (Lunsky, Frijters, Griffiths, Watson, & Williston, 2007). In conjunction with the risk assessment process, it is important to identify whether the adolescent with ID being evaluated holds attitudes or interests that would support continued SPOB. The following strategies and tools can be useful in assessing these sexuality issues. ●

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Self-report. Self-report forms are often developed by individual practitioners who have identified their preferred areas of inquiry and questions to ask. These are not standardized or validated instruments and have no manuals or supporting data. In light of these, conclusions and results must be interpreted with caution. Self-report sexuality questionnaires survey the individual for sexual awareness, sexual behavior history, sexual orientation, and basic information about sexual behavior and health. However, because these are written by individual practitioners, it is important to ensure that the materials are written at a level that the individual can comprehend (Blasingame, 2014a) and that the materials be read aloud to the individual (if so indicated by the authors of these questionnaires). As noted above, many adolescents with ID also experience expressive and receptive language challenges. As such, it is important that the evaluator allows time for the adolescent to take in and consider what is being asked. Asking the individual to describe what the individual understands to be the question may help clarify whether questions should be rephrased or bypassed. Blasingame (2014a) has described the importance of adapting the readability of documents used to between the third and sixth grade levels. A limitation is that selfreport forms are idiosyncratically developed and may or may not inquire equally about necessary topics. Further, self-report forms are rarely subjected to empirical research or validation. Sexual knowledge screening. The LifeFacts Sexuality Education (Stanfield, 2008) surveys the individual’s understanding of basic information about a range of related topics. These include names and functions of human anatomy, feminine hygiene, human reproduction and birth control methods, abortion and adoption, sexually transmitted infections, safer sex practices, and basic relationship issues. The individual is presented with an image on a computer and is asked guided questions to explore the person’s knowledge base and understanding of human sexuality. The


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LifeFacts sexual knowledge screening and sex education materials are designed specifically for adults and adolescents with ID or other developmental disabilities. A limitation is that rating the individual’s responses to the questions calls for clinical judgment and may thus vary from evaluator to evaluator. Sexual interests and attitudes assessment. The Abel-Blasingame Assessment System for the Intellectually Disabled (ABID; Blasingame et al., 2011) was developed for use with adult males who have IDs. This was a study of 495 males aged 18–69 (mean = 33.3, median = 30.0, SD = 12.4). Data were collected from 78 sites across the United States between 2005 and 2009. Approximately 10% (n = 49) were identified with a FSIQ between 40 and 54; the other 90% were identified with a FSIQ between 55 and 70, based on evaluator reports. The ABID includes three sources of information (Blasingame et al., 2011). First, the ABID includes a survey—completed by the evaluator—regarding the individual’s level of functioning (estimated or actual intelligence score from file information or prior testing), ability to understand the questions to be posed, and the presenting sexual behavior problems based on the known case information. Second, the ABID includes a questionnaire (written at the second grade level) which is intended to be read aloud as a structured interview by the evaluator who then enters client responses into the computer program. Evaluators are instructed to attend to each client’s level of attention and understanding of the questions. As an example, evaluators are given the following instruction: “Read each question and the corresponding answer choices exactly as written. If the client does not appear to understand the question or parts of the question/answer choices, you may rephrase the question slightly or clarify in order to facilitate comprehension and avoid misunderstanding” (Abel & Blasingame, 2005, p. 5). The ABID questionnaire includes a sex history, a survey of 15 areas of sex problems or offending behaviors, an alcohol and drug history, cognitive distortion endorsements, and sexual fantasy vignette endorsements. Response options include multiple choice, true or false, and yes, sometimes, no, or I don’t know. Third, the ABID uses a visual reaction time measure (VRT) to unobtrusively measure the individual’s sexual interest patterns (Blasingame et al., 2011) while also gathering the client’s subjective rating of yes, sexy, sometimes sexy, or no, not sexy to me.

The ABID was found to have significant internal consistency (alpha = .84) among items on the cognitive distortions scale and social desirability scale (alpha = .80). Among the 10 fantasy vignette categories, Chronbach alpha scores ranged from .82 to .93, showing moderate-to-strong internal consistency. The viewing time measure comparing 22 categories of images showed moderate

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internal consistency with Chronbach alpha scores ranging from .76 to .86. The criterion validity of the ABID to detect sustained sexual interest in children was measured in two ways. The first involved identifying that the fantasy vignette scales were found to be correlated with the number of child sex abuse victims reported by the test takers in the sample. The second method involved demonstration that the viewing time measures (VRT) of sexual interest in children were correlated with the number of child sex abuse victims reported. Convergent validity for fantasy vignettes and the viewing categories was assessed by measuring whether the viewing time could predict two fantasy vignette scales (the male child and female child). These were tested through four models using negative binomial regression. They were further tested using the resampling method of bootstrapping to estimate how well the model would fit a similar data set (Blasingame et al., 2011). Asking the men about their fantasies and sexual interests has utility for the clinician who is assessing risk for re-offense and treatment planning (Blasingame et al., 2011, pp. 119–124). Preliminary data using the ABID with 154 adolescent males with ID have been obtained (Blasingame, in preparation). Although data collection continues, the extant sample includes males aged 13–17 years of age who were referred for assessment due to their exhibiting SPOB, primarily child molestation. The individuals were both adjudicated and non-adjudicated. Using the same instruction set, viewing stimuli, and questionnaire as the original ABID, there appear to be sufficient findings supportive of use of the ABID with adolescents. The fantasy vignette categories have moderate-to-high levels of internal consistency, with Chronbach alpha scores ranging from .82 to .94. The alpha scores for the image categories of the viewing stimuli ranged from .65 to .82. Another significant finding is with the adolescents’ disclosures in response to the ABID problematic sexual behavior history questions. Such disclosures increased by an average of 44% of reporting across the 15 items, beyond what was previously identified in the case records. Although preliminary, these data lend support to the use of the ABID with adolescents with ID. Limitations of the ABID being applied with adolescents include that the preliminary data are based on a small sample. As the study is ongoing, it has yet to be validated, cross validated, or subjected to independent studies. Mental health assessment As noted above, children and adolescents with ID are prone to a variety of behavioral challenges. Individuals with ID are at three to four times greater risk than the general population for having an additional mental health diagnosis (APA, 2000). Frequent comorbid conditions include attention deficit hyperactivity disorder, depression or other mood disorders, psychotic disorders, substance abuse disorders, and conduct disorder (Fletcher, Loschen, Stavraki, & First, 2007). A study in Australia involving 176


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adolescents with ID found that 20% of them were prescribed psychotropic medications (Doan et al., 2013). A typical interview with an adolescent with ID may not identify mental health symptoms (Fletcher et al., 2007; Hurley, 2006). Adolescents with ID are often unable to describe internal, subjective mental experiences. It may be helpful to identify the behavioral phenomena associated with mental disorders and consider these as “behavioral equivalents” in place of diagnostic criteria (Hurley, 2006). Use of a knowledgeable informant is another way to gather information needed for diagnostic purposes.

Use of assessment outcomes As with adolescents without disabilities, the risk assessment process for adolescents with ID involves gathering a significant amount of information regarding the individual, the individual’s family, and the individual’s environment. Incorporating elements regarding psychosocial development, cognitive and school functioning, adaptive skills, traumagenic experiences, comorbid mental health conditions, familial history, experiences and relationships, social skills and competencies, and peer relationships all provide better-informed risk assessments and treatment recommendations. With this holistic foundation, conclusions drawn from the structured risk assessment tools are better contextualized, allowing the identification of client-specific recommendations and interventions. Adolescence is a time of change and transition. There are several dynamic, changing components to one’s risk characteristics (Hempel, Buck, Cima, & Van Marle, 2013), and SPOB are not fixed or uncorrectable. In the absence of a holistically informed evaluation, sole reliance on limited sexual risk assessment tools may lead to compromised or misguided assessment outcomes. Better is a holistic, comprehensive, multidimensional assessment that recognizes the adolescent’s inappropriate sexual behaviors occurred within a life context full of change. From a case management perspective, a collaborative approach between stakeholders is recommended (Blasingame, 2014b). Completing a sexual risk assessment within this broader perspective enables more fully informed decisions that can have greater benefits for stakeholders as well as the individual adolescent. More than just identifying an adolescent’s risk for re-offense, learning better where to intervene and reduce that risk is a highly desirable outcome.

Recommendations for future research Research on risk assessment for SPOB of adolescents with ID who exhibit SPOB remains limited; further research is needed. Suggestions for researchers are offered here.

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Independent validation and cross-validation of the JSORRAT-II, the MEGA♪, and the ABID with the ID adolescent population. Develop assessment instruments specifically for adolescents with ID who experience mental and behavioral health challenges. Explore the effects of different adolescent age segments on SPOB and assessment tools. Explore SPOB exhibited by adolescent females or transgender persons with ID. Explore the effects of experiencing adverse childhood events on later SPOB in adolescents with ID. Identify areas of improvement in reporting, tracking, case management, and court dispositions in these cases.

References Abel, G. G., & Blasingame, G. (2005). The Abel-Blasingame assessment system for individuals with intellectual disabilities (ABID): Administrators manual. Atlanta, GA: Abel Screening, Inc. American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders (4th ed.). Washington, DC: Author. American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed., text revision). Washington, DC: Author. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: Author. Asscher, J. J., van der Put, C. E., & Stams, G. J. J. M. (2012). Differences between juvenile offenders with and without intellectual disability in offense type and risk factors. Research in Developmental Disabilities, 33, 1905–1913. doi:10.1016/j.ridd.2012.05.022 Blasingame, G. (2005). Developmentally disabled persons with sexual behavior problems: Treatment, management, supervision (2nd ed.). Brandon, VT: Safer Society Press. Blasingame, G. (2014a). Practical strategies for working with youth with intellectual disabilities who have sexual behavior problems. In D. Bromberg & W. T. O’Donohue (Eds.), Toolkit for working with juvenile sexual offenders (pp. 479–505). San Diego, CA: Elsevier. Blasingame, G. (2014b). Working with men with intellectual disabilities. In M. Carich & S. Mussack (Eds.), The safer society handbook of sexual abuse assessment and treatment (pp. 303–336). Brandon, VT: The Safer Society Press. Blasingame, G., Abel, G. G., Jordan, A., & Wiegel, M. (2011). The utility and psychometric properties of the Abel-Blasingame assessment system for individuals with intellectual disabilities. Journal of Mental Health Research in Intellectual Disabilities, 4, 107–132. doi:10.1080/19315864.2011.59369 Blasingame, G., Creeden, K., & Rich, P. (2015). Assessment and treatment of adolescents with intellectual disabilities who exhibit sexual problems or offending behaviors. Beaverton, OR: Association for the Treatment of Sexual Abusers. Retrieved from www.atsa.com Boer, D., Tough, S., & Haaven, J. (2004). Assessment of risk manageability of intellectually disabled sex offenders. Journal of Applied Research in Intellectual Disabilities, 17, 275–283. doi:10.1111/j.1468-3148.2004.00214.x Byrne, G. (2017). Prevalence and psychological sequelae of sexual abuse among individuals with an intellectual disability: A review of the recent literature. Journal of Intellectual Disabilities, Online First March, 16, 1–17. doi:10.1177/1744629517698844


15

Clark, C. (1999). Specific intent and diminished capacity. In A. Hess & I. Weiner (Eds.), The handbook of forensic psychology, second edition. New York, NY: John Wiley & Sons. Council, N. R. (2012). Reforming juvenile justice: A developmental approach. Committee on assessing juvenile justice reform. In R. J. Bonnie, R. L. Johnson, B. M. Chemers, & J. A. Schuck (Eds.), Committee on law and justice, division of behavioral and social sciences and education. Washington, DC: The National Academies Press. Craig, L., Stringer, I., & Sanders, C. (2012). Treating sexual offenders with intellectual limitations in the community. The British Journal of Forensic Practice, 14(1), 5–20. doi:10.1108/14636641211204423 Danielsson, H., Henry, L., Messer, D., & Rönnberg, J. (2012). Strengths and weaknesses in executive functioning in children with intellectual disability. Journal of Research in Developmental Disabilities, 33(2), 600–607. doi:10.1016/j.ridd.2011.11.004 Danielsson, H., Henry, L., Ronnberg, J., & Nissson, L.-G. (2010). Executive functions in individuals with intellectual disability. Journal of Research in Developmental Disabilities, 31 (6), 1299–1304. doi:10.1016/j.ridd.2010.07.012 Darling, N. (2007). Ecological systems theory: The person in the center of the circles. Research in Human Development, 4(3–4), 203–217. doi:10.1080/15427600701663023 Doan, T., Ware, R., McPherson, L., van Dooren, K., Bain, C., Carrington, S., … Lennox, N. (2013). Psychotropic medication use in adolescents with intellectual disability living in the community. Pharmacoepidemiology and Drug Safety, 23(1), 69–76. doi:10.1002/pds.3484 Douma, J. C. H., Dekker, M. C., de Ruiter, K. P., Tick, N. T., & Koot, H. M. (2007). Antisocial and delinquent behaviors in youths with mild or borderline disabilities. American Journal on Mental Retardation, 112, 207–220. doi:10.1352/0895-8017(2007)112[207:aadbiy]2.0.co;2 Epperson, D. L., Ralston, C. A., Fowers, D., DeWitt, J., & Gore, K. S. (2006). Actuarial risk assessment with juveniles who offend sexually: Development of the juvenile sexual offense recidivism risk assessment tool-II (JSORRAT-II). In D. Prescott (Ed.), Risk assessment of youth who have sexually abused: Theory, controversy, and emerging strategies (pp. 118–169). Oklahoma City, OK: Woods ‘N’ Barnes. Fagundes, M. (2013, Summer/Fall). DSM-IV-TR diagnoses and risk levels of sexually abusive youth. Perspectives: California Coalition on Sexual Offending Quarterly Newsletter, 1(5–8), 13. Fletcher, R., Loschen, E., Stavrakaki, C., & First, M. (2007). Diagnostic manual-intellectual disability: A clinical guide for diagnosis of mental disorders in persons with intellectual disability. Kingston, NY: National Association for the Dually Diagnosed. Hanson, K. (1997). The development of a brief actuarial risk scale for sexual offence recidivism. Ottawa, ON, Canada: Department of the Solicitor General of Canada. Retrieved from https://www.publicsafety.gc.ca/cnt/rsrcs/pblctns/dvlpmnt-brf-ctrl/index-en.aspx Hanson, K., Sheahan, C., & Van Zuylen, H. (2013). Static-99 and RRASOR predict recidivism among developmentally delayed sexual offenders: A cumulative meta-analysis. Sexual Offender Treatment, 8(1), 1–14. doi:10.1080/19315864.2015.1070221 Hanson, K., & Thornton, D. (1999). Static-99: Improving risk assessment for sex offenders. User Report 99-02. Ottawa: Department of the Solicitor General of Canada. Department of the Solicitor General of Canada website. Retrieved from www.sgc.gc.ca Harrison, P. L., & Oakland, T. (2015). Adaptive behavior assessment system – third edition. San Antonio, TX: The Psychological Corporation. Hempel, I., Buck, N., Cima, M., & van Marle, H. (2013). Review of risk assessment instruments for juvenile sex offenders: What is next? International Journal of Offender Therapy and Comparative Criminology, 57(2), 208–228. doi:10.1177/0306624X11428315

16

G. D. BLASINGAME

Holland, A. (2004). Criminal behavior and developmental disability: An epidemiological perspective. In W. Lindsay, J. Taylor, & P. Sturmey (Eds.), Offenders with developmental disabilities (pp. 22–34). West Sussex, England: John Wiley & Sons. Hurley, A. D. (2006). Mood disorders in intellectual disability. Current Opinion in Psychiatry, 19(5), 465–469. doi:10.1097/01.yco.0000238471.84206.0a Jahoda, A., Dagnan, D., Stenfert Kroese, B., Pert, C., & Trower, P. (2009). Cognitive behavioral therapy: From face to face interaction to a broader contextual understanding of change. Journal of Intellectual Disability Research, 53(9), 759–771. doi:10.1111/j.13652788.2009.01189.x Lounds Taylor, J., Burke, M. M., Smith, L. E., & Hartley, S. L. (2016). Families of adolescents and adults with intellectual and developmental disabilities. In R. M. Hodapp & D. J. Fidler (Eds.), International review of research in developmental disabilities: Fifty years of research in intellectual and developmental disabilities (pp. 195–231). Philadelphia, PA: Elsevier. Lunsky, Y., Frijters, J., Griffiths, D. M., Watson, S. L., & Williston, S. (2007). Sexual knowledge and attitudes of men with intellectual disabilities who sexually offend. Journal of Intellectual and Developmental Disability, 32, 74–81. doi:10.1080/13668250701408004 McCurry, C., McClellan, J., Adams, J., Norrei, M., Storck, M., Eisner, A., & Breiger, D. (1998). Sexual behavior associated with low verbal IQ in youth who have severe mental illness. Mental Retardation, 36(1), 23–30. doi:10.1352/0047-6765(1998)0362.0. CO;2 Miccio-Fonseca, L. C. (2009). MEGA♪: A new paradigm in protocol assessing sexually abusive children and adolescents. Journal of Child and Adolescent Trauma, 2, 124–141. doi:10.1080/19361520902922434 Miccio-Fonseca, L. C. (2010). An ecological risk assessment tool of risk and protective factors for assessing sexually abusive children and adolescents. Journal of Aggression, Maltreatment, and Trauma, 19, 734–756. doi:10.1080/10926771.2010.515542 Miccio-Fonseca, L. C. (2013). MEGA♪: A new paradigm in risk assessment tools for sexually abusive youth. Journal of Family Violence, 28, 623–634. doi:10.1007/s10896-013-9527-8 Miccio-Fonseca, L. C. (2016). MEGA♪ cross-validation findings on sexually abusive females: Implications for risk assessment and clinical practice. Journal of Family Violence, 31(7), 903–911. doi:10.1007/s10896-016-9845-8 Miccio-Fonseca, L. C., & Rasmussen, L. A. (2013). Applicability of MEGA♪ to sexually abusive youth with low intellectual functioning. Journal of Mental Health Research in Intellectual Disabilities, 6, 42–59. doi:10.1080/19315864.2011.650788 Nelson, R. (2011). Predicting recidivism among juvenile sex offenders: The validity of the ERASOR. Psychology Theses. Paper 13. Retrieved from http://docs.rwu.edu/psych_thesis/13 Prentky, R., & Righthand, S. (2003). Juvenile sex offender assessment protocol-II (J-SOAP-II) manual. NCJ 202316. Office of Juvenile Justice and Delinquency Prevention, Juvenile Justice Clearinghouse. Retrieved October 7, 2005, from http://ncjrs.gov Ralston, C. A. (2008). Validation of the juvenile sexual offense recidivism risk assessment toolII. Retrospective theses and dissertations. Paper 15806. Retrieved from http://lib.dr.iastate. edu/cgi/viewcontent.cgi?article=16805&context=rtd Ralston, C. A., Epperson, D. L., & Edwards, S. R. (2016). Cross-Validation of the JSORRAT-II in Iowa. Sexual Abuse: A Journal of Research and Treatment, 28(6), 534–554. doi:10.1177/ 1079063214548074 Ralston, C. A., Sarkar, A., Philipp, G. T., & Epperson, D. L. (2017). The impact of using documented but uncharged offense data on JSORRAT-II predictive validity. Sexual Abuse: A Journal of Research and Treatment, 29(2), 186–202. doi:10.1177/1079063215582011 Rasmussen, L. A. L. (2017, Retrieved September 1, 2017, from). Comparing predictive validity of JSORRAT-II and MEGA♪ with sexually abusive youth in long-term residential custody.


17

International Journal of Offender Rehabilitation and Comparative Criminology, 1–17. doi:10.1177/0306624X17726550 Roesch, R., Zapf, P., Golding, S., & Skeem, J. (1999). Defining and assessing competency to stand trial. In A. Hess & I. Weiner (Eds.), The handbook of forensic psychology, second edition. New York, NY: John Wiley & Sons. Schoon, I., Jones, E., Cheng, H., & Maughan, B. (2012). Family hardship, family instability and children’s cognitive development. Journal of Epidemiology and Community Health, 66 (8), 716–722. doi:10.1136/jech.2010.121228 Sparrow, S. S., Cicchetti, D. V., & Balla, D. A. (2005). Vineland adaptive behavior scales (2nd ed.). Minneapolis, MN: Pearson Assessments. Stanfield, J. (2008). LifeFacts: Sexuality education. Santa Barbara, CA: Author. Retrieved from https://www.stanfield.com/product/lifefacts-sexuality-w1070/ Tough, S. (2001). Validation of two standard risk assessments (RRASOR, 1997; STATIC-99, 1999) on a sample of adult males who are developmentally disabled with significant cognitive deficits. Master’s Thesis, University of Toronto, Toronto, Ontario, Canada. Van Dyke, D., McBrien, D., & Sherbondy, A. (1995). Issues of sexuality in down syndrome. Down Syndrome Research and Practice, 3(2), The Down Syndrome Educational Trust. doi:10.3104/reviews.53 Wechsler, D. (2003). Wechsler Intelligence Scale for Children, Fourth Edition. San Antonio, TX: The Psychological Corporation. Wechsler, D. (2008). Wechsler Adult Intelligence Scale, Fourth Edition. San Antonio, TX: Pearson/Psych. Worling, J. R. (2004). The estimate of risk of adolescent sexual offense recidivism (ERASOR): Preliminary psychometric data. Sexual Abuse: A Journal of Research and Treatment, 16, 235–254. doi:10.1177/107906320401600305 Worling, J. R. (2017, June 14). PROFESOR: Protective + risk observations for eliminating sexual offense recidivism. Retrieved from http://www.profesor.ca/history–rationale.html Worling, J. R., & Curwen, T. (2001). Estimate of risk of adolescent sexual offense recidivism (Version 2.0: The “ERASOR”). In M. C. Calder (Ed.), Juveniles and children who sexually abuse: Frameworks for assessment (pp. 372–397). Lyme Regis, Dorset, UK: Russell House Publishing.