Adolescent sex offenders: Treatment guidelines (WFSBP)

Transcription

1 Adolescent sex offenders: Treatment guidelines (WFSBP) Professor F. THIBAUT University Hospital Cochin, University Sorbonne Paris Cité (Faculty of Medicine Paris Descartes), INSERM U 894, CPN, Paris, France florence.thibaut@aphp.fr University Hospital Cochin Faculty of Medicine Paris Descartes

2 Disclosures Editor-in-Chief of Dialogues in Clinical Neuroscience (the journal receives a grant from Servier) Expert WHO (pharmacodependance) 2015-

3 Definitions Juvenile sexual offenders are: youths between the ages of 12 to 18 who have either been officially charged with a sexual crime, have performed an act that could be officially charged, or have committed sexually abusive/aggressive behaviour or any sexual act with a person of any age against the victim s will or in an aggressive, exploitative or threatening manner Child molesters refer to those who choose only or primarily child victims

4 Definitions Not all sexual offenders suffer from a paraphilic disorder, but only part of them Not all patients with a paraphilic disorder are sexual offenders (paraphilic disorders are not illegal, however acting in response of paraphilic urges may be illegal and could result in severe legal sanctions; e.g. in the case of paedophilia)

5 Be careful All sexual contacts between minors are not harmless: if non-consent, coercion or a significant age difference: sexually abusive behaviour may be reported

6 For juvenile or younger paedophiles, no age is specified and clinical judgment must be used (i.e., sexual maturity of the child and age difference between the victim and the perpetrator)

7 Clinical characteristics Denial is frequent (Ryan 1991) (1,600 child and adolescent sexual offenders (mean age 14 years) (range 5 19)) Comorbidities are frequently reported : mostly substance abuse, affective disorders, ADHD, conduct disorders and antisocial behavior, cognitive difficulties with poor academic performances and learning problems (Malin et al. 2014) as well as personality disorders (33-55%)

8 Clinical characteristics Past histories of sexual (50%) or physical abuse (66 vs. 20% in non-sexual offenders) (Longo 1982; Finkelhor and Araji 1986; Kavousi et al. 1988; Jespersen et al. 2009) Deviant sexual arousal and behaviour are learned in individuals through modelling and conditioning experiences (sexual abuse, porno use?)

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10 Clinical characteristics Family relationships are also frequently dysfunctional with parents having substance abuse problems, criminal and impulsive behaviours or psychiatric disturbances (Knight and Prentky 1993; Worling, 1995)

11 Clinical characteristics Adolescent sexual offenders form a heterogeneous group including: individuals with antisocial personality disorders, adolescents with problematic family background, and adolescents with atypical sexual interests and childhood abuse Different risk factors are predictive of recidivism among these groups

12 Mental retardation Similar or even slightly increased proportion of sexual problems as compared to subjects of average intelligence More often inappropriate, non-assaultive sexual behaviour, such as public masturbation and exhibitionism Less discriminating in their choice of victim ( comparable IQ) (Hayes 1991)

13 Clinical characteristics in children Araji (1997) Mean age of onset between 6 and 9 years Their victims are mostly siblings or friends Most of them have been physically or sexually abused, have learning difficulties, impaired relationships, and dysfunctional families (with inter-parental violence) Longitudinal studies are lacking: which children will persist in their sexual behaviour problems in adolescence and adulthood (Gerardin and Thibaut 2004)

14 Age of onset of deviant sexual fantasies and behavior 42% of males with a paraphilic disorder exhibited deviant sexual arousal by age 15 and 57% by age 19 (74% in case of homosexual pedophilia) (Abel et al., 1985) 15% of adolescent sexual offenders have been shown to go on to adult sexual offending behaviour This raises questions about how to identify deviant sexual interest occurring in adolescence, prior to sexual acting out, and to implement a prevention strategy

15 Recidivism risk factors Failure to complete the treatment program Sexual deviance (especially child sexual interests) Antisocial behaviour Sexual abuse history was also reported (Worling and Curwen 2000; Hanson and Morton Bourgon 2005; Seto and Lalumiere 2010)

16 Scales for prediction of sexual recidivism The Juvenile Sex Offender Assessment Protocol II (J-SOAP-II) (static risk scale) (Prentky and Righthand 2003; Fanniff et al. 2012) The Juvenile Sexual Offence Recidivism Risk Assessment Tool II (J- SORRAT-II) (Epperson 2006) The Estimate of Risk of Adolescent Sexual Offence Recidivism (ERASOR) (Worling and Curwen 2001; Worling 2004) The ERASOR or the J-SOAP-II appeared better in terms of accuracy for prediction of sexual recidivism (Hempel et al., 2013) In the USA, ERASOR and/or J-SOAP-II are used in three-quarters of the programs as compared to two-thirds of the programs in Canada (McGrath et al. 2010) They should only be used as one component of a comprehensive assessment protocol

17 Treatment goals Reducing sexual acting-out risk Improving psychosocial functioning Working on sexual abuse history Treating psychiatric comorbidities or personality disorders if any

18 Psychological and behavioral therapies are always used as first-line treatment approaches Several pharmacological treatment options are available in the most severe cases The treatment choice will essentially depend on the following parameters: patient s previous medical and psychiatric history, patient s observance, intensity of deviant sexual fantasies and sexual preoccupations, comorbid hypersexuality (see Garcia and Thibaut, 2010), risk of sexual violence, completion of growth and puberty

19 Types of psychological treatments Cognitive behavioural treatment (CBT) (90% of the community or residential programs in North America) Psychosocial education (35%) Multimodal treatment and Multisystemic therapy (22%) (McGrath et al. 2010) Classical insight-oriented approaches for the treatment of adolescent sexual offenders are of limited value (The National Task Force on Juvenile Sexual Offending, 1988, USA)

20 CBT

21 Treatment goals: CBT Treatment goals using CBT include: The first step of treatment is motivation and engagement in treatment The next step is to help the juvenile to accept the responsibility for his behaviour, which does not necessarily mean admittance of an offense

22 Others are: helping offenders to reduce deviant sexual arousal and sexual interests, challenging cognitive distortions and rationalizations that support or trigger offending behavior, knowledge of warning signals leading to offending improving victim empathy and social skills, enhancement of impulse control and control of anger Improving substance abuse and antisocial behaviour improving family relationships reducing personal trauma if any sexual education

23 CBT techniques (90% of cases) Covert sensitization: the sexual abuser imagines performing the chain of behaviours that led to some high-risk situation. Prior to engaging in high-risk behaviour in his imagination, the abuser interrupts the chain by imagining an aversive consequence or by imagining successfully escaping the situation (Maletzky 1991; McGrath 2001) 42% of cases in North America, McGrath et al. 2010

24 CBT techniques Minimal arousal conditioning (18%): a variation of covert sensitization (except that the abuser interrupts the chain of behaviours as soon as he (or she) experiences any type of mentally or physically sexually arousing thoughts or feelings (Gray 1995; Jensen 1994))

25 CBT techniques Verbal satiation or masturbatory satiation (a conditioning paradigm of extinction) VS is carried out in the same manner as masturbatory satiation except that the client does not masturbate while verbalizing his abusive sexual fantasies (Maletzky 1991; McGrath 2001) (13-11% of cases in North America) (McGrath et al. 2010) Some studies have used laboratory satiation with plethysmography

26 CBT techniques Imaginal desensitization using deviant sexual stimuli extinction controlled by relaxation

27 MST

28 Treatment goals: MST (22% of cases) Multisystemic treatment (MST) directly addresses: intrapersonal problems (e.g., cognitive problem solving) familial difficulties (e.g., inconsistent discipline, low monitoring, family conflicts) extra-familial problems (e.g., association with deviant peers, school difficulties) associated with youth serious antisocial behaviour (Letourneau et al. 2009) youth denial about the offence

29 PSE

30 Treatment goals: PSE (35% of cases) Psycho-socio-educational approach emphasizes education as a method of helping sexual abusers to change their behaviour. Social skills practice are typically included

31 Pharmacological treatments SSRIs are used in 20-36% of adolescent juvenile sexual offenders (males > females) (USA, Canada, 2010) Antiandrogen treatments are used in 3-27% of male adolescent sexual offenders (USA/Canada) Caution is warranted in children and young adolescents because the effects of antiandrogens on the normal growth and development of youth are not known The American Academy of Child and Adolescent Psychiatry (1999) recommended the use of antiandrogens to be limited to the most severe cases and discouraged their use with youths under the age of 17

32 WFSBP treatment guidelines (Thibaut et al. 2015) Level 1: Sexual offenders with paraphilia without violence. Age > 12 Motivational interviewing (level D) to prevent drop outs Psychological treatment (first line treatment): MST (level C) CBT (level C) PSE (level D) at least if CBT or MST not available Treatment preferentially delivered in peer group settings Community (or residential treatment if indicated) Pharmacological treatment: none

33 WFSBP treatment guidelines (Thibaut et al. 2015) Level 2: (1) Adolescents hands off or hands on. Sexual offenders with low to moderate levels of violence (e.g. indecent exposure, touching the body or genital parts of another person). Age < 17 Motivational interviewing (level D) to prevent drop outs Psychological treatment (first line treatment): MST (level C) CBT (level C) PSE (level D) at least if CBT or MST not available Treatment preferentially delivered in peer group settings Community (or residential treatment if indicated)

34 WFSBP treatment guidelines (Thibaut et al. 2015) Level 2: (2) Pharmacological treatment: SSRIs Increase the dosage at the same dosage as prescribed to OCD (e.g. fluoxetine up to 40 mg/d or sertraline mg/d, depending on age) (level D) Be careful with the increased risk of suicide attempts

35 WFSBP treatment guidelines (Thibaut et al. 2015) Level 3: (1) Adolescent sexual offender with high risk of sexual violence (e.g. associated with coercive sexual sadism in fantasies and/or behavior). Age < 17. Tanner stage V required Motivational interviewing (level D) to prevent drop outs Psychological treatment (first line treatment): MST (level C) CBT (level C) PSE (level D) at least if CBT or MST not available Treatment preferentially delivered in peer group settings Community (or residential treatment if indicated)

36 WFSBP treatment guidelines (Thibaut et al. 2015) Level 3: (2) Pharmacological treatment depends on the risk of sexual violence: Moderate risk: Add to SSRIs antiandrogens at the lowest effective dosage (e.g. cyproterone acetate 50 mg/d) and check every 6 months the need for antiandrogens (level D) If very high risk of sexual violence or failure of previous step: cyproterone acetate ( mg/d) or medroxyprogesterone acetate ( mg/d) if CPA not available or long-acting GnRH agonists (triptoreline or leuprolide acetate 3 mg/month or mg every 3 months (+CPA)

37 WFSBP treatment guidelines (Thibaut et al. 2015) Level 4: Same as level 3 but Age > 17. Tanner stage V required Motivational interviewing (level D) to prevent drop outs Psychological treatment (first line treatment): MST (level C) CBT (level C) PSE (level D) at least if CBT or MST not available Treatment preferentially delivered in peer group settings Community (or residential treatment if indicated Pharmacological treatment: same as level 3 but no time limit for antiandrogen treatment (level C for adults)

38 Reasons for treatment failure Level of motivation Severe history of personal victimization Prior sexual and nonsexual criminal history Extreme levels of distorted beliefs regarding sexual aggression or sexuality, deficits in empathic abilities, and an observable absence in personal or interpersonal coping skills (Hanson and Harris 2000) These targets may be improved with CBT

39 Some general conclusions from the literature When pre- and post-evaluation is available, it is in favor of the treatment, particularly in case of moderate risk of reoffending Drop outs of treatment programs do worse in the long term than sexual offenders who completed the program Differences between older and younger adolescents are suggested Information concerning potential adverse outcomes of treatment was not available In general, adjudicated youths are more motivated for treatment

40 Conclusion Literature in this field is very heterogeneous Long term follow up studies are needed Prevention strategies aiming to identify deviant sexual interest (especially pedophilic interests) occurring in adolescence, prior to sexual acting out, should be implemented

41 References The World Federation of Societies of Biological Psychiatry (WFSBP) guidelines for the treatment of adolescent sexual offenders with paraphilic disorders F Thibaut, JMW Bradford, P Briken, F De La Barra, F Häßler, P Cosyns & the WFSBP Task Force on Sexual Disorders The World Journal of Biological Psychiatry :1-37 OPEN ACCESS

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43 Criminogenic needs (medications): -sexual deviance/paraphilia -hypersexuality/sexual preoccupations WFSBP Treatment Guidelines for adolescent sex offenders (Thibaut et al., 2015)