1. ADDRESSING SEXUAL BEHAVIORS OF ADOLESCENTS WITH DEVELOPMENTAL DISABILITIES
Dr. Kristina Osborne-Oliver, Psy.D., NCSP
Dr. Katrina Emmerich, Psy.D.
Dr. Jennifer Brooks, Psy.D.
Tylea S. Gebbie, MS, CAS
St. Anne Institute, Albany, NY
Presentation Prepared for
NYSATSA 2010 Conference
May 4, 2010

2. Agenda: Topics to Be Covered
Introduction and Definitions of Developmental Disabilities
Autism Spectrum Disorders, Intellectual Disabilities, & Learning Issues
Research on Observable Behaviors, Social Skill Deficits, and Sexualized Behaviors
Treatment Delivery: General Strategies
Evidenced-Based Specialized Treatments recommended for this population
Pharmacological
Educational/Behavioral Approaches
Recommendations of Targeted Social Skills within Sexual Education Curriculum
Specific Intervention Ideas for Therapy with Clients with Developmental Disabilities
Resource List

3. Introduction & Definitions

4. DSM-IV-TR Diagnostic Criteria: Pervasive Developmental Disorders
Pervasive Developmental Disorders (PDD)
Asperger’s Disorder
Autistic Disorder
Rett’s Disorder
Childhood Disintegrative Disorder
Pervasive Developmental Disorder – Not Otherwise Specified
The term “Autistic Spectrum Disorders” (ASD) is often used interchangeably with PDD
Our presentation will focus on Asperger’s, Autistic, and Pervasive Developmental Disorder-Not Otherwise Specified as these areas have been the most widely researched.

5. DSM-IV-TR Diagnostic Criteria: Asperger’s Disorder
A. Qualitative impairment in social interaction, as manifested by at least two of the following:
1. Marked impairment in the use of multiple nonverbal behaviors such as eye-to-eye gaze, facial expression, body postures, and gestures to regulate social interaction
2. Failure to develop peer relationships appropriate to developmental level
3. Lack of spontaneous seeking to share enjoyment, interests, or achievements with other people
4. Lack of social or emotional reciprocity
A3. Lack of spontaneous seeking to share enjoyment, interests, or achievements with other people (e.g., by a lack of showing, bringing, or pointing out objects of interest to other people).

6. DSM-IV-TR Diagnostic Criteria: Asperger’s Disorder (continued)
B. Restricted repetitive and stereotyped patterns of behavior, interests, and activities, as manifested by at least one of the following:
1. Encompassing preoccupation with one or more stereotyped and restricted patterns of interest that is abnormal either in intensity or focus
2. Apparently inflexible adherence to specific, nonfunctional routines or rituals
3. Stereotyped and repetitive motor mannerisms
4. Persistent preoccupation with parts of objects
3. Stereotyped and repetitive motor mannerisms (e.g., hand or finger flapping or twisting, or complex whole-body movements)

7. DSM-IV-TR Diagnostic Criteria: Asperger’s Disorder (continued)
C. The disturbance causes clinically significant impairment in social, occupational, or other important areas of functioning.
D. There is no clinically significant general delay in language
E. There is no clinically significant delay in cognitive development or in the development of age-appropriate self-help skills, adaptive behavior (other than social interaction), and curiosity about the environment in childhood.
F. Criteria are not met for another specific Pervasive Developmental Disorder or Schizophrenia.
D. There is no clinically significant general delay in language (e.g., by a lack of showing, bringing, or pointing out objects of interest to other people).

8. How is Asperger’s Disorder Different from Autistic Disorder?
The criteria for Autistic Disorder are essentially the same as Asperger’s Disorder with the exception that there are criteria for qualitative impairment in communication for Autistic Disorder:
Qualitative impairments in communication as manifested by at least one of the following:
A. Delay in, or total lack of, the development of spoken language
B. Individuals with adequate speech, marked impairment in the ability to initiate or sustain a conversation with others
C. Stereotyped and repetitive use of language or idiosyncratic language
D. Lack of varied, spontaneous make-believe play or social imitative play appropriate to developmental level
There must also be delays in abnormal functioning in at least one of the following areas, with onset prior to age 3 years: (1) social interaction, (2) language as used in social communication, or (3) symbolic or imaginative play.
A. Delay in, or total lack of, the development of spoken language (not accompanied by an attempt to compensate through alternative modes of communication such as gesture or mime).

9. DSM-IV-TR Diagnostic Criteria: Pervasive Developmental Disorder-Not Otherwise Specified (PDD-NOS)
Severe and pervasive impairment in the development of reciprocal social interaction
Associated with impairment in either verbal or nonverbal communication skills or with stereotyped behaviors, interests, and activities
Criteria are not met for a specific Pervasive Developmental Disorder, Schizophrenia, Schizotypal Personality Disorder, or Avoidant Personality Disorder.

10. Asperger’s Disorder: Social-Emotional Domain
Strengths
Capable of learning social skills
Motivated to learn social skills
Encode social situations visually
Follow the rules
Adult relationships/friendships may be established
Innocence and honesty
Weaknesses
Poor social cognition
Poor appreciation of social cues
Minimal eye contact, affect/facial expression, showing/sharing, smiling
Inability to see from another’s perspective
Lack of social reciprocity
Failure to develop peer relationships
Overly sensitive to criticism
May become rigid/anxious under stress
May experience rage and/or depression

11. Asperger’s Disorder: Cognitive Domain
Strengths
No clinically significant delay in cognitive development
Average, above average, or gifted
Excellent rote memory
Excellent visual memory
Concrete thinking
Good long-term memory
Good reading mechanics
Weaknesses
Rigid thinking (one track mind)
Difficulty shifting attention
Poor auditory processing skills
Difficulty with abstract thinking
Problems with organization/planning
Hyperlexia, comprehension, writing problems
Failure to generalize/transfer thinking/skills to other situations
Rote Memory – Lists, rules
Visual Memory – Lists, rules
Concrete thinking – here and now; no hypotheticals
Intense interests (complex topics)
Insistence on completion and perfection

12. The nature of the client
Why is it important to be familiar with Autism Spectrum Disorders (ASDs) when providing services to individuals?
The nature of therapy
Verbal vs. Nonverbal
Auditory vs. Visual
The nature of the client
Those who have been sexually abused
Reactions to abuse
Group work
Those who sexually act out
Victim empathy
The majority of communication is nonverbal but many therapists emphasize the importance of verbal messages.
For children with ASDs, both verbal and nonverbal communication can be easily misperceived and misinterpreted.
Victim empathy is often a necessary component of a risk assessment and resulting treatment.
Empathy is often lacking in individuals with ASDs and needs to be implicitly taught.
Group work is often a recommended component to treatment of individuals who sexually act out.
Group work involves social interactions and good groups often have positive peer relationships.
Appropriate social interactions are more variable for individuals with ASDs and social skills typically need to be implicitly taught.
Some individuals with autism, for example, may be nonverbal and thus not have the language to describe the abuse or their feelings.

13. Definition of Intellectual Disability (ID)
“Intellectual disability (ID) is characterized both by a significantly below-average score on a test of mental ability or intelligence and by limitations in the ability to function in areas of daily life, such as communication, self-care, and getting along in social situations and school activities.”
Sometimes referred to as a cognitive disability or mental retardation
Children with ID can and do learn new skills, but they develop more slowly than children with average intelligence and adaptive skills.
There are different degrees of ID, ranging from mild to profound.
(Centers for Disease Control and Prevention, 2005)

14. DSM-IV-TR Diagnostic Criteria: Mental Retardation
Significantly subaverage intellectual functioning: IQ of approximately 70 or below on individually administered IQ test
Concurrent deficits or impairments in present adaptive functioning in at least two areas
Onset before 18 years of age

15. Degrees of Mental Retardation
Mild Mental Retardation
Moderate Mental Retardation
Severe Mental Retardation
Profound Mental Retardation

16. DSM-IV-TR Diagnostic Criteria: Learning Disorder
“Learning Disorders (LD) are diagnosed when the individual’s achievement on individually administered, standardized tests in reading, mathematics, or written expression is substantially below that expected for age, schooling, and level of intelligence. The learning problems significantly interfere with academic achievement or activities of daily living…”
LDs may persist into adulthood
Prevalence estimates range from 2-10% of the general population, and 5% of the school population

17. Part 200 Classification Criteria: Learning Disability
Learning disability (LD) means a disorder in one or more of the basic psychological processes involved in understanding or in using language, spoken or written, which manifests itself in an imperfect ability to listen, think, speak, read, write, spell, or to do mathematical calculations…The term includes such conditions as perceptual disabilities, brain injury, minimal brain dysfunction, dyslexia and developmental aphasia.  The term does not include learning problems that are primarily the result of visual, hearing or motor disabilities, of mental retardation, of emotional disturbance, or of environmental, cultural or economic disadvantage.”
Response to Intervention (RTI)

18. Common Cognitive Deficits
Attention – the ability to tune in and concentrate
Perception – the ability to make sense of and understand information
Memory – the ability to acquire, hold, and retrieve information
Comprehension – the ability to understand what is being said
Expression – the ability to communicate
Coping with change – flexibility

19. Why is it important to be familiar with Intellectual and Learning Disabilities when providing services to individuals?
Throughout the twentieth century, there was a public perception that there was a link between ID and sex offending
Research has reported higher rates of abuse amongst people with ID
Furey (1994) examined 461 cases of sexual abuse and found that 42% of abuse had been perpetrated by individuals with ID
Less attention has been paid to young people with ID whose sexual behavior is problematic
Evidence that LD is over-represented in services for sexual offenders
Individuals with LD are among the most challenging for services and practitioners

20. Methodological Issues
Inclusion criteria (IQ cut-off)
At what point are individuals with ID expected to understand societal rules?
Source of the sample
Typically drawn from hospitals, prisons, referrals to court, police stations, social and health service referrals
Of 57,000 individuals assesses for the courts in New York, 2.5% had ID
A study of individuals in hospitals found that 35% were diagnosed as having ID
Method of determining ID
Variety of IQ tests
Variety of methods for diagnosing ID
Scrutiny of records and history may vary

21. Treatment Outcomes for Clients with LD
Research suggests that there is a relationship between outcome and length of treatment
Day (1993) found a positive relationship between length of stay over 2 years and a better outcome
Lindsay & Smith (1998) found that individuals in treatment for less than one year showed significantly poorer progress and were more likely to reoffend than those treated for at least 2 years
Variables associated with recidivism
Allowances made by staff
Antisocial attitude
Poor relationship with mother
Denial of crime
Sexual abuse in childhood
Erratic attendance
Poor response to treatment
Low self-esteem
Lack of assertiveness
Offenses involving violence

22. RESEARCH: WHAT WE KNOW ABOUT OUR CLIENTS WITH DEVELOPMENTAL DISABILITIES

23. General Observable Behaviors of Clients with Developmental Disabilities
Standing too close to someone during conversation
Staring inappropriately
Lack of eye contact
Flat or inappropriate facial expression
Getting ‘stuck’ on a particular topic during conversation
‘Stimming’ behaviors such as rocking or hand- flapping

24. Sexually-Related Behaviors of Clients with Developmental Disorders
Research has found that individuals with developmental disabilities may display sexually inappropriate behavior, including:
Masturbating in public
Kissing strangers
Removing clothing in public
Touching others inappropriately
Touching their own private areas in public
Sexual fetishism
Although the literature on sexuality related education is limited, evidence that individuals with autism can benefit from it is accumulating (Koller, 2000).
In order to devise suitable intervention programs for adolescents on the spectrum, it is important to understand what behaviors are displayed in this group are problematic and are not part of the typical repertoire of adolescent behavior. 24

25. Additional Information Regarding the Sexually-Related Behaviors of Clients with Developmental Disorders
Greater tendency to sexually aggress:
Lack of privacy
More impulsive --Often in Public Settings
Naiveté - Inability to understand normal sexual relationships
More likely to present with less serious or intrusive offenses resulting in serious bodily harm, violence, or death
More likely to commit sex offenses across categories and be less discriminating in their victims
More likely to commit sex offenses against younger children and male children
Sex crimes are seen as part of a pattern of poorly controlled behavior rather than sexual deviation
“Abuse without abuser” - Initiator of an abusive sexual act does not understand the concept of consent or the impact of the behavior on others.

26. How Impairments Impact the Sexual Interactions of Clients with Developmental Disabilities
Difficulties in the following areas:
1. Forming effective relationships with peers
2. Learning adaptive social behaviors in an unstructured fashion
3. Reading social cues (both subtle and overt)
4. Interpreting the other person’s feelings
5. Taking another person’s perspective
6. Being flexible in conversational topics
Those difficulties may lead to:
1. Lack of appropriate sexual outlet; considering younger children “safer” to interact with;
2. Inappropriate social interactions; sharing interests/perseverations with younger children;
3. Misinterpretation of another’s body language;
4. Misinterpretation of another’s friendship or loving feelings as sexual;
5. Inability to empathize with victims (“How should I know how she felt?”);
6. Obsessing/perseverating on sex and/or pornography
Could mention Theory of mind specifically for Asperger’s
The cognitive capacity to understand that others have beliefs, desires and intentions that are different from one’s own.
Clients with Asperger’s frequently have difficulty with theory of mind and their ability to empathize with others.
When asked to empathize with their victim, a client with Asperger’s may be unable to do so.
“How should I know how she felt?”

27. Additional Hypotheses Regarding the Cause of Sexually Inappropriate Behavior Among Clients with Developmental Disabilities
Structural
Modeling
Behavioral
Partner Selection
Inappropriate Courtship
Sexual Knowledge
Perpetual Arousal
Learning History
Moral Vacuum
Medical
Medication Side-Effect

28. Differentiating Inappropriate from Deviant Sexual Behaviors
Researchers offer insight into the differentiation of inappropriate sexual behavior from deviant sexual behavior.
Inappropriate sexual expression may result from default as the only allowable expression of sexuality.
Deviant behavior, however, has causes, although not clear in any population, that are similar to deviant behavior found in the non-developmentally delayed population.
Prior to the 1970s, the treatment of public displays of sexual behavior was managed by institutionalization and the differentiation of inappropriate sexual behavior from deviant sexual behavior was moot. Treatment approaches have included the development of sociosexual skills and coping strategies. Other aversive therapies included electric shock, satiation, and covert sensitization. Another treatment option has been hormonal therapy but again, treatment focused on the suppression of sexual expression rather than teaching appropriate sexual expression.
There is a serious risk that an adolescent with AS who engages in sexually inappropriate behavior may be labeled as a sexual offender or even worse as “deviant,” an experience that would only serve to compound the social and emotional difficulties he is already facing. Practitioners face a challenge working with these adolescents to fully assess and differentiate AS as a causal factor in sexually inappropriate behavior rather than assuming the presence of a sexually abusive motivation.
Inappropriate sexual expression may result from default as the only allowable expression of sexuality in an environmental context that does not support appropriate sexual knowledge and relationships in individuals with autism. 28

29. Sexual Victimization of Clients with Developmental Disabilities
How could it happen?
Social deficits may increase vulnerability
Misinterpreting non-verbal cues
Language deficits may increase vulnerability
Misunderstanding language
Some developmental disorders are co-morbid with anxiety and/or depression
These symptoms may appear or worsen following a traumatic event
Children with some developmental disabilities tend to be oversensitive to criticism.
Self-blame may be particularly problematic
Social and language impairments may impact understanding of the abuse

30. DELIVERY OF THERAPY SERVICES: GENERAL TREATMENT STRATEGIES

31. Treatment Guidelines Treatment should be multidimensional
Individual therapy
Group therapy
Close involvement of caretakers
Supportive framework to monitor and reinforce key messages
Focus on the control of elimination of abusive sexual behaviors by:
Identifying positive goals
Enhancing social and relationship skills
Promoting life skills and phased community access
Create a control plan or relapse prevention plan
Create Risk Management Groups
Multidisciplinary team approach
Make decisions regarding mobility, levels of supervision, and community access
Constituency may evolve as the young person’s circumstances change

32. Structure of Therapy Sessions
People with developmental disabilities do better when things are predictable and organized
Temporal supports
Visual timers, stopwatch, schedules, routines
Procedural supports
Outline the steps of an activity
Spatial supports
Provide information about the location of objects
Assertion supports
Help individual initiate and exert control such as in making choices and maintaining self-control
Provide them with a clear overview of the treatment process including the contents, frequency, duration, and place of the sessions and treatment

33. Interventions with Clients with Developmental Disabilities
Interventions should:
Be consistently modeled and supported throughout the external environment
Be practical and success oriented
Be at the client’s developmental level
Be created with and prompted by the client
How will they benefit from the intervention
Increases motivation to participate in treatment
Involve role-play and rehearsal
Give the client something tangible to take with them once that skill is mastered

34. General Therapy Considerations
Engagement – show interest in the clients interests and perseverations and allow them to speak at length about them
Pay attention to the environment – reduce distracting noises, florescent lighting
Praise success – help them to be mindful of their strengths
Use multiple modalities – journaling, story- writing, drawing, role-plays
Deliver information at the client’s pace
Give information in parts
Plan breaks

35. General Therapy Considerations
Provide frequent repetition of concepts
Take time to find the motivation behind the behavior
Example: Unzipped fly
Assist adolescents in generating and taking ownership of information
In the past, fear of “giving the wrong answer” may have resulted in repeated failure and negative self-evaluation
If the client does not understand something
Do the task with them – help them “connect the dots”
Give hints – help point the way
Say directions in a different way

36. Language and Communication
Clients with developmental disabilities may:
Use the wrong terms or words
Misuse time concept words
Confuse sexes or persons in a sentence
Parrot commonly used treatment terms
Therefore:
Clarify everything
Ask yourself – “Does the client really mean what they are saying?”

37. Language and Communication
Your use of verbal and non-verbal communication is very important
Therefore:
Use communication that is clear, concrete, and specific
Be concrete, not abstract
Avoid the use of jargon
Check in frequently with the client
Convert therapeutic terms into plain language – define in simple terms
Draw attention to non-verbal communication and use them as teaching moments
Example:
Instead of saying “you seem upset”
You might say “I notice your arms are crossed and you are frowning. That tells me that you are upset, am I right?”

38. Information Processing
Clients with developmental disabilities can be slow processors of information
Therefore:
Not responding ≠ Being oppositional
Give them additional time to process what you have said
Do not yell or hurry them
If taking time to respond do not assume that they are filtering or editing their response

39. Generalization
Clients with developmental disabilities have difficulty generalizing – taking what you have taught them in therapy and using it in real life situations
Therefore:
Use concrete, vivid, and personalized examples
Do role-plays
Create scenarios that involve multiple settings
Take the client out in public
Best way to help a client to generalize

40. Checking their Comprehension
Clients with developmental disabilities may present as much higher functioning than they really are
For example - May nod their head or answer “yes” when you ask “do you understand?”
Therefore:
Talk in short, ten (at the most) word sentences
Ask the client to repeat what you have said in their own words
Ask the client to give you an example, what they have learned, or how they will change their behavior next time

41. Working with Clients in Groups
Groups can be beneficial to clients with developmental disabilities
Provides a safe environment for learning
Provides practice in social skills and communication
Need to ensure that the group is safe for all members
Clients are vulnerable to being teased, bullied, or ridiculed by peers
Conflict, bullying, or misunderstanding between a client with a developmental disability and other group members can greatly damage group cohesion

42. Working with Clients in Groups
Strategies for increasing involvement
Keep groups active
will retain more and increase interest in coming to group
Make sure the client walks away with something after every session
Focus on simple themes
Incorporate experiential modalities
Drama/play, sand tray, art therapy, music, role play, storytelling, etc.
Have them do something during group
Write on the board, talking stick

43. Working with Clients in Groups
Role of the Group Leader
Facilitator may act as a ‘translator’ between these clients and the other group members
May need to:
Decode the non-verbals of other group members and explain them
Point out what might not be obvious
Interpret what the client says to other group members if it is needed to prevent misunderstandings

44. Evidence-Based Treatment Recommendations

45. There is little research on community- based programs
WHY IS EVIDENCE-BASED SPECIALIZED TREATMENT LIMITED FOR THIS POPULATION?
Issues:
There is no controlled study of any kind, because researchers can’t ethically provide a no-treatment condition
There is little research on community- based programs

46. Psychopharmacological treatments
Direct hormonal intervention to control urges by reducing the effect of sex hormones
Treatment of excessive Masturbation
Lupron (leuprolide), a synthetic nonpeptide analog of human gonadotropin-releasing hormone.
Side effects of aggressive behaviors
Indirect intervention directed at comorbid conditions, such as aggression, impulsivity, and psychiatric disorders that may affect sexual disinhibition

47. Psychopharmacological treatments
Remeron (mirtazapine) is a second-generation antidepressant that has both noradrenergic and serotonergic properties.
Rationale for selecting this drug was for its previously reported antilibidnal effect.
Also has an anticompulsive effect.
SSRIs tend not to be chosen, especially with clients with hyperactivity, irritability, and aggression.
Remeron has found to be effective in the treatment of
Excessive masturbation
Sexual fetishism
Further, placebo-controlled, double-blind studies are needed regarding this topic
Single-case reports describe the efficacy of mirtazapine (Nguyen and Murphey, 2001; Albertini et al., 2006) in the treatment of excessive masturbation
Mirtazapine is a second-generation antidepressant that has both noradrenergic and serotonergic properties. Rationale for selecting this drug was from its previously reported antilibidnal effect (Nyugen and Murphy, 2001; Coskun & Mukaddes, 2008). Also has an anticompulsive effect (SSRIs were not chosen because most participants suffered from hyperactivity, irritability, and aggression).

48. Coskun et al (2009) Study
5 participants showed very much improvement; 3 participants show much improvement, and 1 showed moderate improvement in excessive masturbation.
Side effects included appetite increase; weight gain; and sedation. Other possible side effects could include increase thirst, urination, and one participant experienced a hand tremor.
Other improvements were a decrease in engagement of touching women inappropriately, disrobing in public, and fetishistic behaviors.
Participants were regular patients in an autism clinic in Istanbul University. The study included 10 individuals (2 females and 8 males; age range years old).
Sexualized behaviors included masturbation at home and/or public (100%), touching people inappropriately (50%), disrobing in public (20%), sexual interest in or arousal by some particular body parts or nonhuman objects (20%), and observing people bathing or undressed (10%).
2 participants also had ADHD; 2 had major depression; 3 participants had aggressive behaviors and irritability
Patients started out on dosages of 7.5 to 15 mg/day.
Parents monitored their son/daughter’s engagement in inappropriate sexual behaviors pre- and post-prescription.

49. recommended educational & Cognitive-behavioral approaches

50. Cognitive-Behavioral Treatment
Cognitive-Behavioral Treatment - increasing knowledge base and skill acquisition
Behavioral Targets
Daily living skills
General interpersonal and educational skills (e.g., social skills, sex education)
Specialized behavior skills relating to sexuality and offending
Relapse prevention
Cognitive Targets
Embarrassment
Denial
Minimization
Problems with self-esteem
Problems with communication
Anger Management
Adequate evidence to suggest that anger and violence are highly significant problems in this population and that treatment incorporating CBT and anger management will promote self-regulation and reduce violent incidents

51. CONSIDERATIONS FOR SEXUAL EDUCATION IN TREATMENT
Religious or cultural values of parents, caregivers, or educational staff
May warrant a same-sex teacher
Consent needs to be obtained prior
Provide it at the level of the client’s mental age level and capacity to learn
Do not go beyond the client’s level of sexual interest
Make the activities interesting, exciting, and fun (condom races)
Use colorful charts/pictures, collages, art projects, interactive role plays, have fun!
Start with the basics
Learn the minimum of the basics of anatomy, psychology, and safety (Gill & Hough, 2007).
Masturbation (Cambridge et al., 2003)

52. SOCIAL SKILLS COMPONENTS TARGETED IN SEXUALITY EDUCATION CURRICULUM

53. Based on a review of curricula by Wolfe and Blanchett (2003)
Health and Hygiene
Gender differences, maturation
Everyday and sexual hygiene
Health and wellness
Masturbation
Body and disease
STD and HIV prevention
Birth control
Based on a review of curricula by Wolfe and Blanchett (2003)
Hellemans et al. (2007)
Sexuality education in some form is important for everyone, living with or without a specific disability, in order to acquire sufficient and appropriate knowledge and skills required for developing into a healthy adult with a positive sexual identity and satisfying relationships. A possible categorization of focus, based on the work of Wolfe and Blanchett (2003) suggest a wide range of potential target skills to be taught during sexuality curriculum.

54. Based on a review of curricula by Wolfe and Blanchett (2003)
Relationship Skills
Friendship and intimacy
Responsibility to (sexual) partner
Family types and roles
Feelings and expression
Dating and Marriage
Parenting
Sexual Orientation
Based on a review of curricula by Wolfe and Blanchett (2003)
Hellemans et al. (2007)

55. Self-Protection/Self-Advocacy Skills
Protection against abuse
Sexual feelings
Sexuality as a positive aspect of self
Sexual behaviors other than intercourse
Appropriate/inappropriate touching
Appropriate/inappropriate public/private behaviors
Decision making
Use of condoms
Reduction of fear and myths
Personal rights
Sexual discrimination
Saying “no” to nonconsensual sex and high-risk behaviors
Based on a review of curricula by Wolfe and Blanchett (2003)
Hellemans et al. (2007)

56. OTHER POSSIBLE TREATMENT TOPICS
Sexual consent issues
Understanding the abusive sexual behavior
Understanding the impact on others
Negotiating safe and respectful sexual behaviors
Identifying and managing risk

57. ADDRESSING SEXUAL BEHAVIOR
Do NOT Extinguish a Sexualized Behavior, without having a Replacement Behavior.
Replacement strategies
Need to be simple, easily implemented, and without negative repercussions
May involve both sexual and nonsexual behavior
Involve activities and behaviors that can meet the same perceived needs as the sexual behavior
Need to be fun, playful, safe, and without secrets or shame
Need to feel good and be something that can be enjoyed time and time again
Teaching needs to involve concrete examples and props that are as close to reality as ethically possible – condoms, appropriate oils or other lubricants, synthetic vaginas, synthetic penises, nonpornographic sex education videos, life-size dolls, and other reality-based items.

58. EXAMPLE SCRIPT OF A REPLACEMENT BEHAVIOR FOR PUBLIC MASTURBATION
Instructors should teach appropriate times and places regarding masturbation. The following intervention can be given to a person supervising an individual with autism:
1. Interrupt the behavior.
2. Remind the person of the appropriate place and time for the behavior.
3. Redirect the person to another activity or to an activity that requires the use of both hands.
4. Redirect the person to an activity that involves intense focus or high amounts of physical movement.
5. Redirect the person to an appropriate place to have privacy, such as a bathroom, shower, or private bedroom.
6. Reinforce staying in assigned areas and taking breaks as scheduled, to decrease the likelihood that excessive breaks or trips to the bathroom will occur, and
7. Provide visual evidence of scheduled breaks or private leisure time, so the person can anticipate and plan for personal needs.
Koller (2000)

59. Intervention Ideas for Specialized Treatment with Adolescents with Developmental Disabilities

60. What are Social Stories?
A Social Story is a short story with specific characteristics that describes a social situation, concept, or social skill using a format that is meaningful for persons with developmental disabilities.
Social Stories were originally developed by Carol Gray to teach children with autism how to play games with peers, with the aim to increase their ability to interact socially with others.
It is a popular trend in special education to use Social Stories or scripts to teach appropriate social skills and behaviors to children and youth having autism or related disorders on the spectrum.

61. Social Story Guidelines
Gray has outlined some specific formal aspects and guidelines for constructing Social Stories:
Perspective of the child for whom the story is written should always be adopted and maintained.
Stories are typically written in the first person singular.
Behavioral responses should be stated in positive terms (e.g., I am going to use my low voice.)
Words and/or images can be used to complement the relative visual processing strengths.

62. Basic Sentence Types Used in Social Stories
Descriptive: Describes the social situation in terms of relevant social cues.
Directive: Describes the appropriate behavioral response.
Perspective: Describes the feelings, and/or responses of the student or of others in the situation.
Affirmative: Expresses a commonly shared value or opinion within a given culture or community.
Control: Written from the perspective of a person having autism/PDD, cueing how and when to identify personal strategies to recall and to use
Cooperative: Describes what others will do to assist the student.
Social Stories can be used in a general way to prepare students for changes and unusual situations as a part of going through future stages of sexual development, or they can be written in reaction to evolved problematic situations to offer the student a solution.

63. Borrowed from Tarnai & Wolfe (2008)
Sample Social Stories
“My name is James. Sometimes, I think about sex and private areas. It’s okay to think about sex and private areas. I will try to keep my thoughts to myself. This is very important. I may ask my mom or dad a question if I’m confused” (p. 34).
Borrowed from Tarnai & Wolfe (2008)
An example of a general socio-sexual usage of Social Stories may include statements:

64. Borrowed from Tarnai & Wolfe (2008)
Sample Social Stories
“My name is Amanda. I am 13. My body is growing and changing. My mom knows about growing up. Sometimes, girls get breasts when they are 13. Soon, I will have breasts too. Most women wear bras to hold and cover their breasts. This is a good thing to do. I will wear a bra. If I forget to wear a bra, my mom may remind me before I go to school. Wearing a bra is a part of growing up” (p. 34).
Borrowed from Tarnai & Wolfe (2008)

65. Example of a Social Story that is Situation Specific
“It is okay to have an erection or a “hard-on” while at school. When this happens, I will ask the teacher to be excused to use the bathroom. I will not talk to others about my erection. I know that this is a private thing and it is natural. Erections happen to all boys at some time.”
Gray emphasizes that they student’s comprehension of the story should be checked before proceeding to skill practice of the story. This can be done either in a written or spoken questions and answer format, with comprehension checklist, or by letting the person fill in a version of the story that has blanks. The target social skill can then be practiced in relevant real-life contexts and situations. Gray suggests that social stories first be read in close proximity to a situation where the person is likely to need to use the target skill. Then depending on the progress made, the reading of the story becomes less frequent, and parts can be faded out, until the target behavior becomes a routine of the person’s repertoire.

66. Based on Analysis by Barry & Burlew (2004) and Reynhout & Carter (2006)
Evidence-Based Good Instructional Practices
Corresponding Components of Social Stories Interventions
Explicit Teaching and Demonstration
Task analysis; modeling; cueing; comprehension check; feedback
Explicit Instruction and Drill-practice of Basic Skills
Task analysis with repetition and review
Extensive Active Practice
Practice with corrective feedback
Opportunities to Learn/Practice
Fading with tangible cues
Guided Practice with Feedback
Maintenance/generalization training
Small steps, and practice of each step
Visual Aids/schedules; systematic practice
Organizing Questions for review
Reviewing questions for check of comprehension
Graphic Organizers
Visual Aids (words, images, and schedule
Independently useable/accessible Strategy
Social story is a permanent product, and it has embedded pictorial cues/schedules
The components of Social Stories incorporate instructional tools that are empirically established good practices in special education, and specifically, in interventions for autism. In fact, most components of social stories interventions are suggested for implementation by experts are well known from the literature on explicit teaching, and use of strategies including, task analysis, presentation and practice of small explicit steps, visual aids and graphic organizers, modeling, review and guided practice, corrective feedback, independently accessible reminders and procedural facilitators, and numerous opportunities to practice in both training and general environments for skill maintenance and generalization.

67. Examples of interventions
Increase Positive Behavior and Decrease Negative Behavior
Old Me/New Me
Making Healthy Choices and Thinking About the Consequences
SODA – Stop, Options, Decide, Act
Managing Risk
Danger zones
Thinking Errors and Self-Talk
Thinking errors with pictures

68. RESOURCES: ONLINE and PAPER
See Handout

69. Final Thoughts
Diagnosis may be the same but clients may present very differently
Some people have expressed concern that providing sexual information to certain clients who experience developmental delays pose risks to the community – risk is more if we fail to provide appropriate sexual education.
Necessary to provide education concerning the need for sexual education to guardians or other care providers – if we don’t teach them they will make efforts to teach themselves
Patient and appropriately paced sexual education can prevent problem behaviors from developing.
Use every moment as a teaching moment
The client may not know that a behavior is ineffective or inappropriate. Model for them and explain clearly and specifically what behavior is expected and acceptable.

70. “Don’t label it as ‘They can’t learn’ – Think of it as ‘We haven’t figured out how to teach them yet.’”

71. QUESTIONS? Have other strategies worked for you?

72. CONTACT INFORMATION:
Kristina Osborne-Oliver, Psy.D., NCSP
Katrina Emmerich, Psy.D.
Jennifer Brooks, Psy.D.
Tylea Gebbie, MS., CAS