Presentation on theme: "Dr. Kristina Osborne-Oliver, Psy.D., NCSP Dr. Katrina Emmerich, Psy.D."— Presentation transcript:
1ADDRESSING SEXUAL BEHAVIORS OF ADOLESCENTS WITH DEVELOPMENTAL DISABILITIES Dr. Kristina Osborne-Oliver, Psy.D., NCSPDr. Katrina Emmerich, Psy.D.Dr. Jennifer Brooks, Psy.D.Tylea S. Gebbie, MS, CASSt. Anne Institute, Albany, NYPresentation Prepared forNYSATSA 2010 ConferenceMay 4, 2010
2Agenda: Topics to Be Covered Introduction and Definitions of Developmental DisabilitiesAutism Spectrum Disorders, Intellectual Disabilities, & Learning IssuesResearch on Observable Behaviors, Social Skill Deficits, and Sexualized BehaviorsTreatment Delivery: General StrategiesEvidenced-Based Specialized Treatments recommended for this populationPharmacologicalEducational/Behavioral ApproachesRecommendations of Targeted Social Skills within Sexual Education CurriculumSpecific Intervention Ideas for Therapy with Clients with Developmental DisabilitiesResource List
4DSM-IV-TR Diagnostic Criteria: Pervasive Developmental Disorders Pervasive Developmental Disorders (PDD)Asperger’s DisorderAutistic DisorderRett’s DisorderChildhood Disintegrative DisorderPervasive Developmental Disorder – Not Otherwise SpecifiedThe term “Autistic Spectrum Disorders” (ASD) is often used interchangeably with PDDOur presentation will focus on Asperger’s, Autistic, and Pervasive Developmental Disorder-Not Otherwise Specified as these areas have been the most widely researched.
5DSM-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 interaction2. Failure to develop peer relationships appropriate to developmental level3. Lack of spontaneous seeking to share enjoyment, interests, or achievements with other people4. Lack of social or emotional reciprocityA3. 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).
6DSM-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 focus2. Apparently inflexible adherence to specific, nonfunctional routines or rituals3. Stereotyped and repetitive motor mannerisms4. Persistent preoccupation with parts of objects3. Stereotyped and repetitive motor mannerisms (e.g., hand or finger flapping or twisting, or complex whole-body movements)
7DSM-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 languageE. 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).
8How 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 languageB. Individuals with adequate speech, marked impairment in the ability to initiate or sustain a conversation with othersC. Stereotyped and repetitive use of language or idiosyncratic languageD. Lack of varied, spontaneous make-believe play or social imitative play appropriate to developmental levelThere 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).
9DSM-IV-TR Diagnostic Criteria: Pervasive Developmental Disorder-Not Otherwise Specified (PDD-NOS) Severe and pervasive impairment in the development of reciprocal social interactionAssociated with impairment in either verbal or nonverbal communication skills or with stereotyped behaviors, interests, and activitiesCriteria are not met for a specific Pervasive Developmental Disorder, Schizophrenia, Schizotypal Personality Disorder, or Avoidant Personality Disorder.
10Asperger’s Disorder: Social-Emotional Domain StrengthsCapable of learning social skillsMotivated to learn social skillsEncode social situations visuallyFollow the rulesAdult relationships/friendships may be establishedInnocence and honestyWeaknessesPoor social cognitionPoor appreciation of social cuesMinimal eye contact, affect/facial expression, showing/sharing, smilingInability to see from another’s perspectiveLack of social reciprocityFailure to develop peer relationshipsOverly sensitive to criticismMay become rigid/anxious under stressMay experience rage and/or depression
11Asperger’s Disorder: Cognitive Domain StrengthsNo clinically significant delay in cognitive developmentAverage, above average, or giftedExcellent rote memoryExcellent visual memoryConcrete thinkingGood long-term memoryGood reading mechanicsWeaknessesRigid thinking (one track mind)Difficulty shifting attentionPoor auditory processing skillsDifficulty with abstract thinkingProblems with organization/planningHyperlexia, comprehension, writing problemsFailure to generalize/transfer thinking/skills to other situationsRote Memory – Lists, rulesVisual Memory – Lists, rulesConcrete thinking – here and now; no hypotheticalsIntense interests (complex topics)Insistence on completion and perfection
12The nature of the client Why is it important to be familiar with Autism Spectrum Disorders (ASDs) when providing services to individuals?The nature of therapyVerbal vs. NonverbalAuditory vs. VisualThe nature of the clientThose who have been sexually abusedReactions to abuseGroup workThose who sexually act outVictim empathyThe 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.
13Definition 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 retardationChildren 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)
14DSM-IV-TR Diagnostic Criteria: Mental Retardation Significantly subaverage intellectual functioning: IQ of approximately 70 or below on individually administered IQ testConcurrent deficits or impairments in present adaptive functioning in at least two areasOnset before 18 years of age
16DSM-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 adulthoodPrevalence estimates range from 2-10% of the general population, and 5% of the school population
17Part 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)
18Common Cognitive Deficits Attention – the ability to tune in and concentratePerception – the ability to make sense of and understand informationMemory – the ability to acquire, hold, and retrieve informationComprehension – the ability to understand what is being saidExpression – the ability to communicateCoping with change – flexibility
19Why 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 offendingResearch has reported higher rates of abuse amongst people with IDFurey (1994) examined 461 cases of sexual abuse and found that 42% of abuse had been perpetrated by individuals with IDLess attention has been paid to young people with ID whose sexual behavior is problematicEvidence that LD is over-represented in services for sexual offendersIndividuals with LD are among the most challenging for services and practitioners
20Methodological Issues Inclusion criteria (IQ cut-off)At what point are individuals with ID expected to understand societal rules?Source of the sampleTypically drawn from hospitals, prisons, referrals to court, police stations, social and health service referralsOf 57,000 individuals assesses for the courts in New York, 2.5% had IDA study of individuals in hospitals found that 35% were diagnosed as having IDMethod of determining IDVariety of IQ testsVariety of methods for diagnosing IDScrutiny of records and history may vary
21Treatment Outcomes for Clients with LD Research suggests that there is a relationship between outcome and length of treatmentDay (1993) found a positive relationship between length of stay over 2 years and a better outcomeLindsay & 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 yearsVariables associated with recidivismAllowances made by staffAntisocial attitudePoor relationship with motherDenial of crimeSexual abuse in childhoodErratic attendancePoor response to treatmentLow self-esteemLack of assertivenessOffenses involving violence
22RESEARCH: WHAT WE KNOW ABOUT OUR CLIENTS WITH DEVELOPMENTAL DISABILITIES
23General Observable Behaviors of Clients with Developmental Disabilities Standing too close to someone during conversationStaring inappropriatelyLack of eye contactFlat or inappropriate facial expressionGetting ‘stuck’ on a particular topic during conversation‘Stimming’ behaviors such as rocking or hand- flapping
24Sexually-Related Behaviors of Clients with Developmental Disorders Research has found that individuals with developmental disabilities may display sexually inappropriate behavior, including:Masturbating in publicKissing strangersRemoving clothing in publicTouching others inappropriatelyTouching their own private areas in publicSexual fetishismAlthough 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
25Additional Information Regarding the Sexually-Related Behaviors of Clients with Developmental DisordersGreater tendency to sexually aggress:Lack of privacyMore impulsive --Often in Public SettingsNaiveté - Inability to understand normal sexual relationshipsMore likely to present with less serious or intrusive offenses resulting in serious bodily harm, violence, or deathMore likely to commit sex offenses across categories and be less discriminating in their victimsMore likely to commit sex offenses against younger children and male childrenSex 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.
26How Impairments Impact the Sexual Interactions of Clients with Developmental Disabilities Difficulties in the following areas:1. Forming effective relationships with peers2. Learning adaptive social behaviors in an unstructured fashion3. Reading social cues (both subtle and overt)4. Interpreting the other person’s feelings5. Taking another person’s perspective6. Being flexible in conversational topicsThose 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 pornographyCould mention Theory of mind specifically for Asperger’sThe 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?”
27Additional Hypotheses Regarding the Cause of Sexually Inappropriate Behavior Among Clients with Developmental DisabilitiesStructuralModelingBehavioralPartner SelectionInappropriate CourtshipSexual KnowledgePerpetual ArousalLearning HistoryMoral VacuumMedicalMedication Side-Effect
28Differentiating 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
29Sexual Victimization of Clients with Developmental Disabilities How could it happen?Social deficits may increase vulnerabilityMisinterpreting non-verbal cuesLanguage deficits may increase vulnerabilityMisunderstanding languageSome developmental disorders are co-morbid with anxiety and/or depressionThese symptoms may appear or worsen following a traumatic eventChildren with some developmental disabilities tend to be oversensitive to criticism.Self-blame may be particularly problematicSocial and language impairments may impact understanding of the abuse
30DELIVERY OF THERAPY SERVICES: GENERAL TREATMENT STRATEGIES
31Treatment Guidelines Treatment should be multidimensional Individual therapyGroup therapyClose involvement of caretakersSupportive framework to monitor and reinforce key messagesFocus on the control of elimination of abusive sexual behaviors by:Identifying positive goalsEnhancing social and relationship skillsPromoting life skills and phased community accessCreate a control plan or relapse prevention planCreate Risk Management GroupsMultidisciplinary team approachMake decisions regarding mobility, levels of supervision, and community accessConstituency may evolve as the young person’s circumstances change
32Structure of Therapy Sessions People with developmental disabilities do better when things are predictable and organizedTemporal supportsVisual timers, stopwatch, schedules, routinesProcedural supportsOutline the steps of an activitySpatial supportsProvide information about the location of objectsAssertion supportsHelp individual initiate and exert control such as in making choices and maintaining self-controlProvide them with a clear overview of the treatment process including the contents, frequency, duration, and place of the sessions and treatment
33Interventions with Clients with Developmental Disabilities Interventions should:Be consistently modeled and supported throughout the external environmentBe practical and success orientedBe at the client’s developmental levelBe created with and prompted by the clientHow will they benefit from the interventionIncreases motivation to participate in treatmentInvolve role-play and rehearsalGive the client something tangible to take with them once that skill is mastered
34General Therapy Considerations Engagement – show interest in the clients interests and perseverations and allow them to speak at length about themPay attention to the environment – reduce distracting noises, florescent lightingPraise success – help them to be mindful of their strengthsUse multiple modalities – journaling, story- writing, drawing, role-playsDeliver information at the client’s paceGive information in partsPlan breaks
35General Therapy Considerations Provide frequent repetition of conceptsTake time to find the motivation behind the behaviorExample: Unzipped flyAssist adolescents in generating and taking ownership of informationIn the past, fear of “giving the wrong answer” may have resulted in repeated failure and negative self-evaluationIf the client does not understand somethingDo the task with them – help them “connect the dots”Give hints – help point the waySay directions in a different way
36Language and Communication Clients with developmental disabilities may:Use the wrong terms or wordsMisuse time concept wordsConfuse sexes or persons in a sentenceParrot commonly used treatment termsTherefore:Clarify everythingAsk yourself – “Does the client really mean what they are saying?”
37Language and Communication Your use of verbal and non-verbal communication is very importantTherefore:Use communication that is clear, concrete, and specificBe concrete, not abstractAvoid the use of jargonCheck in frequently with the clientConvert therapeutic terms into plain language – define in simple termsDraw attention to non-verbal communication and use them as teaching momentsExample: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?”
38Information Processing Clients with developmental disabilities can be slow processors of informationTherefore:Not responding ≠ Being oppositionalGive them additional time to process what you have saidDo not yell or hurry themIf taking time to respond do not assume that they are filtering or editing their response
39GeneralizationClients with developmental disabilities have difficulty generalizing – taking what you have taught them in therapy and using it in real life situationsTherefore:Use concrete, vivid, and personalized examplesDo role-playsCreate scenarios that involve multiple settingsTake the client out in publicBest way to help a client to generalize
40Checking their Comprehension Clients with developmental disabilities may present as much higher functioning than they really areFor example - May nod their head or answer “yes” when you ask “do you understand?”Therefore:Talk in short, ten (at the most) word sentencesAsk the client to repeat what you have said in their own wordsAsk the client to give you an example, what they have learned, or how they will change their behavior next time
41Working with Clients in Groups Groups can be beneficial to clients with developmental disabilitiesProvides a safe environment for learningProvides practice in social skills and communicationNeed to ensure that the group is safe for all membersClients are vulnerable to being teased, bullied, or ridiculed by peersConflict, bullying, or misunderstanding between a client with a developmental disability and other group members can greatly damage group cohesion
42Working with Clients in Groups Strategies for increasing involvementKeep groups activewill retain more and increase interest in coming to groupMake sure the client walks away with something after every sessionFocus on simple themesIncorporate experiential modalitiesDrama/play, sand tray, art therapy, music, role play, storytelling, etc.Have them do something during groupWrite on the board, talking stick
43Working with Clients in Groups Role of the Group LeaderFacilitator may act as a ‘translator’ between these clients and the other group membersMay need to:Decode the non-verbals of other group members and explain themPoint out what might not be obviousInterpret what the client says to other group members if it is needed to prevent misunderstandings
45There 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 conditionThere is little research on community- based programs
46Psychopharmacological treatments Direct hormonal intervention to control urges by reducing the effect of sex hormonesTreatment of excessive MasturbationLupron (leuprolide), a synthetic nonpeptide analog of human gonadotropin-releasing hormone.Side effects of aggressive behaviorsIndirect intervention directed at comorbid conditions, such as aggression, impulsivity, and psychiatric disorders that may affect sexual disinhibition
47Psychopharmacological 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 ofExcessive masturbationSexual fetishismFurther, placebo-controlled, double-blind studies are needed regarding this topicSingle-case reports describe the efficacy of mirtazapine (Nguyen and Murphey, 2001; Albertini et al., 2006) in the treatment of excessive masturbationMirtazapine 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).
48Coskun et al (2009) Study5 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 irritabilityPatients 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.
50Cognitive-Behavioral Treatment Cognitive-Behavioral Treatment - increasing knowledge base and skill acquisitionBehavioral TargetsDaily living skillsGeneral interpersonal and educational skills (e.g., social skills, sex education)Specialized behavior skills relating to sexuality and offendingRelapse preventionCognitive TargetsEmbarrassmentDenialMinimizationProblems with self-esteemProblems with communicationAnger ManagementAdequate 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
51CONSIDERATIONS FOR SEXUAL EDUCATION IN TREATMENT Religious or cultural values of parents, caregivers, or educational staffMay warrant a same-sex teacherConsent needs to be obtained priorProvide it at the level of the client’s mental age level and capacity to learnDo not go beyond the client’s level of sexual interestMake the activities interesting, exciting, and fun (condom races)Use colorful charts/pictures, collages, art projects, interactive role plays, have fun!Start with the basicsLearn the minimum of the basics of anatomy, psychology, and safety (Gill & Hough, 2007).Masturbation (Cambridge et al., 2003)
52SOCIAL SKILLS COMPONENTS TARGETED IN SEXUALITY EDUCATION CURRICULUM
53Based on a review of curricula by Wolfe and Blanchett (2003) Health and HygieneGender differences, maturationEveryday and sexual hygieneHealth and wellnessMasturbationBody and diseaseSTD and HIV preventionBirth controlBased 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.
54Based on a review of curricula by Wolfe and Blanchett (2003) Relationship SkillsFriendship and intimacyResponsibility to (sexual) partnerFamily types and rolesFeelings and expressionDating and MarriageParentingSexual OrientationBased on a review of curricula by Wolfe and Blanchett (2003)Hellemans et al. (2007)
55Self-Protection/Self-Advocacy Skills Protection against abuseSexual feelingsSexuality as a positive aspect of selfSexual behaviors other than intercourseAppropriate/inappropriate touchingAppropriate/inappropriate public/private behaviorsDecision makingUse of condomsReduction of fear and mythsPersonal rightsSexual discriminationSaying “no” to nonconsensual sex and high-risk behaviorsBased on a review of curricula by Wolfe and Blanchett (2003)Hellemans et al. (2007)
56OTHER POSSIBLE TREATMENT TOPICS Sexual consent issuesUnderstanding the abusive sexual behaviorUnderstanding the impact on othersNegotiating safe and respectful sexual behaviorsIdentifying and managing risk
57ADDRESSING SEXUAL BEHAVIOR Do NOT Extinguish a Sexualized Behavior, without having a Replacement Behavior.Replacement strategiesNeed to be simple, easily implemented, and without negative repercussionsMay involve both sexual and nonsexual behaviorInvolve activities and behaviors that can meet the same perceived needs as the sexual behaviorNeed to be fun, playful, safe, and without secrets or shameNeed to feel good and be something that can be enjoyed time and time againTeaching 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.
58EXAMPLE 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, and7. Provide visual evidence of scheduled breaks or private leisure time, so the person can anticipate and plan for personal needs.Koller (2000)
59Intervention Ideas for Specialized Treatment with Adolescents with Developmental Disabilities
60What 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.
61Social 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.
62Basic 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 useCooperative: 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.
63Borrowed 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:
64Borrowed 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)
65Example 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.
66Based on Analysis by Barry & Burlew (2004) and Reynhout & Carter (2006) Evidence-Based Good Instructional PracticesCorresponding Components of Social Stories InterventionsExplicit Teaching and DemonstrationTask analysis; modeling; cueing; comprehension check; feedbackExplicit Instruction and Drill-practice of Basic SkillsTask analysis with repetition and reviewExtensive Active PracticePractice with corrective feedbackOpportunities to Learn/PracticeFading with tangible cuesGuided Practice with FeedbackMaintenance/generalization trainingSmall steps, and practice of each stepVisual Aids/schedules; systematic practiceOrganizing Questions for reviewReviewing questions for check of comprehensionGraphic OrganizersVisual Aids (words, images, and scheduleIndependently useable/accessible StrategySocial story is a permanent product, and it has embedded pictorial cues/schedulesThe 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.
67Examples of interventions Increase Positive Behavior and Decrease Negative BehaviorOld Me/New MeMaking Healthy Choices and Thinking About the ConsequencesSODA – Stop, Options, Decide, ActManaging RiskDanger zonesThinking Errors and Self-TalkThinking errors with pictures
69Final ThoughtsDiagnosis may be the same but clients may present very differentlySome 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 themselvesPatient and appropriately paced sexual education can prevent problem behaviors from developing.Use every moment as a teaching momentThe 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.’”
71QUESTIONS? Have other strategies worked for you?