1. Clinical Issues in the Treatment of Adolescents Who Have Engaged in Sexually Abusive Behavior and the DJJ Treatment Model May 9, 2014

2. 2 WELCOME Topics for discussion: Traditional treatment model Current research DJJ SBTP structure and components Measuring impact

3. What People Imagine When They Hear “Sex Offender”

4. But who are they really?

5. Still providing treatment sometimes feels like….

6. Juvenile and Young Adults vs. Adults 6 Traditionally put into 1 category A wide body of knowledge clearly shows that these groups are dramatically different. Research now promotes the need to approach treatment with juveniles differently.

7. 7 Traditional Treatment Approach Use of “cookie cutter” treatment from adult model. Family therapy and possible reunification was not advised. Success was solely the responsibility of the youth. Little focus on healthy living models. Lack of treatment resources to address individual treatment issues.

8. 8 CBT-based models continue to have evidence of effectiveness. Evidence that use of motivational techniques are effective to help with engagement. 3 factors are significant indicators of successful outcomes: 1) Therapeutic intervention philosophy 2) Serving high risk offenders 3) Quality of implementation (i.e., standardization, fidelity) What We Know Today

9. 9 Interventions that quickly bring behavior under control have greatest potential for efficacy. Interpersonal skill development through CBT is effective in addressing sexual behavior problems. Interventions during teen years have greatest impact since this is highest risk time.

10. Evidenced Based Practice for Juveniles Research is “weak” in the area of juveniles. No comprehensively defined EBT currently exists specifically for JSO, yet several E-B components have been identified for juveniles. Family work appears to be the most important to help reduce delinquency and sexual aggression. Mentoring has shown moderate effects especially in the areas of school, drugs and some aggression.

11. Using what we know about Juveniles Sexual recidivism rates between 7-14% General recidivism rate 53% Offense specific treatment lowers recidivism BUT need to fill in the gaps.

12. Using what we know about Juveniles Confrontational styles not as effective. Therapeutic relationship important to developing a trusting environment for disclosure. Treatment should target skill development, not focus solely on discussing the offense. Offense specific issues can be addressed individually.

13. 13 Understanding Adolescence “” Youth are heated by Nature as Drunken men by wind.” Aristotle “I would that there were no age between 10 and 23, for there’s nothing in between but getting wenches with child, wrongdoing the ancestry, stealing, fighting…” Shakespeare

14. 14 Abstract thinking and reasoning are developing Developing social and emotional skills Evolving attitudes and beliefs Shorter attention spans Greater impulsivity Self-focus and narcissism are developmentally normal More dependent on their social environment Traumatic effects of maltreatment may be immediate Maltreatment may be ongoing Adolescent Development

15. 15 Adolescent Development Adolescent brain development plays significant role in offending behaviors—impulsivity and differential perceptions of risk-reward. Sexual deviance & ingrained sexual behavior patterns inconsistent with adolescent development research. Criminal behavior peaks at 15-17 yrs.

16. 16 Offenses more opportunistic, less “predatory”. Arousal patterns appear less set. Motivations of juveniles may be more curiosity based, related to social problems, less due to compulsivity or cycle patterns. Adolescent Development

17. 17 Cognitive Brain Social Moral Sexual Development Factors

18. 18 Youth in early stages of development are not capable of complex planning. Difficulty understanding perspective of others. Limited coping strategies. Cognitive Development

19.  Increasing capacity for abstract thought.  Expanding intellectual interests.  Mostly interested in the present with limited thought to the future.  As youth approach 18 and older they begin to develop the ability for moral reasoning, have thoughts about the meaning of life, and are more able to delay gratification.

20. Brain Development It is no accident that insurance rates are reduced for youth when they turn 25 years old. The brain has not completed full maturity until around the age of 25 or later.

21. 21 Brain Development 3 major regions – brain stem, limbic and cortex. Frontal lobes, essential to problem solving and reasoning and the inhibition of emotion and behavior are not fully developed until early adulthood.

22. Brain Development and Risk Taking  Juveniles have a greater tolerance than adults for ambiguous or unknown risks.

23. Brain Development and Risk Taking Youth will more likely make decisions based on perceived benefits, particularly social rewards, than on negative consequences.

24. Theories on Risk Taking: All Drive and No Brakes Increased need for risk taking in breaking away from parents. May be caused by immature connections between the limbic system (the emotional driver) and the pre-frontal cortex (the brakes). Teens have more difficulty making up their minds as compared to adults.

25. Teaching the Remodeling Brain With the right rewards, youth will spend more time attempting to make the right decision. It has been shown that young adolescents use more of their pre-frontal cortex to a greater extent when evaluating positive performance feedback. Older adolescents have been shown to use more of the pre-frontal cortex during negative performance feedback.

26. Teaching the Remodeling Brain Help youth understand their shifting emotions and mood swings. Educate them about the changes that are happening in their brains. Ask open ended questions to allow them to talk about their feelings. Help them to understand how others may be feeling as they shift from self-focused to other focused.

27. Encouraging Pre-Frontal Cortex Development Help youth create written or visual systems to manage their time and organize tasks. Use interactive exercises such as role play, forced choice scenarios, and value discussions. Incorporate physical activities to emphasize learning.

28. Encouraging Pre-Frontal Cortex Development Give youth concrete examples and utilize more abstract thinking as they mature. Use visual aids whenever possible to assist in creating connections in the brain.

29. 29 Studies show both structural and functional neurological differences between traumatized and non-traumatized individuals. Effects depend on age trauma occurred, frequency of traumatic exposure and availability of caregivers to provide supportive resources. Base-line changes in resting heart rate for individuals with significant trauma experiences. Brain Development and Trauma

30. 30 So What Does This Mean This impacts: Emotions and attitudes towards self and others Attachment - unable to trust self and environment Moral perceptions - right/wrong is skewed/distorted Thinking and behaviors - socially and sexually Decision making and problem solving

31. 31 So What Does This Mean Youth will have: Greater difficulty analyzing their own behavior and behavior of others. Greater risk of demonstrating anger and depression. Decreased ability to develop coping skills. Increases in mood shifts and reduced emotional balance. Difficulty learning and processing information in situations that are emotionally charged. Right and persistent thinking/attitudes/beliefs despite negative results.

32. 32 Relationship to caregiver affects the development of emotional regulation. Trauma/neglect impact the ability to develop positive relationships and ways to deal with intimacy and loneliness. Healthy vs. unhealthy attachment to others Social Development

33. Social-Emotional Development  Struggle with sense of identity  Feel awkward about one’s self and one’s body  Increasing conflict with parents  Shift from parent focus to peer focus  Increased moodiness  Tendency to return to ‘childish’ behavior when stressed

34. 34 Preschool to middle school involves learning to follow rules, avoid punishment, and learn to be obedient. Adolescents/young adults involves a desire to do greatest good to greatest number of people, adherence to self chosen ethical principles. Adolescents very good at pointing out hypocrisy. Moral

35. 35 Sexual Development The stages of sexual development coincide with social, moral, cognitive, and attachment development. Trauma/neglect impact the natural development of sexuality. Sexual behavior can become used as way of coping and self-soothing.

36. Sexual Development Tradition model of avoidance is not appropriate. Sexual behavior should be assessed in the context of “normal” sexual development. Important to normalize appropriate sexual thoughts and behavior. Creating an treatment environment that allows for discussions about appropriate sexual behavior is key in helping youth develop healthy sexual identities and behaviors. 36

37. Sexual Development What is “normal”? YouTube Generation Internet and smart phones = 24/7 access 37

38. Research and Risk Our understanding of how adolescents and adults differ should play an important role in how we assess risk to reoffend.

39. 39 What is it - sexual vs. non-sexual Why it is important to treatment High, moderate and low risk Understanding Risk

40. Risk Prediction relies on “static” factors Goal: predicting violent behavior Risk Management relies on “dynamic” factors Goal: determining what increases or reduces an existing or preexisting condition Understanding Risk

41. Adolescents are moving targets when it comes to predicting risk. A comprehensive assessment is necessary when trying to determine risk. Limitations should be addressed and an “expiration date” provided. Risk factors vary in the course of development for an adolescent. Therefore, what was a risk at age 14 may not be a risk at age 16. Protective factors play an important role when looking at the complete picture of risk. Understanding Risk

42. 42 Typically, the younger the individual, the more important dynamic risk factors are and the less important static risk factors. Risk factors do not operate in isolation, they are complexly interactive. The more “dynamic” the risk picture, the harder it is to predict - education, treatment, family, social, trauma impact etc. Understanding Risk

43. Prior convicted sexual offenses Multiple victims Stranger victims Prior treatment failure Static Risks to Reoffend

44. Deviant sexual interest Sexual preoccupation/obsession Environments supportive of reoffending. (2012) Attitudes supportive of offending* Social Isolation Difficulties establishing peer relationships Family dysfunction Dynamic Risks to Reoffend

45. Prior legally charged offenses Family functioning School achievement and behavior Negative peer relationships Substance use and abuse Use of recreation time Antisocial/pro-criminal attitudes Out of home placements General Risks to Reoffend

46. Denial Victim empathy General psychological problems Factors Not Likely Related to Reoffending

47. Protective Factors Having strong attachments and bonds Good self-regulations and impulse control Positive self-perception Self-efficacy Connections to pro-social peers Connections to pro-social environments

48. 48 There are several important considerations research has shown should be taken when treating youth who sexually offend. Therefore…

49. 49 A Holistic Treatment Approach

50. Developing a “Whole” Person Treatment Approach Confrontational styles not effective. Therapeutic relationship important in developing a trusting environment for disclosure. Treatment focused on helping youth develop skills to become a healthy adult, not solely on discussing the offense.

51. Understanding that the youth is still developing as a person. Normalize developmentally appropriate behavior. Recognizing the positive strengths of youth to help them through the program. Treatment

52. 52 Dialogue with youth about motivation and change. Developing dialogue with individuals’ environment, family, community. Assessing and strengthening emotional regulation is important for success. Treatment

53. Recognize trauma exists and understand how it impacts beliefs, thinking, attitudes, feelings, behaviors, learning, attachment and interpersonal skills. Provide environment where trust can be established to explore the impact traumas. Treatment

54. Cognitive behavioral Skills based Forward focused Family Involvement Focus on dynamic risk Treatment Components

55. Attitudes and justifications supportive of offending Emotional Management Social Competence/Relationship skills Healthy Sexuality Ability to establish peer relationships Treatment Targets

56. General self-management skills Family Education/Functioning Sexual Deviation or Sexual Preoccupation (if applicable) Development of Positive Life Goals Individualized Issues as Needed Treatment Targets

57. 57 Letting go of past practice in order to embrace what we now know. Future-focus & new coping skill development maintains center stage. Treatment is less focused on sexual offending and more focused on intra- and interpersonal development. Adult treatment is emphasized for specialized needs. What Does This Mean?

58. 58 The DJJ Treatment Model

59. 59 Entrance and exit criteria Program structure and guidelines SBTP staff orientation packet SBTP youth orientation packet Quality assurance criteria Adjunct treatment services Program Guide

60. 60 Program Overview Clinical Framework: CBT-Based Treatment Risk-Need-Responsivity Framework Strengths-Based, Forward-Focused Orientation Developmentally-sequenced stage work Group work designed to leverage influential factors throughout process. Addresses multiple learning styles & promotes individual creativity/autonomy. Treatment Continuity: Interplay of thoughts, behaviors, & affect Good Life Plan and Re-Entry Planning Healthy Living

61. 61 SBTP Orientation/Transition Unit SBTP Orientation Cases on Appeal “One Step Forward” Program Transition Peer Mentors

62. 62 SBTP Orientation Major Components

63. 63 Pretest- Posttest Dynamic Risk Functional Ability Substance Use Trauma Social Support Academic Performance Academic Outcome SBTP Standardized Assessment

64. 64 Comprehensive SBTP assessment Re-assessment Post assessment Assessments

65. 65 J-SORRAT-II STATIC 99R J-SOAP-II Structured Risk Assessment Forensic Version (SRA-FV) STABLE/ACUTE 2007 Risk Assessment Tools

66. ERASOR Version 2.0 (Estimate of Risk of Adolescent Sex Offender Recidivism) Assessment Tools

67. Viljoen et al (2012): Found all juvenile instruments were adequate in that those with higher scores tended to re- offend more than those with lower scores. (64- 67%) However, no ONE risk factor predicted who would sexually reoffend. Assessment Tools

68. 68 Case Conceptualization Assessment Youth Version:Adult Version: Substance Abuse Subtle Screening Inventory – Adolescent 2 Substance Abuse Subtle Screening Inventory Juvenile Sex Offender Assessment Protocol II / JSORRAT II Structured Risk Assessment- Forensic Version Light/ Static 99 Child and Adolescent Functional Assessment Scale Global Assessment of Functioning Trauma Symptom InventoryTrauma Symptom Checklist-40 CA-YASI

69. Good Lives Assessment and Plan Good Lives Theory: Normalize the desire for the need and develop healthy skills to obtain them. Strength based approach Good Lives vs. Relapse “Red Thread” Assignment for SBTP

70. Good Lives Plan: Six Needs Life: Having basic needs met; caring for physical health, safety. Knowledge: Feeling that you have sufficient information and understanding of yourself and the world. Friendship: Having close connections to family, peers, romantic partners or other individuals. 70

71. Good Lives Plan: Six Needs Community: Possessing a sense of belonging to a larger group of individuals with shared interests. Happiness: Overall feeling of contentment with life. Creativity: Having the ability to express self in unique ways that bring meaning. 71

72. Good Lives Plan Assignment Orientation Stage One Stage Four Stage Six 72

73. 73 Healthy Living Curriculum Unit One: Orientation Multiple Intelligence Assessment of sexual beliefs (pre-post test) Unit Two: Physiological Development Stages of development (prenatal–death) Normal brain development

74. 74 Healthy Living Curriculum Unit Three: Psycho-Social Development Adolescent Development 1. Establishing identity 2. Establishing autonomy 3. Establishing intimacy 4. Accepting your sexuality 5. Achievement Five Parts of Human Sexuality 1. Sexualization 2. Sensuality 3. Intimacy 4. Sexual Identity 5. Sexual Health and Reproduction Unit Four: Healthy Communication 3 parts of face to face communication 3 basic communication styles Can you hear me?

75. 75 Healthy Living Curriculum Unit Five: Non-Sexual Relationships Components of a strong relationship Create a sociogram Unit Six: Trauma and Development Learn the definition of trauma How trauma affects brain development

76. 76 Healthy Living Curriculum Unit Seven: Healthy Sexuality 4 R’s of Sexuality 1. Respect 2. Responsibility 3. Recognition 4. Relationship What is healthy sexuality Unit Eight: Myths, Facts and Sexual Health Correctly name male and female body parts STD’s symptoms and treatment Contraception

77. 77 Healthy Living Curriculum Unit Nine – Sexuality and the Law Sexual Harassment DJJ’s Sexual Harassment Policy Megan’s Law Jessica’s Law Unit Ten – Bringing it all together Summary Babe and activity

78. 78 The SBTP recognizes the importance of youth and family involvement in enhancing the youth’s rehabilitation and treatment outcomes A youth’s inability to have a healthy relationship is one of the biggest risks for re-offense Family Involvement

79. 79 Contact begins at Orientation Unit. Specific procedures for family reunification. Goal for SBTP is to have at least 1 family/support member engaged in the youth’s treatment at all times. Family Involvement

80. 80 Family/Support During Orientation 1) Early Identification and Engagement Clinician completes Parent Assessment form. Youth identifies support individual during initial case conference. Collaborative effort of staff to help youth identify a support member. Youth fills out family/support survey consent form.

81. 81 Residential Sexual Behavior Treatment Program

82. 82 Major Program Components Stage Work Resource Groups Ind/Family Therapy Embedded Journaling Plant/Pet Care Family Support Video Rap Series Biblio- Therapy Re-Entry Planning Integrated SA Tx. Mental Health Tx. Outcomes Evaluation

83. 83 Residential Program Provides an intense therapeutic community and various services including: Individual treatment based on risk of recidivism and offense dynamics Specific abusive/offending sexual behavior treatment Psycho-educational and clinical resource groups Individual and family counseling Frequent re-assessment of dynamic sexual offending risk factors, including both criminogenic factors and protective factors that are on going

84. TREATMENT STAGES Orientation1: Autobiography 2: Responsibility & Accountability 3: Attachment, Loss, & Early Connections 4 : Behavior Patterns & Restorative Justice 5: Effective Decision- Making 6: Re-Entry Planning & Good Life 7: Moving On

85. About the Stage Primary Purpose, Major Objectives & Major Components Facilitator Grid for Facilitated Exercises Projected Timeframe for Completion Number of Hours of Homework Integrated Interactive Journal Work Red Flags Suggested Activities Group Work Expected Affect and Behavior Evaluation of Stage Work Treatment Team Authorization Standardization Of Stage Work

86. Detailed instructions throughout to guide youth and prompt youth when staff involvement is needed Illustrative vignettes to promote increased understanding Attempts to be inclusive through representations in pictures, vignettes, books, films Projected number of homework hours indicated per stage—use as broad gauge 2 nd to 9 th grade reading levels Interactive Journal work embedded throughout stage work Learning objectives and exercise checklist provided Exercises: Facilitated, Reviewed, Debriefed with a Treatment Team member, or completed independently Youth Manual & Youth Activities

87. All-Inclusive Treatment Guide Format Instructions for Use & Symbol Key (review symbol key) Facilitator Instructions Embedded Youth Manual Group-Guided Stage Work Activities (embedded) Appendices Experiential Group Activities Section Biblio-Therapy Curriculum Section Video-Therapy Curriculum Section Family Forum Guide Section Resource Group Curriculum Section Outcomes Evaluation Section Facilitator’s Manual

88. 88 Stage One: Autobiography Timeline Eco Map Genogram Delinquent, Sexual, SA, & Gang History Cultural Identity Connections Good Life Plan Re-Entry Plan

89. Stage Two: Responsibility and Accountability Good Life BARJ Self- Mgmt. Skills Thoughts, Feelings, Affect in Action Past experiences= opportunities for learning Personal Responsibility

90. Behavior Checks Starts in Stage Two continues until end of program. Youth should be working on two behavior checks at all times. Youth discuss success and struggles during groups and individual sessions. 90

91. 91 Stage Three: Attachment, Loss, and Early Connections

92. Interpersonal Checks Starts in Stage Three continues until end of program. Youth should be working on two behavior checks at all times. Youth discuss success and struggles during groups and individual sessions. 92

93. Stage Four: Behavioral Patterns &Restorative Justice Behavioral Work Victim Awareness Restorative Justice Progress Report

94. 94 Stage Four Progress Report Behavior Change Progress Report Good Life Plan Progress Report Re-Entry Plan Progress Report Youth summarizes and presents the following: 1. What have you learned about yourself so far in terms of how you think, feel and behave. 2. What have you learned about the way in which your thoughts, feelings, and behaviors are related to each other? 3. How you saw yourself when you first began treatment & now 4. What you will need to focus on now to ensure your long-term success in the program.

95. Stage Five: Effective Decision Making Faulty Messages/Faulty Language (REBT-based work) New Decision-Making Skills Effective Decision- Making Old Me/New Me Challenging/ Disputing How I See Me

96. 96 Stage Six: Re-Entry Planning & Achieving My Good Life

97. 97 Stage Seven: Moving On

98. 98 Resource Groups

99. 99 SBTP Core Resource Groups 1. Orientation Resource Group: Introduction to the SBTP 2. Skill of the Week 3. Express Yourself 4. Moods Matter 5. Restorative Justice

100. 100 SBTP Specialized Resource Groups 1. Substance Abuse Treatment 2. Anger Control Training (ACT) 3. Criminal Thinking Errors 4. Surviving Trauma 5. Interpersonal Skills and Development

101. 101 Incorporated into stage group sessions as prescribed or needed Diversity of experiential type activities Developed for repeat use 7 primary themes consistent w/SBTP model Promotes continuity of treatment through reinforcement Experiential Group Activities

102. 102 Experiential Group Exercises 1. Popping Gender Messages 2. Feeling Charades 3. My Strengths/Your Strengths 4. Taking Control of Peer Pressure 5. Not Letting Negative Peers Control Us 6. Hot Topics 7. The Power of Group

103. 103 Plant and Pet Care Starts at Stage 3 Responsibility of care is progressive

104. 104 Use of stories/reading to promote increased understanding of key issues Addresses universality & provides alternative narratives Personal accounts or stories that highlight significant relevant messages and/or lessons Selection Criteria: Relevance of central issue & potential ability to relate to major characters Readability based on broad range of developmental levels Appropriateness of content and language Biblio-Therapy Curriculum

105. 105 Gifted Hands: The Ben Carson Story (autobiographical; overcoming odds and achieving significant personal success through work There are no Children Here: The Story of Two Boys Growing up in the Other America (family survival through violence and tough times) Out of the Madness (autobiographical; parental addiction; youth survival) Med Head: My Knock Down, Drag Out, Drugged Up Battle with my Brain (biographical; adolescent mental health issues) Across the Wire: Life and Hard Times on the Mexican Border (immigration, poverty) Always Running : (autobiographical; gang culture; breaking free from gang life) Books

106. 106  Built on same premises as Biblio-Therapy using film as the medium  Intended for large group, can be used in small groups, as needed Selection Criteria  Relevance of central issue  Relevance/potential ability to relate to major characters  Appropriateness of content and language  Diversity of overall selections Video-Therapy

107. 107 Antoine Fisher The Blind Side Coach Carter Freedom Writers Glory Road Hoop Dreams Pay It Forward The Pursuit of Happyness Remember the Titans Stand and Deliver Films

108. 108 Family/Support During Residential Family forums Family Counseling

109. 109 SBTP Family Forums  Each youth has at least 1 participant  Co-facilitated by 2 members of Treatment Team  Information dissemination & facilitated discussion,  Time for informal discussions among participants and shared meal  Promote engagement throughout treatment.  Aid re-entry planning  Promote broader support networks among clients/supports

110. 110 Family Forum Guide Topics 1. Family and/or Support Orientation to Treatment 2. Support & Nurturing: Building Healthy Relationships 3. The Legal System and Legal Issues related to Sexual Behaviors 4. Building Bridges from Within: The Power of Social Support & Dealing with Stigma 5. Re-Entry Planning: Preparing for a Successful Future 6. A Celebration of Support: Facilitated Discussion, Open Forum, and Luncheon 7. Family/Support Topic Choice

111. 111 Multi-systemic therapy works Family Counseling Reduces parent and youth denial about offense Removes barriers to effective parenting Enhances parenting knowledge Promotes affection and communication among family members

112. 112 Most Importantly Conjoint work with family members and other appropriate persons in the youth’s social ecology is essential in the development of plans for risk reduction, relapse prevention and victim’s safety.

113. 113 Provides different levels of treatment for those who completed SBTP and for whom the Core Program is not appropriate Focuses on probation preparation Mentors for Orientation Unit Transition

114. 114 Specialized Versions Spanish versions of youth manual Spanish version of books Use of Spanish sub-titles

115. 115 SBTP Outcome Measures  Major/Primary Outcomes 1. Sexual recidivism = data from those released 2. Non-Sexual recidivism = data from those released 3. Dynamic Risk (J-SOAP/SRA-FVL & CA-YASI) = orientation, six months, completion 4. Functional Ability (CAFAS/GAF) = orientation, three months, completion 5. Trauma = orientation, following trauma treatment, completion 6. Substance Abuse* = orientation, following substance abuse treatment, completion 7. Social Support Network = initial engagement and sustained participation (at least 6 months)

116. 116 SBTP Outcome Measures Secondary Outcomes 1. Academic Performance = pre DJJ GPA, 2 nd period GPA, completion GPA 2. Academic Outcomes = Completion of GED or diploma 3. Therapeutic Alliance = Helping Alliance questionnaire II, 6 months Other Data Points 1. Youth Surveys 2. Family Surveys 3. Compliance/Audit Tool

117. Resources Neari Press: www.nearipress.orgwww.nearipress.org Safer Society Press: www.safersociety.orgwww.safersociety.org Ethnicity and Family Therapy 3 rd Edition 2005 McGoldrick, M., Giordano, J.& Garcia Preto, N. Current Perspectives: Robert E. Longo & David Prescott Current Applications: Robert E. Longo & David Prescott

118. 118 Additional Questions

119. 119 THANK YOU!