Assessment of Inappropriate S exually H armful B ehaviour in P eople with IDD

1. Assessment of Inappropriate Sexually Harmful Behaviour in People with IDD Dr Lesley Steptoe, BSc, Dip Foren. Psychol, PhD, CPsychol, FBPS

2. Aim of today • Noted similarities between sex offenders with IDD and their mainstream counterparts • Psychometrics • Determining IDD • Characteristics of sex offenders with IDD • Several hypotheses for sexual offending in IDD • Assessment of sexual offending • Risk assessment – Actuarial, Structured Clinical Judgement and Dynamic assessments

3. A Challenge • Easy to assume that what suits one group relative to assessment and treatment should suit all • However • Methodological differences between studies and difficulties of standardisation of normative data for sex offenders with IDD provides challenge to this

4. Psychometrics • Assessment of: • Values and attitudes and beliefs • Emotional stability • Crucial to assessment of risk probability and protective factors • Assessment responses should be compared to normative data from the same population • Evaluate how close the responses are to the average for that client group

5. Aim of Assessment • Objective measurement of a particular psychological construct with accuracy and reliability for that client group • Lack of normative data for sex offenders with IDD in some assessments • Throws doubt on the reliability of the results

6. Intellectual and Developmental Disability (IDD) • Diagnostic and Statistical Manual 5th Edition (DSM V): • Full-scale IQ of less than 70 as measured by a reliable and valid test of intellectual functioning • At least two deficits of adaptive behaviour • Onset should be pre-18 years.

7. The Assessment Process • Relationship between level of intellectual functioning and level of difficulty within the understanding of the assessment process (Lindsay 2009) • Assessor should be sensitive to the need for adaptation throughout all aspects of client assessment

8. Wechsler Adult Intelligence Scale (Fourth Edition) - (WAIS IV UK) • Provides FSIQ and range • Four index ratings • Verbal Comprehension (VCI) • Perceptual Reasoning (PRI) • Working Memory (WMI) • Processing Speed (PSI)

9. Additional calculations • In certain cases sig differences between index ratings • General Ability Index (GAI) = (VCI + PRI) • Cognitive Proficiency Index (CPI) =(WMI + PSI) • FSIQ < 70 may indicate IDD but not definitive

10. Adaptive Behaviour • Ability to blend into society un-noticed • Personal independence • Social responsibility • Assessment of: • Communication • Social participation • Independent living • Deficits must be pervasive – home, leisure, work, school

11. Onset pre 18 • Self report re schooling – may not be accurate? • Collateral information from files and family- if available • All three criteria met – determine level of IDD • Remain aware of gains in neuro development relative to age – also of cognitive decline issues • Consider how level of intellectual functioning may impact on intervention process and risk management

12. Assessments to Determine IDD? Assessment of Intellectual Functioning: • Wechsler Adult Intelligence Scale IV edition (WAIS IV UK) Assessment of Adaptive Behaviour: • Vineland Scales of Adaptive Behaviour, (Sparrow, Balla & Cicchetti, 1984). • Adaptive Behaviour Scale: Residential and Community (Nihira et al. 1993)

13. Characteristics of SO’s with IDD Studies suggest higher incidence of: • Family psychopathology • Psychosocial deprivation • Behavioural disturbances at school • Higher prevalence of psychiatric illness • Higher prevalence of social and sexual naivety • Poor ability to form normal social and sexual relationships • Poor impulse control • Lower levels of conceptual/abstract reasoning.

14. Several Hypotheses • What are the underpinning drivers and maintenance factors for sexual offending behaviour in offenders with IDD? • Several hypotheses have emerged

15. Counterfeit Deviance • Lack of sexual knowledge rather than deviant sexual interest, poor social skills, limited opportunity to establish sexual relationships, sexual naivety • Higher levels of sexual knowledge in comparison to controls for sex offenders with IDD (Michie et al 2006) • SO’s with IDD – deviant sexual arousal and cognitive distortions noted (Murphy et al 1983)

16. Experiences of sexual abuse • Not all sex offenders with IDD have been sexually abused (Lindsay and Macleod 2001) • Not all individuals who have been sexually abused will go on to sexually abuse (Briggs & Hawkins 1996) • Comparison of 48 SO’s with IDD and 50 non sex offenders with IDD – 38% vs. 12.7% sexually abused (Lindsay et al 2000)

17. Mental illness • 47 male patients referred for antisocial sexual behaviour 32% had a Psychiatric diagnosis (Day 1994) • Lund (1990) Danish Criminal Register – 274 offenders with learning disability 20.9% had sexual offences – 91.7% had a diagnosis of mental illness (87.5% categorised as behavioural disorders). • Differences in classification of mental illness may account for discrepant results?

18. Impulsivity • Assumes SO’s with IDD are more impulsive than their non disabled counterparts • No difference in impulsivity between SO’s with IDD and non disabled counterparts (Parry & Lindsay 2003) • SO’s with IDD have been shown to demonstrate delayed gratification through display of simple grooming behaviours until an opportunity presents itself (Lindsay 2004)

19. Lack of Discrimination • Less discriminating in their victim choice • 68% of mixed group offenders have committed a sexual offence – 33% against adults, 28% against children, 18% indecent exposure (Scorzelli et al 1979) • Tend to have low specificity for age and gender of victims • Greater tendency to offend against male children and younger children (Blanchard et al 1999)

20. Empathy deficits • National study of sex offender treatment providers – 93% - development of victim empathy is important (Knopp & Stevenson 1989) • Many offenders demonstrate problems in perspective taking and empathy (Ward et al 1998) • Difficulties in understanding victims distress, impact on victim and wider circle of support (Wakeling and Webster 2007) • 349 offenders with IDD - ability to demonstrate empathy directly related to IQ (Joliffe & Farrington 2004)

21. No one size fits all • Hypotheses each have value • Over past 15 years could apply each hypotheses, either separately or combined, to various members of the Pathways to Progress psychological group therapy for sex offenders with IDD • So what should we assess relative to sexual offending behaviour?

22. Assessment of SO’s with IDD • Structured Risk Assessment (SRA) model (Thornton 2002) – helpful to structure the assessment process • Main dynamic risk factors fall into four domains • Sexual interests • Distorted attitudes • Social and emotional functioning • Self management

23. Sexual Interests • Sexual interests and sexual drive considered as primary motivators by many authors • Deviant sexual preferences in SO’s shown to determine those SO’s who show continuity of offence pathways (Craig Lindsay & Browne 2010)

24. Distorted Attitudes • Faulty thought processes about victims, sexuality or the offences, that serve to justify, sexual offending behaviour • Meta analysis (Hanson & Morton-Bourgon, 2005) - denial and minimisation unrelated to sexual recidivism while more general attitudes showing a general tolerance for sexual offending behaviour being associated with sexual recidivism.

25. Distorted Attitudes • Adapted Victim Empathy (Beckett & Fisher, 1994) • The Adapted Victim Consequences Task – adapted from the Victim Empathy Questionnaire (Bowers, Mann & Thornton, 1995) • Questionnaire on Attitudes Consistent with Sexual Offenders (QACSO) (Lindsay, Carson & Whitefield, 2000; Broxholme & Lindsay, 2003) • Abel and Becker Cognition Scale (Abel, Becker & Cunningham-Rathner,1984) • Sex Offences Self-Opinion Scale (SOSAS: Bray & Forshaw, 1996)

26. Social and Emotional Functioning • Attachment - Poor childhood attachment has been noted widely in sexual offenders’ histories • Family backgrounds typified by neglect, violence and disruption, with parents of adolescent sex offenders found to be rejecting, abusive or emotionally detached towards their children • Poor social skills, little understanding of relationship issues and a lack of empathy

27. Social and Emotional Functioning • Adapted Self Esteem Questionnaire – adapted version of Thornton’s Brief Self Esteem Scale (Thornton, Beech & Marshall, 2004) • Adapted Emotional Loneliness Scale – adapted from the Russell, Peplan and Cutrona’s (1980) UCLA Emotional Loneliness scale • Adapted Relationship Questionnaire –adapted version of the Relationship Questionnaire - Bartholomew, K. & Horowitz, L. M. (1991) adapted by (Steptoe, 2011) • The Nowicki-Strickland Internal-External Locus of Control Scale (Nowicki, 1976)

28. Self Regulation • Ability to plan, problem solve and regulate dysfunctional impulses that might lead down a pathway of sexual offending behaviour • Patterns of anti-social behaviour and impulsivity have been identified as precursors of sexual recidivism • Similarities between this concept and Factor 2 in the PCL-R (Hare, 1991) which has been found to predict sexual recidivism (Thornton 2002)

29. Self Regulation • Adapted Relapse Prevention Interview (Beckett, Fisher, Mann & Thornton, 1997) • The Psychopathy Checklist – Revised (PCL-R: Hare, 1991) (adapted by Morrissey, 2003) • Self-Regulation Pathways Model (Ward & Hudson,1998)

30. Sexual Recidivism in SO’s with IDD • 21 – 50% of offenders had committed a sexual crime (Gross 1985) • 28% of 331 men in hospital setting had committed a sexual offence • 34% in sex offenders released from prison (Kilmecki et al 1994) • Sex offenders with IDD reoffend at a rate of 6 times that of non IDD sex offenders at 2 years and 3 times that of non IDD sex offenders at 4 years

31. Risk Assessment • 1950’s and 60’s unstructured professional judgements in the past were no better than chance • Lack of rules – low inter rater reliability • Low content validity – clinicians may or may not attend to variables that actually relate to violent or sexually violent behaviour • Low predictive validity -failing to attend to important risk factors - attending to irrelevant variables - or giving improper weight to risk factors - inevitably decreases the accuracy of decisions

32. Actuarial Approach • Highly structured risk assessment scales • Empirically determined predictor variables which correlate with sexual recidivism • Scores correspond to risk categories (low, medium, high) future risk probability • Limitations • Based on historical information • No dynamic factors • Lack of sensitivity to changes

33. Actuarial Risk Assessments (ARAI’s) • Rapid Risk Assessment for Sexual Offence Recidivism (RRASOR) • Static 99 (Hanson & Thornton 1999, 2002) • Minnesota Sex Offender Screening Tool–Revised (Epperson, Kaul, & Hesselton, 1998) (MnSOST-R) • Sex Offender Risk Appraisal Guide (SORAG) Quinsey, Harris, Rice & Cormier (2006)

34. Challenges • Reliance on charges and convictions • Behaviour perpetrated may be representative of sexual offending behaviour • Police may not proceed – why? • Oppressive • Capacity • Concerns over equality and diversity • Victim – has IDD (Capacity) or is a member of staff in a secure hospital setting?

35. Structured Professional Judgement • Specifies a fixed set of operationally defined risk variables • Explicit manual based coding procedures • Structure aids inter rater reliability • Consideration is given to priority and relevance • Judgement of low, moderate or high risk categories • Concentrates on risk formulation and risk management

36. Psychopathy • Much debated topic in offenders with IDD • Assessment PCL-R or PCL-YV • Ongoing criticism re inter rater reliability in real world compared to manual • PCL-R with adaptation guidelines for use with offenders with IDD (Morrissey 2003) • Psychopathic traits in some SO’s with IDD in community setting - tend to be more challenging to risk manage • Low secure ward higher prevalence

37. Structured Professional Judgement • Sexual Violence Risk – 20 (SVR-20) (Boer et al, 1997) • HCR-20 (Webster et al, 1997/2013) • Risk of Sexual Violence Protocol (RSVP) (Hart, Kropp et al, 2003) • Psychopathy Checklist – Revised (PCL-R) (Hare, 1991) (adapted by Morrissey 2003)

38. Dynamic Risk Assessment • Assessment of Risk and Manageability of Individuals with Developmental and Intellectual Limitations who Offend - Sexually (ARMIDILO-S) • Specifically for use with individuals with borderline intelligence, or a mild intellectual impairment • Good predictive validity with different samples of sex offenders • Positively evaluated in qualitative studies as a case management instrument • Used with an actuarial test and an appropriate structured clinical guideline (SVR-20 or RSVP)

39. ARMIDILO-S • Items in the scale are distributed amongst: staff/environment and client dynamic factors, both of which are further differentiated into stable and acute dynamic groups. • Stable factors – may change over months or years • Acute factors – may change over hours or days • Protective variables included to assist risk judgement and risk management plan

40. Item classification • 1. Stable Dynamic Items (staff and environment) • 2. Acute Dynamic Items (staff and environment) • 3. Stable Dynamic Items (client) • 4. Acute Dynamic Items (client) • Determine which variables are of most relevance to the client and which items are, or are not, indicative of elevated risk

41. Dynamic Risk Assessment • Assessment of Risk and Manageability of Individuals with Developmental and Intellectual Limitations Who Offend - Sexually (ARMIDILO-S) Lofthouse, Lindsay, Totsika, Hastings, Boer, & Haaven (2013)

42. Evaluation of ARMIDILO-S • Within 64 adult males with IDD with a history of sexual offending behaviour. • Evaluation of ARMIDILO-S alongside Static 99 and VRAG • ARMIDILO-S resulted in the best prediction of sexual reoffending (ARMIDILO-S total score AUC=.92), (STATIC-99 AUC=.75,VRAG=.58) (Lofthouse et al 2013)

43. Evaluation of ARMIDILO-S • Blacker, et al., (2011) 88 offenders – 44 mainstream 44 sex offenders with special needs matched on risk items on the RRASOR • ARMIDILO-S best predictor for sexual reconviction (ARMIDILO-Stable, AUC=.60; ARMIDILO-Acute, AUC=.73),RRASOR (AUC=.53) RM2000-V (AUC=.50) • SVR-20 yielded a higher score (AUC=.73) for the non-IDD sample, IDD sample (AUC =.45)

44. References • There is a list of references that may be of interest, available to collect at end of presentation