Jennifer A. Joslin
 

As the need for effective treatment programs for juvenile sex offenders continues to grow, it is important to examine current theoretical perspectives and treatment applications for this population. This paper will explore the nature of sexual offending, the types of sexual offenses committed by juveniles, factors contributing to these offenses, as well as other demographics of pertaining to juvenile sex offenders. A review of the literature will be provided detailing the types of treatment currently in use with this client group, including family therapy, individual therapy and group therapy. A comparison between inpatient, residential treatment and out-patient, community-based treatment is made. Three juvenile sexual offender treatment programs in the state of Illinois are compared and contrasted regarding clientele and treatment strategies, and a theoretical treatment program is suggested. Other important topics discussed are the practice implications for social workers, policy and treatment related road-blocks, and issues in staff training and support. 
 
 

Introduction

Sexual assault is one of the fastest growing violent crimes in the country (Shaw, 1999). Approximately 20% of all people charged with a sexual offense in the United States are juveniles (Federal Bureau of Investigation, 1993), with approximately 60% of all sexual offenses committed against children under the age of twelve perpetrated by these young offenders (Bourke & Donohue, 1996). Among adult sex offenders, almost 50% report that their first offense occurred during adolescence (Rubenstein, Yeager, Goodstein & Lewis, 1993). There is also evidence indicating that juvenile sex offenders may go on to commit over 380 sexual offenses during their lifetime (Ertl & McNamara, 1997). Although these statistics suggest that juvenile sex offenses are more prevalent than was once thought, estimates are likely to be low due to issues of secrecy and under-reporting.

Survivors of sexual assault suffer both immediate and long-term problems that are likely to impact their mental health, self-esteem, feelings of safety, and relationships with others, to name a few. Perpetrators of sexual offenses are also affected by the negative outcomes of their behavior, and as mentioned, they often display these patterns of sexually deviant behavior throughout their lives. These patterns are resistant to change, and some young offenders seem to be unaware of the seriousness or deviance of their behavior (Ryan, 1998, 1999). Statistics such as those mentioned earlier, and the high risk that perpetrators pose to their victims and the community at large, supports the need for effective treatment programs that will decrease the likelihood that offenders will continue such destructive patterns of behavior.
 

Definitions Related to Sexually Deviant Behavior

In order to examine the treatment of juvenile sexual offenders, it is important to first define the terms related to such discussions. There has been some controversy over what types of sexual behaviors should be considered normal, age appropriate, and exploratory versus what types of behaviors are considered deviant and harmful (Ryan, 1999; Shaw, 1999). There has been some progress with this struggle as more research has been done, and definitions have been provided more frequently to describe what is meant by sexually deviant behavior. The literature on this topic appears to use a variety of terms interchangeably. For example, juvenile “sexual assault,” “sexually abusive behavior,” and “sexual offenses,” are all used to describe the acts of the perpetrator against their victim (Ertl & McNamara, 1997; Griffin, Williams, Hawkes, & Vizard, 1997; Muster, 1992; Shaw, 1999). All of these acts describe behavior that occurs without consent, without equality, or with the use of coercion (Shaw, 1999). As Ryan (1999) explains, “it is not the sexual behavior that defines sexual abuse, but rather, it is the nature of the interaction and the relationship that give an accurate definition” (p. 424). Consent is described by Shaw (1999), as including all of the following:

(1) understanding what is proposed, (2) knowledge of societal standards for what is proposed, (3) awareness of potential consequences and alternatives, (4) assumption that agreement or disagreement will be respected equally, (5) voluntary decision, and (6) mental competence. Equality is defined as “two participants operating with the same level of power in a relationship, neither being controlled or coerced by the other.” Coercion is defined as “exploitation of authority, use of bribes, threats of force, or intimidation to gain cooperation or compliance” (p. 58S).

There are also several categories which describe the type of offenses committed by juvenile sex offenders. Ertl and McNamara (1997) refer to three types of sexual offenses: those which are referred to as “hands off” offenses, which include voyeurism, making obscene phone calls, and exhibitionism; “hands on” offenses, which usually include some type of force, aggression, or coercion, such as fondling or rape; and pedophiliac offenses, in which the victim is at least four years younger than the perpetrator. It should be noted, that offenders may also select victims who are significantly lower functioning than themselves, putting them in a position of power so that they can manipulate their victim. Additionally, although some of the terms used in the literature seem to be used interchangeably, some definitions clearly have different meanings. For example, Shaw (1999) uses pedophilia to describe sexual activities focused on a prepubescent child, generally younger than 13 years of age. The differing descriptions of terms used in the field should be reexamined and brought to consensus to avoid confusion and to increase consistency amongst researchers.
 

Motives/Factors Related to Sexual Offending

Sexual offenders have also been categorized by their motives and factors that have contributed to their pattern of offending. Becker (1988) describes four types of sexual abusers with most offenders displaying features of each: (1) the true paraphiliac with a well-established pattern of deviant sexual arousal; (2) an antisocial youth who not only sexually offends, but exploits people in other ways as well when the opportunity presents itself; (3) an adolescent with a psychiatric or neurological/biological disorder that affects his/her ability to control aggressive and sexual impulses; (4) an adolescent that does not have adequate social and interpersonal skills, who seeks sexual gratification from younger children because it is unavailable from peer groups.
 

Theories About Why Juveniles Offend

There are a number of theories that postulate how a juvenile becomes a sex offender, although few of these theories have been systematically researched. The literature in this area is greatly lacking and more comprehensive information regarding these theories is desperately needed in order to assist with early detection, risk identification, and to provide adequate services prior to the occurrence of more serious sexual offenses.

One of the more prevalent views on sexual aggression by adolescents incorporates components of the social learning theory (Burton, Nesmith, & Badten, 1997; Hudson & Ward, 2000; Hunter & Figueredo, 2000). As such, this view takes into account the high percentage of juvenile sex offenders that have themselves been the victim of sexual abuse (Burton et al., 1997). For example, Friedrich, Grambsch, Damon, Hewitt, Koverola, Lang, Wolfe, and Broughton (as cited in Burton, et al., 1997) found that children who had been sexually abused scored significantly higher on the Child Sexual Behavior Inventory and displayed significantly more sexual behaviors than their nonabused counterparts. They also found a pattern of family distress and emphasized the significance of family variables in the sexual behavior of children. Family variables considered to be particularly relevant include: parent-child relationships, chemical dependency, and the parents' own history of abuse (Burton et al.). A more specific description of how social learning theory is applied to this population is provided by Burton et al., who explain that,

Behavior, cognitive and other personal factors, and the environment are the three factors in this framework, which reciprocally determine or affect one another. When sexual behaviors that are aggressive and inappropriate for the child's age are paired with positive reinforcement, the child may learn to regard these behaviors as appropriate, normal, and worthwhile. The perceived rewards may be physiological, social, or psychological (p. 160).

Their study supported the use of this learning theory and led them to several conclusions. If the social learning theory can provide an explanation as to why juveniles may become sexual offenders, then treatment strategies may also need to incorporate social learning theory principles and cognitive-behavioral interventions. For example, treatment may involve addressing cognitive distortions or helping the clients to understand the behavioral processes that lead to their pattern of offending. If they are aware of these processes, they may then be able to interrupt the cycle and choose alternative behaviors, as is used with relapse prevention.

Additional support for social learning theory has been provided by Hunter and Figueredo (2000), who found that adolescent sex offenders had more deficiencies in the areas of self-confidence, independence, assertiveness, and self-satisfaction than nonperpetrating youths and they were more apt to blame themselves for negative life events. These youth were described as lacking social competencies and in need of increased family support. Youths in the study who had described their families as being less supportive of them after the discovery of the abusive behavior were more likely to have later sexually perpetrated against younger children. Hunter and Figueredo thus support the use of cognitive-behavioral interventions, social skills training, exposure to various stimulus and response patterns, and peer-mediated interventions, which are all found within the principles of the social learning theory.

Hudson and Ward (2000) also explore components of the social learning theory, focusing on interpersonal competency. They also believe that cognitive distortions play a large role in facilitating juvenile sex offenses. They maintain that deficits in social competencies are key to the causes and maintenance of sexually aggressive behavior. They also suggest an emphasis on using an attachment approach to promote intimacy and empathy, which are important components in most treatment programs.

Another theoretical perspective offered in the literature is that of a self-psychological perspective. This theory, evidenced in the clinical findings of Kohut (as cited in Chorn & Pareka, 1997), suggests that, " a self is present from birth, that disintegrates when its need for mirroring and idealization are repeatedly frustrated... hostile-destructive aggressiveness results from the repeated frustration of needs by caregivers" (p. 211). Chorn and Pareka's (1997) research on this theory conclude that, "sexual offending was related to disfigurements in the separation-individuation process of childhood," (p. 222) and that "the characteristic approach-avoidance behavior of this stage persisted because grandiose-exhibitionistic self-representations and omnipotent-voyeuristic (idealized) object representations were never modulated by a balance of parental functions" (p. 222). This theory seems to suggest that a focus should be placed on individual psychotherapy, to examine the youth's weakened sense of self and the thoughts and perceptions surrounding the offenses that indicate a difficult detachment from "parental objects." It should be noted that the self-psychological perspective is not evident in other juvenile sex offender literature, and it should be seen only as adding to the body of research on theories on offending.

Family violence has also been theorized as a predictor of juvenile sex offending. Throughout the literature, there is an emphasis on family roles, sexual abuse in the family, chemical dependency, other components of family violence. Caputo, Frick, and Brodsky (1999) tested this theory and found that although juvenile sex offenders in general witness a great deal of domestic violence, so too did youth who had been convicted of other, nonsexual, offenses. Furthermore, they did not find that poor impulse control, callous-unemotional traits, or sexist attitudes towards women could explain the link between witnessing domestic violence and contact offending. Additionally, they found that although juvenile sex offenders did have a fairly high rate of sexist beliefs, this was common to offenders in general. As family violence seems to be inherent in the histories of both sexual and nonsexual offenders, further research would be useful in determining what, if any, specific correlates exist between violence and aggressive offenses.
 

Demographics of Juvenile Sex Offenders

It is also important to note the demographics of juvenile sex offenders. If accurate information can be gathered regarding the background histories of perpetrators, the nature of their offenses, and other contributing factors to their behavior, treatment programs will be more likely to be able to identify and address important issues with offenders. Ryan, Miyoshi, Metzner, Krugman, and Fryer (1996) gathered information about a sample of 1,616 youths from 30 states, between the ages of 5 and 21, who had been referred for a specialized evaluation and/or treatment for sexual offenses. Race, income, and religion were similar to that of the general population. A number of interesting correlates were found when the experiences of these youths were examined. Most of these youth had experienced some traumatic situations in their past. For example, 41.8% had been victims of physical abuse, 39.1% had experienced sexual abuse, 25.9% had been neglected, and 63.4% had witnessed some type of family violence in the home. At the time that the clients were referred, 63% had committed nonsexual offenses such as shoplifting, theft, burglary, assault, vandalism, arson or running away. Of the sexual offenses that they committed, 91% of these were perpetrated against a victim between the ages of three and sixteen, with 63% younger than age nine. Twice as many of the offenses involved female victims, with the average number of victims known at the time of intake 7.7. Of these victims, 38% were blood relatives living in the same household.

In addition to demographics about the offenders in this sample, Ryan et al. (1996) rated the youths’ empathy, remorse, sense of responsibility, and levels of denial. At the time of their initial assessment, 86% of the clients admitted that a sexual offense had occurred, however, only 19.4% of these accepted full responsibility, and 32.8% attributed little or no responsibility to themselves. Sixty-two percent were rated as expressing little or no empathy for their victim, and 51% expressed little or no remorse or guilt. In addition, although approximately two thirds of the perpetrators (63.6%) blamed themselves for the offense, one third blamed the victim.

Ryan et. al (1996) also gathered clinicians’ impressions of the clients in relation to assertiveness, maturity, and sexual education. Their findings suggest that the offenders in this sample may be less assertive, less mature, and less educated than their peers. Furthermore, almost 70% of the offenders were described as possessing less than average or distorted sexual knowledge. In addition, despite sociodemographic variables that are similar to the general population, such as race, religion, parental income, etc., family functioning and individual social competence appeared impaired.

The statistics presented here should not be taken at face value as there may be many other factors influencing a juvenile’s propensity to offend. However, some important issues have been raised. It is concerning that the perpetrators of these offenses may have no remorse or understanding of the harm that they are inflicting on others. A lack of sexual knowledge and social skills is also problematic. In an effort to reduce the recidivism rates of juvenile sex offenders and to help them learn more appropriate patterns of behavior, a number of specialized treatment programs have been developed. The number of such specialized programs that work with juvenile sex offenders has grown rapidly over the past two decades from one such program in 1975 to over 600 programs in 1995 (Ertl & McNamara, 1997; Worling & Curwen, 2000).
 

A Review of the Literature: Treatment Approaches/Settings

In reviewing the literature, it is apparent that treatment programs for juvenile sex offenders vary in their approach to working with youth in terms of the issues that are addressed, the theoretical perspectives that are employed, and the primary focus of treatment, whether it be the victim’s own history of abuse or their role as offenders (Muster, 1992). However, there are also a number of similarities among programs that are consistently addressed and deemed an important part of the treatment process. It will be important to compare both the similarities and differences of these programs to gain a better understanding of what kind of treatment is available, what approaches are used, and why.

The setting of juvenile sex offender programs vary, generally consisting of either inpatient residential treatment or outpatient/community-based facilities. There are several things to take into consideration when determining whether or not a client should receive residential or outpatient services. Two considerations in particular are noted. The first involves the premise that the safety of the community should be of the utmost importance. The second consideration involves ensuring that youth are placed in the least restrictive environments possible (Ertl & McNamara, 1997; Shaw, 1999). Bourke and Donohue (1996) have provided suggestions for determining which setting should be used, stating that,

Inpatient care is typically recommended for juvenile sex offenders in the following situations: (1) the offenses have been numerous and/or have involved more than one individual; (2) aggression was used during the assault (s); (3) severe emotional and behavioral problems are present; (4) antisocial attitudes are demonstrated; (5) there is poor motivation for treatment; (6) suicidal or homicidal ideation is present; (7) a volatile relationship at home threatens the safety of the individual; (8) a victim is present in the juvenile sex offender’s home (p. 57).

The treatment components of sexual offender programs vary. There are, however, some consistent themes that appear prevalent in the majority of programs. Such issues include but are not limited to: accepting responsibility for behavior, identifying a pattern or cycle of offending, learning to interrupt the cycle, developing empathy for the victim, increasing the use of appropriate social skills, addressing one’s own history of abuse, decreasing deviant forms of sexual arousal, increasing accurate sexual knowledge, enhancing interpersonal skills, improving family relationships, and increasing awareness of the possibility of relapse as well as learning methods to prevent this (Ertl & McNamara, 1997; Ryan, 1999; Shaw, 1999; Worling & Curwen, 2000).

There are also some different treatment methods, some of which are controversial for use with juveniles. Examples of these types of treatments include: covert sensitization, in which the offender learns to associate negative responses to sexually appealing situations which are considered to be deviant; assisted covert sensitization, in which an aversive stimulus, such as an unpleasant odor, is used to create a negative reaction; imaginal desensitization, in which the sex offender uses relaxation techniques to interrupt sexually stimulating imagery or to inhibit the sexual arousal cycle; satiation techniques, involving the offender masturbating until ejaculation to sexually appropriate imagery which portrays affection and tenderness, and then masturbating to sexually deviant material and switching to thoughts of the sexually appropriate material before ejaculating; and sexual arousal reconditioning, in which sexual arousal is paired with appropriate sexual stimulation or fantasies (Ertl & McNamara, 1997; Muster, 1992; Shaw, 1999). Psychopharmacological treatments have also been considered for use in treatment with juveniles to reduce levels of testosterone, although the use of such treatments is not recommended unless the youth is over the age of sixteen, and the sexual offenses that have been committed are frequent and severe. These types of treatments may have harmful effects on growth and development and are not widely used due to these and other ethical considerations (Muster, 1992; Shaw, 1999).

Several types of therapy have also been used with juvenile sex offenders. Individual therapy, group therapy, and family therapy have all been used alone or in combination in various treatment facilities. Group therapy is the most common form of therapy and is deemed to be most helpful in treating sex offenders. Group therapy allows members to confront one another on issues that they are very familiar with. Members are not easily manipulated about issues of sexual perpetration and therefore make it difficult for participants to engage in minimization or denial (Ertl & McNamara, 1997; Shaw, 1999). Shaw (1999) also identifies topics for group discussion such as: trust, betrayal, secrecy, guilt, loss, helplessness, powerlessness, sexual feelings, self-esteem, anger management, problem-solving skills, and social skills.

Individual therapy is generally not recommended for use as a sole treatment. Disadvantages such as the potential for the therapist to be manipulated, denial being more easily sustained, less confrontation, and the lack of opportunity to learn from other offenders, are all cited as reasons for not using individual therapy alone. It may, however, be useful in helping offenders engage in a trusting relationship and explore their own histories of abuse (Shaw, 1999).

Family therapy is also generally seen as a beneficial part of treatment with juvenile sex offenders (Griffin et al., 1997; Shaw, 1999). It may be within the family context that some youth have gained their understanding of relationships with others, aggression, and gender roles. Family therapy may help open the lines of communication in order to build a support network for the youth and help the family understand the dynamics of the youth’s offending patterns. It may be especially important to use family therapy with families in which there has been incest, or if a youth is or will be living with the family following treatment (Shaw, 1999).
 

Evaluating the Success of Specialized Treatment Programs

Worling and Curwen (2000) evaluated the success of a specialized treatment program by examining recidivism rates among the clientele following treatment, any time from two years following the completion of treatment to 10 years after treatment. They found that within the context of their study, specialized juvenile sex offender programs may be helpful in reducing recidivism rates. Relative to their comparison group, there was a 72% reduction in sexual offending for adolescents who had completed at least 12 months of treatment. Their findings suggest that a comprehensive treatment program that combines a strong family-relationship component with offense specific interventions may be most successful in work with adolescent sex offenders. This is one of few studies that has tested the effectiveness of such programs with a long-term follow up to determine if additional offenses have been committed.

As is it important to conduct program evaluations and long term follow up with treatment programs to determine their effectiveness, it would also be useful to be aware of what factors may contribute to a sex offender's likelihood to withdraw from a program prior to completion. Kraemer, Salisbury, and Spielman (1998) conducted a study to determine what these factors are. The variables examined during this study were: age, defensiveness, impulsivity, criminal prosecution, sexual knowledge, psychological maladjustment, and obsession with fantasies. Their results indicate that only two of these seven variables, impulsivity, and client age, could be used to determine treatment noncompletion. Testing measures indicated that those impulsive subjects were perceived as such because of their egocentricity. As a result, impulsive youth are more likely to act on their impulses without first taking into account their victim's point of view prior to satisfying their desires. This may prove to be an area for further study to determine how to work with particularly impulsive clients. In relation to the variable of age, younger offenders were found to be more amenable to treatment than older clients. Several explanations may be offered to account for this finding. Younger clients may be more easily shaped due to their continuing developmental needs. They also tend to be more open to shaping and education than more seasoned offenders. Regardless of the reasoning behind these results, predictors of noncompletion provide an important contribution to the literature. If such factors are identified, specialized treatment strategies for these individuals can be further explored and may be useful in working with clients with different needs.

Although there are a number of articles on juvenile sex offending, the research seems to describe treatment approaches and modalities, rather than testing program and treatment effectiveness. There seems to be a great need for further research that tests the effectiveness of these approaches. Comparative analyses of treatment strategies may be helpful in determining what works best with offenders while taking their histories and the type of offenses that they have committed into consideration. Furthermore, long term follow up will be an essential component in testing treatment effectiveness.

Other kinds of research may be useful as well. Further exploration of risk factors that may contribute to the likelihood that an adolescent will sexually offend may help target youth who are at greater risk for offending for early assessment and intervention. It may also be helpful to examine the effectiveness of specific treatment techniques and topics, as it appears that many issues are addressed during treatment. How these issues are addressed and in what combination may lead to a more effective program with varying amounts of time spent on particular issues. As mentioned earlier, further examination of which issues take priority in treatment may greatly increase the effectiveness of programs. There may be benefits associated with addressing offender's own histories of abuse first. Similarly, it may be that a perpetrator's pattern of offending should take priority. This may be an important consideration in treatment planning.
 

Support and Training for Direct Care Workers

Support and training for care providers who work with juvenile sex offenders is another topic worthy of further practice consideration and research. Griffin et al. (1997) describe the importance of communication, support, and emotional processing for the individuals and treatment teams working with juvenile sex offenders. This type of work often proves to be emotionally demanding. They suggest that professional "carers" will often find themselves mirroring their clients' high levels of anxiety, resistance, denial, sexual excitement, and emotional reactions. They recommend discussion groups for treatment providers to guard against these pitfalls, as well as to help them process common emotional reactions and provide support for one another. The young offenders are likely to be sensitive to their worker's perceptions of their behavior, and this could have a strong impact on the success of their treatment. Care givers are also likely to be more effective in their positions if they feel supported and comfortable with the type of work that they are doing.
 

Suggestions for Treatment: A Theoretical Juvenile Sex Offender Treatment Program

A thorough review of the literature in addition to an in-depth interview with three juvenile sex offender treatment provider supervisors (see Appendix) has been useful in making recommendations for a comprehensive residential treatment program for juvenile sex offenders. The following recommendations are based on a culmination of the above mentioned information, although the empirical evaluation research is lacking to support them. A comprehensive treatment approach that incorporates the various developmental, social, therapeutic, cognitive, and supportive needs of children and adolescents is recommended. Focus on any one area without consideration of the whole person would prove to be futile. If a thorough screening/evaluation process is used as a precursor to treatment, and the treatment provided is comprehensive, incorporating those components mentioned above, juvenile sex offenders are likely to make numerous improvements, most importantly reducing their risk of re-offending.

Screening and evaluation may prove to be an important part of the treatment process. Although this is not thoroughly reviewed in the literature, those interviewed (see Appendix) have made reference to a lack of information about the youth and their histories which have hindered treatment success. Screening should be done to assess what type of risk the client poses, the seriousness of their offenses, what type of treatment methods, in particular, may be useful (as we are working with individuals), what the client's attitude towards treatment is, and if they meet any other pertinent criteria. Evaluation/assessment will be helpful in determining how the client may interact with other residents, what, specifically, may need to be targeted (in terms of social skills or lack thereof, levels of aggression, delinquency, psychiatric issues, drug use, manipulation and other defense mechanisms, etc.). Portions of the screening should include testing for sexual interests (ABEL screen), impulsivity, aggressiveness, IQ (if not already obtained), sexual knowledge, psychiatric issues, grooming techniques, socio-affective functioning, distorted attitudes, etc.

The evaluation and screening process will also be crucial for obtaining background information on the clients. As such, detailed interviews will also be done with the client's family (natural or foster) to: assess their willingness to participate in treatment, assess the degree of family dysfunction, explore issues of sexual abuse within the family (or the parent's own history of abuse), determine what kind of parenting (or lack of), was used in the home, determine what has been modeled by the family members, explore boundary issues, and determine what resources the family has. It will also be necessary to identify the family's strengths and determine what would be necessary for the client to return to the family following the completion of the program.

Other information should be obtained from collateral contacts to ensure that the most accurate information regarding the youth's background and history of offenses are available. Documentation and pertinent information should be secured from DCFS, police reports, court, probation officers, the GAL, other relatives, and SACY. Furthermore, recent psychological evaluations, any psychiatric hospitalization records, previous social history reports, information from the victim's family (if available), previous therapy reports, etc., should be gathered to assist with the assessment.

Treatment methods in this program will incorporate individual, family, and group therapy, with a focus on the last two. The research is clear in identifying the importance of the family when working with this population. Additionally, since the family system is where these youth most likely developed their cognitive distortions, interpersonal dysfunctions, coping skills and other pertinent characteristics, the family will be necessary in addressing these issues. Furthermore, the importance of working with the family increases if the youth will be returning to the home following treatment, particularly if the victim is living in the household. Group therapy is also strongly indicated in the literature to address issues of secrecy through confrontation and peer support. Particularly since there is overwhelming evidence that these youth are experiencing low self-esteem, guilt, powerlessness, abandonment, etc., a group setting will provide the support from others in similar situations, as well as a reality base with which to be challenged by their peers. Groups can also help clients address the numerous psycho-educational topics that should be presented such as: anger management, sexual education, the sexual assault cycle, social skills training, coping strategies, etc. Individual therapy will then serve to reinforce what the clients do in family and group therapy and will provide a safe outlet to express other, more personal, feelings.

A unique characteristic of this program that has not been observed either in much of the literature or during the interviews with treatment providers, is providing a group for parents/care takers of sexually aggressive youth. If staff have a difficult time working with this type of population, it is reasonable to assume that caretakers feel overwhelmed and experience a range of feelings including isolation, guilt, embarrassment, and anger in relation to their child's offense. They may benefit from a group which will provide not only support, but an educational component as well to help them learn about how to work with their own children. All of the treatment programs interviewed expressed a problem with lack of participation from the offender's family, and perhaps if they were eased into treatment by attending groups in which they saw that they were not the only ones going through such difficult issues, they may be more open to treatment down the road. The possibility of other such groups in treatment programs should be explored to determine if there is an interest and if such groups would be effective.

An important aspect of treatment programs that has received some, but far too little, attention, is the role of the direct-care staff. It seems imperative that time be spent on thoroughly training that staff to work with these special needs clients. It is difficult for these care providers to work with such an emotionally draining and highly intensive group of youth without the necessary background information, training, and support. Although there seems to be a desire to implement a "positive peer culture" in most juvenile sex offender programs, the inability of the staff to be consistent and to understand the purpose and reasoning behind such treatment strategies, makes it difficult to achieve success with this approach. Although there appear to be many merits for using this technique, the direct care staff are not trained clinicians and they will need to be provided with constant training and rationales in order to be effective with the implementation of this approach.

Behavior modification should be used in combination with the positive peer culture to address those issues raised in relation to the social learning theory. Youth should be consistently held accountable for their behaviors through the use of a token economy to help them learn to take responsibility for their behavior and to motivate them to change. Alternatives to inappropriate behavior should also be provided to help the client's examine their choices and to assist in future decision-making. This technique should incorporate a level system providing the youth with increasingly larger incentives and rewards for hard work.

An essential focus of the treatment program will be to track the client's progress systematically, identifying triggers to regression in behavior, offending or aggressiveness, and documenting the improvements and regressions in a standardized format. This will include noting what specific treatment(s) had been provided prior to the improvement or regression in behavior and what was done in response by both the staff and the client. Additionally, program evaluation will be a central focus, examining the effects of various treatment strategies, determining client satisfaction/progress, noting staff input, examining progress and therapy notes since the start of treatment, graphing client progress, and surveying families and other involved parties. In addition to evaluation, follow up with clients to determine their success following treatment will be implemented and tracked systematically.

Although some of the components of the treatment program suggested will require additional resources often unavailable to treatment providers, evaluation of program effectiveness is greatly needed. Until research has been done to determine the effectiveness of specific treatment techniques and long-term success, programs will continue to operate using theoretical perspectives and they will lack the empirical research to support their work. If this type of research can be done, additional funding may become available based on positive results and any time wasted on ineffective treatment techniques may be limited.
 

The Role of Social Workers

Social workers can play an important role in the treatment process with juvenile sex offenders. As previously discussed, there should be an extensive assessment process that will require interviewing the youth and their families, gathering information from various sources, and working with collateral contacts (i.e. probation officers, court officials, and caseworkers) to ensure a comprehensive treatment approach (Kaplan & Becker, 1992; Shaw, 1999). Social workers can help to facilitate and complete this process, and then formulate recommendations for treatment.

In programs with a strong family component, social workers can assist in the completion of family assessments. They can also conduct family therapy or groups with parents, working with families to address issues that may have contributed to the juvenile's sexual offending (Ertl & McNamara, 1997; Pithers, Gray, Busconi, & Houchens, 1998). Parents of juvenile sex offenders may also benefit from participating in group therapy to help them with feelings of anger, denial, guilt and confusion (Ertl & McNamara, 1997; Shaw, 1999).

Another potential focus for social workers should involve constructing and implementing a follow up protocol with those offenders who have completed treatment, in order to provide ongoing services as needed. They can also continue to assess the risk for repeat offenses and provide an avenue for support or referrals for the client and their families. This may also help to supply the much needed research information on recidivism rates and the success of treatment programs.

Support and training for staff who work with juvenile sex offenders is another necessity in the field that can be provided by social workers. Working with this type of clientele is extremely demanding and emotionally draining, and there seems to be consistent issues surrounding burnout with this population. Social workers may be helpful by offering groups in which the staff members can process their feelings of anger and frustration as well as receive support from others in similar situations. Further training on working with this special population can also be offered to help the staff understand how treatment strategies impact client success or failure. With a combined effort from social workers, clinicians, psychiatrists, family members, and others involved in the youth's care and treatment, specialized juvenile sex offender programs can continue to make positive strides in identifying youth at risk for offending, providing quality treatment for those who do offend, and reducing the risk for repeat offenses.
 
 
 

Appendix: Interviews with Juvenile Sex Offender Treatment Programs
 
 

(The name of each program described below has been excluded due to lack of consent from the agency to provide such information in written form. The information contained below is based on averages given by those interviewed on an informal basis. Percentages are not statistically accurate, but are rather based on the experiences of the interviewees.)
 

A. About the Interviewee:
 

Program A:
 

Name: Warren Mattson

Title: Clinical Supervisor

Length of time with the program: 14 months

Experience: was the therapist in the acute unit of the agency for one year prior to working with the current program

Special Training: various workshops, has read much of the literature in the field
 

Program B:
 

Name: Karen Robertie

Title: Clinical Supervisor

Length of time with the program: 1 year with current program, two years with the agency

Experience: twelve years experience in social services, program supervisor for a juvenile sexual offender (JSO) program at another agency

Special Training: Masters degree in counseling, various workshops/trainings (w/ a minimum of 60 hours JSO)
 

Program C:
 

Name: Tom Keller

Title: Social Service Supervisor

Length of time with the program: 4 years

Experience: Undergraduate degree psychology/criminology, Masters in Social Work, 3 years with Child Protective Services, provided family treatment and child abuse treatment

Special Training: various trainings and workshops for JSO; 48 hours of SACY (Sexually Aggressive Children and Youth) training withing 6 months prior to working with JSO clients
 

B. ABOUT THE CLIENTS IN THE PROGRAM:
 

		Program A	Program B	Program C
1.	Sex	Male	Male	Residential- Male Outpatient- Both
2.	Age	Program 1: 13-17 Program 2: 16+	5 programs : 1: 6-13 years old 2 & 3: 12-15 years old  4 & 5: 15-21 years old	Residential: 8-18  Outpatient:
3.	Race	Mixed (50% Black, 40% White, 10% Hispanic)	Mixed (60% White, 30% Black, 10% Hispanic	Residential- 70% Black, 20% White, 10% Hispanic Outpatient- 80% Black, 20% White and other minorities
4.	Where are they from (geographically)?	All over Illinois	All over Illinois	All over Illinois (mostly from Chicago)
5.	Are their families involved?	Minimally (20%)	Yes (younger youth have more family involvement- 100%, 12-15 year olds -75%, 15-21 year olds 50%)	Residential- 50% Outpatient- 75%
6.	Who was their primary caretaker?	Usually from single-parent families, most often mom	Usually from single-parent families, most often mom	Usually from single-parent families, most often mom or grandmother
7.	Do they have siblings?	Yes (60%)	Yes, most	Yes, almost all
8.	Who have they offended?	A wide variety of people	A variety	80% family or foster siblings
	Siblings?	Yes	30%	Yes (see above)
	Community?	Yes	70%	Yes
	Male/female?	Whoever is available (70% males)	Whatever is available (50% male 50% female)	Whatever is available (60% female 40% male)
9.	Range of offenses they've committed?	Everything indicated on a SACY plan (rape, voyeurism, frottage, fondling, simulated intercourse, etc.)	Most hand-on offenses with penetration, most things indicated on a SACY plan (fondling, rape, simulated intercourse, frottage)	Variety, everything indicated on a SACY plan (rape, voyeurism, frottage, fondling, simulated intercourse, etc.)
		Program A	Program B	Program C
10.	Characteristics of victims?	Someone more vulnerable	Usually an age difference, more often than a metal difference	60-70% there was an age difference; all have power differential and lack of consent (victim)
11.	Are they categorized (Group I, II, III, IV) based on Toni Cavenaugh-Johnson?	No	No, although this type of information is provided in training	No; use low, moderate, and high risk
12.	What are the contributing factors to their behavior?	History of victimization, family dynamics (poor boundaries), family dysfunction (substance abuse and/or domestic violence)	History of victimization, family dynamics (poor boundaries), family dysfunction (substance abuse and/or domestic violence)	PTSD (history of physical/sexual abuse and neglect), lack of attachment, early sexualization, exposure to pornographic or violent material
13.	What impact do you feel their behavior (offending) has on their functioning (emotional, behavioral, etc.)?	Guilt, shame, removal from family (abandonment), feelings of inadequacy, "core beliefs" are reinforced (powerless, inadequate), legal consequences	Sense of remorse and sorrow about hurting others, guilt, fear of abandonment, negative community response	Low self-esteem, separation from family because of removal and family distancing due to offense, lack of normalcy (being labeled), normal sexual exploration hindered
14.	How many are victims of sexual abuse?	90%	60%	50-60%
15.	How many of the clients have witnessed sexually inappropriate behavior?	Most	Most	Most
	What kind?	Pornography, their own abuse	Pornography, their own abuse	Pornography, their own abuse
16.	How many have witnessed family violence?	80% (100% if family substance abuse is involved)	85-90%	50-60% (all have been neglected)
		Program A	Program B	Program C
17.	How many have committed other types of crimes? What kind?	100%; assault, drug possession/sales, vandalism, theft, etc.	Younger clients, 10%; clients 12-15, 25% (property damage, theft); clients 15-21, 60% (assault, substance related crimes)	Residential: 40% Outpatient: 30% (Includes robbery, car theft, arson, shoplifting, truancy, drug offenses)
	Upon intake, how many of the clients have...
18.	Admitted that an offense occurred?	95%	90%	65% (within the course of the assessment/ 4-5 sessions)
19.	Minimize the seriousness of their offense?	100%	100%	100%
20.	Accepted responsibility for their offense?	None	10%	10% (varies by age)
21.	Expressed empathy for their victims?	None	10%	10-15% (varies by age)
22.	Expressed remorse or guilt about their offenses?	80%	30%	10% (varies by age)

 
 
 
 

C. ABOUT THE PROGRAM:
 

1.	How many youth are in the program?	Program 1: 10 youth  Program 2: 14 youth	Program 1: 14 youth Programs 2 & 3: 12 youth  Programs 4 & 5: 20 youth	Residential 3 dorms- Dorm 1: 9 youth Dorm 2: 11 youth Dorm 3: 11 youth Outpatient: 50 youth
2.	What are the requirements for eligibility for the program?	Other failed JSO placements, highly aggressive, psychiatric issues, pattern of offending	A sexual offense must, most have a severe offense or pattern of offending	A sexual offense must, most have a severe offense or pattern of offending
		Program A	Program B	Program C
	Age?	Program 1: 13-17 Program 2: 16+  (Cannot be 19+)	5 programs : 1: 6-13 years old 2 & 3: 12-15 years old  4 & 5: 15-21 years old	Residential: 8-18 years old Outpatient: 4-21 years old
	Sex?	Male only	Male only	Residential: Male only Outpatient: Both
	IQ?	Prefer 70+	Prefer 70+	Prefer 70+
	Diagnosis?	None specified	None specified	Not specified
	SACY status?	Yes, if wards of the state	Yes, if wards of the state	Yes; all are wards
	Degree of the offense?	Severe or repetitive	doesn't matter if there is also a pattern of offending	Residential: moderate risk level (determined by SACY status/assessment) Outpatient: low-moderate risk (can be maintained in the community
	Willingness to participate in treatment?	Not necessary	Don't have to be totally willing, but can't outright refuse	Residential: not necessary; Outpatient: will work with both
	Who won't you take?	19+ year olds	Developmentally delayed, heavy psychiatric issues, severely aggressive	Residential: girls, kids without special education needs Outpatient: No family involvement; high risk offenders Both: severely DD
3.	How do you choose who you will take?	Referrals are examined on the above criteria and a gatekeeper makes decision; waiting list taken in order	Referrals are examined on the above criteria	First come first serve if they meet the criteria; no waiting list for outpatient
4.	Where do you get your referrals?	50% DCFS, 50% Department of Mental Health (DMH) or Probation	50% DCFS, 50% Probation	SACY, DCFS, POS agencies, some court (1-2%)
5.	Where does your agency get its funding?	Contracts with DCFS, SACY, DMH, Court/Probation, Medicaid	Mostly from DCFS contracts, Medicaid, County Probation, or Department of Corr., some from DMH	DCFS, small contract with DOC, private donations, Medicaid (Residential)
6.	What kind of treatment do you provide?
		Program A	Program B	Program C
a.	Family Therapy?	Yes	Yes	Yes
	Who in the family should participate?	Primary care takers (foster parents), natural parents, siblings at times	Usually just the primary care takers; as treatment progresses, others in the home & extended family	Primary care takers, siblings living in the home, other in the home
	What is the focus?	Preparing families to work with youth upon discharge, exploring family dysfunction	Assessment, helping the family accept what has happened and understand what this means	Cognative-behavioral approach, some structural; SACY issues; how did the youth become an offender, what are the current risks, accountability
	What issues are addressed?	Teaching appropriate parenting skills, in addition to that listed above	Learning the youth's cycle of offending and relapse plan, teaching appropriate parenting skills	Denial, family history, the child's own victimization, current risks in the home, family roles and relationships
	Are the parents encouraged to participate?	Yes	Yes	Yes
b.	Individual Therapy?	Yes	Yes	Yes
	What is the focus?	Learning the cycle of offending, learning triggers, exploring "core beliefs," discussing their own victimization	Learning the cycle of offending, discussing their own victimization (Also a "sexual therapist" who helps them with what they need to do to change)	Accepting accountability, reducing risk for re-offense/identifying risks, resolving past trauma, improving self-esteem & life skills
	What issues are addressed?	Taking responsibility, expressing empathy, feelings of inadequacy and powerlessness	How things are going in the daily milieu, how they go there, anything else client wants to discuss	Client's own victimization, communication skills, discussing feelings, anger management, school, job, community involvement, psycho-sexual educational
c.	Group Therapy?	Yes	Yes	Yes
		Program A	Program B	Program C
	What is the focus?	The cycle of offending, taking accountability for offenses, confrontation by peers	2 types of groups: 5 times/week, therapy groups and 3-5 times/week, group counseling such as psycho-educational groups); therapy groups include family or sexuality issues, why the kids are there, they are challenging (peers confront one another)	Accepting accountability, identifying risk factors (Has a sex offender treatment, fantasy group/journal, and spiritual development group)
	What issues/topics are addressed?	Sexual fantasies, sex education, issues in the milieu, coping styles, family/interpersonal issues, risk for re-offending, anger management	Psycho-educational groups include an emotions, social skills, values enhancement, chemical dependency, and anger management group	Some psycho-educational, anger management, dormitory behavior, what is offending, understanding the cycle, masturbation
	How many youth in a group?	Varies	Most groups are chosen by program except specialty groups (ie: CD groups)	Varies
	How do you decide who participates in the group?	Based on treatment team decision	By program	Based on treatment team decision
	What, if any, educational components are provided?	What is an offender, the sexual offense cycle, sex education, social skills training, coping strategies	Listed above	Listed above
	Is confrontation used in the groups?	Yes	Yes, peer confrontation is encouraged; not abusive confrontation	Yes, to help identify distorted thinking, clarify misconception, encourage details, etc.
d.	Does the program focus on the youth's history of abuse or on the pattern of offending?	On the pattern of offending because that's why the youth are in the program	On the pattern of offending because that's why the youth are in the program	On the pattern of offending because that's why the youth are in the program
		Program A	Program B	Program C
e.	What kind of treatment/interventions do the direct care takers provide?	A mix of behavior modification (level system) and PPC; social skills training, anger management, process client's reactions to various stimulus	A mix of behavior modification with level systems and PPC; staff are role models and nurturing	Behavior modification; provide support; at least 1 attends therapy groups; serves as a "primary" to help client process info and provide alternatives
	Is behavior modification or Positive Peer Culture (PPC) used?	Yes (see above)	Yes, PPC is explained in the pre-placement interview; youth check-in group after school, support one another; PPC also used as an intervention; sometimes youth initiate PPC, otherwise staff prompt them; keeps issues of control in check	There are components of PPC, but nothing formalized; peer involvement is limited
f.	Why did you choose the treatment methods you use? Based on what?	As a result of SACY criteria	Literature supports the use of group work; SACY regulations guide program treatment components; look at what other successful programs are doing; based on what has worked in the past	Evolution from adult treatment models, 12- step programs; addictions; looked at other juvenile sex offender programs; developmental component
7.	What is the program's view on confrontation in general? How confrontational is the program?	Assertive confrontation is used and considered appropriate and necessary	Yes, as mentioned above, peer and staff confrontation used in a supportive manner	Confrontation is used because it's more difficult to manipulate in a group than individually; not hard core
8.	Approximately how long do the youth stay in this program before completion?	Until they're ready (1-3 years)	18-24 months has been average; starting to become longer due to low IQ and maturity levels	Residential: 2-2 ½ years Outpatient: 1 year
9.	What do clients need to do to be deemed appropriate to leave the program?	Must have a clear understanding of their issues and an ability to implement a relapse prevention plan; SACY must deem appropriate to be in the community	80-90% of their ITP goals should be met; must express empathy; must role play or engage in a real apology session with their victim	Accept accountability, identify risks, do assignments/victim presentations, do an autobiography; know the offense cycle; relapse prevention plan

 
 

D. UPON COMPLETION OF THE PROGRAM:
 

		Program A	Program B	Program C
1.	What is the completion rate of clients?			Residential: 80-90% Outpatient: 60-70%
2.	What kind of follow up/outpatient is recommended after the completion of the program?	All youth receive outpatient/follow up care; must continue to participate in individual and group therapy	All youth receive outpatient/follow up	Mandatory for residential clients for 3 months to 1 year; individual and family therapy offered
3.	Do you follow the success/recidivism of your clients once their discharged?	No; there are legal issues with this involving confidentiality; it's very hard to follow clients	Yes; there are 2 after-care coordinators who have monthly phone contact for 6 months, then every 3 months for up to three years (for kids who finish treatment)	Yes; there is a 6 month and 1 year questionnaire; get information from caseworkers
4.	How do you know if your treatment was successful?
a.	Short term?	No re-offense; participate in outpatient	Assessed by after-care workers; no re-offense; participate in outpatient	No re-offense; no jail
b.	Long term?	Cannot tell long term	After-care workers follow for up to three years; cannot determine client functioning as adults	Cannot tell long term
c.	How do you know which part of the treatment leads to successful outcomes?	Don't know	Don't know	Don't know

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

E. PROGRAM EVALUATION:
 

		Program A	Program B	Program C
1.	What kind of program evaluation does your agency do?	Quality assurance (for documentation); SACY audits	Quality assurance (for documentation); periodic program evaluations; they are part of a corporate chain based in MN that looks at programs; audits; flow of information with sister program; follow up surveys to families, Caseworkers and Probation officers	Informal: case reviews/staffings on clients through which trends are discovered; feedback from staff; communication with colleagues; surveys of clients and staff of satisfaction

 
 

F. PROBLEMS WITH TREATMENT:
 

	What are the problems you encounter with...
1.	Treatment?	Inability of youth to accept responsibility	Working with humans who make mistakes; families are hard to work with (keep family secrets); obtaining all background information	Lack of family involvement; lack of adequate background information/ documentation about offenses
2.	Working with this type of population?	Challenging, can be aggressive and need other types of treatment (ie; psychiatric); lack of a positive male influence; lack of family support & involvement	Staff sometimes traumatized by youth behavior and/or histories; change is slow and hard to see sometimes (can be frustrating)	secondary traumatization of staff; burnout
		Program A	Program B	Program C
3.	What other problems do you face?	Staff issues- difficult to train, can be inconsistent, are not able to follow through with PPC techniques consistently, since they aren't therapists they don't always understand underlying principles, staff can be reactive and also power/control seeking	Programs need to be smaller to provide more individualized attention; burn out and training of staff; trying to get a hold of people (probation officers, caseworkers, etc.); getting people on board to do what's in the best interest of the clients	long term evaluation of program success; insufficient resources (monetary); transportation for outpatient clients and for families

 
 

G. POLICY:
 

1.

What policy issues need to be addressed?

Consistency with legal system (doesn't always hold youth accountable for aggressive behavior); consistency within the state is not good (some clients end up in prison when others do not)

Working with governing agencies (inappropriate attempts by DCFS to step youth down when they are not appropriate for such a move); kids are there too long due to lack of appropriate placements following treatment

Finding placements for youth upon discharge from the residential program

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

References

Becker, J.V. (1988). Adolescent sex offenders. Behavior Therapy, 11, 185-187.

Bourke, M.L., & Donohue, B. (1996). Assessment and treatment of juvenile sex offenders: An empirical review. Journal of Child Abuse, 5, 47-70.

Burton, D.L., Nesmith, A.A., & Badten, L. (1997). Clinician's views on sexually aggressive children and their families: a theoretical explanation. Child Abuse & Neglect, 21, (2), 157-170.

Caputo, A.A., Frick, P.J., Brodsky, S.L. (1999). Family violence and juvenile sex offending: the potential mediating role of psychopathic traits and negative attitudes toward women. Criminal Justice and Behavior, 26, (3), 338-356.

Chorn, R., Parekh, A.D. (1997). Adolescent sexual offenders: a self-psychological perspective. American Journal of Pyschotherapy, 51, (2), 210-228.

Ertl, M.A., & McNamara, J.R. (1997). Treatment of juvenile sex offenders: A review of the literature. Child and Adolescent Social Work Journal, 14 (3), 199-221.

Federal Bureau of Investigation. (1993). Uniform crime reports for the United States, U.S. Department of Justice, Washington, DC.

Griffin, S., Williams, M., Hawkes, C., & Vizard, E. (1997). The Professional Carers' Group: supporting group work for young sexual abusers. Child Abuse and Neglect, 21, 681-690.

Hudson, S.M., & Ward, T. (2000). Interpersonal competency in sex offenders. Behavior Modification, 24, (4), 494-527.

Hunter, J.A., & Figueredo, A.J. (2000). The influence of personality and history of sexual victimization in the prediction of juvenile perpetrated child molestation. Behavior Modification, 24, (2), 241-263.

Kaplan, M.S. & Becker, J.V. (1992). Adolescent perpetrators of incest. In R.T. Ammerman & M. Hersen (Eds.) Assessment of family violence. [332-347]. New York: Wiley.

Kraemer, B.D., Salisbury S.B., Spielman, C.R. (1998). Pretreatment variables associated with treatment failure in a residential juvenile sex-offender program. Criminal Justice and Behavior, 25 (2), 190-202.

Muster, N.J. (1992). Treating the adolescent victim-turned-offender. Adolescence, 27, (106), 441-450.

Pithers, W.D., Gray, A., Busconi, A., & Houchens, P. (1998). Caregivers of children with sexual behavior problems: psychological and familial functioning. Child Abuse & Neglect, 22, 129-141.

Rubenstein, M., Yeager, M.A., Goodstein, B.A., & Lewis, D.O. (1993). Sexually assaultive male juveniles: A follow-up. American Journal of Psychiatry, 150, 262-265.

Ryan, G., Miyoshi, T.J., Metzner, J.L., Krugman, R.D., & Fryer, G.E. (1996). Trends in a national sample of sexually abusive youths. American Academy of Child and Adolescent Psychiatry, 35, (1), 17-25.

Ryan, G. (1998). What is so special about specialized treatment? Journal of Interpersonal Violence, 13, (5), 647-652.

Ryan, G. (1999). Treatment of sexually abusive youth. Journal of Interpersonal Violence, 14, (4), 442-436.

Shaw, J.A. (1999). Practice parameters for the assessment and treatment of children and adolescents who are sexually abusive of others. Journal of American Academy of Child and Adolescent Psychiatry, 38, (12), (Suppl.), 55S-76S.

Worling, J.R., & Curwen, T. (2000). Adolescent sexual offender recidivism: success of specialized treatment and implications for risk prediction. Chile Abuse and Neglect, 24, (7), 965-982.