See other articles in PMC that cite the published article. Abstract This article raises serious concerns regarding the widespread use of unproven interventions with juveniles who sexually offend and suggests innovative methods for addressing these concerns.
Methodologically sophisticated research studies i. The moral and ethical mandate for such research is evident when considering the alternative, in which clinicians and society are willing to live in ignorance regarding the etiology and treatment of juvenile sexual offending and to consign offending youths to the potential harm of untested interventions.
Encouraging signs of a changing ethical climate include recent federal funding of a randomized clinical trial examining treatment effectiveness with sexually offending youths and the introduction of separate i.
Furthermore, the annual costs associated with sexual victimization in the U. Social and fiscal costs are also borne by sexual offenders, many of whom are removed from their families and placed in confinement for years and then required to publicly register for their offenses, often for 25 years to life.
Therefore, effective interventions are needed for offending youth to reduce sexual victimization and to increase the likelihood that such youth can become law-abiding and productive citizens. The present article seeks to address what we believe are serious ethical concerns posed by the most widely used treatments for juveniles who sexually offend. We argue that the red flag raised by Chaffin and Bonner about the inadequacy of the empirical base for treating juvenile sexual offenders has not been lowered.
Indeed, there has been an almost complete lack of rigorous research on effective interventions for juvenile sexual offenders. We bear a moral duty to increase scrutiny of extant treatment approaches and to develop new and innovative approaches that are effective and that clearly do no harm.
In the subsequent sections of this paper, we describe characteristics of juveniles who commit sexual offenses, typical treatments for these juveniles, and the current state of treatment outcome research with juvenile sexual offenders. We then describe treatment and research gaps and the ethical problems entailed by these gaps, and we end with suggestions for improving the current ethical climate in the treatment of juveniles who sexually offend.
Characteristics of the Population The development of effective interventions for juveniles who sexually offend requires an understanding of the correlates and causes of sexual offending in youths. Likewise, juvenile sexual offenders have verbal skills i. Peer Relations Studies have shown that juvenile sexual offenders are more likely to be socially inept and isolated from same-age peers than are other juvenile offenders or nondelinquent youths Blaske et al.
Moreover, this latter study found that juvenile sexual offenders, similar to other delinquent youths, associate more extensively with deviant peers that do nondelinquent youths.
School Factors Juvenile sexual offending has been linked with academic and behavioral difficulties in school, including low achievement, below expected grade placement Fehrenbach et al. However, direct comparisons of sexually offending and nonsexually offending delinquents e. In conclusion, predictors and correlates of juvenile sexual offending behavior parallel those of nonsexually delinquent youth and occur across the ecological systems in which youths are naturally embedded.
As is described next, however, the most widely used treatment model for juveniles who sexually offend generally fails to address behavioral drivers that occur beyond the individual youth and focuses heavily on factors that might not predict youth sexual offending e.
Current Treatments Specialized treatments for juveniles who have engaged in sexually aggressive behavior have been widely available since see Knopp et al. A survey of current programs indicate few substantive changes since the development of specialized treatments McGrath et al. Nearly all programs responding to the McGrath et al. These treatment targets are often addressed in separate modules that each last for several weeks and include specific homework assignments and group exercises.
Community-based treatment groups usually meet hours per week, whereas residential treatment groups often meet for hours per week McGrath et al. Individual and family sessions are held less frequently, and neither peers nor schools are regularly targeted in typical interventions McGrath et al. Although the research literature reviewed earlier strongly indicates that sexually offending youths are influenced by multiple ecological systems, most current treatments focus heavily on presumed psychosocial deficits in the individual youth.
For example, a frequent emphasis on reduction of deviant sexual arousal does not correspond with what is known about juveniles who sexually offend. Another problem with the predominant approaches to treatment is the fact that many sexually offending youths desist from future offending even in the absence of intervention.
The same issue has been raised regarding the relapse prevention RP model as used with adult offenders see e. Given the apparent disconnect between the drivers of juvenile sexual offending behavior and the prevailing treatment approach i. This literature is reviewed next. Importantly, none of these three studies involved random assignment to treatment conditions. There are several reasons why the CBT-RP treatment approach might not represent the most effective care for juvenile sexual offenders.
First, as noted previously, core treatment targets in CBT-RP do not appear to map well onto known correlates of sexual offending behavior. To be effective, interventions need to move beyond a focus on the individual youth to address behavioral drivers that occur at the family, peer, school, and community systems in which the youth is embedded. In fact, treatment outcomes might be negatively affected by the group and residential settings used in CBT-RP.
Residential treatment carries additional risks beyond the potential for deviancy training. In sum, the need for more effective treatment approaches than the CBT-RP model for juvenile sexual offenders seems clear. Indeed, across studies and in spite of considerable variation in research methods and measurement e. The aforementioned literature and a recent report from a prospective, longitudinal study van Wijk et al. Thus, we would argue that treatment approaches must have the flexibility to address the known correlates of such offending.
Moreover, because there is considerable overlap in the correlates of juvenile sexual offending and nonsexual offending, it seems reasonable to suggest that broad-based treatments that are effective with nonsexually offending delinquent youths may hold some promise for the treatment of sexual offenders as well Milloy, Three intervention models that have been identified as effective for treating nonsexually offending delinquent youths are Functional Family Therapy FFT; Alexander et al.
These treatment models are family- and community-based, use behavioral intervention techniques, and are individualized and comprehensive to address multiple problems among juvenile offenders and their families. Furthermore, each of these models has strong quality assurance protocols to support treatment fidelity and to overcome barriers to desired clinical outcomes.
As described in subsequent sections of this paper, findings from several studies already support the potential viability of MST with juvenile sexual offenders.
Prior to reviewing the MST studies, we first suggest reasons why failing to subject interventions to empirical evaluation represents an ethical concern and why this failure has occurred specifically with regards to juvenile sex offender treatment. Klin and Cohen argued persuasively for an ethical mandate to conduct empirically rigorous research in child and adolescent psychiatry. Klin and Cohen noted that an acknowledgement of ignorance is ethical but insufficient—where there is ignorance there is also a mandate for responsible, respectful, and continued research.
Members of these organizations are mandated to provide care that adheres to the highest scientific standards. Given these ethical imperatives and the numerous public and private agencies devoted to funding research on mental and behavioral health problems, why is there so little research on treatments for juveniles who sexually offend? As noted by Wagner, Swenson, and Henggeler , some professionals who work with juvenile sexual offenders have argued that it is unethical to randomly assign youths to groups to evaluate treatment effectiveness and that the best care should be provided to everyone.
A number of prominent researchers e. Both the intolerance to randomization and the willingness to deliver treatment as yet untested by rigorous research must be challenged.
Randomized clinical trials are the most powerful and ethically defensible way to evaluate treatments for juveniles who sexually offend. The first was a federally-funded study that began in and aimed to examine the feasibility of treating high risk sex offenders in community settings.
Compromises to the original project design, low referral rates, and high attrition ultimately resulted in sample sizes too small to support treatment outcome analyses D.
Laws, personal communication, February 28, The second trial i. The treated and untreated groups did not differ in their sexual recidivism rates i. We believe that the combined failure of these three studies to support CBT-RP had a chilling effect on federal funding for sex offender treatment research. The report acknowledged an absence of empirical support for most assumptions about the characteristics of juvenile sexual offenders and relied on consensus by the report authors in making treatment recommendations.
The treatment practices recommended by NAPN for juvenile sexual offenders were based largely on interventions developed for adult sexual offenders, with few adaptations to address salient developmental differences between these populations.
Unfortunately the NAPN recommendations had the appearance of established and highly regarded treatment guidelines. We believe that the presumed need for specialized treatment for juvenile sexual offenders, coupled with the popularity of the CBT-RP model for adult sexual offenders, likely contributed to the unbridled acceptance of the NAPN recommendations and a willingness among professionals from various disciplines to ignore the lack of treatment outcome research for juvenile sexual offenders.
Pessimism About Sexual Offender Treatment Effectiveness A third contributing factor to the lack of treatment outcome research is a general consensus that treatment does not work. These statements provided little hope that treated youth would or could improve. Such pessimism seems largely unjustified. Pessimism regarding treatment effectiveness is also reflected in state and federal legislation pertaining to juvenile sexual offenders.
Sex-offender-specific legislation began proliferating throughout the U. The recently enacted Adam Walsh Child Protection Act , for example, requires juveniles who are as young as 14 years of age and convicted of certain sexual crimes e. Some individual state laws are even more draconian. In passing such bills, federal and state legislators have ignored or discounted evidence regarding the low recidivism rates of juvenile sexual offenders, suggesting that the majority of elected officials simply refuse to believe that juvenile sexual offenders can be effectively treated outside of prison walls.
In addition, several states e. These laws can have the unfortunate effect of prohibiting the implementation of newer, evidence-based interventions.
In direct response to this concern, some boards are developing protocols to permit the implementation of evidence-based interventions M. Novel Ways to Improve the Current Ethics Climate We have presented a bleak picture of the state of research on treatment outcomes for juveniles who sexually offend. There are several encouraging signs, however, that suggest the treatment and research communities are ready for change.
Matching Treatment to Psychosocial Needs MST has been in development for more than 25 years and is widely regarded as one of the best validated treatments for juvenile nonsexual offenders Elliott, ; U. Department of Health and Human Services, Family systems theory views the family as a rule-governed system and an organized whole that transcends the sum of its separate parts.
From this perspective, it is assumed that problematic individual behaviors and symptoms are intimately related to patterns of interaction between family members and must always be understood within the context of those interaction patterns. Thus, a therapist working from a family systems conceptual framework would consider not only how parental discipline strategies influence youth antisocial behaviors but also how the antisocial behaviors of the youth shape and guide the behaviors of the parents, and what function the antisocial behaviors might serve in the family.
Thus, although the interactions between the youth and family or peers are seen as important, the connections between the systems are viewed as equally important. It is assumed, then, that youth behavior problems such as sexual aggression can be maintained by problematic transactions within any given system or between some combination of pertinent systems. To more fully account for clinical issues relevant to juveniles who sexually offend, investigators have adapted MST for use with this population, specified the adaptation in a supplemental therapist training manual, and developed a training program for therapists and supervisors.
To date, two completed studies have examined the efficacy of MST in addressing sexual offending by juveniles and an on-going study is examining the effectiveness of MST with this population. Youths and their families were randomly assigned to treatment conditions: Recidivism results at 3-year follow-up were encouraging.
Significantly fewer youths in the MST condition were rearrested for sexual crimes Furthermore, the mean frequency of rearrests for nonsexual crimes was lower for the youths who received MST 0. Youth were randomly assigned to MST or usual services a combination of cognitive-behavioral group and individual treatment administered in a juvenile court setting. Compared to youths who received usual services, youths who received MST showed improvements on a range of instrumental outcomes immediately following treatment, including fewer emotional and behavioral problems, less delinquent behavior self-reported , improved peer relations, improved family relations, and better grades in school.
Importantly, these outcomes did not vary on the basis of youth and family background variables or pretreatment arrest characteristics. In a study that applied a cost-benefit model for criminal justice programs Washington State Institute for Public Policy, to the results of the Borduin and Schaeffer 8. The positive outcomes demonstrated by the two efficacy trials laid the foundation for our current effectiveness trial funded by the National Institute of Mental Health.