Dwyer, R.G., and E.J. Letourneau. (2011). Juveniles who sexually offend: Recommending a treatment program and level of care. Child and Adolescent Psychiatric Clinics of North America, 20(3), 413-429.

By Lori Whitten, Staff Writer, RTI International, Rockville, MD

Adolescents commit an estimated 23 percent of all sex offenses and are responsible for 4 percent of all such offenses against adults and 33 percent of those against children of all ages. These estimates are consistent with national arrest data from 2008, in which adolescents accounted for 15 percent of forcible rapes and 18 percent of sex offenses other than forcible rape and prostitution.

R. Gregg Dwyer, M.D., Ed.D., of the Medical University of South Carolina, and Elizabeth J. Letourneau, Ph.D., of the Johns Hopkins School of Public Health, reviewed the still-evolving field of juvenile sex offender treatment to determine how mental health professionals should best evaluate, treat, and assess recidivism risk for adolescent sex offenders. The authors found that methodologically sound longitudinal studies of this population were lacking but that many effective and empirically based treatments for these youth have been developed (see table).

The authors say that risk-assessment methods to predict future offenses among these young people require more empirical support and that such data could help identify protective and risk factors and appropriate targets for treatment and management. With these important steps, treatment specialists will be able to continue to improve and advance family-focused therapies that protect both young offenders and those in the community.

Historically, two ideas have dominated the approach to addressing juvenile sex offenders: (1) such offenders are viewed as adults, so adolescent development and other differences need not be taken into consideration in therapy; and (2) such offences stem from traits that are not modifiable, so the goal of treatment is to control rather than change behavior. But Dwyer and Letourneau assert that evidence refutes these ideas. They point to the fundamental problems of one-size-fits-all treatments and the failures inherent when applying therapies developed for adults to juveniles, who are not yet physically, cognitively, emotionally, and socially mature.

The field is beginning to shift away from these old ideas, according to the authors, and is now in the process of embracing a new paradigm. This new view holds that

• sexual offending is a behavior rather than a diagnosis;
• these juveniles are not a homogeneous population;
• sexual development runs along a continuum from normalcy to deviancy, with no clear line between normal and pathologic; and
• there is no universal or dominant explanation for juvenile sex offending.

A shift to a new mindset about juvenile sex offenders requires changes in the approach to treatment and evaluation. To tailor therapy to the individual, the authors say that mental health professionals must conduct a comprehensive evaluation to identify the behavior’s cause, risk factors, and treatment targets as well as other problems unrelated to sexual offending. During evaluation, therapists should gather clinical information from records and interviews with youth, parents or caregivers, and other relevant individuals. Young sexual offenders and their parents or caregivers should complete assessment instruments. Mental health professionals may also test for physiological abnormalities (e.g., hormonal, sexual arousal patterns), and therapists should continue to evaluate patients throughout treatment.

To address the many different needs identified during evaluation, the authors say therapists should use comprehensive, flexible, and family-focused treatment and management methods rather than the obsolete standard approach. According to the authors, the duration of an intervention often appears to exceed what is necessary, with residential treatments frequently lasting between 1 and 2 years, and community-based treatments often exceeding a year. These durations should be reviewed and realigned with youth and family needs, the authors assert, and not based on widely held conceptions regarding the necessary duration of treatment.

A growing body of evidence indicates that the most promising treatments for young sexual offenders target specific factors related to an individual’s sexual offending behavior. These factors may include general delinquency, antisocial tendencies, atypical sexual interests (e.g., sexual interest in prepubescent children or coercive sex with peers or adults), and history of child sexual abuse victimization. Research also suggests that some factors—for example, empathy with the victim or distorted cognitions about coercive sex or sex with children--do not predict re-offending and should not be a significant focus of treatment.

Risk assessments for youth recidivism influence many critical decisions involving treatment intensity, supervision requirements, confinement to secure facilities, and whether a youth should confined to a secure facility, or register as a sex offender and be subject to community notification. Dwyer and Letourneau say that national standards for conducting such assessments would be helpful but are not currently available, and that the methods for evaluating recidivism have yet to be fully established. Although mental health professionals currently rely on various risk-assessment instruments, the authors caution that the evidence supporting the value of these tools is limited.

Dwyer and Letourneau suggest that the field needs to develop longitudinal research to identify risk and protective factors for juvenile sex offending as well as rigorous treatment outcomes studies. Such research will help therapists customize treatment to the needs of youths and foster their development into healthy and productive adults.

For more information contact Dr. R. Gregg Dwyer, Medical University of South Carolina in Charleston, SC, dwyer@musc.edu, and Dr. Elizabeth J. Letourneau, Johns Hopkins Bloomberg School of Public Health in Baltimore, MD, eletourn@jhsph.edu.

Treatments for Juveniles Who Sexually Offend

Various evidence-based therapeutic models for youth sex offenders are currently in use.