Working with Youth and Adults with Cognitive Impairments and Developmental Delays who Have Sexually Problematic Behavior:The Easter Seals Experience
Working with Youth and Adults with Cognitive Impairments andDevelopmental Delays who Have Sexually Problematic Behavior: The Easter Seals ExperienceCrystal Cookman, M.A. Robert Kinscherff, Ph.D., Esq. Derek Edge, M.A. James Mlynarski, M.S.Mandy Graves, M.S.W. Elizabeth J. Shepherd, Ph.D.
Easter Seals Mission StatementEaster Seals provides exceptional services to ensure that all people with disabilities or special needs and their families have equal opportunity to live, learn, work and play in their communities.
Easter SealsCommunity Based Services Adult Services Preventative Services Program
Program ParticipantsIndividuals with: Developmental Disabilities Mental Health needs Mental Retardation Traumatic Brain InjuryIn addition to – or in combination with – the above categories, participants in the preventative services program also are treated specifically for high-risk behavior.
Easter Seals New HampshireAs an affiliate of the national organization, we provide services in: New Hampshire, Vermont, Rhode Island, Maine, New York. Our headquarters are located in Manchester, NH.Agency (New Hampshire only) $53 million operating budget in NH CBS -14 million Preventative Services – $2.9 million (of CBS) 25,000 people served in NH in 2008 CBS – 350 people served Preventative Services – 58 $3.2 million free services in 2008
Development of Preventative Services2004 – Referral for 3 person home and 2 EFCplacements.Reviewed number of eligible clients already in servicesOffered specialized service - hired skilled ResidentialManager with specific training and skills.Increased behavioral support – added behavior specialistBegan offering counseling with graduate interns2006 - Received contract for entire region2008 – Hire F/T clinician, additional Behavior Specialist2008 – Hire Dr. Kinscherff, initiate Assessment Team,integrate agency-wide services and clinicians
Preventative Services58 people served (not including assessment services) 13 – Staffed residential services 10 – Enhanced family care 4 – Supported living 3 – Vocational support 28 – Counseling services 8 – Residential/Vocational programs in development. $2.9 million gross revenue (with $700,000 additional services in development)
Preventative Services30 People Served in Day & Residential Services Male - 80% (24/30) Female - 20% (6/30) Court involvement - 67% (20/30) History of incarceration - 27% (8/30) Registered Offenders - 6% (2/30)
Preventative Services/CBS Program Staff67 – Program Staff/Direct Support7 – Utility Staff cross trained in multiple programs9 – Program Managers2 - Behavior Specialists1.5 – Clinician/Therapist2 – Assessment Specialists1 – Occupational Therapist1 - Clinical Director1- Residential Director
Clinical ServicesCrisis Supports/24-hour support networkTherapy/Counseling ServicesAssessment ServicesBehavior Support ServicesOccupational TherapyNursing Services
Programs – CBSResidential Services Day / Vocational 24 hour staffed Services residential homes Job Development Enhanced Family Care Job Coaching Companion/Paid Transportation roommate Transition programs Respite Services for Recreation Providers and Families Educational/ Independent Living Functional Learning
Treatment of Adults withProblematic Sexual Behavior
Differences between Registered SexOffenders and Problematic Sexual BehaviorRSO PSBTreatment Treatment Motivational Cognitive Behavioral Therapy/In vivo Interviewing Opportunistic/ Predatory Reactive/ Group session Impulsive Missed Individual, Group, session=violation of Family Therapy parole “Perfect Storm” Theory Treatment Flower Analogy
Limited ConfidentialityMulti-disciplinary team approachStaff involved in sessionNo secretsWorking on developing a sign off sheet fortreatment
Individualized PlanningAssessments identify strengths andchallengesTeam approach (input from all teammembers)Assess what motivates client, what aretheir interests
Adult Clients ServedHeterogeneous groupOpportunistic/Reactive v. PredatoryHigh Risk Behavior (anger, self injurious, PSB)Mental health diagnosisDevelopmental Delays
Risk TolerancePopulation specificAlone TimeIdentify risk in terms of PSB as well asperipheral risks (anger, anxiety, etc) andhow they interactResponsibility of team to defineparametersMonthly meetings with team
Step ProgramPlan developed by therapist and behaviorspecialistPurpose: relaxing supervisionStability in supportive factors to notreoffendOutline what is to be tracked
Step ProgramStep 1(Day 1-30)NO Target Behavior - 1(Day 1- Step 5(Day 121-150)No Target Behavior- 5(Day 121- Behavior-Skills Rehearsed with reminders and with ¾ hr. at residence, ¾ hr. instaff cues. (See attached skill sheet). community. Phone check-ins every check-Tools will be reviewed 2x’s/day with 2x’ 1/4hr.HCP. (See attached documentationrequirements). No alone time. Step 6(Day 151-180)No Target Behavior- 6(Day 151- Behavior- 1hr. at residence, 1 hr. in community.Step 2(Day 31-60)No Target Behavior - 2(Day 31- Phone check ins-every 1/4 hr. ins-Skills Rehearsed with or w/o reminders, with documented and submitted tostaff/HCP cues.½ hr. alone time at cues.½ Therapist and CM.residence, with phone check in every10 minutes by HCP-to be documented HCP- Step 7(Day 151-180)No Target Behavior- 2and given to therapist and CM. 7(Day 151- Behavior- hrs./day unsupervised in the community-1 day/work. Phone check community-Step 3(61-90)No Target Behavior – Skills 3(61- ins-every 1/4 hr. documented and ins-Rehearsed without reminder1/2hr. reminder1/2hr. submitted to Therapist and CM.2x’s/day alone time at residence-non-2x’ residence- non-consecutive-with phone check-insconsecutive - check- **Check-ins to occur at least as listed in **Check-every 10 minutes. By HCP. each step. Sporadic check-ins are check- encouraged.Step 4(Day 91-120)No Target Behavior, 4(Day 91-Skills Rehearsed without reminder½ hr. at reminder½residence-15 min. phone check-in byresidence- check-HCP, ¼ hr. w/o supervision.¼ hr. may supervision.¼be used for banking, library, orconvenience store.
Intensive Level Individualized TreatmentOur Customers needscome FIRST in all thatwe do, every day.WHATEVER ITTAKES!
Facilities for TreatmentZachary Rd FacilityBoys Group HomeGirls Group HomeCommunity ReadinessProgramIndividual ServiceOption (ISO)
Education/Training of StaffMust be 21 years of ageBachelors’ level: Residential staffMasters’ level: Clinical staffMonth long training and observation ofresidents before working on the floor
ClientsMales/Females age 13 – 21School placement, DCYF, or on ProbationES takes any child “no reject or eject policy” –minimize hospitalizations (unique)Cognitive capabilities: the full scale MR,borderline, to normal rangeMost children arrive with a simple assault charge
TreatmentStandard Treatments Alternative Treatments Individual Therapy Community Inclusion Group Therapy Therapy session with staff present Individual Counseling Chaperone training for Psychiatry the staff (risk Medication management) Nursing “REWIND” Treatment Case management TCI OT, PT, Speech Mirror Reality Session in community
Brief Case ExamplesThe best way to explain how Easter Seals doesthings differently with youth with cognitivedisabilities is to give some examples. Jonny; Description, issues, treatment John ; Description, issues, treatment Dustin; Description, issues, treatment Travis; Description, issues, treatment
Risk Assessment of Individuals with Disabilities
Center for Sex Offender Management A Project of the Office of Justice Programs, US Dept of Justice www.csom.orgSex offenders with developmental disabilitiespose as clear a threat to public safety as sexoffenders without developmental disabilitiesDevelopmental disabilities do not cause orexcuse sexual offendingSex offenders with developmental disabilitiesshould be provided treatment that is appropriateto their developmental capacity and their level ofcomprehension
Center for Sex Offender Management A Project of the Office of Justice Programs, US Dept of Justice www.csom.orgTo assess effectively whether a sex offenderwith developmental disabilities can beadequately managed in the community… Evaluate the offender’s level of cognitive impairment to gauge his or her suitability for community supervision Work with treatment providers who are knowledgeable about sex offending behavior and have treated developmentally disabled individuals Work intensively with personnel from mental health and social service departments, group home staff, and others who may be involved closely in the offender’s daily life
Standards of Practice for Sex Offender Treatment Programs in New HampshireAssessment • Prior to entering a contractual agreement for treatment, the offender shall participate in an assessment/evaluation. At a minimum, this should include a clinical interview, which consists of: 1. A complete history including social, sexual, criminal, medical, and substance abuse; 2. The dynamics of the sexual offending behavior; 3. Identification of problem areas and treatment goals.
Methods of ReferralAdolescents: Easter Seals Residential Facilities Intensive Level Treatment Units Group Homes Co-Occurring Program Autism Clinic Juvenile Delinquency Matters
Methods of ReferralAdults: Bureau of Developmental Disability Area Agencies “updates” Transition from adolescent services Transition from prison Transition from Designated Receiving Facility Positive on criminal background check Easter Seals Community Based Programs “updates” Transfer from another agency Change in level of supervision (least restrictive setting) Court System
Case Types (Completed or In Progress)Adults – 37 (4 female, 33 male)Adolescents – 10 (1 female, 9 male)Sexual Risk – 28 Transition to least restrictive setting – 4 Decrease level of supervision – 3 Transition to adult services – 4 To obtain agency services – 5 Civil Commitment – 1 Ability to be around children – 1 Ability to return to family home - 2 Updated assessment – 5Violence Risk – 12 Youthful Offender – 2 Transition to adult services – 3 To obtain agency services - 1 General risk of harm to self or others – 6 Updated assessment – 3Other case types include: Criminal Responsibility, Competency to StandTrial, Munchausen by Proxy and fire setting
Living Situations of EvalueesFamily home – 7Residential facility – 9Foster care - 1Enhanced foster care – 6Staffed home – 2Provider home – 4Independent living – 4State hospital – 2Jail – 6Designated Receiving Facility - 2
General Standards of Practice in Risk AssessmentApproaches: Clinical assessment Actuarial assessment Guided-clinical assessment Adjusted actuarial approachThe “standard” approach is a combination of: Actuarial assessment tools Structured clinical interviewingDerived from evaluation of adult male sexoffenders
General Principles of Forensic AssessmentClear identification of the referral source and theclientKnowledge of guardianship issuesUnderstanding of legal status of caseInclude multiple sources of informationcombined with a thorough file reviewCorroborate information obtained when possibleRespect the scope and limitations of the data
Some Standard Assessment ComponentsDiscussion of informed consent and limitationsof confidentialityRecord reviewInformation from third partiesClinical interviewing Assessment of mental status Assessment of history (e.g., family, psychiatric, educational, vocational, medical, sexual)Administration of assessment measuresWritten reportFeedback session
Some Typical Assessment Issues and Goals What was the problematic behavior? What was the motivation for the behavior? What was the purpose of the behavior? What was the context of the behavior? Each client has a unique set of characteristics and/or risk factors that are tied to the risk they pose in any given situation.
Some Atypical Assessment IssuesWhat is the motivation for the behavior? Criminal intent? Antisocial tendencies? Psychopathy? Deviant arousal? Sexually reactive? Underlying psychiatric disorder? Cognitive/developmental proclivities? Attention seeking? Sadness, anger, fear? History of abuse/neglect? Over-sexualized history?
More Atypical Assessment IssuesHomogeneity of the behavior, but…Heterogeneity of the population.Differential diagnosis Clinical issues vs. assessment of riskRelated issues and risks: Exploitation Other criminal activity Daily functioning and adaptive skills Supports
Types of Assessment ToolsObjective/LaboratoryActuarialEmpirically ValidatedStructured Clinical JudgmentClinical Assessment Tools
Typical Risk Assessment ToolsLaboratory Tools Penile Plethysmograph Abel Assessment of Sexual Interest-2 (AASI-2) PolygraphActuarial Tools STATIC-99 STABLE & ACUTE-2007 Hare Psychopathy Checklist Violence Risk Assessment Guide (VRAG) Sexual Offender Risk Assessment Guide (SORAG) Level of Service Inventory – Offender (LSI-O)
Typical Risk Assessment ToolsEmpirically Validated Novaco Anger Scale State-Trait Anxiety Inventory-II (STAXI-II) Suicide Probability ScaleStructured Clinical Judgment Tool HCR-20 Risk for Sexual Violence Protocol (RSVP) Structured Assessment of Violence Protocol in Youth (SAVRY) Adult Sex Offender Assessment Protocol (ASOAP) Juvenile Sex Offender Assessment Protocol (JSOAP)
Typical Risk Assessment ToolsClinical Assessment Tools Abel & Becker Sexual Interest Card Sort (questionnaire version) Bumby Cognitive Distortions Scale Child Sexual Behavior Questionnaire
Challenges in Applying These Tools to Individuals with Disabilities Norming samples Face validity Construct validity Counterfeit Deviance Philosophy of Risk Tolerance: Human Rights versus Public Protection Questionnaires and self report
Applying Risk FactorsWould our population skew the sample? Static Factors where this population may be overrepresented due to disability Live with biological parents School maladjustment Male victims History of being sexually victimized Static Factors: underrepresentation Age at time of offense Substance use Number of convictions Presence of violence
Applying Risk FactorsDynamic Factors Intimate relationships Employment Sexual preoccupation Phallometric testing Attitudes “condoning” sexual offending Higher level cognition: denial, remorse, empathy, self awareness Motivation for change and internalization of treatment
New Tools in DevelopmentGene Abel, MD – Georgia Abel-Blasingame Assessment System for Individuals with Intellectual Disabilities (ABID)Vermont Department of Corrections Treatment Intervention and Progress Scale for Sexual Abusers with Intellectual Disabilities (TIPS-ID)William Lindsay, PhD – Scotland Questionnaire on Attitudes Consistent with Sexual Offending Dynamic Risk Assessment and Management System Dundee Provocation Inventory
ConceptualizationEvaluation of identified risk factors Static Dynamic (stable, acute)Consideration of level of cognitive, emotional,social functioningIdentification of: Strengths Protective Factors Supports Times when the individual does well
Development of a Risk Management PlanDevelop a general relapse prevention plan Operationalize the contexts of higher and lower risk Identify high-risk situations and make plans to avoid and/or tolerate Provide support for healthy lifestyle reflecting the values of recovery Establish a support system of persons knowledgeable about the client and his/her offense cycleDetermine and provide level of support andsupervision needed
Development of a Risk Management PlanEvaluate: Engagement in treatment Effectiveness of treatmentConsider: Access to victim population Access/availability of triggers Past behavior: opportunistic vs. planful Exposure to/education on normative sexual education Legal issuesEstablish an alliance with the client regardingmanagement of the problem behaviorProvide motivation for the client to activelyparticipate in treatment and supervision
Other ThoughtsRisk assessment and management is anongoing process… Dynamic risk factors Changes in home, school, vocation, family, environment New relationships Emerging sexuality New developmental phases & challenges Onset of new behaviors… What has changed? Why now?
Background Information42 year old Caucasian maleBorderline Intellectual Functioning,Cerebral Palsy, PedophiliaSignificant language impairment, uses AACdevice.Raised in foster care in early yearsAttended residential school and graduatedfrom public school in NH
Background InformationFamily history of mental illness (paternal andmaternal)Family history of substance and alcohol abuseFamily has limited/severed most contact sinceconvictionWitness to domestic abusePhysically and sexually abused by parents/peersLong term social and emotional isolation
Vocational HistoryYogurt factory (post incarceration)Department of Education – SystemsTechnicianJanitor & substitute janitor – high school &elementary school (2 schools)Hardware storeDishwasherAssembly position
Legal HistoryNo prior arrests until 2005Arrested in sting operation in 2005 for attemptto solicit (what he thought) was a child.Also arrested for 2 counts of Child Pornography 2 counts of delivering child pornography 10 counts of child pornography in another countyPled guilty to all charges
SentenceNH DOC (county jail due to disability and pleaagreement)Entered April 2006, released April 2008Three years’ probation Required to attend Offender Treatment Required to have no unsupervised time with minors Required to have no computer accessRequired to register with the State of NH
MMPI-2Highly sensitive to criticism – can act with angerhostilityLongstanding distrust, expects unfair treatmentFails to take responsibility, tendency to blameOverly sensitive and rigid in relationships –thusnegatively impacting themOver-responds to perceived slights or rejectionLikely to resist treatment that doesn’t meet hisideas of his needs & wants
Bumby Cognitive Distortions ScaleAlthough in treatment – Mike failed to negatively endorse many rape/molestation items… Examples on Molestation Scale Positively endorsed more items then negatively endorsed Felt that offenders are unfairly punished Children are seductive and eager to have sex with adults Examples on Rape Scale Rape is the result of stress If women don’t resist they are willing
Abel Becker Sexual Interest Card SortEndorsed scenarios with adult males asmost arousingInconsistently endorsed pedophilicinterests in young boys and girlsRated none of the pedophilic, rape,sadism, masochism as repulsive and ratedmore than 1/3 as neither arousing norrepulsive
PlethysmographSignificantly high levels of response to all stimulidepicting sexual activity with boysSignificantly high levels of response toconsensual sex with male partnerShow significant levels to female child, but lessthan boysResponses conflict with self reportResponses indicate that his arousal pattern isnot likely to be exclusively pedophilic
FormulationCP – likely contributed to diminished social,emotional, and moral developmentHistory of poor social skills, diffused boundaries,over-attachment, misreads social cues, andsocial isolationAbove likely contributed to over-identificationwith children who are less threatening to himcompared to adultsEmotional naïve and quickly becomesemotionally attached to most males that areattentive to him
FormulationOperates primarily to avoid punishmentdemonstrating his limited moral developmentNo apparent empathy during interview; he neverseems to recognize the impact of his actionsLongstanding history of using maladaptivecoping skills to deal with sexual urgesPresents significant risk if restrictions areremoved prior to treatment and thedevelopment of internal prohibitions againstacting on pedophilic urges
TreatmentProgram Focus Areas:1. Interest Addressed in treatment settings – CBT, behavioral techniques, cognitive restructuring, basic education, etc.1. Access Environmental management model to provide oversight and safety Supervision
Interest vs. AccessInterest – Treatment Access – Program Social skills training Supervision Sex education & Perimeter and internal intimacy education alarms Legal education Staff supervision Relapse prevention Telephone/mail techniques screening Room/house searches
General Areas of FocusAdmission of offense Problem solving skillsResponsibility Managing impulsesSexual education Stable employmentSexual attitudes Stable residentialSexual interests Peer/family influencesOther high risk behavior Adult relationshipsCriminal attitude Attitude toward treatmentEmotion management Risk managementMH stability knowledgeStage of change Risk management application
General Stages of Treatment1. Stop high-risk/offending behavior2. Development of responsibility3. Understand high risk areas4. Develop alternate behavior5. Develop and maintain a healthy lifestyleTreatment Stages
Levels of Participation1. Active2. Variable3. Passive4. Non-participationLevels of Participation
Community Survey Review Neighborhood/Community1. Immediate disqualifiers2. Detailed listing of property and siteCommunity Survey
ResidenceDuplex with staffed residential model adjacent Provide phone call checks Physical checks 7am, 3pm, 11pm40 hours of staffing M-F 6 hours Saturday-Sunday – 5 hoursADT alarm system
Service ContractServices are voluntary for Mike and Easter Seals.Four Contracted Areas:1. Administrative2. Residential3. Employment & Community4. Clinical/TreatmentService Contract
Preventative Services PlanDemographic information Overview of treatmentBackground and treatment goalsHistory of high risk and Triggers/antecedentsoffending behavior General program rulesCurrent level of Environmentalsupervision modificationsOverview of most recent Training requirementsrisk assessment and Documentationrecommendations requirementsVarious risk management Approvals pagesstrategies Preventative Services Plan
Working with Youth and Adults with Cognitive Impairments andDevelopmental Delays who Have Sexually Problematic Behavior: The Easter Seals ExperienceCrystal Cookman, M.A. Robert Kinscherff, Ph.D., Esq. Derek Edge, M.A. James Mlynarski, M.S.Mandy Graves, M.S.W. Elizabeth J. Shepherd, Ph.D. www.eastersealsnh.org Community Based Services: 603-262-9383