Cognitive-behavioural treatment for men with intellectual disabilities and sexually abusive behaviour: a pilot study

Background Cognitive‐behaviour therapy (CBT) seems to be becoming the treatment of choice for non‐disabled sex offenders. Nevertheless, there have been relatively few evaluations of such treatment for men with intellectual disabilities (ID) and sexually abusive behaviour. Method A pilot study providing CBT for two groups of men with ID is described. Measures of change in sexual knowledge, victim empathy and cognitive distortions were collected, together with a log of further sexually abusive behaviour. Results Fifteen men were offered treatment but some dropped out and some declined to take part in the research. The results for the eight men who consented to the research and completed treatment showed significant positive changes in sexual knowledge and victim empathy (two men completed both groups, making 10 sets of data in all). Cognitive distortions showed significant change on only one of the two measures. Some men showed further sexually abusive behaviour either during or after the treatment group (all had been previously diagnosed as on the autistic spectrum). Conclusion There is a need for a larger multi‐site trial of treatment with a broad set of measures and the ability to analyse who benefits from such treatments and who does not.     

Sexually abusive behaviour in an adolescent boy with the 48,XXYY syndrome: a case study

This paper describes the case of a sexually abusive adolescent boy with an unusual and rare chromosomal disorder, the 48,XXYY syndrome. Few such cases have been reported in the literature and there is no known association with sexually abusive behaviour. Following a presentation of his case history, the assessment and treatment of his sexually abusive behaviour is described, most of which occurred whilst he was detained in secure accommodation. Unfortunately, the cognitive-behavioural treatment programme appeared to have little effect in reducing his risk of reoffending. He lacked interest and motivation such that it proved difficult to engage him in interventions aimed at changing his attitudes and behaviour. Further, he appeared unable to understand the emotional consequences for the victims of his abusive behaviour. Consequently, he continues to be sexually aroused by children, experiencing sadistic sexual fantasies, and to hold beliefs supporting sexual involvement with children. Copyright © 1996 Whurr Publishers Ltd.     

Psychiatric disorders and characteristics of abuse in sexually abused children and adolescents with and without intellectual disabilities

The purpose of this study was to compare sexually abused children and adolescents, with and without intellectual disabilities (ID), in terms of post-abuse psychiatric disorders, features of the sexual abuse, and sociodemographic characteristics. The study included sexually abused children aged 6–16 years, who were sent to three different child mental health units for forensic evaluation; there were 102 cases (69 girls and 33 boys) with ID and 154 cases (126 girls and 28 boys) without ID. Researchers retrospectively examined the files, social examination reports, and the judicial reports of the cases. It was determined that in the group with ID, sexual abuse types including penetration and contact had higher rates, they were exposed to more frequent repeated abuses, the abuses were revealed with their own reports at a later period and lower rates, and post-abuse pregnancies were more frequent. It was also determined that the abuser was a familiar person and a family member at lower rates and more than one abuser was encountered more frequently, compared to the group without ID. While no difference was determined between the two groups in terms of the frequency of post-abuse post-traumatic stress disorder (PTSD) and major depressive disorder (MDD), conduct disorder (CD) was observed more frequently in the group with ID. This study emphasizes that sexual abuse, which is an important problem in individuals with ID, has different features and effects.     

Sexual abuse, antisocial behaviour and substance use: gender differences in young community adolescents

OBJECTIVE: To investigate gender-specific relationships between self-reported sexual abuse, antisocial behaviour and substance use in a large community sample of adolescents. METHOD: A cross-sectional study of students aged, on average, 13 (n = 2596), 14 (n = 2475) and 15 years (n = 2290), from 27 schools in South Australia with a questionnaire including sexual abuse, frequency and severity of substance use, depressive symptomatology (CES-D), family functioning (McMaster Family Assessment Device), and antisocial behaviour (an adapted 22-item Self-Report Delinquency Scale). Logistic regression analyses using HLM V5.05 with a population-average model were conducted. RESULTS: In the model considered, reported sexual abuse is significantly independently associated with antisocial behaviour, controlling for confounding factors of depressive symptomatology and family dysfunction, with increased risks of three- to eightfold for sexually abused boys, and two- to threefold for sexually abused girls, compared to nonabused. Increased risks of extreme substance use in sexually abused girls (age 13) and boys (ages 13-15) are more than fourfold, compared to nonabused. Age differences were not statistically significant. CONCLUSION: Childhood sexual abuse is a risk factor for the development of antisocial behaviour and substance use in young adolescents. Clinicians should be aware of gender differences.     

Impact of sexual abuse on the HIV-risk-related behavior of adolescents in intensive psychiatric treatment

OBJECTIVE: This study compared the HIV-risk-related behaviors and attitudes of adolescents with and without a history of sexual abuse who were in intensive psychiatric treatment. METHOD: Adolescent patients (N=208) completed measures of psychological functioning and HIV-related knowledge, attitudes, and behaviors. RESULTS: Among sexually active adolescents in psychiatric treatment (N=116), those with a history of abuse reported significantly less condom self-efficacy (emotional ability to use condoms), less knowledge of HIV, less impulse control, less frequent use and purchase of condoms, and significantly higher rates of sexually transmitted diseases than their peers. Multiple logistic regression indicated that a history of sexual abuse was strongly associated with inconsistent condom use. CONCLUSIONS: Sexual abuse was associated with HIV-risk-related attitudes and behaviors among adolescents in psychiatric treatment. Clinicians should thus view a history of sexual abuse as a marker for sexual behavior that puts adolescents at risk for HIV.     

Abstract

Background: Selling sex is not uncommon among adolescents and we need to increase our knowledge of how this affects them. Aim: The aim of this study was to investigate adolescents who sell sex regarding sexual, mental and physical abuse, mental health as estimated by using the Hopkins Symptom Check List-25 (HSCL-25), self-harm behaviour and the adolescents’ experience of receiving help and support. Methods: The study was carried out on a national representative sample of adolescents (mean age 18.3 years) in Swedish high schools in the final year of their 3-year programme. The study had 3498 participants and a response rate of 60.4%. Results: Of the adolescents, 1.5% stated that they had sold sexual services. The selling of sex was associated with a history of sexual, mental and physical abuse. Poorer mental health and a higher degree of self-harm behaviour were reported among the adolescents who had sold sex. Help and support was sought to a greater extent by adolescents who had sold sex but these adolescents were not as satisfied with this help and support as the other adolescents. Conclusions: Adolescents that sell sex are a group especially exposed to sexual, mental and physical abuse. They have poorer mental health and engage in more self-harm behaviour than other adolescents. They are in need of more help and support than other adolescents and it is reasonable to assert that more resources, research and attention should be directed to this group to provide better help and support in the future.     

Summary of the practice parameters for the assessment and treatment of children and adolescents who are sexually abusive of others. American Adademy of Child and Adolescent Psychiatry

This summary provides an overview of the assessment and treatment recommendations contained in the Practice Parameters for the Assessment and Treatment of Children and Adolescents Who are Sexually Abusive of Others. The parameters were written to aid clinicians in the assessment and treatment of children and adolescents with symptoms of sexually abusive behavior. The assessment and treatment of children and adolescents with sexually abusive behavior requires an understanding of normal sexual development. A multiplicity of biological and psychosocial factors determines the child's sexual development, gender role, sexual orientation, patterns of sexual arousal, sexual cognitions, sexual socialization, and the integration of sexual and aggressive patterns of behavior. The individual's sexuality evolves in concert and as a result of interaction with family, ethnic, social, and cultural influences. These parameters summarize what we know about the epidemiology and phenomenology of sexually abusive youths and provide guidelines for the assessment and the selection of treatment interventions for these youths. Essential considerations in the assessment and treatment of sexually abusive youths, as well as the different categories of sexually abusive youths which should be recognized and which influence treatment decisions, are presented. The spectrum of currently available psychosocial and biological treatments will be summarized.     

Facing sexual violence in a rape emergency room: identification,projective identification,and the myth of nemesis

This article focuses on the relationship between identification and sexual abuse. Three subsequent levels are considered, namely, the relationship between (1) the abuser and the victim, (2) the gynecologist or social worker of the Rape Emergency Room (RER) and the victim, and (3) the gynecologist or social worker and the entire RER staff. In the relationship with a rape victim, the gynecologist and the social worker may perceive unexpected negative feelings such as fear, horror, impotence, despair, or even anger which can interfere in the identification with the victim. Rape can be considered also as a concrete form of devaluation through concrete penetration of the victim. As an example, a myth of sexual abuse will be presented: the rape of Nemesis by Zeus.     

Les expériences d’adversité chez les auteurs d’infractions à caractère sexuel

Research has suggested that children who experience violence and sexual abuse are at risk for inappropriate behavior, including repeating the violence and sexual abuse as adults. Many theories posit that sexual victimization in childhood plays an important role in later sexual offending against children and studies generally find an association between childhood sexual abuse and sexual offending against children. The most prominent hypothesis about offenses against children is the “sexually abused – sexual abuser”. This hypothesis predicts that individuals victimized in childhood will perpetrate sexual abuse upon child victims in the future. This research's objective was to assess the childhood experience of care and abuse among sex offenders (sexual assault on children, adult or the both) in comparison to non-sex offenders in a forensic population (n = 99). These experiences are evaluated with the Childhood Experience of Care and Abuse (CECA), based on a semi-structured interview. The CECA evaluates the chronology, duration, and the intensity (no, low, moderate, high) of the different types of adversity (antipathy, neglect, parental violence, sexual, physical or psychological abuse). The aim is to identify the different adversities and types of care experienced by sex offenders, by type of type of sex offenders in comparison to non-sex offenders. The results are: non-sex offenders present fewer sexual abuses than AICS with young extrafamilial victims and AICS with children and adult victims. However, the severity of the abuse does not vary between the groups compared to neglect, physical abuse and parental violence. These three types of adversity are usually with a marked severity among non-sex offenders. The AICS showed less marked severities.     

Psychiatric status of intrafamilial child sexual abuse victims

The initial psychiatric profile of a large sample of sexually abused children who presented at an outpatient child psychiatry clinic was assessed. The results identified a wide diversity in victim responses to incest. The older the victim, the closer the relationship of the offender to the child, the greater the frequency of abuse incidents, the longer the duration of the abuse, the offender having a history of alcohol abuse, and the victim being a victim of physical abuse as well as sexual abuse were all related to the presence of a DSM-III axis I clinical disorder.     

Sexually abused girls: patterns of psychopathology and exploration of risk factors

This paper studies the patterns of psychopathology in sexually abused girls. It also explores some environmental risk factors for psychopathology including abuse characteristics and environmental experiences. The data are derived from the baseline assessment of 81 sexually abused girls referred to the London Child Sexual Abuse Psychotherapy Outcome Study (collaborative Tavistock and Maudsley project). Data about abuse were collected from the parent or foster parent using a standardised, semi-structured interview format. The girls psychopathology was assessed using the Kiddie-SADS schedule. Widespread and serious psychopathology in sexually abused girls attending a psychotherapy clinic previously reported in a smallscale study was confirmed; so, too, was the extent of comorbidity and impairment of psychosocial functioning. Further, a significant association was found between children looked after away from home and high rates of Separation Anxiety Disorder. No such significant associations were found for Major Depressive Disorder nor impairment of functioning. Multivariate prediction analysis revealed that significant predictors of Major Depressive Disorder consisted of seriousness of abuse, the abuser not being a parent figure, and the abuse not being recent; the only significant predictor of Separation Anxiety Disorder was that the abuser was not a parent figure; finally, impairment of general functioning was strongly predicted by the greater seriousness of abuse and also by the abuser/s not being a parent figure. Theoretical explanations advanced for the reported associations have a sense of face validity: that girls abused by strangers will be at risk of developing Separation Anxiety Disorders; that serious sexual abuse is followed by the development of a Major Depressive Disorder and a high level of impairment of social functioning.     

Sexual and physical abuse during early childhood or adolescence and later drug addiction

Sexual or physical abuse of children are discussed as possible causes or risk-factors for psychiatric disorders like posttraumatic stress disorder, alcohol and drug addiction. The aim of this study was to identify possible differences between sexually or physically abused and non-abused patients with polytoxic drug abuse. METHOD: 100 patients with polytoxic drug abuse were interviewed during their therapy about a history of sexual abuse prior to the age of sixteen. Using different questionnaires we tried to find possible differences between drug users being sexually abused or not and risk factors for later drug addiction. RESULTS: 70% of the female and 56% of the male drug users had been sexually abused as children, 40% of the male and 50% of the female participants had a history of severe sexual abuse with sexual intercourse. In over 50% friends or relatives were the perpetrators committed the crime, in no case the parents had. More than 40% showed also a history of physical abuse. Significantly more drug users than alcohol abusers had a sexual trauma. Especially severe sexual abuse was associated with abuse of hard illegal drugs. Furthermore, we could find significantly more symptoms such as autoaggressive and suicidal behaviour, social isolation, reduced emotional binding to others, tendency to be persistently victimized, prostitution and violence against others in the group of sexually abused. Many of these symptoms are not only characteristic of addiction, but can be found also in other psychiatric diseases such as borderline and eating disorder. In conclusion, we could not find a significant correlation between sexual abuse and later drug addiction. 80% of the drug users themselves did not relate the fact of being sexually abused as child to later drug abuse. However, there seems to be a positive correlation between sexual abuse and a more severe addiction to illegal drugs as well as higher rates of symptoms with a negative course of the disease. For this group of patients with an unfavourable prognosis special therapeutic concepts are needed.     

Gender identification and sex role attribution in sexually abused adolescent females

An exploratory study of the association between child sexual abuse and subsequent gender identification and sex role attribution was conducted with 93 adolescent females. Victims of intrafamilial sexual abuse with a history of psychotherapeutic treatment were compared with nonabused subjects with a history of treatment and nonabused control subjects with no treatment history. Measures of gender identity found that sexually abused and nonabused treatment groups differed significantly from the no-treatment controls. Distinct patterns of gender identification emerged for the sexually abused victims. Hypothesized differences in sex role attribution were not found. Potential directions for future research are proposed and implications and recommendations for treatment are discussed.     

Clinical considerations related to victimization dynamics and post-traumatic stress in the group treatment of sexually abused boys

Clinical considerations inherent in the development of a boy's time-limited psychoeducational sexual abuse trauma group are described. The sexually abused boy's impact struggles are divided into two categories: victimization dynamics and post-traumatic stress. Within each category, five impact-specific dynamics are presented. The victimization dynamics are: victim/victimizer identity struggle; abandonment fear; accelerated sexual arousal; body conflict and shame. The post-traumatic stress dynamics are: psychophysiological dysregulation; post- sexual abuse re-enactment potential; post- sexual abuse triggers; intrusion and numbing. These dynamics are central to the group's development and purpose. Within this framework, group structure, confidentiality limitations, role of caretakers, role of group therapists, and impact-specific group activities are also examined.     

Male adolescent sex offenders against children: similarities and differences between those offenders with and those without a history of sexual abuse

This study compares a defined sample of male adolescents (n = 36) with regard to their personal development, family characteristics and the types of offence they committed. Adolescent sex offenders with (n = 16) and without (n = 20) a history of sexual abuse who had offended against children were investigated during ongoing criminal proceedings by means of questionnaires and intelligence tests. The most important characteristic that distinguishes the two groups from each other is the more frequent absence of the parents of adolescents who committed sexual offences against children and had a history of sexual abuse. The consequences to be drawn from these results with regard to aggressive sexual delinquency in adolescence are discussed and suggestions are made with regard to further avenues of investigation.     

Disclosure of child sexual abuse. For better or for worse

The data presented here offer a longitudinal perspective on sexually abused children. Disclosure data are postulated to be important variables in the short-term and long-term victim-to-patient process. Fifty-five per cent of the 156 children seen purposefully disclosed their sexual abuse, most frequently to their mothers. Children who never told, but were seen after accidental disclosures, showed less distress, whether hiding minor or major forms of sexual abuse. This finding support the clinical impression that disclosure adds extra stress on children and cannot be expected of every victim. A history of past mental health intervention did not seem to enhance the child's ability to tell. Education of all professionals is critical. Approximately 18 months after the end of the crisis intervention offered at intake, 115 of the 156 cases were re-evaluated. Overall, most children showed improvements on standardized tests, but 24 per cent got worse. Specific symptoms were found to cluster in four groups: acute anxiety, characterologic, family dynamics, and specific symptoms related to sexual abuse (sexual maladjustment, prostitution, revictimization, sexually assaultive behavior). Although the data seem to support the notion that crisis intervention by trained clinicians is helpful, it is too early to tell if the ominous findings described in adult survivors can really be decreased. The impact of disclosing child sexual abuse on entire families should not be underestimated, even in cases of extrafamilial abuse. The poor ratings parents gave law enforcement, judicial, and Child Protective Service professionals may be linked to the reluctance of victims to disclose their abuse and underscores the need to review current procedures and practices. Overall, a great majority of parents did see the sexual abuse as harmful to the child and to the family, but they were evenly divided about whether the disclosure was harmful or helpful to the child and family. A final word of caution comes from the 19 per cent of adolescents who regretted their disclosures. For clinicians and for researchers, the data presented here lead to further questions. A longer follow-up period is needed to assess whether these victims will be similar to the adults described in the literature or will become survivors with less pathology and less pain.     

The ability of teacher reports to identify child sexual abuse victims

This study concerns the validation of an instrument, the SAB2, designed to measure child behaviour and to help identify emotional problems which arise because the child has been a victim of child sexual abuse. Clinically disturbed children, mainstream school children and sexually abused youngsters were assessed. Reliability and validity tests were carried out and a factor analysis was performed which produced seven factors. Finally, the mean factor scores of 35 sexually abused girls were compared with a control sample of 112 girls. The sexual abuse group was found to have significantly higher mean scores than controls on all factors and on the total instrument score. However, closer examination of the scores revealed that 15 of the female sexually abused group did not display any problematic behaviours, whereas the other 20 presented with high scores on all factors and a significantly higher score than any other group on the sexual behaviour factor. The instrument was capable of distinguishing behavioural disturbance arising from sexual abuse from that arising from other sources. However, the instrument failed to detect the 15 ‘silent’ abused cases. It is unclear whether this sub-group has protective factors operating which minimise (or help to mask) the impact of sexual abuse, or whether the effects of the abuse will manifest later in life.     

Sexual abuse in children and adolescents with intellectual disability

The present authors conducted a study of the occurrence of victimization and the perpetration of sexual abuse among 43 in‐patients with intellectual disability aged between 9 and 21 years who were admitted to a child and adolescent psychiatric in‐patient department over a period of 5 years. A retrospective case‐note review was employed that explored the nature and severity of abuse in relation to the age, gender and level of disability. The prevalence of abuse or abusive behaviour, i.e. 14% of 300 admissions, did not change over time. In 13 out of the 43 cases, the issue of sexual abuse was identified after admission. Victimization alone occurred in 21 cases, perpetration alone in six cases, and both victimization and perpetration in 16 cases. Fifty per cent of the victims had been abused by a member of their close or extended family. Most cases (62%) were adolescents. There was only one instance of a victim being abused by a female. However, there were five girls who were perpetrators, all of whom had previously been victims. By contrast, 11 out of the 17 male perpetrators had been victims. Despite difficulties of disclosure, it was possible to establish that severely disabled patients had suffered sexual abuse. The present data support theories which (1) recognize gender differences in sexual abuse patterns and (2) have a developmental perspective, incorporating the influence of adolescence.     

Violence in the lives of adult borderline patients

The purpose of this study was to assess the experiences of adult violence reported by a sample of criteria-defined borderline patients and axis II controls. The experiences of having had a physically abusive partner and/or having been raped reported by 362 personality-disordered inpatients were assessed blind to diagnostic status using a semistructured research interview. Forty-six percent of borderline patients reported having been a victim of violence since the age of 18. Borderline patients (N = 290) were significantly more likely than axis II controls (N = 72) to report having had a physically abusive partner, having been raped, having been raped multiple times, having been raped by a known perpetrator, and having been both physically assaulted by a partner and raped. Female borderline patients were significantly more likely than male borderline patients to have been physically and/or sexually assaulted as adults (50% vs. 26%). However, a significantly higher percentage of borderline patients of both genders reported experiences of adult violence than controls of the same gender. Four risk factors were found to significantly predict whether borderline patients had an adult history of being a victim of violence: female gender, a substance use disorder that began before the age of 18, childhood sexual abuse, and emotional withdrawal by a caretaker. The results of this study suggest that both male and female borderline patients are at substantial risk for being physically and/or sexually victimized as adults.