NADD Bulletin Volume X Number 3 Article 2

Complete listing

Behavioral Risk Management: Strategies to Support Dually Diagnosed Men Who Exhibit Inappropriate Sexual Behavior

Karen M. Ward
Rebecca L. Bosek

The sexuality of people with intellectual disabilities is not well understood. They are described as people who are either asexual or lack the ability to control their sexuality (Churchill, Craft, Holding, & Horrocks, 1996). Attempts at age appropriate social and sexual behavior are often ignored, severely suppressed, or punished. Also, they are at increased risk for victimization, including sexual assault (Petersilia, 2000; Sorenson, 2001).

While there is no direct link between sexual assault and subsequent offending, a history of sexual victimization is a risk factor for abuse of others (Sobsey, 1994). Other risk factors include mental health symptoms, lack of sex education, maladaptive sexual practices, skill deficits, and problematic environments (Hingsburger, Chaplin, Hirstwood, Tough, Nethercott, & Roberts-Spence, 1999; Nezu, Nezu, & Dudek, 1998; Ward & Bosek, 2002). Interventions should be individually designed and distinguish between behavior resulting from inappropriate sexual expression and deviant sexual interests (Hingsburger, Griffiths, & Quinsey, 1991; Langevin & Curnoe, 2002). Also, skill development and environmental arrangements are critical (Griffiths, Quinsey, & Hingsburger, 1989; Ward & Bosek, 2002). Finally, to promote successful community living, interventions should include case management focusing on a variety of lifestyle issues (Haaven & Coleman, 2000).

Behavioral Risk Management Overview

Behavioral Risk Management is a community-based, wraparound approach to support men with intellectual disabilities to live safely in the community (Ward & Bosek, 2002). It is a set of strategies that includes ongoing assessment of community risk, teaching self-management skills and alternative behavior, along with diligent monitoring of risky behavior and environments. Behavioral risk management is an attempt to balance individual support needs and lifestyle choices. A major objective of the approach is to replace inappropriate and sexual offending behavior with private, safe, and legal sexual options. The goal is to create flexible supports that can respond immediately to mental health issues and other needs while maintaining community safety.

Description of Program Participants

Over 60 adult and adolescent males have participated or currently receive Behavioral Risk Management services through the Center for Psychosocial Development Clinic. The table below describes program participants at the time of referral. Please note that descriptors are not mutually exclusive.

 

Table 1. Descriptions of Program Participants

 

Disability   

Intellectual Disability89%   

Mental Health Disorders73%   

Fetal Alcohol Spectrum Disorder43%   

Adverse Experiences   

Witnessed Extreme Violence59%   

Sexually Victimized67%   

Criminal History   

Charged with Sexual Offense41%   

Criminal Record for Non-Sexual Offense35%   

   

Offense HistoryAdults

(N=38)Adoles

(N=25)   

Inappropriate Sexual Behavior Against Children or (includes Peers for Adolescents)

68%

100%   

Inappropriate Sexual Behavior Against Adults

63%

12%   

Living Situation/Supervision/Employment   

Independent Living8%   

Supported Living92%   

Unsupervised Access to the Community67%   

Employed29% 

 

Risk Assessment

The first step in designing appropriate community-based services is a comprehensive risk assessment. The primary goal of the assessment is to identify the risk factors that contribute to and maintain the inappropriate behavior, severity of the behavior, and potential risk to the community. Individualized, wraparound interventions are based on a careful analysis of the unique circumstances that precipitated the behavior and identification of the participant's needs related to his inappropriate sexual behavior.

It is important to obtain as much information as possible about the history of the participant’s inappropriate sexual behavior. Critical information is often deleted, inconsistent, or inaccurate in records. Therefore, an extensive review of all case files (e.g., legal, school, medical, mental health, employment, and residential placement) is conducted. Key informant interviews with parents, guardians, or care providers, as well as the participants, are conducted to obtain information not found in case records. A structured interview format, the Functional Assessment of High-Risk Interview Form for Parents and Service Providers-R (Ward & Bosek, 2003a), is used to obtain information about historical factors (e.g., family violence and victimization); consequences that have been associated with the inappropriate sexual behavior; other challenging behavior (e.g., stealing, verbal or physical aggression); medical issues; and environmental factors that might be contributing to the behavior (e.g., level of supervision, loneliness, boredom, or negative role models). A similar format, the Functional Assessment of High-Risk Interview Form for the Individual-R (Ward & Bosek, 2003b), is used to assess the participant’s general understanding of his own behavior, internal motivations, and the extent he assumes responsibility for the behavior.

Since inaccurate or limited information about sex and sexuality can be a risk factor for inappropriate sexual behavior, the Socio-Sexual Knowledge and Attitudes Assessment Tool–Revised (Griffiths & Lunsky, 2003) is administered. This instrument assesses basic knowledge about sex and sexuality, along with attitudes regarding socio-sexual behavior and practices.

Finally, the Supports Intensity Scale (American Association on Mental Retardation, 2004) is used to assess support needs then analyzed in relation to the participant’s risky behavior. This information helps to target areas for supervision and monitoring and prevents using overly restrictive strategies.

Specialized measures such as the Reiss Screen for Maladaptive Behavior (Reiss, 1994) and the Emotional Problems Scales (Prout & Strohmer, 1991) are used when mental health symptoms are severe or require further assessment. Also, when participants have experienced abuse and appear to be exhibiting behavior suggestive of or resulting from trauma, measures of post-traumatic stress disorder are used.

Risk Management Support Planning

The risk assessment details the issues and environments most relevant to the participant’s offense pattern, and a risk management support plan is developed from it. Specifically, the plan identifies: (a) risky situations and behavior; (b) alternative behavior (e.g., self-management skills, avoidance strategies, and socio-sexual skills); (c) support strategies (e.g., teaching, coaching, and supervision); and (d) tracking and monitoring systems. Also, the plan delineates external controls with rationales for imposing them, with objective measures to justify withdrawal of these controls to provide accountability for programmatic decisions.

Risk factors that contribute to the participant’s offending are specific, concrete, and objectively defined. For instance, a risk factor for someone with an offense history that includes indecent exposures toward children might include “being alone in public bathrooms and/or in parks” rather than “being around children in the community.” Risk factors can occur across a number of different dimensions including time, settings, materials, and behavior; and interventions can be arranged accordingly.

Since the community presents many situations that will be encountered on a daily basis, the risk management support plan targets specific situations and incorporates strategies to help the participant avoid them or manage the antecedents. Because it is not possible to arrange risk-free community living, interventions must be reasonable given the constraints of time, resources, and staffing patterns. 

The plan also incorporates the participant’s long-range lifestyle goals, along with steps to achieve them. Lifestyle goals describe the living situation, work, school, or recreational opportunities the participant wants. Because risk management strategies may be restrictive and intrusive at first, recognizing long-range lifestyle goals and designing strategies to help the participant succeed helps increase motivation as well as ensures service delivery in the least restrictive environment.

Of critical importance to the plan’s integrity is including the participant in the process. It is important that the plan is developed in a format the participant understands. A written version of the plan in concrete, simple language works well with people who can read and write. A variety of other formats have been used, including pictures of risky situations (e.g., stop signs or avoidance symbols superimposed on the pictures), audio tapes, and video tapes. Environmental strategies such as posting pictures or reminders of the plan in strategic locations (e.g., on the refrigerator, by the telephone at home, on the work locker, or on a card in the wallet) help to keep the plan visible. The long-term success of the participant to live in the community depends on his motivation and ability to understand his own behavior and to use self-management skills.

Therapeutic Intervention and Skill Development

A psycho-educational group model works best to teach new skills and alternative behavior. Groups meet weekly for 1.5 hours. The main objectives are that participants learn to: (a) identify and name their target population; (b) identify and verbalize personal risky situations that lead to inappropriate sexual behavior; (c) use coping strategies to escape/avoid risky situations; and (d) understand the social and legal consequences of inappropriate or sexual offending behavior. For many participants, another objective is to demonstrate the ability to discriminate potential from unavailable dates/sexual partners.

The goal is to teach and support the participant to self-manage or self-regulate his behavior. Risky situations are defined as people, places, events, or materials that put the person at risk for inappropriate or sexual offending behavior. The role of the facilitator is to assist the participants to identify their personal risky situations. Many risky situations are obvious. For example, a risky situation for a person who has sexually offended against underage children is unsupervised contacts with this target population. A risky place might be a video arcade where youth frequent. A risky event might be attending the matinee of a play or musical program. Finally, risky materials might include pictures of children, children’s clothing, or coloring books. However, there are times when risky situations are much less obvious. For example, we worked with an exhibitionist who liked cartoons depicting characters that disappeared. In this participant’s mind, watching a cartoon character disappear reminded him of how he exposed his genitals, covered himself, and hid; thereby absolving himself of responsibility for his behavior. In another example, a participant liked to wear a face mask or gloves at work made out of materials that reminded him of the diapers worn by his victims.

Initially, participants have trouble identifying risky situations. Some attend group and claim they have not had any risky situations the previous week. Others have an awareness of what risky situations are but think denying them indicates treatment progress. In either case, it is important to continually remind participants they encounter risky situations daily and using skills to self-manage these risky situations is the real indicator of treatment progress.   

Overall, we have found that when participants acquire a general overview of the process, most begin to openly discuss their risky situations. When they begin addressing this issue, they identify many risky situations that are surprises to family members and staff. This is the primary reason why identifying risky situations is crucial to successful intervention.

Simultaneous to talking about risky situations, participants learn specific behavior they can use to escape, avoid, or deal with their risk. Participants have used several coping strategies that are easy to use and effective. They include:

Stop/Think/Decide

The participant learns to repeat and respond to the following script either silently or out loud:  Stop (I am in a high-risk situation!), Think (What will happen if I continue?), and Decide (How can I escape or avoid this situation?).  For this coping strategy, members are taught to think of a traffic light as a visual aid.

Self-Report to a Support Person

These strategies involve the use of support persons.  Participants are taught to self-report risky thoughts or situations to an agreed upon support person(s). Self-reporting serves several functions: (a) immediate assistance and someone to rely upon; (b) interruption of the risky thought, fantasy, or behavior; and (c) reinforcement for identifying and coping with risky situations.

Visual Screening

Visual screening strategies are environmental actions that provide the member with ways to escape or avoid the risky situation. Typical strategies include: (a) remove risky stimuli from home or work; (b) look the other way; (c) close the blinds/curtains/door; (d) cross the street; (e) change seat on public transportation; and (f) leave the situation.

It is also important for participants to understand the social and legal consequences of inappropriate and sexual offending behavior. Several strategies are used to teach them. Listening to the unpleasant memories of participants who have been adjudicated or convicted of sexual offenses helps to make the consequences more real. Asking participants to share how their family or friends felt as a result of their behavior helps them to understand that inappropriate or sexual offending behavior causes pain and embarrassment. For example, participants have described how family members became distant or rejected them. Others discussed how they lost friends, dates, or romantic relationships, once their behavior was known. We have worked with many participants who disclosed that the parents of their partner or date terminated the relationship because they did not want a family member involved with a “sex offender.” When participants hear that there are potential losses associated with inappropriate or sexual offending behavior, they begin to develop an increased awareness and appreciation that people in their social networks will not tolerate this behavior. This is an important concept as having a “girlfriend” is a strong motivator for many of our participants.

To illustrate the legal consequences for sexual offending behavior, we keep a large notebook of newspaper articles describing what happened to sex offenders. When questions arise or issues are discussed, the group facilitator refers to newspaper articles. Seeing a newspaper article with a convicted sex offender’s picture along with the accompanying story makes potential consequences more concrete. Alaska, like many states, has a Sex Offender Registry, located on the Internet. Computer printouts from the Registry are periodically brought to group to illustrate how sexual offending behavior can follow the participant throughout his life. When participants realize friends, neighbors, employers, or even strangers can access information about their crimes, they develop an understanding that their criminal sexual behavior is not secret and private. 

When the team considers it therapeutic, participants take short informational trips. They visit the police station or jail. Discussions are held with police officers or jail guards. Participants learn about the process of being arrested for and convicted of sex crimes. They see what jail food is like and observe where inmates sleep. They learn that few personal possessions are allowed in these facilities, and that many personal articles are considered contraband. These trips are particularly beneficial for participants preoccupied with glamorous television shows and movies depicting police officers and prison life. After the visit, the reality of what jail is like sets in, and members readily acknowledge they do not want to spend time incarcerated.  

Socio-sexual skill training is crucial for people with intellectual disabilities who display inappropriate sexual behavior. Skill deficits and lack of knowledge directly contribute to problematic patterns of thinking and behavior. The primary objective of this training is to assist members to engage in legal and safe sexual alternatives. Some of the skill training topics include: (a) sex education and sexuality; (b) friendship and dating; (c) boundaries and personal safety; (d) personal safety and risk reduction; and (e) managing risks in relationships. Strategies to foster opportunities to meet potential partners are developed with the family or support team. Examples include attending special dances, going on small group outings, or double dating with support people. Along with teaching participants to successfully interact in the community, it is important to teach them that age-appropriate, consenting, sexual partners may not always be available. In these cases, participants are reminded that masturbation is a personal decision. When participants make the choice to do so, we work with family members and support personnel to ensure that participants have a private place to do so, along with access to stimuli.

Clinical Case Management

A clinical case manager makes home visits at least once a month to ensure supports are in place and working. These visits are opportunities to review the risk management support plan, to observe environmental risks, and to discuss progress. Case managers also schedule opportunities for participants to practice skills in a variety of community settings.

Supervision and Environmental Arrangements

Supervision strategies involve the use of environmental controls and arrangements to ensure community safety while alternative skills and behavior are taught. Supervision is extended to all environments, including home, work or school, and the community at large. The overall goal is to reduce the need for a high level of restrictive environmental controls.  Decisions to reduce or modify the level of supervision are made by the team based on clinical and behavioral data. Although our approach incorporates a high degree of supervision around the risky variables identified from our risk assessment process; the purpose is not to create a jail in the community, but to focus supervision on the right (risky) variables.

The most common and effective environmental controls are presented in the following section. 

Electronic monitoring

Silent alarms on windows and doors are used to transmit warnings to a central alarm at an on-site program area and/or to a remote beeper worn by staff. The alarm signals any unauthorized apartment entrance or exit. Alarms are used when participants pose a risk to other members of the household, especially during the night, or for those who should not be alone in the community. Alarms make it possible for participants to live in supervised apartments while safeguarding the community. They provide participants with more privacy and personal freedom than physical supervision. As a final note, alarms do not prohibit a person from evacuating the premises in an emergency situation; an important factor in maintaining personal safety.

Although electronic monitoring is a highly intrusive method of supervision, it is not a guaranteed solution. One program participant timed how long it took staff to leave his apartment to reset his alarm in the apartment next door. In the 5-10 seconds it took for the alarm to be reset, he left the apartment building using a nearby stairwell. He was gone for an hour before staff discovered his absence.

Television

Television can be a source of stimuli for inappropriate sexual thoughts or behavior, such as children’s shows or commercials for children’s items (e.g., baby food, toys, diapers). Television also contains stimuli that cannot always be anticipated. We use several methods to monitor television viewing including reviewing and selecting shows that can be watched, staff presence during viewing, restricting access to a television set in the participant’s apartment or bedroom, or blocking cable channels. We are considering the use of a more elaborate monitoring system that connects a video monitor to the participant's television and enables staff to spot check what is being viewed. A less expensive alternative to monitor television viewing is to visually check on a frequent, unannounced schedule.

Print materials

Newspapers, magazines, books, mail order catalogues, cereal boxes, and even the telephone book have pictures that may trigger inappropriate thoughts. Many of our participants have offenses directed against children. Often print material includes pictures of children and items associated with them. Clothing catalogues depict young children wearing underwear; the local telephone book has an illustration of how to perform first aid on a very young child, and during a mail screening activity, one program participant pointed out 15 different items in a local weekly coupon book that he could use for fantasizing and masturbation. 

Telephone

In some cases, telephone access must be limited. Toll numbers for erotic conversations can easily lead to problems. One young man amassed a $49,000 phone bill calling 900 numbers. Another participant ran up a large bill after mistakenly believing the person on the other end of the line was interested in a long-term friendship. Also, it may be necessary to ensure telephones are not used to contact victims or targets. 

Periodic environmental screening

Some participants bring inappropriate stimuli into the home, work, or school environments. Regular discreet searches are conducted to locate these materials. Participants and family members sign an informed consent, and confiscation of contraband is written into the risk management support plan.

Internet

The Internet is a source of inappropriate stimuli and opportunities to engage in risky behavior. For example, one participant used the Internet to access pictures related to his primary sexual interest in children’s feet.

External controls are slowly decreased, as increasingly responsible behavior is demonstrated. Electronic alarms may be faded to just night hours. A participant who had all of his television programs screened and monitored was given access to a television under the agreement that he would record all television programs watched. The “television log” was brought to staff and the appropriateness of the programs was discussed.

There are several supervision strategies that enable participants to access the community and practice skills. By determining the typical amount of time to perform a routine task, staff can monitor the length of time the participant is gone. Intervention (i.e., going to look for the person) occurs only when the time limit is exceeded. Beepers and cell phones are used to keep in touch with participants without being intrusive.

Monitoring

To ensure accountability and appropriateness of the plan, a monitoring data system is defined for each risky situation and corresponding intervention. Data related to activities and behavioral indicators are collected monthly on a High-Risk Behavior Checklist-R (Ward & Bosek, 2003c). Behavior in three main categories are tracked: (a) inappropriate sexual behavior (e.g., sexual comments, touching self or others, lengthy staring, stalking victims, and the possession of risky stimuli such as pornographic magazines or videos); (b) changes in program participation (e.g., not going to work, school, or therapy groups, not taking medications, alcohol or drug use, and not complying with external controls); and (c) collateral behavior (e.g., losing emotional control, suicidal comments, attempts at self-harm, assault of others, property destruction, isolation, and secretiveness). This information as well as observations, helps the team to determine the level of supervision and support the participant needs on an ongoing basis.

Outcomes

The goals of the program are to: (a) ensure community safety; (b) increase opportunities for lifestyle choices; and (c) reduce the cost of supervision (e.g., time & effort). Outcome indicators include incidents of inappropriate sexual behavior and sexual offenses, changes in living situations, changes in the level of supervision provided during community activities; and opportunities to participate in preferred and chosen social and recreational activities in the community. For many participants, services are long-term but ebb and flow in intensity, as support needs change.

References

American Association on Mental Retardation (2004). Supports intensity scale. Washington,DC: American Association on Mental Retardation.

Churchill, J., Craft, A., Holding, A., & Horrocks, C. (Eds.). (1996). It could never happen here! The prevention and treatment of sexual abuse of adults with learning disabilities in residential settings (Rev. ed.). Chesterfield/Nottingham, Great Britain: ARC & NAPSAC.

Griffiths, D. M., & Lunsky, Y. (2003). Socio-sexual knowledge and attitudes assessment tool-revised. Wood Dale, IL: Stoelting Co.

Griffiths, D. M., Quinsey, V. L., & Hingsburger, D. (1989). Changing inappropriate sexual behavior: A community-based approach for persons with developmental disabilities. Baltimore, MD: Paul H. Brooks.

Haaven, J. L., & Coleman, E. M. (2000). Treatment of the developmentally disabled sex offender. In D. R. Laws, S. M. Hudson, & T. Ward (Eds.), Remaking relapse prevention with sex offenders: A sourcebook (pp. 369-388). Thousand Oaks, CA: Sage Publications Inc.

Hingsburger, D., Chaplin, T., Hirstwood, K., Tough, S., Nethercott, A., & Roberts-Spence, D. (1999). Intervening with sexually problematic behavior in community environments. In J. R. Scotti & L. H. Meyer (Eds.), Behavioral intervention: Principles, models and practices (pp. 213-236). Baltimore, MD: Brookes.

Hingsburger, D., Griffiths, D., & Quinsey, V. (1991). Detecting counterfeit deviance: Differentiating sexual deviance from sexual inappropriateness. The Habilitative Mental Healthcare Newsletter, 10, 51-54.

Langevin, R., & Curnoe, S. (2002). Assessment and treatment of sex offenders who have a developmental disability. In D. M. Griffiths, D. Richards, P. Fedoroff, & S. L. Watson (Eds.), Ethical dilemmas: Sexuality and developmental disability (pp. 387-416). Kingston, NY: NADD Press.

Nezu, C. M., Nezu, A. M., & Dudek, J. A. (1998). A cognitive behavioral model of assessment and treatment for intellectually disabled sex offenders. Cognitive and Behavioral Practice, 5, 25-64.

Petersilia, J. (2000). Invisible victims: Violence Against Persons with Disabilities. Human Rights, 27, 9-12.  

Prout, H. T., & Strohmer, D. C. (1991). EPS: Emotional problems scales. Odessa, FL: Psychological Assessment Resources, Inc. 

Reiss, S. (1994). Reiss screen for maladaptive behavior: Test manual (2nd Edition). Chicago, IL: IDS Publishing Corporation.

Sobsey, D. (1994). Violence and abuse in the lives of people with disabilities: The end of silent acceptance? Baltimore, MD: Paul H. Brookes.

Sorenson, D. (2001). The invisible victims. Paper presented at the 2001 Arc National Convention, New Orleans, LA. 

Ward, K. M., & Bosek, R. L. (2003a). Functional assessment of high-risk interview form for parents and service providers-r. Unpublished, University of Alaska, Anchorage.

Ward, K. M., & Bosek, R. L. (2003b) Functional assessment of high-risk interview form for the individual-r. Unpublished, University of Alaska, Anchorage.  

Ward, K. M., & Bosek, R. L. (2003c). High-risk behavior checklist-r. Unpublished, University of Alaska, Anchorage.

Ward, K. M., & Bosek, R. L., (2002). Behavioral risk management: Supporting individuals with developmental disabilities who exhibit inappropriate sexual behaviors. Research & Practice for Persons with Severe Disabilities, 27(1), 27-42.