| The Diagnosis and Treatment of Child Sex-Abusing Children in a Therapeutic Community Problem: To assess and treat children who have sexually abused other children. Method Subjects: The subjects consisted of 50 consecutive referrals to a therapeutic community over a ten-year period. They were then aged 9-14 years with a predominance of boys over girls (males 40; females 10). Procedure (diagnosis and treatment): • Diagnosis the methods of diagnosing children who are likely to be sexual abusers or have already shown such tendencies consist firstly in differentiating different kinds of abusing youngsters into the following diagnostic categories. Category A those who participate in sexual play with another child of the same sex or the opposite sex usually aged around 2-10. Category B where there is a sexual drive due to fantasies of a sexual nature but there is no coercion towards another child, be it male or female, usually aged 10-14 years. Category C where there is a strong sexual drive combined with stimulation by fantasy towards a sex object with some or considerable coercion being used, for gratification aged 13-15 years. Table 1 Types of Sexually Abusing Youngsters
• Wechsler Intelligence Test for Children Form R. • Educational Testing • Schonell Reading Test • Schonell Spelling Test • Lowenstein Arithmetic Diagnostic Test. • Protocols for Sex Abuse Evaluation by Richard Gardner (published 1995 by Creative Therapeutics) • History of family influence conducive to the development of significant psychopathology. • Long-standing history of emotional deprivation. • Intellectual impairment. • Childhood history of sex abuse. • Long-standing history of very strong urges. • Impulsivity. • Narcissism. • Coercive dominating behaviour. • Passivity and impaired self-assertion. • Substance abuse. • Poor judgement. • Child pornographic material. • Distortion • Emphasis on paedophilia. • Utilisation of seductivity. • Avoidance of taking lie detector test. • Tendency toward psychopathic behaviour. • Numerous victims. • Other Diagnostic testing • The MMPI to assess the likelihood of psychopathology. • The Eysenck Personality Inventory measuring introversion/extroversion, psychoticism, neuroticism as well as the lie score. • The Children's Apperception Test or the Thematic Apperception Test for older children. • The Rorschach Assessment scheme following the Harrower Method. • Sentence Completion Test.It will be noted that the combination of the objective and projective testing as well as interviewing are also part of the diagnostic approach to each child before he/she was accepted into the therapeutic community.Objective of the Diagnostic EvaluationThe objective of the diagnostic evaluation was as follows: • To assess strength of sex drive and its direction, in vivo and fantasy. • To assess strength of aggression. • To obtain the psychoticism score using the EPQ. • To assess ego development and self-esteem via educational attainment. • To assess social skills. • To investigate history of sexual development and most especially whether the children had themselves been sexually abused. • To investigate the frequency and severity of sexual abuse committed by the child upon another. • To use the MMPI to assess the psychopathic score. Treatment Approaches:These consisted of general treatment approaches as outlined in the diagram of 23 psychotherapeutic approaches, which follows. In addition to this, specific treatment methods were used. These included the following: • Close and constant supervision initially and less so when progress has been made. • Dealing with fantasies of sexual abuse. • Transferring fantasies when older towards adults and away from children and towards the members of the opposite sex if possible. • Training in social skills, hence developing a capacity for seduction rather than rape or forced sexual imposition. • Promoting introjections or identifying with the potential victim. • Promoting areas that increase the capacity for self-esteem through educational progress and in other ways. • Individual confrontation therapy as well as group confrontation therapy. • No child was considered ready to leave the therapeutic community and school until the majority of staff and the client himself or herself felt that they were unlikely to be, or less likely to be, a danger to others, via sexual abuse. • A combination of rational emotive behaviour therapy was at the very central core of treatment with children being required to be responsible for actions now and in the future.Needless to say different therapeutic approaches are required when dealing with different kinds of sexual abusing categories. Where aggression is involved to a large degree, this must be dealt with as a matter of urgency. In all cases, however, sexual fantasies misdirected towards children need to be curbed and eventually redirected.Most Useful Treatment Methods with Sex Abusers :According to observations by the Consultant Psychologist, the staff and the youngsters themselves, the most effective approaches were specific procedures in order to redeem young sexual abusers such as: • Cognitive behaviour therapy i.e. attempting to gain the cooperation of the child • To be made aware of the problems and then to change both attitudes and behaviour. • To seek to change in attitudes and behaviour in relation to sexual targets and substitute an alternative target for their sexuality. • Careful and continuous observation and monitoring and recording of behaviour while within the therapeutic community. Actions or evidence that provide information of child sex abuse continuing or the avoidance of it when there is an opportunity of doing so are equally significant features to be observed. • Promoting constructive inter-personal skills to take the place of negative behaviours such as conning, bullying and aggressive demeanour. • Improving self-esteem through progress in educational attainment by providing, (following an educational assessment), educational therapy. Also required are remedying learning problems such as dyslexia, dysorthographia, dyscalculia and other problems through sensitive expert individual teaching as well as small group teaching. The assessing or progress made periodically and obtaining figures on gains in reading, spelling and mathematics as well as writing and other subjects and feeding this information back to the individual concerned. • In the case of older youngsters, providing vocational assessments regarding interests and aptitudes and temperament, and training youngsters to achieve appropriate vocational goals and to develop a sense of personal worth as a result. • Making the individual and most especially those in category B and C aware of the legal consequences of continuing their paedophile activities and reminding them repeatedly that to avoid incarceration, they must forego their earlier habits and seek substitute sexual activities that are regarded as acceptable by society.Specific Assessment Procedures :There are currently no useful specific assessment procedures (in my view) for those who are accused of sexual abuse, be they young persons or adults. For this reason the author of this paper has constructed two diagnostic procedures. These are related in that many of the items of one are also inherently located in the other, hence providing a double check on responses. These responses were originally designed as ideographic measures rather than normative in scope. They identify mot merely symptoms or background features of potential and actual sex abusers, but also identify different kinds of abusers i.e. those from Categories A, B or C. These instruments are: • The Lowenstein Sexual Abuse Personality Inventory (LSAPI) directed towards those alleged to be sex abusers. • The Lowenstein Sex Abuse Interview consisting of a number of items associated with sexual abuse or providing etiological aspects.Much of the information (traits and background) of sexual abuse concomitants has been obtained from clinical experience and specific research as well as from Dr. Gardner's books, Protocols for the Sex Abuse Evaluation and True and False Accusations of Child Sexual Abuse. Dr. Gardner is one of the most important experts in the U.S.A. in this area. * In the LSAPI, there is consistency and a lie score to check against reliability as to the individual's choice of items. The lie score could also point to validity or non-validity of the inventory. Lie scales however, are prone to a number of other interpretations than a desire to deceive, including the desire to see oneself in a socially acceptable light, or a failure to acknowledge or know oneself with any degree of accuracy.An answer sheet is used with the inventory that is easy to score and follows after the Interview Schedule has been completed.The answer sheet summarises: (1) the frequency of positive sex abuse items occurring; (2) (L) Lie Scale score; (3) consistency of responses.With a maximum of 26 items referring to positive evidence of sex abuse having occurred on the personality test, it was found that an interpretation was possible as to how likely it was that sex abuse occurred and was likely to continue occurring (see interpretation scores sheet). It must be stated a lack of agreement between the Inventory and the information obtained via the standardised interview, and high Lie scores and lack of consistency scores, needs to lead to further probing as to diagnosis and incidation. This is in order to obtain a true and valid account of the accuracy of the sexual abuse test and interview. It should also be seen as a way of being able to predict future sexual abuse. The full diagnostic assessments were carried out on admittance to the therapeutic community after the first year and after the second year.The Inventory was also useful in differentiating between level or severity of sexual abuse of Group A, B and C. Appropriate treatment procedures could thereby be used to rehabilitate offenders. This was especially the case for Group C. Lowenstein Sexual Abuse Personality Inventory (LSAPI) for the Accused
* Gardner, R. A. The above books mentioned are published by Creative Therapeutics, 155 County Road, Cresskill , New Jersey , 07626-0317 , U.S.A. L S A P I Accused Answer Sheet Name: . Age: . Sex: ...Date of test: . Occupation: ...
LOWENSTEIN SEXUAL ABUSE PERSONALITY INVENTORY (LSAPI)(FOR THE ACCUSED)SCORING SHEET • Add all A's marked in Column I and put total at the bottom of the page. This and column III will be the total sexual abuse score for the accused having committed the offence. • Add all B's marked in Column III and put total at the bottom of the page. Add this to the total obtained from adding column I for the total sexual abuse score. Maximum score 26. • The last score is obtained by following rhythm a, b; a, b etc Any time the rhythm is interrupted or missed a lie occurs in column II. The higher the score the less valid the result as a whole, due to high lie score. Maximum score 14 L. • The consistency scores are obtained by comparing the following items:- (Each time there is a discrepancy between the two items appearing in the graph below, an inconsistency has occurred.) Hence No. 1 & 22 must be the same to be consistent. Maximum score = 10. The higher the score the higher the consistency.
Lowenstein Sexual Abuse Personality Inventory (LSAPI) for the Accused. Scoring Sheet: Interpretation Scores:21-26 Very likely to be a sexual abusers. 15-20 Tendency towards the possibility of sexual abuse. 8-14 Area of non-differentiation. 7-12 Not tending towards sexual abuse of children. 1-6 Not at all likely to have sexually abused children. Standardised Interview for Individual Accused of Child Sexual AbuseYes = + No = - (more likelihood of being a sexual abuser). (less likely of being a sexual abuser).This short interview questionnaire should be used in combination with the Personality Test, which involves the accused of sexual abuse and consists of 40 questions. The interview plus a personality test in the area of child sexual abuse must be viewed together to obtain maximum validity of the respondent's likelihood of being a child sex abuser.
This should ideally be verified by submitting the individual to a standardised intelligence test such as one of the Wechsler Tests. Results:The results comprise a comparison, not so much between Group A, B and C but the changes in all the groups from the initial assessment (I) to the assessment carried out a year later and finally the assessment after two years indicated by (III). Table 1 shows Group A with the mean scores related to aggression, psychoticism, psychopathy and danger of a sexual nature followed by Reading Age (RA). Table 2 does the same for Group B, and Table 3 for Group C.From the results can be seen that there is a gradual reduction of aggression in all groups but most importantly in Groups B and C. The psychoticism scores also are gradually reduced as are scores in psychopathy and danger of a sexual nature. Reading ages or the gaining in educational achievement also undoubtedly affect self-esteem and this consistently rises as a result of the individualised education programmes at the centre. Table 1: (Group A)
Comparison was made between the initial assessment I and the final assessment following two years on the Eysenck Personality Questionnaire, the MMPI score related to psychopathy, aggression, the Lowenstein Accused Personality Inventory, and Reading Age.Group A Initial and Final Assessment EPQ scores t value = 4.44 degree of freedom = 6 2 tailed sig = 0.004 standard deviation = 2.215 Psychopathy t value = 5.14 degree of freedom = 6 2 tailed sig = 0.002 standard deviation = 7.724Aggression t value = 2.71 degree of freedom = 6 2 tailed sig = 0.035 standard deviation = 1.397Lowenstein Sex Accused Personality Inventory t value = 11.89 degree of freedom = 6 2 tailed sig = 0.001 standard deviation = 2.478 Reading Age t value = - 10.48 degree of freedom = 6 2 tailed sig = 0.001 standard deviation = 1.125 Group B Initial and Final Assessment EPQ scores t value = 7.52 degree of freedom = 12 2 tailed sig = 0.001 standard deviation = 2.103Psychopathy t value = 9.28 degree of freedom = 12 2 tailed sig = 0.001 standard deviation = 13.216Aggression t value = 3.10 degree of freedom = 12 2 tailed sig = 0.001 standard deviation = 1.609Lowenstein Sex Accused Personality Inventory t value = 14.55 degree of freedom = 12 2 tailed sig = 0.001 standard deviation = 2.764Reading Age t value = - 10.11 degree of freedom = 12 2 tailed sig = 0.001 standard deviation = - 1.471Group C Initial and Final AssessmentEPQ scores t value = 14.00 degree of freedom = 29 2 tailed sig = 0.001 standard deviation = 2.883Psychopathy t value = 12.54 degree of freedom = 29 2 tailed sig = 0.001 standard deviation = 17.146Aggression t value = 14.19 degree of freedom = 29 2 tailed sig = 0.001Lowenstein Sex Accused Personality Inventory t value = 22.09 degree of freedom = 30 2 tailed sig = 0.001Reading Age t value = - 22.13 degree of freedom = 30 2 tailed sig = 0.001 Conclusions: • The most successfully treated categories of children who were involved with sexual play or sexually abusing other children were in Category A and B. Here approximately 90% were considered to be virtually rehabilitated. • The most difficult category to treat and whose sexual proclivity was not always redeemed was Category C. • The earlier sex-abusing children were identified, diagnosed and treated, the greater likelihood of eventual successful treatment and rehabilitation. • Those children with the lowest aggression were more likely to respond to treatment than those with high level of aggression. • Aggression and its treatment were of primary importance in the treatment of child sex abusers of other children. • Only a small proportion of child sex abusing children were themselves sexually abused. • Children who successfully gained in educational ways were more likely to make progress to remedy their sexual abuse status than those who did not make such progress. • There was little difference between male and female sexual abusers in the area of aggression, psychoticism, psychopathy and these being combined with sexual needs and fantasies leading to category C type behaviour. • A 3-year follow-up showed that improvement made in treatment was maintained, there being no further incidents of sexual abuse reported. • When treatment was less effective or interrupted by early leaving before the 2-year period, further incidents of sexual abuse of youth by youth were reported at follow-up. • The essential aspect of treatment was close monitoring of the behaviour of the youth especially during the first six months to a year of treatment. Thereafter there needed to be a very gradual relaxation of scrutiny. • Verbal feedback of changes in attitudes had to take second place in importance to observed behaviour as validity of improvement in sexual conduct. • The capacity for self-control of aberrant sexual behaviour was a critical aspect as well as finding an acceptable substitute of sexual behaviour for that previously practised. • After leaving the centre, child protection or other agencies needed to be involved to continue some monitoring of behaviour of previous young child sex abusers. • There is a vital need for the long-term follow-up of children treated for being sexual abusers. This is despite the difficulties involved in this such as being able to trace the abusers and former abusers. Discussion of Results: Youths who sexually abuse other youths must be distinguished between and provided with psychological and milieu-type treatment as well as education appropriate to their needs. While distinguishing between sexual curiosity on the one hand, sexual needs and sexual needs combined with aggression can be difficult at times, this distinguishing helps those who treat this problem.Sometimes sexual curiosity is loosely associated with strong sexual fantasies. At times, as in category C, there is an association with aggression and category B there equally may be some aggression involved. Hence there is an overlap between the three categories. Category C is the group towards which there should be the greatest concern and hence with this group, treatment, both individual and group, is most vital.Being able to identify and diagnose group C at an early age is likely to make treatment more effective. Rational emotive approaches are likely to be more effective when they are combined with behavioural expectations, and monitoring. This requires close observation and a great variety of interactions with others, especially when such youngsters think themselves to be unobserved. One must always be on one's guard to avoid being lulled into complacency, especially in those youngsters with high psychopathy score. Words are less important than actions. One must always consider the behaviour of children as predominant rather than what they report about how they feel regarding their rehabilitation.Hence long term treatment and monitoring are of great importance. Working with a family of such youngsters is also important when this is possible as many return for short or long periods back to their families. At the completion of their time in treatment, there is a need for long-term follow-up.Other signs of maladjustment, which are likely to be linked in some way with sexual abuse of others, must receive attention. Of especial importance is low self-esteem due to poor educational attainments, a tendency to rely on aggression to achieve goals, poor social skills and difficulties in controlling impulses. Often there are also problems with families, which require therapeutic intervention.Exploring the possibility of the young sexual abuser having been abused also needs to be unearthed and dealt with through discussion, both on an individual and in a group therapy basis. Three emotional reactions tend to occur: • Tendency to blame themselves resulting in self-loathing for perhaps not having done enough to stop the abuse on themselves taking place. • A murderous hatred for the abuser. • There is also resentment expressed towards those who failed to protect them from the abuse suffered.It would seem important to combine self-reporting, observations by staff and family as well as the results of psychological testing to ascertain the relative success or failure of treatments. There are few, if any studies, which compare treated and non-treated groups as to short and long term outcome. It is in this area that much diagnostic and therapeutic work must yet be done. Dr L. F. Lowenstein , M.A.,DIP.PSYCH.,Ph.D . S OUTHERN E NGLAND P SYCHOLOGICAL S ERVICES ( SEPS ) Tel/Fax: 023 8069 2621 (Received September 2004) |
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