Assessment and Treatment of Sexual Offenders with Intellectual Disabilities

A Handbook

Leam A. Craig, William R. Lindsay, Kevin D. Browne, Leam A. Craig, William R. Lindsay, Kevin D. Browne

• Publisher: Wiley-Blackwell
• Year: 2010
• Print ISBN: 9780470058398, 9780470058381
• eBook ISBN: 9780470975855
• Edition: 1
• Topic: Psychology
• Subtopic: Forensic Psychology
• Index: Psychology

A practical handbook for practitioners that covers the assessment, treatment and management of sexual offenders with intellectual disabilities – an area of growing interest within clinical forensic psychology.

• New for the Wiley Series in Forensic Clinical Psychology: a practical handbook that covers the assessment, treatment and management of sexual offenders with intellectual disabilities
• Summarises the research literature on the characteristics and prevalence of sexual offenders with intellectual disabilities
• Discusses risk assessment and innovations in treatment and management
• Includes contributors world-renowned in the field of assessment and treatment of sexual offenders with intellectual disabilities such as Tony Ward, Glynis Murphy, and Douglas Boer

PART ONE

Introduction

Chapter 1

Overview and Structure of the Book

Leam A. Craig, William R. Lindsay and Kevin D. Browne

Introduction

The relationship between behavioural disturbance and forensic problems in people with intellectual disability (ID) is subtle. There is no doubt that many behaviour problems in people with severe and profound ID would be construed as offences in more able individuals. One of the determining characteristics of an ‘offence’ is that the perpetrator is aware of behaviour that is socially sanctioned or censured. Even when someone with mild ID may understand the nature of the offence, the criminal justice response and the response of carers is diverse across cases and situations (Clare & Murphy, 1998; Swanson & Garwick, 1990).

A problem encountered in researching the topic of sex offenders with ID is the range and interchange of terms used to describe individuals or groups of individuals with intellectual disabilities. Some authors use the term ‘learning disability’, ‘learning impairment’, ‘learning disorders’, ‘learning difficulties’, ‘intellectual disabilities’ and ‘developmentally delayed’. This confuses and blurs the applicability of the research findings as sample sources vary, even though the aim is to encapsulate the same group. For the purpose of this chapter the term ‘intellectual disability’ will be used, which can be defined as:

• A significantly reduced ability to understand new or complex information, to learn new skills (impaired intelligence). A reduced ability to cope independently (impaired social functioning);
• Arising before adulthood (under 18 years of age) and having a lasting effect on development.

(Department of Health, 2001, p.14).

The Department of Health (2001) note that this encompasses a large range of disabilities, with a basic categorisation into four groups, based on IQ scores; which is the method most studies utilise: 50–70 – mild; 35–50 – moderate; 20–35 – severe; < 20 - profound. Assessments are usually conducted using the Wechsler Intelligence Scale for Children – Third Edition (WISC-III: Wechsler, 1991) or the Wechsler Adult Intelligence Scale – Third Edition (WAIS-III: Wechsler, 1999) with less than 70 indicating a level of intellectual disability. The assessment of social functioning causes more difficulty for research because of varying assessments and the inconsistent use of the term (O'Callaghan, 1999). Highlighting methodological problems with studies, Murphy, Harnett & Holland 1995 found none of the prison sample of sex offenders investigated had an IQ assessed under 70 but 21 percent had been referred to special schools, which may be an indication for some authors to classify these individuals as intellectually disabled.

General methodological difficulties with work in this area are that offenders with ID are only mentioned as part of larger offender cohorts. Where studies are specifically directed towards offenders with ID many studies are small in subject numbers (Johnston & Halstead, 2000). This is particularly true for sexual offenders with ID (Courtney, Rose & Mason, 2006; Craig, Stringer & Moss, 2006; Lindsay, Olley, Baillie & Smith, 1999). Under the auspices of The Prison Reform Trust (PRT), Loucks (2007) examined the attitudes and resources for people with ID within the criminal justice system in England and Wales. From this review it was estimated that 20–30 per cent of offenders have ID that interfere with their ability to cope within the criminal justice system. The Mottram (2007) research estimates that approximately 30 per cent of offenders within the prison system have an IQ less than 80. It is generally considered that the prevalence rates for offenders within the population of individuals with ID may be higher than those in the general population.

In his report, The Incidence of Hidden Disabilities in the Prison Population, Rack (2005) suggests that 20 per cent of the prison population has some form of hidden disability. Further research reported in the July 2006 edition of Community Care suggests that up to 7 per cent of the prison population is learning disabled and a further 23 per cent of prisoners are ‘borderline’ (PRT, 2006). On the other hand, Holland and Persson (in press) studied the prison population in Victoria, Australia and found a prevalence rate of around 1 per cent which is consistent with the prevalence of people with ID in the general population.

Many of the characteristics that are attributed to sexual offenders often overlap with those individuals categorised with ID. For example, research highlights the impulsive actions of individuals with ID, and this may increase the chances of them being involved in sex offences. However, these factors may also increase the likelihood of detection and give a biased picture of the relative prevalence of individuals with ID involved in sex offences.

The need for competent assessment and treatment of sexual offenders with ID has never been greater. The population in custody in England and Wales on 31 May 2008 was 82,822 (2 per cent more than a year earlier), with 82,372 in prison. In May 2009 this figure rose to 83,300 in custody, of which, 82,900 were in prison. Among the sentenced prison population, sexual offences saw an increase by 4 per cent from May 2007, rising to 7,573 sexual offenders (Ministry of Justice, 2008). In May 2009 this rose to 7, 907 sexual offenders (Ministry of Justice, 2009) a further increase of 4 per cent on the previous year. However, of these figures, it is not clear how many sexual offenders with ID are currently held in prison. While initial screening of prisoners at reception into prison or during induction may highlight problems, such testing is not systematic (Murphy, Harrold, Carey & Mulrooney, 2000) nor are these tools specific enough to identify intellectual disabilities (Williams & Atthill, 2005). The true estimate of the number of people with ID in prison remains unknown. Assuming an equal distribution in IQ scores across the prison sex offender sample, based on Mottram (2007) estimations, there could be as many as 2,271 sexual offenders with ID currently in prisons in England and Wales. Even taking the lower figures reported by Holland and Persson (in press) the estimate would be around 800, which remains a significant number of individuals requiring special procedures for assessment and treatment. If one includes those on probation and community orders (see Lindsay, Michie and Lambrick, Chapter 15), the figures rise considerably.

Since the 1980s there has been a growing interest in the assessment and treatment of sexual offenders with ID, and researchers and practitioners have developed a range of assessment protocols and treatment interventions for this client group. Specifically in relation to assessing sexual offenders with ID a range of psychometric measures have now been developed and standardised (Lindsay, Michie, Whitefield, Martin, Grieve & Carson, 2006; Murphy, Powell, Guzman & Hays, 2007) allowing for a more accurate assessment of risk and treatment need (Lindsay & Taylor, 2009). Similarly, clinicians and researchers have begun to address the problem of treatment for men with ID who have offended sexually. Without necessarily admitting clients for in-patient treatment, several reports have suggested the feasibility of such treatment (Craig, Stringer & Moss, 2006; Lindsay, Neilson, Morrison & Smith, 1998; Lindsay, Olley, Baillie & Smith, 1999; Murphy, 2007).

Clearly, this is rapidly developing area of interest where clinicians are experimenting intellectually and conceptually with how best to assess and improve treatment services for this client group. The PRT (2006) recently made a number of recommendations regarding the diagnostic assessment and management of offenders with ID. It is hope that this volume goes some way to addressing the assessment and treatment needs in sexual offenders with ID.

Structure of the Book

The book itself is divided into a number of sections as follows:

Introduction

The second chapter in the introductory section of the book is by Leam Craig and William Lindsay who explore the characteristics, prevalence, and assessment issues for sexual offenders with ID. It is important first of all to describe in detail the client group this book focuses on and aetiological theories of sexual offending by men with ID. They provide an up-to-date review of the theories of sexual offending by men with ID and argue that such behaviour is unlikely to be comprehensively described by a single theory but by a combination of several theories including tendencies toward sexual offending, personality traits and impulsiveness can be considered alongside the hypothesis of counterfeit deviance. Unlike non-ID sexual offenders, accurate estimations of prevalence of sexual offending by men with ID are often difficult to establish. In reviewing the prevalence and reconviction rates for this client group they note that, because of poorly controlled studies and methodological differences, it is extremely difficult to conclude that there are any characteristics which might be considered unique to the client group. Nevertheless, there is some consistency in the literature that sex offenders with ID pose a greater risk of sexual recidivism in a shorter time period than their non-ID counterparts. Craig and Lindsay explore the specific types of offending and re-offending as well as the familial and offence characteristics.

Part One: Background, Theory and Incidence

We begin this section with Susan Hayes (Chapter 3) who explores the developmental pathways in intellectually disabled sex offenders. This chapter reviews the developmental pathways from adverse childhood experiences to juvenile sex offending and adult sex crimes. As there is a dearth of research and the limitations of existing research on developmental characteristics of sexual offenders with ID, Hayes draws upon studies of non-disabled populations of offenders in order to extrapolate factors, conditions and events experienced by those with ID. The influence of a person having an ID in relation to these developmental pathways is specifically considered and this is compared to individuals with neuro-developmental deficits (such as ADHD) and young people without deficits or disabilities. She concludes that the earlier the investment in young people's lives, the more cost-effective the intervention to prevent sex offending.

This is followed by Chapter 4 from Kevin Browne and Michelle McManus, who seek to identify the characteristics of family sexual abuse committed by adolescents with ID and its relation to sibling abuse and incest. The role of parents/carers and the potential impact on the family are discussed with the aim of identifying opportunities for prevention of sex offences by adolescents and adult with ID.

Finally in this section, Lynne Eccleston, Tony Ward and Barry Waterman (Chapter 5) consider the application of the self-regulation model (SRM) (Ward & Hudson, 1998) to sexual offending in men with ID. The SRM has seen a great deal of research since 2000 as part of understanding the relapse prevention process in non-ID (Bickley & Beech, 2002) and ID sexual offenders. The SRM represents a breakthrough in understanding the relapse process and links to the Good Lives Model which has also been tested with sexual offenders with ID (Keeling, Rose & Beech, 2006; Langdon, Maxted & Murphy, 2007; Lindsay, Steptoe & Beech, 2008). Eccleston, Ward and Waterman describe the aetiology of the model and provide case examples of how the model can be applied to sex offenders with ID. They argue that ID sexual offenders are capable of explicit planning in addition to implicit planning and they can be less impulsive and opportunistic than previously considered. This has implications for treatment and management strategies, and they offer guidance on therapeutic approaches and techniques.

Part Two: Diagnostic Assessment and Comorbidity

This section of the book deals with issues of diagnostic assessment frameworks and comorbidity. In Chapter 6, Fabian Haut and Eleanor Brewster discuss the prevalence of mental illness in people with ID and the diagnosis and treatment of some of the more common diagnosed disorders. From reviewing the literature they suggest there are significant issues with mental illness for people with ID and that the prevalence of schizophrenia and other non-affective psychoses is considerably higher in people with ID than in the general adult population. They describe some of the difficulties in establishing dual diagnosis in people with ID and go on to consider different forms of pharmacological treatment for differing disorders. They then discuss pervasive developmental disorders – for example, autism, Asperger's syndrome and attention deficit hyperactivity disorder, which are often identified in people with ID – and describe the difficulties in dual diagnosing forms of mental illness. Finally, they discuss offending and sexual offending in people with autistic spectrum disorders. They conclude that although there is little to link specific psychiatric diagnoses with sexual offences, effective treatment of a comorbid psychiatric condition in people with an ID may help to reduce a person's offending behaviour, particularly if it is driven by mental illness.

In Chapter 7, Dorothy Griffiths, Paul Fedoroff and Deborah Richards discuss sexual and gender identity disorders identified within the DSM-IV-TR under three distinct sections: Sexual Dysfunctions, Gender Identity Disorders and Paraphilias. They review how these criteria are applied to persons with ID. The authors demonstrate how additional cautions should be applied when utilising the DSM-IV-TR criteria with persons with ID. Its application to this population requires knowledge of the nature of the disabling condition the person experiences and the impact of their life experiences on the commission of the offence. They make important but often overlooked points regarding the relationship between diagnosis of these disorders and sexual offences. As Seto (2008) points out, paedophilia (a psychiatric diagnosis) is an important factor in child molestation (a sexual offence) but the causal link between the two is not inevitable.

Part Three: Risk Assessment

In this section, three chapters consider issues around the assessment of risk and factors associated with sexual re-offending. William Lindsay and John Taylor (Chapter 8) begin this section and provide a comprehensive review of the risk factors associated with sexual offence recidivism within the mainstream literature and discuss how these risk factors can be applied to sexual offenders with ID.

Following on from this, in Chapter 9, Catrin Morrisey provides an overview of the relevant literature related to personality disorder and psychopathy in particular, both for forensic populations in general and for those with ID who offend sexually. Morrisey emphasises the importance of assessing for personality disorder in those referred to sex offender treatment in ID settings and that failing to recognise such disorder may result in...

Table of contents

• Cover
• Title Page
• Copyright
• Dedication
• About the Editors
• Contributors
• Foreword
• Acknowledgements
• Part One: Introduction
• Part Two: Diagnostic Assessment and Comorbidity
• Part Three: Risk Assessment
• Part Four: Assessing Treatment Need And Deviancy
• Part Five: Provisions and Treatment
• Part Six: Future Directions
• Index