The treatment of juveniles who have sexually offended (JwSO) is challenging in several respects. While the harm done to the victims and prevention of future harm is always a concern, other issues need to be addressed. This includes a possible personal history of child abuse of the JwSO, other trauma history, family dysfunctions, substance abuse, school and peer problems, and comorbid psychiatric conditions. A recent ATSA Forum article (Ralph, 2017) recommends evaluating and considering another area of functioning for JwSO as well, prosocial or moral reasoning. That article suggested prosocial reasoning as a developmentally related criminogenic risk factor for these youth. This hypothesis relates to Bonner's (2012) finding that early adolescence is a high risk, transitory developmental period for committing illegal sexual behaviors, and there is no evidence that most JwSO have a lifelong, incurable sexual disorder or paraphilia. For example, a 14-year-old male may have adult sexual abilities and drive, but still have immature social judgment. Those 14-year-olds who may have deficits, relative to the average 14-year-old, regarding prosocial reasoning, may be at greater risk for general and sexual delinquency. Notably Bonner provides evidence that 14-year-olds have the highest incidence regarding sexual crimes of any age group, presumably related to this mismatch of abilities and judgment. 

A relevant consideration is whether deficits in prosocial reasoning are treatable. Are there interventions that enhance prosocial reasoning, and have beneficial effects for youth on probation such as reducing recidivism or other positive outcomes? The current article will address this issue. There is a significant treatment literature regarding effective methods to promote prosocial reasoning in youth on probation, including Reasoning and Rehabilitation (R&R) and its adaptation for adolescents (R&R2;Ross & Hilborn, 2003), Moral Reconation Therapy (MRT;Little & Robinson, 1988), and Aggression Replacement Training (ART;Goldstein, Glick, & Gibbs, 1998). Also research by the author regarding prosocial treatments with JwSO is presented.

Reasoning & Rehabilitation (R&R) Program

The Reasoning & Rehabilitation (R&R) program is a cognitive-behavioral group based intervention developed in Canada, and is supported by positive outcome studies (Antonowicz, 2005). A youth version for those under the supervision of social services or juvenile justice agencies was developed, the R&R2 Short Version for Youth (Ross & Hilborn, 2003). It is listed by the Washington State Institute for Public Policy (2016) as a beneficial practice for juveniles. The treatment model for the R&R2 uses a handbook, takes 12 sessions, and requires 18 contact hours. The authors of the R&R2 note:

Neuroscience has established that adolescence is a period during which youths are experiencing extraordinarily rapid brain development. Based on the neurocriminology model, the youth are engaged in prosocial simulation training and prosocial role-taking throughout the program in order to stimulate their development of prosocial neuronal connections - the foundation of a prosocial identity. (Ross & Hilborn, 2003, para. 7)

Field testing was conducted in Estonia, and an evaluation study was subsequently done in Scotland which found that youth who completed the R&R2 program had reduced antisocial attitudes and risk of offending, and improved problem-solving ability and behavior (Curran, 2006). Further research is needed to show the generalizability and robustness of these findings, and no research has yet been done using with model with JwSO.

Moral Reconation Therapy (MRT)

MRT is another group-based intervention, which uses a workbook as part of treatment (Little & Robinson, 1988). Training at accredited sites is required for use of the workbook. For youth the treatment program can be completed in approximately 26 sessions. Ferguson and Wormith (2013) reviewed 33 studies of MRT and reduction in recidivism was used as an outcome measure. They calculated an overall effect size for MRT of d= .32, but the juvenile effect size was d=.14. Two articles (Burnette, et al., 2003; Burnette, et al., 2004) showed positive changes with youth on probation using MRT, including increases in the level of moral reasoning. It is also listed by the Substance Abuse and Mental Health Services Administration as an evidence-based practice, and is included under juvenile interventions by the Washington State Institute for Public Policy in their meta-analytic review as a beneficial practice (2016). Although no studies with either MRT program have been used with JwSO,both MRT and R&R2 reduce recidivism with the general probation population, of which JwSO are a subset. Therefore, it is reasonable to hypothesize that these programs would also be effective with JwSO.

Aggression Replacement Training (ART)

Another approach which addresses moral or prosocial reasoning skills is ART (Goldstein, Glick, & Gibbs, 1998). It was developed primarily for juveniles on probation, using developmental psychology theories and research regarding child cognitive development, social learning, moral reasoning, and anger and emotional control. A central feature of this model is the promotion of moral or prosocial reasoning. The effectiveness of ART in reducing recidivism with youth on probation is also documented in a number of studies (e.g. Goldstein, Nensén, Daleflod, & Kalt, 2005). Amendola and Oliver (2010) in summarizing the literature note that ART is a "Model Program" for the United States Office of Juvenile Justice and Delinquency Prevention, and the United Kingdom Home Office.

The effectiveness of ART appears to be established for the general probation population. A question is whether ART is also effective and promotes positive outcomes for the subset of youth on probation with sexual offenses. The effectiveness of ART with JwSO was addressed in three related studies completed by the author. The same residential setting for JwSO was used in these studies. The first study was conducted in 2009 using a matched time series design with randomization (N=19). Outcomes were assessed using a psychological symptom inventory. Beneficial outcomes were found for reduced levels of psychological distress. This was the first randomized design done with any population with ART or with JwSO. However, it's important to note that long-term indicators such as recidivism or sexual acting out were not used as outcome measures.

A subsequent study in 2012, attempted to replicate these findings, but did not include a control group (Ralph, 2015a). However, additional psychological assessment techniques were used. The findings supported the hypothesis that ART contributed to therapeutic changes on psychological outcomes for youth in residential JwSO treatment. On the Child Behavior Checklist (Achenbach & Rescorla, 2001) completed by caregivers, five scales showed improvement from pre- to post- treatment which were Social Problems, Attention Problems, Rule Breaking Behavior, Externalized Total, and Total. On the Symptom Checklist 90-R (Derogatis & Savitz, 2000) completed by the youth, the Anxiety scale showed significant changes. On the Youth Outcome Questionnaire (Burlingame, Wells, Cox, & Lambert, 2004) completed by caregivers, Critical Items also showed positive changes. Two measures of prosocial reasoning, the Washington University Sentence Completion Test (Hy & Loevinger, 1996), and the Prosocial Reasoning Outcomes (Ralph, 2016a) also showed positive changes. This 2012 study was the first to show changes in prosocial reasoning with ART. It is important to note that this study did not include a control group and had methodological limitations, including ruling out maturation, testing, or a placebo effect as rival hypotheses to explain changes in scores.

In both the 2009 and 2012 studies open-ended focus groups were conducted with ART participants where they reported positive outcomes consistent with the quantitative findings. Youth generally identified the following ART strategies as helpful in being able to inhibit impulsive or counterproductive responses to adverse situations, and to formulate more positive and prosocial action alternatives. Youth described that they could "check themselves before they wrecked themselves." Importantly they also described a "virtuous cycle" in contrast to their usual impulsive behavior. When youth began using prosocial coping strategies they began using them more because of the reinforcement from the positive results of these approaches.

A subsequent longitudinal study (Ralph, 2015b) was carried out which followed all youth admitted to the same residential program from 2006 to 2012 (n =129 male youth ages 12 – 17). Sexual acting out was one of several outcomes studied, and 126 cases had complete data regarding this variable. This variable was defined as any episode of significant sexual acting out, some of which may have been considered a violation of the law. A total of 20.6% of youth had at least one such episode. Also a total of 20.9% youth completed the ART program during that time period. The rate of sexual acting out for those who participated in ART was 7.4%, compared to 24.2% for those who did not. A one-tailed Fisher's Exact Test was used to compare the groups, which were significantly different, p=.042.

Although this series of research studies has various methodological issues, together they show promise that ART was related to general psychological outcomes and associated with reduction in sexual acting out. Further larger scale studies are needed to confirm these preliminary results.

Being a Pro

The author has developed a treatment workbook for promoting prosocial reasoning, titled Being a Pro (Ralph, 2016b). It was influenced by research regarding measures of prosocial reasoning (Ralph, 2017), and also research on ART noted above. The structure of the Being a Pro workbook was informed by current research regarding best practices for youth on probation, notably the studies reported above with JwSO youth with ART. These are summarized in a prior article (Ralph, 2012). Approaches which emphasize counseling and skill building are manualized, have fidelity checks, training and supervision of practitioners, are more effective for youth on probation. These factors are also emphasized by Lipsey (2009) in his review article of effective interventions for youth on probation. Goense, Assink, Stams, Boendermaker, and Hoeve (2016) conducted a meta-analysis of 17 studies of interventions for juveniles with antisocial behavior. They found a medium treatment effect when integrity was high (d = 0.633, p < 0.001), but no significant effect when integrity was low (d = 0.143, ns). Both fidelity and outcomes measures were incorporated into the Being a Pro model. An outcome study was conducted for Being a Pro with 39 male adolescents (average age 15.7 years) on probation, in either outpatient or residential treatment for sexual offending (Ralph, In press). Results were consistent with the hypothesis of positive changes in prosocial behavior and reasoning as a result of the prosocial intervention, theBeing a Pro workbook. However, the design of a simple pre-post test did not rule out all rival hypotheses, and further research is necessary to validate the effectiveness of this approach.

Summary

There is reasonable evidence from research on ART and MRT that approaches which promote prosocial reasoning in youth on probation generally are effective in reducing recidivism. MRT as noted above was also associated with improved psychological functioning in youth on probation. Also the ART studies with JwSO reported above indicate it is associated with positive psychological outcomes for these youth. The studies and methods reviewed had limitations, and additional research is warranted. Prosocial treatment methods and their theory are consistent with neurodevelopmental research regarding adolescence being a "critical period" in the development of prosocial behaviors. It is a period when these skills are developing, and also youth with deficits are at greater risk for delinquent outcomes. This seems consistent with the hypothesis that adolescence may be a critical period of brain plasticity to promote prosocial reasoning. In summary, the above research suggests that treatment of JwSO might include interventions to promote prosocial reasoning.

References

Amendola, M., & Oliver, R. (2010). Aggression replacement training stands the test of time. Reclaiming Children and Youth, 19, 47-50.

Antonowicz, E. (2005). The reasoning and rehabilitation program: Outcome evaluations with offenders. In M. McMurran & J. McGuire, Eds. Social problem-solving and offending: Evidence, evaluation and evolution (pp. 163-182). Hoboken, NJ: John Wiley & Sons, Ltd.

Bonner, B. (2012). Don’t shoot: We’re your children. What we know about children and adolescents with sexual behavior problems. Retrieved February 20, 2017, from Boy Scouts of America, http://www.scouting.org/filestore/nyps/presentations/Children-with-Sexual-Behavior-Problems-Bonner.ppt

Burlingame, M., Wells, M. G., Lambert, M. J. (2004). Youth Outcome Questionnaire (Y-OQ). In M. E. Maruish (Ed.), The use of psychological testing for treatment planning and outcomes assessment (pp. 235-273). New York, NY: Routledge.

Burnette, K. D., Swan, E. S., Robinson, K. D., Woods-Robinson, M., & Little, G. L. (2003). Effects of MRT on male juvenile offenders participating in a therapeutic community program. Cognitive-Behavioral Treatment Review,12(2), 2-5.

Burnette, K. D., Swan, E. S., Robinson, K., Woods-Robinson, M., & Little, G. L. (2004). Treating youthful offenders with moral reconation therapy: A recidivism and pre-posttest analysis. Cognitive-Behavioral Treatment Review, 3(4), 14-15.

Derogatis, L. R., & Savitz, K. L. (2000). The SCL-90-R and the Brief Symptom Inventory (BSI) in primary care. In M. E. Maruish (Ed.), Handbook of psychological assessment in primary care settings (pp. 297-334). Mahwah, NJ: Lawrence Erlbaum Associates.

Ferguson, L. M., & Wormith, J. S. (2013). A meta-analysis of moral reconation therapy. International Journal of Offender Therapy and Comparative Criminology, 57:1076-106.

Goense, P. B., Assink, M., Stams, G. J., Boendermaker, L., & Hoeve, M. (2016). Making ‘what works’ work: A meta-analytic study of the effect of treatment integrity on outcomes of evidence-based interventions for juveniles with antisocial behavior. Aggression and Violent Behavior, 31, 106-115.

Goldstein, A. P., Nensén, R., Daleflod, B., & Kalt, M. (Eds.). (2005). New perspectives on aggression replacement training: Practice, research and application. John Wiley & Sons.

Goldstein, A., Glick, B., & Gibbs, J. (1998). Aggressions replacement training (Rev. Ed.), Champaign, IL: Research Press.

Hy, L. X., & Loevinger, J. (1996). Measuring ego development. Hillsdale, NJ: Lawrence Erlbaum Associates, Inc.

Kim, B., Benekos, P. J., & Merlo, A. V. (2016). Sex offender recidivism revisited. Trauma, Violence, & Abuse, 17(1), 105-117.

Lipsey, M. W. (2009). The primary factors that characterize effective interventions with juvenile offenders: A meta-analytic overview. Victims and Offenders, 4, 124-147.

Little, G. L., & Robinson, K. D. (1988). Moral reconation therapy: A systematic step-by-step treatment system for treatment resistant clients. Psychological Reports, 62(1), 135-151.

Nezu, C. M., D’Zurilla, T. J., & Nezu, (2005). Problem-solving therapy: Theory, practice, and application to sex offenders. In M. McMurran & J. McGuire, Eds. Social problem-solving and offending: Evidence, evaluation and evolution (pp. 103-123). Hoboken, NJ: John Wiley & Sons, Ltd.

Ralph, N. (2012). Prosocial interventions for juveniles with sexual offending behaviors. In B. Schwartz (Ed.), The sex offender: Issues in assessment, treatment, and supervision (pp. 18-29). Kingston, NJ: Civic Research Institute.

Ralph, N. (2015a). A follow up study of a prosocial intervention for juveniles who sexually offend. Sex Offender Treatment, 10(1).

Ralph, N. (2015b). A longitudinal study of factors predicting outcomes in a residential program for treating juveniles who sexually offend. Sex Offender Treatment. 10(2).

Ralph, N. (2016a). An instrument for assessing prosocial reasoning in probation youth.Sex

Offender Treatment. 11(1).

Ralph, N. (2016b). Being a Pro. Burlington, VT: Safer Society Press.

Ralph, N. (2017). Moral reasoning in juveniles who sexually offend. ATSA Forum, IX (2).

Ralph, N. (In press). A validation study of a prosocial reasoning intervention for juveniles under probation supervision. Sex Offender Treatment.

Ross, R. R. & Hilborn, J. (2003). R&R 2: Short version for youth. Cognitive Centre of Canada: Ottawa. Retrieved from http://www.cognitivecentre.ca/rr2youth.

Steinberg, L. (2015). Age of opportunity: Lessons from the new science of adolescence. Boston: Mariner Books, Houghton Mifflin Harcourt.

Washington State Institute for Public Policy. (2016). Benefit-Cost Results: Juvenile justice. Retrieved April 11, 2017, from http://www.wsipp.wa.gov/BenefitCost?topicId=1