|Prosocial Treatment Methods for Juveniles Who Sexually Offended|
|Norbert Ralph |
San Leandro, CA
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
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.
& 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
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
(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.
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
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
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 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
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
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.
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.
M., & Oliver, R. (2010). Aggression replacement training stands the test of
time. Reclaiming Children and Youth,
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.
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
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.
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.
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.
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.
L. M., & Wormith, J. S. (2013). A meta-analysis of moral reconation
therapy. International Journal of
Offender Therapy and Comparative Criminology, 57:1076-106.
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.
A. P., Nensén, R., Daleflod, B., & Kalt, M. (Eds.). (2005). New perspectives on aggression replacement
training: Practice, research and application. John Wiley & Sons.
A., Glick, B., & Gibbs, J. (1998). Aggressions
replacement training (Rev. Ed.), Champaign, IL: Research Press.
L. X., & Loevinger, J. (1996). Measuring
ego development. Hillsdale, NJ: Lawrence Erlbaum Associates, Inc.
B., Benekos, P. J., & Merlo, A. V. (2016). Sex offender recidivism
revisited. Trauma, Violence, & Abuse,
M. W. (2009). The primary factors that characterize effective interventions
with juvenile offenders: A meta-analytic overview. Victims and Offenders, 4, 124-147.
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.
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.
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.
N. (2015a). A follow up study of a prosocial intervention for juveniles who
sexually offend. Sex Offender Treatment,
N. (2015b). A longitudinal study of factors predicting outcomes in a
residential program for treating juveniles who sexually offend. Sex Offender Treatment. 10(2).
N. (2016a). An instrument for assessing prosocial reasoning in probation youth.Sex
Offender Treatment. 11(1).
N. (2016b). Being a Pro. Burlington,
VT: Safer Society Press.
N. (2017). Moral reasoning in juveniles
who sexually offend. ATSA Forum, IX (2).
N. (In press). A validation study of a prosocial reasoning intervention for
juveniles under probation supervision. Sex
R. R. & Hilborn, J. (2003). R&R
2: Short version for youth. Cognitive Centre of Canada: Ottawa. Retrieved
L. (2015). Age of opportunity: Lessons
from the new science of adolescence. Boston: Mariner Books, Houghton
State Institute for Public Policy. (2016). Benefit-Cost
Results: Juvenile justice. Retrieved April 11, 2017, from