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Working with Youth and Adults with Cognitive Impairments and Developmental Delays who Have Sexually Problematic Behavior:The Easter Seals Experience
1. Working with Youth and Adults with
Cognitive Impairments and
Developmental Delays who Have Sexually
Problematic Behavior:
The Easter Seals Experience
Crystal Cookman, M.A. Robert Kinscherff, Ph.D., Esq.
Derek Edge, M.A. James Mlynarski, M.S.
Mandy Graves, M.S.W. Elizabeth J. Shepherd, Ph.D.
2. Easter Seals Mission Statement
Easter Seals provides
exceptional services
to ensure that all
people with
disabilities or special
needs and their
families have equal
opportunity to live,
learn, work and play
in their communities.
4. Program Participants
Individuals with:
Developmental Disabilities
Mental Health needs
Mental Retardation
Traumatic Brain Injury
In addition to – or in combination with – the above
categories, participants in the preventative
services program also are treated specifically for
high-risk behavior.
5. Treatment Needs
Problematic Sexual Behavior(s)
Sex Offender Treatment
Violent Offenders
Anger Management
Arson
Behavior Management Needs – ABA
Environmental Security Needs
Medical Needs
Medication Monitoring/Administration
6. Easter Seals New Hampshire
As an affiliate of the national organization, we provide services
in: New Hampshire, Vermont, Rhode Island, Maine, New York.
Our headquarters are located in Manchester, NH.
Agency (New Hampshire only)
$53 million operating budget in NH
CBS -14 million
Preventative Services – $2.9 million (of CBS)
25,000 people served in NH in 2008
CBS – 350 people served
Preventative Services – 58
$3.2 million free services in 2008
7. Development of Preventative Services
2004 – Referral for 3 person home and 2 EFC
placements.
Reviewed number of eligible clients already in services
Offered specialized service - hired skilled Residential
Manager with specific training and skills.
Increased behavioral support – added behavior specialist
Began offering counseling with graduate interns
2006 - Received contract for entire region
2008 – Hire F/T clinician, additional Behavior Specialist
2008 – Hire Dr. Kinscherff, initiate Assessment Team,
integrate agency-wide services and clinicians
8. Preventative Services
58 people served (not including assessment services)
13 – Staffed residential services
10 – Enhanced family care
4 – Supported living
3 – Vocational support
28 – Counseling services
8 – Residential/Vocational programs in development.
$2.9 million gross revenue (with $700,000 additional
services in development)
9. Preventative Services
30 People Served in Day & Residential
Services
Male - 80% (24/30)
Female - 20% (6/30)
Court involvement - 67% (20/30)
History of incarceration - 27% (8/30)
Registered Offenders - 6% (2/30)
10. Preventative Services/CBS
Program Staff
67 – Program Staff/Direct Support
7 – Utility Staff cross trained in multiple programs
9 – Program Managers
2 - Behavior Specialists
1.5 – Clinician/Therapist
2 – Assessment Specialists
1 – Occupational Therapist
1 - Clinical Director
1- Residential Director
11. Clinical Services
Crisis Supports/24-hour support network
Therapy/Counseling Services
Assessment Services
Behavior Support Services
Occupational Therapy
Nursing Services
12. Programs – CBS
Residential Services Day / Vocational
24 hour staffed Services
residential homes Job Development
Enhanced Family Care Job Coaching
Companion/Paid Transportation
roommate Transition programs
Respite Services for Recreation
Providers and Families
Educational/
Independent Living Functional Learning
14. Differences between Registered Sex
Offenders and Problematic Sexual Behavior
RSO PSB
Treatment Treatment
Motivational Cognitive Behavioral
Therapy/In vivo
Interviewing
Opportunistic/
Predatory
Reactive/
Group session
Impulsive
Missed Individual, Group,
session=violation of Family Therapy
parole “Perfect Storm” Theory
Treatment
Flower Analogy
17. Adult Clients Served
Heterogeneous group
Opportunistic/Reactive v. Predatory
High Risk Behavior (anger, self injurious, PSB)
Mental health diagnosis
Developmental Delays
18. Risk Tolerance
Population specific
Alone Time
Identify risk in terms of PSB as well as
peripheral risks (anger, anxiety, etc) and
how they interact
Responsibility of team to define
parameters
Monthly meetings with team
19. Step Program
Plan developed by therapist and behavior
specialist
Purpose: relaxing supervision
Stability in supportive factors to not
reoffend
Outline what is to be tracked
20. Step Program
Step 1(Day 1-30)NO Target Behavior -
1(Day 1- Step 5(Day 121-150)No Target Behavior-
5(Day 121- Behavior-
Skills Rehearsed with reminders and with ¾ hr. at residence, ¾ hr. in
staff cues. (See attached skill sheet). community. Phone check-ins every
check-
Tools will be reviewed 2x’s/day with
2x’ 1/4hr.
HCP. (See attached documentation
requirements). No alone time. Step 6(Day 151-180)No Target Behavior-
6(Day 151- Behavior-
1hr. at residence, 1 hr. in community.
Step 2(Day 31-60)No Target Behavior -
2(Day 31- Phone check ins-every 1/4 hr.
ins-
Skills Rehearsed with or w/o reminders, with documented and submitted to
staff/HCP cues.½ hr. alone time at
cues.½ Therapist and CM.
residence, with phone check in every
10 minutes by HCP-to be documented
HCP- Step 7(Day 151-180)No Target Behavior- 2
and given to therapist and CM. 7(Day 151- Behavior-
hrs./day unsupervised in the
community-1 day/work. Phone check
community-
Step 3(61-90)No Target Behavior – Skills
3(61- ins-every 1/4 hr. documented and
ins-
Rehearsed without reminder1/2hr.
reminder1/2hr. submitted to Therapist and CM.
2x’s/day alone time at residence-non-
2x’ residence- non-
consecutive-with phone check-ins
consecutive - check- **Check-ins to occur at least as listed in
**Check-
every 10 minutes. By HCP. each step. Sporadic check-ins are
check-
encouraged.
Step 4(Day 91-120)No Target Behavior,
4(Day 91-
Skills Rehearsed without reminder½ hr. at
reminder½
residence-15 min. phone check-in by
residence- check-
HCP, ¼ hr. w/o supervision.¼ hr. may
supervision.¼
be used for banking, library, or
convenience store.
22. Intensive Level Individualized
Treatment
Our Customers' needs
come FIRST in all that
we do, every day.
WHATEVER IT
TAKES!
23. Facilities for Treatment
Zachary Rd Facility
Boys Group Home
Girls Group Home
Community Readiness
Program
Individual Service
Option (ISO)
24. Education/Training of Staff
Must be 21 years of age
Bachelors’ level: Residential staff
Masters’ level: Clinical staff
Month long training and observation of
residents before working on the floor
25. Clients
Males/Females age 13 – 21
School placement, DCYF, or on Probation
ES takes any child “no reject or eject policy” –
minimize hospitalizations (unique)
Cognitive capabilities: the full scale MR,
borderline, to normal range
Most children arrive with a simple assault charge
26. Treatment
Standard Treatments Alternative Treatments
Individual Therapy Community Inclusion
Group Therapy Therapy session with
staff present
Individual Counseling
Chaperone training for
Psychiatry the staff (risk
Medication management)
Nursing “REWIND” Treatment
Case management TCI
OT, PT, Speech Mirror Reality
Session in community
27. Brief Case Examples
The best way to explain how Easter Seals does
things differently with youth with cognitive
disabilities is to give some examples.
Jonny; Description, issues, treatment
John ; Description, issues, treatment
Dustin; Description, issues, treatment
Travis; Description, issues, treatment
29. Center for Sex Offender Management
A Project of the Office of Justice Programs, US Dept of Justice
www.csom.org
Sex offenders with developmental disabilities
pose as clear a threat to public safety as sex
offenders without developmental disabilities
Developmental disabilities do not cause or
excuse sexual offending
Sex offenders with developmental disabilities
should be provided treatment that is appropriate
to their developmental capacity and their level of
comprehension
30. Center for Sex Offender Management
A Project of the Office of Justice Programs, US Dept of Justice
www.csom.org
To assess effectively whether a sex offender
with developmental disabilities can be
adequately managed in the community…
Evaluate the offender’s level of cognitive impairment
to gauge his or her suitability for community
supervision
Work with treatment providers who are
knowledgeable about sex offending behavior and
have treated developmentally disabled individuals
Work intensively with personnel from mental health
and social service departments, group home staff,
and others who may be involved closely in the
offender’s daily life
31. Standards of Practice for Sex Offender
Treatment Programs in New Hampshire
Assessment
• Prior to entering a contractual agreement for
treatment, the offender shall participate in an
assessment/evaluation. At a minimum, this should
include a clinical interview, which consists of:
1. A complete history including social, sexual,
criminal, medical, and substance abuse;
2. The dynamics of the sexual offending
behavior;
3. Identification of problem areas and treatment
goals.
32. Methods of Referral
Adolescents:
Easter Seals Residential Facilities
Intensive Level Treatment Units
Group Homes
Co-Occurring Program
Autism Clinic
Juvenile Delinquency Matters
33. Methods of Referral
Adults:
Bureau of Developmental Disability Area Agencies
“updates”
Transition from adolescent services
Transition from prison
Transition from Designated Receiving Facility
Positive on criminal background check
Easter Seals Community Based Programs
“updates”
Transfer from another agency
Change in level of supervision (least restrictive setting)
Court System
34. Case Types
(Completed or In Progress)
Adults – 37 (4 female, 33 male)
Adolescents – 10 (1 female, 9 male)
Sexual Risk – 28
Transition to least restrictive setting – 4
Decrease level of supervision – 3
Transition to adult services – 4
To obtain agency services – 5
Civil Commitment – 1
Ability to be around children – 1
Ability to return to family home - 2
Updated assessment – 5
Violence Risk – 12
Youthful Offender – 2
Transition to adult services – 3
To obtain agency services - 1
General risk of harm to self or others – 6
Updated assessment – 3
Other case types include: Criminal Responsibility, Competency to Stand
Trial, Munchausen by Proxy and fire setting
35. Living Situations of Evaluees
Family home – 7
Residential facility – 9
Foster care - 1
Enhanced foster care – 6
Staffed home – 2
Provider home – 4
Independent living – 4
State hospital – 2
Jail – 6
Designated Receiving Facility - 2
36. General Standards of Practice in
Risk Assessment
Approaches:
Clinical assessment
Actuarial assessment
Guided-clinical assessment
Adjusted actuarial approach
The “standard” approach is a combination of:
Actuarial assessment tools
Structured clinical interviewing
Derived from evaluation of adult male sex
offenders
37. General Principles of Forensic Assessment
Clear identification of the referral source and the
client
Knowledge of guardianship issues
Understanding of legal status of case
Include multiple sources of information
combined with a thorough file review
Corroborate information obtained when possible
Respect the scope and limitations of the data
38. Some Standard Assessment Components
Discussion of informed consent and limitations
of confidentiality
Record review
Information from third parties
Clinical interviewing
Assessment of mental status
Assessment of history (e.g., family, psychiatric,
educational, vocational, medical, sexual)
Administration of assessment measures
Written report
Feedback session
39. Some Typical Assessment Issues and Goals
What was the problematic behavior?
What was the motivation for the behavior?
What was the purpose of the behavior?
What was the context of the behavior?
Each client has a unique set of characteristics
and/or risk factors that are tied to the risk they
pose in any given situation.
40. Some Atypical Assessment Issues
What is the motivation for the behavior?
Criminal intent?
Antisocial tendencies? Psychopathy?
Deviant arousal?
Sexually reactive?
Underlying psychiatric disorder?
Cognitive/developmental proclivities?
Attention seeking?
Sadness, anger, fear?
History of abuse/neglect? Over-sexualized history?
41. More Atypical Assessment Issues
Homogeneity of the behavior, but…
Heterogeneity of the population.
Differential diagnosis
Clinical issues vs. assessment of risk
Related issues and risks:
Exploitation
Other criminal activity
Daily functioning and adaptive skills
Supports
43. Typical Risk Assessment Tools
Laboratory Tools
Penile Plethysmograph
Abel Assessment of Sexual Interest-2 (AASI-2)
Polygraph
Actuarial Tools
STATIC-99
STABLE & ACUTE-2007
Hare Psychopathy Checklist
Violence Risk Assessment Guide (VRAG)
Sexual Offender Risk Assessment Guide (SORAG)
Level of Service Inventory – Offender (LSI-O)
44. Typical Risk Assessment Tools
Empirically Validated
Novaco Anger Scale
State-Trait Anxiety Inventory-II (STAXI-II)
Suicide Probability Scale
Structured Clinical Judgment Tool
HCR-20
Risk for Sexual Violence Protocol (RSVP)
Structured Assessment of Violence Protocol in Youth
(SAVRY)
Adult Sex Offender Assessment Protocol (ASOAP)
Juvenile Sex Offender Assessment Protocol (JSOAP)
45. Typical Risk Assessment Tools
Clinical Assessment Tools
Abel & Becker Sexual Interest Card Sort
(questionnaire version)
Bumby Cognitive Distortions Scale
Child Sexual Behavior Questionnaire
46. Challenges in Applying These Tools
to Individuals with Disabilities
Norming samples
Face validity
Construct validity
Counterfeit Deviance
Philosophy of Risk Tolerance: Human
Rights versus Public Protection
Questionnaires and self report
47. Applying Risk Factors
Would our population skew the sample?
Static Factors where this population may be
overrepresented due to disability
Live with biological parents
School maladjustment
Male victims
History of being sexually victimized
Static Factors: underrepresentation
Age at time of offense
Substance use
Number of convictions
Presence of violence
48. Applying Risk Factors
Dynamic Factors
Intimate relationships
Employment
Sexual preoccupation
Phallometric testing
Attitudes “condoning” sexual offending
Higher level cognition: denial, remorse, empathy,
self awareness
Motivation for change and internalization of
treatment
49. New Tools in Development
Gene Abel, MD – Georgia
Abel-Blasingame Assessment System for Individuals
with Intellectual Disabilities (ABID)
Vermont Department of Corrections
Treatment Intervention and Progress Scale for Sexual
Abusers with Intellectual Disabilities (TIPS-ID)
William Lindsay, PhD – Scotland
Questionnaire on Attitudes Consistent with Sexual
Offending
Dynamic Risk Assessment and Management System
Dundee Provocation Inventory
50. Conceptualization
Evaluation of identified risk factors
Static
Dynamic (stable, acute)
Consideration of level of cognitive, emotional,
social functioning
Identification of:
Strengths
Protective Factors
Supports
Times when the individual does well
51. Development of a
Risk Management Plan
Develop a general relapse prevention plan
Operationalize the contexts of higher and lower risk
Identify high-risk situations and make plans to avoid
and/or tolerate
Provide support for healthy lifestyle reflecting the
values of recovery
Establish a support system of persons knowledgeable
about the client and his/her offense cycle
Determine and provide level of support and
supervision needed
52. Development of a
Risk Management Plan
Evaluate:
Engagement in treatment
Effectiveness of treatment
Consider:
Access to victim population
Access/availability of triggers
Past behavior: opportunistic vs. planful
Exposure to/education on normative sexual education
Legal issues
Establish an alliance with the client regarding
management of the problem behavior
Provide motivation for the client to actively
participate in treatment and supervision
53. Other Thoughts
Risk assessment and management is an
ongoing process…
Dynamic risk factors
Changes in home, school, vocation, family,
environment
New relationships
Emerging sexuality
New developmental phases & challenges
Onset of new behaviors…
What has changed? Why now?
55. Background Information
42 year old Caucasian male
Borderline Intellectual Functioning,
Cerebral Palsy, Pedophilia
Significant language impairment, uses AAC
device.
Raised in foster care in early years
Attended residential school and graduated
from public school in NH
56. Background Information
Family history of mental illness (paternal and
maternal)
Family history of substance and alcohol abuse
Family has limited/severed most contact since
conviction
Witness to domestic abuse
Physically and sexually abused by parents/peers
Long term social and emotional isolation
57. Vocational History
Yogurt factory (post incarceration)
Department of Education – Systems
Technician
Janitor & substitute janitor – high school &
elementary school (2 schools)
Hardware store
Dishwasher
Assembly position
58. Legal History
No prior arrests until 2005
Arrested in sting operation in 2005 for attempt
to solicit (what he thought) was a child.
Also arrested for
2 counts of Child Pornography
2 counts of delivering child pornography
10 counts of child pornography in another county
Pled guilty to all charges
59. Sentence
NH DOC (county jail due to disability and plea
agreement)
Entered April 2006, released April 2008
Three years’ probation
Required to attend Offender Treatment
Required to have no unsupervised time with minors
Required to have no computer access
Required to register with the State of NH
61. MMPI-2
Highly sensitive to criticism – can act with anger
hostility
Longstanding distrust, expects unfair treatment
Fails to take responsibility, tendency to blame
Overly sensitive and rigid in relationships –thus
negatively impacting them
Over-responds to perceived slights or rejection
Likely to resist treatment that doesn’t meet his
ideas of his needs & wants
62. Bumby Cognitive Distortions Scale
Although in treatment – Mike failed to negatively
endorse many rape/molestation items…
Examples on Molestation Scale
Positively endorsed more items then negatively
endorsed
Felt that offenders are unfairly punished
Children are seductive and eager to have sex with
adults
Examples on Rape Scale
Rape is the result of stress
If women don’t resist they are willing
63. Abel Becker Sexual Interest
Card Sort
Endorsed scenarios with adult males as
most arousing
Inconsistently endorsed pedophilic
interests in young boys and girls
Rated none of the pedophilic, rape,
sadism, masochism as repulsive and rated
more than 1/3 as neither arousing nor
repulsive
64. Plethysmograph
Significantly high levels of response to all stimuli
depicting sexual activity with boys
Significantly high levels of response to
consensual sex with male partner
Show significant levels to female child, but less
than boys
Responses conflict with self report
Responses indicate that his arousal pattern is
not likely to be exclusively pedophilic
65. Formulation
CP – likely contributed to diminished social,
emotional, and moral development
History of poor social skills, diffused boundaries,
over-attachment, misreads social cues, and
social isolation
Above likely contributed to over-identification
with children who are less threatening to him
compared to adults
Emotional naïve and quickly becomes
emotionally attached to most males that are
attentive to him
66. Formulation
Operates primarily to avoid punishment
demonstrating his limited moral development
No apparent empathy during interview; he never
seems to recognize the impact of his actions
Longstanding history of using maladaptive
coping skills to deal with sexual urges
Presents significant risk if restrictions are
removed prior to treatment and the
development of internal prohibitions against
acting on pedophilic urges
68. Treatment
Program Focus Areas:
1. Interest
Addressed in treatment settings – CBT,
behavioral techniques, cognitive restructuring,
basic education, etc.
1. Access
Environmental management model to provide
oversight and safety
Supervision
69. Interest vs. Access
Interest – Treatment Access – Program
Social skills training Supervision
Sex education & Perimeter and internal
intimacy education alarms
Legal education Staff supervision
Relapse prevention Telephone/mail
techniques screening
Room/house searches
70. General Areas of Focus
Admission of offense Problem solving skills
Responsibility Managing impulses
Sexual education Stable employment
Sexual attitudes Stable residential
Sexual interests Peer/family influences
Other high risk behavior Adult relationships
Criminal attitude Attitude toward treatment
Emotion management Risk management
MH stability knowledge
Stage of change Risk management
application
71. General Stages of Treatment
1. Stop high-risk/offending behavior
2. Development of responsibility
3. Understand high risk areas
4. Develop alternate behavior
5. Develop and maintain a healthy lifestyle
Treatment Stages
74. Community Survey
Review Neighborhood/Community
1. Immediate disqualifiers
2. Detailed listing of property and site
Community Survey
75. Residence
Duplex with staffed residential model adjacent
Provide phone call checks
Physical checks 7am, 3pm, 11pm
40 hours of staffing
M-F 6 hours
Saturday-Sunday – 5 hours
ADT alarm system
76. Service Contract
Services are voluntary for Mike and Easter Seals.
Four Contracted Areas:
1. Administrative
2. Residential
3. Employment & Community
4. Clinical/Treatment
Service Contract
77. Preventative Services Plan
Demographic information Overview of treatment
Background and treatment goals
History of high risk and Triggers/antecedents
offending behavior General program rules
Current level of Environmental
supervision modifications
Overview of most recent Training requirements
risk assessment and Documentation
recommendations requirements
Various risk management Approvals pages
strategies Preventative Services
Plan
78. Working with Youth and Adults with
Cognitive Impairments and
Developmental Delays who Have Sexually
Problematic Behavior:
The Easter Seals Experience
Crystal Cookman, M.A. Robert Kinscherff, Ph.D., Esq.
Derek Edge, M.A. James Mlynarski, M.S.
Mandy Graves, M.S.W. Elizabeth J. Shepherd, Ph.D.
www.eastersealsnh.org
Community Based Services: 603-262-9383
